The Swedish childhood diabetes study: indications of severe psychological stress as a risk factor for type 1 (insulin-dependent) diabetes mellitus in childhood

Feasibility and Challenges with Measuring Adverse Childhood Experiences in the Pediatric Intensive Care Unit

Purpose

The Adverse Childhood Experiences (ACEs) screening tool captures some experiences of childhood adversity, ranging from abuse to parental separation. Research has shown a correlation between ACEs and both adult and childhood disease. This study evaluated the feasibility of conducting ACE screening in the pediatric intensive care unit (PICU) and investigated associations with markers for severity of illness and utilization of resources.

Methods

This was a cross sectional study screening for ACEs among children admitted to a single quaternary medical-surgical PICU. Children age 0-18 years old admitted to the PICU over a one-year period were considered for enrollment. A 10-question ACE screen was used to evaluate children for exposure to ACEs. Chart review was used to collect demographic and clinical data.

Results

Of the 432 parents approached for enrollment, 400 (92.6%) agreed to participate. Most parents reported an ACE score of zero (68.9%) while 31% of participants experienced at least 1 ACE, of whom 14.8% experienced ≥ 2 ACEs. There was not a statistically significant association between ACE score and length of stay (p-value = 0.26) or level of respiratory support in patients with asthma (p-value = 0.15) or bronchiolitis (p-value = 0.83). The primary reasons for not approaching families were parent availability, non-English speaking parents, and social work concerns.

Conclusions

This study demonstrates feasibility to collect sensitive psychosocial data in the PICU and highlights challenges to enrollment.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40653-023-00555-9.

Parental history of psychiatric disorders and risk of type 1 diabetes in the offspring

OBJECTIVE

To examine risk of type 1 diabetes mellitus (T1DM) in the offspring of parents with a psychiatric history at the birth of the child, which would suggest potential shared familial or environmental risk factors between T1DM and psychiatric disorders.

METHODS

We established a cohort including all children born in Sweden in 1997-2016, and their parents. Children were followed up from birth until 31 Dec 2017, using national registers. Relative risk for T1DM was estimated by incidence rate ratios (RR) with 95% confidence intervals (CI), calculated from Poisson regression. We examined psychiatric subtypes, T1DM risk within subgroups and in relation to the timing of exposure.

RESULTS

The study cohort included 1,497,949 children. During follow-up, 7,794 cases of T1DM were identified. Children of mothers with psychiatric disorders at delivery had a higher risk of T1DM (RR 1.10 [95%CI 1.01-1.20]). Psychiatric diagnoses in fathers or assigned after delivery was not associated with increased T1DM risk. The observed association disappeared after adjusting for T1DM in parents; however, remained significant in female offspring. Maternal eating disorder (RR 1.53 [1.17-2.00]) and obsessive-compulsive disorder (RR 1.62 [1.02-2.58]) were associated with offspring T1DM, independent of parental T1DM.

CONCLUSION

Our results do not support a strong genetic link between psychiatric conditions and T1DM. However, the risks of offspring T1DM were increased in subgroups of female offspring and in offspring of mothers with a history of eating disorder or obsessive-compulsive disorder, independent of heredity for T1DM, which may warrant further investigation in future studies.

The Multifactorial Progression from the Islet Autoimmunity to Type 1 Diabetes in Children

Type 1 Diabetes (T1D) results from autoimmune destruction of insulin producing pancreatic ß-cells. This disease, with a peak incidence in childhood, causes the lifelong need for insulin injections and necessitates careful monitoring of blood glucose levels. However, despite the current insulin therapies, it still shortens life expectancy due to complications affecting multiple organs. Recently, the incidence of T1D in childhood has increased by 3-5% per year in most developed Western countries. The heterogeneity of the disease process is supported by the findings of follow-up studies started early in infancy. The development of T1D is usually preceded by the appearance of autoantibodies targeted against antigens expressed in the pancreatic islets. The risk of T1D increases significantly with an increasing number of positive autoantibodies. The order of autoantibody appearance affects the disease risk. Genetic susceptibility, mainly defined by the human leukocyte antigen (HLA) class II gene region and environmental factors, is important in the development of islet autoimmunity and T1D. Environmental factors, mainly those linked to the changes in the gut microbiome as well as several pathogens, especially viruses, and diet are key modulators of T1D. The aim of this paper is to expand the understanding of the aetiology and pathogenesis of T1D in childhood by detailed description and comparison of factors affecting the progression from the islet autoimmunity to T1D in children.

Trajectories of Childhood Adversity and Type 1 Diabetes: A Nationwide Study of One Million Children

OBJECTIVE

Experiencing adversities in childhood may increase the risk of type 1 diabetes through hyperactivation of the stress response system, but the empirical evidence is conflicting. We aim to describe the age-specific incidence of type 1 diabetes for males and females separately in five predefined groups covering the most common trajectories of adversity among Danish children.

RESEARCH DESIGN AND METHODS

We included all 1,081,993 children without parental type 1 diabetes born in Denmark from 1980 to 1998. We used register data to estimate age-specific incidence rates of type 1 diabetes in five trajectory groups of adversity characterized by 1) low adversity, 2) early life material deprivation, 3) persistent material deprivation, 4) loss or threat of loss in the family, and 5) cumulative high adversity. All analyses were stratified by sex.

RESULTS

In total, 5,619 people developed type 1 diabetes before 2016. We found only minor differences when comparing the incidence rates of type 1 diabetes between the trajectory groups. The only clear exceptions were in the high versus low adversity group, in which males had a higher incidence of type 1 diabetes in childhood (<11 years [incidence rate ratio (IRR) 1.78 (95% CI 1.31-2.42)]) and females had a higher incidence in early adulthood (≥16 years [IRR 2.19 (95% CI 1.57-3.07)]).

CONCLUSIONS

Childhood adversities were generally not associated with age-specific incidence of type 1 diabetes except among those exposed to a very high and increasing annual rate of childhood adversities. Differences between highly exposed males and females seem to depend on age at onset of type 1 diabetes.

Accumulation of childhood adversities and type 1 diabetes risk: a register-based cohort study of all children born in Denmark between 1980 and 2015

BACKGROUND

Previous studies have indicated an association between childhood adversities and type 1 diabetes but have been underpowered and limited by selection. We aim to quantify the effect of accumulation of childhood adversities on type 1 diabetes risk, and to assess whether the effect differs between males and females in a large and unselected population sample.

METHODS

We used register-based data covering all children born in Denmark between 1980 and 2015, totalling >2 million children. We specified a multi-state model to quantify the effect of accumulation of childhood adversities on type 1 diabetes risk. The effects of specific childhood adversities on type 1 diabetes were estimated using proportional hazards models.

RESULTS

Accumulation of childhood adversities had a quantitatively small effect on type 1 diabetes risk among females [adjusted hazard ratio (HR) per adversity increase: 1.07; 95% confidence interval (CI): 1.02-1.11], but not among males (adjusted HR per adversity increase: 0.99; 95% CI: 0.97-1.03). Females exposed to extreme numbers (7+) of adversities had two times higher risk of type 1 diabetes compared with unexposed females (adjusted HR: 2.06; 95% CI: 1.10-3.86).

CONCLUSIONS

In an unselected total population sample, we generally find no or negligible effects of childhood adversities on type 1 diabetes risk, which may be reassuring to persons with type 1 diabetes who are concerned that personal trauma contributed to their disease. There is a very small group of females exposed to a high degree of adversity who may have a higher risk of type 1 diabetes and this group needs further attention.

