Age at diagnosis predicts deterioration in glycaemic control among children and adolescents with type 1 diabetes

Abstract

BackgroundPoor glycemic control early in the course of type 1 diabetes mellitus (T1DM) increases the risk for microvascular complications. However, predictors of deteriorating control after diagnosis have not been described, making it difficult to identify high-risk patients and proactively provide aggressive interventions.ObjectiveWe examined whether diagnostic age, gender, and race were associated with deteriorating glycemic control during the first 5 years after diagnosis.Participants2218 pediatric patients with T1DM.MethodsWe conducted a longitudinal cohort study of pediatric patients with T1DM from the Midwest USA, 1993–2009, evaluating within-patient glycated hemoglobin (HbA1c) trajectories constructed from all available HbA1c values within 5 years of diagnosis.Results52.6% of patients were male; 86.1% were non-Hispanic Caucasian. The mean diagnostic age was 9.0±4.1 years. The mean number of HbA1c values/year/participant was 2.4±0.9. HbA1c trajectories differed markedly across age groups, with older patients experiencing greater deterioration than their younger counterparts (p<0.001). HbA1c trajectories, stratified by age, varied markedly by race (p for race×diagnostic age <0.001). Non-Hispanic African-American patients experienced higher initial HbA1c (8.7% vs 7.6% (71.6 vs 59.6 mmol/mol); p<0.001), and greater deterioration in HbA1c than non-Hispanic Caucasian patients across diagnostic ages (rise of 2.04% vs 0.99% per year (22.3 vs 10.8 mmol/mol/year); p<0.0001).ConclusionsOlder diagnostic age and black race are major risk factors for deterioration in glycemic control early in the course of T1DM. These findings can inform efforts to explore the reasons behind these differences and develop preventive interventions for high-risk patients.

High HbA1c at onset cannot be used as a predictor for future metabolic control for the individual child with type 1 diabetes mellitus

“…The patients with high HbA1c at diagnosis continued to have poor metabolic control as a group. This is in line with a study by Clements et al, where older age at diagnosis was a predictor for deterioration in glycemic control during the first five years after diagnosis, and they also presented with higher HbA1c values . This could be due to hormone‐ induced insulin resistance during puberty .…”

Clinically meaningful and lasting HbA1c improvement rarely occurs after 5 years of type 1 diabetes: an argument for early, targeted and aggressive intervention following diagnosis

“…Crucially, previous reports [3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18] have largely examined individuals with pre-existing type 1 diabetes (i.e. not from the time of diagnosis).…”

ISPAD Clinical Practice Consensus Guidelines 2018: Diabetes in adolescence

“…The DCCT has unequivocally shown that intensive insulin therapy reduces risk of long‐term vascular complications, largely through improved HbA1c levels, and that better metabolic control in the early years of diabetes is also important in reducing this risk . Metabolic control commonly deteriorates during adolescence in many, but not all, patients with T1D . This may be due to physiological and to psychosocial influences, leading to insulin resistance, poor treatment adherence, eating disorders, and depression .…”

“…This may be due to physiological and to psychosocial influences, leading to insulin resistance, poor treatment adherence, eating disorders, and depression . Certain demographic and socioeconomic factors are also associated with higher HbA1c . Metabolic control during adolescence appears to have a greater association of microvascular complication in later life when compared with subsequent metabolic control in adult years …”