Psychological care in children and adolescents with type 1 diabetes in a real‐world setting and associations with metabolic control

Background: International guidelines recommend psychosocial care for children and adolescents with type 1 diabetes. Objective: To assess psychological care in children and adolescents with type 1 diabetes in a real-world setting and to evaluate associations with metabolic outcome. Methods: Delivery of psychological care, HbA1c, and rates of severe hypoglycemia and diabetic ketoacidosis (DKA) in children and adolescents with type 1 diabetes from 199 diabetes care centers participating in the German diabetes survey (DPV) were analyzed. Results: Overall, 12 326 out of 31 861 children with type 1 diabetes were supported by short-term or continued psychological care (CPC). Children with psychological care had higher HbA1c (8.0% vs 7.7%, P<.001) and higher rates of DKA (0.032 vs 0.021 per patient-year, P<.001) compared with children without psychological care. In age-, sex-, diabetes duration-, and migratory background-matched children, HbA1c stayed stable in children supported by CPC during follow-up (HbA1c 8.5% one year before psychological care started vs 8.4% after two years, P = 1.0), whereas HbA1c was lower but increased significantly by 0.3% in children without psychological care (HbA1c 7.5% vs 7.8% after two years, P <.001). Additional HbA1c-matching showed that the change in HbA1c during follow-up was not different between the groups, but the percentage of children with severe hypoglycemia decreased from 16.3% to 10.7% in children receiving CPC compared with children without psychological care (5.5% to 5.8%, P =.009). Conclusions: In this real-world setting, psychological care was provided to children with higher HbA1c levels. CPC was associated with stable glycemic control and less frequent severe hypoglycemia during follow-up

Worse glycemic control, higher rates of diabetic ketoacidosis, and more hospitalizations in children, adolescents, and young adults with type 1 diabetes and anxiety disorders

The aim of the study was to explore the metabolic characteristics and outcome parameters in youth with type 1 diabetes and anxiety disorders. HbA1c levels, rates of severe hypoglycemia, diabetic ketoacidosis (DKA), and hospital admission in children, adolescents, and young adults with type 1 diabetes and an anxiety disorder from 431 diabetes-care-centers participating in the nationwide German/Austrian/Swiss/Luxembourgian diabetes survey DPV were analyzed and compared with youth without anxiety disorders. Children, adolescents, and young adults with type 1 diabetes and anxiety disorders (n = 1325) had significantly higher HbA1c (8.5% vs. 8.2%), higher rates of DKA (4.2 vs. 2.5 per 100 patient-years), and higher hospital admission rates (63.6 vs. 40.0 per 100 patient-years) than youth without anxiety disorders (all p < 0.001). Rates of severe hypoglycemia did not differ. Individuals with anxiety disorders other than needle phobia (n = 771) had higher rates of DKA compared to those without anxiety disorders (4.2 vs. 2.5 per 100 patient-years, p = 0.003) whereas the rate of DKA in individuals with needle phobia (n = 555) was not significantly different compared to those without anxiety disorders. Children, adolescents, and young adults with anxiety disorders other than needle phobia had higher hospitalization rates (73.7 vs. 51.4 per 100 patient-years) and more inpatient days (13.2 vs. 10.1 days) compared to those with needle phobia (all p < 0.001). Children, adolescents, and young adults with type 1 diabetes and anxiety disorders had worse glycemic control, higher rates of DKA, and more hospitalizations compared to those without anxiety disorders. Because of the considerable consequences, clinicians should screen for comorbid anxiety disorders in youth with type 1 diabetes

Diabetes and gender incongruence: frequent mental health issues but comparable metabolic control – a DPV registry study

ContextThe condition when a person’s gender identity does not match the sex assigned at birth is called gender incongruence (GI). Numbers of GI people seeking medical care increased tremendously over the last decade. Diabetes mellitus is a severe and lifelong disease. GI combined with diabetes may potentiate into a burdensome package for affected people.ObjectiveThe study aimed to characterize people with GI and diabetes from an extensive standardized registry, the Prospective Diabetes Follow-up Registry (DPV), and to identify potential metabolic and psychological burdens.MethodsWe compared demographic and clinical registry data of persons with type 1 or type 2 diabetes and GI to those without GI and used propensity score matching (1:4) with age, diabetes duration and treatment year as covariates.Results75 persons with GI, 49 with type 1 and 26 with type 2 diabetes were identified. HbA1c values were similar in matched persons with type 1 or 2 diabetes and GI compared to those without GI. Lipid profiles showed no difference, neither in type 1 nor in type 2 diabetes. Diastolic blood pressure was higher in the type 1 and GI group than in those without, whereas systolic blood pressure showed comparable results in all groups. Depression and anxiety were significantly higher in GI people (type 1 and 2). Non-suicidal self-injurious behaviour was more common in type 1 and GI, as was suicidality in type 2 with GI.ConclusionMental health issues are frequent in people with diabetes and GI and need to be specially addressed in this population

