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Pramanik S, Mondal S, Palui R, Ray S. Type 2 diabetes in children and adolescents: Exploring the disease heterogeneity and research gaps to optimum management. World J Clin Pediatr 2024; 13:91587. [DOI: 10.5409/wjcp.v13.i2.91587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 04/07/2024] [Accepted: 04/18/2024] [Indexed: 06/07/2024] Open
Abstract
Over the past 20 years, the incidence and prevalence of type 2 diabetes mellitus (T2DM) in children and adolescents have increased, particularly in racial and ethnic minorities. Despite the rise in T2DM in children and adolescents, the pathophysiology and progression of disease in this population are not clearly understood. Youth-onset T2DM has a more adverse clinical course than is seen in those who develop T2DM in adulthood or those with T1DM. Furthermore, the available therapeutic options are more limited for children and adolescents with T2DM compared to adult patients, mostly due to the challenges of implementing clinical studies. A better understanding of the mechanisms underlying the de-velopment and aggressive disease phenotype of T2DM in youth is important to finding effective prevention and management strategies. This review highlights the key evidence about T2DM in children and adolescents and its current burden and challenges both in clinical care and research activities.
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Affiliation(s)
- Subhodip Pramanik
- Department of Endocrinology, Neotia Getwel Healthcare Centre, Siliguri 734010, West Bengal, India
| | - Sunetra Mondal
- Department of Endocrinology, NRS Medical College and Hospital, Kolkata 700014, West Bengal, India
| | - Rajan Palui
- Department of Endocrinology, The Mission Hospital, Durgapur 713212, West Bengal, India
| | - Sayantan Ray
- Department of Endocrinology, All India Institute of Medical Sciences, Bhubaneswar, Bhubaneswar 751019, Odisha, India
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Fan Y, Chow E, Lim CKP, Hou Y, Tsoi STF, Fan B, Lau ESH, Kong APS, Ma RCW, Wu H, Chan JCN, Luk AOY. Comparison of β-Cell Function and Insulin Sensitivity Between Normal-Weight and Obese Chinese With Young-Onset Type 2 Diabetes. Diabetes 2024; 73:953-963. [PMID: 38506952 DOI: 10.2337/db23-0966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 03/17/2024] [Indexed: 03/22/2024]
Abstract
Normal-weight individuals with usual-onset type 2 diabetes have reduced β-cell function and greater insulin sensitivity compared with their obese counterparts. The relative contribution of β-cell dysfunction and insulin resistance to young-onset type 2 diabetes (YOD) among normal-weight individuals is not well established. In 44 individuals with YOD (24 with normal weight and 20 with obesity) and 24 healthy control individuals with normoglycemia (12 with normal weight and 12 with obesity), we conducted 2-h 12 mmol/L hyperglycemic clamps to measure acute (0-10 min) and steady-state (100-120 min) insulin and C-peptide responses, as well as insulin sensitivity index. Normal-weight individuals with YOD had lower acute insulin response, steady-state insulin and C-peptide responses, and a higher insulin sensitivity index compared with their obese counterparts with YOD. Compared with BMI-matched healthy control individuals, normal-weight individuals with YOD had lower acute and steady-state insulin and C-peptide responses but a similar insulin sensitivity index. The impairment of steady-state β-cell response relative to healthy control individuals was more pronounced in normal-weight versus obese individuals with YOD. In conclusion, normal-weight Chinese with YOD exhibited worse β-cell function but preserved insulin sensitivity relative to obese individuals with YOD and BMI-matched healthy individuals with normoglycemia. The selection of glucose-lowering therapy should account for pathophysiological differences underlying YOD between normal-weight and obese individuals. ARTICLE HIGHLIGHTS
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Affiliation(s)
- Yingnan Fan
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, People's Republic of China
| | - Elaine Chow
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, People's Republic of China
- Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, People's Republic of China
- Phase 1 Clinical Trial Centre, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, People's Republic of China
- Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, People's Republic of China
| | - Cadmon K P Lim
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, People's Republic of China
- Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, People's Republic of China
| | - Yong Hou
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, People's Republic of China
| | - Sandra T F Tsoi
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, People's Republic of China
| | - Baoqi Fan
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, People's Republic of China
| | - Eric S H Lau
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, People's Republic of China
| | - Alice P S Kong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, People's Republic of China
- Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, People's Republic of China
- Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, People's Republic of China
| | - Ronald C W Ma
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, People's Republic of China
- Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, People's Republic of China
- Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, People's Republic of China
| | - Hongjiang Wu
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, People's Republic of China
| | - Juliana C N Chan
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, People's Republic of China
- Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, People's Republic of China
- Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, People's Republic of China
| | - Andrea O Y Luk
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, People's Republic of China
- Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, People's Republic of China
- Phase 1 Clinical Trial Centre, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, People's Republic of China
- Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, People's Republic of China
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Marcovecchio ML, Hendriks AEJ, Delfin C, Battelino T, Danne T, Evans ML, Johannesen J, Kaur S, Knip M, Overbergh L, Pociot F, Todd JA, Van der Schueren B, Wicker LS, Peakman M, Mathieu C. The INNODIA Type 1 Diabetes Natural History Study: a European cohort of newly diagnosed children, adolescents and adults. Diabetologia 2024; 67:995-1008. [PMID: 38517484 PMCID: PMC11058619 DOI: 10.1007/s00125-024-06124-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 01/24/2024] [Indexed: 03/24/2024]
Abstract
AIMS/HYPOTHESIS Type 1 diabetes is an heterogenous condition. Characterising factors explaining differences in an individual's clinical course and treatment response will have important clinical and research implications. Our aim was to explore type 1 diabetes heterogeneity, as assessed by clinical characteristics, autoantibodies, beta cell function and glycaemic outcomes, during the first 12 months from diagnosis, and how it relates to age at diagnosis. METHODS Data were collected from the large INNODIA cohort of individuals (aged 1.0-45.0 years) newly diagnosed with type 1 diabetes, followed 3 monthly, to assess clinical characteristics, C-peptide, HbA1c and diabetes-associated antibodies, and their changes, during the first 12 months from diagnosis, across three age groups: <10 years; 10-17 years; and ≥18 years. RESULTS The study population included 649 individuals (57.3% male; age 12.1±8.3 years), 96.9% of whom were positive for one or more diabetes-related antibodies. Baseline (IQR) fasting C-peptide was 242.0 (139.0-382.0) pmol/l (AUC 749.3 [466.2-1106.1] pmol/l × min), with levels increasing with age (p<0.001). Over time, C-peptide remained lower in participants aged <10 years but it declined in all age groups. In parallel, glucose levels progressively increased. Lower baseline fasting C-peptide, BMI SD score and presence of diabetic ketoacidosis at diagnosis were associated with lower stimulated C-peptide over time. HbA1c decreased during the first 3 months (p<0.001), whereas insulin requirement increased from 3 months post diagnosis (p<0.001). CONCLUSIONS/INTERPRETATION In this large cohort with newly diagnosed type 1 diabetes, we identified age-related differences in clinical and biochemical variables. Of note, C-peptide was lower in younger children but there were no main age differences in its rate of decline.
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Affiliation(s)
- M Loredana Marcovecchio
- Department of Paediatrics, University of Cambridge, Cambridge, UK.
- Department of Paediatric Diabetes and Endocrinology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
| | - A Emile J Hendriks
- Department of Paediatrics, University of Cambridge, Cambridge, UK
- Department of Paediatric Diabetes and Endocrinology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Carl Delfin
- Department of Pharmacometrics, Novo Nordisk A/S, Søborg, Denmark
| | - Tadej Battelino
- Department of Endocrinology, Diabetes and Metabolism, University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Thomas Danne
- Centre for Paediatric Endocrinology, Diabetology, and Clinical Research, Auf Der Bult Children's Hospital, Hannover, Germany
| | - Mark L Evans
- Wellcome MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Jesper Johannesen
- Translational Type 1 Diabetes Research, Clinical Research, Steno Diabetes Center Copenhagen, Herlev, Denmark
- Department of Paediatrics, Copenhagen University Hospital, Herlev, Denmark; Institute of Health and Medical Sciences, University of Copenhagen, Herlev, Denmark
| | - Simranjeet Kaur
- Translational Type 1 Diabetes Research, Clinical Research, Steno Diabetes Center Copenhagen, Herlev, Denmark
- Department of Paediatrics, Copenhagen University Hospital, Herlev, Denmark; Institute of Health and Medical Sciences, University of Copenhagen, Herlev, Denmark
| | - Mikael Knip
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Pediatric Research Center, New Children's Hospital, Helsinki University Hospital, Helsinki, Finland
| | - Lut Overbergh
- Clinical and Experimental Endocrinology, Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Flemming Pociot
- Translational Type 1 Diabetes Research, Clinical Research, Steno Diabetes Center Copenhagen, Herlev, Denmark
- Department of Paediatrics, Copenhagen University Hospital, Herlev, Denmark; Institute of Health and Medical Sciences, University of Copenhagen, Herlev, Denmark
| | - John A Todd
- Centre for Human Genetics, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Bart Van der Schueren
- Clinical and Experimental Endocrinology, Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Linda S Wicker
- Centre for Human Genetics, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Mark Peakman
- Immunology & Inflammation Research Therapeutic Area, Sanofi, MA, USA
| | - Chantal Mathieu
- Clinical and Experimental Endocrinology, Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
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Thomas NJ, Jones AG. The challenges of identifying and studying type 1 diabetes in adults. Diabetologia 2023; 66:2200-2212. [PMID: 37728732 PMCID: PMC10628058 DOI: 10.1007/s00125-023-06004-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 07/14/2023] [Indexed: 09/21/2023]
Abstract
Diagnosing type 1 diabetes in adults is difficult since type 2 diabetes is the predominant diabetes type, particularly with an older age of onset (approximately >30 years). Misclassification of type 1 diabetes in adults is therefore common and will impact both individual patient management and the reported features of clinically classified cohorts. In this article, we discuss the challenges associated with correctly identifying adult-onset type 1 diabetes and the implications of these challenges for clinical practice and research. We discuss how many of the reported differences in the characteristics of autoimmune/type 1 diabetes with increasing age of diagnosis are likely explained by the inadvertent study of mixed populations with and without autoimmune aetiology diabetes. We show that when type 1 diabetes is defined by high-specificity methods, clinical presentation, islet-autoantibody positivity, genetic predisposition and progression of C-peptide loss remain broadly similar and severe at all ages and are unaffected by onset age within adults. Recent clinical guidance recommends routine islet-autoantibody testing when type 1 diabetes is clinically suspected or in the context of rapid progression to insulin therapy after a diagnosis of type 2 diabetes. In this moderate or high prior-probability setting, a positive islet-autoantibody test will usually confirm autoimmune aetiology (type 1 diabetes). We argue that islet-autoantibody testing of those with apparent type 2 diabetes should not be routinely undertaken as, in this low prior-prevalence setting, the positive predictive value of a single-positive islet antibody for autoimmune aetiology diabetes will be modest. When studying diabetes, extremely high-specificity approaches are needed to identify autoimmune diabetes in adults, with the optimal approach depending on the research question. We believe that until these recommendations are widely adopted by researchers, the true phenotype of late-onset type 1 diabetes will remain largely misunderstood.
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Affiliation(s)
- Nicholas J Thomas
- Department of Clinical and Biological Sciences, University of Exeter, Exeter, UK
- Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | - Angus G Jones
- Department of Clinical and Biological Sciences, University of Exeter, Exeter, UK.
- Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK.
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Misra S, Ke C, Srinivasan S, Goyal A, Nyriyenda MJ, Florez JC, Khunti K, Magliano DJ, Luk A. Current insights and emerging trends in early-onset type 2 diabetes. Lancet Diabetes Endocrinol 2023; 11:768-782. [PMID: 37708901 DOI: 10.1016/s2213-8587(23)00225-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 07/01/2023] [Accepted: 07/19/2023] [Indexed: 09/16/2023]
Abstract
Type 2 diabetes diagnosed in childhood or early adulthood is termed early-onset type 2 diabetes. Cases of early-onset type 2 diabetes are increasing rapidly globally, alongside rising obesity. Compared with a diagnosis later in life, an earlier-onset diagnosis carries an unexplained excess risk of microvascular complications, adverse cardiovascular outcomes, and earlier death. Women with early-onset type 2 diabetes also have a higher risk of adverse pregnancy outcomes. The high burden of complications renders individuals with early-onset type 2 diabetes at future risk of multimorbidity and interventions to reverse these concerning trends should be a priority. Within the early-onset cohort, disease pathophysiology and interventions have been better studied in paediatric-onset (<19 years) type 2 diabetes compared to adults; however, young adults aged 19-39 years (a larger number proportionally) are not well characterised and are also invisible in the current evidence base supporting management, which is derived from trials in later-onset type 2 diabetes. Young adults with type 2 diabetes face challenges in self-management that older individuals are less likely to experience (being in education or of working age, higher diabetes distress, and possible obesity-related stigma and diabetes-related stigma). There is a major research gap as to the optimal strategies to deploy in managing type 2 diabetes in adolescents and young adults, given that current models of care appear to not work as well in this age group. In the face of manifold risk factors (obesity, female sex, social deprivation, non-White European ethnicity, and genetic risk factors) prevention strategies with tailored lifestyle interventions, where needed, are likely to have greater success, but more evidence is needed. In this Review, we draw on evidence from both adolescents and young adults to provide a contemporary update on the current insights and emerging trends in early-onset type 2 diabetes.
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Affiliation(s)
- Shivani Misra
- Division of Metabolism, Digestion and Reproduction, Imperial College London, London, UK; Department of Diabetes and Endocrinology, Imperial College Healthcare NHS Trust, London, UK.
| | - Calvin Ke
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Medicine, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Shylaja Srinivasan
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, University of California at San Francisco, San Francisco, CA, USA
| | - Alpesh Goyal
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
| | - Moffat J Nyriyenda
- Medical Research Council-Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine, Uganda Research Unit, Entebbe, Uganda; London School of Hygiene and Tropical Medicine, London, UK
| | - Jose C Florez
- Diabetes Unit and Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA; Programs in Metabolism and Medical and Population Genetics, Broad Institute, Cambridge, MA, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Kamlesh Khunti
- Diabetes Research Centre, Leicester General Hospital, University of Leicester, Leicester, UK
| | - Dianna J Magliano
- Baker Heart and Diabetes Institute, Melbourne, Australia; School of Public Health and Prevention, Monash University Melbourne, Melbourne, Australia
| | - Andrea Luk
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
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Vidmar AP, Durazo-Arvizu R, Weigensberg MJ, Alderete TL, Goran MI. Rapid Decline in β-Cell Function and Increasing Adiposity Are Associated With Conversion to Type 2 Diabetes in At-Risk Latino Youth. Diabetes 2023; 72:735-745. [PMID: 36972018 PMCID: PMC10202769 DOI: 10.2337/db22-1034] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 03/22/2023] [Indexed: 04/16/2023]
Abstract
Youth-onset type 2 diabetes (T2D) is becoming increasingly prevalent, especially among Latino youth, and there is limited information on its pathophysiology and causative factors. Here, we describe findings from a longitudinal cohort study in 262 Latino children with overweight/obesity at risk of developing T2D with annual measures of oral and intravenous glucose tolerance (IVGTT), body composition, and fat distribution. Logistic binomial regression was used to identify significant predictors in those who developed T2D compared with matched control participants, and mixed-effects growth models were used to compare rates of change in metabolic versus adiposity measures between groups. Overall conversion rate to T2D at year 5 was 2% (n = 6). Rate of decline in disposition index (DI), measured with an IVGTT, over 5 years was three times higher in case patients (-341.7 units per year) compared with the extended cohort (-106.7 units per year) and 20 times higher compared with control participants (-15.2 units per year). Case patients had significantly higher annual increases in fasting glucose, hemoglobin A1c (HbA1c), waist circumference, and trunk fat, and there was an inverse correlation between rate of decline in DI and rates of increase in adiposity measures. T2D development in at-risk Latino youth is associated with a substantial and rapid decrease in DI that is directly correlated with increases in fasting glucose, HbA1c, and adiposity. ARTICLE HIGHLIGHTS Youth-onset type 2 diabetes is becoming increasingly prevalent, especially among Latino youth, and there is limited information on its pathophysiology and causative factors. Overall conversion rate to type 2 diabetes over 5 years was 2%. In youth who converted to type 2 diabetes, disposition index decreased rapidly by 85% compared with that in patients who did not convert during the study period. There was an inverse correlation between rate of decline in disposition index and rates of increase in various adiposity measures.
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Affiliation(s)
- Alaina P. Vidmar
- Division of Endocrinology, Department of Pediatrics, Saban Research Institute, Children’s Hospital Los Angeles, Los Angeles, CA
- Department of Pediatrics, Keck School of Medicine, Los Angeles, CA
| | - Ramon Durazo-Arvizu
- Southern California Clinical and Translational Science Institute Biostatistics Core, The Saban Research Institute, Children’s Hospital Los Angeles, Los Angeles, CA
| | - Marc J. Weigensberg
- Department of Pediatrics, University of Southern California, Los Angeles, CA
| | - Tanya L. Alderete
- Department of Integrative Physiology, University of Colorado Boulder, Boulder, CO
| | - Michael I. Goran
- Division of Endocrinology, Department of Pediatrics, Saban Research Institute, Children’s Hospital Los Angeles, Los Angeles, CA
- Department of Pediatrics, Keck School of Medicine, Los Angeles, CA
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Novac CN, Mihai DA, Boboc AA, Platica C, Nemuc A, Radulian G. Changes in C-Peptide Values in Children with Type 1 Diabetes - a Three-Year Study. MAEDICA 2023; 18:182-189. [PMID: 37588842 PMCID: PMC10427091 DOI: 10.26574/maedica.2023.18.2.182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
Background: C-peptide is used as an important indicator of residual insulin secretion in patients diagnosed with type 1 diabetes mellitus (T1DM) and treated with insulin. Aim:We have aimed to monitor the serum C-peptide (CP) levels during the first three years after diagnosis of T1DM in a cohort of children admitted to the Diabetes Department of "M. S. Curie" Emergency Clinical Hospital for Children, Bucharest, Romania, and to investigate the factors that could influence the rate of decline in its secretion. Method:We conducted a longitudinal, retrospective cohort study on a group of 215 children and adolescents who met the inclusion criteria and were monitored in our clinic over the course of a long period of time. We analyzed several parameters, including fasting serum CP values at diagnosis and yearly throughout T1DM evolution, the severity of diabetic ketoacidosis (DKA) at onset, HbA1c at diagnosis, family history of T1DM/T2DM, patient gender and presence of concurrent acute infectious disease at diagnosis, with the purpose of evaluating their influence on the preservation of endogenous insulin secretion. Based on serum CP value measured three years after T1DM onset, patients were divided into two groups: group 1, with low insulin residual secretion (CP < 0.6 ng/mL), and group 2, with preserved insulin residual secretion (CP ≥0.6 ng/mL) Results:At the moment of diagnosis, patients in group 1 were younger than those in group 2 (6.03 ± 3.54 years and 9.76 ± 2.75 years, respectively). The proportion of children with diabetic ketoacidosis (DKA) at onset was greater in group 1 (68% of patients) than group 2, in which the majority of subjects (60%) did not have DKA. The C-peptide value at diagnosis was significantly lower (0.55 ± 0.36 ng/mL) among patients in group 1 than those in group 2 (1.11 ± 0.59 ng/mL). In group 1 there was a higher proportion of patients (65%) with acute infectious disease at onset. Family history of T1DM/T2DM was associated with a more rapid decline in CP values. Our data showed no correlation between CP levels monitored for three years and HbA1c at diagnosis and no association with the gender of each patient. Conclusion:Patients with higher CP concentrations at diagnosis maintained increased values (> 0.6 ng/mL) three years after disease onset. Younger children had a faster decline of CP secretion during the first three years following diabetes diagnosis. In patients with severe symptoms (DKA) and associated infectious disease at onset, a risk of rapid CP decline was found.