Psychological Stress, Intestinal Barrier Dysfunctions, and Autoimmune Disorders: An Overview

Autoimmune disorders (ADs) are multifactorial diseases involving, genetic, epigenetic, and environmental factors characterized by an inappropriate immune response toward self-antigens. In the past decades, there has been a continuous rise in the incidence of ADs, which cannot be explained by genetic factors alone. Influence of psychological stress on the development or the course of autoimmune disorders has been discussed for a long time. Indeed, based on epidemiological studies, stress has been suggested to precede AD occurrence and to exacerbate symptoms. Furthermore, compiling data showed that most of ADs are associated with gastrointestinal symptoms, that is, microbiota dysbiosis, intestinal hyperpermeability, and intestinal inflammation. Interestingly, social stress (acute or chronic, in adult or in neonate) is a well-described intestinal disrupting factor. Taken together, those observations question a potential role of stress-induced defect of the intestinal barrier in the onset and/or the course of ADs. In this review, we aim to present evidences supporting the hypothesis for a role of stress-induced intestinal barrier disruption in the onset and/or the course of ADs. We will mainly focus on autoimmune type 1 diabetes, multiple sclerosis and systemic lupus erythematosus, ADs for which we could find sufficient circumstantial data to support this hypothesis. We excluded gastrointestinal (GI) ADs like coeliac disease to privilege ADs not focused on intestinal disorders to avoid confounding factors. Indeed, GIADs are characterized by antibodies directed against intestinal barrier actors.

Psychological stress and type 1 diabetes mellitus: what is the link?

INTRODUCTION

Type 1 diabetes mellitus (T1DM) is a chronic disease characterized by the destruction of insulin-producing β-cells of the pancreas. The current paradigm in this disease's etiopathogenesis points toward the interplay of genetic and environmental factors. Among the environmental variables, dietary factors, intestinal microbiota, toxins, and psychological stress have been implicated in disease onset. Areas covered: This review aims to investigate the relationship between psychological stress and T1DM by presenting evidence from epidemiological studies, animal models, and to provide the mechanism involved in this association. The literature search was conducted through PubMed to identify studies that investigate the connection between stress and T1DM. Experimental designs, such as case-control, and retrospective and prospective cohorts studies, were included. Expert commentary: A wide array of evidence, ranging from epidemiological to animal models, points toward the role of psychological stressors in T1DM pathogenesis. Various mechanisms have been proposed, including the hypothalamic-pituitary-adrenal (HPA) axis, influence of the nervous system on immune cells, and insulin resistance. Further research could investigate the gene-stress interactions to evaluate the risk of T1DM development.

The role of stress in the mosaic of autoimmunity: An overlooked association

Stress is defined as the pscyophysiological reaction in which the steady state is disturbed or threatened. Stress is not always perceived as a negative response. Stress results when environmental demands exceed an individuals' adaptive capacities. Autoimmune diseases are heterogeneous group of chronic diseases which occur secondary to loss of self antigen tolerance. The etiopathogenesis of autoimmune disease is uncertain. Genetic factors as well as environmental factors appear to interplay, leading to a cascade of events resulting in disease onset. Stress has been postulated to play a role in disease onset in the genetically susceptible patients. During the stress response, catecholamines and glucocorticoids are released from locus coeruleus and adrenal gland. These biomolecules exert control over various immune cells in the innate and adaptive arms of the immune system, thereby altering the cytokine profile released. The increase of IL-4 promotes T-helper 2 (T_h2) cell differentiation, while the decrease in IL-12 and the increased IL-10 production reduce the number of T-helper 1 (T_h1) cells. The relationship between stress and autoimmune diseases is intricate. Stress has been shown to be associated with disease onset, and disease exacerbations in rheumatoid arthritis, systemic lupus erythematosus, inflammatory bowel disease, multiple sclerosis, Graves' disease as well as other autoimmune conditions. In certain conditions such as psoriasis, stress has been implicated in delaying lesion clearance upon the application of standard treatment regimes. Finally, psychological therapy and cognitive behavioral therapy aimed to reduce stress levels was shown to be effective in influencing better outcomes in many autoimmune diseases. The purpose of this paper is to closer inspect the clinical evidence regarding the role of stress on influencing the various aspects of disease entities.

Influence of early-life parental severe life events on the risk of type 1 diabetes in children: the DiPiS study

AIMS

Stress and severe life events (SLEs) modify autoimmune disease susceptibility. Here, we aimed to establish if SLEs reported by parents during the first 2 years of life influence the risk of developing type 1 diabetes (T1D) using data from the prospective Diabetes Prediction in Skåne (DiPiS) study.

METHODS

Prospective questionnaire data recorded at 2 months (n = 23,187) and 2 years of age (n = 3784) from the DiPiS cohort of children were included in the analysis. SLEs were analyzed both by groups and as a combined variable. A Cox proportional hazards model was used to calculate hazard ratios (HRs) for T1D diagnosis for the total cohort and for the HLA-DQ2/8 high-risk population. Affected first-degree relatives, HLA-DQ risk group, paternal education level, and parents' country of birth were included as covariates.

RESULTS

There was a significantly increased risk of T1D in children with SLEs occurring during the child's first 2 years of life for both the total cohort (HR 1.67; 95% CI 1.1, 2.7; p = 0.03) and the DQ2/8 cohort (HR 2.2; 95% CI 1.1, 4.2; p = 0.018). Subgroup analysis of events related to unemployment, divorce, or family conflict showed a significant hazard for these events occurring both during and after pregnancy in the DQ2/8 cohort (HR 2.17; 95% CI 1.1, 4.3; p = 0.03 and HR 4.98; 95% CI 2.3, 11; p < 0.001, respectively) and after pregnancy in the total cohort (multiple regression HR 2.07; 95% CI 1.01, 4.2; p = 0.047).

CONCLUSIONS

Children of parents experiencing an SLE during the child's first 2 years of life were at increased risk of T1D. Further studies including those measuring immune and stress-related biomarkers are necessary to validate the findings.

Depression differed by midnight cortisol secretion, alexithymia and anxiety between diabetes types: a cross sectional comparison

BACKGROUND

Increased prevalence of depression is found in both type 2 diabetes (T2D) and type 1 diabetes (T1D). Melancholia and atypical depression differ by cortisol secretion and clinical features. The aim was to compare the clinical presentation of T1D and T2D patients in relation to self-reported depression, self-reported anxiety, alexithymia, obesity, and midnight salivary cortisol (MSC).

METHODS

Comparative cross-sectional design. The participants were consecutively recruited from one hospital diabetes outpatient clinic: 24 T2D patients (31-59 years) and 148 T1D patients (32-59 years). Self-reported depression, anxiety and alexithymia were assessed by Hospital Anxiety and Depression scale and Toronto Alexithymia Scale-20. MSC, HbA1c, anthropometrics and data from medical records were collected. Multiple logistic regression analyses were performed.

RESULTS

Comparisons of prevalence between diabetes types showed for T2D/T1D: depression 25%/12% (P = 0.10); high MSC (≥9.3 nmol/L) 38%/22% (P = 0.13); alexithymia 25%/13% (P = 0.12); anxiety 38%/35% (P = 0.82). The prevalence of high MSC did not differ between depressed and non-depressed T2D patients (17% vs. 44%, P = 0.35), but differed between depressed and non-depressed T1D patients (53% vs. 18%, P = 0.003). The alexithymia prevalence differed between depressed and non-depressed T2D patients (67% vs.11%, P = 0.018), and between depressed and non-depressed T1D patients (47% vs. 11%, P < 0.001). The anxiety prevalence did not differ between depressed and non-depressed T2D patients (67% vs. 28%, P = 0.15), but differed between depressed and non-depressed T1D patients (76% vs. 30%, P < 0.001). The obesity prevalence (BMI ≥30 kg/m²) was 83% for depressed T2D patients and 6% for depressed T1D patients. In the T2D patients, depression was associated with alexithymia (Adjusted odds ratio (AOR) 15.0). In the T1D patients, depression was associated with anxiety (AOR 11.0), foot complications (AOR 8.5), HbA1C >70 mmol/mol (AOR 6.4), and high MSC (≥9.3 nmol/L) (AOR 4.8).