Chronic complications and impact of psychosocial risk factors on glycaemic control in children, adolescents and young adults with type 1 diabetes

In den letzten Jahren hat die Forschung in der Diabetologie versucht, die Pathomechanismen, die zu mikro- und makrovaskulären diabetischen Komplikationen bei Diabetes mellitus Typ 1 führen, zu beschreiben und zu identifizieren (Forbes und Cooper, 2013). Die durch Hyperglykämie entstandenen irreversiblen Advanced Glycation End Products (AGEs) spielen vermutlich eine wichtige Rolle bei der Vermittlung hyperglykämiebedingter, chronischer Komplikationen (Stitt et al., 2004; Ahmed, 2005; Giacco und Brownlee, 2012; Holt und Hanley, 2012; Forbes und Cooper, 2013; Russell und Cooper, 2015). Die hier vorliegende Arbeit untersuchte die Advanced Glycation End Products (AGEs) bei Kindern, Jugendlichen und jungen Erwachsenen mit Diabetes mellitus Typ 1 und die Zusammenhänge zu klinischen und laborchemischen Parametern und der glykämischen Stoffwechsellage: Bei Kindern und Jugendlichen mit Diabetes mellitus Typ 1 mit kurzer Diabetesdauer und ohne diabetische Komplikationen wurden im Vergleich zu gesunden Kindern und Jugendlichen erhöhte Serumkonzentrationen der mittels Fluoreszenz-Spektroskopie gemessenen AGEs nachgewiesen. Die beobachteten Korrelationen zwischen den AGE-Konzentrationen im Serum und den Cholesterol- und Triglyzeridkonzentrationen bei Kindern und Jugendlichen mit Diabetes mellitus Typ 1 können ein Hinweis darauf sein, dass veränderte Lipidspiegel die Entstehung von AGEs bei Diabetes mellitus Typ 1 begünstigen. Weiterhin wurde das von Adipozyten sezernierte Hormon Adiponektin, welches als protektiv hinsichtlich der Entwicklung artherosklerotischer Veränderungen beschrieben wird, in der vorliegenden Arbeit untersucht (Kubota et al., 2002; Blüher und Mantzoros, 2015; Fasshauer und Blüher, 2015). Niedrige Adiponektinspiegel sind in vielen frühen Studien mit einem deutlich erhöhten Risiko, an kardiovaskulären Erkrankungen zu erkranken, assoziiert (Matsuda et al., 2002; Pischon et al., 2004; Matsuzawa et al., 2004; Fasshauer und Blüher, 2015). Wie bei Erwachsenen so zeigten sich auch bei Kindern und Jugendlichen mit Diabetes mellitus Typ 1 im Vergleich zu gesunden Kindern und Jugendlichen paradoxerweise jedoch erhöhte Adiponektinspiegel (Costacou et al., 2005; Frystyk et al., 2005; Hadjadi et al., 2005; Maahs et al., 2005; Saraheimo et al., 2005; Forsblom et al., 2011). Eine befriedigende Erklärung, warum die Adiponektinspiegel bei Menschen mit Diabetes mellitus Typ 1 höher liegen, gibt es bisher nicht. Schließlich wurde in der vorliegenden Arbeit der Verlauf einer unbehandelten Mikroalbuminurie bei Kindern und Jugendlichen mit Diabetes mellitus Typ 1 untersucht. Die Mikroalbuminurie ist nicht nur mit einem signifikant höherem Risiko, eine Nephropathie zu entwickeln, assoziiert, sondern die Mikroalbuminurie geht auch mit einer deutlich erhöhten Mortalität bei Menschen mit Diabetes mellitus Typ 1 einher (Chiarelli et al., 2002, Hovind et al., 2004; Bogdanovic et al., 2008; Groop et al., 2009; Vergouwe et al., 2010; Orchard et al., 2010; Donaghue et al., 2014; Bundesärztekammer (BÄK) et al., 2015). Sowohl bei Erwachsenen als auch besonders bei Jugendlichen ist sehr häufig eine Regression der persistierenden Mikroalbuminurie im Verlauf zu beobachten (Chiarelli et al., 2002; Perkins et al., 2003; Steinke et al., 2005; Stone et al., 2006). Eine längere Diabetesdauer und ein Migrationshintergrund konnten als signifikante Risikofaktoren für die Entwicklung und Progression einer unbehandelten Mikroalbuminurie identifiziert werden. Wichtiges Ziel der Forschung ist ferner, Faktoren für eine gute und schlechte glykämische Stoffwechsellage zu identifizieren, da die Stoffwechsellage ein bedeutender Prädiktor diabetischer mikro- und makrovaskulärer Komplikationen ist (The Diabetes Control and Complications Trial Research Group, 1993; Brownlee, 2001; Nathan, 2005; White et al., 2008; Madonna und Caterina, 2011; Donaghue et al., 2014; Lind et al., 2014; S3-Leitlinie der DDG und AGPD 2015). Psychosoziale Faktoren und psychische und psychiatrische Komorbiditäten haben hier eine herausragende Bedeutung (Rosilio et al., 1998; Craig et al., 2002; DeVries et al., 2004; Hassan et al., 2006; Hanberger et al., 2008; Skinner und Cameron, 2010; Johnson et al., 2012; S3-Leitlinie der DDG und AGPD 2015). In den vorliegenden Arbeiten wurden Zusammenhänge zwischen sozioökonomischem Status, modernen Lebensgewohnheiten wie Medienkonsum und der glykämischen Stoffwechsellage, und der Einfluss antipsychotischer Begleitmedikation (Neuroleptika) auf die Häufigkeit akuter Komplikationen und die Stoffwechsellage untersucht: Neben einer längeren Diabetesdauer waren ein niedriger sozioökonomischer Status und ein hoher Medienkonsum signifikante Faktoren für eine schlechte Stoffwechsellage bei Kindern, Jugendlichen und jungen Erwachsene