RESUMEN
AIM: To assess the associations between demographic and clinical characteristics and sensor glucose metrics in young children with type 1 diabetes, using masked, continuous glucose monitoring data from children aged 2 to < 8 years. RESEARCH DESIGN AND METHODS: The analysis included 143 children across 14 sites in the USA, enrolled in a separate clinical trial. Eligibility criteria were: age 2 to <8 years; type 1 diabetes duration ≥3 months; no continuous glucose monitoring use for past 30 days; and HbA1c concentration 53 to <86 mmol/mol (7.0 to <10.0%). All participants wore masked continuous glucose monitors up to 14 days. RESULTS: On average, participants spent the majority (13 h) of the day in hyperglycaemia (>10.0 mmol/l) and a median of ~1 h/day in hypoglycaemia (<3.9 mmol/l). Participants with minority race/ethnicity and higher parent education levels spent more time in target range, 3.9-10.0 mmol/l, and less time in hyperglycaemia. More time in hypoglycaemia was associated with minority race/ethnicity and younger age at diagnosis. Continuous glucose monitoring metrics were similar in pump and injection users. CONCLUSIONS: Given that both hypo- and hyperglycaemia negatively impact neurocognitive development, strategies to increase time in target glucose range for young children are needed.
Asunto(s)
Glucemia/metabolismo , Diabetes Mellitus Tipo 1/tratamiento farmacológico , Diabetes Mellitus Tipo 1/metabolismo , Hipoglucemiantes/administración & dosificación , Insulina/administración & dosificación , Automonitorización de la Glucosa Sanguínea , Niño , Preescolar , Femenino , Hemoglobina Glucada/metabolismo , Control Glucémico , Humanos , Bombas de Infusión Implantables , Sistemas de Infusión de Insulina , Masculino , Monitoreo AmbulatorioRESUMEN
AIM: To compare the characteristics of children and adolescents with type 1 vs. type 2 diabetes in the Pediatric Diabetes Consortium (PDC) registries. METHODS: Participants were 10 to < 21 years of age at diagnosis; there were 484 with type 1 diabetes and 1236 with type 2 diabetes. RESULTS: Children and adolescents with type 2 diabetes were more likely to be female, overweight/obese, and from low-income, minority ethnic families. Children and adolescents with type 1 diabetes were more likely to present with diabetic ketoacidosis and have higher mean HbA1c levels at diagnosis. More than 70% in both cohorts achieved target HbA1c levels < 58 mmol/mol (< 7.5%) within 6 months, but fewer participants with type 1 than type 2 diabetes were able to maintain target HbA1c levels after 6 months consistently throughout 3 years post diagnosis. Of the 401 participants with type 2 diabetes with ≥ 24 months diabetes duration on enrolment in the registry, 47% required no insulin treatment. Median C-peptide levels were 1.43 mmol/l in the subset of participants with type 2 diabetes in whom it was measured, but only 0.06 mmol/l in the subset with type 1 diabetes. CONCLUSIONS: Although families of children and adolescents with type 2 diabetes face greater socio-economic obstacles and risk factors for poor diabetes outcomes, the greater retention of residual endogenous insulin secretion likely contributes to the increased ability of children and adolescents with type 2 diabetes to maintain target HbA1c during the first 3 years of diabetes diagnosis.
