Nutrition and Obesity in the Pathogenesis of Youth-Onset Type 1 Diabetes and Its Complications

Type 1 Diabetes Polygenic Scores Improve Diagnostic Accuracy in Pediatric Diabetes Care

Background

Accurately classifying pediatric diabetes can be challenging for providers, and misclassification can result in suboptimal care. In recent years, type 1 diabetes (T1D) polygenic scores, which quantify one's genetic risk for T1D based on T1D risk allele burden, have been developed with good discriminating capacity between T1D and not-T1D. These tools have the potential to improve significantly diagnostic provider accuracy if used in clinic.

Methods

We applied T1D polygenic scores to a group of pediatric patients (n=1846) with genetic data available in the Boston Children's Hospital PrecisionLink Biobank, including 96 individuals diagnosed with T1D.

Results

Patients with a clinical diagnosis of T1D had higher T1D polygenic scores compared to controls (Wilcoxon rank-sum P<0.0001). Sixty-nine of the 74 individuals with diabetes and a T1D polygenic score exceeding an externally validated cutoff for distinguishing T1D from not-T1D were confirmed to have T1D. There were multiple cases where T1D polygenic scores would have clinical utility. An elevated T1D polygenic score suggested T1D in a pancreatic autoantibody (PAA)- negative individual with negative MODY genetic testing and a phenotype matching T1D. A low T1D polygenic score accurately indicated atypical diabetes in an individual found to have HNF1B-MODY. One individual had positive PAA, but the provider noted that the patient may not have classic T1D, as later suggested by a low T1D polygenic score.

Conclusion

T1D polygenic scores already have clinical utility to aid in the accurate diagnosis of pediatric diabetes. Efforts are now needed to advance their use in clinical practice.

Prevalence and factors associated with vitamin D deficiency in children and adolescents with type 1 diabetes mellitus: Baseline data from a clinical trial in Rio de Janeiro

OBJECTIVES

The therapeutic potential of vitamin D has been studied regarding adjuvant interventions. Some studies have evaluated the factors associated with vitamin D deficiency (VDD) in healthy populations, but they are scarce in children and adolescents with type 1 diabetes mellitus (T1DM). The objective of this study was to describe the prevalence of and factors associated with VDD in children and adolescents with T1DM.

METHODS

This was a cross-sectional analysis of the baseline data from a controlled clinical trial. Participants were between 7 and 16 y old, diagnosed with T1DM for at least 1 y, and classified as having VDD when 25-hydroxyvitamin D (25[OH]D) was less than 30 ng/mL. The following data were collected: sociodemographic, clinical, laboratory, lifestyle, anthropometric, and Fok-I polymorphism (rs2228570). A multivariable logistic regression model was developed to adjust the effect of potential confounders. The odds ratio (OR) with 95% confidence interval (CI) was used. The significance level used was 5%.

RESULTS

A total of 143 children and adolescents were enrolled; 51% were female and the mean age was 11.5 ± 2.2 y old. The prevalence of VDD was 79% and the mean 25(OH)D of participants with VDD was 19.2 ± 6.1 ng/mL. The factors associated with VDD were low level of physical activity (OR, 2.9, 95% CI, 1.1-7.6, P = 0.031), poor glycemic control (OR, 5.0, 95% CI, 1.9-13.2, P = 0.001), and excess weight (OR, 3.6, 95% CI, 1.1-11.1, P = 0.029).

CONCLUSIONS

A high prevalence of VDD was observed as well as some associated lifestyle and clinical variables. Recommendations for children and adolescents with T1DM include monitoring their 25(OH)D and encouraging healthy eating practices and routine physical exercise.

Triglyceride-glucose index in adolescents with type 1 diabetes mellitus

BACKGROUND AND AIM

Even though HbA1c can be obtained easily and accurately by blood test, the cost may limit its availability for some patients and their proper follow-up. The triglyceride-glucose index has been shown to have an association with HbA1c in other populations, but it hasn't been studied in adolescents with T1DM yet. The aim of this study is to assess the association of TyG index with glycaemic control in adolescents with T1DM.