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Affiliation(s)
| | - Doina-Andrada Mihai
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
- "Prof. Dr. N. Paulescu" National Institute of Diabetes, Nutrition and Metabolic Diseases, Bucharest, Romania
| | - Anca Andreea Boboc
- "M. S. Curie" Emergency Clinical Hospital for Children, Bucharest, Romania
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Cristina Platica
- "M. S. Curie" Emergency Clinical Hospital for Children, Bucharest, Romania
| | - Anca Nemuc
- INOE National Institute of Research and Development for Optoelectronics, Magurele, Romania
| | - Gabriela Radulian
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
- "Prof. Dr. N. Paulescu" National Institute of Diabetes, Nutrition and Metabolic Diseases, Bucharest, Romania
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Redondo MJ, van Raalte DH. Age Ain't Nothing But a Number . . . or Is It? Diabetes Care 2023; 46:1135-1136. [PMID: 37220267 PMCID: PMC10234734 DOI: 10.2337/dci23-0013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Affiliation(s)
- Maria J. Redondo
- Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX
| | - Daniël H. van Raalte
- Department of Endocrinology and Metabolism, Amsterdam University Medical Centers, VU University Medical Center, Amsterdam, the Netherlands
- Diabetes Center, Amsterdam University Medical Centers, VU University Medical Center, Amsterdam, the Netherlands
- Research Institute for Cardiovascular Sciences, VU University, Amsterdam, the Netherlands
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Ginnard OZB, Redondo MJ, Lyons SK. Diabetes of Unclear Type in an Adolescent Boy With Multiple Islet-cell Autoantibody Positivity Successfully Managed With Glucagon-like Peptide-1 Receptor Agonist Alone: A Case Report. Can J Diabetes 2023; 47:90-93. [PMID: 36075851 PMCID: PMC10024250 DOI: 10.1016/j.jcjd.2022.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 07/06/2022] [Accepted: 07/20/2022] [Indexed: 01/31/2023]
Abstract
Diabetes classification has traditionally considered type 1 and type 2 diabetes as 2 separate entities with different pathogenic mechanisms. However, clinicians and researchers see increasingly more exceptions to this conventional paradigm, leading to a concept of mixed phenotypes in diabetes classification. Herein we report the case of an adolescent with unclear diabetes type due to the presence of obesity, robust endogenous insulin production, multiple islet autoantibody positivity and severe hyperglycemia at diabetes diagnosis that has been successfully treated with liraglutide therapy alone. Our case report highlights the difficulty of diabetes classification and subsequent need for personalized medicine with regard to diabetes management.
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Affiliation(s)
- Olivia Z B Ginnard
- Section of Diabetes and Endocrinology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, United States.
| | - Maria J Redondo
- Section of Diabetes and Endocrinology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, United States
| | - Sarah K Lyons
- Section of Diabetes and Endocrinology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, United States
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Eason RJ, Thomas NJ, Hill AV, Knight BA, Carr A, Hattersley AT, McDonald TJ, Shields BM, Jones AG. Routine Islet Autoantibody Testing in Clinically Diagnosed Adult-Onset Type 1 Diabetes Can Help Identify Misclassification and the Possibility of Successful Insulin Cessation. Diabetes Care 2022; 45:2844-2851. [PMID: 36205650 DOI: 10.2337/dc22-0623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 08/23/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Recent joint American Diabetes Association and European Association for the Study of Diabetes guidelines recommend routine islet autoantibody testing in all adults newly diagnosed with type 1 diabetes. We aimed to assess the impact of routine islet autoantibody testing in this population. RESEARCH DESIGN AND METHODS We prospectively assessed the relationship between islet autoantibody status (GADA, IA-2A, and ZNT8A), clinical and genetic characteristics, and progression (annual change in urine C-peptide-to-creatinine ratio [UCPCR]) in 722 adults (≥18 years old at diagnosis) with clinically diagnosed type 1 diabetes and diabetes duration <12 months. We also evaluated changes in treatment and glycemia over 2 years after informing participants and their clinicians of autoantibody results. RESULTS Of 722 participants diagnosed with type 1 diabetes, 24.8% (179) were autoantibody negative. This group had genetic and C-peptide characteristics suggestive of a high prevalence of nonautoimmune diabetes: lower mean type 1 diabetes genetic risk score (islet autoantibody negative vs. positive: 10.85 vs. 13.09 [P < 0.001] [type 2 diabetes 10.12]) and lower annual change in C-peptide (UCPCR), -24% vs. -43% (P < 0.001).After median 24 months of follow-up, treatment change occurred in 36.6% (60 of 164) of autoantibody-negative participants: 22.6% (37 of 164) discontinued insulin, with HbA1c similar to that of participants continuing insulin (57.5 vs. 60.8 mmol/mol [7.4 vs. 7.7%], P = 0.4), and 14.0% (23 of 164) added adjuvant agents to insulin. CONCLUSIONS In adult-onset clinically diagnosed type 1 diabetes, negative islet autoantibodies should prompt careful consideration of other diabetes subtypes. When routinely measured, negative antibodies are associated with successful insulin cessation. These findings support recent recommendations for routine islet autoantibody assessment in adult-onset type 1 diabetes.
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Affiliation(s)
- Russell J Eason
- University of Exeter College of Medicine & Health, Exeter, U.K.,Royal Devon University Healthcare NHS Foundation Trust, Exeter, U.K
| | - Nicholas J Thomas
- University of Exeter College of Medicine & Health, Exeter, U.K.,Royal Devon University Healthcare NHS Foundation Trust, Exeter, U.K
| | - Anita V Hill
- Royal Devon University Healthcare NHS Foundation Trust, Exeter, U.K
| | - Bridget A Knight
- University of Exeter College of Medicine & Health, Exeter, U.K.,Royal Devon University Healthcare NHS Foundation Trust, Exeter, U.K
| | - Alice Carr
- University of Exeter College of Medicine & Health, Exeter, U.K
| | - Andrew T Hattersley
- University of Exeter College of Medicine & Health, Exeter, U.K.,Royal Devon University Healthcare NHS Foundation Trust, Exeter, U.K
| | - Timothy J McDonald
- University of Exeter College of Medicine & Health, Exeter, U.K.,Royal Devon University Healthcare NHS Foundation Trust, Exeter, U.K
| | | | - Angus G Jones
- University of Exeter College of Medicine & Health, Exeter, U.K.,Royal Devon University Healthcare NHS Foundation Trust, Exeter, U.K
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11
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Grönberg A, Espes D, Carlsson PO, Ludvigsson J. Higher risk of severe hypoglycemia in children and adolescents with a rapid loss of C-peptide during the first 6 years after type 1 diabetes diagnosis. BMJ Open Diabetes Res Care 2022; 10:10/6/e002991. [PMID: 36384886 PMCID: PMC9670837 DOI: 10.1136/bmjdrc-2022-002991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 10/18/2022] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION The progression to insulin deficiency in type 1 diabetes is heterogenous. This study aimed to identify early characteristics associated with rapid or slow decline of beta-cell function and how it affects the clinical course. RESEARCH DESIGN AND METHODS Stimulated C-peptide was assessed by mixed meal tolerance test in 50 children (<18 years) during 2004-2017, at regular intervals for 6 years from type 1 diabetes diagnosis. 40% of the children had a rapid decline of stimulated C-peptide defined as no measurable C-peptide (<0.03 nmol/L) 30 months after diagnosis. RESULTS At diagnosis, higher frequencies of detectable glutamic acid decarboxylase antibodies (GADA) and IA-2A (p=0.027) were associated with rapid loss of beta-cell function. C-peptide was predicted positively by age at 18 months (p=0.017) and 30 months duration (p=0.038). BMI SD scores (BMISDS) at diagnosis predicted higher C-peptide at diagnosis (p=0.006), 3 months (p=0.002), 9 months (p=0.005), 30 months (p=0.022), 3 years (p=0.009), 4 years (p=0.016) and 6 years (p=0.026), whereas high HbA1c and blood glucose at diagnosis predicted a lower C-peptide at diagnosis (p=<0.001) for both comparisons. Both GADA and IA-2A were negative predictors of C-peptide at 9 months (p=0.011), 18 months (p=0.008) and 30 months (p<0.001). Ten children had 22 events of severe hypoglycemia, and they had lower mean C-peptide at 18 months (p=0.025), 30 months (p=0.008) and 6 years (p=0.018) compared with others. Seven of them had a rapid decline of C-peptide (p=0.030), and the odds to experience a severe hypoglycemia were nearly fivefold increased (OR=4.846, p=0.04). CONCLUSIONS Low age and presence of multiple autoantibodies at diagnosis predicts a rapid loss of beta-cell function in children with type 1 diabetes. Low C-peptide is associated with an increased risk of severe hypoglycemia and higher Hemoglobin A1C. A high BMISDS at diagnosis is predictive of remaining beta-cell function during the 6 years of follow-up.
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Affiliation(s)
- Annika Grönberg
- Department of Women's and Children's Health, Uppsala Universitet Institutionen for kvinnors och barns halsa, Uppsala, Sweden
| | - Daniel Espes
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
- Science for Life Laboratory, Department of Medical Cell Biology, Uppsala University, Uppsala, Sweden
| | - Per-Ola Carlsson
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
- Science for Life Laboratory, Department of Medical Cell Biology, Uppsala University, Uppsala, Sweden
| | - Johnny Ludvigsson
- Department of Biomedical and Clinical Scienses, Linkopings Universitet, Linkoping, Sweden
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12
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Abstract
First envisioned by early diabetes clinicians, a person-centred approach to care was an aspirational goal that aimed to match insulin therapy to each individual's unique requirements. In the 100 years since the discovery of insulin, this goal has evolved to include personalised approaches to type 1 diabetes diagnosis, treatment, prevention and prediction. These advances have been facilitated by the recognition of type 1 diabetes as an autoimmune disease and by advances in our understanding of diabetes pathophysiology, genetics and natural history, which have occurred in parallel with advancements in insulin delivery, glucose monitoring and tools for self-management. In this review, we discuss how these personalised approaches have improved diabetes care and how improved understanding of pathogenesis and human biology might inform precision medicine in the future.
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Affiliation(s)
- Alice L J Carr
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK.
| | - Carmella Evans-Molina
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
- Department of Anatomy, Cell Biology, and Physiology, Indiana University School of Medicine, Indianapolis, IN, USA
- Department of Biochemistry and Molecular Biology, Indiana University School of Medicine, Indianapolis, IN, USA
- Center for Diabetes and Metabolic Diseases, Indiana University School of Medicine, Indianapolis, IN, USA
- Herman B. Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, IN, USA
- Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
| | - Richard A Oram
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK.
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13
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Achenbach P, Hippich M, Zapardiel-Gonzalo J, Karges B, Holl RW, Petrera A, Bonifacio E, Ziegler AG. A classification and regression tree analysis identifies subgroups of childhood type 1 diabetes. EBioMedicine 2022; 82:104118. [PMID: 35803018 PMCID: PMC9270253 DOI: 10.1016/j.ebiom.2022.104118] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 06/04/2022] [Accepted: 06/06/2022] [Indexed: 12/22/2022] Open
Abstract
Background Diabetes in childhood and adolescence includes autoimmune and non-autoimmune forms with heterogeneity in clinical and biochemical presentations. An unresolved question is whether there are subtypes, endotypes, or theratypes within these forms of diabetes. Methods The multivariable classification and regression tree (CART) analysis method was used to identify subgroups of diabetes with differing residual C-peptide levels in patients with newly diagnosed diabetes before 20 years of age (n=1192). The robustness of the model was assessed in a confirmation and prognosis cohort (n=2722). Findings The analysis selected age, haemoglobin A1c (HbA1c), and body mass index (BMI) as split parameters that classified patients into seven islet autoantibody-positive and three autoantibody-negative groups. There were substantial differences in genetics, inflammatory markers, diabetes family history, lipids, 25-OH-Vitamin D3, insulin treatment, insulin sensitivity and insulin autoimmunity among the groups, and the method stratified patients with potentially different pathogeneses and prognoses. Interferon-ɣ and/or tumour necrosis factor inflammatory signatures were enriched in the youngest islet autoantibody-positive groups and in patients with the lowest C-peptide values, while higher BMI and type 2 diabetes characteristics were found in older patients. The prognostic relevance was demonstrated by persistent differences in HbA1c at 7 years median follow-up. Interpretation This multivariable analysis revealed subgroups of young patients with diabetes that have potential pathogenetic and therapeutic relevance. Funding The work was supported by funds from the German Federal Ministry of Education and Research (01KX1818; FKZ 01GI0805; DZD e.V.), the Innovative Medicine Initiative 2 Joint Undertaking INNODIA (grant agreement No. 115797), the German Robert Koch Institute, and the German Diabetes Association.
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Affiliation(s)
- Peter Achenbach
- Institute of Diabetes Research, Helmholtz Zentrum München, German Research Center for Environmental Health, Munich-Neuherberg, Germany; German Center for Diabetes Research (DZD), Munich, Germany; Technical University Munich, School of Medicine, Forschergruppe Diabetes at Klinikum rechts der Isar, Munich, Germany
| | - Markus Hippich
- Institute of Diabetes Research, Helmholtz Zentrum München, German Research Center for Environmental Health, Munich-Neuherberg, Germany; German Center for Diabetes Research (DZD), Munich, Germany
| | - Jose Zapardiel-Gonzalo
- Institute of Diabetes Research, Helmholtz Zentrum München, German Research Center for Environmental Health, Munich-Neuherberg, Germany
| | - Beate Karges
- Division of Endocrinology and Diabetes, Medical Faculty, RWTH Aachen University, D 52074 Aachen, Germany
| | - Reinhard W Holl
- German Center for Diabetes Research (DZD), Munich, Germany; Institute of Epidemiology and Medical Biometry, ZIBMT, University of Ulm, D 89081 Ulm, Germany
| | - Agnese Petrera
- Research Unit Protein Science and Metabolomics and Proteomics Core Facility, Helmholtz Zentrum Munich - German Research Center for Environmental Health, Neuherberg, Germany
| | - Ezio Bonifacio
- German Center for Diabetes Research (DZD), Munich, Germany; DFG Center for Regenerative Therapies Dresden, Faculty of Medicine, Technische Universität Dresden, Dresden, Germany; Institute for Diabetes and Obesity, Helmholtz Zentrum München, German Research Center for Environmental Health, Munich-Neuherberg, Germany
| | - Anette-G Ziegler
- Institute of Diabetes Research, Helmholtz Zentrum München, German Research Center for Environmental Health, Munich-Neuherberg, Germany; German Center for Diabetes Research (DZD), Munich, Germany; Technical University Munich, School of Medicine, Forschergruppe Diabetes at Klinikum rechts der Isar, Munich, Germany.
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14
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Carr AL, Inshaw JR, Flaxman CS, Leete P, Wyatt RC, Russell LA, Palmer M, Prasolov D, Worthington T, Hull B, Wicker LS, Dunger DB, Oram RA, Morgan NG, Todd JA, Richardson SJ, Besser RE. Circulating C-Peptide Levels in Living Children and Young People and Pancreatic β-Cell Loss in Pancreas Donors Across Type 1 Diabetes Disease Duration. Diabetes 2022; 71:1591-1596. [PMID: 35499624 PMCID: PMC9233242 DOI: 10.2337/db22-0097] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 04/16/2022] [Indexed: 11/13/2022]
Abstract
C-peptide declines in type 1 diabetes, although many long-duration patients retain low, but detectable levels. Histological analyses confirm that β-cells can remain following type 1 diabetes onset. We explored the trends observed in C-peptide decline in the UK Genetic Resource Investigating Diabetes (UK GRID) cohort (N = 4,079), with β-cell loss in pancreas donors from the network for Pancreatic Organ donors with Diabetes (nPOD) biobank and the Exeter Archival Diabetes Biobank (EADB) (combined N = 235), stratified by recently reported age at diagnosis endotypes (<7, 7-12, ≥13 years) across increasing diabetes durations. The proportion of individuals with detectable C-peptide declined beyond the first year after diagnosis, but this was most marked in the youngest age group (<1-year duration: age <7 years: 18 of 20 [90%], 7-12 years: 107 of 110 [97%], ≥13 years: 58 of 61 [95%] vs. 1-5 years postdiagnosis: <7 years: 172 of 522 [33%], 7-12 years: 604 of 995 [61%], ≥13 years: 225 of 289 [78%]). A similar profile was observed in β-cell loss, with those diagnosed at younger ages experiencing more rapid loss of islets containing insulin-positive (insulin+) β-cells <1 year postdiagnosis: age <7 years: 23 of 26 (88%), 7-12 years: 32 of 33 (97%), ≥13 years: 22 of 25 (88%) vs. 1-5 years postdiagnosis: <7 years: 1 of 12 (8.3%), 7-12 years: 7 of 13 (54%), ≥13 years: 7 of 8 (88%). These data should be considered in the planning and interpretation of intervention trials designed to promote β-cell retention and function.
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Affiliation(s)
- Alice L.J. Carr
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, U.K
- Corresponding authors: Alice Carr, , Rachel Besser, , or Sarah Richardson,
| | - Jamie R.J. Inshaw
- JDRF/Wellcome Diabetes and Inflammation Laboratory, Wellcome Centre for Human Genetics, Nuffield Department of Medicine, University of Oxford, Oxford, U.K
| | - Christine S. Flaxman
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, U.K
| | - Pia Leete
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, U.K
| | - Rebecca C. Wyatt
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, U.K
| | - Lydia A. Russell
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, U.K
| | - Matthew Palmer
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, U.K
| | - Dmytro Prasolov
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, U.K
| | - Thomas Worthington
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, U.K
| | - Bethany Hull
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, U.K
| | - Linda S. Wicker
- JDRF/Wellcome Diabetes and Inflammation Laboratory, Wellcome Centre for Human Genetics, Nuffield Department of Medicine, University of Oxford, Oxford, U.K
| | - David B. Dunger
- Department of Paediatrics, Addenbrooke's Hospital, University of Cambridge, Cambridge, U.K
| | - Richard A. Oram
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, U.K
| | - Noel G. Morgan
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, U.K
| | - John A. Todd
- JDRF/Wellcome Diabetes and Inflammation Laboratory, Wellcome Centre for Human Genetics, Nuffield Department of Medicine, University of Oxford, Oxford, U.K
- National Institute of Health Research (NIHR) Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, U.K
| | - Sarah J. Richardson
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, U.K
- Corresponding authors: Alice Carr, , Rachel Besser, , or Sarah Richardson,
| | - Rachel E.J. Besser
- JDRF/Wellcome Diabetes and Inflammation Laboratory, Wellcome Centre for Human Genetics, Nuffield Department of Medicine, University of Oxford, Oxford, U.K
- National Institute of Health Research (NIHR) Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, U.K
- Corresponding authors: Alice Carr, , Rachel Besser, , or Sarah Richardson,
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15
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Li GH, Huang K, Dong GP, Zhang JW, Gong CX, Luo FH, Luo XP, Wang CL, Zhu M, Li P, Wang L, Fu JF. Clinical Incidence and Characteristics of Newly Diagnosed Type 1 Diabetes in Chinese Children and Adolescents: A Nationwide Registry Study of 34 Medical Centers. Front Pediatr 2022; 10:888370. [PMID: 35783304 PMCID: PMC9242427 DOI: 10.3389/fped.2022.888370] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 04/19/2022] [Indexed: 12/01/2022] Open
Abstract
Objective To investigate the clinical incidence and characteristics of type 1 diabetes mellitus (T1DM) of children and adolescents at the time of initial diagnosis in China. Methods Data on all pediatric patients with newly diagnosed T1DM were retrospectively collected from 34 medical centers in 25 major cities in China from January 2015 to January 2020. Patients were classified into three age groups: <5 years, 5 to <10 years, and ≥10 years of age. The same patient population was also categorized into diabetic ketoacidosis (DKA) and non-DKA groups based on clinical criteria. Results The mean annual clinical incidence of T1DM was 3.16/100,000 from the years 2015 to 2019. A total of 6,544 patients with newly diagnosed T1DM aged 0-16 years (median 7.84 ± 3.8) were studied [ages <5 years (29.3%), 5 to <10 years (38.7%), and ≥10 years (32%)], 52.4% of them were women. In total, 90.5% of the cases were occurred in individuals without a family history. Patients had lower C-peptide (CP) and body mass index (BMI) z scores when compared with healthy children, 41.8% of them had measurable T1DM-related antibodies and 52.7% had DKA. Among all three age groups, the <5 years group had the lowest BMI z score, CP, and glycated hemoglobin (HbA1c) on average, while it had the highest incidence rate of DKA (56.9%). Compared to the non-DKA group, the DKA group was significantly younger, with a lower BMI z score and CP, higher antibody positive rate, HbA1c, and the rate of insulin pump therapy. Conclusion The clinical incidence of T1DM in children and adolescents in China was 3.16/100,000. Patients with DKA at the first diagnosis of T1DM have a worse β-cell function. Public health measures for the prevention and treatment of T1DM should focus on preschoolers (aged <5 years) in particular, considering the severity and the highest frequency of DKA in this age group. More efforts should be dedicated to early screening and diagnosis of the T1DM.
