Risk factors for poor glycemic control in diabetic children in France

Diabetes knowledge in adolescents with type 1 diabetes and their parents and glycemic control

OBJECTIVE

To evaluate diabetes knowledge and skills (DKS) in adolescents (>10 year) with type 1 diabetes (T1D) and their parents, and its effect on glycemic control.

METHODS

A ready-to-use program and a standardized questionnaire comprising 50 true-false questions based on this program, were elaborated by a National Committee, to help dispensing education at diagnosis of T1D. The questionnaire was completed by 2933 T1D patients (49% girls, 51% boys; 14.1 ± 2.5 year), 2180 mothers and 798 fathers, in 115 pediatric centers. Associations between DKS score (number of correct answers), glycated hemoglobin (HbA1c) and sociofamilial characteristics were assessed.

RESULTS

DKS score increased with age, and was higher in girls than in boys and in mothers than in fathers; it correlated strongly between adolescents and their own parents; it was higher when adolescents had previously participated in diabetes camp and when parents had higher academic levels. HbA1c decreased significantly with parents' higher DKS score and academic level, and when both parents lived together. Mean adolescent DKS score was significantly higher in patients with HbA1c below 8% or 8.5% than for patients with HbA1c above these thresholds.

CONCLUSION

A large survey in T1D children and adolescents and their parents showed associations between DKS and glycemic control, and the major role of sociofamilial factors.

Insulin regimens, diabetes knowledge, quality of life, and HbA1c in children and adolescents with type 1 diabetes

OBJECTIVES

To further describe the changes in insulin therapy regimens and hemoglobin A1c (HbA1c) in children and adolescents with type 1 diabetes, and their associations with diabetes knowledge and quality of life.

RESEARCH DESIGN AND METHODS

The study included 4293 children and adolescents (12.9 ± 2.6 yr, diabetes >1 yr) attending AJD (Aide aux Jeunes Diabétiques) summer camps between 2009 and 2014. The distribution of insulin regimens and associations between HbA1c, therapeutic regimens, diabetes knowledge (AJD questionnaire), and Quality of Life (Ingersoll et Marrero, Hvidoere Study Group short version) were assessed.

RESULTS

The percentage of youth treated with insulin pumps increased up to about 45%, basal bolus stabilized around 40%, and other regimens decreased majorly. HbA1c was higher with premixed insulins only regimens (9.05 ± 2.43%), but there was no difference between pump (8.12 ± 1.09%), basal bolus (8.32 ± 1.33%) and two to three injections (8.18 ± 1.28%). Mean HbA1c decreased by 0.014% per year. The percentage of HbA1c <7.5% increased by 1.5% per year, and the percentages of HbA1c >9% or >10% decreased by 4 and 5.5%, changes being greater with the pump. HbA1c was weakly associated with diabetes knowledge, and strongly with general health perception and perception about diabetes.

CONCLUSION

The percentage of children and adolescents with the highest risk of complications decreased markedly. The distribution of HbA1c better depicts the glycemic control in a population than the mean or the percentage of patients reaching the target (7.5%). HbA1c was more strongly associated with general health perception than with therapeutic regimens and diabetes knowledge.

Glycemic control and sponsor rank of military dependents with type 1 diabetes mellitus

BACKGROUND

Disparities in glycemic control are reported in children with type 1 diabetes related to differences in access to health care and socioeconomic status. In the US military, rank is an indicator of socioeconomic status, but all have complete health care access without cost.

OBJECTIVE

We sought to determine if glycemic control in children with type 1 diabetes differs if their sponsor (parent) is an officer vs. enlisted military service member.

METHODS

We performed a cross-sectional retrospective chart review of children with type 1 diabetes >1 yr duration whose parent is a military service member.

RESULTS

A total of 281 subjects met study criteria, 136 (48.4%) having an enlisted and 145 (51.6%) having an officer sponsor. The groups differed by race with 38.2% black in the enlisted and 9% black in the officer group (p < 0.001). The median enlisted average hemoglobin A1c (HbA1c) over the most recent year of available data was significantly higher than the officer group (9.2 vs. 8.4%, p < 0.001). The difference remained significant when controlled for age and race. Diabetes-related hospitalizations were greater in the enlisted group (39.0 vs. 19.3%, p < 0.001). More subjects in the officer group were on insulin pumps (54.5 vs. 28.7%, p < 0.001).