CONCLUSIONS

The depressed T2D patients had traits of atypical depression, without associated high MSC (≥9.3 nmol/L) and anxiety, but the association with alexithymia was strong. The depressed T1D patients had traits of melancholia with associated high MSC and anxiety. The obesity prevalence was high in depressed T2D patients and low in depressed T1D patients.

Serious life events and the risk of latent autoimmune diabetes in adults (LADA) and Type 2 diabetes

AIM

It has been suggested that experiencing serious life events may promote Type 1 diabetes in children. Studies in adults are lacking, as are studies on the interaction of life events with genetic factors. We aimed to investigate life events and the risk of latent autoimmune diabetes in adults (LADA) and Type 2 diabetes while taking into account HLA genotype.

METHODS

Analysis was based on 425 incident cases of LADA, 1417 incident cases of Type 2 diabetes and 1702 population-based controls recruited in Sweden between 2010 and 2016. Self-reported information on life events including conflicts, divorce, illness/accidents, death and financial problems experienced during the 5 years preceding diagnosis/index year was used. Odds ratios (ORs) and 95% confidence intervals (95% CI) were calculated by logistic regression and adjusted for age, sex, BMI, family history of diabetes, smoking, physical activity and education.

RESULTS

Overall there was no association between experience of any life event and either LADA (OR 0.86, 95% CI 0.68-1.08) or Type 2 diabetes (OR 1.00, 95% CI 0.83-1.21). The results were similar for individual events as well as in separate analysis of men and women. Similar results were seen in more autoimmune LADA (glutamic acid decarboxylase antibodies > median) [OR (any life event) 0.88, 95% CI 0.64-1.21] and in LADA carriers of the high-risk HLADR4-DQ8 genotype (OR 0.89, 95% CI 0.61-1.29).

CONCLUSIONS

Our findings indicate that experience of a serious life event, including the death of a family member, divorce or financial problems, is not associated with an increased risk of LADA, overall or in genetically susceptible individuals.

Labor market consequences of childhood onset type 1 diabetes

This paper examines the effect of the onset of Type 1 Diabetes Mellitus (T1DM) before 15 years of age on labor market outcomes and contributes to the literature on effects of childhood health on adult socioeconomic status. Using national Swedish socioeconomic register data 1991-2010 for 2485 individuals born 1972-1978 with onset of T1DM in 1977-1993, we find that T1DM in childhood has a negative effect on labor market outcomes later in life. Part of the T1DM effect is channeled through occupational field which may be related to both choice and opportunities. Although the magnitude of the effect is only directly generalizable to illnesses with similar attributes as T1DM, the results suggest that causality in the often observed correlation between health and socioeconomic status, at least partly, is explained by an effect running from health to earnings. This has implications for research and policy on strategies to reduce socioeconomic-related health inequality. Our findings also shed light on productivity losses, measured by employment status and earnings due to childhood onset T1DM, which have implications for both the individual and society.

Childhood adversity and adult health: Evaluating intervening mechanisms

Substantial evidence has accumulated supporting a causal link between childhood adversity and risk for poor health years and even decades later. One interpretation of this evidence is that this linkage arises largely or exclusively from a process of biological embedding that is not modifiable by subsequent social context or experience - implying childhood as perhaps the only point at which intervention efforts are likely to be effective. This paper considers the extent to which this long-term association arises from intervening differences in social context and/or environmental experiences - a finding that would suggest that post-childhood prevention efforts may also be effective. Based on the argument that the selected research definition of adult health status may have implications for the early adversity-adult health linkage, we use a representative community sample of black and white adults (N = 1252) to evaluate this relationship across three health indices: doctor diagnosed illnesses, self-rated health, and allostatic load. Results generally indicate that observed relationships between childhood adversity and dimensions of adult health status were totally or almost totally accounted for by variations in adult socioeconomic position (SEP) and adult stress exposure. One exception is the childhood SEP-allostatic load association, for which a statistically significant relationship remained in the context of adult stress and SEP. This lone finding supports a conclusion that the impact of childhood adversity is not always redeemable by subsequent experience. However, in general, analyses suggest the likely utility of interventions beyond childhood aimed at reducing exposure to social stress and improving social and economic standing. Whatever the effects on adult health that derive from biological embedding, they appear to be primarily indirect effects through adult social context and exposure.

Enterovirus and type 1 diabetes: What is the matter?

A complex interaction of genetic and environmental factors can trigger the immune-mediated mechanism responsible for type 1 diabetes mellitus (T1DM) establishment. Environmental factors may initiate and possibly sustain, accelerate, or retard damage to β-cells. The role of environmental factors in this process has been exhaustive studied and viruses are among the most probable ones, especially enteroviruses. Improvements in enterovirus detection methods and randomized studies with patient follow-up have confirmed the importance of human enterovirus in the pathogenesis of T1DM. The genetic risk of T1DM and particular innate and acquired immune responses to enterovirus infection contribute to a tolerance to T1DM-related autoantigens. However, the frequency, mechanisms, and pathways of virally induced autoimmunity and β-cell destruction in T1DM remain to be determined. It is difficult to investigate the role of enterovirus infection in T1DM because of several concomitant mechanisms by which the virus damages pancreatic β-cells, which, consequently, may lead to T1DM establishment. Advances in molecular and genomic studies may facilitate the identification of pathways at earlier stages of autoimmunity when preventive and therapeutic approaches may be more effective.

Experience of a serious life event increases the risk for childhood type 1 diabetes: the ABIS population-based prospective cohort study

AIMS/HYPOTHESIS

The aim of this study was to prospectively investigate whether psychological stress during childhood may be a risk factor for manifest type 1 diabetes.

METHODS

The All Babies In Southeast Sweden (ABIS) study invited all families with babies born between 1 October 1997 and 30 September 1999 in southeast Sweden to participate. Our study subsample includes 10,495 participants in at least one of the data collections at 2-3, 5-6, 8 and 10-13 years of age not yet diagnosed with type 1 diabetes at inclusion; 58 children were subsequently diagnosed. Age at diagnosis was obtained from the national register SweDiabKids in 2012. Family psychological stress was measured via questionnaires given to the parents assessing serious life events, parenting stress, parental worries and the parent's social support.

RESULTS

Childhood experience of a serious life event was associated with a higher risk of future diagnosis of type 1 diabetes (HR 3.0 [95% CI 1.6, 5.6], p = 0.001) after adjusting for heredity of type 1 diabetes and age at entry into the study. The result was still valid when controlling for heredity of type 2 diabetes, size for gestational age, the parents' education level and whether the mother worked at least 50% of full time before the child's birth (HR 2.8 [95% CI 1.5, 5.4], p = 0.002), and also when childhood BMI was added to the model (HR 5.0 [95% CI 2.3, 10.7], p < 0.001).

CONCLUSIONS/INTERPRETATION

This first prospective study concluded that experience of a serious life event in childhood may be a risk factor for manifest type 1 diabetes.

The role of Toll-like receptors and vitamin D in diabetes mellitus type 1--a review

It is widely accepted that type 1 diabetes mellitus (T1DM) is an autoimmune disease resulting from an interaction between immunologic, genetic and environmental factors. However, the exact mechanism leading to the development of T1DM remains incomplete. There is a large body of evidence pointing towards the important role of toll-like receptor (TLR) activation and vitamin D deficiency in T1DM pathogenesis. In this article, we review the available data on the influence of TLRs' level of activation and vitamin D status on the risk of the development of T1DM in humans and rodent models. We also summarize the current information regarding the interactions between TLRs' level of activation, vitamin D status and various environmental factors, such as enteroviral infections, the gut microbiota and breastfeeding substitution, among others. Our results stipulate that vitamin D seems to protect against T1DM by reducing the TLRs' level of activation.