METHODS

This cross-sectional study included a sample of 36 adolescents (50% female) from the paediatric unit of the San Juan Hospital in Alicante (Spain). Data on sociodemographics, growth parameters, glycaemic control, and blood tests results were collected after routine visits.

RESULTS

A higher TyG index was statistically associated with a higher BMI, percentile and z-score, a higher triglyceride, HbA1c and glucose levels and with the triglycerides/HDL, the total cholesterol/HDL, the TyG-BMI and the TyG-waist circumference indexes.

CONCLUSION

The TyG index is a simple and non-invasive biomarker that could serve as a valuable adjunct to HbA1c monitoring in adolescents with T1DM. It may have a potential utility as a screening tool for early identification of patients at risk for developing metabolic complications such as insulin resistance and dyslipidemia.

Beyond the insulin pump: Unraveling diabetes tech dependency

The use of technology for Type 1 diabetes (T1D) has significantly developed in the last 20 years leading to several benefits in life-style management but also to potentially overreliance and addiction to such life changing devices. Insulin pumps (CSII) being small, discreet and sophisticated, offer features such as customizable basal rates, bolus calculators and integration with Continuous Glucose Monitoring (CGM) systems becoming a must have for diabetic patients. Indeed CGM, firstly introduced in the late 1990s and now being highly sophisticated provide trends and patterns hence allowing a better management of T1D. In this review we inquire the multifactorial aspects of dependency on diabetes technology, focusing not only on the benefits and the advancements these automations offer, but also the challenges, limits and possible risks associated with overreliance on them. Specifically, the impact that early introduction to technology had on patients, the dependency on CSII and CGM, the importance of learning and self-management skills and strategies for addressing unexpected events.

Mendelian randomization study reveals a causal relationship between body mass index in children and risk of autoimmune diseases

Newly emerging evidence indicates that body mass index (BMI) is a potential risk factor for autoimmune diseases (ADs). Nevertheless, the exact causal connection between ADs and BMI in children remains uncertain. To investigate the relationship between BMI in children and ADs, a 2-sample Mendelian randomization (MR) analysis was conducted. In this analysis, several regression methods were utilized, including the inverse-variance weighted (IVW), weighted mode, weighted median, and MR-Egger regression. Publicly available summary statistics datasets from meta-analyses of genome-wide association studies (GWAS) were employed, specifically focusing on BMI in children of European descent (n = 39,620) from the UK Biobank (ebi-a-GCST90002409) as the exposure group. The outcomes were derived from individuals included in the Finnish biobank study FinnGen, with 42,202 cases and 176,590 controls representing the ADs group (finngen_R5_AUTOIMMUNE). For instrumental variables, we carefully selected 16 single nucleotide polymorphisms (SNPs) from GWAS on BMI in children. Our analysis implemented the IVW method, which demonstrated supporting evidence for a causal association between BMI in children and ADs. The results indicated a significant effect with a beta coefficient of 0.22, standard error (SE) of 0.05, odds ratio (OR) of 1.25, and a 95% confidence interval (CI) ranging from 1.13 to 1.38, with a P-value of <.05. We also utilized the weighted median method, which yielded similar findings to the IVW method. The OR estimates from the weighted median analysis showed a beta coefficient of 0.20, SE of 0.06, OR of 1.22, and a 95% CI ranging from 1.08 to 1.36, with a P-value of <.05. No significant association was observed in the MR-Egger and Weighted mode analyses. The findings from the MR analysis suggest that there is evidence supporting a potential causal link between BMI in children and an increased susceptibility to ADs.

An adipocentric perspective of pancreatic lipotoxicity in diabetes pathogenesis

Obesity and diabetes represent two increasing and invalidating public health issues that often coexist. It is acknowledged that fat mass excess predisposes to insulin resistance and type 2 diabetes mellitus (T2D), with the increasing incidence of the two diseases significantly associated. Moreover, emerging evidence suggests that obesity might also accelerate the appearance of type 1 diabetes (T1D), which is now a relatively frequent comorbidity in patients with obesity. It is a common clinical finding that not all patients with obesity will develop diabetes at the same level of adiposity, with gender, genetic, and ethnic factors playing an important role in defining the timing of diabetes appearance. The adipose tissue (AT) expandability hypothesis explains this paradigm, indicating that the individual capacity to appropriately store energy surplus in the form of fat within the AT determines and prevents the toxic deposition of lipids in other organs, such as the pancreas. Thus, we posit that when the maximal storing capacity of AT is exceeded, individuals will develop T2D. In this review, we provide insight into mechanisms by which the AT controls pancreas lipid content and homeostasis in case of obesity to offer an adipocentric perspective of pancreatic lipotoxicity in the pathogenesis of diabetes. Moreover, we suggest that improving AT function is a valid therapeutic approach to fighting obesity-associated complications including diabetes.

