ISPAD Clinical Practice Consensus Guidelines 2022: Other complications and associated conditions in children and adolescents with type 1 diabetes

Adolescent Girls With Type 1 Diabetes Develop Changes in Bone Prior to Evidence of Clinical Neuropathy

CONTEXT

Neuropathy and fracture are prevalent complications of type 1 diabetes (T1D). Although correlated in the clinical literature, it remains unknown whether neuropathy contributes to the initiation of bone loss at the earliest stages of disease.

METHODS

We performed a single-center, cross-sectional study to quantify parameters of nerve and bone health in adolescent girls with T1D (n = 21) and associated controls (n = 12). Groups were well matched for age, height, strength, and physical activity.

RESULTS

By high-resolution peripheral quantitative computed tomograpy, participants with T1D had lower trabecular bone volume fraction at the distal radius (-14.6%, P-adj = .095) and the tibia (-12.8%, P-adj = .017) and decreased trabecular thickness (-8.3% radius, P-adj = .007; -7.5% tibia, P-adj = .034) after adjustment for body size. In the tibia only, cortical bone mineral density was increased by 8.6% (P-adj = .024) and porosity was decreased by 52.9% with T1D (P-adj = .012). There were no significant differences in bone density by dual-energy x-ray absorptiometry. Participants with T1D also had lower circulating levels of osteocalcin (-30%, P = .057), and type I collagen cross-linked C-telopeptide (-36%, P = .035), suggesting low bone formation and turnover in T1D. Based on the Michigan Neuropathy Screening Instrument, 9.5% of those with T1D had clinical evidence of diabetic peripheral neuropathy. However, consideration of neuropathy status failed to explain the widespread T1D-associated changes in bone.

CONCLUSION

Our study defines early deficits in trabecular bone microarchitecture, decreased cortical porosity in the tibia, and suppression of biomarkers of bone turnover in adolescent girls with T1D, prior to the onset of symptomatic peripheral neuropathy. These findings inform our understanding of the rapid progression of skeletal disease in young girls with T1D and suggests that early detection and management strategies may help to prevent fracture and related comorbidities later in life.

Body composition in a pediatric population with type-1 diabetes - The importance of planned physical exercise

OBJECTIVE AND METHODS

This study aimed to assess the body composition of pediatric patients with type-1 diabetes (T1D) in a Portuguese pediatric endocrinology/diabetic clinic, using the InBody 570 bioimpedance system. Preschool children (<6 years) and those recently diagnosed (<6 months) were excluded.

RESULTS

The study included 78 patients (53% female). Median age at assessment was 14 years, with 81% pubertal children. Eighty-seven percent were using continuous subcutaneous insulin infusion (CSII), 25% with an automated closed-loop model. Median HbA1c was 7.3%. Most had an adequate body mass index (BMI) standard deviation score (62%) and 48% engaged in regular physical exercise (PE) outside of school. Median percentage body fat (PBF) was 21.5% and was abnormal in 48%, with median visceral adiposity of 4. Despite adequate BMI, 11% had excessive PBF. PBF was significantly associated with visceral fat (r=0.79; P<0.001), female gender (P<0.001) and PE performed out of school (P=0.005). PE was associated with lower PBF (P=0.005), lower visceral fat (P=0.002), and higher muscle-to-fat ratio (P=0.006).

CONCLUSION

Engaging in physical exercise out of school correlated significantly with improved body composition, characterized by reduced PBF and diminished visceral adiposity. Considering the known benefits of physical exercise for metabolic and glycemic control, this study highlights the importance of promoting regular physical exercise in T1D patients.

International Society for Pediatric and Adolescent Diabetes Clinical Practice Consensus Guidelines 2024: Insulin and Adjunctive Treatments in Children and Adolescents with Diabetes

The International Society for Pediatric and Adolescent Diabetes (ISPAD) guidelines represent a rich repository that serves as the only comprehensive set of clinical recommendations for children, adolescents, and young adults living with diabetes worldwide. This chapter builds on the 2022 ISPAD guidelines, and updates recommendations on the principles of intensive insulin regimens, including more intensive forms of multiple daily injections with new-generation faster-acting and ultra-long-acting insulins; a summary of adjunctive medications used alongside insulin treatment that includes details on pramlintide, metformin, glucagon-like peptide-1 (GLP-1) receptor agonists (GLP-1RA) and sodium-glucose cotransporter inhibitors; and key considerations with regard to access to insulin and affordability to ensure that all persons with diabetes who need insulin can obtain it without financial hardship.

Geographic information system mapping and predictors of glycemic control in children and youth with type 1 diabetes: a study from Western India

OBJECTIVES

Geographic Information System (GIS) mapping, is a novel way to provide insights into spatial distribution of type 1 diabetes (T1D) and associations between T1D outcomes and potential predictors. We aimed to explore GIS in children with T1D, and identify predictors of poor glycemic control.