Asunto(s)
Diabetes Mellitus Tipo 1/epidemiología , Diabetes Mellitus Tipo 2/epidemiología , Cetoacidosis Diabética/epidemiología , Etnicidad/estadística & datos numéricos , Grupos Minoritarios/estadística & datos numéricos , Obesidad/epidemiología , Adolescente , Péptido C/sangre , Niño , Diabetes Mellitus Tipo 1/tratamiento farmacológico , Diabetes Mellitus Tipo 1/etnología , Diabetes Mellitus Tipo 1/metabolismo , Diabetes Mellitus Tipo 2/tratamiento farmacológico , Diabetes Mellitus Tipo 2/etnología , Diabetes Mellitus Tipo 2/metabolismo , Femenino , Hemoglobina Glucada/metabolismo , Control Glucémico , Humanos , Hipoglucemiantes/uso terapéutico , Insulina/uso terapéutico , Masculino , Sobrepeso/epidemiología , Pobreza , Sistema de Registros , Distribución por Sexo , Resultado del Tratamiento , Adulto JovenAsunto(s)
Automonitorización de la Glucosa Sanguínea , Glucemia/metabolismo , Diabetes Mellitus Tipo 1/sangre , Hemoglobina Glucada/metabolismo , Hipoglucemia/prevención & control , Padres/educación , Actitud Frente a la Salud , Niño , Preescolar , Diabetes Mellitus Tipo 1/tratamiento farmacológico , Femenino , Humanos , Hipoglucemiantes/uso terapéutico , Lactante , Recién Nacido , Insulina/sangre , Insulina/uso terapéutico , Sistemas de Infusión de Insulina , Masculino , Padres/psicologíaRESUMEN
AIMS: To assess the pharmacokinetic and pharmacodynamic profile of a single dose of empagliflozin in young people with Type 2 diabetes to identify the appropriate doses for further paediatric development. METHODS: We conducted a single-dose, open-label, randomized, parallel-group study with empagliflozin 5 mg, 10 mg and 25 mg in young people with Type 2 diabetes aged 10-17 years. RESULTS: Of 39 participants screened, 27 were randomized and completed the study; their mean (± sd) age was 14.1±2.0 years and body weight was 96.7±23.5 kg. Compared with similar studies in adults with Type 2 diabetes, the maximum observed plasma concentrations were slightly lower with the 10-mg and 25-mg doses, and the area under the plasma concentration-time curve was slightly lower with the 10-mg but slightly higher with the 25-mg dose. The adjusted mean increases in urinary glucose excretion were 53 g/24 h (95% CI 32,74), 73 g/24 h (95% CI 52,94) and 87 g/24 h (95% CI 68,107), and the adjusted mean decreases in fasting plasma glucose were 0.9 mmol/l (95% CI -1.6,-0.1), 0.9 mmol/l (95% CI -1.7,-0.2) and 1.1 mmol/l (95% CI -1.8,-0.5) for the 5- 10- and 25-mg doses, respectively. There were no serious adverse events and one investigator-reported drug-related event (dehydration). CONCLUSIONS: After a single oral dose of empagliflozin, adults and young people with Type 2 diabetes had similar exposure-response relationships after adjusting for significant covariates. These data support testing 10-mg and/or 25-mg doses of empagliflozin in an upcoming paediatric phase III Type 2 diabetes trial. (ClinicalTrials.gov registration no.: NCT02121483).
Asunto(s)
Compuestos de Bencidrilo/farmacocinética , Diabetes Mellitus Tipo 2/tratamiento farmacológico , Diabetes Mellitus Tipo 2/metabolismo , Glucósidos/farmacocinética , Hipoglucemiantes/farmacocinética , Inhibidores del Cotransportador de Sodio-Glucosa 2/farmacocinética , Administración Oral , Adolescente , Compuestos de Bencidrilo/administración & dosificación , Glucemia/efectos de los fármacos , Glucemia/metabolismo , Niño , Diabetes Mellitus Tipo 2/sangre , Relación Dosis-Respuesta a Droga , Femenino , Glucósidos/administración & dosificación , Humanos , Hipoglucemiantes/administración & dosificación , Masculino , Inhibidores del Cotransportador de Sodio-Glucosa 2/administración & dosificaciónRESUMEN
BACKGROUND: An important area of research in childhood obesity is the identification of factors that predict or moderate the responses to obesity intervention programmes, yet few studies have examined the impact of self-esteem and family functioning on obesity treatment outcomes. OBJECTIVES: We sought to determine whether baseline self-esteem and family functioning predicted or moderated childhood obesity intervention outcomes at 6 months. METHODS: From 2009 to 2011, seventy-five 10-16 year old, racially/ethnically diverse obese youths with abnormal glucose tolerance were randomized to 6 months of an intensive family-based obesity lifestyle intervention (Bright Bodies) or routine outpatient Clinic Care. We examined youth self-concept, parent-rated family functioning and 6-month outcomes (youths' glucose tolerance, weight, body mass index and percent fat). We set the significance threshold as P ≤ 0.05 for moderator and predictor analyzes. RESULTS: Having poor family functioning and self-concept scores indicating high anxiety and low self-esteem at baseline predicted poor 6-month outcomes overall (Bright Bodies and Clinic Care groups combined). Additionally, baseline self-esteem and family functioning moderated treatment effects such that Bright Bodies outperformed Clinic Care in youths with low self-esteem and poorly functioning families, whereas youths with high self-esteem and high-functioning families did similarly well with either intervention. DISCUSSION: Our findings suggest intensive family-based lifestyle programmes are particularly beneficial for youth with low self-esteem and poorly functioning families.