Epigenetic regulation of the placental HSD11B2 barrier and its role as a critical regulator of fetal development

"Fetal programming" is a term used to describe how early-life experience influences fetal development and later disease risk. In humans, prenatal stress-induced fetal programming is associated with increased risk of preterm birth, and a heightened risk of metabolic and neurological diseases later in life. A critical determinant of this is the regulation of fetal exposure to glucocorticoids by the placenta. Glucocorticoids are the mediators through which maternal stress influences fetal development. Excessive fetal glucocorticoid exposure during pregnancy results in low birth weight and abnormalities in a number of tissues. The amount of fetal exposure to maternal glucocorticoids depends on the expression of HSD11B2, an enzyme predominantly produced by the syncytiotrophoblast in the placenta. This protects the fetus by converting active glucocorticoids into inactive forms. In this review we examine recent findings regarding placental HSD11B2 that suggest that its epigenetic regulation may mechanistically link maternal stress and long-term health consequences in affected offspring.

Influence of lifestyle on the course of type 1 diabetes mellitus

Type 1 diabetes (T1DM) is an autoimmune disease that requires insulin treatment from the time of diagnosis. Its clinical course depends on both genetic and environmental factors, and the lifestyle of a patient modulates their interaction. The evidence about the influence of lifestyle on the course of T1DM is increasing. In this paper, we present evidence on the relationship between lifestyle parameters and diabetes-related outcomes. We discuss the most commonly addressed factors associated with lifestyle, such as physical activity, nutrition and smoking, and those with sparse evidence in T1DM, such as socioeconomic status, sleep duration, psychological stress and illicit drugs intake.

Psychological stress in children may alter the immune response

Psychological stress is a public health issue even in children and has been associated with a number of immunological diseases. The aim of this study was to examine the relationship between psychological stress and immune response in healthy children, with special focus on autoimmunity. In this study, psychological stress was based on a composite measure of stress in the family across the domains: 1) serious life events, 2) parenting stress, 3) lack of social support, and 4) parental worries. PBMCs, collected from 5-y-old high-stressed children (n = 26) and from 5-y-old children without high stress within the family (n = 52), from the All Babies In Southeast Sweden cohort, were stimulated with Ags (tetanus toxoid and β-lactoglobulin) and diabetes-related autoantigens (glutamic acid decarboxylase 65, insulin, heat shock protein 60, and tyrosine phosphatase). Immune markers (cytokines and chemokines), clinical parameters (C-peptide, proinsulin, glucose), and cortisol, as an indicator of stress, were analyzed. Children from families with high psychological stress showed a low spontaneous immune activity (IL-5, IL-10, IL-13, IL-17, CCL2, CCL3, and CXCL10; p < 0.01) but an increased immune response to tetanus toxoid, β-lactoglobulin, and the autoantigens glutamic acid decarboxylase 65, heat shock protein 60, and tyrosine phosphatase (IL-5, IL-6, IL-10, IL-13, IL-17, IFN-γ, TNF-α, CCL2, CCL3, and CXCL10; p < 0.05). Children within the high-stress group showed high level of cortisol, but low level of C-peptide, compared with the control group (p < 0.05). This supports the hypothesis that psychological stress may contribute to an imbalance in the immune response but also to a pathological effect on the insulin-producing β cells.

Disease history and medication use as risk factors for the clinical manifestation of type 1 diabetes in children and young adults: an explorative case control study

Background

There is a highly variable asymptomatic period of beta cell destruction prior to the clinical presentation of type1 diabetes. It is not well known what triggers type 1 diabetes to become a clinically overt disease. This explorative study aimed to identify the association between disease history/medication use and the clinical manifestation of type 1 diabetes.

Methodology/Principal Findings

An explorative case control study was conducted in the Dutch PHARMO Record Linkage System. Cases (n  = 1,107) were younger than 25 years and had at least 2 insulin prescriptions between 1999 and 2009. For each case, up to 4 controls (without any prescription for the glucose lowering medications (n  = 4,424)) were matched by age and sex. Conditional logistic regression analysis was used to evaluate the association between disease history/medication use in the year prior to the diagnosis of type1 diabetes and clinical manifestation of this disease. Type1 diabetes was significantly associated with a history of mental disorder (odds ratio (OR) 8.0, 95% confidence interval (CI) 1.5–43.7), anemia (OR 5.1, 95% CI 1.1–22.9), and disease of digestive system (OR 2.6, 95% CI 1.2–5.5). The following drug exposures were significantly associated with the clinical manifestation of type 1 diabetes: “systemic hormonal preparations” (OR 1.7, 95% CI 1.1–2.6), medications for “blood and blood forming organs” (OR 1.6, 95% CI 1.1–2.6), “alimentary tract and metabolism” (OR 1.3, 95% CI 1.1–1.6), and “anti-infectives for systemic use” (OR 1.2, 95% CI 1.01–1.4).

Conclusions

Our explorative study demonstrated that in the year prior to the presentation of type1 diabetes in children and young adults, hospitalization for a diverse group of diseases and drug exposures were significantly more prevalent compared with age- and sex-matched diabetes-free controls.

Relationship between Ljungan virus antibodies, HLA-DQ8, and insulin autoantibodies in newly diagnosed type 1 diabetes children

Environmental factors, including viral infections, may explain an increasing and fluctuating incidence of childhood type 1 diabetes (T1D). Ljungan virus (LV) isolated from bank voles have been implicated, but it is unclear whether LV contributes to islet autoimmunity, progression to clinical onset, or both, of T1D. The aim was to test whether LV antibodies (LVAb) were related to HLA-DQ and islet autoantibodies in newly diagnosed T1D patients (n=676) and controls (n=309). Patients, 0-18 years of age, diagnosed with T1D in 1996-2005 were analyzed for LVAb, HLA-DQ genotypes, and all seven known islet autoantibodies (GADA, IA-2A, IAA, ICA, ZnT8RA, ZnT8WA, and ZnT8QA). LVAb at 75(th) percentile, defined as cut off, was 90 (range 6-3936) U/mL and 4(th) quartile LVAb were found in 25% (170/676) of which 64% were <10 (n=108, p<0.0001), and 27% were<5 (n=45; p<0.0001) years old. The 4(th) quartile LVAb in children <10 years of age correlated to HLA DQ2/8, 8/8, and 8/X (p<0.0001). Furthermore, in the group with 4(th) quartile LVAb, 55% were IAA positive (p=0.01) and correlation was found between 4(th) quartile LVAb and IAA in children <10 years of age (p=0.035). It is concluded that 1) LVAb were common among the young T1D patients and LVAb levels were higher in the younger age groups; 2) 4(th) quartile LVAb correlated with IAA; and 3) there was a correlation between 4(th) quartile LVAb and HLA-DQ8, particularly in the young patients. The presence of LVAb supports the notion that prior exposure to LV may be associated with T1D.

Family psychological stress early in life and development of type 1 diabetes: the ABIS prospective study

AIMS

This study investigated whether psychological stress in the family during the child's first year of life are associated with the risk of childhood type 1 diabetes (T1D). According to the beta-cell stress hypothesis all factors that increase the need for, or the resistance to, insulin may be regarded as risk factors for T1D.

METHODS

Among 8921 children from the general population with questionnaire data from one parent at child's birth and at 1 year of age, 42 cases of T1D were identified up to 11-13 years of age. Additionally 15 cases with multiple diabetes-related autoantibodies were detected in a sub-sample of 2649 children.

RESULTS

Cox regression analyses showed no significant associations between serious life events (hazard ratio 0.7 for yes vs. no [95% CI 0.2-1.9], p=0.47), parenting stress (0.9 per scale score [0.5-1.7], p=0.79), or parental dissatisfaction (0.6 per scale score [0.3-1.2], p=0.13) during the first year of life and later diagnosis of T1D, after controlling for socioeconomic, demographic, and diabetes-related factors. Inclusion of children with multiple autoantibodies did not alter the results.

