Cardiovascular risk factors from diagnosis in children with type 1 diabetes mellitus: a longitudinal cohort study

Sociodemographic inequities and use of hybrid closed-loop systems associated with obesity in youth with type 1 diabetes

AIMS

This study aimed to describe changes over time in rates of overweight and obesity and to identify factors associated with obesity in youth with type 1 diabetes.

METHODS

We analyzed data from 7360 diabetes medical visits among 2242 youth with type 1 diabetes for ≥1 year followed at a pediatric, tertiary care, academic medical center between 2018 and 2023. Multivariable generalized estimating equations (GEE) analysis and conditional logistic regression (CLR), where each patient had both control (not obesity) and case (obesity) status, were conducted.

RESULTS

Adjusted annual percentages of patients with obesity increased from 13.8 % in 2018 to 18.2 % in 2023 (P = 0.006); rates of overweight did not differ significantly over time. In multivariable GEE analysis, public insurance (P = 0.026), lower Child Opportunity Index score (P = 0.027), and use of hybridclosed-loop (HCL) systems (P = 0.023) were associated with obesity. In CLR, use of continuous glucose monitor and HCL systems and the sum of their effects (P = 0.002) were associated with obesity.

CONCLUSIONS

This study revealed increasing rates of obesity in children with type 1 diabetes and identified sociodemographic and diabetes care-related factors associated with obesity, highlighting targets for intervention to decrease future risk of cardiovascular complications.

Investigating the presence and detectability of structural peripheral arterial changes in children with well-regulated type 1 diabetes versus healthy controls using ultra-high frequency ultrasound: a single-centre cross-sectional and case-control study

Background

Children with type 1 diabetes have an increased risk of macrovascular complications. This study used ultra-high frequency ultrasound (UHFUS), enabling differentiation of intima thickness (IT), and media thickness (MT) in peripheral arteries, to examine early peripheral arterial changes in children with type 1 diabetes (CWD).

Methods

This cross-sectional and case-control study performed at the Queen Silvia Children's Hospital, Gothenburg, Sweden included CWD, aged 6-15.99 y/o, diabetes duration ≥5 years, compared to age and sex matched healthy controls. Exclusion criteria included other medical conditions or treatments besides insulin, abnormal examination findings or inability to handle extensive examinations. UHFUS measurements from the radial, dorsal pedal (DP), and carotid arteries as well as blood samples, blood pressure (BP)- and BMI z-score were collected from all study participants, and glucometrics from CWD.

Findings

Study inclusion was performed during 02/25/2019-06/28/2022, and a total of 50 CWD, and 41 healthy controls were included in the study. Of these, five CWD and four healthy controls were excluded, resulting in 45 (22 girls (49%), 23 boys (51%)) CWD (12.0 (2.3) y/o) and 37 (19 girls (51%), 18 boys (49%)) healthy controls (11.3 (2.5) y/o) included in data analysis. CWD had a mean HbA1c of 6.6% (48.1 mmol/mol), higher DBP z-scores (p = 0.019), DP IT, DP intima-media thickness (IMT), and radial IT compared with controls (p = 0.003, p = 0.008, and p = 0.002, respectively). Carotid IT was correlated with time in range (r = -0.47, p = 0.014), time in tight range (r = -0.64, p < 0.001), and glucose variability (r = 0.40, p = 0.004) in CWD. Time in tight range and longitudinal HbA1c were the strongest determinants for carotid IT in CWD, and type 1 diabetes diagnosis was the strongest determinant for IT across all arteries.

Interpretation

Children with well-regulated type 1 diabetes show early vascular changes in radial and DP arteries. Regression analyses indicate significant links between IT and hyperglycaemia and type 1 diabetes diagnosis respectively, indicating that structural arterial changes start in the intima. Our findings further emphasise increased time in normoglycemia as the most crucial action to prevent cardiovascular complications in type 1 diabetes. Additional larger studies are needed to confirm and further interpret the meaning of these results.