CONCLUSION

Dependent children of enlisted service members with type 1 diabetes have higher HbA1c levels, more diabetes-related hospitalizations, and are less likely to use insulin pumps than children of officers. These differences are likely linked to socioeconomic status and education levels given the universal access to health care within the military system.

Ethnic differences in the incidence of type 1 diabetes in Norway: a register-based study using data from the period 2002-2009

BACKGROUND

Few studies have looked at variation in type 1 diabetes incidence between immigrant groups within a country.

OBJECTIVE

To investigate differences in incidence rates of childhood-onset type 1 diabetes between immigrant groups and ethnic Norwegians, and their contribution to the number of incident cases of type 1 diabetes in Norway.

SUBJECTS

The study includes 2221 individuals with newly onset type 1 diabetes diagnosed during 2002-2009 in children of 0-14 yr in Norway registered in the nationwide and population-based Norwegian Childhood Diabetes Registry.

METHODS

Incident cases were classified in seven groups based on country of maternal birth and three age groups. Statistics Norway provided the corresponding population sizes. Incidence rates were compared by Poisson regression.

RESULTS

The overall incidence rate was 34.0 cases per 100,000 person-years (95% CI: 32.6, 35.5). There were large variations in incidence across the immigrant groups (p < 0.001), ranging from 6.8 per 100,000 person-years (95% CI: 1.9-17.5) for South/East Asians to 26.0 cases per 100,000 person-years (95% CI: 11.9-49.3) for sub-Saharan Africans. The differences remained significant after adjusting for age and gender.

CONCLUSIONS

There are large variations in the rate of incidence of type 1 diabetes across the ethnic groups, and several immigrant groups have significantly lower incidence than ethnic Norwegians. Immigrant groups contributed ca. 5% of the total cases of type 1 diabetes and influence the overall incidence in Norway only to a small extent.

Hospital admission for diabetic ketoacidosis or severe hypoglycemia in 31,330 young patients with type 1 diabetes

OBJECTIVE

To investigate rates and risk factors of hospital admission for diabetic ketoacidosis (DKA) or severe hypoglycemia in young patients with established type 1 diabetes.

DESIGN

In total, 31,330 patients with type 1 diabetes (median age 12.7 years) from the Diabetes Patienten Verlaufsdokumentation (DPV) Prospective Diabetes Registry treated between 2011 and 2013 in Germany were included.

METHODS

Admission rates for DKA (pH < 7.3 or bicarbonate <15 mmol/l) and severe hypoglycemia (requiring assistance from another person) were calculated by negative binomial regression analysis. Associations of DKA or hypoglycemia with patient and treatment characteristics were assessed by multivariable regression analysis.

RESULTS

The mean admission rate for DKA was 4.81/100 patient-years (95% CI, 4.51-5.14). The highest DKA rates were observed in patients with HbA1c ≥ 9.0% (15.83 (14.44-17.36)), age 15-20 years (6.21 (5.61-6.88)) and diabetes duration of 2-4.9 years (5.60 (5.00-6.27)). DKA rate was higher in girls than in boys (5.35 (4.88-5.86) vs 4.34 (3.95-4.77), P = 0.002), and more frequent in migrants than in non-migrants (5.65 (4.92-6.49) vs 4.57 (4.23-4.93), P = 0.008). The mean admission rate for severe hypoglycemia was 1.45/100 patient-years (1.30-1.61). Rates were higher in migrants compared to non-migrants (2.13 (1.72-2.65) vs 1.28 (1.12-1.47), P < 0.001), and highest in individuals with severe hypoglycemia within the preceding year (17.69 (15.63-20.03) vs patients without preceding hypoglycemia 0.42 (0.35-0.52), P < 0.001). Differences remained significant after multivariable adjustment.

CONCLUSIONS

The identification of at-risk individuals for DKA (patients with high HbA1c, longer diabetes duration, adolescents, girls) and for severe hypoglycemia (patients with preceding severe hypoglycemia, migrants) may facilitate targeted diabetes counselling in order to prevent these complications.

Equal access to health care may diminish the differences in outcome between native and immigrant patients with type 1 diabetes

BACKGROUND/OBJECTIVE

Previous studies have found that ethnicity influences glycemic control. We hypothesized that differences between Nordic and non-Nordic patients are less pronounced for children with type 1 diabetes in high incidence countries in Northern Europe.

