PerspectiveIn the Journals Plus

Most children, adults not meeting ADA goals for type 1 diabetes management

Show Citation

January 28, 2019

Only 17% of children and 21% of adults with type 1 diabetes are meeting HbA1c targets outlined in American Diabetes Association guidelines, with glycemic control worsening over 8 years of follow-up among adolescents in particular, according to an analysis of registry data published in Diabetes Technology & Therapeutics.

Nicole C. Foster

“The take-home message here is that only a minority of adults and children with type 1 diabetes are achieving ADA goals in the United States,” Nicole C. Foster, MS, senior biostatistician at the Jaeb Center for Health Research in Tampa, Florida, told Endocrine Today. “Glycemic control has not improved over the past 5 to 7 years.”

Foster and colleagues analyzed diabetes management and outcomes data from 22,697 children and adults with type 1 diabetes registered with T1D Exchange clinics (50% girls and women; 82% white; 74% with private health insurance; 49% with overweight or obesity). Participants who were followed for 5 years completed questionnaires on diabetes management and acute complications, similar to questionnaires completed at enrollment. Researchers assessed insulin pump and continuous glucose monitoring use, noninsulin glucose-lowering medication use and HbA1c levels, as well as incidence of severe hypoglycemia and diabetic ketoacidosis and the timing and frequency of insulin administration. Researchers made cross-sectional comparisons of data collected during 2010-2012 with data collected during 2016-2018 (n = 12,705) and used linear regression models to assess the association between HbA1c and time period and logistic regression to analyze the association between reported severe hypoglycemia and diabetic ketoacidosis and insulin pump use, CGM use and HbA1c.

HbA1c increases

Researchers found that mean HbA1c in 2016-2018 increased from 8.1% at age 5 years to 9.3% from age 15 to 18 years, decreasing to 8% by age 28 years, further decreasing to between 7.5% to 7.9% at age 30 years and older. Only 17% of children achieved the ADA’s target HbA1c goal of 7.5%, whereas 21% of adults achieved the ADA target goal of 7%, according to researchers. Mean HbA1c changed little between the two observation periods, apart from adolescents.

The researchers also observed an increased uptake in diabetes technology. Within the cohort, insulin pump use rose from 57% in 2010-2012 to 63% in 2016-2018. CGM use rose from 7% in 2010-2012 to 30% in 2016-2018, with a 10-fold rise observed among children aged 12 years and younger. Across all age groups, HbA1c was lower in pump and CGM users (P < .001). There were racial disparities in the frequency of insulin pump and CGM use across all age groups, according to the researchers.

In analyses of participants with data from both observation periods and at least 3 years’ diabetes duration in 2010-2012 (n = 9,657), mean HbA1c was higher, rising from 7.8% in 2010-2012 to 8.4% in 2016-2018 (P < .001). Researchers noted the increase over time was predominantly seen in young adults.

Metformin was the most common noninsulin medication used, though only observed in 6% of adults.

Management for adolescents

“Clinicians may be disheartened to see that, despite a substantial increase in use of CGM, glycemic control has not improved and may have worsened in adolescents/young adults over the past 5 to 7 years,” Foster said. “It is of note to remember that, while HbA1c may not have improved, HbA1c remains lowest in CGM users and insulin pump users, and CGM users and pump users were less likely to experience severe hypoglycemia and diabetic ketoacidosis.”

The study follows a position statement the ADA released in August, reported by Endocrine Today. In the statement, the authors noted that type 1 diabetes management for children and adolescents must not be extrapolated from adult diabetes care, and providers should consider a child’s evolving developmental stages in creating an adaptive care plan to best suit his or her changing needs.

The authors further noted that adolescence is a time that can disrupt diabetes care and communication between family members, youth and providers, adding that cognitive development and medical decision-making skills will affect a wide variety of risk-taking behaviors. – by Regina Schaffer

For more information:

Nicole C. Foster, MS, can be reached at the Jaeb Center for Health Research, 15310 Amberly Drive, Suite 350, Tampa, FL 33647; email: t1dstats3@jaeb.org.

Disclosures: The authors report no relevant financial disclosures.

itj+ Infographic

itj+ Perspective

Perspective

It is not a surprise to learn that more patients with type 1 diabetes are using technology like continuous glucose monitoring and insulin pumps. What is surprising is that, in terms of outcomes, we did not move an inch from 6 years ago. These numbers — only 17% of children and 21% of adults with type 1 diabetes are meeting HbA1c targets — are a big surprise for me, considering the increased use of CGM and insulin pump therapy.

In particular, the observed increase in HbA1c among adolescents with type 1 diabetes is also a surprise, as this group is supposedly more technology savvy. In general, the study shows a lot of very interesting observations, and we need to dive deeply into all of them to try to find out what is going on.

It is also important to remember that most of these data are likely overestimated, including the data on CGM and pump usage, as these are patients from an endocrinology practice, not patients seeing a primary care physician. In the overall type 1 population, the numbers are perhaps even worse.

One observation, which is mentioned in this study, is that although more people with type 1 diabetes are using technology and uploading their data, few are downloading and reviewing the data. In the future, better tools that can give patients feedback that they can act on immediately will help. This is one issue.

The other issue is a lack of options. We have one way of treating people with type 1 diabetes, which is insulin. Today, we have a more overweight and obese type 1 generation vs. previous generations. The number of people with overweight or obesity and type 1 diabetes is now close to 60%. They are not only fighting type 1, they are fighting insulin resistance and the consequences of excess weight. These people need new therapy options and support tools that provide better feedback to really move the needle in terms of outcomes.

Osama Hamdy, MD, PhD, FACE

Medical Director, Obesity Clinical Program

Director of Inpatient Diabetes Program, Joslin Diabetes Center

Harvard Medical School

Disclosure: Hamdy reports he receives research support from the National Dairy Council and Novo-Nordisk, and is a consultant for Abbott Nutrition and Merck, an advisor for Astra-Zeneca and a stock holder in Healthimation Inc.