The impact of daily mean air temperature on the proportion of time in hypoglycemia in 2,582 children and adolescents with type 1 diabetes - Is this association clinically relevant?

OBJECTIVES

To study the potential association between increases in daily mean air temperature and time below range (TBR <54 mg/dl) and time above range (TAR >250 mg/dl) in children and adolescents with type 1 diabetes.

RESEARCH DESIGN AND METHODS

Individuals with type 1 diabetes <21 years with information on daily glucose profiles from the diabetes prospective follow-up study (DPV) were included (n = 2582). Further inclusion criteria were age at least 6 months at diabetes onset, diabetes duration for at least one year and treatment years 2020-2021. Mean daily air temperature and other meteorological parameters from 78 measurement stations in Germany were linked to the individual glucose sensor profile via the five-digit postcode areas of residency. We used multivariable repeated measures fractional logistic regression models with a compound symmetry covariance structure to study the association between a 1 °C increase in daily mean temperature and time in specific glucose ranges.

RESULTS

A 1 °C increase in daily mean temperature was associated with an acute (Odds Ratio (OR) 1.009 (95%-CI 1.007, 1.011)) and up to 7 days delayed (OR 1.003 (1.001, 1.005)) increase in TBR <54 mg/dl. Moreover, an acute decrease in TAR >250 mg/dl (OR 0.997 (0.996, 0.997)) was found.

CONCLUSIONS

Results of the DPV registry showed small, but statistically significant changes in TBR and TAR in association with a short-term temperature increase. Higher blood flow and faster insulin absorption might be one possible mechanism. In times of increasing temperature fluctuations meteorological impacts on time in range could become even more relevant.

Incidence and presentation of new-onset type 1 diabetes in children and adolescents from Germany during the COVID-19 pandemic 2020 and 2021: Current data from the DPV Registry

AIMS

To determine whether the incidence of type 1 diabetes mellitus (T1D), autoantibody-negative diabetes, and diabetic ketoacidosis (DKA) at diabetes onset in 2020 and 2021 changed when compared to long-standing trends.

METHODS

Our study is based on diabetes manifestation data of the 0.5-<18-year-old children/adolescents from the German multicenter Diabetes Prospective Follow-up Registry. Based on long-term pre-pandemic trends from 2011 to 2019, we estimated adjusted incidence rate ratios (IRR) for T1D and DKA, and prevalence rate ratios (PRR) regarding autoantibody status with 95 % confidence intervals (CI) for the years 2020 and 2021 (observed versus predicted rates), using multivariable negative binomial or beta-binomial regression, respectively.

RESULTS

We analyzed data of 30,840 children and adolescents with new-onset T1D. The observed incidences were significantly higher than the predicted incidences (IRR₂₀₂₀ 1.13 [1.08-1.19]; IRR₂₀₂₁ 1.20 [1.15-1.26]). The prevalence of autoantibody-negative diabetes did not change (PRR₂₀₂₀ 0.91 [0.75-1.10]; PRR₂₀₂₁ 1.03 [0.86-1.24]). The incidence of DKA during the pandemic was higher than predicted (IRR₂₀₂₀ 1.34 [1.23-1.46]; IRR₂₀₂₁ 1.37 [1.26-1.49]).

CONCLUSIONS

An increase in the incidences of T1D and DKA, but not of autoantibody-negative diabetes was observed during both pandemic years. Further monitoring and efforts for DKA prevention at onset are necessary.

Prevalence trends of type 1 and type 2 diabetes in children and adolescents in North Rhine-Westphalia, the most populous federal state in Germany, 2002-2020

AIMS

To estimate the prevalence and temporal trends of type 1 and type 2 diabetes mellitus in children and adolescents (type 1 diabetes: 0-19 years, type 2 diabetes: 10-19 years) in North Rhine-Westphalia (NRW), Germany, from 2002 to 2020.

METHODS

The NRW Diabetes Registry records new cases based on three data sources (median completeness of ascertainment 99% for type 1 diabetes, 94% for type 2 diabetes). We determined age- and/or sex-standardized prevalence estimates (95% confidence intervals) per 100,000 individuals. Differences in age and sex, as well as time trends, were examined by Poisson regression. Furthermore, joinpoint regression was used to evaluate changes in prevalence trends over time.

RESULTS

At the end of 2020, the estimated type 1 diabetes prevalence was 247.1 (240.3; 253.9) with an annual increase of 2.9% (2.7%; 3.1%). The type 2 diabetes prevalence was 12.7 (10.6; 14.9) and increased by 6.4% (5.6%; 7.3%) per year. The prevalence trends were not uniform over the total period and flattened considerably in recent years.

CONCLUSIONS

The prevalence of type 1 and type 2 diabetes has increased significantly but at a lower rate in recent years. Continued surveillance of the prevalence is essential for the planning of health care resources and prevention measures.

COVID-19 Lockdown Periods in 2020: Good Maintenance of Metabolic Control in Adults with Type 1 and Type 2 Diabetes

During the COVID-19 pandemic, there were increased concerns about glycemic control in patients with diabetes. Therefore, we aimed to assess changes in diabetes management during the COVID-19 lockdown for patients with type 1 or type 2 diabetes mellitus (T1DM, T2DM) in Germany. We included data from 24,623 patients (age>18 years) with T1DM (N=6,975) or T2DM (N=17,648) with documented data in 2019 and 2020 from the multicenter Diabetes-Prospective Follow-up registry (DPV). We conducted a groupwise comparison of identical patients in 2019 and 2020 for different time periods of pandemia. Pairwise differences of continuous parameters of treatment modalities and metabolic outcome between 2019 and 2020 were adjusted for seasonality, age, and diabetes duration. We presented these outcomes as adjusted medians with 95% confidence intervals. Rates were compared using negative-binomial models, dichotomous outcomes were compared using logistic models. Models were additionally adjusted for age and diabetes duration. These outcomes were presented as least-square means with 95% confidence intervals, p-values of<.05 were considered significant.In participants with T1DM, CGI (combined glucose indicator) increased only by 0.11-0.12% in all time periods of 2020 compared to 2019 (all p<0.001) while BMI decreased slightly by -(0.09-0.10) kg/m² (p<0.0001). In participants with T2DM, HbA1c increased by 0.12%, while BMI decreased slightly by -(0.05-0.06) kg/m² (p<0.0001).During the COVID-19 lockdown period, patients with T1DM and T2DM experienced only clinically insignificant changes in glucose control or body weight. Despite lockdown restrictions, patients were able to maintain metabolic control.

