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March CA, Libman IM, Becker DJ, Levitsky LL. From Antiquity to Modern Times: A History of Diabetes Mellitus and Its Treatments. Horm Res Paediatr 2022; 95:593-607. [PMID: 36446320 DOI: 10.1159/000526441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Accepted: 08/07/2022] [Indexed: 12/03/2022] Open
Abstract
The past 200 years have brought an understanding of diabetes and its pathogenesis, as well as the development of treatments that could not have been predicted when the disorder was first clinically described 2000 years ago. Beginning in the late 19th century, the initial descriptions of the microscopic anatomy of the pancreatic islets by Langerhans led to recognition of pancreatic endocrine function. Many investigators attempted to isolate the hypoglycemic factor produced by the pancreas, but Banting, Best, Macleod, and Collip were able to extract and purify "isletin" to treat human diabetes in 1921. Rapid scientific progress over the next 100 years led to an understanding of insulin synthesis, structure and function, production of modified synthetic insulins, and the physiopathology that permitted classification of diabetes subtypes. Improvements in control of diabetes have reduced the risks of complications. In less than two hundred years, we have gone from being unable to measure glucose in blood to being able to offer people with diabetes continuous blood glucose monitoring, linked to continuous subcutaneous insulin infusion. We come ever closer with new drugs and treatments to repair the biochemical defects in type 2 diabetes and to biologically replace islets and their function in type 1 diabetes. This review addresses the history of continuing progress in diabetes care.
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Affiliation(s)
- Christine A March
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ingrid M Libman
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Dorothy J Becker
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Lynne L Levitsky
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
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2
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Ludvigsson J, Cuthbertson D, Becker DJ, Kordonouri O, Aschemeier B, Pacaud D, Clarson C, Krischer JP, Knip M. Increasing plasma glucose before the development of type 1 diabetes-the TRIGR study. Pediatr Diabetes 2021; 22:974-981. [PMID: 34369627 PMCID: PMC8530903 DOI: 10.1111/pedi.13251] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 07/19/2021] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE The β-cell stress hypothesis suggests that increased insulin demand contributes to the development of type 1 diabetes. In the TRIGR trial we set out to assess the profile of plasma glucose and HbA1c before the diagnosis of clinical diabetes compared to nondiabetic children. RESEARCH DESIGN AND METHODS A cohort of children (N = 2159) with an affected first-degree relative and increased HLA risk were recruited 2002-2007 and followed until 2017. To study the relationship between plasma glucose/HbA1c and the development of autoantibodies or clinical disease Kaplan-Meir curves were developed. Mixed models were constructed for plasma glucose and HbA1c separately. RESULTS A family history of type 2 diabetes was related to an increase in plasma glucose (p < 0.001). An increase in glucose from the previous sample predicted clinical diabetes (p < 0.001) but not autoantibodies. An increase of HbA1c of 20% or 30% from the previous sample predicted the development of any autoantibody (p < 0.003 resp <0.001) and the development of diabetes (p < 0.002 resp <0.001. Participants without autoantibodies had lower HbA1c (mean 5.18%, STD 0.24; mean 33.08 mmol/mol, STD 2.85) than those who progressed to clinical disease (5.31%, 0.42; 34.46 mmol/mol, 4.68; p < 0.001) but higher than those who developed any autoantibody (5.10%, 0.30; 32.21 mmol/mol, 3.49; p < 0.001), or multiple autoantibodies (5.11%, 0.35; 32.26 mmol/mol, 3.92; p < 0.003). CONCLUSIONS A pronounced increase in plasma glucose and HbA1c precedes development of clinical diabetes, while the association between plasma glucose or HbA1c and development of autoantibodies is complex. Increased insulin demand may contribute to development of type 1 diabetes.
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Affiliation(s)
- Johnny Ludvigsson
- Crown Princess Victoria Children’s Hospital and Div of Pediatrics, Dept of Biomedical and Clinical Sciences, Linköping university, Linköping, Sweden
| | - David Cuthbertson
- Health Informatics Institute, University of South Florida, Tampa, Florida, USA
| | - Dorothy J Becker
- Department of Pediatrics, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA
| | - Olga Kordonouri
- Diabetes Centre for Children and Adolescents, Kinder- und Jugendkrankenhaus Auf der Bult, Hannover, Germany
| | - Bärbel Aschemeier
- Diabetes Centre for Children and Adolescents, Kinder- und Jugendkrankenhaus Auf der Bult, Hannover, Germany
| | - Daniele Pacaud
- Department of Pediatrics, Alberta Children’s Hospital, Calgary, Alberta
| | - Cheril Clarson
- Department of Pediatrics, University of Calgary, Alberta Children’s Hospital Research Institute, Calgary, Alberta, Canada
| | - Jeffrey P Krischer
- Health Informatics Institute, University of South Florida, Tampa, Florida, USA
| | - Mikael Knip
- Pediatric Research Center, Children’s Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland,Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland,Tampere Center for Child Health Research, Tampere University Hospital, Tampere, Finland,Folkhälsan Research Center, Helsinki, Finland
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Virtanen SM, Cuthbertson D, Nucci AM, Hyytinen M, Ormisson A, Salonen M, Turrini T, Cummings EA, Bradley B, Tanner‐Blasiar M, Becker DJ, Åkerblom HK, Savilahti E, Krischer JP, Knip M. Dietary compliance in a randomized double-blind infant feeding trial during infancy aiming at prevention of type 1 diabetes. Food Sci Nutr 2021; 9:4221-4231. [PMID: 34401073 PMCID: PMC8358383 DOI: 10.1002/fsn3.2389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 05/12/2021] [Accepted: 05/14/2021] [Indexed: 11/20/2022] Open
Abstract
The international Trial to Reduce IDDM in the Genetically at Risk (TRIGR) tested the hypothesis whether extensively hydrolyzed casein-based versus regular cow's milk-based infant formula reduces the risk of type 1 diabetes. We describe dietary compliance in the trial in terms of study formula intake, feeding of nonrecommended foods, and serum cow's milk antibody concentration reflecting intake of cow's milk protein among 2,159 eligible newborn infants with a biological first-degree relative affected by type 1 diabetes and with HLA-conferred susceptibility to type 1 diabetes. The participating infants were introduced to the study formula feeding at the median age of 15 days with a median duration of study formula use of 63 days. During the intervention, 80% of the infants received study formula. Of these, 57% received study formula for at least 2 months. On average, 45.5 l of study formula were used per infant. Only 13% of the population had received a nonrecommended food by the age of 6 months. The dietary compliance was similar in the intervention and control arm. The reported cow's milk consumption by the families matched very well with measured serum casein IgA and IgG antibody concentration. To conclude, good compliance was observed in this randomized infant feeding trial. Compliance varied between the regions and those infants who were breastfed for a longer period of time had a shorter exposure to the study formula. High dietary compliance in infant feeding trial is necessary to allow accurate interpretation of study results.
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Affiliation(s)
- Suvi M. Virtanen
- Health and Well‐Being Promotion UnitFinnish Institute for Health and WelfareHelsinkiFinland
- Faculty of Social Sciences/Unit of Health SciencesTampere UniversityTampereFinland
- Center for Child Health ResearchTampere University HospitalTampere UniversityTampereFinland
- Research Development and Innovation CentreTampere University HospitalTampereFinland
| | | | - Anita M. Nucci
- Department of NutritionGeorgia State UniversityAtlantaGAUSA
| | | | - Anne Ormisson
- Department of PaediatricsUniversity of TartuTartuEstonia
| | | | | | | | - Brenda Bradley
- Children’s Hospital of Eastern OntarioUniversity of OttawaOttawaONCanada
| | | | - Dorothy J. Becker
- Children's Hospital of PittsburghPittsburghPAUSA
- University of PittsburghPittsburghPAUSA
| | | | | | | | - Mikael Knip
- University of HelsinkiHelsinkiFinland
- Children’s HospitalHelsinki University HospitalUniversity of HelsinkiHelsinkiFinland
- Folkhälsan Research CenterHelsinkiFinland
- Department of PediatricsTampere University HospitalTampereFinland
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Nakhla M, Cuthbertson D, Becker DJ, Pacaud D, Ludvigsson J, Knip M, Legault L. Diabetic Ketoacidosis at the Time of Diagnosis of Type 1 Diabetes in Children: Insights From TRIGR. JAMA Pediatr 2021; 175:518-520. [PMID: 33492389 PMCID: PMC7835920 DOI: 10.1001/jamapediatrics.2020.5512] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
This cohort study assesses the risk of diabetic ketoacidosis at the diagnosis of type 1 diabetes among children who participated in the Trial to Reduce Insulin-Dependent Diabetes Mellitus in the Genetically at Risk (TRIGR).
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Affiliation(s)
- Meranda Nakhla
- Department of Pediatrics, Montreal Children’s Hospital, McGill University, Montreal, Quebec, Canada
| | - David Cuthbertson
- Division of Bioinformatics and Biostatistics Pediatric Epidemiology Center, Department of Pediatrics, University of South Florida, Tampa
| | - Dorothy J. Becker
- Division of Endocrinology, UPMC Children’s Hospital, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Daniéle Pacaud
- Department of Pediatrics, Alberta Children’s Hospital, University of Calgary, Calgary, Alberta, Canada
| | - Johnny Ludvigsson
- Linköping University Hospital, Linköping, Sweden,Division of Pediatrics, Department of Clinical and Experimental Medicine, Medical Faculty, Linköping University, Linköping, Sweden
| | - Mikael Knip
- University of Helsinki, Helsinki, Finland,Helsinki University Hospital, Helsinki, Finland
| | - Laurent Legault
- Department of Pediatrics, Montreal Children’s Hospital, McGill University, Montreal, Quebec, Canada
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Nucci AM, Virtanen SM, Cuthbertson D, Ludvigsson J, Einberg U, Huot C, Castano L, Aschemeier B, Becker DJ, Knip M, Krischer JP. Growth and development of islet autoimmunity and type 1 diabetes in children genetically at risk. Diabetologia 2021; 64:826-835. [PMID: 33474583 PMCID: PMC7940594 DOI: 10.1007/s00125-020-05358-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 10/27/2020] [Indexed: 12/30/2022]
Abstract
AIMS/HYPOTHESIS We aimed to evaluate the relationship between childhood growth measures and risk of developing islet autoimmunity (IA) and type 1 diabetes in children with an affected first-degree relative and increased HLA-conferred risk. We hypothesised that being overweight or obese during childhood is associated with a greater risk of IA and type 1 diabetes. METHODS Participants in a randomised infant feeding trial (N = 2149) were measured at 12 month intervals for weight and length/height and followed for IA (at least one positive out of insulin autoantibodies, islet antigen-2 autoantibody, GAD autoantibody and zinc transporter 8 autoantibody) and development of type 1 diabetes from birth to 10-14 years. In this secondary analysis, Cox proportional hazard regression models were adjusted for birthweight and length z score, sex, HLA risk, maternal type 1 diabetes, mode of delivery and breastfeeding duration, and stratified by residence region (Australia, Canada, Northern Europe, Southern Europe, Central Europe and the USA). Longitudinal exposures were studied both by time-varying Cox proportional hazard regression and by joint modelling. Multiple testing was considered using family-wise error rate at 0.05. RESULTS In the Trial to Reduce IDDM in the Genetically at Risk (TRIGR) population, 305 (14.2%) developed IA and 172 (8%) developed type 1 diabetes. The proportions of children overweight (including obese) and obese only were 28% and 9% at 10 years, respectively. Annual growth measures were not associated with IA, but being overweight at 2-10 years of life was associated with a twofold increase in the development of type 1 diabetes (HR 2.39; 95% CI 1.46, 3.92; p < 0.001 in time-varying Cox regression), and similarly with joint modelling. CONCLUSIONS/INTERPRETATION In children at genetic risk of type 1 diabetes, being overweight at 2-10 years of age is associated with increased risk of progression from multiple IA to type 1 diabetes and with development of type 1 diabetes, but not with development of IA. Future studies should assess the impact of weight management strategies on these outcomes. TRIAL REGISTRATION ClinicalTrials.gov NCT00179777.
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Affiliation(s)
- Anita M Nucci
- Department of Nutrition, Georgia State University, Atlanta, GA, USA
| | - Suvi M Virtanen
- Welfare and Health Promotion Unit, Finnish Institute for Health and Welfare, Helsinki, Finland
- Unit of Health Sciences, Faculty of Social Sciences, Tampere University, Tampere, Finland
- Center for Child Health Research, Tampere University and Tampere University Hospital, Tampere, Finland
- The Science Center of Pirkanmaa Hospital District, Tampere, Finland
| | - David Cuthbertson
- Pediatrics Epidemiology Center, University of South Florida, Tampa, FL, USA
| | - Johnny Ludvigsson
- Crown Princess Victoria Children’s Hospital and Division of Pediatrics, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | | | | | - Luis Castano
- Cruces, University Hospital, Biocruces Bizkaia Research Institute, UPV/EHU, CIBERDEM, CIBERER, Endo-ERN, Bilbao-Bizkaia, Spain
| | - Bärbel Aschemeier
- Diabetes Centre for Children and Adolescents, Children’s and Adolescent’s Hospital AUF DER BULT, Hannover, Germany
| | - Dorothy J Becker
- Division of Endocrinology, University of Pittsburgh and UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Mikael Knip
- 3ediatric Research Center, Children’s Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Folkhälsan Research Center, Helsinki, Finland
- Department of Pediatrics, Tampere University Hospital, Tampere, Finland
| | - Jeffrey P Krischer
- Pediatrics Epidemiology Center, University of South Florida, Tampa, FL, USA
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Pacaud D, Nucci AM, Cuthbertson D, Becker DJ, Virtanen SM, Ludvigsson J, Ilonen J, Knip M. Association between family history, early growth and the risk of beta cell autoimmunity in children at risk for type 1 diabetes. Diabetologia 2021; 64:119-128. [PMID: 33026463 PMCID: PMC7716821 DOI: 10.1007/s00125-020-05287-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 08/07/2020] [Indexed: 12/30/2022]
Abstract
AIMS/HYPOTHESIS The aim of this work was to examine the relationship between family history of type 1 diabetes, birthweight, growth during the first 2 years and development of multiple beta cell autoantibodies in children with a first-degree relative with type 1 diabetes and HLA-conferred disease susceptibility. METHODS In a secondary analysis of the Trial to Reduce IDDM in the Genetically at Risk (TRIGR), clinical characteristics and development of beta cell autoantibodies were compared in relation to family history of type 1 diabetes (mother vs father vs sibling) in 2074 children from families with a single affected family member. RESULTS Multiple autoantibodies (≥2 of 5 measured) developed in 277 (13%) children: 107 (10%), 114 (16%) and 56 (18%) born with a mother, father or sibling with type 1 diabetes, respectively (p < 0.001). The HR for time to multiple autoimmunity was 0.54 (95% CI 0.39, 0.75) in offspring of affected mothers (n = 107/1046, p < 0.001) and 0.81 (95% CI 0.59, 1.11) (n = 114/722, p = 0.19) in offspring of affected fathers, compared with participants with a sibling with type 1 diabetes (comparator group n = 56/306). The time to the first autoantibody present (to insulin, GAD, tyrosine phosphatase-related insulinoma-associated 2 molecules, islet cell or zinc transporter 8) was similar in the three groups. Height velocity (z score/year) in the first 24 months was independently associated with developing multiple antibodies in the total cohort (HR 1.31 [95% CI 1.01, 1.70], p = 0.04). A higher birthweight in children born to an affected mother vs affected father or an affected sibling was not related to the risk of multiple autoimmunity. CONCLUSIONS/INTERPRETATION The risk of developing multiple autoantibodies was lower in children with maternal type 1 diabetes. For the whole group, this risk of developing multiple autoantibodies was independent of birthweight but was greater in those with increased height velocity during the first 2 years of life. However, the risk associated with paternal type 1 diabetes was not linked to differences in birthweight or early growth. TRIAL REGISTRATION ClinicalTrials.gov NCT00179777 Graphical abstract.