METHODS

Design: Cross-sectional; Participants: 402 children and youth (187 boys) with T1D. Place of residence (coordinates) of participants were geocoded in GIS. They were divided into two groups living in urban or peri-urban areas using ArcGIS Pro. The characteristics of urban/peri-urban living were linked to sociodemographic and biochemical data and spatial autocorrelation analysis was performed. Association between glycemic control and distance to our unit was studied.

RESULTS

Mean age was 13.2 ± 4.7 years; 196 children were living in urban areas, 206 in peri-urban areas. There was significant difference in HbA1c between groups (Urban 9.9 (9.7, 10.2) %, Peri-urban 10.5 (10.1, 10.8) %) (p=0.004); mean difference 0.5 (0.1, 1.0) with poorer glycemic control and higher prevalence of vitamin D sufficiency in peri-urban and higher prevalence of hypothyroidism in urban areas. There was significant correlation between glycemic control (HbA1c) and distance to our unit r=0.108 (0.023, 0.218) (p=0.031). Individuals with an HbA1c ≥9.5 were residing farther away (58.9 (49.4, 68.5) km) as compared to those with HbA1c <9.5 (44.5 (35.1, 53.9) km) (p<0.05).

CONCLUSIONS

Children with T1D when grouped using GIS had differences in glycemic control and comorbidities; peri-urban participants and those residing further away from our unit had poorer glycemic control. Future efforts may be aimed at identifying centers and channelizing resources towards children showing poor glycemic control, thus optimizing disease management.

Increasing prevalence of thyroid autoimmunity in childhood type 1 diabetes in the pre-COVID but not during the COVID era

Introduction

Studies assessing longitudinal changes in the prevalence of autoimmune thyroiditis (AIT) among the pediatric population are limited. During the COVID-19 era, several papers proposed a rise in AIT cases. Our study aimed to analyze the prevalence of thyroid autoimmunity (TA) over a 10-year period spanning pre-pandemic and pandemic years in a population who are regularly screened for thyroid disturbances.

Materials and methods

This single-center retrospective cohort study analyzed data from 1,361 children and young adults with type 1 diabetes (T1D) treated between 2013 and 2022 in Hungary's largest pediatric endocrinology center. Results of anti-thyroid autoantibodies (anti-thyroid peroxidase/ATPO/and antithyroglobulin/ATG/), thyroid function tests (TFTs) and thyroid ultrasound examinations were obtained. Annual prevalence rates of TA and ultrasound-proven thyroiditis were calculated. Mean (± SD) follow-up period was 4.7 (± 2.8) years.

Results

The overall prevalence of TA among our T1D children was 22.8% ([20.3;25.5], 310 cases) with significantly more girls affected (p<0.001). From 2013 to 2022, TA prevalence rose from 15.9% to 20.6% (p=0.041). The increase was detected during the pre-pandemic years but not in the COVID-19 era. Ultrasound-confirmed thyroiditis was present in 80.0% of examined TA cases. Ultrasound positivity rate was stable during the study period. Among our children with TA, 28.5% exhibited clinically relevant thyroid-stimulating hormone (TSH) abnormalities (most commonly subclinical hypothyroidism) and/or were prescribed thyroid medication. Children with AIT had a significantly elevated risk of thyroid dysfunction compared to those with only thyroid autoantibody positivity (p<0.001).

Conclusion

Our results show a rise in the prevalence of thyroid autoimmunity among T1D children over the past decade, but our data do not support the assumed role of SARS-CoV-2 in the development of the disease.

Case report: Looking for relationship between type 1 diabetes and chronic recurrent osteomyelitis: short literature review and case presentation

Background

Childhood autoimmune disorders involve the immune system attacking its own tissues, leading to varied symptoms, while autoinflammatory disorders result from innate immune system dysregulation, both requiring extensive diagnosis and multidisciplinary management due to their complexity.

Case presentation

We present a unique clinical case of a teenager with a combination of autoimmune and autoinflammatory disorders. The initial manifestation of hip pain, coupled with progressive symptoms over several years and findings in multiple magnetic resonance imaging (MRI) scans, culminated in the diagnosis of chronic recurrent multifocal osteomyelitis (CRMO). Subsequently, the patient was diagnosed with type 1 diabetes (T1D), celiac disease, and juvenile idiopathic arthritis.The therapeutic course proved challenging, marked by unsuccessful attempts with nonsteroidal anti-inflammatory drugs (NSAIDs), and biphosphonates. However, a stable clinical status was ultimately achieved upon the introduction of methotrexate, concomitant with insulin therapy for diabetes and the implementation of a gluten-free diet for celiac disease.

Conclusions

Our case showed that the combination of autoimmune and autoinflammatory diseases, brought not only a challenging diagnostic process, but also complicated treatment.