Feasibility and potential efficacy of a guided internet- and mobile-based CBT for adolescents and young adults with chronic medical conditions and comorbid depression or anxiety symptoms (youthCOACHCD): a randomized controlled pilot trial

Background

Adolescents and young adults (AYA) with a chronic medical condition show an increased risk for developing mental comorbidities compared to their healthy peers. Internet- and mobile-based cognitive behavioral therapy (iCBT) might be a low-threshold treatment to support affected AYA. In this randomized controlled pilot trial, the feasibility and potential efficacy of youthCOACH_CD, an iCBT targeting symptoms of anxiety and depression in AYA with chronic medical conditions, was evaluated.

Methods

A total of 30 AYA (M_age 16.13; SD= 2.34; 73% female), aged 12-21 years either suffering from cystic fibrosis, juvenile idiopathic arthritis or type 1 diabetes, were randomly assigned to either a guided version of the iCBT youthCOACH_CD (IG, n=15) or to a waitlist control group (CG, n=15), receiving an unguided version of the iCBT six months post-randomization. Participants of the IG and the CG were assessed before (t0), twelve weeks after (t1) and six months after (t2) randomization. Primary outcome was the feasibility of the iCBT. Different parameters of feasibility e.g. acceptance, client satisfaction or potential side effects were evaluated. First indications of the possible efficacy with regard to the primary efficacy outcome, the Patient Health Questionnaire Anxiety and Depression Scale, and further outcome variables were evaluated using linear regression models, adjusting for baseline values.

Results

Regarding feasibility, intervention completion was 60%; intervention satisfaction (M = 25.42, SD = 5.85) and perceived therapeutic alliance (M = 2.83, SD = 1.25) were moderate and comparable to other iCBTs. No patterns emerged regarding subjective and objective negative side effects due to participation in youthCOACH_CD. Estimates of potential efficacy showed between group differences, with a potential medium-term benefit of youthCOACH_CD (β = -0.55, 95%CI: -1.17; 0.07), but probably not short-term (β = 0.20, 95%CI: -0.47; 0.88).

Conclusions

Our results point to the feasibility of youthCOACH_CD and the implementation of a future definitive randomized controlled trial addressing its effectiveness and cost-effectiveness. Due to the small sample size, conclusions are premature, however, further strategies to foster treatment adherence should be considered.

Trial registration

The trial was registered at the WHO International Clinical Trials Registry Platform via the German Clinical Trials Register (ID: DRKS00016714, 25/03/2019).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03134-3.

Associations of area deprivation and urban/rural traits with the incidence of type 1 diabetes: analysis at the municipality level in North Rhine-Westphalia, Germany

AIM

To analyse the associations of area deprivation and urban/rural traits with the incidence of type 1 diabetes in the German federal state of North Rhine-Westphalia.

METHODS

Data of incident type 1 diabetes cases in children and adolescents aged <20 years between 2007 and 2014 were extracted from a population-based diabetes register. Population data, indicators of area deprivation and urban/rural traits at the municipality level (396 entities) were obtained from official statistics. Area deprivation was assessed in five groups based on quintiles of an index of multiple deprivation and its seven deprivation domains. Poisson regression accounting for spatial dependence was applied to investigate associations of area deprivation and urban/rural traits with type 1 diabetes incidence.

RESULTS

Between 2007 and 2014, 6143 incident cases were reported (99% completeness); the crude incidence was 22.3 cases per 100 000 person-years. The incidence decreased with increasing employment and environmental deprivation (relative risk of the most vs. the least deprived municipalities: 0.905 [95% CI: 0.813, 1.007] and 0.839 [0.752, 0.937], respectively) but was not associated with the composite deprivation index. The incidence was higher in more peripheral, rural, smaller and less densely populated municipalities, and the strongest association was estimated for the location trait (relative risk of peripheral/very peripheral compared with very central location: 1.231 [1.044, 1.452]).

CONCLUSIONS

The results suggest that the type 1 diabetes risk is higher in more remote, more rural, less densely populated and less deprived areas. Urban/rural traits were stronger predictors of type 1 diabetes risk than area deprivation indicators.

Family and household structure are associated with acute type 1 diabetes complications: results of cross-sectional analyses

AIM

To examine the association of family/household structure with short-term diabetes complications in adolescents and emerging adults with early-onset type 1 diabetes in more detail.

METHODS

Data on 1690 11-21-year-olds with type 1 diabetes were used to estimate associations of family/household structure with self-reported severe hypoglycaemia, hospitalizations for severe hypoglycaemia or diabetic ketoacidosis, applying multiple negative binomial regression.

RESULTS

Compared with living with both biological parents living with a single mother was associated with an increased rate of hospitalizations for ketoacidosis (incidence rate ratio 1.71, 95% CI 1.00-2.82). Incidence rate ratio of hospitalizations for ketoacidosis was similar (1.67, 95% CI 0.91-3.07) if the mother lived with a partner, however, hypoglycaemia-related hospitalizations increased (3.66, 95% CI 1.54-8.71). Participants living with a single father had 4.43 (95% CI 1.30-15.05) /10.42 (95% CI 1.55-70.22) times higher rates of severe hypoglycaemia and related hospitalizations, while living with a father and his partner was associated with an increased incidence rate ratio of hospitalizations for ketoacidosis (3.48, 95% CI 0.96-12.63) compared with living with both biological parents.

