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.
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: firstname.lastname@example.org.
Disclosures: The authors report no relevant financial disclosures.