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Affiliation(s)
- Danièle Pacaud
- Department of Pediatrics, Alberta Children’s Hospital, University of Calgary, Calgary, AB Canada
| | - Anita M. Nucci
- Department of Nutrition, Georgia State University, Atlanta, GA USA
| | - David Cuthbertson
- Pediatrics Epidemiology Center, University of South Florida, Tampa, FL USA
| | - Dorothy J. Becker
- Division of Endocrinology, University of Pittsburgh and UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA USA
| | - Suvi M. Virtanen
- Public Health Promotion Unit, National Institute for Health and Welfare, Helsinki, Finland
- Faculty of Social Sciences/Health, Tampere University, Tampere, Finland
- Center for Child Health Research, Tampere University, Tampere, Finland
- Research, Development and Innovation Centre, Tampere University Hospital, Tampere, Finland
| | - Johnny Ludvigsson
- Crown Princess Victoria Children’s Hospital, Region Östergötland and Division of Pediatrics, Department of Clinical Experimental Medicine, Linkoping University, Linkoping, Sweden
| | - Jorma Ilonen
- Immunogenetics Laboratory, Institute of Biomedicine, University of Turku, Turku, Finland
- Clinical Microbiology, Turku University Hospital, Turku, Finland
| | - Mikael Knip
- Pediatric Research Center, Children’s Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
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March CA, Becker DJ, Libman IM. Nutrition and Obesity in the Pathogenesis of Youth-Onset Type 1 Diabetes and Its Complications. Front Endocrinol (Lausanne) 2021; 12:622901. [PMID: 33828529 PMCID: PMC8021094 DOI: 10.3389/fendo.2021.622901] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 02/15/2021] [Indexed: 12/15/2022] Open
Abstract
Since the 1980s, there has been a dramatic rise in the prevalence of overweight and obesity in pediatric populations, in large part driven by sedentary lifestyles and changing dietary patterns with more processed foods. In parallel with the rise in pediatric obesity in the general population, the prevalence of overweight and obesity has increased among children and adolescents with type 1 diabetes. Adiposity has been implicated in a variety of mechanisms both potentiating the risk for type 1 diabetes as well as exacerbating long-term complications, particularly cardiovascular disease. Treatment options targeting the unique needs of obese pediatric patients, both before and after diagnosis of type 1 diabetes, are limited. In this review, we discuss the history of the epidemiology of the obesity epidemic in the context of pediatric type 1 diabetes, highlight the possible role of obesity in type 1 diabetes pathogenesis and review the concept of "double diabetes". The impact of obesity at and after diagnosis will be discussed, including noted differences in clinical and biochemical markers, lipid abnormalities, and long-term cardiovascular complications. Finally, we will review the existing literature on pharmacologic and nutritional interventions as potential treatment strategies for youth with coexisting type 1 diabetes and obesity.
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Ismail HM, Cleves MA, Xu P, Libman IM, Becker DJ, Marks JB, Skyler JS, Palmer JP, Sosenko JM. The Pathological Evolution of Glucose Response Curves During the Progression to Type 1 Diabetes in the TrialNet Pathway to Prevention Study. Diabetes Care 2020; 43:2668-2674. [PMID: 32900788 PMCID: PMC7576415 DOI: 10.2337/dc20-0701] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 07/27/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Glucose response curves (GRCs) during oral glucose tolerance tests (OGTTs) are predictive of type 1 diabetes. We performed a longitudinal analysis in pancreatic autoantibody-positive individuals to assess 1) characteristic GRC changes during progression to type 1 diabetes and 2) GRC changes in relation to β-cell function changes and to combined glucose and C-peptide response curve (GCRC) changes. RESEARCH DESIGN AND METHODS Among antibody-positive individuals with serial OGTTs in the TrialNet Pathway to Prevention study, GRC changes from first to last OGTTs were compared between progressors (n = 298) to type 1 diabetes and nonprogressors (n = 2,216). GRC changes from last OGTT before diagnosis to diagnostic OGTTs were studied in progressors. RESULTS GRCs changed more frequently from biphasic (two peaks) to monophasic (one peak) GRCs between first and last OGTTs in progressors than in nonprogressors (75.4% vs. 51.0%, respectively; P < 0.001). In contrast, GRCs of progressors changed less frequently from monophasic to biphasic than those of nonprogressors (12.6% vs. 30.6%; P < 0.001). Monotonic (continuous increase) GRCs were present in 47.7% of progressors at diagnosis. The early (30-0 min) C-peptide response decreased in progressors with GRCs changing from biphasic to monophasic between first and last OGTTs (P < 0.001) and from monophasic to monotonic between last and diagnostic OGTTs (P < 0.001). Conversely, the early C-peptide response increased among nonprogressors with GRCs changing from monophasic to biphasic (P < 0.001). Changes in GRCs were related to changes in GCRCs. CONCLUSIONS Characteristic GRC changes, biphasic to monophasic to monotonic, occur during the progression to type 1 diabetes. These GRC changes correspond to decreasing β-cell function.
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Affiliation(s)
- Heba M Ismail
- Division of Endocrinology and Diabetology, Department of Pediatrics, Indiana University, Indianapolis, IN
| | - Mario A Cleves
- Pediatrics Epidemiology Center, College of Medicine, University of South Florida, Tampa, FL
| | - Ping Xu
- Pediatrics Epidemiology Center, College of Medicine, University of South Florida, Tampa, FL
| | - Ingrid M Libman
- Division of Endocrinology, Diabetes and Metabolism, University of Pittsburgh and UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Dorothy J Becker
- Division of Endocrinology, Diabetes and Metabolism, University of Pittsburgh and UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Jennifer B Marks
- Division of Endocrinology, Diabetes and Metabolism, Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Jay S Skyler
- Division of Endocrinology, Diabetes and Metabolism, Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Jerry P Palmer
- VA Puget Sound Health Care System, Seattle, WA.,Department of Medicine, University of Washington, Seattle, WA
| | - Jay M Sosenko
- Division of Endocrinology, Diabetes and Metabolism, Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL
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Miller RG, Yu L, Becker DJ, Orchard TJ, Costacou T. Older age of childhood type 1 diabetes onset is associated with islet autoantibody positivity >30 years later: the Pittsburgh Epidemiology of Diabetes Complications Study. Diabet Med 2020; 37:1386-1394. [PMID: 32011014 PMCID: PMC7369217 DOI: 10.1111/dme.14261] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/29/2020] [Indexed: 01/12/2023]
Abstract
AIMS To examine the association between islet autoantibody positivity and clinical characteristics, residual β-cell function (C-peptide) and prevalence of complications in a childhood-onset (age <17 years), long-duration (≥32 years) type 1 diabetes cohort. METHODS Islet autoantibodies (glutamic acid decarboxylase, insulinoma-associated protein 2 and zinc transporter-8 antibodies) were measured in the serum of participants who attended the 2011-2013 Pittsburgh Epidemiology of Diabetes Complications study follow-up examination (n=177, mean age 51 years, diabetes duration 43 years). RESULTS Prevalences of islet autoantibodies were: glutamic acid decarboxylase, 32%; insulinoma-associated protein 2, 22%; and zinc transporter-8, 4%. Positivity for each islet autoantibody was associated with older age at diabetes onset (glutamic acid decarboxylase antibodies, P=0.03; insulinoma-associated protein 2 antibodies, P=0.001; zinc transporter-8 antibodies, P<0.0001). Older age at onset was also associated with an increasing number of autoantibodies (P = 0.001). Glutamic acid decarboxylase antibody positivity was also associated with lower HbA1c (P = 0.02), insulinoma-associated protein 2 antibody positivity was associated with lower prevalence of severe hypoglycaemic episodes (P=0.02) and both distal and autonomic neuropathy (P=0.04 for both), and zinc transporter-8 antibody positivity was associated with higher total and LDL cholesterol (P=0.01). No association between autoantibody positivity and C-peptide was observed. CONCLUSIONS The strong association between islet autoantibody positivity and older age at type 1 diabetes onset supports the hypothesis of a less aggressive, and thus more persistent, immune process in those with older age at onset. This observation suggests that there may be long-term persistence of heterogeneity in the underlying autoimmune process.
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Affiliation(s)
- R G Miller
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA
| | - L Yu
- School of Medicine, Barbara Davis Center, University of Colorado Denver, Aurora, CO, USA
| | - D J Becker
- Department of Paediatrics, Division of Pediatric Endocrinology and Diabetes, University of Pittsburgh, Pittsburgh, PA
| | - T J Orchard
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA
| | - T Costacou
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA
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Ismail HM, Becker DJ, Libman I, Herold KC, Redondo MJ, Atkinson MA, Cleves MA, Palmer J, Sosenko J. Early and late C-peptide responses during oral glucose tolerance testing are oppositely predictive of type 1 diabetes in autoantibody-positive individuals. Diabetes Obes Metab 2020; 22:997-1000. [PMID: 32003110 PMCID: PMC7341484 DOI: 10.1111/dom.13982] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 01/22/2020] [Accepted: 01/26/2020] [Indexed: 11/29/2022]
Abstract
We examined whether the timing of the C-peptide response during an oral glucose tolerance test (OGTT) in relatives of patients with type 1 diabetes (T1D) is predictive of disease onset. We examined baseline 2-h OGTTs from 670 relatives participating in the Diabetes Prevention Trial-Type 1 (age: 13.8 ± 9.6 years; body mass index z-score: 0.3 ± 1.1; 56% male) using univariate regression models. T1D risk increased with lower early C-peptide responses (30-0 min) (χ2 = 28.8, P < 0.001), and higher late C-peptide responses (120-60 min) (χ2 = 23.3, P < 0.001). When both responses were included in a proportional hazards model, they remained independently and oppositely associated with T1D, with a stronger overall association for the combined model than either response alone (χ2 = 41.1; P < 0.001). Using receiver operating characteristic curve analysis, the combined early and late C-peptide response was more accurately predictive of T1D than area under the curve C-peptide (P = 0.005). Our findings demonstrate that lower early and higher late C-peptide responses serve as indicators of increased T1D risk.
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Affiliation(s)
- Heba M. Ismail
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Dorothy J. Becker
- Division of Endocrinology and Diabetes, University of Pittsburgh and UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ingrid Libman
- Division of Endocrinology and Diabetes, University of Pittsburgh and UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kevan C. Herold
- Department of Immunobiology, Yale University School of Medicine, New Haven, Connecticut
| | - Maria J. Redondo
- Pediatric Diabetes and Endocrinology, Baylor College of Medicine, Texas Children’s Hospital, Houston, Texas
| | - Mark A. Atkinson
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida, Gainesville, Florida
| | - Mario A. Cleves
- Department of Pediatrics, Morsani College of Medicine, University of South Florida, Tampa, Florida
| | - Jerry Palmer
- VA Puget Sound Health Care System, Seattle, Washington, and Department of Medicine, University of Washington, Seattle, Washington
| | - Jay Sosenko
- Division of Endocrinology, Diabetes, and Metabolism, University of Miami, Miami, Florida
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Ferrara-Cook C, Geyer SM, Evans-Molina C, Libman IM, Becker DJ, Gitelman SE, Redondo MJ. Excess BMI Accelerates Islet Autoimmunity in Older Children and Adolescents. Diabetes Care 2020; 43:580-587. [PMID: 31937610 PMCID: PMC7035590 DOI: 10.2337/dc19-1167] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 12/14/2019] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Sustained excess BMI increases the risk of type 1 diabetes (T1D) in autoantibody-positive relatives without diabetes of patients. We tested whether elevated BMI also accelerates the progression of islet autoimmunity before T1D diagnosis. RESEARCH DESIGN AND METHODS We studied 706 single autoantibody-positive pediatric TrialNet participants (ages 1.6-18.6 years at baseline). Cumulative excess BMI (ceBMI) was calculated for each participant based on longitudinally accumulated BMI ≥85th age- and sex-adjusted percentile. Recursive partitioning analysis and multivariable modeling defined the age cut point differentiating the risk for progression to multiple positive autoantibodies. RESULTS At baseline, 175 children (25%) had a BMI ≥85th percentile. ceBMI range was -9.2 to 15.6 kg/m2 (median -1.91), with ceBMI ≥0 kg/m2 corresponding to persistently elevated BMI ≥85th percentile. Younger age increased the progression to multiple autoantibodies, with age cutoff of 9 years defined by recursive partitioning analysis. Although ceBMI was not significantly associated with progression from single to multiple autoantibodies overall, there was an interaction with ceBMI ≥0 kg/m2, age, and HLA (P = 0.009). Among children ≥9 years old without HLA DR3-DQ2 and DR4-DQ8, ceBMI ≥0 kg/m2 increased the rate of progression from single to multiple positive autoantibodies (hazard ratio 7.32, P = 0.004) and conferred a risk similar to that in those with T1D-associated HLA haplotypes. In participants <9 years old, the effect of ceBMI on progression to multiple autoantibodies was not significant regardless of HLA type. CONCLUSIONS These data support that elevated BMI may exacerbate islet autoimmunity prior to clinical T1D, particularly in children with lower risk based on age and HLA. Interventions to maintain normal BMI may prevent or delay the progression of islet autoimmunity.
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Affiliation(s)
| | | | | | - Ingrid M Libman
- Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Dorothy J Becker
- Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
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12
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Acevedo-Calado MJ, Pietropaolo SL, Morran MP, Schnell S, Vonberg AD, Verge CF, Gianani R, Becker DJ, Huang S, Greenbaum CJ, Yu L, Davidson HW, Michels AW, Rich SS, Pietropaolo M. Autoantibodies Directed Toward a Novel IA-2 Variant Protein Enhance Prediction of Type 1 Diabetes. Diabetes 2019; 68:1819-1829. [PMID: 31167877 PMCID: PMC6702638 DOI: 10.2337/db18-1351] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Accepted: 05/30/2019] [Indexed: 02/06/2023]
Abstract
We identified autoantibodies (AAb) reacting with a variant IA-2 molecule (IA-2var) that has three amino acid substitutions (Cys27, Gly608, and Pro671) within the full-length molecule. We examined IA-2var AAb in first-degree relatives of type 1 diabetes (T1D) probands from the TrialNet Pathway to Prevention Study. The presence of IA-2var-specific AAb in relatives was associated with accelerated progression to T1D in those positive for AAb to GAD65 and/or insulin but negative in the standard test for IA-2 AAb. Furthermore, relatives with single islet AAb (by traditional assays) and carrying both IA-2var AAb and the high-risk HLA-DRB1*04-DQB1*03:02 haplotype progress rapidly to onset of T1D. Molecular modeling of IA-2var predicts that the genomic variation that alters the three amino acids induces changes in the three-dimensional structure of the molecule, which may lead to epitope unmasking in the IA-2 extracellular domain. Our observations suggest that the presence of AAb to IA-2var would identify high-risk subjects who would benefit from participation in prevention trials who have one islet antibody by traditional testing and otherwise would be misclassified as "low risk" relatives.
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Affiliation(s)
- Maria J. Acevedo-Calado
- Diabetes Research Center, Division of Diabetes, Endocrinology and Metabolism, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Susan L. Pietropaolo
- Diabetes Research Center, Division of Diabetes, Endocrinology and Metabolism, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Michael P. Morran
- Department of Surgery, College of Medicine, University of Toledo, Toledo, OH
| | - Santiago Schnell
- Department of Molecular & Integrative Physiology and Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, MI
| | - Andrew D. Vonberg
- Diabetes Research Center, Division of Diabetes, Endocrinology and Metabolism, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Charles F. Verge
- School of Women’s and Children’s Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Roberto Gianani
- Diabetes Research Center, Division of Diabetes, Endocrinology and Metabolism, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Dorothy J. Becker
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Shuai Huang
- Department of Industrial & Systems Engineering, University of Washington, Seattle, WA
| | | | - Liping Yu
- Barbara Davis Center for Childhood Diabetes, University of Colorado Denver, Aurora, CO
| | - Howard W. Davidson
- Barbara Davis Center for Childhood Diabetes, University of Colorado Denver, Aurora, CO
| | - Aaron W. Michels
- Barbara Davis Center for Childhood Diabetes, University of Colorado Denver, Aurora, CO
| | - Stephen S. Rich
- Center for Public Health Genomics, Department of Public Health Sciences, University of Virginia, Charlottesville, VA
| | - Massimo Pietropaolo
- Diabetes Research Center, Division of Diabetes, Endocrinology and Metabolism, Department of Medicine, Baylor College of Medicine, Houston, TX
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13
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Williams KV, Becker DJ, Orchard TJ, Costacou T. Persistent C-peptide levels and microvascular complications in childhood onset type 1 diabetes of long duration. J Diabetes Complications 2019; 33:657-661. [PMID: 31239235 PMCID: PMC6690760 DOI: 10.1016/j.jdiacomp.2019.05.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 05/24/2019] [Accepted: 05/24/2019] [Indexed: 01/12/2023]
Abstract
AIMS The aim was to determine if persistent c-peptide in long duration childhood onset (<17 years) type 1 diabetes (T1D) related to microvascular complications. METHODS Pittsburgh Epidemiology of Diabetes Complications (EDC) participants (n = 185) had serum c-peptide levels measured by Mercodia ultra-sensitive ELISA at the 25-year follow-up exam. Microvascular complications between those with and without detectable c-peptide were compared. RESULTS Eighteen (9.7%) participants had detectable median c-peptide levels of 3.8 (2.6, 12.2) pmol/L and did not differ from those without detectable levels. No differences in microalbuminuria, confirmed distal symmetric polyneuropathy, renal failure, or between those with one or more complications were found between the two groups. Proliferative retinopathy (PR) was marginally lower in those with detectable c-peptide (33.3% vs 55.1%, p = 0.08). However, those with c-peptide were somewhat less likely to have fasted for a full 8-h (66.7% vs. 84.9%, p = 0.09). Excluding those not fully fasted, PR no longer approached significance but macroalbuminuria became marginally lower in those with detectable levels (23.4% vs 0%, p = 0.07). CONCLUSIONS Low levels of c-peptide in T1D patients of long duration were detected but were not strongly related to microvascular complications.