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Affiliation(s)
- Guo-Hua Li
- The Children's Hospital of the Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Ke Huang
- The Children's Hospital of the Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Guan-Ping Dong
- The Children's Hospital of the Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Jian-Wei Zhang
- Department of Pediatrics, Shaoxing Maternal and Child Health Care Hospital, Hangzhou, China
| | - Chun-Xiu Gong
- Endocrinology, Genetics, and Metabolism, Beijing Diabetes Center for Children and Adolescents, Medical Genetics Department, Beijing Children's Hospital, Beijing, China
| | - Fei-Hong Luo
- Department of Pediatric Endocrinology and Inherited Metabolic Diseases, Children's Hospital of Fudan University, Shanghai, China
| | - Xiao-Ping Luo
- Department of Pediatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chun-Lin Wang
- Department of Pediatric, The First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Min Zhu
- Department of Endocrinology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Pin Li
- Department of Endocrinology, Shanghai Children's Hospital of Shanghai Jiao Tong University, Shanghai, China
| | - Ling Wang
- Laboratory for Translational Genetics, Department of Human Genetics, KU Leuven, Leuven, Belgium
| | - Jun-Fen Fu
- The Children's Hospital of the Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
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16
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Shah AS, Nadeau KJ, Dabelea D, Redondo MJ. Spectrum of Phenotypes and Causes of Type 2 Diabetes in Children. Annu Rev Med 2022; 73:501-515. [PMID: 35084995 PMCID: PMC9022328 DOI: 10.1146/annurev-med-042120-012033] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Several factors, including genetics, family history, diet, physical activity, obesity, and insulin resistance in puberty, appear to increase the risk of type 2 diabetes in youth. Youth-onset type 2 diabetes is often thought of as a single entity but rather exists as a spectrum of disease with differences in presentation, metabolic characteristics, clinical progression, and complication rates. We review what is currently known regarding the risks associated with developing type 2 diabetes in youth. Additionally, we focus on the spectrum of phenotypes of pediatric type 2 diabetes, discuss the pathogenic underpinnings and potential therapeutic relevance of this heterogeneity, and compare youth-onset type 2 diabetes with type 1 diabetes and adult-onset type 2 diabetes. Finally, we highlight knowledge gaps in prediction and prevention of youth-onset type 2 diabetes.
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Affiliation(s)
- Amy S. Shah
- Cincinnati Children’s Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio 45229, USA
| | - Kristen J. Nadeau
- Children’s Hospital Colorado and University of Colorado Anschutz Medical Campus, Aurora, Colorado 80045, USA
| | - Dana Dabelea
- Lifecourse Epidemiology of Adiposity and Diabetes (LEAD) Center, Department of Epidemiology, and Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, Colorado 80045, USA
| | - Maria J. Redondo
- Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas 77030, USA
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17
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Chylińska-Frątczak A, Pietrzak I, Michalak A, Wyka K, Szadkowska A. Autoimmune reaction against pancreatic beta cells in children and adolescents with simple obesity. Front Endocrinol (Lausanne) 2022; 13:1061671. [PMID: 36589801 PMCID: PMC9794760 DOI: 10.3389/fendo.2022.1061671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 11/21/2022] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION One of the most important complications of obesity is insulin resistance, which leads to carbohydrate metabolism disorders such as type 2 diabetes. However, obesity is also associated with development of an autoimmune response against various organs, including pancreatic beta cells. The prevalence of such autoimmune processes in children and their possible contribution to the increased incidence of type 1 diabetes is currently unclear. Therefore, the present study assessed the prevalence of autoantibodies against pancreatic islet beta cell's antigens in children and adolescents with simple obesity. MATERIAL AND METHODS This prospective observational study included pediatric patients (up to 18 years of age) with simple obesity hospitalized between 2011 and 2016 at the Department of Pediatrics, Diabetology, Endocrinology and Nephrology of the Medical University of Lodz. Children with acute or chronic conditions that might additionally affect insulin resistance or glucose metabolism were excluded. Collected clinical data included sex, age, sexual maturity ratings (Tanner`s scale), body height and weight, waist and hip circumference, amount of body fat and lean body mass. Each participant underwent a 2-hour oral glucose tolerance test with simultaneous measurements of glycaemia and insulinemia at 0`, 60` and 120`. In addition, glycated hemoglobin HbA1c, fasting and stimulated c-peptide, total cholesterol, as well as high- and low-density cholesterol and triglycerides were measured. Insulin resistance was assessed by calculating HOMA-IR index. The following autoantibodies against pancreatic islet beta cells were determined in each child: ICA - antibodies against cytoplasmic antigens of pancreatic islets, GAD - antibodies against glutamic acid decarboxylase, ZnT8 - antibodies against zinc transporter, IA2 - antibodies against tyrosine phosphatase, IAA - antibodies against insulin. RESULTS The study group included 161 children (57.4% boys, mean age 13.1 ± 2.9 years) with simple obesity (mean BMI z-score +2.2 ± 1.6). Among them, 28 (17.4%) were diagnosed with impaired glucose metabolism during OGTT [23 (82.2%) - isolated impaired glucose tolerance (IGT), 3 (10.7%) - isolated impaired fasting glucose (IFG), 2 (7.1%) - IFG and IGT]. Of the children tested, 28 (17.4%) were tested positive for at least one islet-specific autoantibody [with similar percentages in boys (15, 17.4%) and girls (13, 17.3%), p=0.9855], with ICA being the most common (positive in 18, 11.2%), followed by IAA (7, 4.3%), ZnT8 (5, 3.1%), GADA (3, 1.9%) and IA2 (1, 0.6%). There was no association between the presence of the tested antibodies and age, sex, stage of puberty, parameters assessing the degree of obesity, HbA1c, lipid levels and basal metabolic rate. However, autoantibody-positive subjects were more likely to present IFG or IGT in OGTT compared to those who tested completely negative (9, 32.1% vs 19, 14.3%, p=0.0280). Their HOMA-IR was also significantly higher (HOMA-IR: 4.3 ± 1.9 vs 3.4 ± 1.9, p=0.0203) and this difference remained statistically significant after adjusting for sex and age (p=0.0340). CONCLUSIONS Children and adolescents with simple obesity presented a higher prevalence of markers of autoimmune response against pancreatic beta cells than the general population. Most often, they had only one type of antibody - ICA. The presence of autoimmune response indicators against pancreatic islet antigens is more common in obese patients with impaired carbohydrate metabolism and is associated with lower insulin sensitivity.
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Affiliation(s)
- Aneta Chylińska-Frątczak
- Department of Pediatrics, Endocrinology, Diabetology and Nephrology, Maria Konopnicka University Pediatrics Center, Lodz, Poland
| | - Iwona Pietrzak
- Department of Pediatrics, Diabetology, Endocrinology and Nephrology, Medical University of Lodz, Lodz, Poland
- *Correspondence: Iwona Pietrzak,
| | - Arkadiusz Michalak
- Department of Pediatrics, Diabetology, Endocrinology and Nephrology, Medical University of Lodz, Lodz, Poland
- Department of Biostatistics and Translational Medicine, Medical University of Lodz, Lodz, Poland
| | - Krystyna Wyka
- Department of Pediatrics, Oncology and Hematology, Medical University of Lodz, Lodz, Poland
| | - Agnieszka Szadkowska
- Department of Pediatrics, Diabetology, Endocrinology and Nephrology, Medical University of Lodz, Lodz, Poland
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Shi M, Xie Y, Tang R, Zhong T, Zhou Z, Li X. Three-phasic pattern of C-peptide decline in type 1 diabetes patients with partial remission. Diabetes Metab Res Rev 2021; 37:e3461. [PMID: 33928751 DOI: 10.1002/dmrr.3461] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 03/15/2021] [Accepted: 04/13/2021] [Indexed: 12/12/2022]
Abstract
AIMS To explore the different patterns of C-peptide decline in patients with and without partial remission of newly diagnosed type 1 diabetes (T1D). MATERIALS AND METHODS A total of 298 patients with new-onset T1D were followed up regularly at 3 months' interval to investigate the loss of C-peptide. Partial remission was determined by postprandial C-peptide ≥300 pmol/L or insulin dose-adjusted A1c ≤ 9 in the absence of C-peptide. Beta-cell function was defined as preserved, residual or failed by postprandial C-peptide of ≥200 pmol/L, 50-200 pmol/L or ≤50 pmol/L, respectively. RESULTS Altogether, 199 out of 298 patients (125 adults) had partial remission. The pattern of C-peptide change in patients with partial remission was three-phasic, demonstrating an upward trend followed by a downward trend of fast first and then slow, while the pattern in patients without partial remission was biphasic, showing an initial fast fall and a subsequent slower decrease. The patterns remained consistent when patients were stratified by the age of onset. At 3 years, there were 71% of the patients with partial remission still had preserved or residual beta-cell function, while 89% of the patients who had no partial remission developed beta-cell function failure. In patients whose partial remission ended, the average C-peptide was still higher than duration-matched patients without partial remission. CONCLUSIONS Patients with partial remission of T1D have a distinct three-phasic pattern of C-peptide decline, other than the widely recognized biphasic pattern. The effect of partial remission still exists after remission ends.
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Affiliation(s)
- Mei Shi
- Department of Metabolism and Endocrinology, National Clinical Research Center for Metabolic Diseases, Key Laboratory of Diabetes Immunology (Central South University), Ministry of Education, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Yuting Xie
- Department of Metabolism and Endocrinology, National Clinical Research Center for Metabolic Diseases, Key Laboratory of Diabetes Immunology (Central South University), Ministry of Education, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Rong Tang
- Department of Metabolism and Endocrinology, National Clinical Research Center for Metabolic Diseases, Key Laboratory of Diabetes Immunology (Central South University), Ministry of Education, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Ting Zhong
- Department of Metabolism and Endocrinology, National Clinical Research Center for Metabolic Diseases, Key Laboratory of Diabetes Immunology (Central South University), Ministry of Education, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Zhiguang Zhou
- Department of Metabolism and Endocrinology, National Clinical Research Center for Metabolic Diseases, Key Laboratory of Diabetes Immunology (Central South University), Ministry of Education, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Xia Li
- Department of Metabolism and Endocrinology, National Clinical Research Center for Metabolic Diseases, Key Laboratory of Diabetes Immunology (Central South University), Ministry of Education, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
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19
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Cimbek EA, Bozkır A, Usta D, Beyhun NE, Ökten A, Karagüzel G. Partial remission in children and adolescents with type 1 diabetes: an analysis based on the insulin dose-adjusted hemoglobin A1c. J Pediatr Endocrinol Metab 2021; 34:1311-1317. [PMID: 34271601 DOI: 10.1515/jpem-2021-0048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 06/20/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Most patients with type 1 diabetes (T1D) experience a transient phase of partial remission (PR). This study aimed to identify the demographic and clinical factors associated with PR. METHODS This was a longitudinal retrospective cohort study of 133 children and adolescents with T1D. PR was defined by the gold standard insulin dose-adjusted hemoglobin A1c (HbA1c) (IDAA1c) of ≤9. RESULTS Remission was observed in 77 (57.9%) patients. At diagnosis, remitters had significantly higher pH (7.3 ± 0.12 vs. 7.23 ± 0.15, p=0.003), higher C-peptide levels (0.45 ± 0.31 ng/mL vs. 0.3 ± 0.22, p=0.003), and they were significantly older (9.3 ± 3.6 years vs. 7.3 ± 4.2, p=0.008) compared with non-remitters. PR developed more frequently in patients without diabetic ketoacidosis (DKA) (p=0.026) and with disease onset after age 5 (p=0.001). Patients using multiple daily insulin regimen were more likely to experience PR than those treated with a twice daily regimen (63.9 vs. 32%, p=0.004). Only age at onset was an independent predictor of PR (OR: 1.12, 95% CI: 1-1.25; p=0.044). Remitters had lower HbA1c levels and daily insulin requirement from diagnosis until one year after diagnosis (p<0.001). PR recurred in 7 (9%) patients. The daily insulin requirement at three months was lower in remitters with PR recurrence compared to those without (0.23 ± 0.14 vs. 0.4 ± 0.17 U/kg/day, p=0.014). CONCLUSIONS Addressing factors associated with the occurrence of PR could provide a better comprehension of metabolic control in T1D. The lack of DKA and higher C-peptide levels may influence PR, but the main factor associated with PR presence was older age at onset. PR may recur in a small proportion of patients.
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Affiliation(s)
- Emine Ayça Cimbek
- Department of Pediatric Endocrinology, Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Aydın Bozkır
- Department of Pediatrics, Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Deniz Usta
- Department of Pediatrics, Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Nazım Ercüment Beyhun
- Department of Public Health, Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Ayşenur Ökten
- Department of Pediatric Endocrinology, Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Gülay Karagüzel
- Department of Pediatric Endocrinology, Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey
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20
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Carr ALJ, Oram RA, Marren SM, McDonald TJ, Narendran P, Andrews RC. Measurement of Peak C-Peptide at Diagnosis Informs Glycemic Control but not Hypoglycemia in Adults With Type 1 Diabetes. J Endocr Soc 2021; 5:bvab127. [PMID: 34377883 PMCID: PMC8344843 DOI: 10.1210/jendso/bvab127] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Indexed: 01/12/2023] Open
Abstract
Context High-residual C-peptide in longer-duration type 1 diabetes (T1D) is associated with fewer hypoglycemic events and reduced glycemic variability. Little is known about the impact of C-peptide close to diagnosis. Objective Using continuous glucose monitoring (CGM) data from a study of newly diagnosed adults with T1D, we aimed to explore if variation in C-peptide close to diagnosis influenced glycemic variability and risk of hypoglycemia. Methods We studied newly diagnosed adults with T1D who wore a Dexcom G4 CGM for 7 days as part of the Exercise in Type 1 Diabetes (EXTOD) study. We examined the relationship between peak stimulated C-peptide and glycemic metrics of variability and hypoglycemia for 36 CGM traces from 23 participants. Results For every 100 pmol/L-increase in peak C-peptide, the percentage of time spent in the range 3.9 to 10 mmol/L increased by 2.4% (95% CI, 0.5-4.3), P = .01) with a reduction in time spent at level 1 hyperglycemia (> 10 mmol/L) and level 2 hyperglycemia (> 13.9 mmol/L) by 2.6% (95% CI, –4.9 to –0.4, P = .02) and 1.3% (95% CI, –2.7 to –0.006, P = .04), respectively. Glucose levels were on average lower by 0.19 mmol/L (95% CI, –0.4 to 0.02, P = .06) and SD reduced by 0.14 (95% CI, –0.3 to –0.02, P = .02). Hypoglycemia was not common in this group and no association was observed between time spent in hypoglycemia (P = .97) or hypoglycemic risk (P = .72). There was no association between peak C-peptide and insulin dose–adjusted glycated hemoglobin A1c (P = .45). Conclusion C-peptide is associated with time spent in the normal glucose range and with less hyperglycemia, but not risk of hypoglycemia in newly diagnosed people with T1D.
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Affiliation(s)
- Alice L J Carr
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, Devon EX2 5DW, UK
| | - Richard A Oram
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, Devon EX2 5DW, UK
| | - Shannon M Marren
- Great Western Hospitals NHS Foundation Trust, Swindon, SN3 6BB, UK
| | - Timothy J McDonald
- The Academic Department of Blood Sciences, The Royal Devon and Exeter NHS Foundation Trust, Exeter, EX2 5DW, UK
| | - Parth Narendran
- Department of Diabetes, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2GW, UK.,Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, B15 2TT, UK
| | - Robert C Andrews
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, Devon EX2 5DW, UK.,Department of Diabetes, Taunton and Somerset NHS Foundation Trust, Taunton, TA1 5DA, UK
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21
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Lin K, Yang X, Wu Y, Chen S, Zeng Q. Residual β-Cell Function in Type 1 Diabetes Followed for 2 Years after 3C Study. J Diabetes Res 2021; 2021:9946874. [PMID: 34258294 PMCID: PMC8261175 DOI: 10.1155/2021/9946874] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 05/13/2021] [Accepted: 06/20/2021] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE To investigate the natural history and related factors of the pancreatic β-cell function in Chinese type 1 diabetic patients from 3C study Shantou center. METHOD Stimulated C-peptide levels from follow-up data of 201 individuals in 3C study Shantou subgroup starting in 2012 were used. Residual β-cell function was defined as stimulated C - peptide level ≥ 0.2 pmol/mL, on the basis of cut-points derived from the Diabetes Control and Complications Trial (DCCT). RESULTS 36.8% of patients had residual β-cell function, and the percentage was 68.2% in newly diagnosed diabetic patients. COX regression analysis indicated that the age of diagnosis, HbA1C level, and duration were independent factors of residual β-cell function in individuals with ≤5 years duration, but in those with duration ≥5 years, only the age of diagnosis was a predictor. The pancreatic β-cell function mainly declined in the first 5 years of the duration, and the rate of decline was correlated negatively with the duration and age of diagnosis. Receiver operating characteristic (ROC) analysis indicated that the cut-off point of stimulated C-peptide was 0.615 pmol/mL in patients with <5 years duration to have 7% HbA1c. CONCLUSION Age at diagnosis was the strongest predictor for residual C-peptide. There was a more rapid decline of stimulated C-peptide in duration ≤5 years and younger patients. Therefore, intervention therapies of β-cells should start from the early stage, and the recommended target goal of stimulated C-peptide is 0.615 pmol/mL or above.
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Affiliation(s)
- Kun Lin
- Department of Endocrinology, The First Affiliated Hospital of Shantou University Medical College, Shantou, China
| | - Xiaoping Yang
- Department of Endocrinology, The First Affiliated Hospital of Shantou University Medical College, Shantou, China
| | - Yixi Wu
- Department of Endocrinology, The First Affiliated Hospital of Shantou University Medical College, Shantou, China
| | - Shuru Chen
- Shenzhen Huada Gene Technology Service Co., Ltd, Shenzhen, China
| | - Qiong Zeng
- Department of Neurology, The First Affiliated Hospital of Shantou University Medical College, Shantou, China
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22
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Cheng J, Yin M, Tang X, Yan X, Xie Y, He B, Li X, Zhou Z. Residual β-cell function after 10 years of autoimmune type 1 diabetes: prevalence, possible determinants, and implications for metabolism. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:650. [PMID: 33987348 PMCID: PMC8106063 DOI: 10.21037/atm-20-7471] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Background Type 1 diabetes (T1D) has long been considered a progressive autoimmune disease resulting in the failure of pancreatic β-cell function and absolute endogenous insulin deficiency. However, several studies have demonstrated patients with T1D have detectable C-peptide levels long after diagnosis, which has remarkable clinical significance. Since this issue has not been systematically explored in non-Caucasian populations, we aimed to identify the prevalence of residual β-cell function and its related clinical features in Chinese long-term T1D patients. Methods We enrolled 109 patients with T1D for ≥10 years and administered a mixed-meal tolerance test (MMTT). Fasting and postprandial C-peptide (FCP/PCP) levels were measured to evaluate the insulin secretion function of β-cells. Patients whose FCP and PCP levels were both below the lower detection limit (16.7 pmol/L) were grouped as ‘β-cell function depleted’, while others were thought to have ‘residual β-cell function’. Demographic data, metabolic status, and diabetic complications were compared between patients with or without residual β-cell function. Results 38.5% of subjects retained residual β-cell function, and among those, 33.3% responded to MMTT by a two-fold or greater rise of their FCP levels. Clinical features associated with residual β-cell function were older age of diagnosis [27.5 (interquartile range:11.5–37.0) vs. 17.0 (interquartile range: 8.0–30.0) years, P=0.037], lower HbA1c (64.6±20.3 vs. 72.4±18.5 mmol/mol, P=0.026), and reduced rate of hypoglycemia (23.8% vs. 52.2%, P=0.003). Age of diagnosis was positively correlated with detectable FCP level (r=0.393, P=0.020). Individuals diagnosed after 30 years of age tended to retain residual β-cell function (OR =3.016, P=0.044). We found no association between residual β-cell function and chronic diabetic complications. Conclusions Residual β-cell function can be found in nearly 40% of long-term patients with T1D in China and is associated with older age at diagnosis and better glucose control. The relationship between residual β-cell function and chronic diabetic complications remains to be explored.