CONCLUSIONS

No association between psychological stress early in life and development of T1D could be confirmed.

Increase in the incidence of type 1 diabetes in Israeli children following the Second Lebanon War

BACKGROUND

Type 1 diabetes is an autoimmune disease occurring in genetically susceptible individuals. The precipitating cause is unclear. Recently, the Second Lebanon War exposed a large civilian population in northern Israel to significant psychological stress in the form of repeated barrages of missile attacks.

HYPOTHESIS

We hypothesized that trends in regional incidence of type 1 diabetes before and after the war would reflect an association with stress.

METHODS

All type 1 diabetes patients aged 0-17 yr who were reported to the Israel Juvenile Diabetes Register (n = 1822) in the four pre-war (2002-2005) and two post-war years (2006-2007) were included in the study. The patients were stratified by gender, age, ethnicity, family history of type 1 diabetes, season at diagnosis, and region of residency, namely, those who lived in the northern regions that were attacked and those in other regions.

RESULTS

The post-war incidence of type 1 diabetes was increased in the northern regions (rate ratio, RR = 1.27; p = 0.037), with no change in the other regions. This change was more prominent in males (RR = 1.55; p = 0.005) but similar in summer and winter, in different ages, and in different ethnic groups. There was no change in the proportion of new patients with a family history of the disease.

CONCLUSIONS

For the first time in a large population, we found a positive association between the trauma of war and an increase in the incidence of type 1 diabetes in children and adolescents. The increase in incidence was not associated with genetic susceptibility to the disease.

Pyridoxal 5'-phosphate (PLP) deficiency might contribute to the onset of type I diabetes

The incidence of type I diabetes is rising worldwide, particularly in young children. Type I diabetes is considered a multifactorial disease with genetic predisposition and environmental factors participating. Currently, despite years of research, there is no consensus regarding the factors that initiate the autoimmune response. Type I diabetes is preceded by autoimmunity to islet antigens, among them the protein glutamic acid decarboxylase, GAD-65. Pyridoxal 5'-phosphate (PLP) is formed from vitamin B6 by the action of pyridoxal kinase. Interaction of GAD65 with PLP is necessary for GAD65-mediated synthesis of the neurotransmitter γ-aminobutyric acid (GABA). PLP is also a required cofactor for dopamine synthesis by L-aromatic decarboxylase (L-AADC). Both GAD65 and L-AADC are expressed in pancreatic islets. Here it is proposed that lack of the vitamin B6 derivative pyridoxal 5'-phosphate might contribute to the appearance of pancreatic islet autoimmunity and type I diabetes onset.

Environmental factors associated with childhood-onset type 1 diabetes mellitus: an exploration of the hygiene and overload hypotheses

OBJECTIVE

To assess the relationship between selected maternal and infant characteristics and risk of type 1 diabetes mellitus, specifically characteristics identified from birth records that may pertain to the hygiene or overload hypotheses.

DESIGN

Population-based case-control study.

SETTING

Washington State from 1987 to 2005.

PARTICIPANTS

All children younger than 19 years hospitalized for type 1 diabetes (International Classification of Diseases, Ninth Revision codes 250.x1 and 250.x3) identified (n=1852) from hospital discharge data and linked with their birth certificates. Controls (n=7408) were randomly selected from birth records, frequency matched on year of birth.

MAIN EXPOSURES

Maternal factors included age, race, educational attainment, marital status, use of Medicaid insurance, body mass index, prepregnancy weight, prior births, timing and adequacy of prenatal care, and cesarean delivery. Infant factors included birth weight, size for gestational age, and gestational age.

MAIN OUTCOME MEASURE

The main outcome was first hospitalization for type 1 diabetes mellitus; adjusted odds ratios were estimated for the association of selected maternal and infant characteristics with type 1 diabetes.

RESULTS

Consistent with the hygiene hypothesis, type 1 diabetes was negatively associated with having older siblings (for >or=3 siblings, odds ratio [OR], 0.56; 95% confidence interval [CI], 0.45-0.70) and with indicators of lower economic status or care access, such as an unmarried mother (OR, 0.79; 95% CI, 0.69-0.91), inadequate prenatal care (OR, 0.53; 95% CI, 0.40-0.71), or Medicaid insurance (OR, 0.67; 95% CI, 0.58-0.77). Related to the overload hypothesis, maternal body mass index of 30 or higher (OR, 1.29; 95% CI, 1.01-1.64) was associated with increased risk of diabetes.

CONCLUSION

Environmental factors related to decreased antigenic stimulation in early life and maternal obesity may be associated with type 1 diabetes.

Psychological stress as a factor potentially contributing to the pathogenesis of Type 1 diabetes mellitus

Diabetes mellitus Type 1 (T1D) is an autoimmune disorder attributed to both genetic and environmental factors. The aim of this study was to identify certain stressful conditions potentially associated with the pathogenesis and/or expression of T1D. The study group included 107 children with diabetes (CD) and 153 controls of comparable age and gender distribution at diagnosis of T1D (10.73+/-3.62 yr vs 9.59 +/-3.42 yr, respectively). The parents of both groups completed a questionnaire on socioeconomic status and stressful life events or adverse situations at home and school.

RESULTS

Lower social class was more prevalent among the mothers of CD (p=0.002) in comparison with the controls. Stressful life events (parental death, divorce, parental job loss), problems at home (parental abuse, parental dispute) and at school (poor performance) were more frequently observed in the CD group than in the controls (parental death: p=0.05, job loss: p=0.05, parental abuse: p=0.002, quarrels between parents: p=0.05, and among siblings p=0.002, poor school performance: p=0.037). A stepwise logistic regression analysis indicated that lower maternal social class [odds ratio (OR): 3.86, 95% confidence interval (CI): 1.37,10.9], parental dispute or divorce (OR: 2.78, 95%CI: 0.97,7.95), body mass index (OR: 0.87, 95%CI: 0.78,0.97), increasing age (OR: 1.14, 95%CI: 1.02,1.27) were the factors potentially influencing the occurrence of T1D, while the 2-yr period prior to diabetes occurrence emerged as the most important one (OR: 2.49, 95%CI: 1.14,5.42).

CONCLUSION

Children with diabetes seem to experience certain stressful conditions with significantly increased frequency compared to controls, especially during the 2 yr preceding the diagnosis of T1D, with a higher clustering in those of lower social class. The resultant stress possibly contributes to the development of T1D in genetically susceptible individuals.

Early infant feeding and risk of type 1 diabetes mellitus-a nationwide population-based case-control study in pre-school children

BACKGROUND

The evidence on the role of environmental factors in the development of type 1 diabetes is conflicting. Reducing potential bias and the variety of exposures, we investigated the association between type 1 diabetes risk and nutritional and environmental exposures in pre-school children.

METHODS

This nationwide population-based case-control study included 760 cases under 5 years of age newly diagnosed with type 1 diabetes during 1992-1995. From the general population, 1,871 controls were randomly selected and individually matched on age ( +/- 1 year), sex, and residence. Information on infant diet, foetal, perinatal and socio-economic factors, and familial diabetes was obtained by a parent-administered questionnaire. Data were analysed by multiple conditional logistic regression.

RESULTS

Duration of breastfeeding and age at introduction of bottle-feeding were inversely associated with type 1 diabetes risk according to a dose-response relationship (trend test p < 0.05). Adjusted odd ratios (95% CI) for a long breastfeeding period and a late introduction of bottle-feeding (>or=5 month versus < 2 weeks) were 0.71 (0.54-0.93) and 0.80 (0.62-1.04), respectively. Familial type 1 diabetes, maternal age > 40 years, and low birth weight were found more frequently among diabetic than among control children. Current cow's milk consumption, higher social status, and a larger family were associated with a reduced diabetes risk. Up to one half of the diabetic cases in the population could be attributed to modifiable exposures.