Asunto(s)
Obesidad Infantil/psicología , Autoimagen , Programas de Reducción de Peso/métodos , Adolescente , Índice de Masa Corporal , Peso Corporal , Niño , Etnicidad , Femenino , Humanos , Masculino , Padres , Obesidad Infantil/terapia , Resultado del TratamientoRESUMEN
OBJECTIVES: The aim of the study was to characterize glucose levels and variability in young children with type 1 diabetes (T1D). METHODS: A total of 144 children of 4-10 yr old diagnosed with T1D prior to age 8 were recruited at five DirecNet centers. Participants used a continuous glucose monitor (CGM) every 3 months during an 18-month study. Among the 144 participants, 135 (mean age 7.0 yr, 47% female) had a minimum of 48 h of CGM data at more than five of seven visits and were included in analyses. CGM metrics for different times of day were analyzed. RESULTS: Mean hemoglobin A1c (HbA1c) at the beginning and end of the study was 7.9% (63 mmol/mol). Fifty percent of participants had glucose levels >180 mg/dL (10.0 mmol/L) for >12 h/d and >250 mg/dL (13.9 mmol/L) for >6 h/d. Median time <70 mg/dL (3.9 mmol/L) was 66 min/d and <60 mg/dL (3.3 mmol/L) was 39 min/d. Mean amplitude of glycemic excursions (MAGE) was lowest overnight (00:00-06:00 hours). The percent of CGM values 71-180 mg/dL (3.9-10.0 mmol/L) and the overall mean glucose correlated with HbA1c at all visits. There were no differences in CGM mean glucose or coefficient of variation between the age groups of 4 and <6, 6 and <8, and 8 and <10. CONCLUSIONS: Suboptimal glycemic control is common in young children with T1D as reflected by glucose levels in the hyperglycemic range for much of the day. New approaches to reduce postprandial glycemic excursions and increase time in the normal range for glucose in young children with T1D are critically needed. Glycemic targets in this age range should be revisited.
Asunto(s)
Glucemia/análisis , Diabetes Mellitus Tipo 1/sangre , Factores de Edad , Automonitorización de la Glucosa Sanguínea , Niño , Preescolar , Ritmo Circadiano , Diabetes Mellitus Tipo 1/complicaciones , Diabetes Mellitus Tipo 1/epidemiología , Femenino , Humanos , Lactante , MasculinoRESUMEN
AIMS: Improving glycaemic control in people with Type 1 diabetes is known to reduce complications. Our aim was to compare glycaemic control among people with Type 1 diabetes using data gathered in regional or national registries. METHODS: Data were obtained for children and/or adults with Type 1 diabetes from the following countries (or regions): Western Australia, Austria, Denmark, England, Champagne-Ardenne (France), Germany, Epirus, Thessaly and Thessaloniki (Greece), Galway (Ireland), several Italian regions, Latvia, Rotterdam (The Netherlands), Otago (New Zealand), Norway, Northern Ireland, Scotland, Sweden, Volyn (Ukraine), USA and Wales) from population or clinic-based registries. The sample size with available data varied from 355 to 173 880. Proportions with HbA1c < 58 mmol/mol (< 7.5%) and ≥ 75 mmol/mol (≥ 9.0%) were compared by age and sex. RESULTS: Data were available for 324 501 people. The proportions with HbA1c 58 mmol/mol (< 7.5%) varied from 15.7% to 46.4% among 44 058 people aged < 15 years, from 8.9% to 49.5% among 50 766 people aged 15-24 years and from 20.5% to 53.6% among 229 677 people aged ≥ 25 years. Sex differences in glycaemic control were small. Proportions of people using insulin pumps varied between the 12 sources with data available. CONCLUSION: These results suggest that there are substantial variations in glycaemic control among people with Type 1 diabetes between the data sources and that there is room for improvement in all populations, especially in young adults.