mit Diabetes mellitus Typ 1. Erstmalig konnte außerdem gezeigt werden, dass bei Kindern, Jugendlichen und jungen Erwachsenen mit Diabetes mellitus Typ 1, die mit Neuroleptika behandelt wurden, die glykämische Stoffwechsellage schlechter und die Rate an akuten Komplikationen höher im Vergleich zu denjenigen ohne Medikation war. Ärzte und Diabetologen, die Kinder, Jugendliche und junge Erwachsene mit Diabetes mellitus Typ 1 mit diesen Risikofaktoren behandeln, sollten ihre Betreuung entsprechend gestalten, um die Stoffwechsellage zu verbessern und um akute und chronische Komplikationen präventiv vermeiden zu können.Over the last years, research in type 1 diabetes focused on identifying the pathomechanisms of micro- and macrovascular diabetic complications (Forbes and Cooper, 2013). Advanced Glycation End Products (AGEs) play an important role in the pathogenesis of chronic complications caused by hyperglycaemia (Stitt et al., 2004; Ahmed, 2005; Giacco and Brownlee, 2012; Holt and Hanley, 2012; Forbes and Cooper, 2013; Russell and Cooper, 2015). The present work studied Advanced Glycation End Products (AGEs) in children, adolescents and young adults with type 1 diabetes and its associations to clinical and laboratory parameters, and glycaemic control: Children and adolescents with type 1 diabetes with short diabetes duration and without diabetic complications had elevated serum concentrations of fluorescent AGEs compared to healthy children and adolescents. The correlations between concentrations of AGEs and cholesterol and triglycerid levels may indicate that altered lipid levels contribute to the formation of AGEs. Moreover, the author examined adiponectin levels in youth with type 1 diabetes. Adiponectin is a hormone secreted by adipocytes and with protective effects as to the development of atherosclerosis (Kubota et al., 2002; Blüher and Mantzoros, 2015; Fasshauer and Blüher, 2015). Many early studies showed, that low adiponectin concentrations are associated with an increased risk of cardiovascular disease (Matsuda et al., 2002; Pischon et al., 2004; Matsuzawa et al., 2004; Fasshauer and Blüher, 2015). Unexpectedly, adults as well as children and adolescents with type 1 diabetes had elevated adiponectin levels. (Costacou et al., 2005; Frystyk et al., 2005; Hadjadi et al., 2005; Maahs et al., 2005; Saraheimo et al., 2005; Forsblom et al., 2011). The reason why adiponectin levels are elevated in type 1 diabetes remains unclear. Lastly, the author of the present work investigated the natural course of untreated microalbuminuria in children and adolescents with type 1 diabetes. Microalbuminuria is not only associated with an increased risk of developing nephropathy but mortality is also increased in subjects with type 1 diabetes with microalbuminuria (Chiarelli et al., 2002, Hovind et al., 2004; Bogdanovic et al., 2008; Groop et al., 2009; Vergouwe et al., 2010; Orchard et al., 2010; Donaghue et al., 2014; Bundesärztekammer (BÄK) et al., 2015). Persistent microalbuminuria in both adults and adolescents frequently shows regression (Chiarelli et al., 2002; Perkins et al., 2003; Steinke et al., 2005; Stone et al., 2006). In the present work diabetes duration and migration background were significant risk factors for the development and progression of microalbuminuria. Identification of factors associated with glycaemic control is important because glycaemic control is a pivotal predictor of micro- and macrovascular complications in type 1 diabetes. (The Diabetes Control and Complications Trial Research Group, 1993; Brownlee, 2001; Nathan, 2005; White et al., 2008; Madonna and Caterina, 2011; Donaghue et al., 2014; Lind et al., 2014; S3-Leitlinie der DDG and AGPD 2015). Psychosocial factors and the presence of psychiatric comorbidities play a crucial role (Rosilio et al., 1998; Craig et al., 2002; DeVries et al., 2004; Hassan et al., 2006; Hanberger et al., 2008; Skinner and Cameron, 2010; Johnson et al., 2012; S3-Leitlinie der DDG and AGPD 2015). In the present work the author studied associations between socioeconomic status, modern life habits like media consumption habits, and glycaemic control, and the impact of antipsychotic medication (neuroleptics) on the frequency of acute complications and glycaemic control: Long diabetes duration, low socioeconomic status, and extensive media consumption were significant risk factors for poor glycaemic control in children, adolescents and young adults with type 1 diabetes. Lastly, children, adolescents and young adults with neuroleptic medication had worse glycaemic control and the frequency of acute complications was higher compared to those without neuroleptic medication. Physicians and diabetologists caring for children, adolescents and young adults with type 1 diabetes need to know about these risk factors in order to improve glycaemic control and to prevent acute and chronic complications

