Severity at onset of childhood type 1 diabetes in countries with high and low incidence of the condition

doi:10.1016/S0168-8227(01)00328-X

Diabetes Research and Clinical Practice

Volume 55, Issue 3, March 2002, Pages 247-254

https://doi.org/10.1016/S0168-8227(01)00328-X Get rights and content

Abstract

Severity of Type 1 diabetes mellitus (DM) at presentation was compared between south-east Sweden and Lithuania where incidence of childhood Type 1 diabetes is three times lower than in Sweden. New cases of diabetes at age 0–15 years from August 1995 to March 1999 in south-east Sweden and from August 1996 to August 2000 in Lithuania were included. Symptoms and clinical characteristics at diagnosis were recorded. Data about the close environment were collected using questionnaires. Lithuanian children were diagnosed in a more severe condition, mean pH 7.30 and HbA_1c 11.5% compared with mean pH 7.36 and HbA_1c 9.7% in Swedish children (P<0.0001). More Lithuanian than Swedish children were diagnosed in ketoacidosis (pH≤7.2, hyperglycaemia and ketonuria), 21.3 versus 7.3% (P<0.0001). Only 4.6% of Swedish children and 1.0% of Lithuanian children had no symptoms (P=0.007). Children in families with at least one first degree relative with diabetes (12.2% in Sweden and 8.4% in Lithuania, NS) had laboratory values at diagnosis closer to normal than sporadic cases in either country. Factors predicting ketoacidosis in Sweden were an unemployed mother and absence of infections in the 6 months before diagnosis. In Lithuania it was younger age and mother with less education. Additional educational activities for doctors are needed in countries with low incidence to reduce prevalence of ketoacidosis at onset.

Introduction

Type 1 diabetes mellitus is a heterogeneous disease. There are subtypes that differ from the classical Type 1 diabetes seen in Caucasians [1], [2]. Classical Type 1 diabetes shows differences in expression and course of disease related to age [3], genetic background [4], [5], season at onset [6] and characteristics at diagnosis [7], [8].

Different combinations of genetic and environmental factors determine different incidence of diabetes in different countries [9], [10], [11], [12], [13]. They may also cause different degrees of islet β-cell damage leading to diverse clinical manifestations in countries with high and low incidence of Type 1 diabetes. Differences in clinical manifestation might also appear because of less awareness about the disease in countries with low incidence, and that might contribute to a delayed diagnosis.

There are published descriptions of clinical characteristics at onset in different populations. However they are often difficult to compare as descriptions are based on different definitions and methods of measurement [14], [15], [16], [17], [18], [19]. Therefore it is of interest to compare clinical manifestation in countries with a high and low incidence of Type 1 diabetes and where type and time of data collection are similar.

Sweden and Lithuania are geographically close, sharing a similar climate. Nevertheless incidence of Type 1 childhood diabetes differs dramatically between these countries [20], [21], [22], [23]. In 1997 in south-east Sweden childhood incidence was 31.9/100 000 children according to the National Swedish incidence registry and in Lithuania it was 10.2/100 000 children [24]. The aim of our study was to compare clinical manifestation of childhood Type 1 diabetes in Sweden and Lithuania, as examples of countries with a high and low incidence of Type 1 diabetes.

Section snippets

Patients

This work is a part of a case-control study, ‘Diabetes and Environment around the Baltic Sea’ (DEBS), which is carried out in south-east Sweden (including Östergötland, Småland, Öland, Blekinge) in parts of the Skåne counties, the neighbouring areas to Lithuania, and in the whole of Lithuania. Most (83.4%) of the children newly diagnosed with Type 1 diabetes in south-east Sweden, and 49.5% of newly diagnosed children in Skåne region since 1 August 1995, and all newly diagnosed children since 1

Results

Swedish children were younger at the moment of diagnosis than were the Lithuanian children, mean age being 8.5 and 9.3 years (P=0.007). There were similar proportions of children in Sweden diagnosed in age groups 5–9 and 10–15 years, while the highest proportion of Lithuanian children was diagnosed around puberty. Distribution of newly diagnosed children by age and in both countries is given in Fig. 1.