Asunto(s)
Diabetes Mellitus Tipo 1/tratamiento farmacológico , Hemoglobina Glucada/metabolismo , Hipoglucemiantes/uso terapéutico , Sistemas de Infusión de Insulina/estadística & datos numéricos , Insulina/uso terapéutico , Sistema de Registros , Adolescente , Adulto , Austria , Dinamarca , Diabetes Mellitus Tipo 1/metabolismo , Inglaterra , Femenino , Francia , Alemania , Grecia , Adhesión a Directriz , Humanos , Irlanda , Italia , Letonia , Masculino , Países Bajos , Nueva Zelanda , Irlanda del Norte , Noruega , Guías de Práctica Clínica como Asunto , Escocia , Suecia , Ucrania , Estados Unidos , Gales , Australia Occidental , Adulto JovenRESUMEN
Behavioural economics refers to the study of psychological and cognitive factors that relate to decision-making processes. This field is being applied increasingly to health care settings, in which patients receive tangible reinforcers or incentives for meeting objective behavioural criteria consistent with healthy lifestyles. This article reviews the background and efficacy of reinforcement interventions in general, and then as applied to behaviours related to diabetes prevention and management. Specifically, reinforcement interventions have been applied with some notable success towards promoting greater attendance at medical appointments, enhancing weight loss efforts, augmenting exercising regimes, improving medication adherence and increasing blood glucose monitoring. Suggestions for promising areas of future research are provided, keeping in mind the controversial nature of these interventions.
Asunto(s)
Conducta de Reducción del Riesgo , Diabetes Mellitus/terapia , Terapia por Ejercicio/psicología , Predicción , Humanos , Cumplimiento de la Medicación/psicología , Motivación , Aceptación de la Atención de Salud/psicología , Refuerzo en Psicología , Pérdida de PesoRESUMEN
AIMS: To describe satisfaction with continuous glucose monitoring in Type 1 diabetes; to correlate continuous glucose monitoring satisfaction scores with usage; and to identify common themes in perceived benefits and barriers of monitoring reported by adults, youths and the parents of youths in the Juvenile Diabetes Research Foundation continuous glucose monitoring trials. METHODS: The Continuous Glucose Monitoring Satisfaction Scale questionnaire was completed after 6 months of monitoring. Participants also answered open-ended queries of positive and negative attributes of continuous glucose monitoring. RESULTS: More frequent monitoring was associated with higher satisfaction for adults (n = 224), youths (n = 208) and parents of youths (n = 192) (all P < 0.001) in both the 'benefits' and 'hassles' sub-scales of the Continuous Glucose Monitoring Satisfaction Scale, but the greatest differences between the two groups involved scores on hassle items. Common barriers to monitoring use included insertion pain, system alarms and body issues; while common benefits included glucose trend data, opportunities to self-correct out-of-range glucose levels and to detect hypoglycaemia. CONCLUSIONS: As frequent use of continuous glucose monitoring is associated with improved glycaemic control without increased hypoglycaemia it is important to overcome barriers, reinforce benefits and set realistic expectations for this technology in order to promote its more consistent and frequent use in individuals with Type 1 diabetes.
Asunto(s)
Diabetes Mellitus Tipo 1/sangre , Hemoglobina Glucada/metabolismo , Satisfacción del Paciente , Calidad de Vida/psicología , Adolescente , Adulto , Automonitorización de la Glucosa Sanguínea , Diabetes Mellitus Tipo 1/psicología , Femenino , Humanos , Masculino , Encuestas y Cuestionarios , Adulto JovenRESUMEN
Despite the increased prevalence of type 2 diabetes mellitus (T2DM) in the pediatric population, there is limited information about the relative effectiveness of treatment approaches. This article describes the rationale and design of a National Institutes of Health-sponsored multi-site, randomized, parallel group clinical trial designed to test the hypothesis that aggressive reduction in insulin resistance early in the course of T2DM is beneficial for prolongation of glycemic control, as well as improvement in associated abnormalities and risk factors. Specifically, the trial compares treatment with metformin with two alternate approaches, one pharmacologic (combining metformin treatment with rosiglitazone) and one combining metformin with an intensive lifestyle intervention program. The Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY) study recruits 800 patients over a 4-yr period and follows them for a minimum of 2 yr and maximum of 6 yr. Patients are 10-17 yr of age, within 2 yr of diagnosis of diabetes at the time of randomization, lack evidence of autoimmunity, and have sustained C-peptide secretion. The primary outcome is time to loss of glycemic control, defined as a hemoglobin A1c >8% for 6 consecutive months. Secondary outcomes include the effect of the alternative treatments on insulin secretion and resistance, body composition, nutrition, physical activity and fitness, cardiovascular risk monitoring, microvascular complications, quality of life, depression, eating pathology, and resource utilization. TODAY is the first large-scale, systematic study of treatment effectiveness for T2DM in youth. When successfully completed, this study will provide critical new information regarding the natural history of T2DM in youth, the benefits of initiating early aggressive treatment in these patients, and the efficacy of delivering an intensive and sustained lifestyle intervention to children with T2DM.
