DKA at Diagnosis of Type 1 Diabetes Skyrockets in US Kids

April 21, 2015

Researchers in Colorado have documented a more than 50% increase in the incidence of diabetic ketoacidosis (DKA) at diagnosis of type 1 diabetes in children in the state between 1998 and 2012. DKA at the time of diagnosis of type 1 diabetes is "life-threatening and has detrimental long-term effects," say Arleta Rewers, MD, PhD, of University of Colorado School of Medicine, Denver, and colleagues in their research letter published in the April 21, 2015 issue of the Journal of the American Medical Association.

"To our knowledge, this is the only report of increasing incidence of DKA in the developed world," they note. "This incidence is consistent with incidences in countries with poor access to healthcare and low physician and community awareness of diabetes and is much higher than incidences reported in Canada or the UK," they add.

Senior author Marian Rewers, MD, PhD, of Barbara Davis Childhood Center for Diabetes, Denver, Colorado, told Medscape Medical News there are several reasons for the "skyrocketing" increase in DKA observed, adding: "It's a complicated picture."

Part of the explanation is economic, and part is due to the fact that families, and in many cases healthcare professionals, just do not recognize the symptoms of type 1 diabetes, he said.

Relationship of DKA Incidence to Economics Is Complex

Dr Rewers and colleagues examined temporal trends in DKA at type 1 diabetes diagnosis in youths up to age 18 who were eventually referred to the Barbara Davis Center, which serves more than 80% of youth with diabetes in Colorado.

Proportions of children with DKA at diagnosis were 29.9% in 1998, 35.0% in 2007, and 46.2% in 2012, a 55% increase between the start and finish of the study (P < .001 for trend), "suggesting a growing number of youth may experience delays in diagnosis and treatment" of type 1 diabetes, the researchers say.

Younger age (odds ratio [OR], 1.8) and African American race (OR, 1.80) were associated with a higher risk, whereas private insurance (OR, 0.37) and history of type 1 diabetes in a first-degree relative (OR, 0.35) were associated with a lower risk.

Dr Rewers said the relationship of DKA incidence with economics and insurance is complex.

The rise correlated temporally with an increase in prevalence of child poverty in Colorado from 10% in 2008 to 18% in 2012.

"If you look at the data, the annual rates of DKA track with the dates of recessions, with an initial increase seen after 2000 and then the most recent increase following the latest recession, starting between 2007 and 2009," he explained.

"In the past," in the 1990s and early 2000s, it was uninsured children who were most at risk of DKA, "not only recent immigrants but also local folk who couldn't afford insurance," he said.

But this situation has "largely disappeared" with changes made to Medicaid and the Affordable Care Act (ACA), with less than 2% of children now left uninsured.

Those covered by public insurance increased from 17.1% in 2007 to 37.5% in 2012, while the rest are on private plans — although the latter number has decreased by 20%, so they are now "meeting in the middle," he said.

And while private insurance has traditionally been protective against children presenting with DKA, the pendulum is now starting to swing the other way, with an increasing proportion of families on "bronze-tier" plans with high deductibles, for example, through work-sponsored schemes, who may struggle, Dr Rewers explained.

Families, Healthcare Providers, Miss Type 1 Diabetes, Lack Facilities to Diagnose It

Also hugely problematic is the fact that many families, and indeed some healthcare providers, just don't recognize the signs of type 1 diabetes, Dr Rewers stressed.

"If the family has no relative with diabetes, they don't know the signs and symptoms, and they don't make the connection if their kid is skinny, losing weight, and drinking a lot," he said.

"There is a lack of community awareness of…diabetes, despite all of the efforts that we, and many others, including the Juvenile Diabetes Research Fund [JDRF], have put in, with posters and presentations; it is not enough."

And healthcare providers such as primary-care physicians and nurse practitioners are missing cases of type 1 diabetes, too, he says.

"The amount of time that a medical provider spends with a child is now minimal, and it used to be possible to do a cheap, 50-cent urine test for ketones next door [to the office], but now many don't have the facilities to do this, there is a lack of point-of-care ability to measure this."

And even in the best healthcare maintenance organizations (HMOs), cases of type 1 diabetes are still being missed, Dr Rewers stressed, describing a boy "with unspecific symptoms" referred to an eye, nose, and throat expert by a primary-care practitioner. The ENT "didn't notice the boy had lost 15 lb in weight between the two visits," he observes, pointing out that weight loss "is one of the simplest markers of type 1 diabetes."

"This is not working the way it's meant to work," he observed, noting that much of this "is modifiable," but the purely economic factors "are more difficult to fix."

Is Population Screening for Autoantibodies the Way Forward?

Comparing the rates of DKA seen in their study with those from other developed nations, Dr Rewers said the Colorado figures are poor.

In some Scandinavian countries, such as Sweden and Finland, they have managed to get the DKA rate at diagnosis of type 1 diabetes down to 15%, "which is a third of what we have seen, so compared to those countries we are not doing very well."

In Canada, the rate is around 20% to 25%, and this is the average in most European countries too, he said.

Interestingly, a nationwide campaign in Austria to lower the rate of DKA, "in which they did all the right things," had no effect, he said. "So we are getting desperate looking for new avenues."

One way in which it may be possible to reduce the DKA rate significantly is to screen populations for children who may go on to develop type 1 diabetes by testing for antibodies indicating islet-cell autoimmunity, he explained. "The studies that have done this have been able to lower the rate of DKA to 10% or less."

"We are contemplating this in Colorado; in the long term, this is the way to go," Dr Rewers said.

Indeed, his team has trialed an approach there whereby they use either a one-time screening, at age 2 or 3 years, which "could identify 60% of children who are on the way to diabetes," he explained to Medscape Medical News.

If repeated once more, "the screening would identify 80%" of such patients.

"This could be most conveniently done during routine well-child visits to primary-care providers. We have piloted this approach in Denver, last year. The screening was well received by parents and healthcare providers," he said, noting that full results will be presented at the American Diabetes Association Scientific Sessions in Boston, Massachusetts, in June.

Dr A Rewers reports receiving personal fees from the Diabetes Technology Society and Roche Diagnostics International. Disclosures for the coauthors are listed in the article.

JAMA. 2015;313:1570-1572. Extract

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