Significantly more children in Sweden than in Lithuania reported that they had an infection

Discussion

The present study shows that there are differences in clinical presentation of Type 1 diabetes between Sweden and Lithuania. The peak of incidence among Lithuanian children was found around puberty, while a similar picture in Sweden or other Western European countries was found about 20 years ago [28], [29], [30], [31], [32], [33], [34]. The age distribution of Swedish children diagnosed with Type 1 diabetes in this study suggests that the incidence of Type 1 diabetes has moved towards a

Acknowledgments

This work was supported by Barndiabetesfonden (the Swedish Child Diabetes Foundation), Novo Nordisk, Nordic Council and Swedish Institute. We would like to thank all the doctors and nurses working in the project and children and their parents for participation in the project. Grant support by the Swedish Children Diabetes Foundation, Novo Nordisk, Nordic Council, Swedish Institute.

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Diabetic Ketoacidosis in Type 1 Diabetes Onset in Latin American Children
2024, Journal of Pediatric Health Care
To describe the patterns of diabetic ketoacidosis (DKA) occurrence in children newly diagnosed with type 1 diabetes (T1DM) across several Latin American pediatric diabetes centers from 2018 to 2022.
A retrospective chart review included children under 18 with new-onset T1DM from 30 Latin American pediatric diabetes centers (Argentina, Chile, and Peru) between 30 December 2018 and 30 December 2022. Multiple logistic regression models examined the relationships between age, gender, medical insurance, BMI, and DKA at new-onset T1DM. As far as we know, there are no large studies in Latin American countries exploring the patterns of DKA in new-onset T1DM.
A total of 2,026 (983 females) children, median age 9.12 (5.8 -11.7) years with new-onset-T1DM were included. Approximately 50% had no medical insurance. Mean glucose values were 467 mg/dL, pH 7.21, bicarbonate 13 mEq/L, HbA1c 11.3%, and BMI 18. The frequency of DKA was 1,229 (60.7%), out of which only 447 (36%) were severe. There was a significant decrease in the frequency of DKA as age increased: 373 (70.2%) in children under 6, 639 (61.6%) in those between 6 and 12, 217 and (47.5%) in those over 12. Children with medical insurance (58.8%) had a significantly lower frequency of DKA than those without (62.7%). The multiple logistic regression models showed that DKA was significantly and inversely associated with age [OR, 0.72 (95% CI 0.60–0.86)], BMI [OR, 0.95 (95% CI 0.92–0.99)], and medical insurance [OR, 0.75 (95% CI 0.60–0.94)] adjusted for sex.
Latin American children with new-onset T1DM exhibited a substantial occurrence of DKA. Younger ages and the lack of medical insurance were significantly associated with DKA in new-onset T1DM.
Preventing ketoacidosis at the time of diagnosis of type 1 diabetes in children and adolescents
2015, Medecine des Maladies Metaboliques
Le diabète de type 1 est de plus en plus fréquent avant l’âge de 15 ans, et plus encore avant l’âge de 5 ans. La fréquence de l’acidocétose au moment du diagnostic chez l’enfant et l’adolescent est très élevée en France, avec une importante morbidité et plusieurs décès chaque année. Le retard au diagnostic peut être évité par l’information des professionnels et du grand public, sur les signes révélateurs du diabète et sur l’urgence du diagnostic, en particulier chez les plus jeunes enfants. Le rôle des médecins généralistes est crucial pour cette prévention.
Type 1 diabetes is occurring more and more frequently before 15 years of age, particularly before age 5 years. The prevalence of ketoacidosis at the time of diagnosis in children and adolescents is very high in France, with an important morbidity and several deaths everyyear. The delay before diagnosis can be reduced with the information of professionals and the general population, about revealing symptoms of diabetes and urgency to make diagnosis, particularly in young children. General practitioners have a crucial role in this prevention.
Ketoacidosis at time of diagnosis of type 1 diabetes in children and adolescents: Effect of a national prevention campaign
2015, Archives de Pediatrie