Asunto(s)
Diabetes Mellitus Tipo 2/terapia , Conductas Relacionadas con la Salud , Hipoglucemiantes/uso terapéutico , Metformina/uso terapéutico , Tiazolidinedionas/uso terapéutico , Adolescente , Niño , Diabetes Mellitus Tipo 2/tratamiento farmacológico , Quimioterapia Combinada , Femenino , Humanos , Estilo de Vida , Masculino , Rosiglitazona , Resultado del TratamientoRESUMEN
AIMS/HYPOTHESIS: The prevalence of altered glucose metabolism in obese children and adolescents is growing at a significant rate, especially in ethnic minorities. It is not clear whether young people of different ethnic backgrounds differ in their adaptive mechanisms to obesity-related insulin resistance. The aim of this study was to evaluate the early insulin response and insulin clearance in response to an oral glucose load in obese children and adolescents. METHODS: Seven hundred and nine obese children and adolescents underwent an OGTT. Indices of the early insulin response and insulin clearance were compared in participants of White European, African American and Hispanic origin. RESULTS: Participants of the three ethnic groups demonstrated similar mechanisms of adaptation to increasing insulin resistance, but with different magnitudes. African American subjects had a greater early insulin response and decreased insulin clearance than their White European and Hispanic counterparts. This happened regardless of whether the cohort was divided by glucose tolerance level or by level of insulin sensitivity. IGT across ethnic groups was characterised by a marked decline in the acute insulin response in the context of severe insulin resistance and very low insulin clearance. CONCLUSIONS/INTERPRETATION: In obese children and adolescents, mechanisms of adaptation to obesity related to insulin resistance are similar across ethnic groups. The greater early insulin response needed to maintain glucose tolerance in young people of ethnic minorities may partially explain their greater tendency to develop type 2 diabetes.
Asunto(s)
Adaptación Fisiológica , Resistencia a la Insulina/etnología , Resistencia a la Insulina/fisiología , Células Secretoras de Insulina/metabolismo , Obesidad/etnología , Obesidad/metabolismo , Adolescente , Antropometría , Niño , Estudios de Cohortes , Femenino , Prueba de Tolerancia a la Glucosa , Humanos , Insulina/metabolismo , Secreción de Insulina , Masculino , Sensibilidad y EspecificidadRESUMEN
BACKGROUND: Microalbuminuria (MA) has emerged as a strong predictor of cardiovascular (CV) events, even in nondiabetic adults. While the mechanisms behind this association remain to be established, most studies suggest that MA is the result of increased vascular leakage denoting endothelial dysfunction associated with early vasculopathy. OBJECTIVE: To examine if a urine albumin creatinine ratio (UACR) in the microalbuminuric range is related to metabolic markers of CV risk in obese and pre-diabetic youth recruited from an obesity clinic. METHODS: MA was defined as a UACR between 2.0 and 20 mg/mmol. Subjects with gross proteinuria (UACR>20 mg/mmol) were excluded from the study. Analyses were performed to assess the relationship of MA and markers of CV risk, including body mass index (BMI), % body fat, blood pressure (BP), lipid profile, inflammatory markers, insulin sensitivity indexes and degrees of oral glucose tolerance. MA was also correlated with risk factor constellations unique to the metabolic syndrome, a distinct CV risk entity. RESULTS: Postchallenge alterations in glucose metabolism and overall loss in insulin sensitivity were strongly and positively correlated with the presence of MA (P = 0.002 and 0.01, respectively). Neither the metabolic syndrome nor any of the individual CV risk factors examined were associated with MA. CONCLUSIONS: These data suggest that early glucose toxicity, as reflected by postchallenge elevations in plasma glucose even below the diagnostic cutoff for diabetes mellitus may contribute to the presence of MA. Whether MA is equally as predictive of CV disease in youth, as in adulthood, remains to be investigated.
