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Incidence and Risk Factors of Type 1 Diabetes: Implications for the Emergency Department

Npod LogoType 1 diabetes (T1D) is one of the most common endocrine diseases in children. A chronic autoimmune disease, about 65,000 children worldwide develop T1D each year. (1)  It accounts for about 5% of all diabetes cases. There is no known way to prevent it, and the only effective treatment requires frequent blood glucose monitoring and the use of insulin to stay alive. (2)

The incidence of T1D in the United States, Europe, and Australia has been increasing for the last four decades.  According to the Juvenile Diabetes Research Foundation, the incidence among European children aged one to five years old is increasing at 5.4% annually—much higher than other age groups. Similar trends are reported in the United States.  At the current rate, the number of T1D cases will double during this decade. (3)  (Interestingly, allergic reactions, food allergies, and other autoimmune diseases are also on the rise.) 

There are two striking trends connected to the T1D epidemic:
1.    The disease is occurring much earlier in life.
2.    The disease is striking in people previously considered to be at low or moderate genetic risk.

TID is caused by a combination of genetic and unknown environmental factors. Identifying the specific triggers is part of current research—what is causing these immunoregulation defects?  The answer isn’t yet known, but the drastic increase worldwide rules out genetics alone as the cause.

Research has focused on several hypotheses regarding T1D epidemiology.  Investigators have considered infection, early childhood diet, vitamin D, environmental pollutants, increased height velocity, obesity, and insulin resistance as possible causes or triggers.  Forlenza and Rewers, from the Department of Pediatrics at University of Colorado, report that during the past year the evidence has strengthened for early childhood infections, dietary proteins, and insulin resistance as risk factors for T1D, but not vitamin D exposure or environmental pollutants. (4)

While children are more easily diagnosed, treated, and followed for T1D these days, about a third of them will develop diabetic ketoacidosis (DKA) at some point, defined by a blood bicarbonate of < 15 mmo/L and/or venous pH <7.25/arterial or capillary pH <7.30.  They may possibly present to the Emergency Department, most likely with advanced DKA symptoms:
•    Nausea/vomiting
•    Abdominal pain
•    Confusion
•    Kussmaul respirations
•    Breath that smells fruity
•    Fever
•    Unconsciousness

Some patients will present with DKA related to new onset or previously undiagnosed T1D.  The Search for Diabetes in Youth Study, a multicenter, population-based registry of diabetes with diagnosis before 20 years of age, reported the prevalence of DKA at diagnosis to be 25.5%.  More than half (54%) of the 3666 patients were hospitalized at diagnosis, including 93% with DKA and 41% without DKA.  (5) 

A systematic review of 46 studies, published in the British Medical Journal in 2011, sought to identify the factors associated with diabetic ketoacidosis DKA at the time of diagnosis of T1D in children and young adults.  The studies covered more than 24,000 children in 31 countries. 

Risk factors for DKA at the onset of type 1 diabetes (6):
•    Younger age, as noted earlier
•    Diagnostic error
•    Ethnic minority status
•    Lack of health insurance in the US
•    Lower body mass index
•    Preceding infection
•    Delayed treatment
Of note is the observation that the mean duration between onset of symptoms and development of DKA is over 14 days.  Up to a third of children have at least one medical consultation during that period, suggesting a possible window of opportunity for early intervention. (6)

Conversely, protective factors for DKA include: (6)
•    Having a first degree relative with TID at the time of diagnosis
•    Higher parent education
•    Higher background incidence of TiD
•    Presence of a structured diabetes treatment team

Emergency Medicine plays an essential role in the care of the T1D child.  While care and treatment is constantly improving, unexpected events will send these children to the Emergency Department for rapid diagnosis and transfer to an inpatient setting.  Knowledge of the rise of incidence of T1D, as well as some factors affecting DKA, will contribute to awareness and response when a T1D case presents.

1.  DIAMOND Project Group. Incidence and trends of childhood type 1 diabetes worldwide 1990-1999. Diabet Med 2006; 23: 857-66. [PubMed]
2.  Centers for Disease Control and Prevention website, April 17, 2012
3.  Juvenile Diabetes Research Foundation website, April 13, 2012
4.  Forlenza GP, Rewers M.  The epidemic of type 1 diabetes: what is it telling us?
Curr Opin Endocrinol Diabetes Obes. 2011 Aug; 18(4): 248-51 [PubMed]
5.  Rewers A, Klingensmith G, Davis C, Petitti DB, Pihoker C, Rodriguez B, Schwartz ID, Imperatore G, Williams D, Dolan LM, Dabelea D.  Presence of diabetic ketoacidosis at diagnosis of diabetes mellitus in youth:  the Search for Diabetes in Youth Studay.  Pediatrics 2008 May; 121 (5): e 1258-66 [PubMed]
5.  Usher-Smith J, Thompson MJ, Sharp SJ, Walter, FM. Factors associated with the presence of diabetic ketoacidosis at diagnosis of diabetes in children and young adults:  a systematic review. British Medical Journal 2011; 343: d4092 [PubMed]Type 1 diabetes (T1D) is one of the most common endocrinediseases in children. A chronic autoimmune disease, about 65,000 childrenworldwide develop T1D each year. (1)  It accounts for about 5% of all diabetescases. There is no known way to prevent it, and the only effective treatmentrequires frequent blood glucose monitoring and the use of insulin to stay alive.(2)

 

The incidence of T1D in the United States, Europe, andAustralia has been increasing for the last four decades.  According to the Juvenile Diabetes ResearchFoundation, the incidence among European children aged one to five years old isincreasing at 5.4% annually—much higher than other age groups. Similar trendsare reported in the United States.  Atthe current rate, the number of T1D cases will double during this decade. (3)  (Interestingly, allergic reactions, foodallergies, and other autoimmune diseases are also on the rise.) 