CONCLUSIONS

Findings of our exploratory analyses point to different self-reported diabetes outcomes depending on the family/household structure. If confirmed in future studies, they may help to identify young people with diabetes at risk of short-term diabetes complications.

Multicentre analysis of hyperglycaemic hyperosmolar state and diabetic ketoacidosis in type 1 and type 2 diabetes

AIMS

To compare diabetes patients with hyperglycaemic hyperosmolar state (HHS), diabetic ketoacidosis (DKA), and patients without decompensation (ND).

METHODS

In total, 500,973 patients with type 1 or type 2 diabetes of all ages registered in the diabetes patient follow-up (DPV) were included. Analysis was stratified by age (≤ / > 20 years) and by manifestation/follow-up. Patients were categorized into three groups: HHS or DKA-during follow-up according to the most recent episode-or ND.

RESULTS

At onset of diabetes, HHS criteria were met by 345 (68.4% T1D) and DKA by 9824 (97.6% T1D) patients. DKA patients had a lower BMI(-SDS) in both diabetes types compared to ND. HbA1c was higher in HHS/DKA. During follow-up, HHS occurred in 1451 (42.2% T1D) and DKA in 8389 patients (76.7% T1D). In paediatric T1D, HHS/DKA was associated with younger age, depression, and dyslipidemia. Pump usage was less frequent in DKA patients. In adult T1D/T2D subjects, metabolic control was worse in patients with HHS/DKA. HHS and DKA were also associated with excessive alcohol intake, dementia, stroke, chronic kidney disease, and depression.

CONCLUSIONS

HHS/DKA occurred mostly in T1D and younger patients. However, both also occurred in T2D, which is of great importance in the treatment of diabetes. Better education programmes are necessary to prevent decompensation and comorbidities.

Heart failure among people with Type 2 diabetes mellitus: real-world data of 289 954 people from a diabetes database

AIM

Comparing people with Type 2 diabetes mellitus with and without heart failure in terms of metabolic control, therapeutic regimen and comorbidities.

METHODS

The Prospective Diabetes Registry (DPV) is a longitudinal documentation system for demographics, medical care and outcome in people with diabetes mellitus. It consists of follow-up data from people with diabetes mellitus who have agreed to be recorded in the registry. Clinical data are submitted by general practitioners, specialists and clinics throughout Germany and Austria. Some 289 954 people with Type 2 diabetes mellitus (years 2000 to 2015) were analysed using demographic statistics and adjustment for confounders based on linear and logistic regression analysis.

RESULTS

People with Type 2 diabetes mellitus (ICD code: E11) and heart failure (ICD code: I50) (N = 14 723) were older, more often women and presented with longer diabetes duration compared with those without heart failure. After adjustment for age, gender and diabetes duration, people with heart failure showed lower HbA_1c , higher BMI and more intense insulin therapy. Analysis revealed that people with heart failure were more often treated with insulin, and more frequently received anti-hypertensives and lipid-lowering medication. They presented with lower systolic and diastolic BP. People with heart failure more frequently showed a history of comorbidities.

CONCLUSION

Heart failure is common in diabetes mellitus, but the prevalence in the DPV is lower frequent than expected. The reason for improved metabolic control in heart failure may be intensified therapy with insulin, lipid-lowering medication and anti-hypertensives in this cohort.

Comparative characteristics of older people with type 1 diabetes treated with continuous subcutaneous insulin infusion or insulin injection therapy: data from the German/Austrian DPV registry

AIM

To compare clinical characteristics and outcomes in adults with type 1 diabetes aged ≥ 60 years using continuous subcutaneous insulin infusion (CSII) vs. insulin injection therapy. Further, to determine the percentage of older adults with type 1 diabetes using CSII.

RESEARCH DESIGN AND METHODS

Retrospective study using data of the Diabetes Prospective Follow-up Registry (DPV). Including percentage CSII use from 2008 to 2018, and the characteristics of 9547 individuals extracted from the DPV in March 2019 (N = 1404 CSII; N = 8143 insulin injection therapy). Wilcoxon rank sum tests were used for continuous variables and chi-square tests for categorical variables to compare clinical characteristics of people using CSII vs. insulin injection therapy. Adjusted analyses used generalized linear models to compare diabetes-related outcomes.

RESULTS

CSII usage has increased in older adults (from 12% in 2008 to 23% in 2018). After adjustment, CSII was associated with lower HbA_1c [60.7 mmol/mol (7.7 ± 0.1%) vs. 62.8% (7.9 ± 0.1%)], lower daily insulin dose (0.49 ± 0.02 vs. 0.61 ± 0.01 IU/kg), fewer days in hospital (8.1 ± 0.12 vs. 11.2 ± 0.11 days/person-year), fewer severe hypoglycaemic events (0.16 ± 0.02 vs. 0.21 ± 0.03 events/person-year) and fewer diabetic ketoacidosis (0.06 ± 0.01 vs. 0.08 ± 0.01 events/person-year). Individuals on CSII showed lower rates of microalbuminuria and also have a diagnosis of depression and neuropathy.

CONCLUSIONS

A growing number of older adults are using insulin pumps. Older age in itself should not be seen as a contraindication for CSII.

The Transatlantic HbA1c gap: differences in glycaemic control across the lifespan between people included in the US T1D Exchange Registry and those included in the German/Austrian DPV registry

AIM

To compare HbA_1c levels across the lifespan in people with type 1 diabetes in the USA with those in Germany/Austria, and to examine potential differences in HbA_1c levels between sexes, insulin delivery methods and minority status.

METHODS

Data were extracted from the US T1D Exchange Registry (n=18 381 participants from 73 sites) and from the German/Austrian Prospective Diabetes Follow-up Registry, the DPV (n=32 643 participants from 362 sites). Mean HbA_1c was calculated for each year of age for individuals aged ≤25 years, and at 2-year age intervals for individuals aged >25 years. Curves for mean HbA_1c by age were estimated using locally weighted scatterplot smoothing. HbA_1c differences between registries, sexes, insulin delivery methods, and minority status were assessed by age group using multiple linear regression.