CONCLUSIONS

Our findings indicate that infant feeding is associated with type 1 diabetes risk and that a considerable part of new type 1 diabetic cases is potentially preventable.

The Environmental Determinants of Diabetes in the Young (TEDDY) study: study design

The primary objective of this multicenter, multinational, epidemiological study is the identification of infectious agents, dietary factors, or other environmental exposures that are associated with increased risk of autoimmunity and type 1 diabetes mellitus (T1DM). Factors affecting specific phenotypic manifestations such as early age of onset or rate of progression or with protection from the development of T1DM will also be identified. The Environmental Determinants of Diabetes in the Young (TEDDY) is an observational cohort study in which newborns who are younger than 4 months and have high-risk human leukocyte antigen alleles in the general population or are first-degree relatives (FDRs) of patients affected with T1DM will be enrolled. Six clinical centers in the USA and Europe will screen 361,588 newborns, of which it is anticipated that 17,804 will be eligible for enrollment with just over 7,800 followed. Recruitment will occur over 5 yr, with children being followed to the age of 15 yr. Identification of such factors will lead to a better understanding of disease pathogenesis and result in new strategies to prevent, delay, or reverse T1DM.

Life events and their impact on bladder control in children

OBJECTIVE

To investigate the relationship between incidence and nature of life events within families and age of bladder control acquisition in healthy children.

SUBJECTS AND METHODS

Thirty-five parents of 36, 6-year-old children were interviewed using the Coddington life events questionnaire.

RESULTS

The children had experienced a total of 185 life events (mean 5, median 4.5, range 1-12) before the time of dryness. The most common were related to childcare/occupation of parent (51%), illness/injury/death (24%), family composition (16%) and living conditions (9%). There was a strong correlation between the number of life events and the age of dryness; the more life events and the older the child was when experiencing them, the later the child became dry. The only single event that was significantly associated with a later age of dryness was the birth of a sister or brother. In general, children had reacted positively (39%) or neutrally, but to 30% of events there was a negative reaction. There was a correlation between the reaction of the child and adaptation to the life event, and if the child had difficulty adapting to an event, that child became day dry at a later age.

CONCLUSION

Although life events are a natural part of daily life, this study supports the conclusion that a large number of events and events to which the child has difficulty adapting can be of importance for the age of acquisition of bladder control.

Stressful life events and psychological dysfunctions before the onset of type 1 diabetes mellitus

AIM

To test the hypothesis that stressful life events and psychological dysfunction increase the risk for development of type 1 diabetes mellitus (DM1).

METHOD

A case-control study comprising 105 children with DM1 and 210 controls matched by age +/- 1 year), sex and place of residence. Conditional univariate and multivariate logistic regressions were used to analyze the data.

RESULTS

After adjustment for possible confounders, the following factors were positively related to DM1: parents' job-related issues changed or lost job (odds ratio [OR] 11.5, 95% confidence interval [CI] 1.6-81.8); other severe life events--severe accident, hospitalization or death of close friend, quarrels between parents, war in republics of former Yugoslavia, near-drowning in a pool, falling down, unhurt participant of an accident (OR 68.5, 95% CI 13.5-349.0); other minor life events--conflicts with parents/teacher/neighbors, lost in town, physical attack, failure in competition, penalty, examination, death of pet, presence at lightning strike, thrown out of dwelling (OR 32.7, 95% CI 6.3-169.6); and learning problems (OR 17.5, 95% CI 4.3-71.6).

CONCLUSION

These results support the hypothesis that stressful life events and psychological dysfunctions are associated with DM1.

Cord Blood Islet Autoantibodies Are Related to Stress in the Mother during Pregnancy

A 2-month psychological questionnaire concerning pregnancy was answered by 20,920 nondiabetic mothers of singletons. Retrospective analysis showed increased levels of islet autoantibodies (IA) in 290 (1.4%) newborns. High IA levels in the child's cord blood correlated strongly with IA levels in the mother (GADA r = 0.91, P < 0.0001; IA-2A r = 0.75, P = 0.0001). High IA levels were found in newborns whose mothers during pregnancy had been more worried than usual (P = 0.04), had worried that the child would be sick (P = 0.01) or not survive (P = 0.002), or had experienced serious life events, like "serious accident in the family" (P < 0.0001) or "experienced violence" (P = 0.02). Associations with increased worries by the mother remained in newborns with high type 1 diabetes mellitus (T1DM)-human leukocyte antigen (HLA) risk, but not in non-HLA risk children. The prospective follow-up of these children will determine the importance of this early IA for postnatal islet autoimmunity, type 1 diabetes, or both.

Environmental factors in the development of Type 1 diabetes

Environmental factors appear to play an important role in the pathogenesis of childhood-onset type 1 diabetes (T1D). The most important factors are thought to be infectious, dietary, perinatal, and psychosocial. Enteroviruses (especially Coxsackie B virus), breastfeeding, the early presence or lack of certain foods, birth weight, childhood over-nutrition, maternal islet autoimmunity, and negative stress events have been shown to be related to the prevalence of T1D. However, clear conclusions to date are limited because most studies lacked power to detect exposure/disease associations, were not prospective or long-term, did not start in infancy, had imprecise or infrequent exposure estimates, had confounding exposures, and failed to account for genetic susceptibility. In addition to the identification of specific antigenic triggers, several more general hypotheses, including the accelerator and hygiene hypotheses, are testable approaches worth pursuing.

The Belgrade childhood diabetes study - comparison of children with type 1 diabetes with their siblings

A case-control study was conducted in Belgrade (about 320,000 inhabitants 0-16 years old) during the period 1994-97, comprising 68 diabetic children (cases) and 68 controls chosen from the siblings of the cases. Analysis using multivariable logistic regression analysis indicated the following independent risk factors for Type 1 diabetes: higher birth order, infections during the 6 months preceding the onset of the disease and stressful events. Out of individual stressful and psychological factors, 'other' stressful events (severe accident or hospitalisation or death of a close friend, conflict with a teacher, death of a pet, failure in competition, quarrel between parents, punishment, physical attack, war in republics of former Yugoslavia and near drowning in the pool) and learning problems were independent risk factor for Type 1 diabetes. The results obtained in this study of siblings supports the hypothesis that environmental factors play a role in the development of Type 1 diabetes.

Psychological stress and the risk of diabetes-related autoimmunity: a review article

The beta cell stress hypothesis suggests that any phenomenon that induces insulin resistance, and thereby extra pressure on the beta cells, should be regarded as a risk factor for type 1 diabetes (T1D). Psychological stress decreases insulin sensitivity and increases insulin resistance and may hence be important in the development/onset of T1D. The aim of the current review article was to evaluate existing empirical evidence concerning an association between psychological stress and development/onset of T1D as well as diabetes-related autoimmunity. Ten retrospective case-control studies were found. Nine studies showed a positive association between stress and development/onset of T1D in children, adolescents or adults. One study did not find an association between stress and development/onset of T1D. An association between stress and diabetes-related autoimmunity was found at 1 and 2-3 years of age in a large epidemiological study of the general population. The hypothesis that psychological stress (via beta cell stress or direct influence on the immune system) may contribute to the induction or progression of diabetes-related autoimmunity has gained some strong initial support, but is in need of further empirical verification. It seems much clearer that stress can precipitate manifest T1D, although the biological mechanisms are still not known.