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Affiliation(s)
- Jin Cheng
- National Clinical Research Center for Metabolic Disease, Key Laboratory of Diabetes Immunology, Ministry of Education, Department of Metabolism and Endocrinology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Min Yin
- National Clinical Research Center for Metabolic Disease, Key Laboratory of Diabetes Immunology, Ministry of Education, Department of Metabolism and Endocrinology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Xiaohan Tang
- National Clinical Research Center for Metabolic Disease, Key Laboratory of Diabetes Immunology, Ministry of Education, Department of Metabolism and Endocrinology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Xiang Yan
- National Clinical Research Center for Metabolic Disease, Key Laboratory of Diabetes Immunology, Ministry of Education, Department of Metabolism and Endocrinology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Yuting Xie
- National Clinical Research Center for Metabolic Disease, Key Laboratory of Diabetes Immunology, Ministry of Education, Department of Metabolism and Endocrinology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Binbin He
- National Clinical Research Center for Metabolic Disease, Key Laboratory of Diabetes Immunology, Ministry of Education, Department of Metabolism and Endocrinology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Xia Li
- National Clinical Research Center for Metabolic Disease, Key Laboratory of Diabetes Immunology, Ministry of Education, Department of Metabolism and Endocrinology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Zhiguang Zhou
- National Clinical Research Center for Metabolic Disease, Key Laboratory of Diabetes Immunology, Ministry of Education, Department of Metabolism and Endocrinology, The Second Xiangya Hospital of Central South University, Changsha, China
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23
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Steck AK, Liu X, Krischer JP, Haller MJ, Veijola R, Lundgren M, Ahmed S, Akolkar B, Toppari J, Hagopian WA, Rewers MJ, Elding Larsson H. Factors Associated With the Decline of C-Peptide in a Cohort of Young Children Diagnosed With Type 1 Diabetes. J Clin Endocrinol Metab 2021; 106:e1380-e1388. [PMID: 33035311 PMCID: PMC8244121 DOI: 10.1210/clinem/dgaa715] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Indexed: 12/30/2022]
Abstract
CONTEXT Understanding factors involved in the rate of C-peptide decline is needed to tailor therapies for type 1 diabetes (T1D). OBJECTIVE Evaluate factors associated with rate of C-peptide decline after a T1D diagnosis in young children. DESIGN Observational study. SETTING Academic centers. PARTICIPANTS A total of 57 participants from the Environmental Determinants of Diabetes in the Young (TEDDY) study who were enrolled at 3 months of age and followed until T1D, and 56 age-matched children diagnosed with T1D in the community. INTERVENTION A mixed meal tolerance test was used to measure the area under the curve (AUC) C-peptide at 1, 3, 6, 12, and 24 months postdiagnosis. OUTCOME Factors associated with rate of C-peptide decline during the first 2 years postdiagnosis were evaluated using mixed effects models, adjusting for age at diagnosis and baseline C-peptide. RESULTS Adjusted slopes of AUC C-peptide decline did not differ between TEDDY subjects and community controls (P = 0.21), although the former had higher C-peptide baseline levels. In univariate analyses combining both groups (n = 113), younger age, higher weight and body mass index z-scores, female sex, an increased number increased number of islet autoantibodies, and IA-2A or ZnT8A positivity at baseline were associated with a higher rate of C-peptide loss. Younger age, female sex, and higher weight z-score remained significant in multivariate analysis (all P < 0.02). At 3 months after diagnosis, higher HbA1c became an additional independent factor associated with a higher rate of C-peptide decline (P < 0.01). CONCLUSION Younger age at diagnosis, female sex, higher weight z-score, and HbA1c were associated with a higher rate of C-peptide decline after T1D diagnosis in young children.
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Affiliation(s)
- Andrea K Steck
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, Colorado
| | - Xiang Liu
- Health Informatics Institute, University of South Florida, Tampa, Florida
| | - Jeffrey P Krischer
- Health Informatics Institute, University of South Florida, Tampa, Florida
| | - Michael J Haller
- Department of Pediatrics, University of Florida, Gainesville, Florida
| | - Riitta Veijola
- Department of Pediatrics, PEDEGO Research Unit, MRC Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Markus Lundgren
- Department of Clinical Sciences, Lund University CRC, Skåne University Hospital, Malmö, Sweden
| | - Simi Ahmed
- Immunology of T1D, JDRF International, New York, New York
| | - Beena Akolkar
- Division of Diabetes, Endocrinology and Metabolism, National Institute of Diabetes, Digestive, and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Jorma Toppari
- Institute of Biomedicine, Research Centre for Integrative Physiology and Pharmacology, University of Turku, Turku, Finland
- Pacific Diabetes Research Institute, Seattle, Washington
| | | | - Marian J Rewers
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, Colorado
| | - Helena Elding Larsson
- Department of Clinical Sciences, Lund University CRC, Skåne University Hospital, Malmö, Sweden
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24
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Dabelea D, Sauder KA, Jensen ET, Mottl AK, Huang A, Pihoker C, Hamman RF, Lawrence J, Dolan LM, Agostino RD, Wagenknecht L, Mayer-Davis EJ, Marcovina SM. Twenty years of pediatric diabetes surveillance: what do we know and why it matters. Ann N Y Acad Sci 2021; 1495:99-120. [PMID: 33543783 DOI: 10.1111/nyas.14573] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/14/2021] [Accepted: 01/20/2021] [Indexed: 12/23/2022]
Abstract
SEARCH for Diabetes in Youth (SEARCH) was initiated in 2000 as a multicenter study to address major gaps in the understanding of childhood diabetes in the United States. An active registry of youth diagnosed with diabetes at age <20 years since 2002 assessed prevalence, annual incidence, and trends by age, race/ethnicity, sex, and diabetes type. An observational cohort nested within the population-based registry was established to assess the natural history and risk factors for acute and chronic diabetes-related complications, as well as the quality of care and quality of life of children and adolescents with diabetes from diagnosis into young adulthood. SEARCH findings have contributed to a better understanding of the complex and heterogeneous nature of youth-onset diabetes. Continued surveillance of the burden and risk of type 1 and type 2 diabetes is important to track and monitor incidence and prevalence within the population. SEARCH reported evidence of early diabetes complications highlighting that continuing the long-term follow-up of youth with diabetes is necessary to further our understanding of its natural history and to develop the most appropriate approaches to primary, secondary, and tertiary prevention of diabetes and its complications. This review summarizes two decades of research and suggests avenues for further work.
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Affiliation(s)
- Dana Dabelea
- Lifecourse Epidemiology of Adiposity and Diabetes Center, Department of Epidemiology and Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Katherine A Sauder
- Lifecourse Epidemiology of Adiposity and Diabetes Center, Department of Epidemiology and Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Elizabeth T Jensen
- Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Amy K Mottl
- Division of Nephrology and Hypertension, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Alyssa Huang
- Department of Pediatrics, University of Washington, Seattle, Washington
| | - Catherine Pihoker
- Department of Pediatrics, University of Washington, Seattle, Washington
| | - Richard F Hamman
- Lifecourse Epidemiology of Adiposity and Diabetes Center, Department of Epidemiology and Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Jean Lawrence
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - Lawrence M Dolan
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Ralph D' Agostino
- Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Lynne Wagenknecht
- Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Elizabeth J Mayer-Davis
- Department of Nutrition and Medicine, University of North Carolina, Chapel Hill, North Carolina
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25
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Yuan JN, Zhang JW, Cutfield WS, Dong GP, Jiang YJ, Wu W, Huang K, Chen XC, Zheng Y, Liu BH, Derraik JGB, Fu JF. Surrogate markers and predictors of endogenous insulin secretion in children and adolescents with type 1 diabetes. World J Pediatr 2021; 17:99-105. [PMID: 33411158 DOI: 10.1007/s12519-020-00382-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 07/12/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND No studies have examined endogenous insulin secretion in pediatric patients with type 1 diabetes in China using the gold-standard mixed-meal tolerance test. Because the latter is labor-intensive, we examined simpler surrogate markers of endogenous insulin secretion in Chinese youth, as previously reported for a European population. METHODS Participants were 57 children and adolescents with type 1 diabetes aged 4.4-16.8 years (56% females). We performed 120-minute mixed-meal tolerance tests with serum C-peptide (CP) measurements every 30 minutes. Severe insulin deficiency (SID) was defined as CP peak < 0.2 nmol/L. Urine CP and creatinine levels were measured at 0 and 120 minutes. RESULTS Twenty-five (44%) patients had SID. Fasting CP levels missed one case (96% sensitivity) with no false positives (100% specificity). While the 120-minute urine CP/creatinine had 100% sensitivity, it yielded markedly lower specificity (63%). Every 1-year increase in diabetes duration and 1-year decrease in age at diagnosis were associated with 37% (P < 0.001) and 20% (P = 0.005) reductions in serum CP area-under-the-curve, respectively. Thus, 86% of children aged < 5 years had SID compared to none among patients aged ≥ 11 years. CONCLUSIONS Simple fasting CP measurements could be used to detect most SID cases in Chinese youth with type 1 diabetes. Fasting CP is a far more reliable measure of endogenous insulin secretion than the more commonly used insulin dose. Therefore, it could more precisely determine insulin secretory capacity to target those who could benefit, if treatments to preserve residual insulin secretion are developed.
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Affiliation(s)
- Jin-Na Yuan
- Department of Endocrinology, National Clinical Research Center for Child Health, The Children's Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Jian-Wei Zhang
- Department of Pediatrics, Shaoxing Women and Children's Hospital, Shaoxing, China
| | - Wayne S Cutfield
- Liggins Institute, University of Auckland, Auckland, New Zealand.,A Better Start-National Science Challenge, University of Auckland, Auckland, New Zealand.,Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Guan-Ping Dong
- Department of Endocrinology, National Clinical Research Center for Child Health, The Children's Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - You-Jun Jiang
- Department of Endocrinology, National Clinical Research Center for Child Health, The Children's Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Wei Wu
- Department of Endocrinology, National Clinical Research Center for Child Health, The Children's Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Ke Huang
- Department of Endocrinology, National Clinical Research Center for Child Health, The Children's Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Xiao-Chun Chen
- Department of Endocrinology, National Clinical Research Center for Child Health, The Children's Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Yan Zheng
- Department of Endocrinology, National Clinical Research Center for Child Health, The Children's Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Bi-Hong Liu
- Department of Endocrinology, National Clinical Research Center for Child Health, The Children's Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - José G B Derraik
- Department of Endocrinology, National Clinical Research Center for Child Health, The Children's Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China.,Liggins Institute, University of Auckland, Auckland, New Zealand.,A Better Start-National Science Challenge, University of Auckland, Auckland, New Zealand.,Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Jun-Fen Fu
- Department of Endocrinology, National Clinical Research Center for Child Health, The Children's Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China.
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26
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Johnson MB, Patel KA, De Franco E, Hagopian W, Killian M, McDonald TJ, Tree TIM, Domingo-Vila C, Hudson M, Hammersley S, Dobbs R, Ellard S, Flanagan SE, Hattersley AT, Oram RA. Type 1 diabetes can present before the age of 6 months and is characterised by autoimmunity and rapid loss of beta cells. Diabetologia 2020; 63:2605-2615. [PMID: 33029656 PMCID: PMC7641942 DOI: 10.1007/s00125-020-05276-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 07/26/2020] [Indexed: 12/11/2022]
Abstract
AIMS/HYPOTHESIS Diabetes diagnosed at <6 months of age is usually monogenic. However, 10-15% of affected infants do not have a pathogenic variant in one of the 26 known neonatal diabetes genes. We characterised infants diagnosed at <6 months of age without a pathogenic variant to assess whether polygenic type 1 diabetes could arise at early ages. METHODS We studied 166 infants diagnosed with type 1 diabetes at <6 months of age in whom pathogenic variants in all 26 known genes had been excluded and compared them with infants with monogenic neonatal diabetes (n = 164) or children with type 1 diabetes diagnosed at 6-24 months of age (n = 152). We assessed the type 1 diabetes genetic risk score (T1D-GRS), islet autoantibodies, C-peptide and clinical features. RESULTS We found an excess of infants with high T1D-GRS: 38% (63/166) had a T1D-GRS >95th centile of healthy individuals, whereas 5% (8/166) would be expected if all were monogenic (p < 0.0001). Individuals with a high T1D-GRS had a similar rate of autoantibody positivity to that seen in individuals with type 1 diabetes diagnosed at 6-24 months of age (41% vs 58%, p = 0.2), and had markedly reduced C-peptide levels (median <3 pmol/l within 1 year of diagnosis), reflecting rapid loss of insulin secretion. These individuals also had reduced birthweights (median z score -0.89), which were lowest in those diagnosed with type 1 diabetes at <3 months of age (median z score -1.98). CONCLUSIONS/INTERPRETATION We provide strong evidence that type 1 diabetes can present before the age of 6 months based on individuals with this extremely early-onset diabetes subtype having the classic features of childhood type 1 diabetes: high genetic risk, autoimmunity and rapid beta cell loss. The early-onset association with reduced birthweight raises the possibility that for some individuals there was reduced insulin secretion in utero. Comprehensive genetic testing for all neonatal diabetes genes remains essential for all individuals diagnosed with diabetes at <6 months of age. Graphical abstract.
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Affiliation(s)
- Matthew B Johnson
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | - Kashyap A Patel
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | - Elisa De Franco
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | | | | | - Timothy J McDonald
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
- Blood Sciences, Royal Devon & Exeter NHS Foundation Trust, Exeter, UK
| | - Timothy I M Tree
- Department of Immunobiology, School of Immunobiology & Microbial Sciences, Kings College London, London, UK
- NIHR Biomedical Research Centre Guys and St Thomas' NHS Foundation Trust and Kings College London, London, UK
| | - Clara Domingo-Vila
- Department of Immunobiology, School of Immunobiology & Microbial Sciences, Kings College London, London, UK
| | - Michelle Hudson
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
- National Institute for Health Exeter Research Clinical Research Facility, Royal Devon & Exeter NHS Foundation Trust, Exeter, UK
| | - Suzanne Hammersley
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
- National Institute for Health Exeter Research Clinical Research Facility, Royal Devon & Exeter NHS Foundation Trust, Exeter, UK
| | - Rebecca Dobbs
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
- National Institute for Health Exeter Research Clinical Research Facility, Royal Devon & Exeter NHS Foundation Trust, Exeter, UK
| | | | - Sian Ellard
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | - Sarah E Flanagan
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | - Andrew T Hattersley
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | - Richard A Oram
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK.
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27
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Donnelly C, Williams A. Investigating the potential impact of post translational modification of auto-antigens by tissue transglutaminase on humoral islet autoimmunity in type 1 diabetes. Metabol Open 2020; 8:100062. [PMID: 33103101 PMCID: PMC7569324 DOI: 10.1016/j.metop.2020.100062] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 09/07/2020] [Accepted: 09/26/2020] [Indexed: 11/15/2022] Open
Abstract
Background Post-translational modification (PTM) of antigens plays a role in the pathogenesis of many autoimmune disorders. In coeliac disease (CD), tissue transglutaminase (tTG) deamidates gliadin peptides to activate the immune response against the gut endomysium. CD is six times more prevalent in type 1 diabetes (T1D) patients than in the general population. Hypothesis tTG also modifies auto-antigens implicated in the pathogenesis of T1D, leading to an autoimmune response to pancreatic β-cells. Methods tTG PTM was investigated in the following auto-antigens, which had been previously shown to have high importance in the development of T1D: glutamic acid decarboxylase isoform 65 (GAD65), full length islet antigen (IA-2), intracellular portion of IA-2 (IA-2ic), and both isoforms of zinc transporter 8 (ZnT8W and ZnT8R), on antibody binding. Radiolabelled antigen was incubated with tTG for 20 h at 37 °C in 100 mM Denver buffer, 3.33 nM CaCl2, at pH 7.3. Antibody binding in 20 mixed samples from the Bart’s-Oxford (BOX) cohort was measured by radiobinding assay. Results Results varied between serum samples. Generally, tTG treatment of ZnT8W, ZnT8R and IA-2ic showed no significant change in antigen: autoantibody binding, while increases in binding were observed with tTG-treated GAD65 and full length IA-2. Conclusion In the case of GAD65, full length IA-2, the strength of antibody: antigen binding increased after incubation with tTG. However, the exact tTG-modification events that occurred requires further elucidation. Post-translational modification of antigens plays a role in the pathogenesis of many autoimmune disorders. Celiac disease is six times more prevalent in type 1 diabetics. Tissue transglutaminase modifies auto-antigens GAD65 and full-length IA-2 to increase antibody binding.
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Affiliation(s)
| | - Alistair Williams
- Diabetes and Metabolism, Translational Health Sciences, University of Bristol, Southmead Hospital, Bristol, UK
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28
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Pastore I, Bolla AM, Montefusco L, Lunati ME, Rossi A, Assi E, Zuccotti GV, Fiorina P. The Impact of Diabetes Mellitus on Cardiovascular Risk Onset in Children and Adolescents. Int J Mol Sci 2020; 21:ijms21144928. [PMID: 32664699 PMCID: PMC7403998 DOI: 10.3390/ijms21144928] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 07/07/2020] [Accepted: 07/09/2020] [Indexed: 12/20/2022] Open
Abstract
The prevalence of diabetes mellitus is rising among children and adolescents worldwide. Cardiovascular diseases are the main cause of morbidity and mortality in diabetic patients. We review the impact of diabetes on establishing, during childhood and adolescence, the premises for cardiovascular diseases later in life. Interestingly, it seems that hyperglycemia is not the only factor that establishes an increased cardiovascular risk in adolescence. Other factors have been recognized to play a role in triggering the onset of latent cardiovascular diseases in the pediatric population. Among these cardiovascular risk factors, some are modifiable: glucose variability, hypoglycemia, obesity, insulin resistance, waist circumference, hypertension, dyslipidemia, smoking alcohol, microalbuminuria and smoking. Others are unmodifiable, such as diabetes duration and family history. Among the etiological factors, subclinical endothelial dysfunction represents one of the earliest key players of atherosclerosis and it can be detected during early ages in patients with diabetes. A better assessment of cardiovascular risk in pediatric population still represents a challenge for clinicians, and thus further efforts are required to properly identify and treat pediatric patients who may suffer from cardiovascular disease later in early adulthood.
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Affiliation(s)
- Ida Pastore
- Division of Endocrinology, ASST Fatebenefratelli-Sacco, 20157 Milan, Italy; (I.P.); (A.M.B.); (L.M.); (M.E.L.); (A.R.)
| | - Andrea Mario Bolla
- Division of Endocrinology, ASST Fatebenefratelli-Sacco, 20157 Milan, Italy; (I.P.); (A.M.B.); (L.M.); (M.E.L.); (A.R.)
| | - Laura Montefusco
- Division of Endocrinology, ASST Fatebenefratelli-Sacco, 20157 Milan, Italy; (I.P.); (A.M.B.); (L.M.); (M.E.L.); (A.R.)
| | - Maria Elena Lunati
- Division of Endocrinology, ASST Fatebenefratelli-Sacco, 20157 Milan, Italy; (I.P.); (A.M.B.); (L.M.); (M.E.L.); (A.R.)
| | - Antonio Rossi
- Division of Endocrinology, ASST Fatebenefratelli-Sacco, 20157 Milan, Italy; (I.P.); (A.M.B.); (L.M.); (M.E.L.); (A.R.)
| | - Emma Assi
- International Center for T1D, Pediatric Clinical Research Center Romeo ed Enrica Invernizzi, Department of Biomedical and Clinical Science L. Sacco, University of Milan, 20157 Milan, Italy;
| | - Gian Vincenzo Zuccotti
- Pediatric Clinical Research Center Romeo ed Enrica Invernizzi, DIBIC, Università di Milano and Department of Pediatrics, Buzzi Children’s Hospital, 20157 Milan, Italy;
| | - Paolo Fiorina
- Division of Endocrinology, ASST Fatebenefratelli-Sacco, 20157 Milan, Italy; (I.P.); (A.M.B.); (L.M.); (M.E.L.); (A.R.)
