Improved metabolic control in children and adolescents with type 1 diabetes: a trend analysis using prospective multicenter data from Germany and Austria

Joachim Rosenbauer, Axel Dost, Beate Karges, Andreas Hungele, Anna Stahl, Christina Bächle, Eva Maria Gerstl, Christian Kastendieck, Sabine E Hofer, Reinhard W Holl, DPV Initiative and the German BMBF Competence Network Diabetes Mellitus, Joachim Rosenbauer, Axel Dost, Beate Karges, Andreas Hungele, Anna Stahl, Christina Bächle, Eva Maria Gerstl, Christian Kastendieck, Sabine E Hofer, Reinhard W Holl, DPV Initiative and the German BMBF Competence Network Diabetes Mellitus

Abstract

Objective: To investigate the temporal trend of metabolic control and potential predictors in German and Austrian children and adolescents with type 1 diabetes.

Research design and methods: This study is based on a large, multicenter database for prospective longitudinal documentation of diabetes care in Germany and Austria. Data from 30,708 patients documented in 305 diabetes centers between 1995 and 2009 were analyzed. Generalized linear mixed regression models were used to adjust trend analysis for relevant confounders.

Results: Unadjusted mean HbA(1c) decreased from 8.7 ± 1.8% in 1995 to 8.1 ± 1.5% in 2009. In multiple regression analysis, treatment year, age, sex, diabetes duration, migration background, BMI-SDS, and daily insulin dose were significant predictors of metabolic control (P < 0.001). After multiple adjustment, mean HbA(1c) decreased significantly by 0.038% per year (95% CI 0.032-0.043%), average odds ratio (OR) per year for HbA(1c) >7.5% (>9.0%) was 0.969 (95% CI 0.961-0.977) (0.948, 95% CI 0.941-0.956). Intensified insulin regimen was associated with lower frequency of poor metabolic control (HbA(1c) >9%; P = 0.005) but not with average HbA(1c) (P = 0.797). Rate of severe hypoglycemia and hypoglycemic coma decreased significantly (relative risk [RR] per year 0.948, 95% CI 0.918-0.979; RR 0.917, 95% CI 0.885-0.950) over the study period. Diabetic ketoacidosis rate showed no significant variation over time.

Conclusions: This study showed a significant improvement in metabolic control in children and adolescents with type 1 diabetes during the past decade and a simultaneous decrease in hypoglycemic events. The improvement was not completely explained by changes in the mode of insulin treatment. Other factors such as improved patient education may have accounted for the observed trend.

Figures

Figure 1
Figure 1
Time trends of metabolic control and acute diabetes complications. Multiple adjusted estimates of mean HbA1c (A), proportion of patients with HbA1c >7.5% (B) or HbA1c >9.0% (C), and rates of severe hypoglycemia (D), hypoglycemic coma (E), and DKA (F) by year of treatment. Estimates are derived from multiple (generalized) linear mixed models including year of treatment, age at follow-up, sex, diabetes duration, migration background, BMI-SDS, mode of therapy (CT, MDI, or CSII), insulin dose per kg body weight and day, and size and type of diabetes center as fixed independent variables and diabetes center as random independent variable. Analyses for metabolic control and DKA are based on 30,021 patients because of missing values for BMI-SDS and/or daily insulin dose (n = 687), and analyses for hypoglycemic events are based on 27,586 patients because of missing values for hypoglycemic events (n = 2,748) and BMI-SDS and/or insulin dose (n = 374). Time trends in dependent variables (represented by solid lines) and estimates of average changes per year (absolute decrease, OR, and RR) were derived from multiple (generalized) linear mixed models by including a linear trend term for calendar year. Vertical whiskers represent 95% CIs.

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