The Overlap between Type 1 Diabetes and Celiac Disease in Children and the Role of Tissue Transglutaminase-IgA Positivity in Endoscopy Decision

INTRODUCTION

Celiac disease (CD)-related antibody positivity in children with type 1 diabetes (T1D) may fluctuate and become negative spontaneously. There are uncertainties about the optimal tissue transglutaminase IgA (tTG-IgA) titre and timing of endoscopy in the diagnosis of CD, and this study aimed to contribute to the debate on the tTG-IgA threshold titre for endoscopy decisions in children with T1D.

METHODS

The data of 991 children with T1D who had undergone serologic evaluation for CD were analysed retrospectively. The tTG-IgA positivity rate and the upper limit of normal (ULN) tTG-IgA positivity were assessed. Participants were grouped according to the frequency, course, and test results of tTG-IgA tests. Those with and without histopathologic diagnosis of CD by endoscopic biopsy were compared in terms of tTG-IgA screening time and tTG-IgA predictive values.

RESULTS

In 10.2% (n:101) of all cases, tTG-IgA antibody was positive and endoscopic biopsy was performed in 68.3% (n:69) of these cases. Of all cases, 4.3% (n:43) were diagnosed with CD by endoscopic biopsy. A tTG-IgA titre of 7×ULN and above was found to be the best predictive value for the diagnosis of CD with 79.1% sensitivity, 80.8% specificity 87.2% positive predictive value, and 70% negative predictive value.

CONCLUSIONS

Approximately 10% of antibody positive cases showed fluctuating and low-titre positivity, and no CD was detected by endoscopic biopsy in the group with fluctuating antibody course. The results of our study suggest that endoscopy in children with tTG-IgA levels 7×ULN or above may prevent both false-positive results and missed cases.

International Society for Pediatric and Adolescent Diabetes Clinical Practice Consensus Guidelines 2024: Diabetes Technologies - Insulin Delivery

The International Society for Pediatric and Adolescent Diabetes (ISPAD) guidelines represent a rich repository that serves as the only comprehensive set of clinical recommendations for children, adolescents, and young adults living with diabetes worldwide. This chapter builds on the 2022 ISPAD guidelines, and summarizes recent advances in the technology behind insulin administration, with special emphasis on insulin pump therapy, especially on glucose-responsive integrated technology that is feasible with the use of automated insulin delivery (AID) systems in children and adolescents. The International Society for Pediatric and Adolescent Diabetes (ISPAD) guidelines represent a rich repository that serves as the only comprehensive set of clinical recommendations for children, adolescents, and young adults living with diabetes worldwide. This chapter builds on the 2022 ISPAD guidelines, and summarizes recent advances in the technology behind insulin administration, with special emphasis on insulin pump therapy, especially on glucose-responsive integrated technology that is feasible with the use of automated insulin delivery (AID) systems in children and adolescents.

Glycaemic control metrics and metabolic dysfunction-associated steatotic liver disease in children and adolescents with type 1 diabetes

AIM

The aim was to examine the prevalence of metabolic dysfunction-associated steatotic liver disease (MASLD), a risk factor for atherosclerotic cardiovascular disease, and its association with glycaemic control metrics in children and adolescents with type 1 diabetes (T1D).

MATERIALS AND METHODS

We enrolled 244 children and adolescents with T1D (115 girls, mean age: 16.2 ± 3.2 years). The diagnosis of MASLD was defined by the presence of hepatic steatosis on ultrasonography in combination with at least one of five common cardiometabolic risk factors. Metrics of short-term and long-term glycaemic control, blood pressure, lipids, anthropometric characteristics and three genetic variants strongly related to MASLD susceptibility (rs738409 [patatin-like phospholipase domain-containing 3], rs58542926 [transmembrane 6 superfamily member 2] and rs1260326 [glucokinase regulator]) were assessed. Characteristics of these subjects with and without MASLD were compared using the unpaired Student t test, Mann-Whitney test or χ2 test as appropriate. Logistic regression analyses were performed to determine the main independent predictors of MASLD.

RESULTS

The prevalence of MASLD was 27.5% in children and adolescents with T1D. Blood pressure, total cholesterol, low-density lipoprotein (LDL) cholesterol, non-high-density lipoprotein cholesterol, HbA1c and time above range (TAR) were significantly higher in subjects with MASLD than in those without MASLD. Mean HbA1c values from diabetes onset (adjusted odds ratio [OR]: 1.703, 95% confidence interval [CI]: 1.040-2.787, p = 0.034), TAR (adjusted OR: 1.028, 95% CI: 1.009-1.047, p = 0.006) and plasma LDL cholesterol (adjusted OR: 1.045, 95% CI: 1.013-1.078, p = 0.004) were independently associated with the presence of MASLD.

CONCLUSIONS

MASLD is a common condition in children and adolescents with T1D. The mean HbA1c values from diabetes onset, TAR and LDL cholesterol levels were the independent predictors of MASLD.