Can we slow the rising incidence of childhood-onset autoimmune diabetes? The overload hypothesis

Overload of the beta cell, mediated by a variety of mechanisms, may sensitise it to immune damage and apoptosis, and thus accelerate ongoing autoimmune processes leading to its destruction. Environmental risk determinants that may exert such overload effects include insulin resistance due to excess fat cell accumulation, and increased insulin requirement due to a high growth rate, physical stress (infection, inflammation) or psychological stress. The increasing incidence of childhood diabetes, and the shift to younger age at onset, is unlikely to be driven by environmental risk factors that have been associated with initiation of autoimmunity, e.g. virus infections or early infant feeding. Risk factors that may accelerate beta cell destruction have shown a steady increase in the population, and are more plausible causes of such a pattern of change. Child growth, weight and birthweight are well-established estimates of community wealth and increase in most countries of Europe. Overfeeding of children early in life leads to both accelerated growth and weight, and even a moderate excess of child growth, not necessarily associated with obesity, is associated with risk of type 1 diabetes. New, safe and effective immune-modulating drugs for possible arrest of the autoimmune process may become available in time, but in the interim these accelerating factors may be targeted. Public health programmes for pregnant mothers and young families, aiming at changing overfeeding and the sedentary lifestyle of the children would be preferable to other alternatives. Interventions such as these would be safe and could potentially influence future risks of type 1 and type 2 diabetes and other major threats to adult health.

Mothers' experiences of serious life events increase the risk of diabetes-related autoimmunity in their children

OBJECTIVE

Stressful life events have been shown to constitute a risk factor for type 1 diabetes during childhood. Our aim was to investigate in the general child population (i.e., irrespective of genetic risk for type 1 diabetes) whether mothers' experiences of serious life events, such as divorce and violence, were associated with diabetes-related autoimmunity in their children at age 2.5 years.

RESEARCH DESIGN AND METHODS

The study cohort was comprised of the first 5,986 consecutive children and their families from the prospective population-based All Babies in Southeast Sweden project for whom 2.5-year study data were available. Data were drawn from parental questionnaires that included questions about experiences of serious life events and the blood samples taken from the children when the children were age 2.5 years. The blood samples were analyzed for diabetes-related autoantibodies against tyrosine phosphatase and GAD.

RESULTS

Mothers' experiences of divorce (odds ratio 3.6, 95% CI 1.4-9.6, P < 0.05) and violence (2.9, 1.0-7.8, P < 0.05) were associated with diabetes-related autoimmunity in the children, independent of a family history of type 1 diabetes.

CONCLUSIONS

The results support the beta-cell stress hypothesis and suggest that maternal experiences of serious life events such as divorce and violence seem to be involved in the induction or progression of diabetes-related autoimmunity in children at age 2.5 years, independent of family history of type 1 diabetes.

Hospitalization because of diabetes and bereavement: a national cohort study of parents who lost a child

AIMS

To examine whether parents who lost a child have an increased risk of hospitalization because of Type 1 or Type 2 diabetes.

METHODS

We identified all parents who lost a child in Denmark from 1980 to 1996 (stress exposed), and compared them with parents randomly selected from all other parents in the country at that time without such a bereavement. Fifteen non-bereaved families were matched to each bereaved family for family size and the age of the children. First hospitalizations for Type 1 or Type 2 diabetes were monitored in these two groups up to 18 years after the bereavement. There were 21 062 parents in the bereaved cohort and 293 745 parents in the non-bereaved cohort. The study was based upon linkage of several national registers, and first-time hospitalization with diabetes (Type 1 or Type 2) was the end point.

RESULTS

Five hundred and fifty-one cases were hospitalized because of Type 1 diabetes and 1569 cases because of Type 2 diabetes. There was a 29% higher risk of hospitalization because of Type 1 diabetes [95% CI -5 to 75%; corresponding to a relative risk (RR) of 1.29; 95% CI 0.95-1.75] and a 44% higher risk of hospitalization because of Type 2 diabetes (95% CI 21-71%; corresponding to an RR of 1.44; 95% CI 1.21-1.71) in the bereaved cohort. The high risk of hospitalization because of Type 2 diabetes following bereavement was only statistically significant for mothers.

CONCLUSIONS

Psychological stress may be a contributing cause of, or have prognostic importance for, both Type 1 and Type 2 diabetes, but a statistically significant association was only seen for Type 2 diabetes.

Mothers' attachment insecurity and diabetes-related autoantibodies in their infants

Psychological stress may, via hormonal levels, increase insulin resistance. The aim of this study was to investigate whether mothers' attachment insecurity is associated with the induction or progression of diabetes-related autoimmunity in early childhood. Adult attachment interviews were conducted with 18 mothers of infants who were positive, and 32 mothers of infants who were negative, for glutamic acid decarboxylase, selected from ABIS, a large prospective population-based project. The proportion of children with insecure mothers was larger, but not significantly so, in the autoantibody-positive group than in the negative group. If an association exists between maternal attachment insecurity and diabetes-related autoimmunity during infancy, it does not appear to be strong.

A new model for understanding the role of environmental factors in the origins of chronic illness: a case study of type 1 diabetes mellitus

There is a need for a new pathophysiological model explaining and linking the role of numerous non-genetic factors believed to contribute to origins of many chronic physical diseases. This article presents a theoretical model for explaining the confusing and often contradictory findings regarding the role of environmental influences in type 1 diabetes, a disease that has been widely studied, for which clear diagnostic criteria exist, and for which development of effective prevention strategies represents significant challenges. The model is formulated from the large database of research regarding increasing understanding of the interaction between environmental factors, physiology, and autonomic regulatory function. Data is integrated from research in the fields of the experience-dependent maturation of the nervous system and the neurophysiology of traumatic stress to demonstrate how disruptions in early bonding and attachment, including adverse events such as traumatic stress, are capable of causing: (1) long-term imbalances in autonomic regulatory function and (2) relative dominance of sympathetic or parasympathetic activity. The proposed model of autonomic dysfunction suggests that ongoing mechanisms promoting high glucose in the context of decreasing insulin production in type 1 diabetes represent a state of relative sympathetic dominance influenced by environmental factors affecting autonomic, immune and endocrine systems during critical period programming. The model further identifies a link between the many seemingly unrelated non-genetic risk factors, and appears capable of explaining contradictions and enigmas in epidemiological and clinical studies regarding non-genetic origins of type 1 diabetes, including the role of stress, variation in age of onset, and duration of the preclinical phase.

Psychological stress may induce diabetes-related autoimmunity in infancy

OBJECTIVE

In retrospective studies, a number of disparate environmental factors (including experiences of serious life events) have been proposed as trigger mechanisms for type 1 diabetes or the autoimmune process behind the disease. Psychosocial stress in families may affect children negatively due to a link to hormonal levels and nervous signals that in turn influence both insulin sensitivity/insulin need and the immune system. Our aim was to investigate whether psychological stress, measured as psychosocial strain in families, is associated with diabetes-related autoimmunity during infancy.

RESEARCH DESIGN AND METHODS

The first 4,400 consecutive 1-year-old children from a large prospective population-based project participated in the study. Parents completed questionnaires at birth and at 1 year, including various measures of psychosocial stress (e.g., parenting stress) and sociodemographic background. Blood samples drawn from the children at 1 year were analyzed for type 1 diabetes-associated autoantibodies toward tyrosine phosphatase and GAD. Antibodies toward tetanus toxoid were used as non-diabetes-related control antibodies.

RESULTS

Psychosocial factors, i.e., high parenting stress (odds ratio 1.8 [95% CI 1.2-2.9], P < 0.01), experiences of a serious life event (2.3 [1.3-4.0], P < 0.01), foreign origin of the mother (2.1 [1.3-3.3], P < 0.001), and low paternal education (1.6 [1.1-2.3], P < 0.01) were associated with diabetes-related autoimmunity in the child, independent of family history of diabetes.

CONCLUSIONS

Psychological stress, measured as psychosocial strain in the family, seems to be involved in the induction, or progression, of diabetes-related autoimmunity in the child during the 1st year of life.

Socio-economic characteristics in children with coeliac disease

AIM

To study the relationship between socio-economic factors and coeliac disease.