Coeliac disease is associated with depression in children and young adults with type 1 diabetes: results from a multicentre diabetes registry

Aims!#!To analyse the association between coeliac disease (CD) and depression in children, adolescents, and young adults with type 1 diabetes (T1D).!##!Methods!#!We included 79,067 T1D patients aged 6-20 years, with at least six months of diabetes duration, and treatment data between 1995 and 2019 were documented in the diabetes patient follow-up registry. We categorized patients into four groups: T1D only (n = 73,699), T1 + CD (n = 3379), T1D + depression (n = 1877), or T1D + CD + depression (n = 112).!##!Results!#!CD and depression were significantly associated (adjusted OR: 1.25 [1.03-1.53]). Females were more frequent in both the depression and the CD group compared with the T1D only group. Insulin pumps were used more frequently in T1D + CD and T1D + depression compared with T1D only (both p &amp;lt; .001). HbA1c was higher in T1D + depression (9.0% [8.9-9.0]), T1D + CD + depression (8.9% [8.6-9.2]), both compared with T1D only (8.2% [8.2-8.2], all p &amp;lt; .001). We found comorbid autism, attention deficit hyperactivity disorder, anxiety, schizophrenia, and eating disorders more frequently in the T1D + CD + depression group compared with T1D only (all p &amp;lt; .001).!##!Conclusions!#!CD and depression are associated in young T1D patients. The double load of T1D and CD may lead to an increased risk for depression. Depression was associated with additional psychological and neurological comorbidities. Aside from imperative CD screening after T1D diagnosis and regular intervals, depression screening might be helpful in routine care, especially in patients with diagnosed CD

Estimated Glomerular Filtration Rates Calculated by New and Old Equations in Children and Adolescents With Type 1 Diabetes-What to Do With the Results?

Background: To apply and evaluate various equations for estimated glomerular filtration rates (eGFR) in a large paediatric type 1 diabetes population and compare the eGFR values with urinary creatinine clearances (UCC) in a subset of patients. Methods: Six eGFR formulae applicable for children and adolescents were used for calculation of eGFR values in 36,782 children/adolescents with type 1 diabetes. Via regression models, factors influencing eGFR values were identified. eGFR values were compared with measured UCC in 549 patients. Spearman correlation coefficients were given to assess the relation of eGFR and UCC values. Bland-Altman-Plots with corresponding linear regression were drawn to evaluate the agreement between eGFR and UCC. Results: eGFR values differed widely depending on the formula used, resulting in a percentage of pathological values <60 mL/min/1.73 m2 up to 8%. Regression models showed age, sex, and duration of diabetes as influencing factors. Microalbuminuria was associated with significantly higher eGFR values for all formulae. In comparison of eGFR with UCC, the highest correlation coefficient was 0.33, the lowest 0.01. Bland-Altman-Plots demonstrated graphically a poor agreement between eGFR and UCC, regardless of the formula used. Conclusions: The broad range of eGFR values indicate that an ideal eGFR formula for children and adolescence with T1D is yet missing. The minimal agreement between measured UCC and eGFR values urges us to be careful in application and interpretation of eGFR values regardless of the formula used