The Association between Dietary Pattern, Obesity, and Glycemic Control of Children and Adolescents with Type 1 Diabetes Mellitus

AIMS

To evaluate the association between dietary patterns, obesity, and glycemic control in children and adolescents with type 1 diabetes mellitus (T1DM).

METHODS

A cross-sectional study was carried out in 2015 at a diabetes reference center in Rio de Janeiro. Sociodemographic data and those related to outpatient follow-ups were obtained from the medical records. The assessment of food consumption was performed using a 24 h food recall. Obesity was defined as body mass index-for-age (BMI-for-age) ≥ +1 z-score. Glycemic control was assessed using glycated hemoglobin (HbA1c). Dietary patterns were generated by factorial analysis, and each individual's adherence to these dietary patterns was determined by the factor loadings and then classified into terciles.

RESULTS

The study population included 120 children and adolescents, among whom 5 dietary patterns were identified. The prevalence of obesity was 31.7% (n = 38), and 64.2% (n = 77) of the participants had inadequate glycemic control. We observed that individuals with higher adherence to dietary pattern five, characterized by a greater consumption of ultra-processed foods, had higher odds of having higher HbA1c levels (OR = 3.49; 95% CI = 1.18-11.16).

CONCLUSIONS

Higher consumption of ultra-processed foods can be detrimental to glycemic control in children and adolescents. Thus, food intake monitoring is of paramount importance as part of the multidisciplinary care of patients with T1DM.

New advances in type 1 diabetes

Type 1 diabetes is an autoimmune condition resulting in insulin deficiency and eventual loss of pancreatic β cell function requiring lifelong insulin therapy. Since the discovery of insulin more than 100 years ago, vast advances in treatments have improved care for many people with type 1 diabetes. Ongoing research on the genetics and immunology of type 1 diabetes and on interventions to modify disease course and preserve β cell function have expanded our broad understanding of this condition. Biomarkers of type 1 diabetes are detectable months to years before development of overt disease, and three stages of diabetes are now recognized. The advent of continuous glucose monitoring and the newer automated insulin delivery systems have changed the landscape of type 1 diabetes management and are associated with improved glycated hemoglobin and decreased hypoglycemia. Adjunctive therapies such as sodium glucose cotransporter-1 inhibitors and glucagon-like peptide 1 receptor agonists may find use in management in the future. Despite these rapid advances in the field, people living in under-resourced parts of the world struggle to obtain necessities such as insulin, syringes, and blood glucose monitoring essential for managing this condition. This review covers recent developments in diagnosis and treatment and future directions in the broad field of type 1 diabetes.

Fat-to-muscle ratio is associated with insulin resistance and cardiometabolic disorders in adults with type 1 diabetes mellitus

AIMS

This study aimed to investigate the correlation of the fat-to-muscle ratio (FMR) with insulin resistance (IR) and cardiometabolic disorders (CMD) in patients with type 1 diabetes mellitus (T1DM).

MATERIALS AND METHODS

We retrospectively recruited 420 adults with T1DM [52.6% men, median age 32.4 (24.5, 43.0) years]. Body composition was assessed by bioelectrical impedance analysis and FMR was calculated. The characteristics of the overall participants were compared between tertiles of FMR. Logistic regression analyses were performed to assess the association of FMR tertiles with IR and cardiometabolic risk factors.