An Evidence-Based Measure to Assess Self-Efficacy Among Adolescents With Type 1 Diabetes Mellitus in Jordan

PURPOSE

The purpose of the study was to assess self-efficacy among adolescents with type 1 diabetes mellitus and to identify its contributing factors using a new measure based on the International Society for Pediatric and Adolescent Diabetes Guidelines: the Type 1 Diabetes Mellitus Self-Efficacy Scale (T1DM-SES).

METHOD

A descriptive, cross-sectional design was used to collect data from 161 adolescents ages between 12 and 18 via an online questionnaire survey, including demographic and management-related variables and the 21 items of T1DM-SES.

RESULTS

Results demonstrated that adolescents had high self-efficacy levels regarding the basic needs to manage their diabetes and relatively moderate and low levels regarding more sophisticated needs, such as adjusting insulin dose to correct fluctuated glucose levels, covering carbohydrates, and managing ketoacidosis at home. Adolescent females and adolescents who have working mothers or caregivers demonstrated higher levels of self-efficacy, whereas adolescents who have another family member with T1DM reported lower levels.

CONCLUSION

Assessing adolescents' self-efficacy using evidence-based measures is crucial for informing health education plans. There should be a greater focus on acquiring the advanced knowledge and skills necessary for adolescents to manage the constantly evolving challenges of diabetes management. Access to health care and sufficient health insurance coverage that encompasses modern technology are fundamental for the effective management of T1DM.

Clinical Characteristics and Prevalence of Celiac Disease in a Large Cohort of Type 1 Diabetes from Saudi Arabia

Background and Objectives: The link between celiac disease (CD) and type 1 diabetes (T1D) has been well-documented in the medical literature and is thought to be due to a shared genetic predisposition in addition to environmental triggers. This study aimed to determine the seroprevalence and biopsy-proven CD (PBCD) prevalence in individuals with T1D from Saudi Arabia and identify their clinical characteristics and the impact on glycemic control. Materials and Methods: A total of 969 children and adolescents with confirmed T1D were investigated. Prospective and retrospective data were collected to include clinical, anthropometric, and biochemical data. Total IgA and anti-TTG-IgA antibodies were screened to detect seropositive cases. Upper intestinal endoscopy and biopsy were performed to find BPCD. Results: The seroprevalence of CD was 14.6% (141/969), while BPCD prevalence was 7.5%. Females had a higher prevalence than males: 17.8% vs. 9.8%, p < 0.001. The CD group had lower HbA1c and more frequent hypoglycemia than the seronegative group. Conclusions: This study highlighted the high prevalence of CD in T1D Saudi patients. CD has multiple effects on glycemic control, growth, and puberty in children and adolescents with T1D. We emphasize the importance of early screening for CD at the time of diabetes diagnosis and periodically after that or if any atypical features present, especially anemia, growth delay, underweight, or frequent hypoglycemia.

Insights in Nutrition to Optimize Type 1 Diabetes Therapy

Nutrition is an essential part of therapy for type 1 diabetes and is constantly evolving, offering growing opportunities to prevent this disease, slow down its evolution, and mitigate it. An attempt was made to bring together the current state of knowledge. In the path from the preclinical phase of the disease to its clinical onset, there is a phase known as the "honeymoon period" or partial remission, where different possible dietary options for combatting this disease have been presented. The most commonly used dietary models were compared, and the most frequent co-existing pathologies, such as overweight, non-alcoholic fatty liver disease, dyslipidemia, celiac disease, and metabolic instability, were addressed from their nutritional and dietary perspectives to provide clinicians with an updated framework of knowledge and support researchers in further investigations into the topic. Finally, a glimpse into the possible interplay between nutrition and the gut microbiome, food security, and ultra-processed food is provided. It is hoped that clinicians treating people with type 1 diabetes will be provided with further opportunities for the daily management of their patients through personalized nutrition.

Managing Children and Adolescents with Type 1 Diabetes and Coexisting Celiac Disease: Real-World Data from a Global Survey

INTRODUCTION

Celiac disease (CD) is among the diseases most commonly associated with type 1 diabetes (T1D). This study aimed to evaluate the worldwide practices and attitudes of physicians involved in pediatric diabetes care regarding diagnosing and managing CD in children with T1D.

METHODS

The 30-item survey was conducted between July and December 2023 aimed at targeting pediatricians with special interest in T1D and CD. It was shared by the JENIOUS - young investigators group of the International Society of Pediatric and Adolescent Diabetes (ISPAD) - and the YES - early career group of the European Society for Pediatric Endocrinology (ESPE).

RESULTS

Overall, 180 physicians (67.8% female) from 25 countries responded. Among respondents, 62.2% expected sustaining optimal glycemic control in children with T1D and CD (T1D + CD) to be more difficult than in children with T1D alone. Majority (81.1%) agreed that more specific guidelines are needed. The follow-up routine for patients with T1D + CD differed, and one-quarter of physicians scheduled more frequent follow-up checkups for these patients. Seventy percent agreed multidisciplinary outpatient clinics for their follow-up is needed. In the multivariate ordinal logistic regression model, a statistically significant predictor of a higher degree of practice according to ISPAD 2022 guidelines was a higher level of country income (OR = 3.34; p < 0.001).

