Children With Type 1 Diabetes Not Meeting A1c Targets

Miriam E. Tucker

January 24, 2013

Less than a third of youth with type 1 diabetes cared for by endocrinologists are meeting recommended hemoglobin A1c targets, a large registry-based study found.

The data, from an analysis of 13,316 participants younger than 20 years in a nationwide registry, were published online January 22 in Diabetes Care by Jamie R. Wood, MD, Children's Hospital Los Angeles, and colleagues.

The findings come at a time of escalating incidence of type 1 diabetes (T1D) in children. A second paper also published online January 22 in Diabetes Care documents a 29% increase in T1D among youth in Philadelphia over a 20-year period. That study was reported by Terri H. Lipman, PhD, from the University of Pennsylvania School of Nursing, Philadelphia, and colleagues.

Philadelphia's increased incidence in T1D is typical of worldwide patterns, pediatric endocrinologist Georgeanna J. Klingensmith, MD, professor of pediatrics and director of pediatric endocrinology at the University of Colorado School of Medicine, Aurora, and director of pediatric services at the Barbara Davis Center for Diabetes, Denver, told Medscape Medical News.

"The increase seems to be 2.5% to 4% per year around the world…. Why this is occurring we do not know. We are seeing twice as many new-onset children today as we did 20 years ago," said Dr. Klingensmith.

"I think it is a big concern that T1D is increasing. We do not have enough physicians to care for the current number of children. We have not trained twice as many pediatric — or adult — endocrinologists to care for this increase in T1D," she told Medscape Medical News.

Not Meeting Goals

The hemoglobin A1c data come from the registry of the Type 1 Diabetes Exchange Clinic Network, which includes 67 US-based endocrinology practices. The type 1 registry began enrolling patients in September 2010.

Of the 13,316 participants, 5% were aged 1 to 5 years, 40% were 6 to 12 years, and 55% were 13 to 19 years. The group had a mean age of 12.7 years and mean diabetes duration of 5.6 years. Most (78%) were white. Just over half (55%) used insulin pumps and 3% used continuous glucose monitors.

The study investigated the proportion of children and adolescents meeting established clinical guidelines: The American Diabetes Association (ADA) recommends hemoglobin A1c targets of less than 8.5% for children younger than 6 years, less than 8.0% for those aged 6 to 12, and less than 7.5% for those aged 13 up to 20. The International Society for Pediatric and Adolescent Diabetes (ISPAD) recommends a target of 7.5% or less for children of all ages.

Overall, just 32% met the ADA targets for their age group and 25% met the ISPAD goals. By age, the proportions meeting the ADA goals were 64% for the under-6-year age group, 43% for 6- to 12-year-olds, and 21% for the 13- to 19-year-olds.

Wearing an insulin pump made a difference only for the younger two groups. Among those aged 1 to 5 years who wore pumps, 79% met ADA and 37% met ISPAD targets, compared with just 50% and 17%, respectively of those taking insulin injections. For the 6- to 12-year age group, those proportions were 50% and 32% with the pump vs 34% and 20% of those taking injections.

Those differences were significant (P < .001) after adjustment for diabetes duration, race/ethnicity, household income, insurance, and self-monitoring of blood glucose.

However, among those aged 13 to 19 years, 24% and 27% of pump users and just 18% and 20% of injection users met the ADA and ISPAD targets, respectively (P = .11 and .02).

Black participants were significantly less likely than were white or Hispanic patients to meet the targets, 14% overall compared with 34% for white and 28% for Hispanics (adjusted P < .001).

In contrast to the glycemic goals, patients in the registry were far more likely to meet ADA and ISPAD goals for blood pressure, body mass index (BMI), HDL and LDL cholesterol, and triglycerides, ranging from 63% for BMI to 95% for HDL cholesterol, Dr. Wood and colleagues report.

Achieving A1c goals is difficult even in the best of care circumstances, Dr. Klingensmith noted.

"I think there are a number of barriers to achieving targets in children — really all people with T1D. Fear of hypoglycemia is a major barrier in parents of young children and persists in many parents and patients. Unwillingness to test as often as is recommended and needed for good care is a major reason for not meeting A1c goals."

Continuous glucose monitoring technology holds the potential to improve glycemic control for kids as the technology improves, she told Medscape Medical News.

"Sensors can improve care. Children and families who can use a sensor consistently can have an A1c below 7% and not have hypoglycemia…but sensors are expensive and not yet uniformly covered by insurance."

And at present, she added, "The sensors are currently too big and not accurate enough."

Type 1 on the Rise

Increasing numbers of children with T1D as seen in the Philadelphia Pediatric Diabetes Registry threaten to further worsen the clinical picture.

During 2000–2004, a total of 277 cases of T1D in children to age 14 years were identified from combined city hospital and school records, giving an overall age-adjusted incidence of 17.0 per 100,000 per year.

In contrast, incidences in 1985–1989, 1990–1994 and 1995–1999 were just 13.4, 13.3, and 14.8 per 100,000 per year, respectively. All of those rates were significantly less than the 2000–2004 rate, with none of the 95% confidence intervals crossing 1.0.

Overall, there was a 1.3-fold increase from 1985–1989 to 2000–2004, with a yearly increase of about 1.5%. For black children, the increase in incidence was approximately 2.3% per year, Dr. Lipman and colleagues report.

Notably steep rises were seen among white children aged 10 to 14 years, for whom the incidence increased 115% from 1995–1999 to 2000–2004, and "of particular concern," in black children aged 0 to 4 years, who had a 3-fold rise over the 20 years of the registry.

Looking Ahead

According to Dr. Klingensmith, these data suggest that primary-care physicians will be seeing more children with T1D and should be alert for signs of diabetic ketoacidosis. However, because detailed knowledge is required to analyze insulin-pump and glucose-sensor data to optimize management, "primary-care providers will be less able to provide expert care for children with T1D, so developing close relationship with endocrinologists who can provide consultation will be important."

She added, "Also as a nation, we need to expand our ability to provide care at a distance with telehealth via video conferencing, which will make the limited number of pediatric endocrinologists better able to care for children in rural areas."

Funding for the T1D Exchange is provided by the Leona M. and Harry B. Helmsley Charitable Trust. Dr. Wood has received consultant payments from Medtronic; the coauthors have disclosed no relevant financial relationships. The authors of the Philadelphia registry study have disclosed no relevant financial relationships. Dr. Klingensmith has research support from Novo Nordisk and is a consultant for Novo Nordisk as a safety monitor for a study.

Diabetes Care. Published online January 22, 2013. Wood Abstract, Lipman Abstract