- International Center for T1D, Pediatric Clinical Research Center Romeo ed Enrica Invernizzi, Department of Biomedical and Clinical Science L. Sacco, University of Milan, 20157 Milan, Italy;
- Nephrology Division, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115, USA
- Correspondence: ; Tel.: +1-617-919-2624
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29
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Barrett T, Jalaludin MY, Turan S, Hafez M, Shehadeh N. Rapid progression of type 2 diabetes and related complications in children and young people-A literature review. Pediatr Diabetes 2020; 21:158-172. [PMID: 31804738 PMCID: PMC7028065 DOI: 10.1111/pedi.12953] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 10/25/2019] [Accepted: 12/02/2019] [Indexed: 01/05/2023] Open
Abstract
Type 2 diabetes (T2D) is suggested to progress faster in children and young people vs type 1 diabetes (T1D) in the same age group and T2D in adults. We reviewed the evidence base for this. A literature search was performed of PubMed-indexed publications between 2000 and 2018, for the terms "pediatric" and "T2D." Results were combined and filtered for those relating to "progression." Searches of abstract books from Latin American and Asian congresses were performed to include these populations. Pediatric populations were defined as <25 completed years of age. Of the articles and congress abstracts found, 30 were deemed relevant. Dividing the studies into categories based on how T2D progresses, we found the following: (a) yearly beta-cell function deterioration was shown to be 20% to 35% in children with T2D compared with 7% to 11% in adults with T2D, despite similar disease durations; (b) retinopathy progression was likely dependent on diabetes duration rather than diabetes type; however, nephropathy, neuropathy and probably hypertension progressed faster in youth-onset T2D vs T1D. Nephropathy progression was similar to adults with T2D, allowing for disease duration. Youth with T2D had a worse cardiovascular (CV) risk profile than youth with T1D, and a faster progression to CV death. (c) Progression to treatment failure was faster in youth-onset T2D vs adult-onset T2D. Substantial evidence exists for faster progression of T2D in pediatric patients vs T1D or adult-onset T2D. New treatments targeting the pathology are needed urgently to address this issue.
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Affiliation(s)
- Timothy Barrett
- Institute of Cancer and Genomic SciencesUniversity of BirminghamBirminghamUK
| | | | - Serap Turan
- Department of Pediatrics, Subdivision of Endocrinology and DiabetesMarmara University, School of MedicineIstanbulTurkey
| | - Mona Hafez
- Diabetes and Endocrinology Unit, Department of PediatricsCairo UniversityCairoEgypt
| | - Naim Shehadeh
- Endocrinology, Diabetes & Metabolism InstituteRambam Health Care CampusHaifaIsrael
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30
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Chiavaroli V, Derraik JGB, Jalaludin MY, Albert BB, Ramkumar S, Cutfield WS, Hofman PL, Jefferies CA. Partial remission in type 1 diabetes and associated factors: Analysis based on the insulin dose-adjusted hemoglobin A1c in children and adolescents from a regional diabetes center, Auckland, New Zealand. Pediatr Diabetes 2019; 20:892-900. [PMID: 31237756 DOI: 10.1111/pedi.12881] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 04/25/2019] [Accepted: 06/10/2019] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Partial remission (PREM) by the insulin dose-adjusted HbA1c (IDAA1c) method has not been evaluated for the combined associations of ethnicity and socioeconomic status in children and adolescents with type 1 diabetes (T1D). OBJECTIVE To investigate prevalence and predictors of PREM defined by IDAA1c. METHODS Six hundred fourteen of 678 children (aged <15 years) with new-onset T1D (2000-2013) from a regional pediatric diabetes service (Auckland, New Zealand). RESULTS Overall rate of PREM at 3 months was 42.4%, and lower in Māori/Pacific children (28.6%; P = .006) and those of other ethnicities (28.8%; P = .030) compared with New Zealand Europeans (50.4%). Comparing the most and least deprived socioeconomic quintiles, the odds of PREM were lower among the most deprived (adjusted odds ratio [aOR] 0.44; P = .019). Lower rates of PREM were seen in children aged 0 to 4.9 years (23.8%) and 10 to 14 years (40.9%) than in children aged 5 to 9.9 years (57.4%; P < .05). Further predictors of lower rates of PREM were ketoacidosis at diagnosis (aOR 0.54 with DKA; P = .002) and diabetes duration (aOR 0.84 per month; P < .0001). Patient's sex, body mass index standard deviation score, or autoantibodies were not associated with PREM. PREM at 3 months was associated with lower HbA1c over 18 months compared with children not in PREM (65.0 vs 71.3 mmol/mol; P < .0001), independent of ketoacidosis. CONCLUSIONS This study on a regional cohort of youth with T1D showed social and ethnic disparities in rates of PREM defined by IDAA1c. Further research into reducing ketoacidosis rates at diagnosis and addressing factors associated with lower rates of PREM in non-European children are important health priorities.
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Affiliation(s)
- Valentina Chiavaroli
- Liggins Institute, University of Auckland, Auckland, New Zealand.,Neonatal Intensive Care Unit, Pescara Public Hospital, Pescara, Italy
| | - José G B Derraik
- Liggins Institute, University of Auckland, Auckland, New Zealand.,A Better Start - National Science Challenge, University of Auckland, Auckland, New Zealand.,Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Muhammad Y Jalaludin
- Liggins Institute, University of Auckland, Auckland, New Zealand.,Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Benjamin B Albert
- Liggins Institute, University of Auckland, Auckland, New Zealand.,Starship Children's Health, Auckland District Health Board, Auckland, New Zealand
| | - Selvarajan Ramkumar
- Department of Endocrinology, Apollo Hospitals, Chennai, India.,Department of Endocrinology, Madras Medical College, Chennai, India
| | - Wayne S Cutfield
- Liggins Institute, University of Auckland, Auckland, New Zealand.,A Better Start - National Science Challenge, University of Auckland, Auckland, New Zealand.,Starship Children's Health, Auckland District Health Board, Auckland, New Zealand
| | - Paul L Hofman
- Liggins Institute, University of Auckland, Auckland, New Zealand.,Starship Children's Health, Auckland District Health Board, Auckland, New Zealand
| | - Craig A Jefferies
- Liggins Institute, University of Auckland, Auckland, New Zealand.,Starship Children's Health, Auckland District Health Board, Auckland, New Zealand
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31
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Li X, Cheng J, Huang G, Luo S, Zhou Z. Tapering decay of β-cell function in Chinese patients with autoimmune type 1 diabetes: A four-year prospective study. J Diabetes 2019; 11:802-808. [PMID: 30767397 DOI: 10.1111/1753-0407.12907] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 12/05/2018] [Accepted: 02/12/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND This study investigated the natural progression of β-cell function in Chinese autoimmune type 1 diabetic (T1D) patients and clarified factors possibly influencing the course of the disease. METHODS The natural progression of β-cell function of 325 newly diagnosed Chinese autoimmune T1D patients was assessed by fasting and postprandial C-peptide (FCP and PCP, respectively) levels. β-Cell function failure was defined as FCP <50 pM and PCP <100 pM, whereas preserved β-cell function was defined as FCP >200 pM or PCP >400 pM. β-Cell function that did not meet these criteria was described as residual. RESULTS At initial recruitment, 33.3% of patients had β-cell function failure, whereas 41.0% and 25.8% of patients had preserved or residual β-cell function, respectively. The percentage of patients who developed β-cell function failure during follow-up at 12, 24, 36, and 48 months after recruitment to the study was 55.8%, 75.6%, 86.7%, and 92.7%, respectively. Moreover, the slope of the β-cell function curve decreased over time, indicating that the pattern of its decline was non-linear and tapering. Seven percent of patients did not develop β-cell function failure within 4 years after diagnosis. Patients with lower initial FCP levels were more likely to develop β-cell function failure. CONCLUSIONS Chinese autoimmune T1D patients have considerable residual β-cell function at initial diagnosis, and the manner of progression of β-cell function failure is non-linear with a tapering decay rate. Furthermore, initial FCP levels may predict β-cell function failure in Chinese autoimmune T1D patients.
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Affiliation(s)
- Xia Li
- Institute of Metabolism and Endocrinology, The Second Xiangya Hospital and the Diabetes Center, Key Laboratory of Diabetes Immunology, Ministry of Education, Central South University, National Clinical Research Center for Metabolic Diseases, Changsha, China
| | - Jin Cheng
- Institute of Metabolism and Endocrinology, The Second Xiangya Hospital and the Diabetes Center, Key Laboratory of Diabetes Immunology, Ministry of Education, Central South University, National Clinical Research Center for Metabolic Diseases, Changsha, China
| | - Gan Huang
- Institute of Metabolism and Endocrinology, The Second Xiangya Hospital and the Diabetes Center, Key Laboratory of Diabetes Immunology, Ministry of Education, Central South University, National Clinical Research Center for Metabolic Diseases, Changsha, China
| | - Shuoming Luo
- Institute of Metabolism and Endocrinology, The Second Xiangya Hospital and the Diabetes Center, Key Laboratory of Diabetes Immunology, Ministry of Education, Central South University, National Clinical Research Center for Metabolic Diseases, Changsha, China
| | - Zhiguang Zhou
- Institute of Metabolism and Endocrinology, The Second Xiangya Hospital and the Diabetes Center, Key Laboratory of Diabetes Immunology, Ministry of Education, Central South University, National Clinical Research Center for Metabolic Diseases, Changsha, China
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32
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Oram RA, Sims EK, Evans-Molina C. Beta cells in type 1 diabetes: mass and function; sleeping or dead? Diabetologia 2019; 62:567-577. [PMID: 30767048 PMCID: PMC6688846 DOI: 10.1007/s00125-019-4822-4] [Citation(s) in RCA: 88] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 11/27/2018] [Indexed: 12/12/2022]
Abstract
Histological analysis of donor pancreases coupled with measurement of serum C-peptide in clinical cohorts has challenged the idea that all beta cells are eventually destroyed in type 1 diabetes. These findings have raised a number of questions regarding how the remaining beta cells have escaped immune destruction, whether pools of 'sleeping' or dysfunctional beta cells could be rejuvenated and whether there is potential for new growth of beta cells. In this Review, we describe histological and in vivo evidence of persistent beta cells in type 1 diabetes and discuss the limitations of current methods to distinguish underlying beta cell mass in comparison with beta cell function. We highlight that evidence for new beta cell growth in humans many years from diagnosis is limited, and that this growth may be very minimal if at all present. We review recent contributions to the debate around beta cell abnormalities contributing to the pathogenesis of type 1 diabetes. We also discuss evidence for restoration of beta cell function, as opposed to mass, in recent-onset type 1 diabetes, but highlight the absence of data supporting functional recovery in the setting of long-duration diabetes. Finally, future areas of research are suggested to help resolve the source and phenotype of residual beta cells that persist in some, but not all, people with type 1 diabetes.
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Affiliation(s)
- Richard A Oram
- RILD Level 3, Institute of Biomedical and Clinical Science, University of Exeter Medical School, Royal Devon and Exeter Hospital, Barrack Road, Exeter, EX2 5DW, UK.
- NIHR Exeter Clinical Research Facility, University of Exeter Medical School, Exeter, UK.
- The Academic Renal Unit, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK.
| | - Emily K Sims
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- The Herman B Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Carmella Evans-Molina
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA.
- The Herman B Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, IN, USA.
- Department of Medicine, Indiana University School of Medicine, 635 Barnhill Drive, MS 2031A, Indianapolis, IN, 46202, USA.
- Roudebush VA Medical Center, Indianapolis, IN, USA.
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33
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Duca LM, Reboussin BA, Pihoker C, Imperatore G, Saydah S, Mayer-Davis E, Rewers A, Dabelea D. Diabetic ketoacidosis at diagnosis of type 1 diabetes and glycemic control over time: The SEARCH for diabetes in youth study. Pediatr Diabetes 2019; 20:172-179. [PMID: 30556249 PMCID: PMC6361710 DOI: 10.1111/pedi.12809] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 12/05/2018] [Accepted: 12/10/2018] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND The diagnosis of type 1 diabetes (T1D) in youth is often associated with diabetic ketoacidosis (DKA). We aimed to evaluate if the presence of DKA at diagnosis of T1D is associated with less favorable hemoglobin A1c (HbA1c) trajectories over time. METHODS The SEARCH for Diabetes in Youth study of 1396 youth aged <20 years with newly diagnosed T1D were followed for up to 13 (median 8 [interquartile range or IQR 6-9]) years after diagnosis. Of these, 397 (28%) had DKA (bicarbonate level < 15 mmol/L and/or pH < 7.25 (venous) or < 7.30 (arterial or capillary) or mention of DKA in medical records) at diabetes onset. Longitudinal HbA1c levels were measured at each follow-up visit (average number of HbA1c measures 3.4). A linear piecewise mixed effects model was used to analyze the effect of DKA status at diagnosis of T1D on long-term glycemic control, adjusting for age at diagnosis, diabetes duration at baseline, sex, race/ethnicity, household income, health insurance status, time-varying insulin regimen and glucose self-monitoring, study site, and baseline fasting C-peptide level. RESULTS At baseline, HbA1c levels were significantly higher in youth with T1D diagnosed in DKA vs those who were not (9.9% ± 1.5% vs 8.5% ± 1.4%, respectively). After the first year with diabetes, there was a significant difference in the rate of change in HbA1c levels by DKA status: HbA1c was 0.16% higher each year in youth with DKA compared to those without (interaction P-value<0.0001), after adjusting for aforementioned covariates. CONCLUSIONS DKA at T1D diagnosis is associated with worsening glycemic control over time, independent of demographic, socioeconomic, and treatment-related factors and baseline fasting C-peptide.
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Affiliation(s)
- Lindsey M Duca
- Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Beth A Reboussin
- Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Catherine Pihoker
- Department of Pediatrics, University of Washington, Seattle, Washington
| | - Giuseppina Imperatore
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Sharon Saydah
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Elizabeth Mayer-Davis
- Departments of Nutrition and Medicine, Gillings School of Global Public Health and School of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Arleta Rewers
- Department of Pediatrics, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado
| | - Dana Dabelea
- Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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34
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Exploring C-peptide loss in type 1 diabetes using growth curve analysis. PLoS One 2018; 13:e0199635. [PMID: 29969494 PMCID: PMC6029769 DOI: 10.1371/journal.pone.0199635] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 06/11/2018] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES C-peptide (CP) loss in type 1 diabetes (T1D) is highly variable, and factors influencing it are poorly understood. We modelled CP values in T1D patients from diagnosis for up to 6 years, treating the serial data as growth curves plotted against time since diagnosis. The aims were to summarise the pattern of CP loss (i.e. growth curve shape) in individual patients in simple terms, and to identify baseline characteristics that predict this pattern in individuals. MATERIALS AND METHODS Between 1976 and 2011, 442 T1D patients initially aged <18y underwent 120-minute mixed meal tolerance tests (MMTT) to calculate area under the curve (AUC) CP, at 3, 9, 18, 30, 48 and 72 months after diagnosis (n = 1537). The data were analysed using the novel SITAR mixed effects growth curve model (SuperImposition by Translation And Rotation). It fits a mean AUC growth curve, but also allows the curve's mean level and rate of fall to vary between individuals so as to best fit the individual patient curves. These curve adjustments define individual curve shape. RESULTS The square root (√) AUC scale provided the best fit. The mean levels and rates of fall for individuals were normally distributed and uncorrelated with each other. Age at diagnosis and √AUC at 3 months strongly predicted the patient-specific mean levels, while younger age at diagnosis (p<0.0001) and the 120-minute CP value of the 3-month MMTT (p = 0.002) predicted the patient-specific rates of fall. CONCLUSIONS SITAR growth curve analysis is a useful tool to assess CP loss in type 1 diabetes, explaining patient differences in terms of their mean level and rate of fall. A definition of rapid CP loss could be based on a quantile of the rate of fall distribution, allowing better understanding of factors determining CP loss and stratification of patients into targeted therapies.
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35
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Shields BM, McDonald TJ, Oram R, Hill A, Hudson M, Leete P, Pearson ER, Richardson SJ, Morgan NG, Hattersley AT, Roep BO, Tree TI, Hammersley S, Bolt R, Hill AV. C-Peptide Decline in Type 1 Diabetes Has Two Phases: An Initial Exponential Fall and a Subsequent Stable Phase. Diabetes Care 2018; 41:1486-1492. [PMID: 29880650 PMCID: PMC6027962 DOI: 10.2337/dc18-0465] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 04/16/2018] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The decline in C-peptide in the 5 years after diagnosis of type 1 diabetes has been well studied, but little is known about the longer-term trajectory. We aimed to examine the association between log-transformed C-peptide levels and the duration of diabetes up to 40 years after diagnosis. RESEARCH DESIGN AND METHODS We assessed the pattern of association between urinary C-peptide/creatinine ratio (UCPCR) and duration of diabetes in cross-sectional data from 1,549 individuals with type 1 diabetes using nonlinear regression approaches. Findings were replicated in longitudinal follow-up data for both UCPCR (n = 161 individuals, 326 observations) and plasma C-peptide (n = 93 individuals, 473 observations). RESULTS We identified two clear phases of C-peptide decline: an initial exponential fall over 7 years (47% decrease/year [95% CI -51, -43]) followed by a stable period thereafter (+0.07%/year [-1.3, +1.5]). The two phases had similar durations and slopes in patients above and below the median age at diagnosis (10.8 years), although levels were lower in the younger patients irrespective of duration. Patterns were consistent in both longitudinal UCPCR (n = 162; ≤7 years duration: -48%/year [-55, -38]; >7 years duration -0.1% [-4.1, +3.9]) and plasma C-peptide (n = 93; >7 years duration only: -2.6% [-6.7, +1.5]). CONCLUSIONS These data support two clear phases of C-peptide decline: an initial exponential fall over a 7-year period, followed by a prolonged stabilization where C-peptide levels no longer decline. Understanding the pathophysiological and immunological differences between these two phases will give crucial insights into understanding β-cell survival.
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Affiliation(s)
- Beverley M. Shields
- National Institute for Health Research Exeter Clinical Research Facility, University of Exeter Medical School, Exeter, U.K
| | | | - Richard Oram
- National Institute for Health Research Exeter Clinical Research Facility, University of Exeter Medical School, Exeter, U.K
| | - Anita Hill
- National Institute for Health Research Exeter Clinical Research Facility, University of Exeter Medical School, Exeter, U.K
| | - Michelle Hudson
- National Institute for Health Research Exeter Clinical Research Facility, University of Exeter Medical School, Exeter, U.K
| | - Pia Leete
- Islet Biology Exeter (IBEx), Institute of Biomedical and Clinical Sciences, University of Exeter Medical School, Exeter, U.K
| | - Ewan R. Pearson
- Division of Molecular & Clinical Medicine, School of Medicine, University of Dundee, Dundee, U.K
| | - Sarah J. Richardson
- Islet Biology Exeter (IBEx), Institute of Biomedical and Clinical Sciences, University of Exeter Medical School, Exeter, U.K
| | - Noel G. Morgan
- Islet Biology Exeter (IBEx), Institute of Biomedical and Clinical Sciences, University of Exeter Medical School, Exeter, U.K
| | - Andrew T. Hattersley
- National Institute for Health Research Exeter Clinical Research Facility, University of Exeter Medical School, Exeter, U.K
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Skog O, Korsgren O. Aetiology of type 1 diabetes: Physiological growth in children affects disease progression. Diabetes Obes Metab 2018; 20:775-785. [PMID: 29083510 DOI: 10.1111/dom.13144] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 10/06/2017] [Accepted: 10/25/2017] [Indexed: 12/16/2022]
Abstract
The prevailing view is that type 1 diabetes (T1D) develops as a consequence of a severe decline in β-cell mass resulting from T-cell-mediated autoimmunity; however, progression from islet autoantibody seroconversion to overt diabetes and finally to total loss of C-peptide production occurs in most affected individuals only slowly over many years or even decades. This slow disease progression should be viewed in relation to the total β-cell mass of only 0.2 to 1.5 g in adults without diabetes. Focal lesions of acute pancreatitis with accumulation of leukocytes, often located around the ducts, are frequently observed in people with recent-onset T1D, and most patients display extensive periductal fibrosis, the end stage of inflammation. An injurious inflammatory adverse event, occurring within the periductal area, may have negative implications for islet neogenesis, dependent on stem cells residing within or adjacent to the ductal epithelium. This could in part prevent the 30-fold increase in β-cell mass that would normally occur during the first 20 years of life. This increase occurs in order to maintain glucose metabolism during the physiological increases in insulin production that are required to balance the 20-fold increase in body weight during childhood and increased insulin resistance during puberty. Failure to expand β-cell mass during childhood would lead to clinically overt T1D and could help to explain the apparently more aggressive form of T1D occurring in growing children when compared with that observed in affected adults.