Funding

ALF-agreement, Child Diabetes Foundation, Swedish Diabetes Foundation, and the Sahlgrenska University Hospital Foundations.

Evaluation of Serum Soluble Lectin-like Oxidised Low-Density Lipoprotein Receptor-1 (sLOX-1) Level in Children with Non-Complicated Type-1 Diabetes Mellitus (T1DM) and Its Relationship with Carotid Intima Media Thickness (cIMT)

Background: The objective of this study was to evaluate serum soluble lectin-like oxidized low-density lipoprotein receptor-1 (sLOX-1) levels in children with type-1 diabetes mellitus (T1DM) without any atherosclerotic complications and to investigate whether there was an association with early atherosclerotic processes in these children. Methods: The study's design entailed a prospective cross-sectional observational study methodology. The patient group consisted of 80 consecutive children aged 8-18 years who had been diagnosed with T1DM for at least ten years and had not developed any chronic clinical complications related to T1DM. The control group consisted of 72 completely healthy children with similar demographic characteristics. Serum levels of sLOX-1 were measured, and carotid intima-media thickness (cIMT) was evaluated using ultrasonography in all subjects. Results: A statistical analysis of the results was conducted. The serum sLOX-1 level was found to be significantly higher in the patient group than in the control group (0.49 ± 0.11 vs. 0.82 ± 0.35; p < 0.001). The statistical significance observed was maintained in the multivariable logistic regression analysis (p < 0.001). A significant correlation was identified between cIMT and serum sLOX-1 levels (r = 0.669, p < 0.001). The receiver operating characteristic curve for sLOX-1 indicated that a cutoff value greater than 0.65 ng/mL was associated with T1DM. Conclusions: Serum sLOX-1 levels were markedly elevated in children with T1DM who had not yet manifested chronic complications. These findings suggest that elevated serum sLOX-1 levels may be associated with the progression of atherosclerosis in children with T1DM.

Relationship between liver and cardiometabolic health in type 1 diabetes

Introduction

Type 1 diabetes (T1D) is a chronic condition marked by insulin deficiency and hyperglycemia, with an increasing global incidence, particularly among children. Despite improvements in diabetes management, individuals with T1D continue to experience higher rates of cardiovascular disease (CVD), the leading cause of mortality in this population. Traditional CVD risk factors such as dyslipidemia and poor glycemic control are insufficient to fully explain the elevated risk in T1D, prompting further investigation into additional factors. Emerging evidence suggests that metabolic dysfunction-associated steatotic liver disease (MASLD) plays a critical role in this heightened CVD risk.

Objective

This narrative review aims to explore the relationship between MASLD and CVD in individuals with T1D. The review focuses on the prevalence of MASLD, its contributing risk factors, and the potential impact of liver dysfunction on cardiovascular outcomes in this population.

Methods

A review of existing literature was conducted, focusing on observational studies, cohort studies, and meta-analyses that investigate the prevalence of MASLD in T1D populations and its association with CVD. The review also examines the physiological mechanisms linking MASLD and CVD, including insulin resistance, systemic inflammation, and hepatic dyslipidemia. Key studies were evaluated to identify patterns in MASLD prevalence based on diagnostic modalities and to assess the independent contribution of MASLD to cardiovascular risk in T1D patients.

Conclusion

MASLD is increasingly recognized as a significant contributor to CVD in individuals with T1D, particularly in those with shared risk factors like obesity and insulin resistance. Evidence suggests that MASLD exacerbates hepatic and systemic metabolic dysfunction, increasing CVD risk through mechanisms such as chronic inflammation and atherogenic lipid profiles. Routine liver health assessments and tailored management strategies targeting MASLD should be incorporated into clinical care for individuals with T1D to mitigate long-term cardiovascular complications.

Prevalence of LDL-hypercholesterolemia and other cardiovascular risk factors in young people with type 1 diabetes

BACKGROUND

Mortality and morbidity in people with Type 1 diabetes (T1D) is mainly caused by cardiovascular disease (CVD). Early treatment of cardiovascular risk factors (CVRFs) is of great importance.