CONCLUSIONS

These results showed variations in physicians' practices regarding managing CD in children with T1D, emphasizing the need for more specific guidelines and intensive education of physicians in managing this population, especially in lower-income countries. Our data also suggest the implementation of multidisciplinary outpatient clinics for their follow-up.

Assessment of Skin Autofluorescence and Its Association with Glycated Hemoglobin, Cardiovascular Risk Markers, and Concomitant Chronic Diseases in Children with Type 1 Diabetes

Skin autofluorescence (sAF) measurement is a non-invasive method used to assess tissue advanced glycation end product (AGE) accumulation. This study aims to characterize sAF's association with (1) glycated hemoglobin (HbA1c) values, (2) cardiovascular risk markers, and (3) common comorbidities (autoimmune thyroiditis, celiac disease) in children with type 1 diabetes (T1D).

MATERIALS AND METHODS

A total of 348 children with T1D aged 3-18 years and 85 age- and gender-matched control subjects were enrolled. sAF was quantified using an AGE Reader (Diagnoptics BV, The Netherlands). The analysis covered HbA1c, blood lipid, and C-reactive protein (CRP) levels, ambulatory blood pressure monitoring records, and body composition parameters. The associations between variables and sAF were assessed using the Mann-Whitney U test and Spearman correlation.

RESULTS

We observed significantly higher sAF values in the T1D group compared to the control (1.40 [1.27-1.53] vs. 1.20 [1.07-1.30, AU]; p = 0.004), consistent across all tested age groups. In the T1D group, sAF was positively correlated with current HbA1c, mean of historical HbA1c values, and T1D duration (r values, respectively: 0.27, 0.22, 0.14, all p < 0.01). Percentage of body fat was positively correlated with sAF (r = 0.120; p = 0.044). No significant correlations were found between sAF and lipid fractions, Z-score of BMI, parameters from 24 h ambulatory blood pressure monitoring, or the amount of albumin excreted in urine. sAF was positively correlated with CRP (r = 0.17, p < 0.05). sAF was significantly higher in patients with concomitant celiac disease (1.53 [1.43-1.63] vs. 1.40 [1.27-1.53, AU], p = 0.001).

CONCLUSION

Among young T1D patients with relatively brief diabetes duration, sAF effectively mirrors prior glycemic control, as presented by historical average HbA1c. However, associations with conventional CV risk markers are not evident. The higher sAF values in patients with celiac disease warrant further exploration.

Skin Reactions in Children with Type 1 Diabetes Associated with the Use of New Diabetes Technologies-An Observational Study from a Regional Polish Pediatric Diabetes Center

The study aimed to estimate the prevalence of skin problems in children and adolescents with type 1 diabetes (T1D) using insulin pumps (IPs) and/or continuous glucose monitoring (CGM) in our center and analyze their association with various factors. As part of the international ISPAD JENIOUS-initiated SKIN-PEDIC project, we interviewed and examined patients who visited the regional pediatric diabetes center in Opole (Poland) for four weeks regarding the use of IP and/or CGM and the presence of skin problems. Body mass index (BMI) and glycemic parameters were obtained retrospectively from medical records. Among 115 individuals (45.2% girls, 83.5% IP users, 96.5% CGM users), old scars were the most common skin problem (IP users 53.1%; CGM users 66.4%), while ≥2 types of skin problems co-occurred (IP users 40.6%; CGM users 27.3%). Longer IP use was associated with a higher prevalence of skin problems (50% for IP < 1 year, 98.1%-IP 1-3 years, 100% for IP > 3 years; p < 0.001), pointing out extra attention with IP use > 1 year. No significant associations were found between skin problems and gender, age, BMI centile and glycemic parameters. Dermatological complications were common among children using IP and CGM in our center, highlighting the need for vigilant monitoring and early intervention to manage these skin-related issues effectively.

Adaptation and validation of an artificial intelligence based digital radiogrammetry tool for assessing bone health of indian children and youth with type-1 diabetes

BACKGROUND AND OBJECTIVES

BoneXpert (BX) is an artificial intelligence software used primarily for bone age assessment. Besides, it can also be used to screen for bone health using the digital radiogrammetry tool called bone health index (BHI) for which normative reference values available are calculated from healthy European children. Due to ethnic difference in bone geometry, in a previous study, we generated reference curves based on healthy Indian children. The objectives of this study were: 1) To assess and compare bone health of Indian children with Type 1 diabetes (T1D) using both European and Indian BHI SDS reference data and 2) To identify determinants of poor bone health in Indian children and youth with T1D by using BHI tool (based on BHI-SDS Indian reference data) of BX.

METHOD

The BHI was assessed retrospectively in 1159 subjects with T1D using digitalised left-hand x-rays and SDS were computed using European and Indian data. The demographic, anthropometric, clinical, biochemistry, dual x-ray absorptiometry (DXA) data and peripheral quantitative computed tomography (pQCT) data collection were performed using standard protocols and were extracted from hospital records.