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Affiliation(s)
- Oskar Skog
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Olle Korsgren
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
- Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden
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Stawiski K, Pietrzak I, Młynarski W, Fendler W, Szadkowska A. NIRCa: An artificial neural network-based insulin resistance calculator. Pediatr Diabetes 2018. [PMID: 28626972 DOI: 10.1111/pedi.12551] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Direct measurement of insulin sensitivity in children with type 1 diabetes is cumbersome and time consuming. OBJECTIVE The aim of our study was to develop novel, accurate machine learning-based methods of insulin resistance estimation in children with type 1 diabetes. METHODS A hyperinsulinemic hyperglycemic clamp study was performed to evaluate the glucose disposal rate (GDR) in a study group consisting of 315 patients aged 7.6 to 19.7 years. The group was randomly divided into a training and independent testing set for model performance assessment. GDR was estimated on the basis of simple clinical variables using 2 non-linear methods: artificial neural networks (ANN) and multivariate adaptive regression splines (MARSplines). The results were compared against the most frequently used predictive model, based on waist circumference, triglyceride (TG), and HbA1c levels. RESULTS The reference model showed moderate performance ( R 2 = 0.26) with a median absolute percentage error of 49.1%, and with the worst fit observed in young (7-12 years) children ( R 2 = 0.17). Predictions of the MARSplines model were significantly more accurate than those of the reference model (median error 3.6%, R 2 = 0.44 P < .0001). The predictions of the ANN, however, showed significantly lower error than those of the reference model (P < .0001) and MARSplines (P < .0001) and better fit regardless of patient age. ANN-estimated GDRs were within a ±20% error range in 75% of cases with a median error of 0.6% and an R 2 = 0.66. The predictive tool is available at http://link.konsta.com.pl/gdr. CONCLUSIONS The developed GDR estimation model reliant on ANN allows for an optimized prediction of GDR for research and clinical purposes.
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Affiliation(s)
- Konrad Stawiski
- Department of Biostatistics and Translational Medicine, Medical University of Lodz, Lodz, Poland
| | - Iwona Pietrzak
- Department of Pediatrics, Oncology, Hematology and Diabetology, Medical University of Lodz, Lodz, Poland
| | - Wojciech Młynarski
- Department of Pediatrics, Oncology, Hematology and Diabetology, Medical University of Lodz, Lodz, Poland
| | - Wojciech Fendler
- Department of Biostatistics and Translational Medicine, Medical University of Lodz, Lodz, Poland.,Department of Pediatrics, Oncology, Hematology and Diabetology, Medical University of Lodz, Lodz, Poland.,Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Agnieszka Szadkowska
- Department of Pediatrics, Oncology, Hematology and Diabetology, Medical University of Lodz, Lodz, Poland
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Liu Y, Tan Q, Liu F. Differentially methylated circulating DNA: A novel biomarker to monitor beta cell death. J Diabetes Complications 2018; 32:349-353. [PMID: 29415820 DOI: 10.1016/j.jdiacomp.2017.08.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Revised: 08/25/2017] [Accepted: 08/26/2017] [Indexed: 01/05/2023]
Abstract
Diabetes mellitus (DM) is a metabolic disorder of glucose homeostasis caused by insufficient secretion or inadequate action of insulin. Nowadays, the increased morbidity of DM is a worldwide issue. Pancreatic beta cell death plays a key role in the progress of DM, especially Type 1 diabetes (T1D). Traditional biomarkers, such as C-peptide and islet autoimmune antibodies are limited to reflect beta cell death and to identify high risk patients in the clinical practice. Recently, a novel biomarker, differentially methylated circulating DNA, has become a research hotspot. It has better sensitivity and specificity in the detection of beta cell death. Assays of beta cell-derived differentially methylated insulin DNA in serum are helpful to predict the possibility to develop T1D in the high risk population. They have also been applied to evaluate beta cell death in Type 2 diabetes (T2D), gestational diabetes mellitus (GDM), islet transplantation and islet specific immune therapy. Although more studies are needed to identify the best methylation target sites in the INS gene, differentially methylated circulating DNA may be a good method to evaluate the progression and prognosis of islet related diseases in the future.
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Affiliation(s)
- Yingfeng Liu
- Shanghai Key Laboratory of Diabetes, Shanghai Clinical Medical Center of Diabetes, Shanghai Key Clinical Center of Metabolic Diseases, Shanghai Institute for Diabetes, Department of Endocrinology & Metabolism, Shanghai Jiao-Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Qiyuan Tan
- Shanghai Key Laboratory of Diabetes, Shanghai Clinical Medical Center of Diabetes, Shanghai Key Clinical Center of Metabolic Diseases, Shanghai Institute for Diabetes, Department of Endocrinology & Metabolism, Shanghai Jiao-Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Fang Liu
- Shanghai Key Laboratory of Diabetes, Shanghai Clinical Medical Center of Diabetes, Shanghai Key Clinical Center of Metabolic Diseases, Shanghai Institute for Diabetes, Department of Endocrinology & Metabolism, Shanghai Jiao-Tong University Affiliated Sixth People's Hospital, Shanghai, China.
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Nagl K, Hermann JM, Plamper M, Schröder C, Dost A, Kordonouri O, Rami-Merhar B, Holl RW. Factors contributing to partial remission in type 1 diabetes: analysis based on the insulin dose-adjusted HbA1c in 3657 children and adolescents from Germany and Austria. Pediatr Diabetes 2017; 18:428-434. [PMID: 27416952 DOI: 10.1111/pedi.12413] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 05/24/2016] [Accepted: 06/07/2016] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Insulin dose-adjusted hemoglobin A1c (HbA1C, IDAA1c) correlates well with stimulated C-peptide levels, but has not yet been evaluated in a large cohort of patients with Type 1 diabetes (T1D). METHODS We investigated prevalence of partial remission (PREM) defined by IDAA1c ≤9 in 3657 in children with new-onset T1D who were continuously followed over 6 years. We evaluated the predictors of PREM using the multicenter database from the DPV (Diabetes Patienten Verlaufsdokumentation) registry. RESULTS PREM occurred in 71% of patients. Median duration was 9 (0-21) months. Compared to children <5 years at T1D onset, those aged 5-10 and ≥10 years had twice the chance of developing PREM (OR: 2.08, CI: 1.67-2.60; P < .001 and OR: 2.16, CI: 1.70-2.75; P < .001). Boys were more likely to develop PREM than girls (OR 1.41, CI: 1.18-1.69; P = .0002). Further predictors for PREM were: ketoacidosis, autoantibodies, and HbA1c at T1D onset. These results were confirmed by quantile regression analysis with duration of PREM as dependent variable. CONCLUSION This research on a large cohort provides insight into epidemiologic characteristics of PREM in T1D defined by IDAA1c. As IDAA1c does not discriminate between insulin sensitivity and secretion, available data cannot resolve whether the sex-difference in PREM reflects innate higher insulin resistance in girls, or better beta-cell recovery in boys. Further research is needed to clarify the usefulness and performance of IDAA1c in clinical practice.
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Affiliation(s)
- Katrin Nagl
- Department of Pediatrics and Adolescent Medicine, Medical University Vienna, Austria
| | - Julia M Hermann
- Epidemiology and Medical Biometry, University of Ulm, Germany.,German Center for Diabetes Research (DZD), München-Neuherberg, Germany
| | | | | | - Axel Dost
- Department of Pediatrics, University Hospital Jena, Germany
| | | | - Birgit Rami-Merhar
- Department of Pediatrics and Adolescent Medicine, Medical University Vienna, Austria
| | - Reinhard W Holl
- Epidemiology and Medical Biometry, University of Ulm, Germany.,German Center for Diabetes Research (DZD), München-Neuherberg, Germany
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41
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von Oettingen JE, Wolfsdorf JI, Feldman HA, Rhodes ET. Utility of diabetes-associated autoantibodies for classification of new onset diabetes in children and adolescents. Pediatr Diabetes 2016; 17:417-25. [PMID: 26315669 PMCID: PMC5318301 DOI: 10.1111/pedi.12304] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2015] [Revised: 07/14/2015] [Accepted: 07/15/2015] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE To determine whether measuring diabetes-associated autoantibodies (DAA) in pediatric new onset diabetes (NODM) can be restricted to patients with equivocal diabetes type. RESEARCH DESIGN AND METHODS Retrospective analysis of all patients with NODM admitted to Boston Children's Hospital from 1 October 2007 to 1 July 2013 who had measurement of DAA [glutamic acid decarboxylase, insulin, insulinoma-associated antigen 2 (IA-2)]. Data collection included initial diagnosis of diabetes type before DAA results and at follow-up. We used logistic regression to predict type 1 diabetes (T1D) and developed a clinical score to classify diabetes type. RESULTS Of 1089 patients (45.4% female, 76.7% White, age 10.6 ± 4.5 yr), initial diagnosis was 1021 (93.8%) T1D, 42 (3.9%) type 2 diabetes (T2D), and 26 (2.4%) other. Of 993 patients with clinical T1D, 78 (7.9%) were DAA-, and of 42 patients with clinical T2D, 12 (28.6%) were DAA+. Type of diabetes was reclassified at follow-up in less than 6% of patients. Data from a subset of 736 patients were used to develop a scoring system to predict T1D. Using weight z-score, age, and race, the scoring system had 91.7% sensitivity, 82% specificity, and a positive predictive value of 98.6%, and suggested DAA measurement was unnecessary in 85.3% of patients. Findings were similar in a validation cohort of 234 patients. CONCLUSIONS Application of a simple scoring system may reduce to ∼15% the number of DAA measurements needed to classify diabetes type, resulting in substantial cost savings. Clinical judgment should guide the decision to measure DAA.
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Affiliation(s)
- Julia E von Oettingen
- Division of Endocrinology, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Joseph I Wolfsdorf
- Division of Endocrinology, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Henry A Feldman
- Division of Endocrinology, Boston Children's Hospital, Boston, MA, USA
- Clinical Research Center, Boston Children's Hospital, Boston, MA, USA
| | - Erinn T Rhodes
- Division of Endocrinology, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
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42
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Gregg B, Connor CG, Cheng P, Ruedy KJ, Beck RW, Kollman C, Schatz D, Cengiz E, Tamborlane WV, Klingensmith GJ, Lee JM. C-peptide levels in pediatric type 2 diabetes in the Pediatric Diabetes Consortium T2D Clinic Registry. Pediatr Diabetes 2016; 17:274-80. [PMID: 25940861 DOI: 10.1111/pedi.12280] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Revised: 03/25/2015] [Accepted: 04/07/2015] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To describe C-peptide levels in a large cohort of children with type 2 diabetes T2D and examine associations with demographic and clinical factors. METHODS The Pediatric Diabetes Consortium (PDC) T2D Registry has collected clinical and biologic data from youth with T2D cared for at eight US Pediatric Diabetes Centers. In this study, we assessed C-peptide levels in 331 youth with T2D (mean age, 16.1 ± 2.5 yr; median T2D duration, 2.4 yr). RESULTS Median (interquartile range) for 90 fasted C-peptide measurements was 3.5 ng/mL (2.3-4.8 ng/mL) [1.2 nmol/L (0.8-1.6 nmol/L)] and for 241 random non-fasted C-peptide measurements were 4.2 ng/mL (2.6-7.0 ng/mL) [1.4 nmol/L (0.9-2.3 nmol/L)]. C-peptide levels were lower with insulin therapy (p < 0.001), lower body mass index (p < 0.001), hemoglobin A1c (HbA1c) ≥9% (p < 0.001), and T2D duration ≥ 6 yr (p = 0.04). Among those with duration ≥6 yr being treated with insulin and with a HbA1c level ≥9.0% (75 mmol/L), 75% of the fasted and 80% of the non-fasted C-peptide values were above 0.2 nmol/L. CONCLUSIONS In youth with T2D, a decline in C-peptide is associated with deterioration of metabolic control and the need for insulin treatment. C-peptide levels decrease over time. However, even insulin-treated patients with 6 or more years of T2D and elevated HbA1c levels retain substantial endogenous insulin secretion.
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Affiliation(s)
- Brigid Gregg
- Department of Pediatric Endocrinology, Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
| | | | | | | | - Roy W Beck
- Jaeb Center for Health Research, Tampa, FL, USA
| | | | - Desmond Schatz
- Pediatric Endocrinology, University of Florida, Gainesville, FL, USA
| | - Eda Cengiz
- Pediatric Endocrinology, Yale University, New Haven, CT, USA
| | | | - Georgeanna J Klingensmith
- Department of Pediatrics, Barbara Davis Center for Childhood Diabetes, University of Colorado, Aurora, CO, USA
| | - Joyce M Lee
- Department of Pediatric Endocrinology, Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA.,Child Health Evaluation and Research Unit, University of Michigan, Ann Arbor, MI, USA
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Leslie RD, Palmer J, Schloot NC, Lernmark A. Diabetes at the crossroads: relevance of disease classification to pathophysiology and treatment. Diabetologia 2016; 59:13-20. [PMID: 26498592 DOI: 10.1007/s00125-015-3789-z] [Citation(s) in RCA: 126] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 09/21/2015] [Indexed: 12/16/2022]
Abstract
Diabetes is not a single homogeneous disease but composed of many diseases with hyperglycaemia as a common feature. Four factors have, historically, been used to identify this diversity: the age at onset; the severity of the disease, i.e. degree of loss of beta cell function; the degree of insulin resistance and the presence of diabetes-associated autoantibodies. Our broad understanding of the distinction between the two major types, type 1 diabetes mellitus and type 2 diabetes mellitus, are based on these factors, but it has become apparent that they do not precisely capture the different disease forms. Indeed, both major types of diabetes have common features, encapsulated by adult-onset autoimmune diabetes and maturity-onset diabetes of the young. As a result, there has been a repositioning of our understanding of diabetes. In this review, drawing on recent literature, we discuss the evidence that autoimmune type 1 diabetes has a broad clinical phenotype with diverse therapeutic options, while the term non-autoimmune type 2 diabetes obscures the optimal management strategy because it encompasses substantial heterogeneity. Underlying these developments is a general progression towards precision medicine with the need for precise patient characterisation, currently based on clinical phenotypes but in future augmented by laboratory-based tests.
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Affiliation(s)
- R David Leslie
- Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, E1 2AT, UK.
| | - Jerry Palmer
- University of Washington, VA Puget Sound Health Care System, Seattle, USA
| | - Nanette C Schloot
- Institute for Clinical Diabetology at the German Diabetes Center, Heinrich-Heine University, Düsseldorf, Germany
- Lilly Deutschland GmbH, Bad Homburg, Germany
| | - Ake Lernmark
- Department of Clinical Sciences, Lund University/CRC, Malmö, Sweden
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Liu L, Yang D, Zhang Y, Lin S, Zheng X, Lin S, Chen L, Zhang X, Li L, Liang G, Yao B, Yan J, Weng J. Glycaemic control and its associated factors in Chinese adults with type 1 diabetes mellitus. Diabetes Metab Res Rev 2015; 31:803-10. [PMID: 26386354 DOI: 10.1002/dmrr.2716] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2015] [Revised: 07/12/2015] [Accepted: 08/12/2015] [Indexed: 02/05/2023]
Abstract
BACKGROUND Glycaemic control is a great challenge in the management of type 1 diabetes mellitus (T1DM). There is limited data concerning glycaemic control among adults with T1DM. We used data from the Guangdong T1DM Translational Medicine Study to evaluate glycaemic control and its associated factors in Chinese adults with T1DM. METHODS This cross-sectional analysis included 827 participants who were 18 years of age or older and had been living with T1DM for at least 1 year. Participants with HbA1c levels <7% were compared against those with HbA1c levels ≥ 7%. A multivariate logistic regression model was used to examine factors associated with glycaemic control. RESULTS Among the 827 participants, the mean age was 34.2 ± 12.1 years and the median (interquartile range) duration of diabetes was 6.1 (3.4, 10.4) years. The median HbA1c level was 8.5% (7.5%, 10.2%). Only one-fifth of participants had HbA1c levels <7%. Insufficient glycaemic control (HbA1c ≥ 7%) was strongly associated with infrequent self-monitoring of blood glucose (OR = 1.21, 95% CI 1.14 ~ 1.29, p = 0.000), high insulin dose (OR = 1.27, 95% CI 1.07 ~ 1.52, p = 0.006), smoking (OR = 3.11, 95% CI 1.44 ~ 6.72, p = 0.004), low-frequency clinical visits (OR = 2.74, 95% CI 1.47 ~ 5.10, p = 0.001), the presence of diabetic autoantibodies (OR = 1.63, 95% CI 1.07 ~ 2.48, p = 0.022) and low fasting C-peptide (FCP) levels (OR = 1.21, 95% CI 1.01 ~ 1.46, p = 0.049) after adjustment for age at disease onset, education level, household income and diet control. CONCLUSIONS Most adult patients with T1DM did not achieve the HbA1c target. Identifying determinants for glycaemic control provides us valuable information to improve glycaemic control in these patients. Copyright © 2015 John Wiley & Sons, Ltd.
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Affiliation(s)
- Li Liu
- Department of Endocrinology and Metabolic Disease, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- Guangdong Diabetes Center, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Diabetology, Guangzhou, China
| | - Daizhi Yang
- Department of Endocrinology and Metabolic Disease, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- Guangdong Diabetes Center, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Diabetology, Guangzhou, China
| | - Yan Zhang
- Department of Endocrinology and Metabolic Disease, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- Guangdong Diabetes Center, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Diabetology, Guangzhou, China
| | - Shuo Lin
- Department of Endocrinology and Metabolic Disease, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- Guangdong Diabetes Center, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Diabetology, Guangzhou, China
| | - Xueying Zheng
- Department of Endocrinology and Metabolic Disease, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- Guangdong Diabetes Center, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Diabetology, Guangzhou, China
| | - Shaoda Lin
- Department of Endocrinology, the First Affiliated Hospital of Shantou University, Shantou, China
| | - Lishu Chen
- Department of Endocrinology, the Second Affiliated Hospital of Shantou University Medical College, Shantou, China
| | - Xiuwei Zhang
- Department of Endocrinology, Dongguan People's Hospital, Dongguan, China
| | - Lu Li
- Department of Endocrinology, Shenzhen People's Hospital, Shenzhen, China
| | - Ganxiong Liang
- Department of Endocrinology, Zhongshan People's Hospital, Zhongshan, China
| | - Bin Yao
- Department of Endocrinology and Metabolic Disease, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- Guangdong Diabetes Center, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Diabetology, Guangzhou, China
| | - Jinhua Yan
- Department of Endocrinology and Metabolic Disease, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- Guangdong Diabetes Center, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Diabetology, Guangzhou, China
| | - Jianping Weng
- Department of Endocrinology and Metabolic Disease, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- Guangdong Diabetes Center, Sun Yat-sen University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Diabetology, Guangzhou, China
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Hannon TS, Arslanian SA. The changing face of diabetes in youth: lessons learned from studies of type 2 diabetes. Ann N Y Acad Sci 2015; 1353:113-37. [PMID: 26448515 DOI: 10.1111/nyas.12939] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 08/17/2015] [Accepted: 08/19/2015] [Indexed: 12/18/2022]
Abstract
The incidence of youth type 2 diabetes (T2D), linked with obesity and declining physical activity in high-risk populations, is increasing. Recent multicenter studies have led to a number of advances in our understanding of the epidemiology, pathophysiology, diagnosis, treatment, and complications of this disease. As in adult T2D, youth T2D is associated with insulin resistance, together with progressive deterioration in β cell function and relative insulin deficiency in the absence of diabetes-related immune markers. In contrast to adult T2D, the decline in β cell function in youth T2D is three- to fourfold faster, and therapeutic failure rates are significantly higher in youth than in adults. Whether the more aggressive nature of youth T2D is driven by genetic heterogeneity or physiology/metabolic maladaptation is yet unknown. Besides metformin, the lack of approved pharmacotherapeutic agents for youth T2D that target the pathophysiological mechanisms is a major barrier to optimal diabetes management. There is a significant need for effective therapeutic options, in addition to increased prevention, to halt the projected fourfold increase in youth T2D by 2050 and the consequences of heightened diabetes-related morbidity and mortality at younger ages.