RESULTS

In both registries, mean HbA_1c increased by ~11 mmol/mol (1.0%) between the ages of 9 and 18 years, although at quite different absolute levels: from 66 mmol/mol (8.2%) to 77 mmol/mol (9.2%) in the T1D Exchange Registry, and from 56 mmol/mol (7.3%) to 66 mmol/mol (8.2%) in the DPV. Sex differences were observed in the DPV only. In the T1D Exchange Registry, injection users had higher mean HbA_1c than pump users across the lifespan, whereas in the DPV higher HbA_1c levels in injection users were observed in the age groups 6 to <12 years, 12 to <18 years, and 30 to <50 years (P < 0.001). Minority status was significantly associated with higher HbA_1c in most age groups in both registries.

CONCLUSIONS

Significant differences in HbA_1c were noted between the USA and Germany/Austria, with disparities more pronounced in early childhood through to young adulthood. Further studies should identify causes for these disparities.

Prevalence of prediabetes and type 2 diabetes in children with obesity and increased transaminases in European German-speaking countries. Analysis of the APV initiative

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD), prediabetes and type 2 diabetes mellitus are known to be closely linked with obesity as early as during childhood.

OBJECTIVES

The study aimed to determine the prevalence of prediabetes and T2DM in children with obesity with or without increased transaminases.

METHODS

Data from the observational multicentre (n = 51), cross-sectional Adipositas Patienten Verlaufsbeobachtung registry were analyzed. Mild increase (mild group) was defined by alanine transaminase (ALT) >24 to ≤50 U/L and moderate to severe increase (advanced group) by ALT > 50 U/L. Prediabetes and T2DM were defined according to recent IDF/ISPAD guidelines.

RESULTS

The prevalence of prediabetes and T2DM was 11.9% (95% CI: 11.0-12.8) and 1.4% (95% CI: 1.1-1.7) among all participants (n = 4932; male = 2481; mean age 12.9 ± 2.7 years; BMI-SDS 2.1 ± 0.5; Tanner stage 3.2 ± 1.5). The prevalence of impaired glucose metabolism (prediabetes and T2DM) was 13.8% (95% CI: 12.1-15.4) in the mild, 21.9% (95% CI: 18.8-25.1) in the advanced group, 10.7% (95% CI: 9.4-11.9) in the control group. Mild and advanced groups had greater odds ratios for prediabetes [1.42; 95% CI: 1.17-1.72, 2.26-fold; (1.78-2.86), respectively], the advanced group also for T2DM [2.39 (1.36-4.21)] compared to controls. While an increase in transaminases predominantly affected boys, girls within the advanced group had a higher T2DM prevalence than males (5.4 vs. male 2.1%).

CONCLUSIONS

Children with obesity and increased liver transaminases as surrogates of NAFLD should be screened for T2DM.

Evaluation of lipoprotein-associated phospholipase A2 as a marker for renal microvasculopathy in adolescents with Type 1 diabetes

AIM

To assess the relevance of lipoprotein-associated phospholipase A2 activity as a diagnostic and prognostic marker for renal microvascular diseases.

METHODS

We analysed lipoprotein-associated phospholipase A2 activity and lysophosphatidylcholine levels (as a surrogate marker of oxidative stress) in 165 adolescents (aged 17.0 ± 2.3 years) with a history of Type 1 diabetes greater than 10 years. Clinical data were obtained from the German/Austrian nationwide Diabetes-Patients Follow-up (DPV) registry at blood collection and on average 2.4 ± 1.3 years later at follow-up. Relationships between lipoprotein-associated phospholipase A2 activity and clinical, demographic and laboratory variables, lysophosphatidylcholine levels and presence of albuminuria were evaluated by multivariable linear and logistic regression.

RESULTS

Lipoprotein-associated phospholipase A2 activity was higher in male than female adolescents (P = 0.002). Albuminuria was present in 14% (22/158) of participants at baseline, and 5% (4/86) of participants without albuminuria at baseline developed albuminuria until follow-up. Lipoprotein-associated phospholipase A2 activity was associated neither with present nor with incident albuminuria. Lysophosphatidylcholine did not correlate with lipoprotein-associated phospholipase A2 activity. Cross-sectional bivariate correlation as well as multivariable linear regression analysis revealed a negative correlation of lipoprotein-associated phospholipase A2 activity with HbA_1c and HDL-cholesterol.

CONCLUSIONS

Lipoprotein-associated phospholipase activity was not associated with surrogate markers for oxidative stress and early diabetic nephropathy. The association of decreased lipoprotein-associated phospholipase A2 activity with poor glucose control might limit its function as a predictor of micro- and macrovascular diseases in Type 1 diabetes.

Distinct trajectories of HbA1c in newly diagnosed Type 2 diabetes from the DPV registry using a longitudinal group-based modelling approach

AIM

To identify groups of heterogeneous HbA_1c trajectories over time in newly diagnosed Type 2 diabetes.

METHODS

The study comprised 6355 adults with newly diagnosed Type 2 diabetes (55% men, median age 62 years, baseline BMI 31 kg/m² ) from the Diabetes Patienten Verlaufsdokumentation (DPV) prospective multicentre diabetes registry (Germany, Austria). Individuals were assessed during the first 5 years after diabetes diagnosis if they had ≥ 3 aggregated HbA_1c measurements during follow-up. Latent class growth modelling was used to determine distinct subgroups that followed similar longitudinal HbA_1c patterns (SAS: Proc Traj). Multinomial logistic regression models were used to investigate which variables were associated with the respective HbA_1c trajectory groups.