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Affiliation(s)
- Katherine V Williams
- University of Pittsburgh Department of Epidemiology, DLR Building, 3512 Fifth Avenue, Pittsburgh, PA 15213, United States of America.
| | - Dorothy J Becker
- Children's Hospital of Pittsburgh Division of Endocrinology, 4401 Penn Avenue, Pittsburgh, PA 15224, United States of America.
| | - Trevor J Orchard
- University of Pittsburgh Department of Epidemiology, DLR Building, 3512 Fifth Avenue, Pittsburgh, PA 15213, United States of America.
| | - Tina Costacou
- University of Pittsburgh Department of Epidemiology, DLR Building, 3512 Fifth Avenue, Pittsburgh, PA 15213, United States of America.
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14
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Haller MJ, Long SA, Blanchfield JL, Schatz DA, Skyler JS, Krischer JP, Bundy BN, Geyer SM, Warnock MV, Miller JL, Atkinson MA, Becker DJ, Baidal DA, DiMeglio LA, Gitelman SE, Goland R, Gottlieb PA, Herold KC, Marks JB, Moran A, Rodriguez H, Russell WE, Wilson DM, Greenbaum CJ. Low-Dose Anti-Thymocyte Globulin Preserves C-Peptide, Reduces HbA 1c, and Increases Regulatory to Conventional T-Cell Ratios in New-Onset Type 1 Diabetes: Two-Year Clinical Trial Data. Diabetes 2019; 68:1267-1276. [PMID: 30967424 PMCID: PMC6610026 DOI: 10.2337/db19-0057] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 03/23/2019] [Indexed: 12/19/2022]
Abstract
A three-arm, randomized, double-masked, placebo-controlled phase 2b trial performed by the Type 1 Diabetes TrialNet Study Group previously demonstrated that low-dose anti-thymocyte globulin (ATG) (2.5 mg/kg) preserved β-cell function and reduced HbA1c for 1 year in new-onset type 1 diabetes. Subjects (N = 89) were randomized to 1) ATG and pegylated granulocyte colony-stimulating factor (GCSF), 2) ATG alone, or 3) placebo. Herein, we report 2-year area under the curve (AUC) C-peptide and HbA1c, prespecified secondary end points, and potential immunologic correlates. The 2-year mean mixed-meal tolerance test-stimulated AUC C-peptide, analyzed by ANCOVA adjusting for baseline C-peptide, age, and sex (n = 82) with significance defined as one-sided P < 0.025, was significantly higher in subjects treated with ATG versus placebo (P = 0.00005) but not ATG/GCSF versus placebo (P = 0.032). HbA1c was significantly reduced at 2 years in subjects treated with ATG (P = 0.011) and ATG/GCSF (P = 0.022) versus placebo. Flow cytometry analyses demonstrated reduced circulating CD4:CD8 ratio, increased regulatory T-cell:conventional CD4 T-cell ratios, and increased PD-1+CD4+ T cells following low-dose ATG and ATG/GCSF. Low-dose ATG partially preserved β-cell function and reduced HbA1c 2 years after therapy in new-onset type 1 diabetes. Future studies should determine whether low-dose ATG might prevent or delay the onset of type 1 diabetes.
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Affiliation(s)
| | | | | | | | - Jay S Skyler
- Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL
| | | | | | | | | | | | | | - Dorothy J Becker
- Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL
- University of Pittsburgh, Pittsburgh, PA
| | - David A Baidal
- Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL
| | | | | | | | - Peter A Gottlieb
- University of Colorado Barbara Davis Center for Childhood Diabetes, Aurora, CO
| | | | - Jennifer B Marks
- Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL
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15
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Ismail HM, Evans-Molina C, DiMeglio LA, Becker DJ, Libman I, Sims EK, Boulware D, Herold KC, Rafkin L, Skyler J, Cleves MA, Palmer J, Sosenko JM. Associations of HbA1c with the timing of C-peptide responses during the oral glucose tolerance test at the diagnosis of type 1 diabetes. Pediatr Diabetes 2019; 20:408-413. [PMID: 30891858 PMCID: PMC6655420 DOI: 10.1111/pedi.12845] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 01/23/2019] [Accepted: 03/04/2019] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND In new onset type 1 diabetes (T1D), overall C-peptide measures such as area under the curve (AUC) C-peptide and peak C-peptide are useful for estimating the extent of β-cell dysfunction, and for assessing responses to intervention therapy. However, measures of the timing of C-peptide responsiveness could have additional value. OBJECTIVES We assessed the contribution of the timing of C-peptide responsiveness during oral glucose tolerance tests (OGTTs) to hemoglobin A1c (HbA1c) variation at T1D diagnosis. METHODS We analyzed data from 85 individuals <18 years with OGTTs and HbA1c measurements at diagnosis. Overall [AUC and peak C-peptide] and timing measures [30-0 minute C-peptide (early); 60 to 120 minute C-peptide sum-30 minutes (late); 120/30 C-peptide; time to peak C-peptide] were utilized. RESULTS At diagnosis, the mean (±SD) age was 11.2 ± 3.3 years, body mass index (BMI)-z was 0.4 ± 1.1, 51.0% were male. The average HbA1c was 43.54 ± 8.46 mmol/mol (6.1 ± 0.8%). HbA1c correlated inversely with the AUC C-peptide (P < 0.001), peak C-peptide (P < 0.001), early and late C-peptide responses (P < 0.001 each), and 120/30 C-peptide (P < 0.001). Those with a peak C-peptide occurring at ≤60 minutes had higher HbA1c values than those with peaks later (P = 0.003). HbA1c variance was better explained with timing measures added to regression models (R2 = 11.6% with AUC C-peptide alone; R2 = 20.0% with 120/30 C-peptide added; R2 = 13.7% with peak C-peptide alone, R2 = 20.4% with timing of the peak added). Similar associations were seen between the 2-hour glucose and the C-peptide measures. CONCLUSIONS These findings show that the addition of timing measures of C-peptide responsiveness better explains HbA1c variation at diagnosis than standard measures alone.
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Affiliation(s)
- Heba M. Ismail
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Carmella Evans-Molina
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Linda A. DiMeglio
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Dorothy J. Becker
- Division of Endocrinology and Metabolism, University of Pittsburgh and Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
| | - Ingrid Libman
- Division of Endocrinology and Metabolism, University of Pittsburgh and Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
| | - Emily K. Sims
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana
| | - David Boulware
- Department of Bio-statistics, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Kevan C. Herold
- Department of Immunobiology, Yale University School of Medicine, New Haven, Connecticut
| | - Lisa Rafkin
- Division of Endocrinology, Diabetes, and Metabolism, University of Miami, Miami, Florida
| | - Jay Skyler
- Division of Endocrinology, Diabetes, and Metabolism, University of Miami, Miami, Florida
| | - Mario A. Cleves
- Department of Pediatrics, Morsani College of Medicine, University of South Florida, Tampa, Florida
| | - Jerry Palmer
- Department of Medicine, VA Puget Sound Health Care System, Seattle, Washington,Department of Medicine, University of Washington, Seattle, Washington
| | - Jay M. Sosenko
- Division of Endocrinology, Diabetes, and Metabolism, University of Miami, Miami, Florida
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16
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Williams KV, Cristaldi CL, Miller RG, Arena VC, Libman I, Huang Y, Becker DJ, Orchard TJ. Celiac Autoimmunity Is Associated With Lower Blood Pressure and Renal Risk in Type 1 Diabetes. J Clin Endocrinol Metab 2018; 103:3828-3836. [PMID: 30099548 PMCID: PMC6179181 DOI: 10.1210/jc.2018-00908] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 08/01/2018] [Indexed: 02/07/2023]
Abstract
CONTEXT Though the long-term consequences of celiac disease (CD) in type 1 diabetes are unclear, CD has been associated with increased prevalence of end-stage renal disease (ESRD) independent of type 1 diabetes. OBJECTIVE We evaluated whether celiac autoimmunity is related to the cumulative incidence of microalbuminuria [albumin excretion rate (AER) 20 to 200 µg/min], macroalbuminuria (AER >200 µg/min), and ESRD. DESIGN, PATIENTS, AND METHODS In the prospective follow-up of the Pittsburgh Epidemiology of Diabetes Complications study of childhood-onset type 1 diabetes, 618 participants were screened for tissue transglutaminase (tTG) antibodies with a clinical assay. Nephropathy outcomes were determined at 25 years of diabetes duration. RESULTS Overall, the 33 subjects (5.3%) with strongly positive tTG levels (≥3 times the upper limit of normal) or a reported clinical history of CD had lower baseline blood pressure and lipid values. At 25 years of diabetes duration, a lower cumulative incidence of macroalbuminuria in strongly positive subjects compared with those with negative serology (3.6% vs 30.0%; P = 0.003) remained significant after adjustment for age, HbA1c, lipid measures, and blood pressure (adjusted P = 0.004). No considerable differences between these subjects and tTG-negative groups were found for microalbuminuria (40.0% vs 57.1%) or ESRD (0 vs 4.1%). CONCLUSIONS These findings show that strongly positive celiac autoimmunity status in individuals with childhood-onset type 1 diabetes is associated with lower baseline blood pressure and cholesterol measurements as well as lower macroalbuminuria risk after 25 years of type 1 diabetes duration with no increase in the risk of microalbuminuria or ESRD.
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Affiliation(s)
- Katherine V Williams
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
- Correspondence and Reprint Requests: Katherine V. Williams, MD, MPH, University of Pittsburgh, DLR Building, 3512 Fifth Avenue, Pittsburgh, Pennsylvania 15213. E-mail
| | - Christina L Cristaldi
- Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh and University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Rachel G Miller
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Vincent C Arena
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ingrid Libman
- Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh and University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Yihe Huang
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Dorothy J Becker
- Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh and University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Trevor J Orchard
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
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17
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Haller MJ, Schatz DA, Skyler JS, Krischer JP, Bundy BN, Miller JL, Atkinson MA, Becker DJ, Baidal D, DiMeglio LA, Gitelman SE, Goland R, Gottlieb PA, Herold KC, Marks JB, Moran A, Rodriguez H, Russell W, Wilson DM, Greenbaum CJ, Greenbaum C, Atkinson M, Baidal D, Battaglia M, Becker D, Bingley P, Bosi E, Buckner J, Clements M, Colman P, DiMeglio L, Evans-Molina C, Gitelman S, Goland R, Gottlieb P, Herold K, Knip M, Krischer J, Lernmark A, Moore W, Moran A, Muir A, Palmer J, Peakman M, Philipson L, Raskin P, Redondo M, Rodriguez H, Russell W, Spain L, Schatz D, Sosenko J, Wherrett D, Wilson D, Winter W, Ziegler A, Anderson M, Antinozzi P, Benoist C, Blum J, Bourcier K, Chase P, Clare-Salzler M, Clynes R, Cowie C, Eisenbarth G, Fathman C, Grave G, Harrison L, Hering B, Insel R, Jordan S, Kaufman F, Kay T, Kenyon N, Klines R, Lachin J, Leschek E, Mahon J, Marks J, Monzavi R, Nanto-Salonen K, Nepom G, Orban T, Parkman R, Pescovitz M, Peyman J, Pugliese A, Ridge J, Roep B, Roncarolo M, Savage P, Simell O, Sherwin R, Siegelman M, Skyler J, Steck A, Thomas J, Trucco M, Wagner J, Bourcier K, Greenbaum CJ, Krischer JP, Leschek E, Rafkin L, Spain L, Cowie C, Foulkes M, Insel R, Krause-Steinrauf H, Lachin JM, Malozowski S, Peyman J, Ridge J, Savage P, Skyler JS, Zafonte SJ, Greenbaum CJ, Rafkin L, Sosenko JM, Skyler JS, Kenyon NS, Santiago I, Krischer JP, Bundy B, Abbondondolo M, Adams T, Amado D, Asif I, Boonstra M, Boulware D, Bundy B, Burroughs C, Cuthbertson D, Eberhard C, Fiske S, Ford J, Garmeson J, Guillette H, Geyer S, Hays B, Henderson C, Henry M, Heyman K, Hsiao B, Karges C, Kinderman A, Lane L, Leinbach A, Liu S, Lloyd J, Malloy J, Maddox K, Martin J, Miller J, Moore M, Muller S, Nguyen T, O’Donnell R, Parker M, Pereyra M, Reed N, Roberts A, Sadler K, Stavros T, Tamura R, Wood K, Xu P, Young K, Alies P, Badias F, Baker A, Bassi M, Beam C, Boulware D, Bounmananh L, Bream S, Deemer M, Freeman D, Gough J, Ginem J, Granger M, Holloway M, Kieffer M, Lane P, Law P, Linton C, Nallamshetty L, Oduah V, Parrimon Y, Paulus K, Pilger J, Ramiro J, Luvon AQ, Ritzie A, Sharma A, Shor X, Song A, Terry J, Weinberger M, Wootten J, Fradkin E, Leschek L, Spain C, Cowie S, Malozowski P, Savage G, Beck E, Blumberg R, Gubitosi-Klug L, Laffel R, Veatch D, Wallace J, Braun D, Brillon A, Lernmark B, Lo H, Mitchell A, Naji J, Nerup T, Orchard M, Steffes A, Tsiatis B, Zinman B, Loechelt L, Baden M, Green A, Weinberg S, Marcovina JP, Palmer A, Weinberg L, Yu W, Winter GS, Eisenbarth A, Shultz E, Batts K, Fitzpatrick M, Ramey R, Guerra C, Webb M, Romasco C, Greenbaum S, Lord D, VanBuecken W, Hao M, McCulloch D, Hefty K, Varner R, Goland E, Greenberg S, Pollack B, Nelson L, Looper L, DiMeglio M, Spall C, Evans-Molina M, Mantravadi J, Sanchez M, Mullen V, Patrick S, Woerner DM, Wilson T, Aye T, Esrey K, Barahona B, Baker H, Bitar C, Ghodrat M, Hamilton SE, Gitelman CT, Ferrara S, Sanda R, Wesch C, Torok P, Gottlieb J, Lykens C, Brill A, Michels A, Schauwecker MJ, Haller DA, Schatz MA, Atkinson LM, Jacobsen M, Cintron TM, Brusko CH, Wasserfall CE, Mathews JS, Skyler JM, Marks D, Baidal C, Blaschke D, Matheson A, Moran B, Nathan A, Street J, Leschyshyn B, Pappenfus B, Nelson N, Flaherty D, Becker K, Delallo D, Groscost K, Riley H, Rodriguez D, Henson E, Eyth W, Russell A, Brown F, Brendall K, Herold, Feldman L. Low-Dose Anti-Thymocyte Globulin (ATG) Preserves β-Cell Function and Improves HbA 1c in New-Onset Type 1 Diabetes. Diabetes Care 2018; 41:1917-1925. [PMID: 30012675 PMCID: PMC6105329 DOI: 10.2337/dc18-0494] [Citation(s) in RCA: 96] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 06/12/2018] [Indexed: 02/03/2023]
Abstract
OBJECTIVE A pilot study suggested that combination therapy with low-dose anti-thymocyte globulin (ATG) and pegylated granulocyte colony-stimulating factor (GCSF) preserves C-peptide in established type 1 diabetes (T1D) (duration 4 months to 2 years). We hypothesized that 1) low-dose ATG/GCSF or 2) low-dose ATG alone would slow the decline of β-cell function in patients with new-onset T1D (duration <100 days). RESEARCH DESIGN AND METHODS A three-arm, randomized, double-masked, placebo-controlled trial was performed by the Type 1 Diabetes TrialNet Study Group in 89 subjects: 29 subjects randomized to ATG (2.5 mg/kg intravenously) followed by pegylated GCSF (6 mg subcutaneously every 2 weeks for 6 doses), 29 to ATG alone (2.5 mg/kg), and 31 to placebo. The primary end point was mean area under the curve (AUC) C-peptide during a 2-h mixed-meal tolerance test 1 year after initiation of therapy. Significance was defined as one-sided P value < 0.025. RESULTS The 1-year mean AUC C-peptide was significantly higher in subjects treated with ATG (0.646 nmol/L) versus placebo (0.406 nmol/L) (P = 0.0003) but not in those treated with ATG/GCSF (0.528 nmol/L) versus placebo (P = 0.031). HbA1c was significantly reduced at 1 year in subjects treated with ATG and ATG/GCSF, P = 0.002 and 0.011, respectively. CONCLUSIONS Low-dose ATG slowed decline of C-peptide and reduced HbA1c in new-onset T1D. Addition of GCSF did not enhance C-peptide preservation afforded by low-dose ATG. Future studies should be considered to determine whether low-dose ATG alone or in combination with other agents may prevent or delay the onset of the disease.