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Affiliation(s)
- Tamara S Hannon
- Indiana University School of Medicine, Department of Pediatrics, Sections of Pediatric Endocrinology & Diabetology and Pediatric Comparative Effectiveness Research, Indianapolis, Indiana
| | - Silva A Arslanian
- Children's Hospital of University of Pittsburgh Medical Center, Department of Pediatrics, Divisions of Weight Management and Pediatric Endocrinology, Metabolism and Diabetes Mellitus, Pittsburgh, Pennsylvania
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Freeby MJ, Kringas P, Goland RS, Leibel RL, Maffei A, Divgi C, Ichise M, Harris PE. Cross-sectional and Test-Retest Characterization of PET with [(18)F]FP-(+)-DTBZ for β Cell Mass Estimates in Diabetes. Mol Imaging Biol 2015; 18:292-301. [PMID: 26370678 PMCID: PMC4783444 DOI: 10.1007/s11307-015-0888-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Revised: 07/07/2015] [Accepted: 08/06/2015] [Indexed: 12/15/2022]
Abstract
Purpose The vesicular monoamine transporter, type 2 (VMAT2) is expressed by insulin producing β cells and was evaluated as a biomarker of β cell mass (BCM) by positron emission tomography (PET) with [18F]fluoropropyl-dihydrotetrabenazine ([18F]FP-(+)-DTBZ). Procedures We evaluated the feasibility of longitudinal pancreatic PET VMAT2 quantification in the pancreas in two studies of healthy controls and patients with type 1 or 2 diabetes. VMAT2 binding potential (BPND) was estimated voxelwise using a reference tissue method in a cross-sectional study, followed by assessment of reproducibility using a test-retest paradigm. Metabolic function was evaluated by stimulated c-peptide measurements. Results Pancreatic BPND was significantly decreased in patients with type 1 diabetes relative to controls and the test-retest variability was 9.4 %. Conclusions Pancreatic VMAT2 content is significantly reduced in long-term diabetes patients relative to controls and repeat scans are sufficiently reproducible to suggest the feasibility clinically VMAT2 measurements in longitudinal studies of new onset diabetes. Electronic supplementary material The online version of this article (doi:10.1007/s11307-015-0888-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Matthew J Freeby
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, 90404, USA.,Naomi Berrie Diabetes Center, Columbia University Medical Center, New York, NY, 10032, USA
| | - Patricia Kringas
- Naomi Berrie Diabetes Center, Columbia University Medical Center, New York, NY, 10032, USA
| | - Robin S Goland
- Naomi Berrie Diabetes Center, Columbia University Medical Center, New York, NY, 10032, USA
| | - Rudolph L Leibel
- Naomi Berrie Diabetes Center, Columbia University Medical Center, New York, NY, 10032, USA
| | - Antonella Maffei
- Institute of Genetics and Biophysics Adriano Buzzati-Traverso, Consiglio Nazionale delle Ricerche, 80131, Naples, Italy.,Division of Endocrinology, Department of Medicine, Columbia University Medical Center, New York, NY, 10032, USA
| | - Chaitan Divgi
- Division of Nuclear Medicine and Kreitchman PET Center, Department of Radiology, Columbia University Medical Center, New York, NY, 10032, USA
| | - Masanori Ichise
- Division of Nuclear Medicine and Kreitchman PET Center, Department of Radiology, Columbia University Medical Center, New York, NY, 10032, USA
| | - Paul E Harris
- Naomi Berrie Diabetes Center, Columbia University Medical Center, New York, NY, 10032, USA. .,Division of Endocrinology, Department of Medicine, Columbia University Medical Center, New York, NY, 10032, USA.
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Abstract
Immunotherapies for type 1 diabetes mellitus (T1DM) have been the focus of intense basic and clinical research over the past few decades. Restoring β-cell function is the ultimate goal of intervention trials that target the immune system in T1DM. In an attempt to achieve this aim, different combination therapies have been proposed over the past few years that are based on treatments tackling the various mechanisms involved in the destruction of β cells. The results of clinical trials have not matched expectations based on the positive results from preclinical studies. The heterogeneity of T1DM might explain the negative results obtained, but previous trials have not addressed this issue. However, novel promising combination therapies are being developed, including those that couple immunomodulators with drugs that stimulate β-cell regeneration in order to restore normoglycaemia. This strategy is an encouraging one to pursue the goal of finding a cure for T1DM. This Review summarizes the available data about combination immunotherapies in T1DM, particularly addressing their clinical importance. The available data supporting the use of registered drugs, such as proton pump inhibitors and incretin-based agents, that have been shown to induce β-cell regeneration will also be discussed.
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Affiliation(s)
- Paolo Pozzilli
- Department of Endocrinology and Diabetes, University Campus Bio-Medico, Via Álvaro del Portillo 21, Rome 00128, Italy
| | - Ernesto Maddaloni
- Department of Endocrinology and Diabetes, University Campus Bio-Medico, Via Álvaro del Portillo 21, Rome 00128, Italy
| | - Raffaella Buzzetti
- Department of Experimental Medicine, "Sapienza" University, Viale Regina Elena 324, Rome 00161 Italy
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Davis AK, DuBose SN, Haller MJ, Miller KM, DiMeglio LA, Bethin KE, Goland RS, Greenberg EM, Liljenquist DR, Ahmann AJ, Marcovina SM, Peters AL, Beck RW, Greenbaum CJ. Prevalence of detectable C-Peptide according to age at diagnosis and duration of type 1 diabetes. Diabetes Care 2015; 38:476-81. [PMID: 25519448 DOI: 10.2337/dc14-1952] [Citation(s) in RCA: 152] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE It is generally accepted that complete β-cell destruction eventually occurs in individuals with type 1 diabetes, which has implications for treatment approaches and insurance coverage. The frequency of residual insulin secretion in a large cohort of individuals at varying ages of diagnosis and type 1 diabetes duration is unknown. RESEARCH DESIGN AND METHODS The frequency of residual insulin secretion was determined by measurement of nonfasting serum C-peptide concentration in 919 individuals with type 1 diabetes according to prespecified groups based on age at diagnosis and duration of disease (from 3 to 81 years' duration). Stimulated C-peptide was measured in those with detectable nonfasting values and a group of those with undetectable values as control. RESULTS The overall frequency of detectable nonfasting C-peptide was 29%, decreasing with time from diagnosis regardless of age at diagnosis. In all duration groups, the frequency of C-peptide was higher with diagnosis age >18 years compared with ≤18 years. Nineteen percent of those with undetectable nonfasting C-peptide were C-peptide positive upon stimulation testing. CONCLUSIONS The American Diabetes Association's definition of type 1 diabetes as "usually leading to absolute insulin deficiency" results in clinicians often considering the presence of residual insulin secretion as unexpected in this population. However, our data suggest that residual secretion is present in almost one out of three individuals 3 or more years from type 1 diabetes diagnosis. The frequency of residual C-peptide decreases with time from diagnosis regardless of age at diagnosis, yet at all durations of disease, diagnosis during adulthood is associated with greater frequency and higher values of C-peptide.
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Affiliation(s)
| | | | | | | | | | - Kathleen E Bethin
- School of Medicine and Biomedical Sciences at the University at Buffalo, The State University of New York, Buffalo, NY
| | - Robin S Goland
- Naomi Berrie Diabetes Center at Columbia University, New York, NY
| | | | | | | | | | - Anne L Peters
- Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Roy W Beck
- Jaeb Center for Health Research, Tampa, FL
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Oram RA, McDonald TJ, Shields BM, Hudson MM, Shepherd MH, Hammersley S, Pearson ER, Hattersley AT. Most people with long-duration type 1 diabetes in a large population-based study are insulin microsecretors. Diabetes Care 2015; 38:323-8. [PMID: 25519449 PMCID: PMC5646646 DOI: 10.2337/dc14-0871] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Small studies using ultrasensitive C-peptide assays suggest endogenous insulin secretion is frequently detectable in patients with long-standing type 1 diabetes (T1D), but these studies do not use representative samples. We aimed to use the stimulated urine C-peptide-to-creatinine ratio (UCPCR) to assess C-peptide levels in a large cross-sectional, population-based study of patients with T1D. RESEARCH DESIGN AND METHODS We recruited 924 patients from primary and secondary care in two U.K. centers who had a clinical diagnosis of T1D, were under 30 years of age when they received a diagnosis, and had a diabetes duration of >5 years. The median age at diagnosis was 11 years (interquartile range 6-17 years), and the duration of diabetes was 19 years (11-27 years). All provided a home postmeal UCPCR, which was measured using a Roche electrochemiluminescence assay. RESULTS Eighty percent of patients (740 of 924 patients) had detectable endogenous C-peptide levels (UCPCR >0.001 nmol/mmol). Most patients (52%, 483 of 924 patients) had historically very low undetectable levels (UCPCR 0.0013-0.03 nmol/mmol); 8% of patients (70 of 924 patients) had a UCPCR ≥0.2 nmol/mmol, equivalent to serum levels associated with reduced complications and hypoglycemia. Absolute UCPCR levels fell with duration of disease. Age at diagnosis and duration of disease were independent predictors of C-peptide level in multivariate modeling. CONCLUSIONS This population-based study shows that the majority of long-duration T1D patients have detectable urine C-peptide levels. While the majority of patients are insulin microsecretors, some maintain clinically relevant endogenous insulin secretion for many years after the diagnosis of diabetes. Understanding this may lead to a better understanding of pathogenesis in T1D and open new possibilities for treatment.
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Affiliation(s)
- Richard A Oram
- National Institute for Health Research, Exeter Clinical Research Facility, University of Exeter Medical School, Exeter, U.K
| | - Timothy J McDonald
- National Institute for Health Research, Exeter Clinical Research Facility, University of Exeter Medical School, Exeter, U.K. Department of Blood Sciences, Royal Devon and Exeter NHS Foundation Trust, Exeter, U.K
| | - Beverley M Shields
- National Institute for Health Research, Exeter Clinical Research Facility, University of Exeter Medical School, Exeter, U.K
| | - Michelle M Hudson
- National Institute for Health Research, Exeter Clinical Research Facility, University of Exeter Medical School, Exeter, U.K
| | - Maggie H Shepherd
- National Institute for Health Research, Exeter Clinical Research Facility, University of Exeter Medical School, Exeter, U.K
| | - Suzanne Hammersley
- National Institute for Health Research, Exeter Clinical Research Facility, University of Exeter Medical School, Exeter, U.K
| | - Ewan R Pearson
- Division of Cardiovascular and Diabetes Medicine, Medical Research Institute, Ninewells Hospital and Medical School, University of Dundee, Dundee, U.K
| | - Andrew T Hattersley
- National Institute for Health Research, Exeter Clinical Research Facility, University of Exeter Medical School, Exeter, U.K.
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Lauria A, Barker A, Schloot N, Hosszufalusi N, Ludvigsson J, Mathieu C, Mauricio D, Nordwall M, Van der Schueren B, Mandrup-Poulsen T, Scherbaum WA, Weets I, Gorus FK, Wareham N, Leslie RD, Pozzilli P. BMI is an important driver of β-cell loss in type 1 diabetes upon diagnosis in 10 to 18-year-old children. Eur J Endocrinol 2015; 172:107-13. [PMID: 25378371 DOI: 10.1530/eje-14-0522] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Body weight-related insulin resistance probably plays a role in progression to type 1 diabetes, but has an uncertain impact following diagnosis. In this study, we investigated whether BMI measured at diagnosis was an independent predictor of C-peptide decline 1-year post-diagnosis. DESIGN Multicentre longitudinal study carried out at diagnosis and up to 1-year follow-up. METHODS Data on C-peptide were collected from seven diabetes centres in Europe. Patients were grouped according to age at diagnosis (<5 years, n=126; >5 years <10 years, n=295; >10 years <18 years, n=421; >18 years, n=410). Linear regression was used to investigate whether BMI was an independent predictor of change in fasting C-peptide over 1 year. Models were additionally adjusted for baseline insulin dose and HbA1c. RESULTS In individuals diagnosed between 0 and 5 years, 5 and 10 years and those diagnosed >18 years, we found no association between BMI and C-peptide decline. In patients aged 10-18 years, higher BMI at baseline was associated with a greater decline in fasting C-peptide over 1 year with a decrease (β 95% CI; P value) of 0.025 (0.010, 0.041) nM/kg per m(2) higher baseline BMI (P=0.001). This association remained significant after adjusting for gender and differences in HbA1c and insulin dose (β=0.026, 95% CI=0.0097, 0.042; P=0.002). CONCLUSIONS These observations indicate that increased body weight and increased insulin demand are associated with more rapid disease progression after diagnosis of type 1 diabetes in an age group 10-18 years. This should be considered in studies of β-cell function in type 1 diabetes.
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Affiliation(s)
- A Lauria
- Department of Endocrinology and DiabetesUniversity Campus Bio-Medico, Via Alvaro del Portillo, Rome 21 00128, ItalyMRC Epidemiology UnitCambridge, UKInstitute for Clinical DiabetologyGerman Diabetes Centre, Leibniz-Institute for Diabetes Research and Clinic for Metabolic Diseases Heinrich Heine University, Dusseldorf, GermanySemmelweis University3rd Department of Internal Medicine, Linkoping University, Linkoping, SwedenDivision of PediatricsDepartment of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Linköping, SwedenLaboratory for Experimental Medicine and EndocrinologyKatholieke Universiteit Leuven, Leuven, BelgiumDepartment EndocrinologyHospital Arnau de Vilanova, Lleida, SpainPediatric ClinicVrinnevi Hospital, Norrköping, SwedenDepartment of Biomedical SciencesUniversity of Copenhagen, Copenhagen, DenmarkDepartment of EndocrinologyDiabetes and Rheumatology, Heinrich Heine University, Dusseldorf, GermanyDiabetes Research Center and Academic Hospital (UZ Brussel)Vrije Universiteit Brussel (VUB), Brussel, BelgiumBelgian Diabetes Registry (BDR)Brussels, BelgiumCentre of DiabetesBlizard Institute, Barts and The London School of Medicine, Queen Mary University of London, London, UKDepartment of Molecular Medicine and SurgeryKarolinska Institutet, Stockholm, Sweden
| | - A Barker
- Department of Endocrinology and DiabetesUniversity Campus Bio-Medico, Via Alvaro del Portillo, Rome 21 00128, ItalyMRC Epidemiology UnitCambridge, UKInstitute for Clinical DiabetologyGerman Diabetes Centre, Leibniz-Institute for Diabetes Research and Clinic for Metabolic Diseases Heinrich Heine University, Dusseldorf, GermanySemmelweis University3rd Department of Internal Medicine, Linkoping University, Linkoping, SwedenDivision of PediatricsDepartment of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Linköping, SwedenLaboratory for Experimental Medicine and EndocrinologyKatholieke Universiteit Leuven, Leuven, BelgiumDepartment EndocrinologyHospital Arnau de Vilanova, Lleida, SpainPediatric ClinicVrinnevi Hospital, Norrköping, SwedenDepartment of Biomedical SciencesUniversity of Copenhagen, Copenhagen, DenmarkDepartment of EndocrinologyDiabetes and Rheumatology, Heinrich Heine University, Dusseldorf, GermanyDiabetes Research Center and Academic Hospital (UZ Brussel)Vrije Universiteit Brussel (VUB), Brussel, BelgiumBelgian Diabetes Registry (BDR)Brussels, BelgiumCentre of DiabetesBlizard Institute, Barts and The London School of Medicine, Queen Mary University of London, London, UKDepartment of Molecular Medicine and SurgeryKarolinska Institutet, Stockholm, Sweden
| | - N Schloot
- Department of Endocrinology and DiabetesUniversity Campus Bio-Medico, Via Alvaro del Portillo, Rome 21 00128, ItalyMRC Epidemiology UnitCambridge, UKInstitute for Clinical DiabetologyGerman Diabetes Centre, Leibniz-Institute for Diabetes Research and Clinic for Metabolic Diseases Heinrich Heine University, Dusseldorf, GermanySemmelweis University3rd Department of Internal Medicine, Linkoping University, Linkoping, SwedenDivision of PediatricsDepartment of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Linköping, SwedenLaboratory for Experimental Medicine and EndocrinologyKatholieke Universiteit Leuven, Leuven, BelgiumDepartment EndocrinologyHospital Arnau de Vilanova, Lleida, SpainPediatric ClinicVrinnevi Hospital, Norrköping, SwedenDepartment of Biomedical SciencesUniversity of Copenhagen, Copenhagen, DenmarkDepartment of EndocrinologyDiabetes and Rheumatology, Heinrich Heine University, Dusseldorf, GermanyDiabetes Research Center and Academic Hospital (UZ Brussel)Vrije Universiteit Brussel (VUB), Brussel, BelgiumBelgian Diabetes Registry (BDR)Brussels, BelgiumCentre of DiabetesBlizard Institute, Barts and The London School of Medicine, Queen Mary University of London, London, UKDepartment of Molecular Medicine and SurgeryKarolinska Institutet, Stockholm, Sweden
| | - N Hosszufalusi
- Department of Endocrinology and DiabetesUniversity Campus Bio-Medico, Via Alvaro del Portillo, Rome 21 00128, ItalyMRC Epidemiology UnitCambridge, UKInstitute for Clinical DiabetologyGerman Diabetes Centre, Leibniz-Institute for Diabetes Research and Clinic for Metabolic Diseases Heinrich Heine University, Dusseldorf, GermanySemmelweis University3rd Department of Internal Medicine, Linkoping University, Linkoping, SwedenDivision of PediatricsDepartment of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Linköping, SwedenLaboratory for Experimental Medicine and EndocrinologyKatholieke Universiteit Leuven, Leuven, BelgiumDepartment EndocrinologyHospital Arnau de Vilanova, Lleida, SpainPediatric ClinicVrinnevi Hospital, Norrköping, SwedenDepartment of Biomedical SciencesUniversity of Copenhagen, Copenhagen, DenmarkDepartment of EndocrinologyDiabetes and Rheumatology, Heinrich Heine University, Dusseldorf, GermanyDiabetes Research Center and Academic Hospital (UZ Brussel)Vrije Universiteit Brussel (VUB), Brussel, BelgiumBelgian Diabetes Registry (BDR)Brussels, BelgiumCentre of DiabetesBlizard Institute, Barts and The London School of Medicine, Queen Mary University of London, London, UKDepartment of Molecular Medicine and SurgeryKarolinska Institutet, Stockholm, Sweden
