Frequency of abnormal carbohydrate metabolism and diabetes in a population-based screening of adolescents

OBJECTIVE: To document the frequency of glucose intolerance in adolescents in a population-based study of primarily African-American/Non-Hispanic whites in an urban-suburban school district. STUDY DESIGN: Measurement of fasting and 2-hour post-glucose load plasma glucose concentrations. RESULTS: Carbohydrate intolerance (either impaired fasting glucose, impaired glucose tolerance, or both) was identified in 8.0%, near-diabetes (1 fasting glucose > or = 126 mg/dL [7.0 mmol/L] and/or 2-hour glucose > or = 200 mg/dL [11.1 mmol/L]) in 0.3%, and diabetes in 0.36% (type 1A = 0.24%; type 2 = 0.08%; undiagnosed type 2 = 0.04%). A model for abnormal carbohydrate metabolism was constructed with regression analysis in the Carbohydrate Intolerance (CI)/near-diabetes group and with logistic regression in the entire study population. Risk factors for the development of CI/near-diabetes included having a 1 unit increase in body mass index (BMI) z-score and either being non-Hispanic white or in the pubertal group. Increased fasting glucose correlated with having puberty and decreased BMI z-score, whereas 2-hour glucose correlated with increased BMI z-score. By using National Health and Nutrition Survey (NHANES) III (1988-1994) definitions, impaired fasting glucose was present in 2.0% in this study versus 1.7% (NHANES III). CONCLUSION: The prevalence of CI/near-diabetes was 8.3%. Undiagnosed diabetes mellitus was rare. One third of adolescents with diabetes mellitus could be classified as having type 2 diabetes mellitus. The adult model of the progression of insulin resistance to type 2 diabetes mellitus in adolescents may be valid. Despite the increase in the overweight population since NHANES III, abnormalities in glucose metabolism have not changed significantly.     

Assessment of glycemic control by continuous glucose monitoring system in 50 children with type 1 diabetes starting on insulin pump therapy

OBJECTIVE: To report experience with a continuous glucose monitoring system (CGMS) and to identify factors influencing glycemic control in a large cohort of children and adolescents with type 1 diabetes and change to insulin pump therapy via continuous subcutaneous insulin infusion (CSII). RESEARCH DESIGN and METHODS: In 50 patients [21 boys, 29 girls; median age 12.6 yr (range: 1.3-16.4 yr); diabetes duration 5.0 yr (0.2-13.3)], hemoglobin A1c (HbA1c) and ambulatory CGMS were performed before and 6 wk after starting CSII. Average glucose concentration per 24 h, during day and night time as well as number of excursions, duration, and area under the curve (AUC) of glucose values above 180 mg/dL and below 60 mg/dL were calculated from CGMS data. Simultaneously, metabolic control was documented by standardized self-monitoring of blood glucose (SMBG). RESULTS: In the total cohort, HbA1c improved from 8.1 +/- 1.2% at baseline to 7.7 +/- 0.9% after 6 wk of CSII (p <0.001). This effect was more distinct in boys (8.0 +/- 1.4 vs. 7.5 +/- 1.1%, p=0.007) than in girls (8.1 +/- 1.1 vs. 7.8 +/- 0.7%, p=0.039) as well as in patients with poor glycemic control (HbA1c >8.0%) at baseline (8.9 +/- 0.6 vs. 8.1 +/- 0.8%, p <0.001) and in those older than 12 yr (8.2 +/- 1.2 vs. 7.7 +/- 1.0%, p <0.001). At 6 wk of CSII, the values of glucose average per 24 h, AUC and time above 180 mg/dL, particularly during the day, improved. HbA1c was correlated with AUC above 180 mg/dL (r=0.742, p <0.001) and CGMS average glucose per 24 h (r=0.628, p=0.002), but to a lesser extent with SMBG values (r=0.418, p=0.054). CONCLUSION: With the change to CSII, HbA1c improved significantly after 6 wk of therapy. CGMS usage provided additional information about glycemic control in these patients.     

One‐hour plasma glucose concentration during the OGTT: what does it tell about β‐cell function relative to insulin sensitivity in overweight/obese children?

Tfayli H, Jung Lee S, Bacha F, Arslanian S. One‐hour plasma glucose concentration during the OGTT: what does it tell about β‐cell function relative to insulin sensitivity in overweight/obese children? Background: In adults 1‐h plasma glucose concentration cut‐point of 155 mg/dL (8.6 mmol/L) during the oral glucose tolerance test (OGTT) is a strong predictor of future diabetes risk. Objective: We tested the hypothesis that a 1‐h glucose concentration ≥155 mg/dL is associated with lower β‐cell function in overweight/obese youth. Research design and methods: One hundred and thirteen diabetes free overweight/obese youth aged 10–20 yr, underwent evaluation of β‐cell function during a 2 h hyperglycemic clamp ～225 mg/dL (12.5 mmol/L), and insulin sensitivity during a 3 h hyperinsulinemic–euglycemic clamp, and a standard 2 h OGTT. Body composition and abdominal adiposity were determined by DEXA and CT scan. The disposition index (DI) was calculated as the product of first‐phase insulin secretion and insulin sensitivity. Subjects were divided into two categories of 1‐h plasma glucose concentration: <155 mg/dL (n = 69) and ≥155 mg/dL (n = 44). Results: Youth with 1‐h glucose ≥155 mg/dL had lower DI than those with 1‐h glucose <155 mg/dL (295.1 ± 27.4 vs. 498.6 ± 37.7 mg/kg/min, p < 0.001), independent of the glucose tolerance status. In multiple regression models, DI was the strongest contributor to 1‐h glucose concentration explaining ～21% of its variance. Conclusions: Overweight/obese youth with 1‐h glucose ≥155 mg/dL during the oral glucose tolerance test have a significantly lower β‐cell function relative to insulin sensitivity even within the normal glucose tolerance range. Such youth may be at higher risk of future diabetes.     