RESULTS

The BHI correlated well with DXA and pQCT parameters in subjects with T1D. BHI-SDS calculated using Indian reference data had better correlation with height and DXA parameters. 8.6% study participants had low (less than -2) BHI-SDS (Indian), with height SDS having significant effect. Subjects with low BHI-SDS were older, shorter and had higher duration of diabetes. They also had lower IGF1 and vitamin D concentrations, bone mineral density, and trabecular density. Female gender, increased duration of illness, poor glycaemic control, and vitamin D deficiency/insufficiency were significant predictors of poor BHI-SDS.

CONCLUSION

Our study highlights the utility of digital radiogrammetry AI tool to screen for bone health of children with T1D and demonstrates and highlights the necessity of interpretation using ethnicity specific normative data.

Autoimmune comorbidity in type 1 diabetes and its association with metabolic control and mortality risk in young people: a population-based study

AIMS/HYPOTHESIS

This register-based study aimed to describe autoimmune comorbidity in children and young adults from type 1 diabetes onset, and to investigate whether such comorbidity was associated with a difference in HbA1c or mortality risk compared with children/young adults with type 1 diabetes without autoimmune comorbidity.

METHODS

A total of 15,188 individuals from the Swedish National Diabetes Register, registered with type 1 diabetes before 18 years of age between 2000 and 2019, were included. Five randomly selected control individuals from the Swedish population (Statistics Sweden) were matched to each individual with type 1 diabetes (n=74,210 [346 individuals with type 1 diabetes were not found in the Statistics Sweden register at the date of type 1 diabetes diagnosis, so could not be matched to control individuals]). The National Patient Register was used to attain ICD-10 codes on autoimmune diseases and the Cause of Death Register was used to identify deceased individuals.

RESULTS

In the total type 1 diabetes cohort, mean±SD age at onset of type 1 diabetes was 9.5±4.4 years and mean disease duration at end of follow-up was 8.8±5.7 years. Of the individuals with type 1 diabetes, 19.2% were diagnosed with at least one autoimmune disease vs 4.0% of the control group. The HRs for comorbidities within 19 years from onset of type 1 diabetes were 11.6 (95% CI 10.6, 12.6) for coeliac disease, 10.6 (95% CI 9.6, 11.8) for thyroid disease, 1.3 (95% CI 1.1, 1.6) for psoriasis, 4.1 (95% CI 3.2, 5.3) for vitiligo, 1.7 (95% CI 1.4, 2.2) for rheumatic joint disease, 1.0 (95% CI 0.8, 1.3) for inflammatory bowel disease, 1.0 (95% CI 0.7, 1.2) for systemic connective tissue disorder, 1.4 (95% CI 1.1, 1.9) for uveitis, 18.3 (95% CI 8.4, 40.0) for Addison's disease, 1.8 (95% CI 0.9, 3.6) for multiple sclerosis, 3.7 (95% CI 1.6, 8.7) for inflammatory liver disease and 19.6 (95% CI 4.2, 92.3) for atrophic gastritis. Autoimmune disease in addition to type 1 diabetes had no statistically significant effect on HbA1c or mortality risk.

CONCLUSIONS/INTERPRETATION

To our knowledge, this is the first comprehensive study where young individuals with type 1 diabetes were followed regarding development of a wide spectrum of autoimmune diseases, from onset of type 1 diabetes. In this nationwide and population-based study, there was already a high prevalence of autoimmune diseases in childhood, especially coeliac and thyroid disease. The presence of autoimmune comorbidity did not have a statistically significant effect on metabolic control or mortality risk.

Prevalence and Predictive Factors for Celiac Disease in Children With Type 1 Diabetes: Whom and When to Screen? A Nationwide Longitudinal Cohort Study of Swedish Children

OBJECTIVE

To examine the prevalence and predictive factors for celiac disease (CD) after a diagnosis of type 1 diabetes (T1D) in children and adolescents, to improve the current screening guidelines.

RESEARCH DESIGN AND METHODS

The association between sex, age at T1D diagnosis, HLA, and diabetes autoantibodies, and a diagnosis of CD was examined in 5,295 children with T1D from the Better Diabetes Diagnosis study in Sweden.

RESULTS

The prevalence of biopsy-proven CD was 9.8%, of which 58.2% already had a CD diagnosis before or at T1D onset. Almost all, 95.9%, were diagnosed with CD within 5 years after the T1D diagnosis. Younger age at the T1D diagnosis and being homozygote for DQ2 increased the risk of CD after T1D, but neither sex nor diabetes-related autoantibodies were associated with the risk.

CONCLUSIONS

Age at and time after diabetes diagnosis should be considered in screening guidelines for CD in children with T1D.