RESEARCH DESIGN AND METHODS

We investigated patients aged 0-15 yr in national pediatric registers in Denmark (D), Iceland (I), Norway (N), and Sweden (S) (2006-2009). Ethnic origin was defined by maternal country of birth as being Nordic or non-Nordic (other countries).

RESULTS

The cohort (n = 11,908, 53.0% boys, onset age 7.7 (3.9) yr, diabetes duration 6.1 (3.6) yr, [mean, (SD)]) comprised 921 (7.7%) non-Nordic patients. The frequencies of non-Nordic patients according to country of residence were: 5.7% (D), 2.7% (I), 5.5% (N), and 9.4% (S). Sex distribution and BMI z-score did not differ between Nordic and non-Nordic patients, but non-Nordic patients were 0.5 yr younger at onset than Nordic patients (p < 0.0006). Non-Nordic patients had a lower number of daily insulin bolus injections and higher daily insulin doses compared to their Nordic peers. Patients of non-Nordic origin had slightly higher HbA1c levels (0.6-2.9 mmol/mol, p < 0.001) and, with the exception of Norway, were less frequently treated with CSII (p = 0.002) after adjusting for confounders.

CONCLUSIONS

The reported differences in glycemic regulation between Nordic and non-Nordic type 1 diabetes children and adolescents in four Nordic countries are diminutive, but persist after accounting for treatment intensity.

Migration status in relation to clinical characteristics and barriers to care among youth with diabetes in the US

Migration status and the accompanying diversity in culture, foods and family norms, may be an important consideration for practitioners providing individualized care to treat and prevent complications among youth with diabetes. Approximately 20 % of youth in the US have ≥1 foreign-born parent. However, the proportion and characteristics of youth with diabetes and ≥1 foreign-born parent have yet to be described. Study participants (n = 3,086) were from SEARCH for Diabetes in Youth, a prospective multi-center study in the US. Primary outcomes of interest included HbA1c, body mass index and barriers to care. Multivariable analyses were carried out using logistic regression and analysis of covariance. Approximately 17 % of participants with type 1 diabetes (T1D) and 22 % with type 2 diabetes (T2D) had ≥1 foreign-born parent. Youth with T1D and ≥1 foreign-born parent were less likely to have poor glycemic control [adjusted odds ratio (OR) (95 % confidence interval): 0.70 (0.53, 0.94)]. Among youth with T2D, those with ≥1 foreign-born parent had lower odds of obesity [adjusted OR (95 % CI): 0.35 (0.17, 0.70)]. This is the first study to estimate the proportion and characteristics of youth with diabetes exposed to migration in the US. Research into potential mechanisms underlying the observed protective effects is warranted.

Do social inequalities exist in terms of the prevention, diagnosis, treatment, control and monitoring of diabetes? A systematic review

The major increase in the prevalence of diabetes mellitus (DM) has led to the study of social inequalities in health-care. The aim of this study is to establish the possible existence of social inequalities in the prevention, diagnosis, treatment, control and monitoring of diabetes in Organisation for Economic Co-operation and Development (OECD) countries which have universal healthcare systems. We searched MEDLINE, EMBASE and the Cochrane Database of Systematic Reviews for all relevant articles published up to 15 December 2007. We included observational studies carried out in OECD countries with universal healthcare systems in place that investigate social inequalities in the provision of health-care to diabetes patients. Two independent reviewers carried out the critical assessment using the STROBE tool items considered most adequate for the evaluation of the methodological quality. We selected 41 articles from which we critically assessed 25 (18 cross-sectional, 6 cohorts, 1 case-control). Consistency among the article results was found regarding the existence of ethnic inequalities in treatment, metabolic control and use of healthcare services. Socioeconomic inequalities were also found in the diagnosis and control of the disease, but no evidence of any gender inequalities was found. In general, the methodological quality of the articles was moderate with insufficient information in the majority of cases to rule out bias. This review shows that even in countries with a significant level of economic development and which have universal healthcare systems in place which endeavour to provide medical care to the entire population, socioeconomic and ethnic inequalities can be identified in the provision of health-care to DM sufferers. However, higher quality and follow-up articles are needed to confirm these results.