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Affiliation(s)
| | | | - Jay S. Skyler
- Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL
| | | | | | | | | | | | - David Baidal
- Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL
| | | | | | | | - Peter A. Gottlieb
- University of Colorado Barbara Davis Center for Childhood Diabetes, Aurora, CO
| | | | - Jennifer B. Marks
- Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL
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Long AE, Wilson IV, Becker DJ, Libman IM, Arena VC, Wong FS, Steck AK, Rewers MJ, Yu L, Achenbach P, Casas R, Ludvigsson J, Williams AJK, Gillespie KM. Characteristics of slow progression to diabetes in multiple islet autoantibody-positive individuals from five longitudinal cohorts: the SNAIL study. Diabetologia 2018; 61. [PMID: 29532109 PMCID: PMC6449004 DOI: 10.1007/s00125-018-4591-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
AIMS/HYPOTHESIS Multiple islet autoimmunity increases risk of diabetes, but not all individuals positive for two or more islet autoantibodies progress to disease within a decade. Major islet autoantibodies recognise insulin (IAA), GAD (GADA), islet antigen-2 (IA-2A) and zinc transporter 8 (ZnT8A). Here we describe the baseline characteristics of a unique cohort of 'slow progressors' (n = 132) who were positive for multiple islet autoantibodies (IAA, GADA, IA-2A or ZnT8A) but did not progress to diabetes within 10 years. METHODS Individuals were identified from five studies (BABYDIAB, Germany; Diabetes Autoimmunity Study in the Young [DAISY], USA; All Babies in Southeast Sweden [ABIS], Sweden; Bart's Oxford Family Study [BOX], UK and the Pittsburgh Family Study, USA). Multiple islet autoantibody characteristics were determined using harmonised assays where possible. HLA class II risk was compared between slow progressors and rapid progressors (n = 348 diagnosed <5 years old from BOX) using the χ2 test. RESULTS In the first available samples with detectable multiple antibodies, the most frequent autoantibodies were GADA (92%), followed by ZnT8A (62%), IAA (59%) and IA-2A (41%). High risk HLA class II genotypes were less frequent in slow (28%) than rapid progressors (42%, p = 0.011), but only two slow progressors carried the protective HLA DQ6 allele. CONCLUSION No distinguishing characteristics of slow progressors at first detection of multiple antibodies have yet been identified. Continued investigation of these individuals may provide insights into slow progression that will inform future efforts to slow or prevent progression to clinical diabetes.
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Affiliation(s)
- Anna E Long
- Translational Health Sciences, Bristol Medical School, University of Bristol, Level 2, Learning and Research, Southmead Hospital, Bristol, BS10 5NB, UK
| | - Isabel V Wilson
- Translational Health Sciences, Bristol Medical School, University of Bristol, Level 2, Learning and Research, Southmead Hospital, Bristol, BS10 5NB, UK
| | - Dorothy J Becker
- Division of Endocrinology and Diabetes, Children's Hospital of University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ingrid M Libman
- Division of Endocrinology and Diabetes, Children's Hospital of University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Vincent C Arena
- Division of Endocrinology and Diabetes, Children's Hospital of University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - F Susan Wong
- Division of Infection and Immunity, Cardiff School of Medicine, Cardiff University, Heath Park, Cardiff, UK
| | - Andrea K Steck
- Barbara Davis Center for Childhood Diabetes, University of Colorado School of Medicine, Aurora, CO, USA
| | - Marian J Rewers
- Barbara Davis Center for Childhood Diabetes, University of Colorado School of Medicine, Aurora, CO, USA
| | - Liping Yu
- Barbara Davis Center for Childhood Diabetes, University of Colorado School of Medicine, Aurora, CO, USA
| | - Peter Achenbach
- Institute of Diabetes Research, Helmholtz Zentrum München and Forschergruppe Diabetes, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - Rosaura Casas
- Division of Pediatrics, Department of Clinical and Experimental Medicine, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden
| | - Johnny Ludvigsson
- Division of Pediatrics, Department of Clinical and Experimental Medicine, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden
| | - Alistair J K Williams
- Translational Health Sciences, Bristol Medical School, University of Bristol, Level 2, Learning and Research, Southmead Hospital, Bristol, BS10 5NB, UK
| | - Kathleen M Gillespie
- Translational Health Sciences, Bristol Medical School, University of Bristol, Level 2, Learning and Research, Southmead Hospital, Bristol, BS10 5NB, UK.
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Ismail HM, Xu P, Libman IM, Becker DJ, Marks JB, Skyler JS, Palmer JP, Sosenko JM. The shape of the glucose concentration curve during an oral glucose tolerance test predicts risk for type 1 diabetes. Diabetologia 2018; 61:84-92. [PMID: 28956083 PMCID: PMC5850999 DOI: 10.1007/s00125-017-4453-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 08/15/2017] [Indexed: 01/13/2023]
Abstract
AIMS/HYPOTHESIS We aimed to examine: (1) whether specific glucose-response curve shapes during OGTTs are predictive of type 1 diabetes development; and (2) the extent to which the glucose-response curve is influenced by insulin secretion. METHODS Autoantibody-positive relatives of people with type 1 diabetes whose baseline OGTT met the definition of a monophasic or biphasic glucose-response curve were followed for the development of type 1 diabetes (n = 2627). A monophasic curve was defined as an increase in OGTT glucose between 30 and 90 min followed by a decline of ≥ 0.25 mmol/l between 90 and 120 min. A biphasic response curve was defined as a decrease in glucose after an initial increase, followed by a second increase of ≥ 0.25 mmol/l. Associations of type 1 diabetes risk with glucose curve shapes were examined using cumulative incidence curve comparisons and proportional hazards regression. C-peptide responses were compared with and without adjustments for potential confounders. RESULTS The majority of participants had a monophasic curve at baseline (n = 1732 [66%] vs n = 895 [34%]). The biphasic group had a lower cumulative incidence of type 1 diabetes (p < 0.001), which persisted after adjustments for age, sex, BMI z score and number of autoantibodies (p < 0.001). Among the monophasic group, the risk of type 1 diabetes was greater for those with a glucose peak at 90 min than for those with a peak at 30 min; the difference persisted after adjustments (p < 0.001). Compared with the biphasic group, the monophasic group had a lower early C-peptide (30-0 min) response, a lower C-peptide index (30-0 min C-peptide/30-0 min glucose), as well as a greater 2 h C-peptide level (p < 0.001 for all). CONCLUSIONS/INTERPRETATION Those with biphasic glucose curves have a lower risk of progression to type 1 diabetes than those with monophasic curves, and the risk among the monophasic group is increased when the glucose peak occurs at 90 min than at 30 min. Differences in glucose curve shapes between the monophasic and biphasic groups appear to be related to C-peptide responses.
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Affiliation(s)
- Heba M Ismail
- Division of Endocrinology, Diabetes and Metabolism, Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center, University of Pittsburgh, 4401 Penn Ave, FP 8129, Pittsburgh, PA, 15224, USA.
| | - Ping Xu
- Pediatrics Epidemiology Center, College of Medicine, University of South Florida, Tampa, FL, USA
| | - Ingrid M Libman
- Division of Endocrinology, Diabetes and Metabolism, Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center, University of Pittsburgh, 4401 Penn Ave, FP 8129, Pittsburgh, PA, 15224, USA
| | - Dorothy J Becker
- Division of Endocrinology, Diabetes and Metabolism, Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center, University of Pittsburgh, 4401 Penn Ave, FP 8129, Pittsburgh, PA, 15224, USA
| | - Jennifer B Marks
- Division of Endocrinology, Diabetes and Metabolism, Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Jay S Skyler
- Division of Endocrinology, Diabetes and Metabolism, Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Jerry P Palmer
- VA Puget Sound Health Care System, Division of Endocrinology, Metabolism, and Nutrition, University of Washington, Seattle, WA, USA
| | - Jay M Sosenko
- Division of Endocrinology, Diabetes and Metabolism, Diabetes Research Institute, University of Miami Miller School of Medicine, Miami, FL, USA
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Ferrara CT, Geyer SM, Evans-Molina C, Libman IM, Becker DJ, Wentworth JM, Moran A, Gitelman SE, Redondo MJ. The Role of Age and Excess Body Mass Index in Progression to Type 1 Diabetes in At-Risk Adults. J Clin Endocrinol Metab 2017; 102:4596-4603. [PMID: 29092051 PMCID: PMC5718698 DOI: 10.1210/jc.2017-01490] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 10/03/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND Given the global rise in both type 1 diabetes incidence and obesity, the role of body mass index (BMI) on type 1 diabetes pathophysiology has gained great interest. Sustained excess BMI in pediatric participants of the TrialNet Pathway to Prevention (PTP) cohort increased risk for progression to type 1 diabetes, but the effects of age and obesity in adults remain largely unknown. OBJECTIVE To determine the effect of age and sustained obesity on the risk for type 1 diabetes in adult participants in the TrialNet PTP cohort (i.e., nondiabetic autoantibody-positive relatives of patients with type 1 diabetes). RESEARCH DESIGN AND METHODS Longitudinally accumulated BMI >25 kg/m2 was calculated to generate a cumulative excess BMI (ceBMI) for each participant, with ceBMI values ≥0 kg/m2 and ≥5 kg/m2 representing sustained overweight or obese status, respectively. Recursive partitioning analysis yielded sex- and age-specific thresholds for ceBMI that confer the greatest risk for type 1 diabetes progression. RESULTS In this cohort of 665 adults (age 20 to 50 years; median follow-up, 3.9 years), 49 participants developed type 1 diabetes. Age was an independent protective factor for type 1 diabetes progression (hazard ratio, 0.95; P = 0.008), with a threshold of >35 years that reduced risk for type 1 diabetes. In men age >35 years and women age <35 years, sustained obesity (ceBMI ≥5 kg/m2) increased the risk for type 1 diabetes. CONCLUSIONS Age is an important factor for type 1 diabetes progression in adults and influences the impact of elevated BMI, indicating an interplay of excess weight, age, and sex in adult type 1 diabetes pathophysiology.
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Affiliation(s)
- Christine T. Ferrara
- Department of Pediatric Endocrinology, University of California at San Francisco, San Francisco, California 94143
| | - Susan M. Geyer
- Department of Informatics and Biostatistics, University of Southern Florida, Tampa, Florida 33620
| | - Carmella Evans-Molina
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana 46202
| | - Ingrid M. Libman
- Department of Pediatric Endocrinology, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania 15224
| | - Dorothy J. Becker
- Department of Pediatric Endocrinology, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania 15224
| | - John M. Wentworth
- Department of Medicine, Royal Melbourne Hospital, Parkville, Victoria 3050, Australia
| | - Antoinette Moran
- Department of Pediatric Endocrinology, University of Minnesota, Minneapolis, Minnesota 55455
| | - Stephen E. Gitelman
- Department of Pediatric Endocrinology, University of California at San Francisco, San Francisco, California 94143
| | - Maria J. Redondo
- Section of Pediatric Endocrinology, Texas Children’s Hospital, Houston, Texas 77030
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21
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Bosi E, Boulware DC, Becker DJ, Buckner JH, Geyer S, Gottlieb PA, Henderson C, Kinderman A, Sosenko JM, Steck AK, Bingley PJ. Impact of Age and Antibody Type on Progression From Single to Multiple Autoantibodies in Type 1 Diabetes Relatives. J Clin Endocrinol Metab 2017; 102:2881-2886. [PMID: 28531305 PMCID: PMC5546870 DOI: 10.1210/jc.2017-00569] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Accepted: 05/11/2017] [Indexed: 12/18/2022]
Abstract
Context Islet autoantibodies are markers of type 1 diabetes, and an increase in number of autoantibodies detected during the preclinical phase predicts progression to overt disease. Objective To refine the effect of age in relation to islet antibody type on progression from single to multiple autoantibodies in relatives of people with type 1 diabetes. Research Design and Methods We examined 994 relatives with normal glucose tolerance who were positive for a single autoantibody, followed prospectively in the TrialNet Pathway to Prevention. Antibodies to glutamic acid decarboxylase (GADA), insulin (IAA), insulinoma-associated antigen 2, and zinc transporter 8 and islet cell antibodies were tested every 6 to 12 months. The primary outcome was confirmed development of multiple autoantibodies. Age was categorized as <8 years, 8 to 11 years, 12 to 17 years, and ≥18 years, and optimal age breakpoints were identified by recursive partitioning analysis. Results After median follow-up of 2 years, 141 relatives had developed at least one additional autoantibodies. Five-year risk was inversely related to age, but the pattern differed by antibody type: Relatives with GADA showed a gradual decrease in risk over the four age groups, whereas relatives with IAA showed a sharp decrease above age 8 years. Recursive partitioning analysis identified age breakpoints at 14 years in relatives with GADA and at 4 years in relatives with IAA. Conclusions In relatives with IAA, spread of islet autoimmunity is largely limited to early childhood, whereas immune responses initially directed at glutamic acid decarboxylase can mature over a longer period. These differences have important implications for monitoring these patients and for designing prevention trials.
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Affiliation(s)
- Emanuele Bosi
- Diabetes Research Institute, San Raffaele Hospital and San Raffaele Vita Salute University, Milan 20132, Italy
| | - David C. Boulware
- Division of Informatics and Biostatistics, University of South Florida, Tampa, Florida 33620
| | - Dorothy J. Becker
- Department of Pediatric Endocrinology, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania 15224
| | - Jane H. Buckner
- Translational Immunology Program, Benaroya Research Institute, Seattle, Washington 98101
| | - Susan Geyer
- Division of Informatics and Biostatistics, University of South Florida, Tampa, Florida 33620
| | - Peter A. Gottlieb
- Barbara Davis Center for Childhood Diabetes, University of Colorado School of Medicine, Aurora, Colorado 80045
| | - Courtney Henderson
- Division of Informatics and Biostatistics, University of South Florida, Tampa, Florida 33620
| | - Amanda Kinderman
- Division of Informatics and Biostatistics, University of South Florida, Tampa, Florida 33620
| | - Jay M. Sosenko
- Division of Endocrinology, University of Miami, Miami, Florida 33136
| | - Andrea K. Steck
- Barbara Davis Center for Childhood Diabetes, University of Colorado School of Medicine, Aurora, Colorado 80045
| | - Polly J. Bingley
- School of Clinical Sciences, University of Bristol, Bristol BS2 8DZ, United Kingdom
| | - Type 1 Diabetes TrialNet Study Group
- Diabetes Research Institute, San Raffaele Hospital and San Raffaele Vita Salute University, Milan 20132, Italy
- Division of Informatics and Biostatistics, University of South Florida, Tampa, Florida 33620
- Department of Pediatric Endocrinology, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania 15224
- Translational Immunology Program, Benaroya Research Institute, Seattle, Washington 98101
- Barbara Davis Center for Childhood Diabetes, University of Colorado School of Medicine, Aurora, Colorado 80045
- Division of Endocrinology, University of Miami, Miami, Florida 33136
- School of Clinical Sciences, University of Bristol, Bristol BS2 8DZ, United Kingdom
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22
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Ferrara CT, Geyer SM, Liu YF, Evans-Molina C, Libman IM, Besser R, Becker DJ, Rodriguez H, Moran A, Gitelman SE, Redondo MJ. Excess BMI in Childhood: A Modifiable Risk Factor for Type 1 Diabetes Development? Diabetes Care 2017; 40:698-701. [PMID: 28202550 PMCID: PMC5399656 DOI: 10.2337/dc16-2331] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 01/30/2017] [Indexed: 02/03/2023]
Abstract
OBJECTIVE We aimed to determine the effect of elevated BMI over time on the progression to type 1 diabetes in youth. RESEARCH DESIGN AND METHODS We studied 1,117 children in the TrialNet Pathway to Prevention cohort (autoantibody-positive relatives of patients with type 1 diabetes). Longitudinally accumulated BMI above the 85th age- and sex-adjusted percentile generated a cumulative excess BMI (ceBMI) index. Recursive partitioning and multivariate analyses yielded sex- and age-specific ceBMI thresholds for greatest type 1 diabetes risk. RESULTS Higher ceBMI conferred significantly greater risk of progressing to type 1 diabetes. The increased diabetes risk occurred at lower ceBMI values in children <12 years of age compared with older subjects and in females versus males. CONCLUSIONS Elevated BMI is associated with increased risk of diabetes progression in pediatric autoantibody-positive relatives, but the effect varies by sex and age.