RESULTS

Four distinct longitudinal HbA_1c trajectory (glycaemic control) groups were found. The largest group (56% of participants) maintained stable good glycaemic control (HbA_1c 42-45 mmol/mol). Twenty-six percent maintained stable moderate glycaemic control (HbA_1c 57-62 mmol/mol). A third group (12%) initially showed severe hyperglycaemia (HbA_1c 97 mmol/mol) but reached good glycaemic control within 1 year. The smallest group (6%) showed stable poor glycaemic control (HbA_1c 79-88 mmol/mol). Younger age at diabetes diagnosis, male sex, and higher BMI were associated with the stable moderate or poor glycaemic control groups. Insulin therapy was strongly associated with the highly improved glycaemic control group.

CONCLUSIONS

Four subgroups with distinct HbA_1c trajectories were determined in newly diagnosed Type 2 diabetes using a group-based modelling approach. Approximately one-third of people with newly diagnosed Type 2 diabetes need either better medication adherence or earlier intensification of glucose-lowering therapy.

Diabetes distress in young adults with early-onset Type 1 diabetes and its prospective relationship with HbA1c and health status

AIM

This study aimed to determine cross-sectional relationships between diabetes distress and health-related variables, and prospective associations between diabetes distress and future glycaemic control (HbA_1c ) and health status among young adults with early-onset Type 1 diabetes.

METHODS

Data were collected from a nationwide cohort study of adults whose Type 1 diabetes onset occurred from 0 to 4 years of age during 1993-2002. Questionnaire surveys were conducted in 2012-2013 and 2015-2016 (N = 584). Diabetes distress was assessed via the Problem Areas in Diabetes (PAID) scale (0-100 points), depressive symptoms via the Patient Health Questionnaire-9 (PHQ-9) and health status via the 12-Item Short Form Health Survey (SF-12) questionnaire. Multivariable linear regression analyses were applied to cross-sectional and longitudinal data.

RESULTS

In the cross-sectional analyses, higher PAID scale total scores (representing higher distress levels) were observed in women than in men and in participants with more severe depressive symptoms. PAID scores were lower in individuals with better physical and mental health. A 1 mmol/mol increase in HbA_1c was associated with a 0.28-point increase [95% confidence interval (95% CI) 0.20, 0.36] in diabetes distress. In longitudinal analyses adjusting for age, sex, socio-economic index and HbA_1c at baseline, a 10-point higher PAID score at baseline was associated with a 1.82 mmol/mol higher HbA_1c level (95% CI 0.43, 3.20) and a 2.48-point lower SF-12 mental health score (95% CI -3.55, -1.42) three years later.

CONCLUSIONS

The cross-sectional and longitudinal analyses results suggest that diabetes distress impairs health-related outcomes in young adults with early-onset diabetes.

Clinical inertia among patients with type 2 diabetes mellitus treated with DPP-4i and/or SGLT-2i

OBJECTIVES

Failure to intensify treatment of patients with type 2 diabetes (T2D) in a timely manner is a common challenge. If newer oral anti-diabetic drugs (NOADs) such as dipeptidyl peptidase-4 inhibitors (DPP-4i) and sodium/glucose cotransporter 2 inhibitors (SGLT-2i) do not achieve metabolic control, injectable therapy like insulin or glucagon-like Peptide 1 (GLP-1) receptor agonists are required. We investigated the time in poor glycaemic control (PC, HbA1c > 7%, >7.5%, >8%) in adults with T2D treated with DPP-4i/SGLT-2i until treatment intensification with insulin/GLP-1 or until the most recent documented visit.

METHODS

T2D ≥ 18 years were identified from the diabetes patient follow-up registry (DPV), which captures data from diabetes specialist care. Patients with ≥2 documented visits with DPP-4i/SGLT-2i treatment and with the most recent treatment year ≥2015 were included.

RESULTS

The study population consisted of 4576 patients treated with DPP-4i/SGLT-2i. A subgroup of 1416 patients were intensified with an injectable therapy. Mean time in PC until intensification with insulin/GLP-1 was 16.7 months (HbA1c > 7%), 15.7 and 15.1 months (HbA1c > 7.5%, HbA1c > 8%) in this subgroup, respectively. Mean time in PC until most recent visit was 12.6, 9.9 and 8.4 months in the subgroup of patients without treatment intensification.

CONCLUSIONS

Even with NOADs, a substantial proportion of T2D do not achieve good metabolic control. These findings may be due to individualized target setting for HbA1c, or reluctance of patients and physicians towards injectable therapy. Effective diabetes management strategies are necessary to reduce the risk of adverse outcomes and to increase quality of life in T2D.

Metabolic control of type 1 diabetes in youth with autism spectrum disorder: A multicenter Diabetes-Patienten-Verlaufsdokumentation analysis based on 61 749 patients up to 20 years of age

BACKGROUND

A paucity of reports in the literature exists concerning the co-existence between autism spectrum disorder (ASD) and type 1 diabetes (T1D).

OBJECTIVE

To compare clinical characteristics, diabetes management and metabolic control in youth with T1D and ASD (T1D-ASD) with youth without ASD (T1D-non ASD).

METHODS

Using the German/Austrian diabetes patient follow-up registry, this study analyzed aggregated data from the last available year of observation for each patient with T1D, ages 1-20 with consistent data on insulin regimen and glycated hemoglobin (A1C), between January, 2005 and March, 2017.

RESULTS

From 61 749 patients, 150 (0.24%) were identified as T1D-ASD. Non-adjusted comparisons showed similar results for mean age at onset and duration of diabetes, but not for gender (male: T1D-ASD: 85.3%; T1D-non ASD: 52.8%; P < .001). Unadjusted comparisons showed no difference for severe hypoglycemia, diabetic ketoacidosis, insulin doses, insulin pump therapy, and body mass index. A statistical difference was observed for A1C (P-value .01) and in the number of blood glucose (SMBG) tests/day (median [interquartile range]: T1D-ASD 6.0 [4.4-7.0]; T1D-non ASD 5.0 [4.4-7.0]; P-value < .001). After adjusting for age, gender, duration of diabetes, and year of observation, only SMBG remained significant (P-value .003). T1D-ASD used psycho-stimulants (15.3% vs 2.2%; P-value < .001), antipsychotics (10.7% vs 0.6%; P-value < .001), and antidepressive medications (3.6% vs 0.7%; P-value < .001) more frequently.