Cutaneous Disorders Masking Celiac Disease: Case Report and Mini Review with Proposal for a Practical Clinical Approach

Celiac disease (CD) is an immune-mediated systemic gluten-related disorder characterized by a wide spectrum of intestinal and extra-intestinal manifestations, including damage to cutaneous and connective tissue. We report a rare case of chronic severe dermatitis involving connective tissue and cutaneous vascular vessels as the main clinical presentation of undiagnosed seronegative gluten disorder. A gluten-free diet dramatically improved the intestinal and cutaneous clinical damage in the patient. Pitfalls and the steps of differential diagnosis are described. We also review the literature regarding studies of CD and connective tissue diseases to extend the knowledge of these rare associations. We propose a practical diagnostic approach in suspected CD in autoimmune cutaneous disorders.

Coexisiting type 1 diabetes and celiac disease is associated with lower Hba1c when compared to type 1 diabetes alone: data from the Australasian Diabetes Data Network (ADDN) registry

AIM

To compare HbA1c and clinical outcomes in adolescents and young adults with type 1 diabetes (T1D), with or without celiac disease (CD).

METHODS

Longitudinal data were extracted from ADDN, a prospective clinical diabetes registry. Inclusion criteria were T1D (with or without CD), ≥ 1 HbA1c measurement, age 16-25 years and diabetes duration ≥ 1 year at last measurement. Multivariable Generalised Estimated Equation models were used for longitudinal analysis of variables associated with HbA1c.

RESULTS

Across all measurements, those with coexisting T1D and CD had lower HbA1c when compared to those with T1D alone (8.5 ± 1.5% (69.4 ± 16.8 mmol/mol) vs. 8.7 ± 1.8% (71.4 ± 19.8 mmol/mol); p < 0.001); lower HbA1c was associated with shorter diabetes duration (B = - 0.06; 95% CI - 0.07 to - 0.05; p < 0.001), male sex (B = - 0.24; - 0.36 to - 0.11; p < 0.001), insulin pump therapy use (B = - 0.46; - 0.58 to - 0.34; p < 0.001), coexistence of T1D and CD (B = - 0.28; - 0.48 to - 0.07; p = 0.01), blood pressure (B = - 0.16; - 0.23 to - 0.09; p < 0.001) and body mass index (B = -- 0.03; - 0.02 to - 0.04; p = 0.01) in the normal range. At last measurement, 11.7% of the total population had a HbA1c < 7.0% (53.0 mmol/mol).

CONCLUSIONS

Across all measurements, coexisting T1D and CD is associated with lower HbA1c when compared to T1D alone. However, HbA1c is above target in both groups.

First International Survey on Diabetes Providers' Assessment of Skin Reactions in Youth With Type 1 Diabetes Using Technological Devices

BACKGROUND

Advances in diabetes technological devices led to optimization of diabetes care; however, long-lasting skin exposure to devices may be accompanied by an increasing occurrence of cutaneous reactions.

METHODS

We used an open-link web-based survey to evaluate diabetes-care providers' viewpoint on prevalence, management practices, and knowledge related to skin reactions with the use of diabetes technological devices. A post hoc analysis was applied to investigate differences in the level of awareness on this topic in relation to the experience in diabetes technology.

RESULTS

One hundred twenty-five responses from 39 different countries were collected. Most respondents (69%) routinely examine patients' skin at each visit. All the preventive measures are not clear and, mainly, homogenously put into clinical practice. Contact dermatitis was the most frequently reported cutaneous complication due to diabetes devices, and its most common provocative causes are not yet fully known by diabetes-care providers. Almost half of the respondents (42%) had discussed the presence of harmful allergens contained in adhesives with device manufacturers. There is general agreement on the need to strengthen knowledge on dermatological complications.

CONCLUSIONS

Although diabetes-care providers are quite aware of the chance to develop skin reactions in people with diabetes using technological devices, there are still some unmet needs. Large follow-up studies and further dissemination tools are awaited to address the gaps revealed by our survey.

A Skin Care Program to Prevent Skin Problems due to Diabetes Devices in Children and Adolescents: A Cluster-Controlled Intervention Study

OBJECTIVE

Diabetes devices that deliver insulin and measure blood glucose levels are cornerstones in modern treatment of type 1 diabetes. However, their use is frequently associated with the development of skin problems, particularly eczema and wounds. Proper skin care may prevent skin problems, yet evidence-based information from interventional studies is missing. Providing this information is the aim of this study.

RESEARCH DESIGN AND METHODS

This cluster-controlled intervention study tested the efficacy of a basic skin care program (including use of lipid cream, removal, and avoidance of disinfection). A total of 170 children and adolescents with type 1 diabetes were included and assigned either to the intervention group (n = 112) or the control group (n = 58). Participants were seen quarterly the first year after device initiation, with clinical assessment and interview in an unblinded setting.