Asunto(s)
Albuminuria/complicaciones , Enfermedades Cardiovasculares/complicaciones , Obesidad/orina , Adolescente , Albuminuria/sangre , Biomarcadores/sangre , Composición Corporal , Índice de Masa Corporal , Enfermedades Cardiovasculares/sangre , Enfermedades Cardiovasculares/orina , Niño , Creatinina/orina , Estudios Transversales , Femenino , Prueba de Tolerancia a la Glucosa , Humanos , Resistencia a la Insulina , Lípidos/sangre , Masculino , Modelos Estadísticos , Obesidad/sangre , Prevalencia , Factores de RiesgoRESUMEN
Currently, goals for the treatment of children and adolescents with type 1 diabetes mellitus are to achieve near normal glycemia; minimize the risks of severe hypoglycemia and excessive weight gain; optimize psychosocial functioning and quality of life (for children and their families); and prevent or delay long-term microvascular complications. Continuous subcutaneous insulin infusion (CSII), or insulin pump therapy, provides a treatment option that can assist in the attainment of all of these goals in all ages of children. Insulin pump therapy provides the opportunity for greater flexibility in meal timing and content due to the convenience of its bolus delivery of insulin. Insulin pump therapy can potentially reduce the risk of exercise-related and nocturnal hypoglycemia, through the use of programmable variable basal infusion rates. In pediatric patients, usage of CSII has been demonstrated to reduce both glycosylated hemoglobin levels and frequency of severe hypoglycemia, without sacrifices in safety, quality of life, or weight gain, particularly in conjunction with the use of new insulin analogs and improvements in pump technology. Clinical studies of safety and efficacy of CSII in children and the use of continuous glucose monitoring to optimize insulin pump therapy are reviewed.
Asunto(s)
Diabetes Mellitus Tipo 1/tratamiento farmacológico , Hipoglucemiantes/administración & dosificación , Sistemas de Infusión de Insulina , Insulina/administración & dosificación , Automonitorización de la Glucosa Sanguínea/métodos , Niño , Ensayos Clínicos como Asunto , HumanosRESUMEN
Little is known about the experiences of mothers raising young children with type 1 diabetes. The purpose of this study was to describe the day-to-day experiences of mothers (N = 28) raising young children under 4 years of age with type 1 diabetes. Descriptive, naturalistic inquiry principles were used to interview subjects, as well as to manage and analyze the data. The mothers reported using the management behavior of constant vigilance. Their concerns about hypoglycemia and providing competent care reflected the interplay between their fears and profound sense of responsibility for managing the disease. Mothers reported having to learn the management behaviors and to occasionally adjust the day-to-day management when either severe hypoglycemia or developmental milestones occurred. Although mothers initially had feelings of incompetence with the care they provided, with time, they became very skilled. There were also reports of limited access to babysitting, child care, or respite services. The intensity of their constant vigilance associated with their concerns, responsibility, and lack of supports resulted in some mothers having physical and/or emotional problems. The findings of the study highlight the importance of identifying family and/or community resources that may provide mothers with support that could reduce some of the tremendous stress and burden of responsibility experienced after diagnosis of diabetes.
Asunto(s)
Cuidadores/psicología , Diabetes Mellitus Tipo 1/enfermería , Madres/psicología , Responsabilidad Parental/psicología , Adaptación Psicológica , Adulto , Conducta Infantil , Preescolar , Femenino , Estado de Salud , Humanos , Hipoglucemia/psicología , Masculino , Privación de Sueño , Apoyo SocialRESUMEN
OBJECTIVE: To determine whether relatively low leptin levels predict changes in adiposity in prepubertal and pubertal obese children. RESEARCH METHODS AND PROCEDURES: In a biracial cohort of 68 obese children (33 male and 35 female; 46 Caucasians and 22 African-Americans, age range 7-18 y), we measured at baseline fasting insulin and leptin levels, height and weight and calculated body mass index (kg/m(2)) and expressed body mass index as (BMI) Z-score. After a 2.5-y follow-up, anthropometric measurements were repeated and changes in weight gain were calculated as changes in BMI Z-score. RESULTS: At baseline obese preadolescent boys and girls had similar age and BMI Z-score, fasting insulin and leptin levels. After an average follow-up of 2.5 y, mean weight change calculated by changes in BMI Z-score from baseline was similar in both groups. In obese adolescent boys and girls at baseline, no significant gender differences were observed for BMI Z-score and insulin levels. In contrast, plasma leptin levels were significantly higher in obese girls compared with obese adolescent boys. At follow-up, there was no significant difference in change in BMI Z-score between obese boys and girls. Multiple linear regression analysis revealed that high basal leptin levels were positively associated with greater changes in BMI Z-score only in girls (r(2)=0.18, P<0.02), after adjusting for basal BMI Z-score, Tanner stage, years of follow-up and basal insulin. High basal leptin levels in girls explained 18% of the weight gain. CONCLUSION: High leptin levels are associated with excessive future weight gain only in girls.