OBJECTIVE

To analyze the prevalence of LDL-hypercholesterolemia and other CVRFs in youth with T1D.

METHODS

Clinical and laboratory parameters, and vascular thickness measurement were obtained in youth with T1D (age 6-18 years, T1D duration >1 year) attending a diabetes clinic. LDL-hypercholesterolemia, microalbuminuria and arterial hypertension were defined as CVRFs.

RESULTS

A total of 333 youth (48% girls; age: 13.3 years [10.3-15.5], median [interquartile range]) participated in the study. The T1D duration was 5.9 years [3.5-9.4] with HbA1c of 7.4% [6.8-8.0]. Intima media thickness (N=223) was 538.0 µm [470.0-618.0]). LDL-hypercholesterolemia was present in 30 participants (9%; 18 girls; age: 14.3 years [11.2-15.7]). None of the participants had persistent microalbuminuria, although 59 (18.3%) had elevated albumin excretion in a random urine specimen. LDL-hypercholesterolemia was associated with increased blood pressure (p<0.05), insulin requirement (p<0.05), HbA1c (p<0.05), triglyceride (p<0.001) and total cholesterol (p<0.001), and a family history of premature CVD (p<0.001), but negatively correlated with HDL cholesterol levels (p<0.05). Sex, pubertal status, duration of diabetes, type of therapy, and physical activity did not differ between participants with and without LDL- hypercholesterolemia. Arterial hypertension was present in 11 participants (3.3%; 4 girls; age: 14.1 years [11.1-16.1]).

CONCLUSION

LDL-hypercholesterolemia affected 9% of youth with T1D in this cohort and was associated with other CVRFs. A holistic therapeutic concept for these young people is essential.

Cardiovascular Disease in Adults with Type 1 Diabetes: Looking Beyond Glycemic Control

PURPOSE OF REVIEW

Despite improvements in treatment, people with type 1 diabetes continue to have increased cardiovascular disease (CVD) risk. Glycemic control does not fully explain this excess CVD risk, so a greater understanding of other risk factors is needed.

RECENT FINDINGS

The authors review the relationship between glycemia and CVD risk in adults with type 1 diabetes and summarize evidence regarding other factors that may explain risk beyond glycemia. Insulin resistance, weight gain, sex differences, genetics, inflammation, emerging markers of risk, including lipid subclasses and epigenetic modifications, and future directions are discussed. As glycemic control improves, an increased focus on other CVD risk factors is warranted in type 1 diabetes. Novel markers and precision medicine approaches may improve CVD prediction, but a lack of type 1 diabetes-specific guidelines for lipids, blood pressure, and physical activity are likely impediments to optimal CVD prevention in this high-risk population.

Resilience and Diabetes Distress at 3 Months Following Diagnosis Predict A1C Trajectories in Youth With Type 1 Diabetes: An Argument for Early Intervention

OBJECTIVE

Youth and adolescents with type 1 diabetes (T1D) are at risk for poor health outcomes. Understanding if psychological factors shortly following diagnosis, such as diabetes distress and resilience, predict glycated hemoglobin (A1C) trajectories may help inform both optimal timing and content of psychosocial interventions for youth with T1D.

METHODS

Youth and adolescents (N = 34) with newly diagnosed T1D completed distress and resilience measures at baseline and 3 months following diagnosis. Using multilevel modeling, we predicted A1C trajectories up to 3 years following diagnosis.

RESULTS

We found that in separate models, higher 3-month diabetes distress and lower 3-month resilience predicted larger increases in A1C years 1-3 following diagnosis.

CONCLUSIONS

Our findings suggest that targeting resilience and diabetes distress within 3 months following diagnosis has implications for the yearly rate of A1C increase up to 3 years later.