L’objectif de cette étude était d’évaluer, au cours de la première année suivant une campagne nationale d’information, l’effet sur la fréquence et la sévérité de l’acidocétose au moment du diagnostic de diabète de type 1 (DT1) chez l’enfant et l’adolescent. Les données suivantes ont été colligées pendant deux années consécutives chez les jeunes de moins de 15 ans ayant un DT1 débutant dans 146 services de pédiatrie : âge, sexe, durée des symptômes, parcours du patient, signes cliniques et biologiques, antécédents familiaux de DT1. L’acidocétose était définie par un pH < 7,30 ou une réserve alcaline (RA) < 15 mmol/L ; l’acidocétose sévère par un pH < 7,10 ou une RA < 5 mmol/L. Pendant la deuxième année, une campagne ayant pour but d’informer les professionnels de santé et les familles a débuté pour éviter les retards au diagnostic. Les données de la première année de campagne (année 1) ont été comparées à celles de l’année avant la campagne (année 0). Le nombre de nouveaux cas de DT1 a été de 1299 pour l’année 0 et 1247 pour l’année 1. Entre l’année 0 et l’année 1, la fréquence de l’acidocétose a diminué, de 43,9 % à 40,5 % (p = 0,08), exclusivement du fait d’une diminution des acidocétoses sévères, de 14,8 à 11,4 % (p = 0,01). Dans les groupes d’âge 0–5 ans et 5–10 ans, la baisse relative de la fréquence de l’acidocétose a été respectivement de 13 % et 15 %, et celle des formes sévères de 23 % et 41 %. Chez les enfants adressés à l’hôpital par un pédiatre ou venus à l’initiative de la famille, elle a été respectivement de 34 et 7 %, et celle des formes sévères de 39 et 32 %. Aucun changement n’a été observé pour les jeunes de 10–15 ans et pour ceux qui ont été adressés par un médecin généraliste. En analyse multivariée, une fréquence plus élevée de l’acidocétose était associée avec le jeune âge de l’enfant (< 5 ans), le fait d’être venu à l’hôpital à l’initiative de la famille plutôt qu’adressé par un médecin, et l’absence d’antécédent familial de DT1. Une fréquence plus élevée d’acidocétose sévère était associée à ces deux derniers facteurs mais pas à l’âge de l’enfant. La fréquence de l’acidocétose sévère au moment du diagnostic de DT1 chez l’enfant et l’adolescent reste élevée, mais la campagne nationale d’information a permis de la diminuer dès la première année. Les résultats ont aussi permis de préciser la stratégie et les cibles de la campagne qui se poursuit, afin de réduire de manière de plus en plus efficace la morbi-mortalité au moment du diagnostic du DT1 chez l’enfant en France.
The aim of the study was to evaluate, after the first year of a national information campaign, the effect on the frequency and severity of diabetic ketoacidosis (DKA) at diagnosis of type 1 diabetes (T1D) in children and adolescents in France. The following data were collected during a 2-year period in people younger than 15 years of age at diagnosis of T1D, in 146 pediatric centers: age, sex, duration of symptoms, patient's previous care, clinical and biological signs, and family history of T1D. DKA was defined as pH < 7.30 or bicarbonate < 15 mmol/L, severe DKA as pH < 7.10 or bicarbonate < 5 mmol/L. During the 2nd year, an information campaign targeting health professionals and families was launched with the objective of reducing the time to diagnosis. Data were compared between the year before the campaign (year 0) and the first year of the campaign (year 1). The number of new cases of T1D was 1299 for year 0 and 1247 for year 1. Between year 0 and year 1, the rate of DKA decreased from 43.9% to 40.5% (P = 0.08), exclusively due to the decrease of severe DKA from 14.8 to 11.4% (P = 0.01). In the 0- to 5-year-old and 5- to 10-year-old age groups, the relative decrease in the rate of DKA was 13% and 15%, and 23% and 41% for severe DKA, respectively. In patients referred to the hospital by a pediatrician or who came at the family's initiative, the decrease was 34% and 7%, and 39% and 32% for severe DKA, respectively. No change was observed in the 10- to 15-year-old group or in those children who were referred by a general practitioner. In multivariate analyses, a higher DKA rate was associated with the young age of the child (< 5 years), being hospitalized at the parents’ initiative rather than being referred by a doctor, and the absence of a family history of T1D. A higher rate of severe DKA was associated with these last two factors but not with the child's age. The frequency of DKA at diagnosis of type 1 diabetes remains high in children and adolescents, but the first year of an information campaign decreased it. The results have also helped better define the strategy and targets of the continuing prevention campaign, to more efficiently reduce the morbidity and mortality of T1D at diagnosis in children and adolescents in France.
Ketoacidosis at diagnosis of type 1 diabetes in French children and adolescents
2014, Diabetes and Metabolism
Citation Excerpt :
The clinical condition can deteriorate rapidly, and diabetic ketoacidosis (DKA) is a common complication at the time of diagnosis [6–8]. The prevalence of DKA varies widely in different countries (15–67%) [9–22]; it has also been reported that DKA at diagnosis is less frequent when there is greater awareness, and when the disease is more common and better known [19]. In France, a study from about 20 years ago showed that the prevalence of DKA at diagnosis was > 40% [21].