METHODS

This study was part of a prospective cohort study of 16 286 children born from 1 October 1997-1 October 1999 (the ABIS study; All Babies in Southeast Sweden). Eight paediatric departments recorded all children with coeliac disease in southeast Sweden. Coeliac disease was confirmed through biopsy. Socio-economic characteristics (maternal employment, civil status, whether parents were born in Sweden, parental education, place of living before pregnancy and during pregnancy, crowded living), infant sex, previous siblings, parental age and maternal alcohol consumption during pregnancy were analysed using logistic regression. All data, except for those related to diagnosis of coeliac disease, were obtained through a questionnaire distributed at birth.

RESULTS

Coeliac disease in the offspring was less common among mothers who had worked < 3 mo during pregnancy (odds ratio, OR = 0.29; 95% CI: 0.09-0.94; p = 0.039). This risk decrease remained after adjustment for confounders (adjusted OR = 0.28; 95% CI: 0.09-0.92; p = 0.035). No other socio-economic factor was related to coeliac disease.

CONCLUSION

This study indicates that most socio-economic factors are probably of little importance to the development of coeliac disease.

Use of healthcare resources, family function, and socioeconomic support during the first four years after preterm birth

OBJECTIVES

To assess the use of healthcare resources for preterm infants and to evaluate family function and socioeconomic support in a defined population from birth to 4 years of age.

METHODS

In a prospective case-control study, 39 singleton preterm infants without prenatal abnormalities born during an 18 month period were studied together with their families. The population consisted of 19 very preterm infants (less than 32 weeks) and 20 randomised moderate preterm infants (32-35 weeks), and the control group comprised 39 full term infants. Contacts with medical services, child health services, and the social welfare system were registered, and family function and life events were studied.

RESULTS

The preterm children were more often readmitted to hospital (odds ratio (OR) 6.6, 95% confidence interval (CI) 2.0 to 22.1) and had more outpatient attendances (OR 5.6, 95% CI 2.1 to 15.0) during their first year of life. Mothers in the preterm group more often used temporary parental allowance than the control mothers (p < 0.001). The number of contacts with the child health services and the social welfare system did not differ significantly from the controls. Neither was there any significant difference with regard to family function or life events at 4 years of age.

CONCLUSIONS

A large proportion of the premature children used specialist care during the first years of life. However, the families of the preterm infants were socially well adapted up to four years after birth compared with the control families.

Influence of smoking and oral contraceptives on bone mineral density and bone remodeling in young women: a 2-year study

The objective of the study was to explore the influence of menstrual irregularities, oral contraceptives and smoking on bone mineral density (BMD) development and bone turnover with time. Healthy young women (n = 118) were divided into four categories: (a) women neither smoking nor using oral contraceptives; (b) women who were smokers; (c) women using oral contraceptives; (d) women who were smoking and using oral contraceptives. They responded to a validated questionnaire with 34 questions concerning lifestyle and the Sense of Coherence scale (SOC). BMD was measured by dual energy x-ray absorptiometry (DEXA). Deoxypyridinoline (DPD) was measured in urine. Data were analyzed by multiple linear regression analysis. Among smokers, BMD level decreased during a 2-year period and smoking was associated with a larger negative change in BMD. Use of oral contraceptives moderated the negative impact of smoking. Women using oral contraceptives at baseline and with regular bleeding induced by contraceptive pills had a significantly higher BMD at baseline and at follow-up. They also had lower SOC than women who had natural regular bleedings. Use of oral contraceptives in combination with smoking was linked to high alcohol consumption and higher frequency of self-reported body weight reduction, which reduced the negative BMD change in this category. DPD level and difference were strongly associated with estrogen influence. It is concluded that smokers without OCs had a negative BMD development and BMD in young women with irregular menstruations seems to be improved by OC.

Modulation of glucocorticoid-induced GAD expression in pancreatic beta-cells by transcriptional activation of the GAD67 promoter and its possible effect on the development of diabetes

GAD is a pancreatic beta-cell autoantigen in humans and nonobese diabetic (NOD) mice. Modulation of GAD expression in pancreatic beta-cells has been suggested to be associated with the development of autoimmune diabetes. Hormonal changes through environmental stimuli are considered to influence the expression of the disease. We determined whether steroid hormones would modulate the expression of GAD in pancreatic beta-cells. We treated NOD mouse beta-cells (MIN6N8a cells) with various steroids, including testosterone, estradiol, progesterone, and cortisol, and examined the expression of GAD67 mRNA. We found that only cortisol enhanced the expression of GAD67, whereas the other steroid hormones had no effect. When we treated MIN6N8a cells with a synthetic glucocorticoid, dexamethasone, we found that GAD67 mRNA expression was stimulated in a dose- and time-dependent manner. Cells treated with 100 nmol/l dexamethasone for 6 h showed a 10-fold increase in the expression of GAD67 mRNA and an increase in GAD67 protein. The upregulation of GAD67 expression in beta-cells by dexamethasone was found to be due to the transcriptional activation of the GAD67 promoter. We then examined whether dexamethasone would influence the development of diabetes in NOD mice. Injection of dexamethasone into neonatal NOD mice resulted in a significant increase in the expression of GAD67 mRNA in pancreatic beta-cells and the development of insulitis and diabetes. We conclude that glucocorticoid hormones can modulate GAD expression by the transcriptional activation of the GAD promoter and may influence the development of autoimmune diabetes in NOD mice.

Family characteristics and life events before the onset of autoimmune type 1 diabetes in young adults: a nationwide study

OBJECTIVE

To elucidate whether family characteristics and stressful life events were associated with onset of autoimmune type 1 diabetes in young adults.

RESEARCH DESIGN AND METHODS

This investigation was based on a nationwide study (Diabetes Incidence Study in Sweden) of newly diagnosed patients aged 15-34 years. Patients clinically classified as type 1 diabetic with antibodies to islet cells and/or to GAD65 were compared with age- and sex-matched control subjects via questionnaire. The questionnaire covered diabetes heredity, social environment, educational level, and life events experienced during the 12 months before diagnosis.

RESULTS

The rate of response was 82% for the diabetic patients and 65% for the control subjects. Questionnaires from 349 diabetic patients and 979 control subjects were considered. Diabetes in relatives was more frequent in the patients (odds ratio [OR]2.6) who were born in Sweden and whose mothers were of Swedish origin. No major stress factors were detected in the diabetic patients; however, in comparison with the control subjects, the diabetic patients had experienced fewer conflicts with their parents and had less often broken contacts with friends.

CONCLUSIONS

Young adults with recent-onset type 1 diabetes were more exposed to heredity for diabetes, but no major prediabetic stress factors were detected. Our study does not directly support the concept that psychosocial stressful life events are involved in the development of autoimmune type 1 diabetes in young adults.

The aetiology of type 1 diabetes: an epidemiological perspective

Type 1 diabetes is increasing rapidly in many parts of the Western world, most evidently in Scandinavia. A low concordance rate of insulin-dependent diabetes mellitus among monozygotic twins clearly indicates that genetic risk factors may be necessary, but are not sufficient for the disease to occur. The strongest genetic risk markers are located in the HLA region of chromosome 6, but these DNA specificities differ in different populations. Risk genes are indicated in other chromosomes of the human genome, suggesting a complex interaction between genes and environment as the cause of the disease. The pathogenesis of the disease is proposed to be autoimmune in nature and environmental risk factors may either initiate autoimmunity or accelerate an already ongoing beta-cell destruction. Risk factors disclosed by epidemiological studies that may accelerate the pathogenetic process are: a cold environment, a high growth rate, infections and stressful life events. Risk factors that may initiate the autoimmune process include early exposure to cow's milk proteins, nitrosamines or early foetal events such as blood group incompatibility or foetal viral infections. In conclusion, population-based epidemiological studies have helped to confirm proposed aetiological models that have arisen from experimental research. These epidemiological studies have also introduced important new findings that may reveal the complex aetiology of the disease and advance understanding closer to the ultimate goal of primary prevention.