Coincidence of juvenile idiopathic arthritis and type 1 diabetes: a case-based review

The study was aimed to review a rare coexistence of type 1 diabetes (T1D) and juvenile idiopathic arthritis (JIA) regarding different clinical approaches to the management and treatment options. Medical complications of the two autoimmune disorders in children and adolescents have been evaluated, particularly in those treated with glucocorticosteroids (GCS) and insulin. A review of the literature regarding reports on concomitant T1D and JIA was conducted using resources available in Medline, Google Scholar, and Web of Science databases, with a specific focus on the combination of T1D and JIA in a pediatric population. The review was extended by our analysis of two patients treated in a single center for this comorbidity. Eligible reports of four cases were found, and including our two original records, a total of six pediatric patients (5 females) were analyzed, of which three had also other autoimmune diseases (thyroiditis, coeliac disease, autoimmune hepatitis), whereas four had been treated with a long-term GCS, and two were receiving biological therapy (etanercept or adalimumab). Only one of them had good metabolic control of diabetes. Diabetes in childhood may coexist with other autoimmune diseases, including rheumatologic conditions. Hyperglycemia can worsen JIA therapy by induction and maintaining inflammation. Using modern diabetes technologies (like personal insulin pumps and continuous glucose monitoring) helps to minimize the deteriorating effect of JIA exacerbations and the rheumatoid treatment on metabolic control of diabetes.

The Problem of Abnormal Body Weight and Dyslipidemia as Risk Factors for Cardiovascular Diseases in Children and Adolescents with Type 1 Diabetes

Diabetes is a disease that affects many people around the world. Its complications are the cause of cardiovascular diseases (CVD) and increased mortality. That is why the search for predictive biomarkers is so important. The aim of the study was to show the prevalence of the problem and risk factors in children and adolescents with type 1 diabetes. These patients are often overweight and obese, and the percentage of lipid disorders is particularly high. The discussed markers of CVD risk in type 1 diabetes include apolipoproteins (apo-B and apo-C3), modified forms of LDL, and the role of high-density lipoprotein (HDL). Recently, a new look at the vasoprotective effect of HDL has appeared, which due to its dysfunctional form in type 1 diabetes may not protect against cardiovascular risk. The HDL proteome in type 1 diabetes has an altered protein composition compared to the healthy population. Another direction of research is determining the importance of trace elements (mainly Mg) in the development of diabetes complications.

Preventing Cardiovascular Complications in Type 1 Diabetes: The Need for a Lifetime Approach

Cardiovascular disease (CVD) remains the main cause of morbidity and mortality in individuals with type 1 diabetes (T1D). Adolescence appears to be a critical time for the development of early subclinical manifestations of CVD, with these changes likely driven by a deterioration in glycemic control during the progression through puberty, combined with the emergence of numerous other traditional cardiometabolic risk factors (e.g., hypertension, dyslipidemia, smoking, alcohol use, obesity, etc.) which emerge at this age. Although hemoglobin A1C has long been the primary focus of screening and treatment strategies, glycemic control remains poor in youth with T1D. Furthermore, screening for cardiovascular risk factors-which are often elevated in youth with T1D-is suboptimal, and use of pharmacological interventions for hypertension and dyslipidemia remains low. As such, there is a clear need not only for better screening strategies for CVD risk factors in youth, but also early interventions to reduce these, if future CVD events have to be prevented. Accumulating evidence has recently suggested that early increases in urinary albumin excretion, even within the normal range, may identify adolescents with T1D who are at an increased risk of complications, and results from pharmacological intervention with statins and ACE inhibitors in these individuals have been encouraging. These data join a growing evidence highlighting the need for a whole-life approach to prevention starting from childhood if efforts to improve CVD outcomes and related mortality in T1D are to be maintained.

Association between age at type 1 diabetes diagnosis and metabolic outcome at young adulthood: a real-life observational study

BACKGROUND

Younger age at diagnosis of type 1 diabetes (T1D) may affect the clinical course and outcome. We examined whether age at diagnosis was associated with glycemic control and metabolic outcome in young adulthood.

METHODS

This observational study included 105 young adults with T1D (current mean age: 21.2 ± 3.0 years, mean age at diagnosis 12.0 ± 4.0 years) followed during 2012 to 2019. Data on HbA1c, glucose variability, continuous glucose monitoring (CGM) metrics, body mass index (BMI), blood pressure (BP), and body composition were collected from medical records from age 18 years until last visit, and the association between age at diagnosis and outcomes was assessed.