RESULTS

Median age and median haemoglobin A1c of all participants were 32.4 (24.5, 43.0) years and 7.4 (6.5, 8.7)%, respectively. The prevalence of IR and CMD was 18% and 38.6%. The FMR significantly differed between men and women [0.39 (0.31, 0.53) vs. 0.74 (0.63, 0.92), respectively, p < .001]. The proportion of IR and CMD gradually increased as the FMR increased. The multivariable-adjusted odd ratios for IR and CMD in FMR tertile 3 compared with tertile 1 were 4.8 [95% confidence interval (CI): (1.9, 12.1)] and 9.7 (95% CI: 4.2, 22.3), respectively, in men. For women, the corresponding odd ratios were 4.0 (95% CI: 1.2, 12.9) for IR and 5.8 (95% CI: 2.4, 13.6) for CMD.

CONCLUSIONS

FMR is associated with IR and CMD in adults with T1DM and could be used as a promising parameter for targeting treatment in T1DM.

Chronic inflammation in high-fat diet-fed mice: Unveiling the early pathogenic connection between liver and adipose tissue

Obesity-induced chronic inflammation has been linked to several autoimmune diseases, including rheumatoid arthritis, type 1 diabetes, and multiple sclerosis. The underlying mechanisms are not yet fully understood, but it is believed that chronic inflammation in adipose tissue can lead to the production of pro-inflammatory cytokines and chemokines, which can trigger immune responses and contribute to the development of autoimmune diseases. However, the underlying mechanisms that lead to the infiltration of immune cells into adipose tissue are not fully understood. In this study, we observed a time-dependent response to a high-fat diet in the liver and epididymal white adipose tissue using gene set enrichment analysis. Our findings revealed a correlation between early abnormal innate immune responses in the liver and late inflammatory response in the adipose tissue, that eventually leads to systemic inflammation. Specifically, our data suggest that the dysregulated NADH homeostasis in the mitochondrial matrix, interacting with the mitochondrial translation process, could serve as a sign marking the transition from liver inflammation to adipose tissue inflammation. Taken together, our study provides valuable insights into the molecular mechanisms underlying the development of chronic inflammation and associated autoimmune diseases in obesity.

Urinary epidermal growth factor reflects vascular health in boys with either obesity or type 1 diabetes. A role for renin, or beyond?

An increased blood pressure is a known comorbidity of both type 1 diabetes (T1DM) and obesity in children. Increasing evidence suggests a subtle interplay between epidermal growth factor (EGF) and renin along the juxtaglomerular system, regulating the impact of blood pressure on kidney health and the cardiovascular system. In this study, we investigated the relation between urinary EGF, serum renin and blood pressure in children with obesity or T1DM. 147 non-obese children with T1DM and 126 children with obesity, were included. Blood pressure was measured and mean arterial pressure (MAP) and the pulse pressure (PP) were calculated. Serum renin and urinary EGF levels were determined with a commercial ELISA kit. Partial Spearman rank correlation coefficients and multiple linear regression models were used to study the association between renin, the urinary EGF/urinary creatinine ratio and blood pressure parameters. The urinary EGF/urinary creatinine ratio is correlated with the SBP and the MAP in boys with obesity as well as in boys with T1DM. Multiple regression analysis showed that sex and pulse pressure in male subjects were found to be independently associated with renin. Sex, the presence of diabetes, age, the glomerular filtration rate and both pulse pressure and mean arterial pressure in male subjects were independently associated with urinary EGF/urinary creatinine. In conclusion, in boys with either obesity or diabetes, pulse pressure and mean arterial pressure are negatively associated with the functional integrity of the nephron, which is reflected by a decreased expression of urinary EGF.

Variation in the incidence of type 1 diabetes mellitus in children and adolescents by world region and country income group: A scoping review

INTRODUCTION

Around 18.7 million of the 537 million people with diabetes worldwide live in low-income and middle-income countries (LMIC), where there is also an increase in the number of children, adolescents, and young adults diagnosed with type 1 diabetes (T1D). There are substantial gaps in data in the current understanding of the epidemiological patterns and trends in incidence rates of T1D at the global level.

METHODS

We performed a scoping review of published studies that established the incidence of T1D in children, adolescents, and young adults aged 0-25 years at national and sub-national levels using PubMed, Embase and Global Health. Data was analyzed using R programming.