Asunto(s)
Leptina/sangre , Obesidad/sangre , Aumento de Peso , Adolescente , Índice de Masa Corporal , Niño , Ayuno , Femenino , Humanos , Insulina/sangre , Modelos Lineales , Estudios Longitudinales , Masculino , Fenotipo , Pubertad , Caracteres SexualesRESUMEN
OBJECTIVE: The Diabetes Control and Complications Trial (DCCT) demonstrated that intensive therapy of type 1 diabetes mellitus reduces the risk of development and progression of microvascular complications. The Epidemiology of Diabetes Interventions and Complications (EDIC) study assessed whether these benefits persisted after the end of DCCT. Results for the adolescent DCCT cohort are reported here. STUDY DESIGN: Of the DCCT adolescent cohort (n = 195), 175 participated in EDIC, 151 had fundus photography, and 156 had albumin excretion rate measured at year 3 or 4. The odds of progression of retinopathy and albuminuria from closeout of the DCCT until EDIC year 4 were assessed. RESULTS: In contrast to the 7.4 years of the DCCT, during which mean hemoglobin A(1c) levels were significantly lower with intensive therapy than conventional therapy (8.06% vs 9.76%; P <.0001), the subsequent first 4 years of EDIC had mean hemoglobin A(1c) levels that were similar between the former intensive and the former conventional groups (8.38% vs 8.45%). However, the prevalence of worsening of 3 steps or more in retinopathy and of progression to proliferative or severe nonproliferative retinopathy were reduced by 74% (P <.001) and 78% (P <.007), respectively, in the former intensive therapy group compared with the former conventional group. CONCLUSIONS: These findings provide further support for the DCCT recommendation that most adolescents with type 1 diabetes receive intensive therapy aimed at achieving glycemic control as close to normal as possible to reduce the risk of microvascular complications.
Asunto(s)
Albuminuria/prevención & control , Diabetes Mellitus Tipo 1/tratamiento farmacológico , Nefropatías Diabéticas/prevención & control , Retinopatía Diabética/prevención & control , Hipoglucemiantes/administración & dosificación , Insulina/administración & dosificación , Adolescente , Adulto , Albuminuria/sangre , Albuminuria/etiología , Estudios de Cohortes , Diabetes Mellitus Tipo 1/sangre , Diabetes Mellitus Tipo 1/complicaciones , Nefropatías Diabéticas/sangre , Nefropatías Diabéticas/etiología , Retinopatía Diabética/sangre , Retinopatía Diabética/etiología , Femenino , Angiografía con Fluoresceína , Hemoglobina Glucada/análisis , Hemoglobina Glucada/efectos de los fármacos , Humanos , Hipoglucemiantes/uso terapéutico , Insulina/uso terapéutico , Masculino , Oportunidad Relativa , Análisis de Regresión , Factores de Tiempo , Resultado del TratamientoRESUMEN
While treatment of Type 1 diabetes mellitus (T1DM) in children and adolescents is especially difficult, recent technological advances have provided new therapeutic options to clinicians and patients. The urgency to achieve strict diabetes control and the introduction of new and improved insulin pumps have been accompanied by a marked increase in use of continuous subcutaneous insulin infusion (CSII) therapy in youth with diabetes. Results of clinical outcome studies indicate that CSII provides a safe and effective alternative to multiple daily injection (MDI) therapy, even when employed in a regular clinic setting in a large number of children. The safety and efficacy of CSII is further enhanced by the introduction of lispro and aspart insulin. The sharper peaks and shorter duration of action of these very rapid-acting insulin analogues provides a means to achieve better control of post-prandial hyperglycaemia with less late post-prandial and nocturnal hypoglycaemia. Glargine insulin, a soluble and essentially peakless long-acting insulin analogue, may provide a better basal insulin for MDI regimens, but there are limited published data with this agent in children with T1DM. A number of systems for pulmonary delivery of insulin are in development and preliminary results of Phase III studies have been promising. Like CSII, inhaled insulin allows the child to take bolus insulin doses before each meal without having to take a premeal injection. A major obstacle to effective treatment is that self-monitoring of three to four blood glucose levels a day often misses the marked glycaemic excursions that characterize T1DM in young patients. On the other hand, new continuous glucose sensing systems provide a wealth of data that can be used to optimize basal and bolus therapy, regardless of how insulin is administered. Even more important, we may finally be at the threshold of development of a practically applicable artificial pancreas.