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Affiliation(s)
| | | | | | | | | | - Rachel Besser
- Oxford University Hospitals NHS Foundation Trust, Oxford, U.K
| | | | | | - Antoinette Moran
- Department of Pediatric Endocrinology, University of Minnesota Masonic Children's Hospital, Minneapolis, MN
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Nucci AM, Virtanen SM, Sorkio S, Bärlund S, Cuthbertson D, Uusitalo U, Lawson ML, Salonen M, Berseth CL, Ormisson A, Lehtonen E, Savilahti E, Becker DJ, Dupré J, Krischer JP, Knip M, Åkerblom HK. Regional differences in milk and complementary feeding patterns in infants participating in an international nutritional type 1 diabetes prevention trial. Matern Child Nutr 2016; 13. [PMID: 27714970 DOI: 10.1111/mcn.12354] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 06/02/2016] [Accepted: 06/07/2016] [Indexed: 01/24/2023]
Abstract
Differences in breastfeeding, other milk feeding and complementary feeding patterns were evaluated in infants at increased genetic risk with and without maternal type 1 diabetes (T1D). The Trial to Reduce IDDM in the Genetically at Risk is an international nutritional primary prevention double-blinded randomized trial to test whether weaning to extensively hydrolyzed vs. intact cow's milk protein formula will decrease the development of T1D-associated autoantibodies and T1D. Infant diet was prospectively assessed at two visits and seven telephone interviews between birth and 8 months. Countries were grouped into seven regions: Australia, Canada, Northern Europe, Southern Europe, Central Europe I, Central Europe II and the United States. Newborn infants with a first-degree relative with T1D and increased human leukocyte antigen-conferred susceptibility to T1D were recruited. A lower proportion of infants born to mothers with than without T1D were breastfed until 6 months of age in all regions (range, 51% to 60% vs. 70% to 80%). Complementary feeding patterns differed more by region than by maternal T1D. In Northern Europe, a higher proportion of infants consumed vegetables and fruits daily compared with other regions. Consumption of meat was more frequent in all European regions, whereas cereal consumption was most frequent in Southern Europe, Canada and the United States. Maternal T1D status was associated with breastfeeding and other milk feeding patterns similarly across regions but was unrelated to the introduction of complementary foods. Infant feeding patterns differed significantly among regions and were largely inconsistent with current recommended guidelines.
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Affiliation(s)
- Anita M Nucci
- Department of Nutrition, Georgia State University, Atlanta, Georgia, USA
| | - Suvi M Virtanen
- Nutrition Unit, National Institute for Health and Welfare, Helsinki, Finland.,School of Health Sciences, University of Tampere, Tampere, Finland.,Center for Child Health Research, Tampere University Hospital, University of Tampere, Tampere, Finland.,The Science Center of Pirkanmaa Hospital District, Tampere, Finland
| | - Susa Sorkio
- Nutrition Unit, National Institute for Health and Welfare, Helsinki, Finland
| | - Sonja Bärlund
- Nutrition Unit, National Institute for Health and Welfare, Helsinki, Finland
| | - David Cuthbertson
- Pediatrics Epidemiology Center, University of South Florida, Tampa, Florida, USA
| | - Ulla Uusitalo
- Pediatrics Epidemiology Center, University of South Florida, Tampa, Florida, USA
| | - Margaret L Lawson
- Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Marja Salonen
- Children's Hospital, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | | | - Anne Ormisson
- Department of Paediatrics, University of Tartu, Tartu, Estonia
| | - Eveliina Lehtonen
- Nutrition Unit, National Institute for Health and Welfare, Helsinki, Finland
| | - Erkki Savilahti
- Children's Hospital, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Dorothy J Becker
- Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA.,University of Pittsburgh, Pittsburgh, PA
| | - John Dupré
- Robarts Research Institute, London, Ontario, Canada
| | - Jeffrey P Krischer
- Pediatrics Epidemiology Center, University of South Florida, Tampa, Florida, USA
| | - Mikael Knip
- Children's Hospital, Helsinki University Hospital, University of Helsinki, Helsinki, Finland.,Research Programs Unit, Diabetes and Obesity, University of Helsinki, Helsinki, Finland.,Folkhälsan Research Center, Helsinki, Finland.,Department of Pediatrics, Tampere University Hospital, Tampere, Finland
| | - Hans K Åkerblom
- Children's Hospital, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
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Baldauff NH, Tfayli H, Dong W, Arena VC, Gurtunca N, Pietropaolo M, Becker DJ, Libman IM. Relationship of adiponectin and leptin with autoimmunity in children with new-onset type 1 diabetes: a pilot study. Pediatr Diabetes 2016; 17:249-56. [PMID: 25754190 PMCID: PMC5944363 DOI: 10.1111/pedi.12267] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Revised: 12/26/2014] [Accepted: 01/30/2015] [Indexed: 01/17/2023] Open
Abstract
AIM To explore racial differences in adiponectin, and leptin and their relationship with islet autoimmunity in children with new-onset type 1 diabetes (T1D). METHODS Medical records were reviewed from a cohort of new-onset clinically diagnosed T1D subjects matched by race, age, gender, and year of diagnosis. Sera were available for 156 subjects (77 African American (AA), 79 Caucasian (C), 48% male, age of 11.1 ± 3.8 yr) and assayed for adiponectin and leptin prior to (D0), 3, 5 d, and 2-4 months (M3) after insulin therapy and islet autoantibodies to GAD, IA2, insulin, and ICA were measured at onset. RESULTS Adiponectin levels increased significantly following insulin therapy by day 5 (D5) (D0: 13.7 ± 7.2 vs. D5: 21.3 ± 9.9 µg/mL, p < 0.0001), but no further significant increase from D5 to M3. At DO, AA had lower adiponectin levels (10.5 vs. 15.7 µg/mL, p = 0.01), were more often overweight than C (55 vs. 18%, BMI ≥ 85th‰) and fewer had positive autoantibodies (72 vs. 87%, p = 0.05). Racial differences in adipocytokines disappeared after adjustment for BMI. At M3, subjects with more number of positive autoantibodies had higher adiponectin levels (p = 0.043) and adiponectin/leptin ratio (ALR) (p = 0.01), and lower leptin levels (p = 0.016). CONCLUSION Adiponectin levels increased acutely with insulin therapy. Significantly lower adiponectin levels in AA were related to greater adiposity and not race. These pilot data showing those with the fewest autoantibodies had the lowest adiponectin levels, supporting the concept that insulin-resistant subjects may present with clinical T1D at earlier stages of β-cell damage.
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Affiliation(s)
- Natalie Hecht Baldauff
- Pediatric Endocrinology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA USA 15224
| | - Hala Tfayli
- Pediatric Endocrinology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA USA 15224. Currently at the American University of Beirut Medical Center, Department of Pediatrics and Adolescent Medicine
| | - Wenxiu Dong
- Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA USA 15261
| | - Vincent C. Arena
- Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA USA, 15261
| | - Nursen Gurtunca
- Pediatric Endocrinology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA USA 15224
| | - Massimo Pietropaolo
- Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, Houston, TX 77030
| | - Dorothy J. Becker
- Pediatric Endocrinology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA USA 15224
| | - Ingrid M Libman
- Pediatric Endocrinology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA USA 15224
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25
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Blackburn J, Locher JL, Morrisey MA, Becker DJ, Kilgore ML. The effects of state-level expenditures for home- and community-based services on the risk of becoming a long-stay nursing home resident after hip fracture. Osteoporos Int 2016; 27:953-961. [PMID: 26400010 DOI: 10.1007/s00198-015-3327-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Accepted: 09/15/2015] [Indexed: 10/23/2022]
Abstract
SUMMARY This study measures the effect of spending policies for long-term care services on the risk of becoming a long-stay nursing home resident after a hip fracture. Relative spending on community-based services may reduce the risk of long-term nursing home residence. Policies favoring alternative sources of care may provide opportunities for older adults to remain community-bound. INTRODUCTION This study aims to understand how long-term care policies affect outcomes by investigating the effect of state-level spending for home- and community-based services (HCBSs) on the likelihood of an individual's nursing home placement following hip fracture. METHODS This study uses data from the 5% sample of Medicare beneficiaries from 2005 to 2010 to identify incident hip fractures among dual-eligibility, community-dwelling adults aged at least 65 years. A multilevel generalized estimating equation (GEE) model estimated the association between an individual's risk of nursing home residence within 1 year and the percent of states' Medicaid long-term support service (LTSS) budget allocated to HCBS. Other covariates included expenditures for Title III services and individual demographic and health status characteristics. RESULTS States vary considerably in HCBS spending, ranging from 17.7 to 83.8% of the Medicaid LTSS budget in 2009. Hip fractures were observed from claims among 7778 beneficiaries; 34% were admitted to a nursing home and 25% died within 1 year. HCBS spending was associated with a decreased risk of nursing home residence by 0.17 percentage points (p 0.056). CONCLUSIONS Consistent with other studies, our findings suggest that state policies favoring an emphasis on HCBS may reduce nursing home residence among low-income older adults with hip fracture who are at high risk for institutionalization.
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Affiliation(s)
- J Blackburn
- Department of Health Care Organization and Policy, University of Alabama at Birmingham School of Public Health, RPHB 330K, 1720 2nd Ave S, Birmingham, AL, 35294-0022, USA.
| | - J L Locher
- Department of Medicine, Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham School of Medicine, 933 19th Street South, CH19 218, Birmingham, AL, 35294-2041, USA
| | - M A Morrisey
- Department of Health Policy and Management, School of Public Health, 306 SPH Administration Building, Texas A&M University, College Station, TX, 77843-1266, USA
| | - D J Becker
- Department of Health Care Organization and Policy, University of Alabama at Birmingham School of Public Health, RPHB 330K, 1720 2nd Ave S, Birmingham, AL, 35294-0022, USA
| | - M L Kilgore
- Department of Health Care Organization and Policy, University of Alabama at Birmingham School of Public Health, RPHB 330K, 1720 2nd Ave S, Birmingham, AL, 35294-0022, USA
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Marshall SL, Edidin D, Arena VC, Becker DJ, Bunker CH, Gishoma C, Gishoma F, LaPorte RE, Kaberuka V, Ogle G, Sibomana L, Orchard TJ. Prevalence and incidence of clinically recognized cases of Type 1 diabetes in children and adolescents in Rwanda, Africa. Diabet Med 2015; 32:1186-92. [PMID: 25604893 DOI: 10.1111/dme.12701] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/15/2015] [Indexed: 01/21/2023]
Abstract
AIMS To determine prevalence and incidence estimates for clinically recognized cases of Type 1 diabetes from the Life For a Child Program (LFAC) with onset < 26 years in six representative districts, and the capital, of Rwanda. METHODS Cases were identified from the LFAC registry and visits to district hospitals. Denominators were calculated from district-level population surveys. Period prevalence data were collected from 1 August 2011 to 31 July 2012 and annual incidence rates were calculated, retrospectively, for 2004-2011. Ninety-five per cent confidence intervals (95% CI) were calculated using a Poisson distribution. RESULTS The prevalence of known Type 1 diabetes in seven districts in Rwanda for ages < 26 years was 16.4 [95% CI 14.6-18.4]/100 000 and for < 15 years was 4.8 [3.5-6.4]/100 000. Prevalence was higher in females (18.5 [15.8-21.4]/100 000) than males (14.1 [11.8-16.7]/100 000; P = 0.01) and rates increased with age. The annual incidence rate for those < 26 years was stable between 2007 and 2011 with a mean incidence over that time of 2.7 [2.0-3.7]/100 000 ( < 15 years = 1.2 [0.5-2.0]/100 000). Incidence rates were higher in females than males and peaked in males at ages 17 and 22 years and in females at age 18 years. CONCLUSIONS Our report of known Type 1 diabetes cases shows lower incidence and prevalence rates in Rwanda than previously reported in the USA and most African countries. Incidence of recognized cases has increased over time, but has recently stabilized. However, the likelihood of missed cases due to death before diagnosis and misdiagnosis is high and therefore more definitive studies are needed.
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Affiliation(s)
- S L Marshall
- University of Pittsburgh Graduate School of Public Health, Department of Epidemiology, Pittsburgh, PA, USA
| | - D Edidin
- Northwestern University, Feinberg School of Medicine, Pediatrics, Chicago
| | - V C Arena
- University of Pittsburgh Graduate School of Public Health, Department of Biostatistics, Pittsburgh, PA, USA
| | - D J Becker
- University of Pittsburgh School of Medicine, Department of Pediatrics, Pittsburgh, PA, USA
| | - C H Bunker
- University of Pittsburgh Graduate School of Public Health, Department of Epidemiology, Pittsburgh, PA, USA
| | - C Gishoma
- Association Rwandaise des Diabetiques, Kigali, Rwanda
| | - F Gishoma
- Association Rwandaise des Diabetiques, Kigali, Rwanda
| | - R E LaPorte
- University of Pittsburgh Graduate School of Public Health, Department of Epidemiology, Pittsburgh, PA, USA
| | - V Kaberuka
- Association Rwandaise des Diabetiques, Kigali, Rwanda
| | - G Ogle
- International Diabetes Federation Life for a Child Program and Australian Diabetes Council, Sydney, Australia
| | - L Sibomana
- University of Pittsburgh Graduate School of Public Health, Department of Epidemiology, Pittsburgh, PA, USA
| | - T J Orchard
- University of Pittsburgh Graduate School of Public Health, Department of Epidemiology, Pittsburgh, PA, USA
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Abstract
Type 1 diabetes (T1D) is an autoimmune disease that results from the destruction of the β cells of the pancreas in genetically at-risk individuals. The autoimmune process that precedes the development of T1D is believed to be triggered by environmental factors, including nutrition. Early introduction of complementary foods has been implicated in the etiology of T1D as a possible explanation of the increasing incidence of the disease, particularly in children younger than 5 years of age. Infant feeding recommendations have been designed to promote adequate growth, provide essential nutrients, and reduce the risk of developing chronic illnesses. The World Health Organization and the American Academy of Pediatrics recommend exclusive breastfeeding to 6 months of age followed by continued breastfeeding as complementary foods are introduced. A lack of compliance with these recommendations has been observed in the general population as well as in infants at high risk for T1D. Dietary factors such as the provision of breast milk and duration of breastfeeding, the age at introduction of cow's milk and gluten-containing foods, as well as other complementary feeding have been investigated. However, the evidence that early infant feeding patterns are linked with T1D currently remains inconclusive.
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Affiliation(s)
- Anita M. Nucci
- Department of Nutrition, Georgia State University, P.O. Box 3995, Atlanta, GA 30303-3995, USA
| | - Suvi M. Virtanen
- Nutrition Unit, National Institute for Health and Welfare, Helsinki, Finland
- School of Health Sciences, University of Tampere, Tampere, Finland
- Center for Child Health Research, University of Tampere and Tampere University Hospital, Tampere, Finland
- The Science Center of Pirkanmaa Hospital District, Tampere, Finland
| | - Dorothy J. Becker
- Division of Endocrinology and Diabetes, University of Pittsburgh and Children's Hospital of Pittsburgh of UPMC, 4401 Penn Ave, Pittsburgh, PA 15224, USA
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Abstract
OBJECTIVE Establishing care with adult providers is essential for emerging adults with type 1 diabetes (T1D) transitioning from pediatric care. Although research evaluating the transition from pediatric to adult care has been focused primarily on patients' perceptions, little is known about the adult providers' perspectives. We sought to ascertain adult providers' perspectives of caring for the medical and psychosocial needs of this patient population. METHODS We developed and mailed a survey to 79 regional adult endocrinologists and 186 primary care physicians (PCPs) identified through 2 regional insurance plans. Questions addressed perceived aptitude in clinical aspects of diabetes management, importance and availability of diabetes team members, and opinions regarding recommended transition methods. RESULTS The response rate was 43% for endocrinologists and 13% for PCPs. Endocrinologists reported higher aptitude in insulin management (P<.01). PCPs reported greater aptitude in screening and treating depression (P<0.01). Although endocrinologists and PCPs did not differ in their views of the importance of care by a comprehensive team, endocrinologists reported better access to diabetes educators and dieticians than PCPs (P<.01). Recommended transition methods were described as useful. CONCLUSION These preliminary results suggest that endocrinologists are better prepared to assume diabetes care of emerging adults, whereas PCPs may be better prepared to screen and treat associated depression. Future studies are needed to determine if a medical home model with cooperative management improves care for emerging adults with T1D.