RESULTS

Age at T1D diagnosis was negatively associated with HbA1c levels (r = -0.368, P = .001), BMI (r = -0.218, P = .026), and diastolic BP (r = -0.215, P = .028). Younger age at diagnosis predicted poorer glycemic control after controlling for T1D duration, sex, socioeconomic status, BMI, and CGM use (r² = 0.19, P = .002). There was a 0.1% greater HbA1c reduction for every yearly increase in age at diagnosis (β = -0.090, P = .042). The mean metabolic age of females diagnosed at <10 years of age was older than their chronological age (P = .049).

CONCLUSIONS

Younger age at T1D diagnosis predicts worse glycemic control at young adulthood, independent of recognized confounding risk factors (disease duration, sex, socioeconomic status, weight, and use of diabetes technology). Female patients diagnosed at a young age have an older metabolic age, indicating the need for lifestyle alteration to improve their basal metabolic rate.

Cardiovascular risk factors in children and adolescents with type 1 diabetes in Italy: a multicentric observational study

AIMS

To assess the prevalence of cardiovascular risk factors (CVRFs) and to identify the variables associated with CVRFs in a cohort of children and adolescents with Type 1 Diabetes.

METHODS

2021 subjects, 2-18 year-old, were recruited in 17 Italian Pediatric Diabetes Centers. Anthropometric, blood pressure, biochemical (HbA1c, lipid profile, ACR), insulin therapy, physical activity level, smoking and family socio-economic status data were collected. CVRFs prevalence and their distribution were analyzed according to age and binary logistic regression was performed with positivity for at least one major CVRF (BMI-SDS > +2SD, blood pressure > 90th percentile, LDL cholesterol>100 mg/dL) as dependent variable and age, duration of illness, gender, HbA1c and physical activity, as independent variables.

RESULTS

The prevalence of CVFRs not at the recommended target was respectively: 32.5% one CVRF, 6.7% two CVRFs and 0.6% three CVRFs, with no significant differences across the 3 age groups (2-10, 10-15, 15-18 years). In the total sample, HbA1c and inadequate physical activity were associated with a higher probability of having at least one major CVRF. This probability was associated with physical activity in the 2-10-year-old group, with physical activity and HbA1c in the 10-15-year-old group and with HbA1c only in subjects older than 15 years.

CONCLUSIONS

More than 30% of subjects had at least a major CVRF. Early detection of CVRFs may be useful to enforce the therapeutic intervention in this subgroup, in order to reduce the risk to develop cardiovascular complications.

Treatment of cardiometabolic risk factors in patients with type 1 diabetes

PURPOSE OF REVIEW

Individuals with type 1 diabetes (T1D) have excess cardiovascular risk and reduced life expectancy. Adolescence is the time when the first signs of vascular complications appear and a critical window for interventions. This article reviews recent evidence on cardiometabolic risk factors and their management in youth with T1D.

RECENT FINDINGS

Adolescents with T1D show early signs of vascular complications, as a result of several cardiometabolic risk factors. Poor glycemic control is one of the main risk factors and the main target of treatment. However, only a minority of adolescents with T1D reaches recommended targets for glycemic control. Hypertension, dyslipidemia, smoking, alcohol use, obesity and insulin resistance are other common cardiometabolic risk factors in this age group. Recent data confirm that screening for these risk factors is suboptimal and use of pharmacological interventions for hypertension and dyslipidemia remains low. Data on adjunctive noninsulin agents to improve glycemic control and other cardiometabolic risk factors are still lacking in this age group.

SUMMARY

Vascular complications and the associated mortality remain a major issue for youth with T1D. Better screening strategies for cardiometabolic risk factors and interventions are required to improve the long-term prognosis of youth with T1D.

The Impact of Diabetes Mellitus on Cardiovascular Risk Onset in Children and Adolescents

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.