DKA at Diagnosis of Type 1 Diabetes Surges in US Kids

BARCELONA — The prevalence of diabetic ketoacidosis (DKA) at the time of diagnosis of type 1 diabetes in children has been dramatically increasing in the United States since 2010, new research suggests.

Data from the five-site SEARCH for Diabetes in Youth Study were presented September 18 here at the European Association for the Study of Diabetes (EASD) 2019 Annual Meeting by Elizabeth T. Jensen, PhD, assistant professor of epidemiology and prevention at the Wake Forest School of Medicine, Winston-Salem, South Carolina.

Between 2010 and 2016, the prevalence of DKA among children at the time of diagnosis of type 1 diabetes increased by about 2% per year in SEARCH, from just over a third to more than 40%.

And although some sociodemographic groups are at higher risk, the increase does not appear to be because of changes in sociodemographic factors, Jensen said.

Rather, she attributes the phenomenon to both the recession of 2008-2010 and the major shift in healthcare over the past several years.

"I think there is evidence that delayed diagnosis increases risk for DKA...The potential that, with the changing landscape of insurance, more people are having to pay more out-of-pocket costs and it is reducing access to preventive care services. More families are making choices not to receive care because of the amount of cost associated with it. That's even true for families that have opted into the [Affordable Care Act] health insurance," she said.

Education Needed for Pediatricians, Family Practitioners, and ER Docs

Clinically, Jensen told Medscape Medical News, "Delayed diagnosis could be a result of families delaying care...or from providers failing to identify the disease earlier in its manifestation."

"Educating families of early symptoms, as well as increasing provider suspicion for disease, could potentially help mitigate this growing trend. New-onset type 1 diabetes is becoming more prevalent in diverse populations, and so providers should be aware of this as well," she said.

These findings are "quite concerning," said Daniel DeSalvo, MD, assistant professor of pediatrics and co-director, Diabetes Clinic CPT, Section of Pediatric Diabetes & Endocrinology, Baylor College of Medicine/Texas Children's Hospital, Houston, when asked for comment.

DeSalvo said he often sees children presenting in DKA whose symptoms have been missed or mistaken for other illnesses by multiple caregivers and healthcare providers.

"To me, the increase in DKA prevalence suggests a critical knowledge gap among parents, caregivers, and healthcare providers, and represents the need for a robust public health campaign for DKA awareness," he said.

"I urge pediatricians, family practice providers, and emergency personnel to be vigilant in screening for type 1 diabetes signs and symptoms so that a timely diagnosis and treatment can be initiated," he emphasized.

As to why the increase in DKA is occurring now, DeSalvo said it may be related to the overall increase in the incidence of type 1 diabetes that has also been occurring in recent years.

Increases in DKA Seen Across Subgroups, Seasons

Researchers analyzed data from all five SEARCH sites, in South Carolina, Ohio, Colorado, Southern California, and Washington State.

Surveillance included all individuals in those regions diagnosed with type 1 diabetes before age 20 years, with a catchment of about 5 million children per year and a racially diverse population. There were about 7600 individuals diagnosed with diabetes during 2010-2016.

Medical records were abstracted to look for evidence of DKA, including a blood bicarbonate < 15 mmol/L, a pH < 7.25 (venous) or < 7.3 (arterial or capillary), or any documentation of DKA diagnosis.

The percentage of individuals who experienced DKA at type 1 diabetes diagnosis rose from 35.3% in 2010 to 40.6% in 2016, a significant increase (P = .01). The overall prevalence in the 6-year period was 38.5%. The proportion with DKA was highest among children aged 0-4 years, but increases were similar among all age groups.

The same increasing trend was also seen by sex, race/ethnicity, and insurance status. Publicly insured kids had higher DKA rates, but again, the increases were similar across groups. There was also no variance by season.

By clinical site, there was one difference: South Carolina had about a 5% per year increase in DKA prevalence compared with about 2% per year at the four other sites. Interestingly, Jensen noted, South Carolina is the only SEARCH site that did not expand Medicaid coverage following passage of the Affordable Care Act in 2010.

"It would be interesting to know whether that's a contributing factor to the rapid increase that we're observing in South Carolina relative to the other SEARCH sites, but of course other factors may be contributing here as well," she commented.

The same increasing trends persisted after adjustment for age group, sex, race/ethnicity, income, parent/caregiver education, insurance status, primary language, SEARCH site, and season, suggesting that "sociodemographic factors do not contribute to the increase observed over time," Jensen emphasized.

DeSalvo told Medscape Medical News, "A delayed diagnosis in type 1 diabetes can have critical health consequences. I am grateful for organizations like Beyond Type 1 who are leading efforts to educate the public about the warning signs of type 1 diabetes. As endocrinologists we have an important role to play as advocates for this public health campaign."

Jensen has reported no relevant financial relationships. DeSalvo has served as a consultant for Dexcom and Insulet.

EASD 2019 Annual Meeting. Presented September 18, 2019. Abstract 166.

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