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Buryk MA, Dosch HM, Libman I, Arena VC, Huang Y, Cheung RK, Trucco M, Pietropaolo M, Becker DJ. Neuronal T-cell autoreactivity is amplified in overweight children with new-onset insulin-requiring diabetes. Diabetes Care 2015; 38:43-50. [PMID: 25414154 PMCID: PMC4274776 DOI: 10.2337/dc14-1861] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Disease-associated T-cell autoreactivities are seen in most type 1 diabetic patients and are thought to emerge before islet autoantibodies, but host factors that impact autoimmune elements remain uncertain. We assessed if adiposity and measures of insulin sensitivity impact T- and B-cell autoimmunity in children with insulin-requiring diabetes. RESEARCH DESIGN AND METHODS Insulin-requiring children and adolescents diagnosed between January 2004 and June 2008 were studied (n = 261): age 9.7 ± 4 years, 92% white, and 60% male. T-cell responses to 10 diabetes-associated antigens, β-cell autoantibodies (GADA, IA-2A, IAA, and ICA), BMI z score (BMIz), and waist percentile were measured at onset and 3 months later. RESULTS All but one subject had either T- or B-cell autoimmunity. Diabetes-associated T-cell autoreactivities were found in 92% of subjects. Higher amplitude T-cell autoreactivities to neuronal diabetes-associated autoantigens were seen in those with the highest BMIz quintile, BMI ≥85th percentile (P < 0.05), and waist circumference ≥85th percentile (P < 0.05). There were no relationships between the number of T-cell reactivities or T-cell diversity with adiposity measures or autoantibody number or type. Patients with positive T-cell reactivities but without autoantibodies had the highest BMIz (P = 0.006). CONCLUSIONS Our observations link obesity and diabetes-related autoimmunity, suggesting an amplification of neuronal T-cell autoimmunity associated with adiposity and/or insulin resistance, with obesity-related inflammation possibly enhancing islet autoimmunity.
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Affiliation(s)
- Melissa A Buryk
- Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA
| | - H-Michael Dosch
- Neurosciences and Mental Health Program, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ingrid Libman
- Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA
| | - Vincent C Arena
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Yihe Huang
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Roy K Cheung
- Neurosciences and Mental Health Program, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Massimo Trucco
- Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA
| | | | - Dorothy J Becker
- Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA
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Marshall SL, Edidin DV, Arena VC, Becker DJ, Bunker CH, Gishoma C, Gishoma F, LaPorte RE, Kaberuka V, Ogle G, Sibomana L, Orchard TJ. Glucose control in Rwandan youth with type 1 diabetes following establishment of systematic, HbA1c based, care and education. Diabetes Res Clin Pract 2015; 107:113-22. [PMID: 25458328 PMCID: PMC4300260 DOI: 10.1016/j.diabres.2014.09.045] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Revised: 08/26/2014] [Accepted: 09/15/2014] [Indexed: 12/18/2022]
Abstract
AIMS To assess change in glycemic control concurrent with increased clinic visits, HbA1c testing, and education. Rates of complications were also examined. METHODS A 1-2 year follow-up of 214 members of the Rwanda Life for a Child program (aged <26 years) with a first HbA1c between June 2009 and November 2010 was conducted. Data were analyzed for the entire cohort and by age (<18 years, ≥18 years). Trajectory analysis was performed to identify trends in HbA1c. RESULTS Mean overall HbA1c decreased significantly from baseline (11.2 ± 2.7%; 99 ± 30 mmol/mol) to one- (10.2 ± 2.6%; 88 ± 28 mmol/mol) and two- (9.8 ± 26%; 84 ± 25 mmol/mol) year follow up visits. The prevalence of microalbuminuria did not significantly change (21.0%, 18.8%, and 19.6%), nor did nephropathy (4.7%, 7.8%, and 5.4%). However, rates of hypertension (31.8%, 44.9%, and 40.3%) were higher than expected. Five HbA1c groups were identified by trajectory analysis, and those with the worst control monitored their glucose significantly fewer times per week. CONCLUSIONS The establishment of regular care, HbA1c testing, and increased education is associated with significant improvements in glycemic control in youth with type 1 diabetes (T1D) in sub-Saharan Africa, but the high prevalence of hypertension is of concern.
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Affiliation(s)
- Sara L Marshall
- University of Pittsburgh Graduate School of Public Health, Department of Epidemiology, Pittsburgh, PA, USA
| | - Deborah V Edidin
- Northwestern University, Feinberg School of Medicine, Pediatrics, Chicago, IL, USA
| | - Vincent C Arena
- University of Pittsburgh Graduate School of Public Health, Department of Biostatistics, Pittsburgh, PA, USA
| | - Dorothy J Becker
- University of Pittsburgh School of Medicine, Department of Pediatrics, Pittsburgh, PA, USA
| | - Clareann H Bunker
- University of Pittsburgh Graduate School of Public Health, Department of Epidemiology, Pittsburgh, PA, USA
| | | | | | - Ronald E LaPorte
- University of Pittsburgh Graduate School of Public Health, Department of Epidemiology, Pittsburgh, PA, USA
| | | | - Graham Ogle
- International Diabetes Federation Life for a Child Program and Australian Diabetes Council, Sydney, NSW, Australia
| | - Laurien Sibomana
- University of Pittsburgh Graduate School of Public Health, Department of Epidemiology, Pittsburgh, PA, USA
| | - Trevor J Orchard
- University of Pittsburgh Graduate School of Public Health, Department of Epidemiology, Pittsburgh, PA, USA.
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Cedillo M, Libman IM, Arena VC, Zhou L, Trucco M, Ize-Ludlow D, Pietropaolo M, Becker DJ. Obesity, islet cell autoimmunity, and cardiovascular risk factors in youth at onset of type 1 autoimmune diabetes. J Clin Endocrinol Metab 2015; 100:E82-6. [PMID: 25250632 PMCID: PMC4283021 DOI: 10.1210/jc.2014-2340] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT The current increase in childhood type 1 diabetes (T1D) and obesity has led to two conflicting hypotheses and conflicting reports regarding the effects of overweight on initiation and spreading of islet cell autoimmunity vs earlier clinical manifestation of preexisting autoimmune β-cell damage driven by excess weight. OBJECTIVE The objective of the study was to address the question of whether the degree of β-cell autoimmunity and age are related to overweight at diabetes onset in a large cohort of T1D youth. DESIGN This was a prospective cross-sectional study of youth with autoimmune T1D consecutively recruited at diabetes onset. SETTING The study was conducted at a regional academic pediatric diabetes center. PATIENTS Two hundred sixty-three consecutive children younger than 19 years at onset of T1D participated in the study. MAIN OUTCOME MEASURES Relationships between body mass index and central obesity (waist circumference and waist to height ratio) and antigen spreading (islet cell autoantibody number), age, and cardiovascular (CVD) risk factors examined at onset and/or 3 months after the diagnosis were measured. RESULTS There were no significant associations between number of autoantibodies with measures of adiposity. Age relationships revealed that a greater proportion of those with central obesity (21%) were in the youngest age group (0-4 y) compared with those without central obesity (6%) (P = .001). PATIENTS with central obesity had increased CVD risk factors and higher onset C-peptide levels (P < .05). CONCLUSIONS No evidence was found to support the concept that obesity accelerates progression of autoantibody spreading once autoimmunity, marked by standard islet cell autoantibody assays, is present. Central obesity was present in almost one-third of the subjects and was associated with early CVD risk markers already at onset.
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Helgeson VS, Reynolds KA, Siminerio LM, Becker DJ, Escobar O. Cognitive adaptation theory as a predictor of adjustment to emerging adulthood for youth with and without type 1 diabetes. J Psychosom Res 2014; 77:484-91. [PMID: 25294781 PMCID: PMC4259892 DOI: 10.1016/j.jpsychores.2014.09.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Revised: 09/20/2014] [Accepted: 09/23/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The purpose of the study was to determine whether resilience, defined by cognitive adaptation theory, predicted emerging adulthood outcomes among youth with and without type 1 diabetes. METHODS Youth with (n=118) and without type 1 diabetes (n=122), who were part of a previous longitudinal study during adolescence, completed on-line questionnaires during their senior year of high school and one and two years later. They were average age 18, 53% female, and 93% white. Questionnaires assessed cognitive adaptation theory (CAT) indicators (self-esteem, mastery, optimism) and psychological, relationship, behavioral, vocational, and, for those with diabetes, diabetes outcomes. RESULTS The CAT index at baseline predicted reduced psychological distress, enhanced psychological well-being, increased friend support, reduced friend conflict, the presence of romantic relationships, reduced likelihood of romantic breakups, higher GPA, higher work satisfaction, and lower work stress during the transition to emerging adulthood. Among those with diabetes, the CAT index predicted better self-care behavior and revealed a marginal relation to better glycemic control. Analyses controlled for baseline levels when appropriate. Findings were stronger one year than two years post high school graduation, and findings were stronger for those with than without diabetes. Youth with diabetes also scored lower on the CAT index than youth without diabetes. CONCLUSIONS These findings suggest that the implications of CAT include not only psychological health but also relationship, vocational, and diabetes outcomes. Those who score lower on CAT indicators should be identified as children so that interventions designed to enhance resilience can be implemented.
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Garg M, Thamotharan M, Becker DJ, Devaskar SU. Adolescents with clinical type 1 diabetes display reduced red blood cell glucose transporter isoform 1 (GLUT1). Pediatr Diabetes 2014; 15:511-8. [PMID: 24552568 PMCID: PMC4208912 DOI: 10.1111/pedi.12127] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Revised: 11/14/2013] [Accepted: 01/08/2014] [Indexed: 01/16/2023] Open
Abstract
Type 1 diabetic (T1D) adolescent children on insulin therapy suffer episodes of both hyper- and hypoglycemic episodes. Glucose transporter isoform GLUT1 expressed in blood-brain barrier (BBB) and red blood cells (RBC) compensates for perturbed circulating glucose toward protecting the supply to brain and RBCs. We hypothesized that RBC-GLUT1 concentration, as a surrogate for BBB-GLUT1, is altered in T1D children. To test this hypothesis, we measured RBC-GLUT1 by enzyme-linked immunosorbent assay (ELISA) in T1D children (n = 72; mean age 15.3 ± 0.2 yr) and control children (CON; n = 11; mean age 15.6 ± 0.9 yr) after 12 h of euglycemia and during a hyperinsulinemic-hypoglycemic clamp with a nadir blood glucose of ~3.3 mmol/L for 90 min (clamp I) or ~3 mmol/L for 45 min (clamp II). Reduced baseline RBC-GLUT1 was observed in T1D (2.4 ± 0.17 ng/ng membrane protein); vs. CON (4.2 ± 0.61 ng/ng protein) (p < 0.0001). Additionally, baseline RBC-GLUT1 in T1D negatively correlated with hemoglobin A1c (HbA1c) (R = -0.23, p < 0.05) but not in CON (R = 0.06, p < 0.9). Acute decline in serum glucose to 3.3 mmol/L (90 min) or 3 mmol/L (45 min) did not change baseline RBC-GLUT1 in T1D or CON children. We conclude that reduced RBC-GLUT1 encountered in T1D, with no ability to compensate by increasing during acute hypoglycemia over the durations examined, may demonstrate a vulnerability of impaired RBC glucose transport (serving as a surrogate for BBB), especially in those with the worst control. We speculate that this may contribute to the perturbed cognition seen in T1D adolescents.
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Affiliation(s)
- Meena Garg
- Department of Pediatrics/Division of Neonatology and Developmental Biology, David Geffen School of Medicine at UCLA & Mattel Children's Hospital UCLA, Los Angeles, CA 90095-1752
| | - Manikkavasagar Thamotharan
- Department of Pediatrics/Division of Neonatology and Developmental Biology, David Geffen School of Medicine at UCLA & Mattel Children's Hospital UCLA, Los Angeles, CA 90095-1752
| | - Dorothy J. Becker
- Division of Endocrinology, Department of Pediatrics, University of Pittsburgh School of Medicine & Children's Hospital of Pittsburgh, Pittsburgh, PA 15213-3205
| | - Sherin U. Devaskar
- Department of Pediatrics/Division of Neonatology and Developmental Biology, David Geffen School of Medicine at UCLA & Mattel Children's Hospital UCLA, Los Angeles, CA 90095-1752,10833, Le Conte Avenue, Room 22-402 MDCC Los Angeles, CA 90095-1752 Tel.No. = 310-825-9357; FAX No. = 310-206-4584;
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Moran A, Pillay K, Becker DJ, Acerini CL. ISPAD Clinical Practice Consensus Guidelines 2014. Management of cystic fibrosis-related diabetes in children and adolescents. Pediatr Diabetes 2014; 15 Suppl 20:65-76. [PMID: 25182308 DOI: 10.1111/pedi.12178] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2014] [Accepted: 06/11/2014] [Indexed: 12/17/2022] Open
Affiliation(s)
- Antoinette Moran
- Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
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35
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Orban T, Bundy B, Becker DJ, Dimeglio LA, Gitelman SE, Goland R, Gottlieb PA, Greenbaum CJ, Marks JB, Monzavi R, Moran A, Peakman M, Raskin P, Russell WE, Schatz D, Wherrett DK, Wilson DM, Krischer JP, Skyler JS. Costimulation modulation with abatacept in patients with recent-onset type 1 diabetes: follow-up 1 year after cessation of treatment. Diabetes Care 2014; 37:1069-75. [PMID: 24296850 PMCID: PMC3964491 DOI: 10.2337/dc13-0604] [Citation(s) in RCA: 136] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE We previously reported that 2 years of costimulation modulation with abatacept slowed decline of β-cell function in recent-onset type 1 diabetes (T1D). Subsequently, abatacept was discontinued and subjects were followed to determine whether there was persistence of effect. RESEARCH DESIGN AND METHODS Of 112 subjects (ages 6-36 years) with T1D, 77 received abatacept and 35 received placebo infusions intravenously for 27 infusions over 2 years. The primary outcome-baseline-adjusted geometric mean 2-h area under the curve (AUC) serum C-peptide during a mixed-meal tolerance test (MMTT) at 2 years-showed higher C-peptide with abatacept versus placebo. Subjects were followed an additional year, off treatment, with MMTTs performed at 30 and 36 months. RESULTS C-peptide AUC means, adjusted for age and baseline C-peptide, at 36 months were 0.217 nmol/L (95% CI 0.168-0.268) and 0.141 nmol/L (95% CI 0.071-0.215) for abatacept and placebo groups, respectively (P = 0.046). The C-peptide decline from baseline remained parallel with an estimated 9.5 months' delay with abatacept. Moreover, HbA1c levels remained lower in the abatacept group than in the placebo group. The slightly lower (nonsignificant) mean total insulin dose among the abatacept group reported at 2 years was the same as the placebo group by 3 years. CONCLUSIONS Costimulation modulation with abatacept slowed decline of β-cell function and improved HbA1c in recent-onset T1D. The beneficial effect was sustained for at least 1 year after cessation of abatacept infusions or 3 years from T1D diagnosis.
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Lyons SK, Becker DJ, Helgeson VS. Transfer from pediatric to adult health care: effects on diabetes outcomes. Pediatr Diabetes 2014; 15:10-7. [PMID: 24350767 PMCID: PMC4097315 DOI: 10.1111/pedi.12106] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Revised: 10/18/2013] [Accepted: 11/06/2013] [Indexed: 01/22/2023] Open
Abstract
The transfer from pediatric to adult diabetes health care for emerging adults with type 1 diabetes (T1D) has received increasing attention in the literature. This review analyzes the effect of this health care transfer on the outcomes of diabetes care visit attendance, glycemic control, and acute diabetes-related complications, and assesses the methodological strength of the studies reporting observational and interventional data. Observational studies, often limited by incomplete data, report a decline in diabetes care visits but an improvement or no change in hemoglobin A1c (HbA1c) after transfer to adult care. Results from studies reporting a transition intervention are restricted by lack of appropriate control groups and the collection of data both before and after transfer of care. Very few methodologically strong studies are available to guide clinicians with the transition from pediatric to adult care, and these shortcomings should be addressed in future studies designed to facilitate and improve the care of emerging adults with T1D.