Glycemic control in diabetic children: role of mother's knowledge and socioeconomic status

The aim of this study is to investigate the role of mother's knowledge and socioeconomic status (SES) of the family on glycemic control in diabetic children. Our sample was taken from successive admissions to the outpatient's diabetes clinics in Tuzla, Bosnia and Herzegovina. Diabetes knowledge was assessed using the Michigan Diabetes Research and Training Center Diabetes Knowledge Test. Glycemic control was assessed by glycosylated hemoglobin (HbA(1C)). The mother's demographics were obtained by self-report. To categorize families' SES, parents' level of education, and current employment were recorded and analyzed using the Hollingshed two-factor index of social position. As expected, higher mother's knowledge was significantly associated with lower HbA(1C) (r = -0.2861705, p = 0.0442). Also, a significant correlation was found between the families' SES and HbA(1C) levels (r = 0.4401921; p = 0.0015). Mothers with more knowledge have children with better metabolic control, and low SES is significantly associated with higher levels of HbA1c. Improvement of mothers' knowledge and family SES may improve glycemic control and ultimately decrease acute and chronic complications of diabetes in children.

Glycemic control in pediatric type 1 diabetes: role of caregiver literacy

OBJECTIVE

Poorly controlled diabetes may occur because caregivers of children with type 1 diabetes fail to comprehend provided diabetes education. We hypothesized that poorly controlled diabetes is associated with lower literacy/numerical skills of caregivers of children with type 1 diabetes.

METHODS

Primary caregivers were evaluated by using Newest Vital Sign (NVS) and a sociodemographic questionnaire. The NVS identifies individuals who are at risk for low health literacy by measuring general literacy/numeracy skills and yields an overall estimate of health literacy. The NVS scores are interpreted to suggest inadequate, limited, or adequate literacy.

RESULTS

Two hundred caregivers of children who had type 1 diabetes with mean hemoglobin A1c (HbA1c) of 8.8 +/- 1.9%, age of 11.8 +/- 3.7 years, duration of disease of 4.8 +/- 3.3 years, and BMI of 20.8 +/- 4.4 kg/m(2) participated. HbA1c in those of inadequate literacy (10.4 +/- 2.2%) was significantly higher than in those of adequate literacy (8.6 +/- 1.7%; P < .001). HbA1c in those whose caregivers had limited literacy (9.5 +/- 2.2%) did not differ significantly from the other 2 groups. On adjusting for independent covariates, we found that children whose caregivers had at least 50% correct math answers had better glycemic control (8.5 +/- 1.7%) than those who failed (9.8 +/- 2.1%; P < .0005).

CONCLUSIONS

Literacy and numerical skills of caregivers significantly influence glycemic control of their children with type 1 diabetes. Assessing literacy/numeracy skills of caregivers and addressing these deficiencies may be crucial in optimizing glycemic control.

[Patient education for children and adolescents with chronic diseases]

The education of children with chronic diseases and of their parents is a treatment procedure that must be integrated into the management of the child's disease: it is essential for his or her physical and psychological health and quality of life. This continuous process is part of long-term follow-up and of the child's development; it is not a procedure that can be carried out once and for all. The program must include initial, follow-up, and advanced education. Treatment education for parents occurs simultaneously with the child's medical management and has the same requirements as that of the child (which means that the time spent in this education requires financial support). The role of the pediatrics departments serving these children is essential, and they must work with other participants, whose roles are not identical to they perform in education for adult patients. Pediatric patient education requires an interdisciplinary pediatric team with specific skills and appropriate liaison with those involved in other aspects of the child's life (e.g., daycare and school). The child's psychological development is central to the design and implementation of pediatric patient education programs. Knowledge of child development is critical in providing these services for children and adolescents; training in this field is required in addition to that necessary for adult patient education. Epidemiologic findings of the increased incidence of several chronic diseases in children must be considered in decisions about the resources allocated to coping with them. The particularities and requirements of adolescence and its interactions with chronic disease must also be considered in specific patient education programs for adolescents, and in the training and skills of healthcare professionals.

Factors associated with glycaemic outcome of childhood diabetes care in Denmark

AIMS

To study how structure and process of care is associated with outcome assessed by HbA(1c).

METHODS

Data for this cross-sectional study originated from the nationwide Danish Registry for Childhood Diabetes and two questionnaires. One questionnaire was sent to all children under 16 years of age with Type 1 diabetes in the year 2000 (N = 1087, response rate 80%). Another questionnaire was sent to the 19 centres in Denmark treating these children (response rate 100%). Simultaneously the children were asked to take a blood sample for central HbA(1c) analysis. Linear mixed models were used for analysis of associations between structure and process indicators and HbA(1c). Age, diabetes duration, sex, ethnicity, family structure and parents' occupational status were included as patient factors possibly affecting HbA(1c).