CONCLUSION

Metabolic control was similar in the T1D-ASD group compared to T1D-non ASD despite their comorbidity. Awareness of ASD remains important in T1D treatment, as both conditions require long-term multi-disciplinary medical follow-up for optimal outcomes.

No change in type 2 diabetes prevalence in children and adolescents over 10 years: Update of a population-based survey in South Germany

Objective of this study was to analyze prevalence changes in type 2 diabetes (T2D) among children and adolescents over the last 10 years. We performed a cross-sectional survey in Baden-Württemberg (BW), Germany, by using a written questionnaire and comparing these results with T2D prevalence data from the same area retrieved in 2004/2005. In 2016, 50 patients with T2D under 20 years of age were registered in BW, Germany, which corresponds to a prevalence rate of 2.42 per 100 000 (95% confidence interval [CI]: 1.75-3.09). The prevalence rate found in the same geographic area 10 years prior was 2.30 per 100 000 (95% CI: 1.70-2.90). Overall, 70% of T2D patients of this age group were treated by adult diabetologists. Concisely the prevalence of T2D in children and adolescents is still low in South Germany, remaining practically unchanged over the past decade.

Risk of recurrent severe hypoglycemia remains associated with a past history of severe hypoglycemia up to 4 years: Results from a large prospective contemporary pediatric cohort of the DPV initiative

OBJECTIVES

In a contemporary cohort of youth with type 1 diabetes, we examined the interval between episodes of severe hypoglycemia (SH) as a risk factor for recurrent SH or hypoglycemic coma (HC).

METHODS

This was a large longitudinal observational study. Using the DPV Diabetes Prospective follow-up data, we analyzed frequency and timing of recurrent SH (defined as requiring assistance from another person) and HC (loss of consciousness or seizures) in 14 177 youths with type 1 diabetes aged <20 years and at least 5 years of follow-up.

RESULTS

Among 14 177 patients with type 1 diabetes, 72% (90%) had no, 14% (6.8%) had 1 and 14% (3.2%) >1 SH (HC). SH or HC in the last year of observation was highest with SH in the previous year (odds ratio [OR] 4.7 [CI 4.0-5.5]/4.6 [CI 3.6-6.0]), but remained elevated even 4 years after an episode (OR 2.0 [CI 1.6-2.7]/2.2 [CI 1.5-3.1]). The proportion of patients who experienced SH or HC during the last year of observation was highest with SH/HC recorded during the previous year (23% for SH and 13% for HC) and lowest in those with no event (4.6% for SH and 2% for HC) in the initial 4 years of observation.

CONCLUSIONS

Even 4 years after an episode of SH/HC, risk for SH/HC remains higher compared to children who never experienced SH/HC. Clinicians should continue to regularly track hypoglycemia history at every visit, adjust diabetes education and therapy in order to avoid recurrences.

Transition to adult diabetes care in Germany-High risk for acute complications and declining metabolic control during the transition phase

OBJECTIVE

There is evidence that transition from pediatric to adult health care is frequently associated with deterioration of health in youths with type 1 diabetes (T1D). The aim of this study was to compare metabolic control, acute complications and microvascular complications in adolescents and young adults before and after transfer to an adult treatment center with respect to the time between first visit in the adult center and last visit in pediatric treatment.

METHODS

All data were collected during routine care and retrieved from the German/Austrian DPV database. We analyzed data as of March 2017.

RESULTS

We found 1283 young adults with available data of the last pediatric treatment year and the first year after transition to adult care. HbA1c increased significantly from 8.95% (74 mmol/mol) before to 9.20% (77 mmol/mol) in the first year after transition. Frequency of DKA with hospitalization (0.10-0.191 per annum, P < .0001) and severe hypoglycemia (0.23-0.46 per annum, P = .013) doubled during transition. Microvascular complications increased dramatically depending on the time between first visit in adult treatment and last visit in pediatric care. We could not find a significant correlation of this rise of microvascular complications to the duration of transition (short or long).

CONCLUSION

This phase of life bears a high risk for detrimental outcome in young adults with T1D. Structured transition programs with case management are therefore needed to improve the transition process and outcomes.

Blood pressure regulation determined by ambulatory blood pressure profiles in children and adolescents with type 1 diabetes mellitus: Impact on diabetic complications

BACKGROUND

The combination of high blood pressure and hyperglycemia contributes to the development of diabetic complications. Ambulatory monitoring of blood pressure (ABPM) is seen as standard to assess blood pressure (BP) regulation.

OBJECTIVE

We evaluated 24-hour BP regulation in 3529 children with type 1 diabetes, representing 5.6% of the patients <20 years of age documented in the DPV registry, and studied the influence of BP parameters including pulse pressure (PP) and blood pressure variability (BPV) on microalbuminuria (MA) and diabetic retinopathy (DR).

RESULTS

BP was increased in this selected cohort of children with diabetes compared to healthy German controls (standard deviation score (SDS) day: systolic BP (SBP) +0.06, mean arterial pressure (MAP) +0.08, PP +0.3; night: SBP +0.6, diastolic BP +0.6, MAP +0.8), while daytime diastolic BP (SDS -0.2) and dipping of SBP and MAP were reduced (SBP -1.1 SDS, MAP 12.4% vs 19.4%), PP showed reverse dipping (-0.7 SDS). Children with microvascular complications had by +0.1 to +0.75 SDS higher BP parameters, except of nocturnal PP in MA and diurnal and nocturnal PP in DR. Reverse dipping of PP was more pronounced in the children with MA (-5.1% vs -0.8%) and DR (-2.6% vs -1.0%). BP alteration was stronger in girls and increased with age.