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Affiliation(s)
- Sarah K Lyons
- Division of Pediatric Endocrinology, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | - Dorothy J Becker
- Division of Pediatric Endocrinology, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | - Vicki S Helgeson
- Department of Psychology, Carnegie Mellon University, Pittsburgh, PA, USA
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Pescovitz MD, Greenbaum CJ, Bundy B, Becker DJ, Gitelman SE, Goland R, Gottlieb PA, Marks JB, Moran A, Raskin P, Rodriguez H, Schatz DA, Wherrett DK, Wilson DM, Krischer JP, Skyler JS. B-lymphocyte depletion with rituximab and β-cell function: two-year results. Diabetes Care 2014; 37:453-9. [PMID: 24026563 PMCID: PMC3898764 DOI: 10.2337/dc13-0626] [Citation(s) in RCA: 168] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE We previously reported that selective depletion of B-lymphocytes with rituximab, an anti-CD20 monoclonal antibody, slowed decline of β-cell function in recent-onset type 1 diabetes mellitus (T1DM) at 1 year. Subjects were followed further to determine whether there was persistence of effect. RESEARCH DESIGN AND METHODS Eighty-seven subjects (aged 8-40 years) were randomly assigned to, and 81 received, infusions of rituximab or placebo on days 1, 8, 15, and 22. The primary outcome-baseline-adjusted mean 2-h area under the curve (AUC) serum C-peptide during a mixed-meal tolerance test (MMTT) at 1 year-showed higher C-peptide AUC with rituximab versus placebo. Subjects were further followed with additional MMTTs every 6 months. RESULTS The rate of decline of C-peptide was parallel between groups but shifted by 8.2 months in rituximab-treated subjects. Over 30 months, AUC, insulin dose, and HbA1c were similar for rituximab and placebo. However, in evaluating change in C-peptide over the entire follow-up period, the rituximab group means were significantly larger as compared within assessment times with the placebo group means using a global test (P = 0.03). Odds ratio for loss of C-peptide to <0.2 nmol/L following rituximab was 0.565 (P = 0.064). B-lymphocytes recovered to baseline values by 18 months. Serum IgG levels were maintained in the normal range but IgM levels were depressed. CONCLUSIONS Like several other immunotherapeutic approaches tested, in recent-onset T1DM, rituximab delays the fall in C-peptide but does not appear to fundamentally alter the underlying pathophysiology of the disease.
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Miller RG, Secrest AM, Ellis D, Becker DJ, Orchard TJ. Changing impact of modifiable risk factors on the incidence of major outcomes of type 1 diabetes: the Pittsburgh Epidemiology of Diabetes Complications Study. Diabetes Care 2013; 36:3999-4006. [PMID: 24170748 PMCID: PMC3836155 DOI: 10.2337/dc13-1142] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The incidence of type 1 diabetes complications appears to be decreasing, but relative contributions of risk factors are unclear. We thus estimated the effect of modifiable risk factors on the incidence of a composite end point, major outcomes of diabetes (MOD). RESEARCH DESIGN AND METHODS The Pittsburgh Epidemiology of Diabetes Complications (EDC) Study was used to derive two cohorts based on diabetes diagnosis year (1960-1969 and 1970-1980). Baseline exam data in the current analysis for the 1960s group were collected in 1986-1988 and for the 1970s in 1996-1998. Each group was followed for 8 years for MOD incidence (diabetes-related death, myocardial infarction, revascularization procedure/blockage ≥50%, stroke, end-stage renal disease, blindness, and amputation). Assessed risk factors include the following: HbA1c, hypertension, microalbuminuria, BMI, hypercholesterolemia, and smoking. Accelerated failure time models were used to estimate the acceleration factor. RESULTS MOD incidence decreased in the 1970s cohort (15.8% [95% CI 11.6-21.4]) compared with the 1960s (22.6% [17.0-29.1]) over the 8-year follow-up (P = 0.06). Hypertension and microalbuminuria were associated with significantly accelerated MOD incidence in both cohorts (P < 0.01 for both). High HbA1c (P = 0.0005), hypercholesterolemia (P = 0.01), and current smoking (P = 0.003) significantly accelerated the incidence of MOD in the 1960s but not 1970s cohort. BMI was not associated with MOD in either cohort. CONCLUSIONS These results suggest that hypertension and microalbuminuria remain important predictors of complications that are not being adequately addressed.
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Helgeson VS, Palladino DK, Reynolds KA, Becker DJ, Escobar O, Siminerio L. Relationships and health among emerging adults with and without Type 1 diabetes. Health Psychol 2013; 33:1125-33. [PMID: 23914816 DOI: 10.1037/a0033511] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE The study's goal was to examine the impact of parent and peer relationships on health behaviors and psychological well-being of those with and without Type 1 diabetes over the transition to emerging adulthood. Emerging adulthood is an understudied developmental period and a high-risk period--especially for those with Type 1 diabetes. METHOD Youth with (n = 117) and without Type 1 diabetes (n = 122) completed questionnaires during their senior year of high school and 1 year later. Measures included supportive and problematic aspects of parent and peer relationships, health behaviors, psychological well-being, and, for those with diabetes, self-care behavior and glycemic control. RESULTS Prospective multiple and logistic regression analysis revealed that friend conflict was a more potent predictor than friend support of changes in health behaviors and psychological well-being. Parent support was associated with positive changes in psychological well-being and decreases in smoking, whereas parent control was related to increases in smoking and depressive symptoms. There was some evidence of cross-domain buffering such that supportive relationships in one domain buffered adverse effects of problematic relationships in the other domain on health outcomes. CONCLUSIONS This longitudinal study showed that parent relationships remain an important influence on, and peer relationships continue to influence, the health behaviors and psychological well-being of emerging adults with and without Type 1 diabetes. Parent relationships also have the potential to buffer the adverse effects of difficulties with peers.
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Affiliation(s)
| | | | | | - Dorothy J Becker
- Department of Pediatric Endocrinology, Children's Hospital of Pittsburgh
| | - Oscar Escobar
- Department of Pediatric Endocrinology, Children's Hospital of Pittsburgh
| | - Linda Siminerio
- Department of Medicine, University of Pittsburgh Medical Center
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Moran A, Bundy B, Becker DJ, DiMeglio LA, Gitelman SE, Goland R, Greenbaum CJ, Herold KC, Marks JB, Raskin P, Sanda S, Schatz D, Wherrett DK, Wilson DM, Krischer JP, Skyler JS, Pickersgill L, de Koning E, Ziegler AG, Böehm B, Badenhoop K, Schloot N, Bak JF, Pozzilli P, Mauricio D, Donath MY, Castaño L, Wägner A, Lervang HH, Perrild H, Mandrup-Poulsen T. Interleukin-1 antagonism in type 1 diabetes of recent onset: two multicentre, randomised, double-blind, placebo-controlled trials. Lancet 2013; 381:1905-15. [PMID: 23562090 PMCID: PMC3827771 DOI: 10.1016/s0140-6736(13)60023-9] [Citation(s) in RCA: 250] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Innate immunity contributes to the pathogenesis of autoimmune diseases, such as type 1 diabetes, but until now no randomised, controlled trials of blockade of the key innate immune mediator interleukin-1 have been done. We aimed to assess whether canakinumab, a human monoclonal anti-interleukin-1 antibody, or anakinra, a human interleukin-1 receptor antagonist, improved β-cell function in recent-onset type 1 diabetes. METHODS We did two randomised, placebo-controlled trials in two groups of patients with recent-onset type 1 diabetes and mixed-meal-tolerance-test-stimulated C peptide of at least 0·2 nM. Patients in the canakinumab trial were aged 6-45 years and those in the anakinra trial were aged 18-35 years. Patients in the canakinumab trial were enrolled at 12 sites in the USA and Canada and those in the anakinra trial were enrolled at 14 sites across Europe. Participants were randomly assigned by computer-generated blocked randomisation to subcutaneous injection of either 2 mg/kg (maximum 300 mg) canakinumab or placebo monthly for 12 months or 100 mg anakinra or placebo daily for 9 months. Participants and carers were masked to treatment assignment. The primary endpoint was baseline-adjusted 2-h area under curve C-peptide response to the mixed meal tolerance test at 12 months (canakinumab trial) and 9 months (anakinra trial). Analyses were by intention to treat. These studies are registered with ClinicalTrials.gov, numbers NCT00947427 and NCT00711503, and EudraCT number 2007-007146-34. FINDINGS Patients were enrolled in the canakinumab trial between Nov 12, 2010, and April 11, 2011, and in the anakinra trial between Jan 26, 2009, and May 25, 2011. 69 patients were randomly assigned to canakinumab (n=47) or placebo (n=22) monthly for 12 months and 69 were randomly assigned to anakinra (n=35) or placebo (n=34) daily for 9 months. No interim analyses were done. 45 canakinumab-treated and 21 placebo-treated patients in the canakinumab trial and 25 anakinra-treated and 26 placebo-treated patients in the anakinra trial were included in the primary analyses. The difference in C peptide area under curve between the canakinumab and placebo groups at 12 months was 0·01 nmol/L (95% CI -0·11 to 0·14; p=0·86), and between the anakinra and the placebo groups at 9 months was 0·02 nmol/L (-0·09 to 0·15; p=0·71). The number and severity of adverse events did not differ between groups in the canakinumab trial. In the anakinra trial, patients in the anakinra group had significantly higher grades of adverse events than the placebo group (p=0·018), which was mainly because of a higher number of injection site reactions in the anakinra group. INTERPRETATION Canakinumab and anakinra were safe but were not effective as single immunomodulatory drugs in recent-onset type 1 diabetes. Interleukin-1 blockade might be more effective in combination with treatments that target adaptive immunity in organ-specific autoimmune disorders. FUNDING National Institutes of Health and Juvenile Diabetes Research Foundation.
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Helgeson VS, Reynolds KA, Snyder PR, Palladino DK, Becker DJ, Siminerio L, Escobar O. Characterizing the transition from paediatric to adult care among emerging adults with Type 1 diabetes. Diabet Med 2013; 30:610-5. [PMID: 23157171 PMCID: PMC3628931 DOI: 10.1111/dme.12067] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2012] [Revised: 09/18/2012] [Accepted: 11/08/2012] [Indexed: 11/26/2022]
Abstract
AIMS The goals of the study were to describe the transition of youth with Type 1 diabetes from paediatric to adult healthcare services, examine the link of this transition with self care and glycaemic control, and distinguish youth who received medical treatment from different physicians in terms of demographic and parent relationship variables. METHODS Youth with Type 1 diabetes (n = 118) were enrolled in a prospective study that examined the transition from the paediatric to adult healthcare systems and were evaluated during their senior year of high school (time 1) and 1 year later (time 2). Data on self care, glycaemic control and parent relationship were collected. RESULTS The majority of youth saw a paediatric endocrinologist at both assessments (n = 64); others saw an adult care physician at both assessments (n = 26) or transitioned from a paediatric endocrinologist to an adult care physician (n = 19). Nine youth saw no physician between time 1 and time 2. There were group differences in demographic and parent relationship variables and self-care behaviour and glycaemic control related to the transition of care. Youth who remained in the paediatric healthcare system had the best self care and did not experience declines in glycaemic control over time. CONCLUSIONS Early transition from the paediatric healthcare system to the adult healthcare system is associated with psychosocial variables and worse glycaemic control. Future research should identify factors that determine optimal timing and strategies to avoid deterioration of care and control during this transition.
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Affiliation(s)
- V S Helgeson
- Psychology Department, Carnegie Mellon University, Pittsburgh, PA, USA.
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Palladino DK, Helgeson VS, Reynolds KA, Becker DJ, Siminerio LM, Escobar O. Emerging adults with type 1 diabetes: a comparison to peers without diabetes. J Pediatr Psychol 2013; 38:506-17. [PMID: 23475831 DOI: 10.1093/jpepsy/jst002] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE This longitudinal study compared emerging adults with and without type 1 diabetes on life path decisions, health behaviors, and psychological well-being during the transition out of high school. METHODS Administered questionnaires during the senior year of high school and 1 year later to 117 emerging adults with diabetes and 122 emerging adults without diabetes. Comparisons were conducted with respect to health status, sex, and school status. RESULTS Those with and without diabetes chose similar life paths and engaged in similar levels of risky behaviors, but disturbed sleep increased for males with diabetes only. Having diabetes was not associated with depressive symptoms, loneliness, or bulimic symptoms, but was associated with lower life satisfaction and lower life purpose over time. CONCLUSIONS Emerging adults with and without diabetes fare similarly on most dimensions studied during the first year out of high school.
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Affiliation(s)
- Dianne K Palladino
- Department of Psychology, Carnegie Mellon University, Pittsburgh, PA 15213, USA.
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Nucci AM, Becker DJ, Virtanen SM, Cuthbertson D, Softness B, Huot C, Wasikowa R, Dosch HM, Åkerblom HK, Knip M. Growth differences between North American and European children at risk for type 1 diabetes. Pediatr Diabetes 2012; 13:425-31. [PMID: 22251851 PMCID: PMC3335929 DOI: 10.1111/j.1399-5448.2011.00840.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2011] [Accepted: 11/17/2011] [Indexed: 11/28/2022] Open
Abstract
AIM To evaluate the relationships between early growth and regional variations in type 1 diabetes (T1D) incidence in an international cohort of children with familial and genetic risk for T1D. METHODS Anthropometric indices between birth to 5 yr of age were compared among regions and T1D proband in 2160 children participating in the Trial to Reduce Insulin-dependent diabetes mellitus in the Genetically at Risk study. RESULTS Children in Northern Europe had the highest weight z-score between birth to 12 months of age, while those in Southern Europe and U.S.A. had the lowest weight and length/height z-scores at most time points (p < 0.005 to p < 0.001). Few differences in z-score values for weight, height, and body mass index were found by maternal T1D status. Using International Obesity Task Force criteria, the obesity rates generally increased with age and at 5 yr were highest in males in Northern Europe (6.0%) and in females in Canada (12.8%). However, no statistically significance difference was found by geographic region. In Canada, the obesity rate for female children of mothers with and without T1D differed significantly at 4 and 5 yr (6.0 vs. 0.0% and 21.3 vs. 1.9%, respectively; p < 0.0125) but no differences by maternal T1D status were found in other regions. CONCLUSIONS There are regional differences in early childhood growth that are consistent with the higher incidence of T1D in Northern Europe and Canada as compared to Southern Europe. Our prospective study from birth will allow evaluation of relationships between growth and the emerging development of autoimmunity and progression to T1D by region in this at-risk population of children.
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Affiliation(s)
- Anita M Nucci
- Division of Nutrition, Georgia State University, Atlanta, GA 30302, USA.
| | - Dorothy J Becker
- Division of Endocrinology, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA, 15224
| | - Suvi M Virtanen
- Nutrition Unit, National Institute for Health and Welfare, Helsinki, Finland, 00300; Tampere School of Public Health, University of Tampere, Finland and Research Unit, Tampere University Hospital, Tampere, Finland, 33014
| | - David Cuthbertson
- University of South Florida, Pediatrics Epidemiology Center, Tampa, FL, 33612
| | - Barney Softness
- Columbia University College of Physicians and Surgeons, Naomi Berrie Diabetes Center, New York, NY, 10032
| | - Celine Huot
- CHU Ste. Justine, Montreal, Quebec, Canada, H3T 1C5
| | | | | | - Hans K Åkerblom
- Children’s Hospital and Biomedicum Helsinki Institute, University of Helsinki, Helsinki, Finland, 00014
| | - Mikael Knip
- Department of Pediatrics, Tampere University Hospital, Tampere Finland, 33014, Children’s Hospital, University of Helsinki and Helsinki University Central Hospital and Folkhälsan Research Center, Helsinki, Finland, 00014
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Levine RJ, Genel M, Cuttler L, Becker DJ, Nieman L, Rosenfield RL. Overcoming burdens in the regulation of clinical research in children. Proceedings of a consensus conference, in historical context. Int J Pediatr Endocrinol 2011; 2011:19. [PMID: 22208165 PMCID: PMC3276425 DOI: 10.1186/1687-9856-2011-19] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/05/2011] [Accepted: 12/30/2011] [Indexed: 11/30/2022]
Abstract
BACKGROUND Many investigators are concerned that the modes of implementation and enforcement of the federal regulations designed to protect children are unduly impeding pediatric clinical research. OBJECTIVE To assess regulatory impediments to clinical research involving children and to develop recommendations to ameliorate them. PARTICIPANTS The Pediatric Endocrine Society and The Endocrine Society convened a consensus conference involving experts and stakeholders in patient-oriented research involving children and adolescents in 2008. CONSENSUS PROCESS Following presentations that reviewed problematic issues around key regulations, participants divided into working groups to develop potential solutions that could be adopted at local and federal levels. Presentations to the full assembly were then debated. A writing committee then drafted a summary of the discussions and main conclusions, placing them in historical context, and submitted it to all participants for comment with the aim of developing consensus. CONCLUSIONS Recommendations designed to facilitate the ethical conduct of research involving children addressed the interpretation of ambiguous regulatory terms such as "minimal risk" and "condition" and called for the development by professional societies of best practice primers for common research procedures that would be informative to both investigators and institutional review boards. A call was issued for improved guidance from the Office for Human Research Protections and Food and Drug Administration as well as for the development by professional societies of a process to monitor progress in improving human subject research regulation. Finally, a need for systematic research to define the nature and extent of institutional obstacles to pediatric research was recognized.