RESULTS

More visits to the outpatient clinic and higher insulin dosage were significantly associated with higher HbA(1c) (P = 0.002 and P = 0.0001, respectively). Increased frequency of blood glucose monitoring (BGM/week) and completed nephropathy screening were significantly associated with lower HbA(1c) value (estimates -0.008 and -0.49, P = 0.02, respectively). The structure indicators were not associated with HbA(1c), but telephone hot-line was positively associated with the process indicator BGM (estimate 4.02, P = 0.04). Children without Danish parents performed BGM significantly less frequently (-7.11, P = 0.0005) and had higher HbA(1c) (0.41, P = 0.06).

CONCLUSIONS

Most process indicators were significantly associated with HbA(1c), indicating relevant action of staff on glucose regulation. The structure indicators were not associated with outcome, necessitating more detailed studies on the influence of staffing resources, treatment strategies and targets in childhood diabetes management.

Educating families from ethnic minorities in type 1 diabetes-experiences from a Danish intervention study

Ethnic minorities may constitute vulnerable groups within Western health care systems as their ability to master severe chronic diseases could be affected by barriers such as different culture and health/illness beliefs, communication problems and limited educational background. An intervention focusing on immigrant families with children with type 1 diabetes is described. The intervention included the development of adapted educational material and guidelines, and a subsequent re-education of children, adolescents and parents from 37 families. The study demonstrated that it was possible to improve health outcome. During the study, the knowledge of diabetes increased, but with considerable differences between the families. HbA(1c) also decreased significantly during the intervention, but increased during follow-up. The paper discusses possible explanations and suggestions for optimising education and calls for new projects where ethnic minorities are active participants in the development of appropriate educational programs and material.

Nationwide cross-sectional survey of 3560 children and adolescents with diabetes in Italy

Clinical characteristics and metabolic control in a large cohort of children with Type 1 diabetes (T1DM) were evaluated. Fifty-three Italian centers for childhood diabetes collected blood samples and clinical records from 3560 consecutive eligible patients aged 1.6-17.10 yr with disease duration >12 months. HbA1c determinations were centralized in a Diabetes Control and Complications Trial-controlled laboratory. HbA1c grand mean was 8.87 +/- 1.77%. Thirty-two percent of the patients had HbA1c values <8.0%. Puberty and disease duration were the main determinants of increase in HbA1c levels (<0.001). HbA1c values were inversely correlated to the frequency of blood glucose monitoring (p<0.001). Among the total population, 53.7% of the patients had 4 or more injections per day, 37.8% three injections, 7.4% < or =2 injections and only 1.1% was on pumps. Daily number of injections increased with age (p<0.001). Hypoglycemia episodes were reported in 17.6% patient-years and diabetic ketoacidosis (DKA) in 1.0% of children, more frequently in those with HbA1c >8.8% (p<0.02). Two thirds of Italian children with T1DM have HbA1c>8% despite regionalized centers, multidisciplinary team approach, free access to appropriate diabetes care, education, frequent blood glucose monitoring and multiple insulin injections.

Diabetes in children and adolescents from ethnic minorities: barriers to education, treatment and good metabolic control

AIM

This paper reports an investigation to establish whether metabolic control is different in children and adolescents from ethnic minorities with type 1 diabetes compared with young Danish patients, and to learn about factors affecting their opportunities to achieve good metabolic control.

BACKGROUND

The prevalence of diabetes in children and adolescents from ethnic minorities in Denmark is increasing. Having a different ethnic background has frequently been described as a risk factor for poor metabolic control, but whether the risk is represented by the ethnicity and immigration itself or in combination with other factors is unclear.

METHODS

The study included data (gender, age, diabetes duration HbA(1c), number of incidents of severe hypoglycaemia and ketoacidosis) from a national register including 919 Danish and 58 children and adolescents from ethnic minorities, questionnaires to all 20 Danish paediatric diabetes centres and questionnaires to 38 families of other ethnic backgrounds completed by professional interpreters. The study was conducted in 2001-2002.