RESULTS

The scoping review identified 237 studies which included T1D incidence estimates from 92 countries, revealing substantial variability in the annual incidence of T1D by age, geographic region, and country-income classification. Highest rates were reported in the 5-9 and 10-14 year age groups than in the 0-4 and 15-19 year age groups, respectively. In the 0-14 year age group, the highest incidence was reported in Northern Europe (23.96 per 100,000), Australia/New Zealand (22.8 per 100,000), and Northern America (18.02 per 100,000), while the lowest was observed in Melanesia, Western Africa, and South America (all < 1 per 100,000). For the 0-19 year age group, the highest incidence was reported in Northern Europe (39.0 per 100,000), Northern America (20.07 per 100,000), and Northern Africa (10.1 per 100,000), while the lowest was observed in Eastern and Western Africa (< 2 per 100,000). Higher incidence rates were observed in high-income countries compared to LMICs. There was a paucity of published studies focusing on determining the incidence of T1D in LMICs.

CONCLUSION

The review reveals substantial variability in incidence rates of T1D by geographic region, country income group, and age. There is a dearth of information on T1D in LMICs, particularly in sub-Saharan Africa, where incidence remains largely unknown. Investment in population-based registries and longitudinal cohort studies could help improve the current understanding of the epidemiological trends and help inform health policy, resource allocation, and targeted interventions to enhance access to effective, efficient, equitable, and responsive healthcare services.

A centennial review of discoveries and advances in diabetes: Children and youth

Diabetes is an increasingly common chronic metabolic disorder in children worldwide. The discovery of insulin in 1921 resulted in unprecedented advancements that improved the lives of children and youth with diabetes. The purpose of this article is to review the history of diabetes in children and youth over the last century and its implications for future developments in the field. We identified 68 relevant events between 1921 and 2021 through literature review and survey of pediatric endocrinologists. Basic research milestones led to the discovery of insulin and other regulatory hormones, established the normal physiology of carbohydrate metabolism and pathophysiology of diabetes, and provided insight into strategies for diabetes prevention. While landmark clinical studies were initially focused on adult diabetes populations, later studies assessed etiologic factors in birth cohort studies, evaluated technology use among children with diabetes, and investigated pharmacologic management of youth type 2 diabetes. Technological innovations culminated in the introduction of continuous glucose monitoring that enabled semi-automated insulin delivery systems. Finally, professional organizations collaborated with patient groups to advocate for the needs of children with diabetes and their families. Together, these advances transformed type 1 diabetes from a terminal illness to a manageable disease with near-normal life expectancy and increased our knowledge of type 2 diabetes and other forms of diabetes in the pediatric population. However, disparities in access to insulin, diabetes technology, education, and care support remain and disproportionately impact minority youth and communities with less resources. The overarching goal of diabetes management remains promoting a high quality of life and improving glycemic management without undermining the psychological health of children and youth living with diabetes.

Impact of an Abdominal Compression Bandage on the Completion of Colonoscopy for Obese Adults: A Prospective Randomized Controlled Trial

METHODS

Eligible patients were randomly allocated into the abdominal bandage and conventional groups during a routine colonoscopy. The primary outcome was CCR.

RESULTS

A total of 250 eligible patients were randomly assigned to the abdominal bandage and conventional groups from January 2021 to April 2021. Eleven patients (five in the abdominal bandage group and six in the conventional group) were excluded due to schedule cancellation after randomization, and 239 patients were eventually included in the final analysis. There were no significant differences between the two groups regarding baseline characteristics (P > 0.05). Furthermore, no significant differences were observed in terms of advanced adenoma detection rate (AADR), polyp detection rate (PDR), bowel preparation scale (BBPS), bubble scale (BS), and withdrawal time between the two groups (P > 0.05). However, compared with the conventional group, the cecal insertion time (CIT) of the abdominal bandage group was significantly shortened (279.00 (234.50-305.75) vs. 421.00 (327.00-485.00), P < 0.001), and the CCR (96.7% vs. 88.2%, P = 0.01) and adenoma detection rate (ADR) (47.5% vs. 32.8%, P < 0.001) were improved. Besides, logistic regression analysis showed that body mass index (BMI) and abdominal compression bandage were associated with CCR.