RESULTS

Eczema or wounds were observed in 33.6% of the intervention group compared with 46.6% of control participants (absolute difference, 12.9% [95% CI -28.7%, 2.9%]; P = 0.10). The adjusted odds of wound development were decreased by 71% in the intervention compared with control group (for wounds, odds ratio 0.29 [95% CI 0.12, 0.68]; P = 0.005). In total, only eight infections were seen, without a higher frequency in the intervention group, despite advice to omit disinfection.

CONCLUSIONS

These data indicate our basic skin care program partially prevented diabetes device-induced skin reactions. However, more preventive strategies with other adhesives, patches, and/or types of lotions are needed for optimized prevention.

Association of oral health with risk of incident micro and macrovascular complications: A prospective cohort study of 24,862 people with diabetes

AIMS

To investigate the association between self-reported oral health and incident micro and macrovascular diabetes complications.

METHODS

This prospective cohort study linked data from the 45 and Up Study, Australia, to administrative health records. The participants were 24,862 men and women, aged ≥45 years, with diabetes at baseline (2006-2009). The oral health of participants was assessed by questionnaire. Incident diabetes complications were determined using hospitalisation data and claims for medical services up until 2019. Hazard ratios for the association between oral health and incident complications were calculated using multivariable cox proportional hazards models.

RESULTS

Almost 60 % of participants had <20 teeth, and 38 % rated their teeth and gums as fair or poor. Compared with those with ≥20 teeth, those with 0 teeth had an increased risk of cardiovascular disease (aHR 1.24, 95 % CI: 1.15, 1.35), lower limb (aHR 1.22, 95 % CI: 1.11, 1.33) and kidney (aHR 1.19, 95 % CI: 1.11, 1.29) complications. Individuals with 1-9 teeth had an increased risk of eye complications (aHR 1.14, 95 % CI: 1.07, 1.22). The associations were generally consistent for poor self-rated teeth and gums.

CONCLUSIONS

Self-reported oral health measures may be a marker of elevated risk of complications in people with diabetes.

The Impact of Different Types of Rice and Cooking on Postprandial Glycemic Trends in Children with Type 1 Diabetes with or without Celiac Disease

The aims of this study were to evaluate: (i) the chemical and nutritional composition of rice before and after cooking and (ii) postprandial glycemic impacts in children and adolescents with type 1 diabetes (T1D) after eating two different types of rice (“Gigante Vercelli” white rice and “Artemide” black rice) or white rice cooked “risotto” style or boiled using an advanced hybrid closed loop (AHCL) system (Tandem Control-IQTM). General composition and spectrophotometric analyses of raw and cooked rice were performed. Eight T1D subjects (four males and four females, aged 11 ± 1.4 years), two with celiac disease (CD), using an AHCL system were enrolled. “Gigante Vercelli” white rice cooked as risotto or boiled and boiled “Artemide” rice were prepared by the same cook on two evenings. Continuous glucose monitoring metrics were evaluated for 12 h after meal consumption. Total dietary fiber was higher for both rice types after cooking compared with raw rice. Cooking as risotto increased polyphenols and antioxidants (p < 0.05) in both rice varieties, and total starch decreased after boiling (p < 0.05) in white rice. There was a significant peak in glycemia after consuming risotto and boiled white rice (p < 0.05), while the mean glycemic peak remained <180 mg/dL in individuals eating boiled Artemide rice. There were no significant differences in automatic basal or auto-bolus insulin deliveries by the AHCL according to different types of rice or cooking method. Our findings suggest that glycemic trends are impacted by the different chemical and nutritional profiles of rice but are nevertheless well controlled by AHCL systems.

[Diabetes mellitus in childhood and adolescence (Update 2023)]

In contrast to adults, type 1 diabetes mellitus (T1D) is the most frequent form of diabetes in childhood and adolescence (> 90%). After diagnosis the management of children and adolescents with T1D should take place in highly specialized pediatric units experienced in pediatric diabetology. The lifelong substitution of insulin is the cornerstone of treatment whereby modalities need to be individually adapted for patient age and the family routine. In this age group the usage of diabetes technology (glucose sensors, insulinpumps and recently hybrid-closed-loop-systems) is recommended. An optimal metabolic control right from the start of therapy is associated with an improved long-term prognosis. Diabetes education is essential in the management of patients with diabetes and their families and needs to be performed by a multidisciplinary team consisting of a pediatric diabetologists, diabetes educator, dietitian, psychologist and social worker. The Austrian working group for pediatric endocrinology and diabetes (APEDÖ) and the ISPAD (International Society for Pediatric and Adolescent Diabetes) recommend a metabolic goal of HbA1c ≤ 7.0%, ((IFCC) < 53 mmol/mol), and a "Time in range" > 70% for all pediatric age groups without the presence of severe hypoglycemia. Age-related physical, cognitive and psychosocial development, screening for associated diseases, avoidance of acute diabetes-related complications (severe hypoglycemia, diabetic ketoacidosis) and prevention of diabetes-related late complications to ensure high quality of life are the main goals of diabetes treatment in all pediatric age groups.