RESULTS

HbA(1c) was significantly higher in children and adolescents from ethnic minorities (mean 9.05 +/- 1.4%) compared with Danish patients (mean 8.62 +/- 1.3%; P = 0.018). There was no significant difference in HbA(1c) among the different ethnic groups, nor in the prevalence of severe hypoglycaemia or ketoacidosis. Patients from different ethnic minorities were unevenly distributed throughout the country, and generally the centres provided limited specialized knowledge and support. The questionnaires completed by the parents revealed limited schooling, lack of professional education and a major need for interpreters; these characteristics were especially prevalent among the mothers.

CONCLUSIONS

Young patients from ethnic minorities have significantly poorer metabolic control compared with Danish patients, and patients with an immigrant background are seen as a vulnerable group with different needs and probably fewer chances of achieving good control. Special education for health care professionals as well as projects to improve methods, quality and knowledge should be encouraged in order to provide tailored support to members of individual ethnic groups. We recommend that the use of professional interpreters should become the gold standard in health care provision to all immigrant families.

Diabetes care provision and glycaemic control in Northern Ireland: a UK regional audit

AIMS

To assess the care received, compared to national guidelines, and to investigate factors associated with glycaemic control in children and adolescents with type 1 diabetes attending clinics in Northern Ireland.

METHODS

An audit of the care provided to all patients attending 11 paediatric diabetes clinics commenced in 2002. A research nurse interviewed 914 patients completing a questionnaire recording characteristics, social circumstances, and aspects of diabetes management, including the monitoring of complications and access to members of the diabetes team. Glycaemic control was measured by glycosylated haemoglobin (HbA1c), determined at a DCCT aligned central laboratory.

RESULTS

The average HbA1c concentration was 8.8% (SD 1.5%), with 20% of patients achieving recommended HbA1c levels of less than 7.5%. In the year prior to the audit, 76% of patients were reviewed by a diabetes specialist nurse and 42% were tested for microalbuminuria. After adjustment for confounding factors, better glycaemic control was identified, particularly in patients who had attended exactly four diabetes clinics in the previous year, were members of the patient association Diabetes UK, and lived with both natural parents.

CONCLUSIONS

In Northern Ireland only a minority of patients achieved recommended HbA1c levels. Furthermore, children and adolescents with diabetes were reviewed by fewer specialists and were less intensively monitored for microvascular complications than recommended. There was evidence of better control in children who were members of Diabetes UK, suggesting that parental attitude and involvement could lead to benefits.

[Comparison of pre-dinner regular versus pre-lunch NPH of a third insulin application in adolescents with type 1 diabetes from a Public Health Service]

The majority of the type 1 Diabetes (DM1) patients are seen in Public Health Services. The management of these children, by several reasons, did not meet most of the standards for good diabetes control. In the present study we compare 2 different insulin treatment strategies in 53 uncontrolled DM1 adolescents despite a twice-a-day insulin regimen. A regimen: NPH + R before breakfast, R insulin before dinner and bedtime NPH. B regimen: NPH + R before breakfast and lunch and bedtime NPH. This was a 12-month open-label, randomized, clinical trial conducted in a Public Hospital. BMI (A: 23.4+/-3.5 Kg/m2 x B: 23.5+/-0.8 Kg/m2), average daily insulin dose (A: 1.04+/-0.28 U/Kg/d x B: 1.08+/-0.22 U/Kg/d) as well as the overall frequency of severe hypoglycemia (A: 9.4% x B: 7.5%) were similar in both groups during the study. However, HbA1c values at the end of the study were significantly lower in the B (9%) as compared to the A regimen (7,5%; p = 0.05). In conclusion, we have shown that breakfast and lunchtime NPH + R insulin plus bedtime NPH insulin is superior to pre-dinner R insulin plus breakfast and bedtime NPH insulin for overall glycemic control with similar weight status and comparable frequency of hypoglycemia. Thus, three times a day NPH insulin application is a feasible option for public service patients.

[Factors associated with childhood diabetes manifesting as ketoacidosis and its severity]

INTRODUCTION

Type 1 diabetes in children in France is frequently diagnosed at the stage of ketoacidosis (DKA).

PATIENTS AND METHODS

A prospective study was performed in a group of 72 children (mean age = 9.4 years) at onset of diabetes, in order to determine which factors were associated to DKA and to the severity of DKA (pH < 7.10) at diagnosis.