 

There are two striking trends connected to the T1D epidemic:

1.    The disease is occurring much earlier in life.

2.    The disease is striking in people previouslyconsidered to be at low or moderate genetic risk.

 

TID is caused by a combination of genetic and unknownenvironmental factors. Identifying the specific triggers is part of currentresearch—what is causing these immunoregulation defects?  The answer isn’t yet known, but the drasticincrease worldwide rules out genetics alone as the cause.

 

Research has focused on several hypotheses regarding T1Depidemiology.  Investigators haveconsidered infection, early childhood diet, vitamin D, environmentalpollutants, increased height velocity, obesity, and insulin resistance aspossible causes or triggers.  Forlenzaand Rewers, from the Department of Pediatrics at University of Colorado, reportthat during the past year the evidence has strengthened for early childhoodinfections, dietary proteins, and insulin resistance as risk factors for T1D,but not vitamin D exposure or environmental pollutants. (4)

 

While children are more easily diagnosed, treated, andfollowed for T1D these days, about a third of them will develop diabeticketoacidosis (DKA) at some point, defined by a blood bicarbonate of < 15mmo/L and/or venous pH <7.25/arterial or capillary pH <7.30.  They may possibly present to the EmergencyDepartment, most likely with advanced DKA symptoms:

   Nausea/vomiting

   Abdominal pain

   Confusion

   Kussmaul respirations

   Breath that smells fruity

   Fever

   Unconsciousness

 

Some patients will present with DKA related to new onset orpreviously undiagnosed T1D.  The Searchfor Diabetes in Youth Study, a multicenter, population-based registry ofdiabetes with diagnosis before 20 years of age, reported the prevalence of DKAat diagnosis to be 25.5%.  More than half(54%) of the 3666 patients were hospitalized at diagnosis, including 93% withDKA and 41% without DKA.  (5) 

 

 A systematic reviewof 46 studies, published in the BritishMedical Journal in 2011, sought to identify the factors associated withdiabetic ketoacidosis DKA at the time of diagnosis of T1D in children and youngadults.  The studies covered more than24,000 children in 31 countries. 

 

Risk factors for DKA at the onset of type 1 diabetes (6):

      Younger age, as noted earlier

      Diagnostic error

      Ethnic minority status

      Lack of health insurance in the US

      Lower body mass index

      Preceding infection

      Delayed treatment

Of note is the observation that the mean duration betweenonset of symptoms and development of DKA is over 14 days.  Up to a third of children have at least onemedical consultation during that period, suggesting a possible window of opportunityfor early intervention. (6)

 

Conversely, protective factors for DKA include: (6)

      Having a first degree relative with TID at thetime of diagnosis

      Higher parent education

      Higher background incidence of TiD

      Presence of a structured diabetes treatment team

 

Emergency Medicine plays an essential role in the care ofthe T1D child.  While care and treatmentis constantly improving, unexpected events will send these children to theEmergency Department for rapid diagnosis and transfer to an inpatientsetting.  Knowledge of the rise ofincidence of T1D, as well as some factors affecting DKA, will contribute toawareness and response when a T1D case presents.

 

1.  DIAMOND ProjectGroup. Incidence and trends of childhood type 1 diabetes worldwide 1990-1999. Diabet Med 2006; 23: 857-66. [PubMed]

2.  Centers forDisease Control and Prevention website, April 17, 2012

3.  Juvenile DiabetesResearch Foundation website, April 13, 2012

4.  Forlenza GP,Rewers M.  The epidemic of type 1diabetes: what is it telling us?

Curr Opin EndocrinolDiabetes Obes. 2011 Aug; 18(4): 248-51 [PubMed]

5.  Rewers A,Klingensmith G, Davis C, Petitti DB, Pihoker C, Rodriguez B, Schwartz ID,Imperatore G, Williams D, Dolan LM, Dabelea D.  Presence of diabetic ketoacidosis at diagnosisof diabetes mellitus in youth:  theSearch for Diabetes in Youth Studay.  Pediatrics 2008 May; 121 (5): e 1258-66[PubMed]

5.  Usher-Smith J,Thompson MJ, Sharp SJ, Walter, FM. Factors associated with the presence ofdiabetic ketoacidosis at diagnosis of diabetes in children and youngadults:  a systematic review. British Medical Journal 2011; 343: d4092[PubMed]

 

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