CONCLUSION

There is an early and close link between 24-hour blood pressure regulation and the development of diabetic complications not only for systolic, diastolic, and mean arterial BP but also for the derived BP parameter PP and BPV in our selected patients.

Both the frequency of HbA1c testing and the frequency of self-monitoring of blood glucose predict metabolic control: A multicentre analysis of 15 199 adult type 1 diabetes patients from Germany and Austria

BACKGROUND

The objective of this study was to examine the association between metabolic control and frequency of haemoglobin A_1c (HbA_1c ) measurements and of self-monitoring of blood glucose, as well as the interaction of both.

METHODS

Data of 15 199 adult type 1 diabetes patients registered in a standardized electronic health record (DPV) were included. To model the association between metabolic control and frequency of HbA_1c testing or of self-monitoring of blood glucose, multiple hierarchic regression models with adjustment for confounders were fitted. Tukey-Kramer test was used to adjust P values for multiple comparisons. Vuong test was used to compare non-nested models.

RESULTS

The baseline variables of the study population were median age 19.9 [Q1; Q3: 18.4; 32.2] years and diabetes duration 10.4 [6.8; 15.7] years. Haemoglobin A_1c was 60.4 [51.5; 72.5] mmol/mol. Frequency of HbA_1c testing was 8.0 [5.0; 9.0] within 2 years, and daily self-monitoring of blood glucose frequency was 5.0 [4.0; 6.0]. After adjustment, a U-shaped association between metabolic control and frequency of HbA_1c testing was observed with lowest HbA_1c levels in the 3-monthly HbA_1c testing group. There was an inverse relationship between self-monitoring of blood glucose and HbA_1c with lower HbA_1c associated with highest frequency of testing (>6 daily measurements). Quarterly HbA_1c testing and frequent self-monitoring of blood glucose were associated with best metabolic control. The adjusted Vuong Z statistic suggests that metabolic control might be better explained by HbA_1c testing compared to self-monitoring of blood glucose (P < .0001).

CONCLUSION

This research reveals the importance of quarterly clinical HbA_1c monitoring together with frequent self-monitoring of blood glucose in diabetes management to reach and maintain target HbA_1c .

Risk factors for necrobiosis lipoidica in Type 1 diabetes mellitus

AIMS

To compare the clinical and metabolic characteristics of patients with Type 1 diabetes and necrobiosis lipoidica with those of patients with Type 1 diabetes who do not have necrobiosis lipoidica. A multicentre analysis was performed.

METHODS

Clinical and laboratory data were obtained from 64 133 patients (aged 0-25 years) with Type 1 diabetes with and without necrobiosis lipoidica who were registered in the German/Austrian Diabetes Prospective Documentation Initiative registry. Data were analysed using multivariable regression modelling. Age, diabetes duration, treatment year and sex were considered as confounding factors.

RESULTS

Results adjusted for demographic variables are presented. In patients with necrobiosis lipoidica, metabolic control was worse (HbA_1c 72 vs. 67 mmol/mol, 8.7% vs. 8.3%; P = 0.0065) and the duration of diabetes was longer [6.24 (3.28-9.97) vs. 5.11 (2.08-8.83) years; P = 0.014; not adjusted]. Patients with necrobiosis lipoidica required higher insulin doses than those without (1.02 vs. 0.92 U/kg/day; P < 0.0001). There was no significant difference in the frequency of microvascular complications (microalbuminuria and retinopathy) between the groups. Furthermore, 24.8% and 17.5% of patients with Type 1 diabetes with and without necrobiosis lipoidica, respectively, had elevated thyroid antibodies (P = 0.051). Necrobiosis lipoidica was correlated with coeliac disease in patients with Type 1 diabetes (3.4% vs. 1.0%; P = 0.0035).

CONCLUSIONS

Our data indicate a strong correlation between hyperglycaemia and the development of necrobiosis lipoidica. We postulate that the underlying pathogenic processes differ from those leading to microalbuminuria and retinopathy, and additional immunological mechanisms may play a role.

Interaction of Pubertal Development and Metabolic Control in Adolescents with Type 1 Diabetes Mellitus

BACKGROUND

In T1DM, delayed pubertal development and reduced final height are associated with inadequate metabolic control.

OBJECTIVE

To assess whether T1DM affects pubertal growth spurt and whether metabolic control during puberty is gender-related.

METHODS

Using a large multicentre database, longitudinal data from 1294 patients were analysed. Inclusion criteria: complete records of height and HbA1c from the age of seven to 16 years. Exclusion criteria: other significant chronic diseases and medications, T1DM duration less than three months, and initial BMI < 3rd or >97th percentile.

RESULTS

Growth velocity (GV) was impaired with a significant reduction of peak GV by 1.2 cm in boys. HbA1c increase during male puberty was lower except for a period of 1.5 years. The highest HbA1c increase in boys coincided with maximum growth spurt. In girls, the highest HbA1c increase was observed during late puberty. Even though there is impaired GV, both sexes reach a height at 16 years of age which corresponds to the background population height.

CONCLUSION

Worsening of metabolic control is sex-discordant and associated with gender-specific alterations of GV. However, the vast majority of boys and girls with T1DM seems to reach normal height at the age of 16 years.