RESULTS

Younger age was related to DKA (p = 0.03), but not to its severity. A lesser frequency of DKA was found in children with a family history of insulin-treated diabetes ( p = 0.04). Misdiagnosis was more frequently observed in children with DKA than in children without DKA (p = 0.02) and in case of severe DKA at admission by comparison with non severe cases (76 vs 23%; p = 0.002). Children in low economic intake families exhibited more frequently a severe DKA (77 vs 23%; p = 0.002) and were more frequently misdiagnosed before admission (48% vs 10%; p < 0.01). Urine strips for glucose and ketone determinations were underused for diagnosis before admission (15% only).

CONCLUSION

Those results underline the need to both inform physicians and ameliorate the access to health care for low social class families, in order to take up the challenge of reducing the incidence of DKA at diagnosis in diabetic children in our country.

Risk factors for microalbuminuria in children and adolescents with type 1 diabetes

OBJECTIVES

The aim of this study was to investigate the influence of sex, age, diabetes duration, puberty, blood pressure, glycemic control and parental blood pressure on microalbuminuria in children with type 1 diabetes.

STUDY DESIGN

The study was a multicenter cross-sectional survey including 702 children and adolescents (age = 14.3+/-2.9 yr) with type 1 diabetes duration of 7.6+/-3.1 yr. One third of the population had not undergone pubertal development. Blood pressure was measured in children and their parents using a Dinamap instrument. Microalbuminuria was defined as a urinary albumin excretion rate > or = 15 microg/min measured on at least two out of three urine collections. HbA1c centrally measured by HPLC, was 8.7+/-1.5%.

RESULTS

The proportion of permanent microalbuminuria was 5.1+/-1.6%. The prevalence was significantly enhanced after 10 yr of diabetes duration (11.6+/-5.2%) and complete puberty (8.2+/-3.1%). Independent risk factors for microalbuminuria tested in a logistic regression model were diabetes duration (OR/1 yr = 1.04-1.32), complete puberty (OR = 5.02-8.0), and maternal hypertension (OR = 1.94-4.28). HbA1c had a borderline independent and significant effect (OR/1% = 0.96-1.62; p = 0.07).

CONCLUSIONS

Our results indicate that pubertal adolescents with a long duration of the disease and maternal history of hypertension are candidates for targeted interventions with the objective of reducing the rate of developing nephropathy in these individuals.

Inter-relação de variáveis demográficas, terapêutica insulínica e controle glicêmico em pacientes com diabetes mellitus do tipo 1 atendidos em um hospital universitário

Com o objetivo de avaliar a inter-relação das variáveis demográficas, terapêutica insulínica e controle glicêmico no diabetes do tipo 1 (DM1), foram estudados 86 pacientes (44 F / 42 M), de 21,8±10 anos, 10 (11,6%) pré-púberes, 22 (25,6%) púberes e 54 (62,8%) adultos, com duração do DM de 8,6±7,1 ano e idade do diagnóstico de 13,2±8,5 anos, acompanhados durante o ano de 1997. O número de consultas anuais foi de 3,6±2,2, sem associação com sexo, raça e estágio de Tanner. A dose de insulina total foi de 0,9±0,4 U/kg/dia sendo que 72 deles (83,7%) utilizavam duas injeções por dia; 39 (45,3%) utilizavam insulina de ação rápida dos quais 36 (92,3%) em combinação com insulina de ação intermediária matinal. Na análise de regressão múltipla apenas a HbA1C influenciou a dose de insulina (r=0,45; r²=0,21; p<0,001). A HbA1C foi de 8,4±1,9%, sendo os maiores níveis observados no estágio 4, em comparação aos estágios 1, 2, 3 e 5 de Tanner, respectivamente (10,5±2,4 vs 7,6±1,4 vs 8,9±2,1 vs vs 8,3±2,4 vs 8,2±1,8%; p= 0,02). As adolescentes apresentaram maior HbA1C e IMC que os adolescentes: 10,5±2,5 vs 8,3±2,0% (p= 0,02) e 19,4±1,9 vs 18,3±2,2 kg/m² (p= 0,04), respectivamente. O controle glicêmico foi considerado bom em 50% e péssimo em 31,4% dos pacientes. Concluímos que na amostra estudada houve uma piora do controle glicêmico no estágio final da puberdade, independente do número de consultas e das variáveis demográficas analisadas, e que o elevado número de pacientes com controle péssimo deverá nortear mudanças das estratégias terapêuticas.