Asunto(s)
Diabetes Mellitus Tipo 1/terapia , Terapéutica/tendencias , Administración por Inhalación , Adolescente , Automonitorización de la Glucosa Sanguínea/instrumentación , Automonitorización de la Glucosa Sanguínea/métodos , Humanos , Insulina/administración & dosificación , Insulina/análogos & derivados , Sistemas de Infusión de InsulinaRESUMEN
This study compared glycemic control achieved with insulin lispro or buffered regular human insulin in patients with Type 1 diabetes treated with continuous subcutaneous insulin infusion (CSII) using an external insulin pump. In this 24-week multicenter, randomized, two-way crossover, open-label trial, 58 patients on CSII with adequate glycemic control received either insulin lispro or buffered regular human insulin for 12 weeks, followed by the alternate treatment for another 12 weeks. Efficacy and safety measures included hemoglobin A(1c) (HbA(1c)) at baseline and endpoint, home blood glucose monitoring, hypoglycemia, and frequency of pump catheter occlusion. Patients consumed a standard test meal on three occasions, with determinations of fasting, 1- and 2-h postprandial glucose values. Insulin lispro use was associated with a significantly lower HbA(1c) than was buffered regular human insulin (7.41+/-0.97 vs. 7.65+/-0.85 mmol/l; P=.004). Fasting serum glucose values before the test meal were similar between the two therapies. The 1-h (11.16+/-4.29 vs. 13.20+/-4.68 mmol/l; P=.012) and 2-h (9.64+/-4.10 vs. 12.53+/-4.64 mmol/l; P=.001) postprandial glucose concentrations were significantly lower during treatment with insulin lispro. No differences between treatments were observed in basal or bolus insulin doses, weight gain, or the incidence and rate of hypoglycemia, hyperglycemia, or pump occlusions. When used in external pumps, insulin lispro provides better glycemic control than buffered regular human insulin with a similar adverse event profile.
Asunto(s)
Diabetes Mellitus Tipo 1/tratamiento farmacológico , Sistemas de Infusión de Insulina , Insulina/análogos & derivados , Insulina/administración & dosificación , Adulto , Glucemia/análisis , Automonitorización de la Glucosa Sanguínea , Estudios Cruzados , Falla de Equipo , Ayuno , Femenino , Alimentos , Hemoglobina Glucada/análisis , Humanos , Hipoglucemia/inducido químicamente , Insulina/efectos adversos , Insulina/uso terapéutico , Insulina Lispro , Masculino , Persona de Mediana EdadRESUMEN
OBJECTIVE: Children with type 1 diabetes are usually asked to perform self-monitoring of blood glucose (SMBG) before meals and at bedtime, and it is assumed that if results are in target range, along with HbA(1c) measurements, then overall glycemic control is adequate. However, the brief glimpses in the 24-h glucose profile provided by SMBG may miss marked glycemic excursions. The MiniMed Continuous Glucose Monitoring System (CGMS) has provided a new method to obtain continuous glucose profiles and opportunities to examine limitations of conventional monitoring. RESEARCH DESIGN AND METHODS: A total of 56 children with type 1 diabetes (age 2-18 years) wore the CGMS for 3 days. Patients entered four fingerstick blood samples into the monitor for calibration and kept records of food intake, exercise, and hypoglycemic symptoms. Data were downloaded, and glycemic patterns were identified. RESULTS: Despite satisfactory HbA(1c) levels (7.7 +/- 1.4%) and premeal glucose levels near the target range, the CGMS revealed profound postprandial hyperglycemia. Almost 90% of the peak postprandial glucose levels after every meal were >180 mg/dl (above target), and almost 50% were >300 mg/dl. Additionally, the CGMS revealed frequent and prolonged asymptomatic hypoglycemia (glucose <60 mg/dl) in almost 70% of the children. CONCLUSIONS: Despite excellent HbA(1c) levels and target preprandial glucose levels, children often experience nocturnal hypoglycemia and postprandial hyperglycemia that are not evident with routine monitoring. Repeated use of the CGMS may provide a means to optimize basal and bolus insulin replacement in patients with type 1 diabetes.