Diabetes in Patients with ß-thalassemia or other Hemoglobinopathies - Analysis from the DPV Database

Background: Diabetes mellitus is a common endocrinopathy in patients with thalassemia major, but the occurrence of hemoglobinopathies is rare in Germany and Western Europe. The longitudinal German-Austrian DPV (Diabetes Patienten Verlaufsdokumentation) registry allows a comprehensive characterization of this group of patients. Patients/methods: Patients from the DPV-registry aged<30 years with thalassemia major or other hemoglobinopathies were compared to patients with type 1 diabetes (T1D) and type 2 diabetes (T2D) using the statistical software SAS 9.4. Results: 94 patients (0.13% of patients) with hemoglobinopathies are registered in DPV. 82.4% of 17 patients with thalassemia major, 100% of 12 patients with sickle cell disease (SCD) and >90% of 65 patients with other hemoglobinopathies receive insulin treatment. In the majority of patients with thalassemia major, hemosiderosis is documented. Patients with thalassemia major developed diabetes at a median age of 14.6 [IQR 8.4-18.0] years (9.0 years [5.3-12.5] in T1D; 18.7 years [14.2-25.6] in TD2; both p<0.01). They show high HbA1c/fructosamine levels and frequent hypoglycemia, reflecting poor metabolic control. Conclusion: Diabetes in thalassemia major is probably caused by hemosiderosis due to polytransfusion, while patients with SCD/thalassemia minor are most likely affected by T1D. The high rate of hypoglycemia in patients with ß-thalassemia major may be caused by liver fibrosis and a lack of hepatic glycogen stores.

Current practice of diabetes education in children and adolescents with type 1 diabetes in Germany and Austria: analysis based on the German/Austrian DPV database

BACKGROUND

Diabetes education of patients and/or parents is an essential part of diabetes care with effects on diabetes outcome. The objective of our study was to describe the current practice of diabetes education in Germany and Austria with regard to training frequency, patient age, migration background and diabetes therapy in a large cohort of pediatric patients with diabetes mellitus type 1 (T1DM).

METHODS

We analyzed data from pediatric T1DM patients with diabetes training in 2013 and complete data available for treatment year in the multicenter Diabetes Patienten Verlaufsdokumentation (DPV) registry using sas 9.4.

RESULTS

In 2013 21 871 pediatric patients with T1DM were documented [52.4% male, age: 12.70 (9.35-15.30) yr (median (interquartile range)], diabetes duration: 3.80 (1.45-7.00) yr, migration background: 21.4%, twice daily injections: 5.5%, multiple daily injections: 52.5%, insulin-pump therapy: 42%. Of these 32.31% were trained in 2013. Younger patients and their parents were trained more intensely and more frequently as inpatients compared with older patients (0-6 vs. 6-12 and 12-18 yr: teaching units: 13.07 vs. 12.05 and 9.79; inpatient: 79% vs. 72% and 70%). There was also a difference in training frequency with regard to migration background. Severe hypoglycemia or ketoacidosis resulted in intensification of training (4.0 vs. 2.0%; 7.8 vs. 3.1%). Centre-specific education tools were used frequently alone or in combination with published, standardized education programs.

CONCLUSION

Training frequency was highest in younger patients and during the first year of diabetes. Acute complications resulted in more frequent diabetes training, indicating that currently many education sessions take place in consequence to these complications.

Seasonality at the clinical onset of type 1 diabetes-Lessons from the SWEET database

BACKGROUND

Seasonality at the clinical onset of type 1 diabetes (T1D) has been suggested by different studies, however, the results are conflicting. This study aimed to evaluate the presence of seasonality at clinical onset of T1D based on the SWEET database comprising data from 32 different countries.

METHODS

The study cohort included 23 603 patients (52% males) recorded in the international multicenter SWEET database (48 centers), with T1D onset ≤20 years, year of onset between 1980 and 2015, gender, year and month of birth and T1D-diagnosis documented. Data were stratified according to four age groups (<5, 5-<10, 10-<15, 15-20 years) at T1D onset, the latitude of European center (Northern ≥50°N and Southern Europe <50°N) and the year of onset ≤ or >2009.

RESULTS

Analysis by month revealed significant seasonality with January being the month with the highest and June with the lowest percentage of incident cases (P < .001). Winter, early spring and late autumn months had higher percentage of incident cases compared with late spring and summer months. Stratification by age showed similar seasonality patterns in all four age groups (P ≤ .003 each), but not in children <24 months of age. There was no gender or latitude effect on seasonality pattern, however, the pattern differed by the year of onset (P < .001). Seasonality of diagnosis conformed to a sinusoidal model for all cases, females and males, age groups, northern and southern European countries.

CONCLUSIONS

Seasonality at T1D clinical onset is documented by the large SWEET database with no gender or latitude (Europe only) effect except from the year of manifestation.

Prevalence and comorbidities of double diabetes

BACKGROUND

A growing number of people with type 1 diabetes (T1DM) are identified with features of metabolic syndrome (MS) known as "double diabetes", but epidemiologic data on the prevalence of MS in T1DM and its comorbidities are still lacking. Aim of this cross sectional study is to better estimate the prevalence of MS in T1DM, and to assess its association with comorbidities.

METHODS

Data of 31,119 persons with autoimmune diabetes mellitus were analysed for signs of MS and presence of late complications. Double diabetes was defined as T1DM coexisting with MS (obesity, hypertension, dyslipidemia). Multiple linear or logistic regression analyses were performed to identify associations between double diabetes and late complications.

RESULTS

25.5% (n=7926) of persons with T1DM presented additionally the MS. Persons with double diabetes showed significantly more macrovascular comorbidities (coronary heart disease 8.0% versus 3.0% w/o MS, stroke 3.6% versus 1.6%, diabetic foot syndrome 5.5% versus 2.1%). Also microvascular diseases were increased in people with double diabetes (retinopathy 32.4% versus 21.7%, nephropathy 28.3% versus 17.8%). Both macrovascular and microvascular comorbidities were increased independent of glucose control, even if patients with good metabolic control (HbA1c <7.0%, 53mmol/mol) showed significantly less macrovascular (coronary heart disease 2.3% versus 1.8%, p<0.0001) and microvascular problems (retinopathy 8.7% versus 6.6%, p<0.0001).

CONCLUSIONS

Double diabetes seems to be an independent and important risk factor for persons with T1DM in developing macrovascular and microvascular comorbidities. Therefore, patients should be identified and development of MS should be avoided. Longterm studies are needed to observe the effect of insulin resistance on patients with autoimmune diabetes.