CONCLUSIONS

Abdominal compression bandages could effectively shorten CIT and improve CCR and ADR for obese patients during a routine colonoscopy. This trial is registered with the Chinese Clinical Trial Registry (No. ChiCTR2100043556).

Effects of vitamin D supplementation on glycemic control of children and adolescents with type 1 diabetes mellitus: a systematic review

OBJECTIVES

To evaluate the effect of vitamin D supplementation on glycemic control in children and adolescents with T1DM.

CONTENT

A systematic search was conducted of the Medline/PubMed, Web of Science, Embase, BVS/Lilacs, Cochrane Library, Scopus, Cinahl, Food Science, and FSTA databases. Two reviewers independently extracted article data and assessed quality.

SUMMARY

A total of 1,613 eligible articles were retrieved, ten of which met the selection criteria: eight clinical trials, one retrospective cohort study, and one cross-sectional study. Regarding the cutoff points used to classify vitamin D status, most of the studies set deficiency at 25-hydroxyvitamin D <20 ng/mL, sufficiency at ≥30 ng/mL, and insufficiency as the interval between these values. Regarding intervention strategies, most used cholecalciferol for supplementation, but there was great variation in the dose and supplementation time. When evaluating the effect of vitamin D supplementation on HbA1c, a significant improvement in glycemic control was observed in 50% of the studies. However, only one of these studies was classified as being of positive methodological quality, with three having their quality classified as neutral and one as negative.

OUTLOOK

There is yet no consistent evidence on the effect of vitamin D supplementation on glycemic control as an adjuvant in the treatment of children and adolescents with T1DM.

Adherence to the Mediterranean Diet Is Associated with Better Metabolic Features in Youths with Type 1 Diabetes

Our aim was to evaluate adherence to the Mediterranean diet (MedDiet) among children and adolescents with type 1 diabetes (T1D) in relation to metabolic control. Adherence to the MedDiet was assessed with the Mediterranean Diet Quality Index (KIDMED) questionnaire and physical activity by the International Physical Activity Questionnaire for Adolescent (IPAQ-A) on 65 subjects (32 males, 9–18 years) with T1D. Clinical and metabolic evaluation was performed (standardized body mass index (BMI-SDS), hemoglobin A1C (HbA1c), continuous glucose monitoring metrics when present, blood pressure, lipid profile). Parental characteristics (age, body mass index (BMI), socio-economic status) were reported. The adherence to the MedDiet was poor in 12.3%, average in 58.6%, and high in 29.1% of the subjects. Furthermore, 23.4% of patients were overweight/obese. The most impacting factors on BMI-SDS were skipping breakfast and their father’s BMI. HbA1c and time in range % were positively associated with sweets and fish intake, respectively. Additionally, the father’s socio-economic status (SES) and mother’s age were associated with glucose control. Blood pressure was associated with travelling to school in vehicles, extra-virgin olive oil intake and milk/dairy consumption at breakfast. The promotion of the MedDiet, mainly having a healthy breakfast, is a good strategy to include in the management of T1D to improve glucose and metabolic control. This research is valuable for parents to obtain the best results for their children with T1D.

Type 2 diabetes in pediatrics

Type 2 diabetes (T2D) in adolescents has become an increasing health concern throughout the world and its prevention and screening should be implemented in pediatric care. As clinical features at presentation, in some cases can be similar to type 1 diabetes and family history can be in favour of a monogenic form of diabetes, it is pivotal for physicians to be aware of youth-onset T2D specificities to ensure an accurate diagnosis. The global increase of overweight and obesity can complicate the diagnostic process and makes it essential to apply a systematic approach to each new diagnosis. Microvascular complications may be present at the time of diagnosis and chronic complications are frequent and need to be screened regularly. Regular screening of comorbidities should also be performed. Childhood T2D should be followed up by pediatric diabetes units to avoid diagnostic errors and delay in care. A multidisciplinary approach, by an experienced team, is pivotal to provide treatment options targeting the unique needs of pediatric patients. Treatment programs must include the whole family and address all the aspects of the care (lifestyle, pharmacological therapy, psychological aspects, complications and comorbidities). An organized process of transition to adult care is essential.