TEENs: Most Youth with Type 1 Diabetes Miss Glycemic Goals

Miriam E. Tucker

June 24, 2014

SAN FRANCISCO — Worldwide, nearly three-quarters of young people with type 1 diabetes are not meeting recommended glucose control targets, a large cross-sectional study finds.

Results of the TEENs Registry Study were presented here at the American Diabetes Association (ADA) 2014 Scientific Sessions by Lori M.B. Laffel, MD, chief of the pediatric, adolescent, and young adult section of the Joslin Diabetes Center and associate professor of pediatrics at Harvard Medical School, Boston, Massachusetts.

The TEENs study, funded by Sanofi, is one of the largest ever to assess type 1 diabetes management and the factors that affect it, including psychosocial parameters. The data come from 5960 individuals aged 8 to 25 years seen at 219 diabetes centers in 20 countries in the developed and the developing world, including Europe, the United States, Latin America, the Middle East, North and South Africa, and India.

"Despite modern advances in insulin replacement, the majority of young patients still fail to achieve recommended glycemic targets. In addition, many continue to experience acute complications including both severe hypoglycemia and [diabetic ketoacidosis (DKA)]. Thus, there is a need to identify approaches to improve glycemic control and to optimize health outcomes for youth with type 1 diabetes," Dr. Laffel said from the podium.

Moreover, because the study subjects were recruited from clinics or hospitals caring for at least 100 patients per year with type 1 diabetes and therefore having at least some expertise, the actual proportion of young type 1 patients not achieving recommended targets — HbA1c less than 7.5% for those aged 18 years and younger and less than 7% for ages 19 to 25 years — is likely to be even higher, session comoderator Joseph I. Wolfsdorf, MD, clinical director of the division of endocrinology at Boston Children's Hospital and professor of pediatrics at Harvard Medical School, told Medscape Medical News.

"The TEENs study is really biopsying clinics....What about all those young people with type 1 diabetes who may to go a medical center once or twice at the time of diagnosis or shortly after, but the medical center is 300 miles away and the family doesn't have the resources to go [regularly], so they just get care locally by a pediatrician or family doctor?....What are their A1cs? We don't have those data," said Dr. Wolfsdorf.

Most Kids With Diabetes Not at Target: 1 in 5 have HbA1c >10%

The patients had a mean age of about 15 years and mean diabetes duration of 7 years. Just under half were female, and three-quarters were white. Between 26% and 29% were overweight or obese.

Only about a quarter were using insulin pumps. Of the two-thirds treated with injection regimens, 38% — overall about 25% of the entire cohort — were using non–analog insulin. Use of continuous glucose monitoring was less than 5% overall.

Average HBA1c levels were 8.3% for the 1724 children aged 8 to 12 years, 8.6% for the 2854 adolescents aged 13 to 18, and 8.4% for the 1382 young adults aged 19 to 25.

The proportions reaching the recommended targets were 32% of the younger children, 29% of the teens, and 19% of the young adults. Overall, 72% were not meeting the targets. Particularly worrisome, Dr. Laffel noted, was that 18% — or nearly 1 in 5 — had HbA1c levels of 10% or higher.

Rates of DKA and hypoglycemia were higher among the young adults than either the children or the teens. The percentage reporting at least 1 episode of DKA in the prior 3 months ranged from 5.6% of the 8- to 12-year-olds to 6.6% of the 19–25 age group. Severe hypoglycemia in that time period ranged from 2.2% of the teenagers to 4.1% of the young adults.

Interestingly, while DKA was uniformly more common among those with HbA1c levels above target, severe hypoglycemia was also more common in those above target in the 2 younger age groups.

Reasons for Not Being at Target

In multivariate analysis adjusted for age group and global region, demographic factors associated with achieving target HbA1c were age 8 to 12 vs 19 to 25 (nearly 2.5-fold difference) and type 1 diabetes diagnosis at age 12 or older vs less than 6 years (by about 1.7-fold).

Treatment factors significantly predicting HbA1c target achievement were: performing 5 or more glucose tests a day vs less than 3 (by nearly 2-fold); carbohydrate counting vs simply avoiding sugar; pump vs injections; no DKA vs DKA in the past 3 months (also nearly doubling the odds); and having glucagon in the home vs not.

Psychosocial predictive factors included rare vs some family conflict (by about 1.5-fold), no type 1 diabetes–related financial burden vs some, and living with 2 parents in the home vs not.

Dr. Laffel said that targeting modifiable factors for intervention, such as treatment approaches and family factors, may help optimize HbA1c levels and that providing added support and education to youth with nonmodifiable factors such as at-risk demographics may also help kids reach targets.

Dr. Wolfsdorf told Medscape Medical News, "Certain things are not modifiable. If you're not a 2-parent family, we can't fix that....I think we have minimal ability to significantly [affect] psychosocial dysfunction within families. If we recognize it, we can try to have the patient and parents meet with a psychologist or social worker and work through the issues. I don't know how big an impact that has."

But it's still worth doing, he said. "We should try to identify it, and if you have the resources, steer patients and families toward that kind of help."

Kind of Technology Available Depends on Where Kids Live

Also, if the resources are there, physicians can encourage use all of the available technology, says Dr. Wolfsdorf. But "ultimately, what we need is a method of treating diabetes that significantly reduces the burden of care and automates the process…in other words, an artificial pancreas. Then we'll see significant improvement."

However, he noted that access to such technology varies significantly depending on where in the world one lives. In the United States, insurance is the key, whereas in Europe, healthcare is largely government paid. And of course, the situation is dramatically different in the developing world.

"In certain parts of the world, patients have to buy everything. There's no health insurance. The poor have nothing, and unless charity provides it they will die. In institutions, the resources available to care for patients are largely determined by hospital administrators and hospital leadership and how much they're willing to invest in the care of children with diabetes."

The TEENs study was funded by Sanofi. Dr. Laffel has received grant support from Bayer Diabetes Care; served as a consultant/advisory board member for Bristol-Myers Squibb/AstraZeneca, Sanofi, Novo Nordisk, and Boehringer Ingelheim; and served as a consultant for Johnson & Johnson, LifeScan/Animas, Lilly, Menarini, and Dexcom. Dr. Wolfsdorf has reported no relevant financial relationships.

American Diabetes Association 2014 Scientific Sessions; June 13, 2014. Abstract32-OR, Abstract 259-OR


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