| | - J Ludvigsson
- Department of Endocrinology and DiabetesUniversity Campus Bio-Medico, Via Alvaro del Portillo, Rome 21 00128, ItalyMRC Epidemiology UnitCambridge, UKInstitute for Clinical DiabetologyGerman Diabetes Centre, Leibniz-Institute for Diabetes Research and Clinic for Metabolic Diseases Heinrich Heine University, Dusseldorf, GermanySemmelweis University3rd Department of Internal Medicine, Linkoping University, Linkoping, SwedenDivision of PediatricsDepartment of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Linköping, SwedenLaboratory for Experimental Medicine and EndocrinologyKatholieke Universiteit Leuven, Leuven, BelgiumDepartment EndocrinologyHospital Arnau de Vilanova, Lleida, SpainPediatric ClinicVrinnevi Hospital, Norrköping, SwedenDepartment of Biomedical SciencesUniversity of Copenhagen, Copenhagen, DenmarkDepartment of EndocrinologyDiabetes and Rheumatology, Heinrich Heine University, Dusseldorf, GermanyDiabetes Research Center and Academic Hospital (UZ Brussel)Vrije Universiteit Brussel (VUB), Brussel, BelgiumBelgian Diabetes Registry (BDR)Brussels, BelgiumCentre of DiabetesBlizard Institute, Barts and The London School of Medicine, Queen Mary University of London, London, UKDepartment of Molecular Medicine and SurgeryKarolinska Institutet, Stockholm, Sweden
| | - C Mathieu
- Department of Endocrinology and DiabetesUniversity Campus Bio-Medico, Via Alvaro del Portillo, Rome 21 00128, ItalyMRC Epidemiology UnitCambridge, UKInstitute for Clinical DiabetologyGerman Diabetes Centre, Leibniz-Institute for Diabetes Research and Clinic for Metabolic Diseases Heinrich Heine University, Dusseldorf, GermanySemmelweis University3rd Department of Internal Medicine, Linkoping University, Linkoping, SwedenDivision of PediatricsDepartment of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Linköping, SwedenLaboratory for Experimental Medicine and EndocrinologyKatholieke Universiteit Leuven, Leuven, BelgiumDepartment EndocrinologyHospital Arnau de Vilanova, Lleida, SpainPediatric ClinicVrinnevi Hospital, Norrköping, SwedenDepartment of Biomedical SciencesUniversity of Copenhagen, Copenhagen, DenmarkDepartment of EndocrinologyDiabetes and Rheumatology, Heinrich Heine University, Dusseldorf, GermanyDiabetes Research Center and Academic Hospital (UZ Brussel)Vrije Universiteit Brussel (VUB), Brussel, BelgiumBelgian Diabetes Registry (BDR)Brussels, BelgiumCentre of DiabetesBlizard Institute, Barts and The London School of Medicine, Queen Mary University of London, London, UKDepartment of Molecular Medicine and SurgeryKarolinska Institutet, Stockholm, Sweden
| | - D Mauricio
- Department of Endocrinology and DiabetesUniversity Campus Bio-Medico, Via Alvaro del Portillo, Rome 21 00128, ItalyMRC Epidemiology UnitCambridge, UKInstitute for Clinical DiabetologyGerman Diabetes Centre, Leibniz-Institute for Diabetes Research and Clinic for Metabolic Diseases Heinrich Heine University, Dusseldorf, GermanySemmelweis University3rd Department of Internal Medicine, Linkoping University, Linkoping, SwedenDivision of PediatricsDepartment of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Linköping, SwedenLaboratory for Experimental Medicine and EndocrinologyKatholieke Universiteit Leuven, Leuven, BelgiumDepartment EndocrinologyHospital Arnau de Vilanova, Lleida, SpainPediatric ClinicVrinnevi Hospital, Norrköping, SwedenDepartment of Biomedical SciencesUniversity of Copenhagen, Copenhagen, DenmarkDepartment of EndocrinologyDiabetes and Rheumatology, Heinrich Heine University, Dusseldorf, GermanyDiabetes Research Center and Academic Hospital (UZ Brussel)Vrije Universiteit Brussel (VUB), Brussel, BelgiumBelgian Diabetes Registry (BDR)Brussels, BelgiumCentre of DiabetesBlizard Institute, Barts and The London School of Medicine, Queen Mary University of London, London, UKDepartment of Molecular Medicine and SurgeryKarolinska Institutet, Stockholm, Sweden
| | - M Nordwall
- Department of Endocrinology and DiabetesUniversity Campus Bio-Medico, Via Alvaro del Portillo, Rome 21 00128, ItalyMRC Epidemiology UnitCambridge, UKInstitute for Clinical DiabetologyGerman Diabetes Centre, Leibniz-Institute for Diabetes Research and Clinic for Metabolic Diseases Heinrich Heine University, Dusseldorf, GermanySemmelweis University3rd Department of Internal Medicine, Linkoping University, Linkoping, SwedenDivision of PediatricsDepartment of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Linköping, SwedenLaboratory for Experimental Medicine and EndocrinologyKatholieke Universiteit Leuven, Leuven, BelgiumDepartment EndocrinologyHospital Arnau de Vilanova, Lleida, SpainPediatric ClinicVrinnevi Hospital, Norrköping, SwedenDepartment of Biomedical SciencesUniversity of Copenhagen, Copenhagen, DenmarkDepartment of EndocrinologyDiabetes and Rheumatology, Heinrich Heine University, Dusseldorf, GermanyDiabetes Research Center and Academic Hospital (UZ Brussel)Vrije Universiteit Brussel (VUB), Brussel, BelgiumBelgian Diabetes Registry (BDR)Brussels, BelgiumCentre of DiabetesBlizard Institute, Barts and The London School of Medicine, Queen Mary University of London, London, UKDepartment of Molecular Medicine and SurgeryKarolinska Institutet, Stockholm, Sweden Department of Endocrinology and DiabetesUniversity Campus Bio-Medico, Via Alvaro del Portillo, Rome 21 00128, ItalyMRC Epidemiology UnitCambridge, UKInstitute for Clinical DiabetologyGerman Diabetes Centre, Leibniz-Institute for Diabetes Research and Clinic for Metabolic Diseases Heinrich Heine University, Dusseldorf, GermanySemmelweis University3rd Department of Internal Medicine, Linkoping University, Linkoping, SwedenDivision of PediatricsDepartment of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Linköping, SwedenLaboratory for Experimental Medicine and EndocrinologyKatholieke Universiteit Leuven, Leuven, BelgiumDepartme
| | - B Van der Schueren
- Department of Endocrinology and DiabetesUniversity Campus Bio-Medico, Via Alvaro del Portillo, Rome 21 00128, ItalyMRC Epidemiology UnitCambridge, UKInstitute for Clinical DiabetologyGerman Diabetes Centre, Leibniz-Institute for Diabetes Research and Clinic for Metabolic Diseases Heinrich Heine University, Dusseldorf, GermanySemmelweis University3rd Department of Internal Medicine, Linkoping University, Linkoping, SwedenDivision of PediatricsDepartment of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Linköping, SwedenLaboratory for Experimental Medicine and EndocrinologyKatholieke Universiteit Leuven, Leuven, BelgiumDepartment EndocrinologyHospital Arnau de Vilanova, Lleida, SpainPediatric ClinicVrinnevi Hospital, Norrköping, SwedenDepartment of Biomedical SciencesUniversity of Copenhagen, Copenhagen, DenmarkDepartment of EndocrinologyDiabetes and Rheumatology, Heinrich Heine University, Dusseldorf, GermanyDiabetes Research Center and Academic Hospital (UZ Brussel)Vrije Universiteit Brussel (VUB), Brussel, BelgiumBelgian Diabetes Registry (BDR)Brussels, BelgiumCentre of DiabetesBlizard Institute, Barts and The London School of Medicine, Queen Mary University of London, London, UKDepartment of Molecular Medicine and SurgeryKarolinska Institutet, Stockholm, Sweden
| | - T Mandrup-Poulsen
- Department of Endocrinology and DiabetesUniversity Campus Bio-Medico, Via Alvaro del Portillo, Rome 21 00128, ItalyMRC Epidemiology UnitCambridge, UKInstitute for Clinical DiabetologyGerman Diabetes Centre, Leibniz-Institute for Diabetes Research and Clinic for Metabolic Diseases Heinrich Heine University, Dusseldorf, GermanySemmelweis University3rd Department of Internal Medicine, Linkoping University, Linkoping, SwedenDivision of PediatricsDepartment of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Linköping, SwedenLaboratory for Experimental Medicine and EndocrinologyKatholieke Universiteit Leuven, Leuven, BelgiumDepartment EndocrinologyHospital Arnau de Vilanova, Lleida, SpainPediatric ClinicVrinnevi Hospital, Norrköping, SwedenDepartment of Biomedical SciencesUniversity of Copenhagen, Copenhagen, DenmarkDepartment of EndocrinologyDiabetes and Rheumatology, Heinrich Heine University, Dusseldorf, GermanyDiabetes Research Center and Academic Hospital (UZ Brussel)Vrije Universiteit Brussel (VUB), Brussel, BelgiumBelgian Diabetes Registry (BDR)Brussels, BelgiumCentre of DiabetesBlizard Institute, Barts and The London School of Medicine, Queen Mary University of London, London, UKDepartment of Molecular Medicine and SurgeryKarolinska Institutet, Stockholm, Sweden Department of Endocrinology and DiabetesUniversity Campus Bio-Medico, Via Alvaro del Portillo, Rome 21 00128, ItalyMRC Epidemiology UnitCambridge, UKInstitute for Clinical DiabetologyGerman Diabetes Centre, Leibniz-Institute for Diabetes Research and Clinic for Metabolic Diseases Heinrich Heine University, Dusseldorf, GermanySemmelweis University3rd Department of Internal Medicine, Linkoping University, Linkoping, SwedenDivision of PediatricsDepartment of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Linköping, SwedenLaboratory for Experimental Medicine and EndocrinologyKatholieke Universiteit Leuven, Leuven, BelgiumDepartme
| | - W A Scherbaum
- Department of Endocrinology and DiabetesUniversity Campus Bio-Medico, Via Alvaro del Portillo, Rome 21 00128, ItalyMRC Epidemiology UnitCambridge, UKInstitute for Clinical DiabetologyGerman Diabetes Centre, Leibniz-Institute for Diabetes Research and Clinic for Metabolic Diseases Heinrich Heine University, Dusseldorf, GermanySemmelweis University3rd Department of Internal Medicine, Linkoping University, Linkoping, SwedenDivision of PediatricsDepartment of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Linköping, SwedenLaboratory for Experimental Medicine and EndocrinologyKatholieke Universiteit Leuven, Leuven, BelgiumDepartment EndocrinologyHospital Arnau de Vilanova, Lleida, SpainPediatric ClinicVrinnevi Hospital, Norrköping, SwedenDepartment of Biomedical SciencesUniversity of Copenhagen, Copenhagen, DenmarkDepartment of EndocrinologyDiabetes and Rheumatology, Heinrich Heine University, Dusseldorf, GermanyDiabetes Research Center and Academic Hospital (UZ Brussel)Vrije Universiteit Brussel (VUB), Brussel, BelgiumBelgian Diabetes Registry (BDR)Brussels, BelgiumCentre of DiabetesBlizard Institute, Barts and The London School of Medicine, Queen Mary University of London, London, UKDepartment of Molecular Medicine and SurgeryKarolinska Institutet, Stockholm, Sweden
| | - I Weets
- Department of Endocrinology and DiabetesUniversity Campus Bio-Medico, Via Alvaro del Portillo, Rome 21 00128, ItalyMRC Epidemiology UnitCambridge, UKInstitute for Clinical DiabetologyGerman Diabetes Centre, Leibniz-Institute for Diabetes Research and Clinic for Metabolic Diseases Heinrich Heine University, Dusseldorf, GermanySemmelweis University3rd Department of Internal Medicine, Linkoping University, Linkoping, SwedenDivision of PediatricsDepartment of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Linköping, SwedenLaboratory for Experimental Medicine and EndocrinologyKatholieke Universiteit Leuven, Leuven, BelgiumDepartment EndocrinologyHospital Arnau de Vilanova, Lleida, SpainPediatric ClinicVrinnevi Hospital, Norrköping, SwedenDepartment of Biomedical SciencesUniversity of Copenhagen, Copenhagen, DenmarkDepartment of EndocrinologyDiabetes and Rheumatology, Heinrich Heine University, Dusseldorf, GermanyDiabetes Research Center and Academic Hospital (UZ Brussel)Vrije Universiteit Brussel (VUB), Brussel, BelgiumBelgian Diabetes Registry (BDR)Brussels, BelgiumCentre of DiabetesBlizard Institute, Barts and The London School of Medicine, Queen Mary University of London, London, UKDepartment of Molecular Medicine and SurgeryKarolinska Institutet, Stockholm, Sweden Department of Endocrinology and DiabetesUniversity Campus Bio-Medico, Via Alvaro del Portillo, Rome 21 00128, ItalyMRC Epidemiology UnitCambridge, UKInstitute for Clinical DiabetologyGerman Diabetes Centre, Leibniz-Institute for Diabetes Research and Clinic for Metabolic Diseases Heinrich Heine University, Dusseldorf, GermanySemmelweis University3rd Department of Internal Medicine, Linkoping University, Linkoping, SwedenDivision of PediatricsDepartment of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Linköping, SwedenLaboratory for Experimental Medicine and EndocrinologyKatholieke Universiteit Leuven, Leuven, BelgiumDepartme
| | - F K Gorus
- Department of Endocrinology and DiabetesUniversity Campus Bio-Medico, Via Alvaro del Portillo, Rome 21 00128, ItalyMRC Epidemiology UnitCambridge, UKInstitute for Clinical DiabetologyGerman Diabetes Centre, Leibniz-Institute for Diabetes Research and Clinic for Metabolic Diseases Heinrich Heine University, Dusseldorf, GermanySemmelweis University3rd Department of Internal Medicine, Linkoping University, Linkoping, SwedenDivision of PediatricsDepartment of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Linköping, SwedenLaboratory for Experimental Medicine and EndocrinologyKatholieke Universiteit Leuven, Leuven, BelgiumDepartment EndocrinologyHospital Arnau de Vilanova, Lleida, SpainPediatric ClinicVrinnevi Hospital, Norrköping, SwedenDepartment of Biomedical SciencesUniversity of Copenhagen, Copenhagen, DenmarkDepartment of EndocrinologyDiabetes and Rheumatology, Heinrich Heine University, Dusseldorf, GermanyDiabetes Research Center and Academic Hospital (UZ Brussel)Vrije Universiteit Brussel (VUB), Brussel, BelgiumBelgian Diabetes Registry (BDR)Brussels, BelgiumCentre of DiabetesBlizard Institute, Barts and The London School of Medicine, Queen Mary University of London, London, UKDepartment of Molecular Medicine and SurgeryKarolinska Institutet, Stockholm, Sweden Department of Endocrinology and DiabetesUniversity Campus Bio-Medico, Via Alvaro del Portillo, Rome 21 00128, ItalyMRC Epidemiology UnitCambridge, UKInstitute for Clinical DiabetologyGerman Diabetes Centre, Leibniz-Institute for Diabetes Research and Clinic for Metabolic Diseases Heinrich Heine University, Dusseldorf, GermanySemmelweis University3rd Department of Internal Medicine, Linkoping University, Linkoping, SwedenDivision of PediatricsDepartment of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Linköping, SwedenLaboratory for Experimental Medicine and EndocrinologyKatholieke Universiteit Leuven, Leuven, BelgiumDepartme
| | - N Wareham
- Department of Endocrinology and DiabetesUniversity Campus Bio-Medico, Via Alvaro del Portillo, Rome 21 00128, ItalyMRC Epidemiology UnitCambridge, UKInstitute for Clinical DiabetologyGerman Diabetes Centre, Leibniz-Institute for Diabetes Research and Clinic for Metabolic Diseases Heinrich Heine University, Dusseldorf, GermanySemmelweis University3rd Department of Internal Medicine, Linkoping University, Linkoping, SwedenDivision of PediatricsDepartment of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Linköping, SwedenLaboratory for Experimental Medicine and EndocrinologyKatholieke Universiteit Leuven, Leuven, BelgiumDepartment EndocrinologyHospital Arnau de Vilanova, Lleida, SpainPediatric ClinicVrinnevi Hospital, Norrköping, SwedenDepartment of Biomedical SciencesUniversity of Copenhagen, Copenhagen, DenmarkDepartment of EndocrinologyDiabetes and Rheumatology, Heinrich Heine University, Dusseldorf, GermanyDiabetes Research Center and Academic Hospital (UZ Brussel)Vrije Universiteit Brussel (VUB), Brussel, BelgiumBelgian Diabetes Registry (BDR)Brussels, BelgiumCentre of DiabetesBlizard Institute, Barts and The London School of Medicine, Queen Mary University of London, London, UKDepartment of Molecular Medicine and SurgeryKarolinska Institutet, Stockholm, Sweden
| | - R D Leslie
- Department of Endocrinology and DiabetesUniversity Campus Bio-Medico, Via Alvaro del Portillo, Rome 21 00128, ItalyMRC Epidemiology UnitCambridge, UKInstitute for Clinical DiabetologyGerman Diabetes Centre, Leibniz-Institute for Diabetes Research and Clinic for Metabolic Diseases Heinrich Heine University, Dusseldorf, GermanySemmelweis University3rd Department of Internal Medicine, Linkoping University, Linkoping, SwedenDivision of PediatricsDepartment of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Linköping, SwedenLaboratory for Experimental Medicine and EndocrinologyKatholieke Universiteit Leuven, Leuven, BelgiumDepartment EndocrinologyHospital Arnau de Vilanova, Lleida, SpainPediatric ClinicVrinnevi Hospital, Norrköping, SwedenDepartment of Biomedical SciencesUniversity of Copenhagen, Copenhagen, DenmarkDepartment of EndocrinologyDiabetes and Rheumatology, Heinrich Heine University, Dusseldorf, GermanyDiabetes Research Center and Academic Hospital (UZ Brussel)Vrije Universiteit Brussel (VUB), Brussel, BelgiumBelgian Diabetes Registry (BDR)Brussels, BelgiumCentre of DiabetesBlizard Institute, Barts and The London School of Medicine, Queen Mary University of London, London, UKDepartment of Molecular Medicine and SurgeryKarolinska Institutet, Stockholm, Sweden
| | - P Pozzilli
- Department of Endocrinology and DiabetesUniversity Campus Bio-Medico, Via Alvaro del Portillo, Rome 21 00128, ItalyMRC Epidemiology UnitCambridge, UKInstitute for Clinical DiabetologyGerman Diabetes Centre, Leibniz-Institute for Diabetes Research and Clinic for Metabolic Diseases Heinrich Heine University, Dusseldorf, GermanySemmelweis University3rd Department of Internal Medicine, Linkoping University, Linkoping, SwedenDivision of PediatricsDepartment of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Linköping, SwedenLaboratory for Experimental Medicine and EndocrinologyKatholieke Universiteit Leuven, Leuven, BelgiumDepartment EndocrinologyHospital Arnau de Vilanova, Lleida, SpainPediatric ClinicVrinnevi Hospital, Norrköping, SwedenDepartment of Biomedical SciencesUniversity of Copenhagen, Copenhagen, DenmarkDepartment of EndocrinologyDiabetes and Rheumatology, Heinrich Heine University, Dusseldorf, GermanyDiabetes Research Center and Academic Hospital (UZ Brussel)Vrije Universiteit Brussel (VUB), Brussel, BelgiumBelgian Diabetes Registry (BDR)Brussels, BelgiumCentre of DiabetesBlizard Institute, Barts and The London School of Medicine, Queen Mary University of London, London, UKDepartment of Molecular Medicine and SurgeryKarolinska Institutet, Stockholm, Sweden Department of Endocrinology and DiabetesUniversity Campus Bio-Medico, Via Alvaro del Portillo, Rome 21 00128, ItalyMRC Epidemiology UnitCambridge, UKInstitute for Clinical DiabetologyGerman Diabetes Centre, Leibniz-Institute for Diabetes Research and Clinic for Metabolic Diseases Heinrich Heine University, Dusseldorf, GermanySemmelweis University3rd Department of Internal Medicine, Linkoping University, Linkoping, SwedenDivision of PediatricsDepartment of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Linköping, SwedenLaboratory for Experimental Medicine and EndocrinologyKatholieke Universiteit Leuven, Leuven, BelgiumDepartme
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