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Affiliation(s)
- Robert J Levine
- Interdisciplinary Center for Bioethics, Yale University, New Haven, CT 06520-8293, USA
| | - Myron Genel
- Yale Child Health Research Center, Department of Pediatrics, Yale University School of Medicine, New Haven, CT 06520-8081, USA
| | - Leona Cuttler
- The Center for Child Health and Policy, Case-Western Reserve University, Cleveland OH 44106, USA
| | - Dorothy J Becker
- University of Pittsburgh School of Medicine, Pittsburgh, PA 15224, USA
| | - Lynnette Nieman
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health, Bethesda, MD 20892, USA
| | - Robert L Rosenfield
- The University of Chicago Pritzker School of Medicine, Chicago, IL 60637, USA
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Ize-Ludlow D, Lightfoot YL, Parker M, Xue S, Wasserfall C, Haller MJ, Schatz D, Becker DJ, Atkinson MA, Mathews CE. Progressive erosion of β-cell function precedes the onset of hyperglycemia in the NOD mouse model of type 1 diabetes. Diabetes 2011; 60:2086-91. [PMID: 21659497 PMCID: PMC3142079 DOI: 10.2337/db11-0373] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE A progressive decline in insulin responses to glucose was noted in individuals before the onset of type 1 diabetes. We determined whether such abnormalities occurred in prediabetic NOD mice-the prototypic model for human type 1 diabetes. RESEARCH DESIGN AND METHODS Morning blood glucose was measured every other day in a cohort of NOD females. Glucose tolerance and insulin secretion were measured longitudinally by intraperitoneal glucose tolerance tests in NOD/ShiLtJ and BALB/cJ mice 6 to 14 weeks of age. Arginine-stimulated insulin secretion and insulin sensitivity were assessed during intraperitoneal arginine or intraperitoneal insulin tolerance tests. RESULTS During prediabetes, NOD females displayed a progressive increase in glucose levels followed by an acute onset of hyperglycemia. First-phase insulin responses (FPIRs) during the intraperitoneal glucose tolerance test (IPGTT) declined before loss of glucose tolerance in NOD. The failure of FPIR could be detected, with a decline in peak insulin secretion during IPGTT. Arginine-stimulated insulin secretion remained unchanged during the study period. The decline in insulin secretion in NOD mice could not be explained by changes in insulin sensitivity. CONCLUSIONS There was an impressive decline in FPIR before changes in glucose tolerance, suggesting that impairment of FPIR is an early in vivo marker of progressive β-cell failure in NOD mice and human type 1 diabetes. We portend that these phenotypes in NOD mice follow a similar pattern to those seen in humans with type 1 diabetes and validate, in a novel way, the importance of this animal model for studies of this disease.
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Affiliation(s)
- Diego Ize-Ludlow
- Department of Pediatrics, Division of Pediatric Endocrinology, Diabetes and Metabolism, Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Matthew Parker
- Department of Pathology, University of Florida, Gainesville, Florida
| | - Song Xue
- Department of Pathology, University of Florida, Gainesville, Florida
| | - Clive Wasserfall
- Department of Pathology, University of Florida, Gainesville, Florida
| | - Michael J. Haller
- Department of Pediatrics, University of Florida, Gainesville, Florida
| | - Desmond Schatz
- Department of Pediatrics, University of Florida, Gainesville, Florida
| | - Dorothy J. Becker
- Department of Pediatrics, Division of Pediatric Endocrinology, Diabetes and Metabolism, Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Mark A. Atkinson
- Department of Pathology, University of Florida, Gainesville, Florida
| | - Clayton E. Mathews
- Department of Pathology, University of Florida, Gainesville, Florida
- Corresponding author: Clayton E. Mathews,
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Orban T, Bundy B, Becker DJ, DiMeglio LA, Gitelman SE, Goland R, Gottlieb PA, Greenbaum CJ, Marks JB, Monzavi R, Moran A, Raskin P, Rodriguez H, Russell WE, Schatz D, Wherrett D, Wilson DM, Krischer JP, Skyler JS. Co-stimulation modulation with abatacept in patients with recent-onset type 1 diabetes: a randomised, double-blind, placebo-controlled trial. Lancet 2011; 378:412-9. [PMID: 21719096 PMCID: PMC3462593 DOI: 10.1016/s0140-6736(11)60886-6] [Citation(s) in RCA: 409] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The immunopathogenesis of type 1 diabetes mellitus is associated with T-cell autoimmunity. To be fully active, immune T cells need a co-stimulatory signal in addition to the main antigen-driven signal. Abatacept modulates co-stimulation and prevents full T-cell activation. We evaluated the effect of abatacept in recent-onset type 1 diabetes. METHODS In this multicentre, double-blind, randomised controlled trial, patients aged 6-45 years recently diagnosed with type 1 diabetes were randomly assigned (2:1) to receive abatacept (10 mg/kg, maximum 1000 mg per dose) or placebo infusions intravenously on days 1, 14, 28, and monthly for a total of 27 infusions over 2 years. Computer-generated permuted block randomisation was used, with a block size of 3 and stratified by participating site. Neither patients nor research personnel were aware of treatment assignments. The primary outcome was baseline-adjusted geometric mean 2-h area-under-the-curve (AUC) serum C-peptide concentration after a mixed-meal tolerance test at 2 years' follow-up. Analysis was by intention to treat for all patients for whom data were available. This trial is registered at ClinicalTrials.gov, NCT00505375. FINDINGS 112 patients were assigned to treatment groups (77 abatacept, 35 placebo). Adjusted C-peptide AUC was 59% (95% CI 6·1-112) higher at 2 years with abatacept (n=73, 0·378 nmol/L) than with placebo (n=30, 0·238 nmol/L; p=0·0029). The difference between groups was present throughout the trial, with an estimated 9·6 months' delay (95% CI 3·47-15·6) in C-peptide reduction with abatacept. There were few infusion-related adverse events (36 reactions occurred in 17 [22%] patients on abatacept and 11 reactions in six [17%] on placebo). There was no increase in infections (32 [42%] patients on abatacept vs 15 [43%] on placebo) or neutropenia (seven [9%] vs five [14%]). INTERPRETATION Co-stimulation modulation with abatacept slowed reduction in β-cell function over 2 years. The beneficial effect suggests that T-cell activation still occurs around the time of clinical diagnosis of type 1 diabetes. Yet, despite continued administration of abatacept over 24 months, the decrease in β-cell function with abatacept was parallel to that with placebo after 6 months of treatment, causing us to speculate that T-cell activation lessens with time. Further observation will establish whether the beneficial effect continues after cessation of abatacept infusions. FUNDING US National Institutes of Health.
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Wherrett DK, Bundy B, Becker DJ, DiMeglio LA, Gitelman SE, Goland R, Gottlieb PA, Greenbaum CJ, Herold KC, Marks JB, Monzavi R, Moran A, Orban T, Palmer JP, Raskin P, Rodriguez H, Schatz D, Wilson DM, Krischer JP, Skyler JS. Antigen-based therapy with glutamic acid decarboxylase (GAD) vaccine in patients with recent-onset type 1 diabetes: a randomised double-blind trial. Lancet 2011; 378:319-27. [PMID: 21714999 PMCID: PMC3580128 DOI: 10.1016/s0140-6736(11)60895-7] [Citation(s) in RCA: 268] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Glutamic acid decarboxylase (GAD) is a major target of the autoimmune response that occurs in type 1 diabetes mellitus. In animal models of autoimmunity, treatment with a target antigen can modulate aggressive autoimmunity. We aimed to assess whether immunisation with GAD formulated with aluminum hydroxide (GAD-alum) would preserve insulin production in recent-onset type 1 diabetes. METHODS Patients aged 3-45 years who had been diagnosed with type 1 diabetes for less than 100 days were enrolled from 15 sites in the USA and Canada, and randomly assigned to receive one of three treatments: three injections of 20 μg GAD-alum, two injections of 20 μg GAD-alum and one of alum, or 3 injections of alum. Injections were given subcutaneously at baseline, 4 weeks later, and 8 weeks after the second injection. The randomisation sequence was computer generated at the TrialNet coordinating centre. Patients and study personnel were masked to treatment assignment. The primary outcome was the baseline-adjusted geometric mean area under the curve (AUC) of serum C-peptide during the first 2 h of a 4-h mixed meal tolerance test at 1 year. Secondary outcomes included changes in glycated haemoglobin A(1c) (HbA(1c)) and insulin dose, and safety. Analysis included all randomised patients with known measurements. This trial is registered with ClinicalTrials.gov, number NCT00529399. FINDINGS 145 patients were enrolled and treated with GAD-alum (n=48), GAD-alum plus alum (n=49), or alum (n=48). At 1 year, the 2-h AUC of C-peptide, adjusted for age, sex, and baseline C-peptide value, was 0·412 nmol/L (95% CI 0·349-0·478) in the GAD-alum group, 0·382 nmol/L (0·322-0·446) in the GAD-alum plus alum group, and 0·413 nmol/L (0·351-0·477) in the alum group. The ratio of the population mean of the adjusted geometric mean 2-h AUC of C-peptide was 0·998 (95% CI 0·779-1·22; p=0·98) for GAD-alum versus alum, and 0·926 (0·720-1·13; p=0·50) for GAD-alum plus alum versus alum. HbA(1c), insulin use, and the occurrence and severity of adverse events did not differ between groups. INTERPRETATION Antigen-based immunotherapy therapy with two or three doses of subcutaneous GAD-alum across 4-12 weeks does not alter the course of loss of insulin secretion during 1 year in patients with recently diagnosed type 1 diabetes. Although antigen-based therapy is a highly desirable treatment and is effective in animal models, translation to human autoimmune disease remains a challenge. FUNDING US National Institutes of Health.
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Affiliation(s)
- Diane K Wherrett
- Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
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Taylor AJ, Gary LC, Arora T, Becker DJ, Curtis JR, Kilgore ML, Morrisey MA, Saag KG, Matthews R, Yun H, Smith W, Delzell E. Clinical and demographic factors associated with fractures among older Americans. Osteoporos Int 2011; 22:1263-74. [PMID: 20559818 PMCID: PMC3767033 DOI: 10.1007/s00198-010-1300-8] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2009] [Accepted: 04/26/2010] [Indexed: 10/19/2022]
Abstract
UNLABELLED Medicare claims data were used to investigate associations between history of previous fractures, chronic conditions, and demographic characteristics and occurrence of fractures at six anatomic sites. The study confirmed previously established associations for hip and spine fractures and identified several new associations of interest for nonhip, nonspine fractures. INTRODUCTION This study investigates the associations of a history of fracture, comorbid chronic conditions, and demographic characteristics with incident fractures among Medicare beneficiaries. The majority of fracture incidence studies have focused on the hip and on white females. This study examines a greater variety of fracture sites and more population subgroups than prior studies. METHODS We used Medicare claims data to examine the incidence of fracture at six anatomic sites in a random 5% sample of Medicare beneficiaries during the time period 2000 through 2005. RESULTS For each type of incident fracture, women had a higher rate than men, and there was a positive association with age and an inverse association with income. Whites had a higher rate than nonwhites. Rates were lowest among African-Americans for all sites except ankle and tibia/fibula, which were lowest among Asian-Americans. Rates of hip and spine fracture were highest in the South, and fractures of other sites were highest in the Northeast. Fall-related conditions and depressive illnesses were associated with each type of incident fracture, conditions treated with glucocorticoids with hip and spine fractures and diabetes with ankle and humerus fractures. Histories of hip and spine fractures were associated positively with each site of incident fracture except ankle; histories of nonhip, nonspine fractures were associated with most types of incident fracture. CONCLUSIONS This study confirmed previously established associations for hip and spine fractures and identified several new associations of interest for nonhip, nonspine fractures.
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Affiliation(s)
- A J Taylor
- Department of Epidemiology, University of Alabama at Birmingham, 1530 3rd Avenue South, RPHB 517, Birmingham, AL 35294-0022, USA.
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Secrest AM, Becker DJ, Kelsey SF, Laporte RE, Orchard TJ. Characterizing sudden death and dead-in-bed syndrome in Type 1 diabetes: analysis from two childhood-onset Type 1 diabetes registries. Diabet Med 2011; 28:293-300. [PMID: 21309837 PMCID: PMC3045678 DOI: 10.1111/j.1464-5491.2010.03154.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
AIMS Type 1 diabetes mellitus increases the risk for sudden unexplained death, generating concern that diabetes processes and/or treatments underlie these deaths. Young (< 50 years) and otherwise healthy patients who are found dead in bed have been classified as experiencing 'dead-in-bed' syndrome. METHODS We thus identified all unwitnessed deaths in two related registries (the Children's Hospital of Pittsburgh and Allegheny County) yielding 1319 persons with childhood-onset (age < 18 years) Type 1 diabetes diagnosed between 1965 and 1979. Cause of death was determined by a Mortality Classification Committee (MCC) of at least two physician epidemiologists, based on the death certificate and additional records surrounding the death. RESULTS Of the 329 participants who had died, the Mortality Classification Committee has so far reviewed and assigned a final cause of death to 255 (78%). Nineteen (8%) of these were sudden unexplained deaths (13 male) and seven met dead-in-bed criteria. The Mortality Classification Committee adjudicated cause of death in the seven dead-in-bed persons as: diabetic coma (n =4), unknown (n=2) and cardiomyopathy (n=1, found on autopsy). The three dead-in-bed individuals who participated in a clinical study had higher HbA(1c) , lower BMI and higher daily insulin dose compared with both those dying from other causes and those surviving. CONCLUSIONS Sudden unexplained death in Type 1 diabetes seems to be increased 10-fold and associated with male sex, while dead-in-bed individuals have a high HbA(1c) and insulin dose and low BMI. Although sample size is too small for definitive conclusions, these results suggest specific sex and metabolic factors predispose to sudden unexplained death and dead-in-bed death.
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Affiliation(s)
- A M Secrest
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA, USA
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Secrest AM, Becker DJ, Kelsey SF, LaPorte RE, Orchard TJ. All-cause mortality trends in a large population-based cohort with long-standing childhood-onset type 1 diabetes: the Allegheny County type 1 diabetes registry. Diabetes Care 2010; 33:2573-9. [PMID: 21115767 PMCID: PMC2992193 DOI: 10.2337/dc10-1170] [Citation(s) in RCA: 122] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Although management of type 1 diabetes improved dramatically in the 1980s, the effect on mortality is not clear. RESEARCH DESIGN AND METHODS We report trends in 30-year mortality using the Allegheny County (Pennsylvania) childhood-onset (age <18 years) type 1 diabetes registry (n = 1,075) with diagnosis from 1965-1979, by dividing the cohort into three diagnosis year cohorts (1965-1969, 1970-1974, and 1975-1979). Local (Allegheny County) mortality data were used to calculate standardized mortality ratios (SMRs). RESULTS As of 1 January 2008, vital status was ascertained for 97.0% of participants (n = 1,043) when mean age ± SD and duration of diabetes were 42.8 ± 8.0 and 32.0 ± 7.6 years, respectively. The 279 deaths (26.0%) observed were 7 times higher than expected (SMR 6.9 [95% CI 6.1-7.7]). An improving trend in SMR was seen by diagnosis cohort at 30 years of diabetes duration (9.3 [7.2-11.3], 7.5 [5.8-9.2], and 5.6 [4.0-7.2] for 1965-1969, 1970-1974, and 1975-1979, respectively). Although no sex difference in survival was observed (P = 0.27), female diabetic patients were 13 times more likely to die than age-matched women in the general population (SMR 13.2 [10.7-15.7]), much higher than the SMR for men (5.0 [4.0-6.0]). Conversely, whereas 30-year survival was significantly lower in African Americans than in Caucasians (57.2 vs. 82.7%, respectively; P < 0.001), no differences in SMR were seen by race. CONCLUSIONS Although survival has clearly improved, those with diabetes diagnosed most recently (1975-1979) still had a mortality rate 5.6 times higher than that seen in the general population, revealing a continuing need for improvements in treatment and care, particularly for women and African Americans with type 1 diabetes.
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Affiliation(s)
- Aaron M Secrest
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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