This study aimed to evaluate the frequency of diabetic ketoacidosis (DKA) and its associated factors at the diagnosis of type 1 diabetes (T1D) in French children and adolescents prior to launching a public-health campaign of information to prevent DKA.
Over a 1-year period, 1299 youngsters (aged < 15 years) were diagnosed with T1D at 146 paediatric centres in all regions of France. Age, gender, duration of symptoms, patient's pathway to diagnosis, clinical and biological signs, and family history of T1D were collected for each newly diagnosed patient. DKA was defined as pH < 7.30 or bicarbonate < 15 mmol/L, and severe DKA as pH < 7.10 or bicarbonate < 5 mmol/L.
At the time of diagnosis, 26% of the children were aged 0–5 years, 34% were 5–10 years and 40% were 10–15 years. The overall prevalence of DKA was 43.9% (0–5 years: 54.2%; 5–10 years: 43.4%; and 10–15 years: 37.1%) and 14.8% for severe DKA (0–5 years: 16.6%; 5–10 years: 14.4%; and 10–15 years: 13.9%; < 2 years: 25.3%). Severe DKA was more frequent when the child was hospitalized at the family's behest (26.6%) than when referred by a general practitioner (7.6%) or paediatrician (5.1%; 30.6%, 53.7% and 9.2%, respectively, by patients’ age group). The frequency of DKA decreased to 20.1% (severe DKA: 4.4%) in families with a history of T1D. Multivariate analysis showed that age, pathway to diagnosis, duration of polyuria/polydipsia (< 1 week) and family history of T1D were associated with the presence of DKA, while pathway to diagnosis and family history of T1D were associated with severe DKA.
DKA at the time of T1D diagnosis in children and adolescents is frequent and often severe. Patients’ age, pathway to hospitalization and family history of diabetes were the main factors associated with DKA. These data suggest that a public-health campaign to prevent DKA at diagnosis can help reduce the frequency of DKA and also provide baseline data for evaluating the efficacy of such a campaign.
Diabetic ketoacidosis at diagnosis in Austrian children: A population-based analysis, 1989-2011
2013, Journal of Pediatrics
To analyze the effect of a community-based, poster-focused prevention program on the frequency of diabetic ketoacidosis (DKA) at diabetes onset in Austria.
All newly diagnosed patients with diabetes ≤15 years of age were registered prospectively by the Austrian Diabetes Incidence Study Group. Registered data included initial blood glucose, pH, and ketonuria. DKA was defined as pH < 7.3 and severe DKA as pH < 7.1. Data between 1989 and 2011 were available. In autumn, 2009, a community-based prevention program similar to the Parma Campaign, in which posters were dispensed broadly, was initiated. The frequency of DKA at the onset of diabetes in the years 2005-2009 and 2010-2011 was compared.
During the study period, 4038 children were registered. A total of 37.2% presented with DKA; 26% had a mild and 11.2% a severe form. The frequency of DKA was negatively associated with age at onset. In the years before the intervention program, 26% had mild DKA compared with 27% after the intervention (not significant). The prevalence of severe DKA in the years before the campaign was 12% compared with 9.5% thereafter (not significant). No significant change in the DKA rate at onset by the prevention program could be found when we compared age groups <5, 5 to <10, and 10 to <15 years, neither for mild nor for severe DKA.
The frequency of DKA in children with newly diagnosed type 1 diabetes in Austria is high and did not change despite the efforts of a community-based information program.
Postmortem diagnosis of unsuspected diabetes mellitus
2013, Forensic Science International
Vitreous glucose, blood beta-hydroxybutyrate and glycated hemoglobin were systematically measured in a series of 500 medico-legal autopsies in order to characterize the glycemic control during the weeks preceding death and identify ketoacidosis as the cause of death in diagnosed and unsuspected diabetics. Unenhanced CT-scans, histology and toxicology were performed in all cases. 16 cases of diabetic ketoacidosis were identified based on the results of all investigations. Among those, 13 cases concerned individuals with pre-existing diagnoses of diabetes mellitus whereas 3 cases concerned individuals with undiagnosed diabetes. A recent cocaine use was observed in 2 cases. C-reactive protein, interleukin-6 and interleukin-10 were measured and proved to be increased in all cases of diabetic ketoacidosis, whereas markers of generalized, bacterial infection and sepsis were normal in most of these cases. The results of this study highlight the usefulness of systematically performing biochemistry to identify ketoacidosis in unsuspected diabetics. It also emphasizes the role of toxicology and biochemistry to support the diagnosis of diabetic ketoacidosis and delineate the pathophysiological mechanisms that may disrupt the metabolic balance and finally lead to death in diabetic individuals.

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¹: Swedish participants: Larsson K (Kristianstad), Stenhammar L (Norrköping), Johansson C (Jönköping), Hammarsjö JÅ (Västervik), Edwardsson S (Växjö), Kockum K (Ystad), Neiderud J (Helsingborg), Ivarsson S (Malmö), Lundström G (Kalmar), Ståhle U (Ängelholm). Lithuanian participants: Meškauskien≐ M (Kaunas), Uleckien≐ V (Vilnius), Gylien≐ D (Klaip≐da).

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Severity at onset of childhood type 1 diabetes in countries with high and low incidence of the condition

Abstract

Introduction

Section snippets

Patients

Results

Discussion

Acknowledgments

Diabetes Res. Clin. Pract.

Diabetes Res. Clin. Pract.

Immunogenetic and clinical characterisation of slowly progressive IDDM

Diabetes Care

A novel subtype of type 1 diabetes mellitus characterised by a rapid onset and an absence of diabetes-related antibodies

New Engl. J. Med.

A comparison of childhood and adult type 1 diabetes mellitus

New Engl. J. Med.

HLA-DR3 is associated with more slowly progressive from of Type 1 (insulin-dependent) diabetes

Diabetologia

Autoimmune and clinical characteristics of Type 1 diabetes in children with different genetic risk loads defined by HLA-DQBI alleles

Clin. Sci.

Seasonality of Type 1 (insulin-dependent) diabetes mellitus: values of C-peptide, insulin antibodies and haemoglobin A1c show evidence of a more rapid loss of insulin secretion in epidemic patients

Diabetologia

C-peptide in juvenile diabetics beyond the postinitial remission period. Relation to clinical manifestations at onset of diabetes, remission and diabetic control

Acta Paediatr. Scand.

Natural course of remission in IDDM during first year after diagnosis

Diabetes Care

Trends in the prevalence and incidence of diabetes: insulin-dependent diabetes mellitus in childhood

World Health Stat. Q

Sex differences in the incidence of insulin-dependent diabetes mellitus: an analysis of the recent epidemiological data

Diabetes Metab. Rev.

Worldwide increase in incidence of Type 1 diabetes-the analysis of the data on published incidence trends

Diabetologia

Distribution of insulin-dependent (IDDM)-related HLA alleles correlates with the difference in IDDM in four populations of the Eastern Baltic region

Tissue Antigens

Childhood diabetes in Saudi Arabia

Diabetes Med.

Incidence and severity of ketoacidosis in childhood-onset diabetes in Kuwait

Diabetes Res. Clin. Pract.

Clinical pattern of childhood Type 1 (insulin-dependent) diabetes mellitus in Sudan

Diabetologia

Lister, Mode of presentation of juvenile diabetes

Br. Med. J.

Clinical and laboratory features of Type 1 diabetic children at the time of diagnosis

Diabetes Med.