Elevated fasting triglycerides predict impaired glucose tolerance in adolescents at risk for type 2 diabetes

OBJECTIVE: The aim of this study was to evaluate whether fasting laboratory values can predict impaired glucose tolerance (IGT) in adolescents who are at risk for developing type 2 diabetes mellitus (T2DM). HYPOTHESIS: Elevated fasting triglycerides, a marker for worsening insulin resistance, predict risk for IGT. DESIGN: Following a fast of at least 9 h, laboratory measures, body mass index (BMI), and demographic information were obtained. The subjects then underwent a 75-g oral glucose challenge with a 2-h postchallenge glucose determination. SUBJECTS: Eighty-four adolescents aged 12-20 yr with at least two risk factors for developing T2DM (obesity, family history of T2DM, or acanthosis nigricans) and with either a fasting insulin level > or =25 microU/mL or a homeostasis model assessment of insulin resistance (HOMA-IR) > or =3.5 were recruited for the study. RESULTS: Ten subjects (12%) had IGT [2-h glucose > or =140 mg/dL (7.77 mmol/L)], and 10 subjects (12%) had impaired fasting glucose [IFG; fasting glucose > or =100 mg/dL (5.55 mmol/L)]. However, only three (30%) subjects with IGT had IFG, though all subjects with IGT had a fasting triglyceride level > or =150 mg/dL (1.70 mmol/L). Of those subjects with elevated triglycerides, 29% had IGT. As a screening test to predict risk for IGT, elevated triglycerides >150 mg/dL had a sensitivity of 100% and a specificity of 68%. The positive predictive value was 29%, and the negative predictive value was 100%. CONCLUSIONS: Screening with fasting glucose alone would have missed 70% of subjects with IGT in this population of insulin-resistant adolescents. However, a fasting triglyceride level > or =150 mg/dL was strongly associated with IGT and may help to identify at-risk adolescents who should undergo formal glucose tolerance testing.     

Reducing postprandial hyperglycemia with adjuvant premeal pramlintide and postmeal insulin in children with type 1 diabetes mellitus

Objective:  The purpose of this study was to determine the effect of adjuvant premeal pramlintide with postmeal insulin on postprandial hyperglycemia in children with type 1 diabetes mellitus (T1DM).
Methods:  Eight adolescents with T1DM on intensive insulin therapy participated in an open-label, non-randomized, crossover study, comparing postprandial glucose excursions in study A (prescribed insulin regimen and given premeal) vs. study B (pramlintide + insulin). Prandial insulin dose for study B was decreased by 20% and given postmeal, while pramlintide was given just before the meal. Blood glucose (BG), glucagon, and pramlintide concentrations were measured basally and at timed intervals during a 300-min study period.
Results:  Postprandial incremental BG for the duration of the study was reduced in study B vs. study A with AUC_{(−60 to 300 min)} (area under the curve) at 6600 ± 2371 vs. 20 230 ± 3126 mg/dL/min (367 ± 132 vs. 1124 ± 174 mmol/L/min) (p < 0.001). Glucagon concentration was suppressed for ∼120 min following administration of 30 μg of pramlintide and postmeal insulin (p < 0.003). No severe hypoglycemic episodes were experienced in this study.
Conclusions:  Postprandial hyperglycemia is considerably reduced in adolescents with T1DM when treated with fixed-dose premeal pramlintide, and precisely calculated postmeal insulin, without significant side effects.     

Continuous glucose monitoring in children with type 1 diabetes: before and after insulin pump therapy

Abstract: Objective: The aim of continuous subcutaneous insulin infusion (CSII) therapy in patients with type 1 diabetes mellitus (T1DM) is to mimic as closely as possible the normal physiologic pattern seen in individuals without diabetes. This study was undertaken to determine the specific areas of improved glycemic control in subjects after initiation of insulin pump therapy and times where further improvement is needed. Research design and methods: Eight patients with T1DM (age 7.5–17 yr) wore the Continuous Glucose Monitoring System (CGMS) (Medtronic MiniMed, Northridge, CA, USA) for 3 d before and 3 months after initiation of insulin pump therapy. The CGMS, which measures inter‐ stitial glucose concentrations every 5 min for a 72‐h period, was used to evaluate glucose profiles. Patients entered 4–5 fingerstick blood glucose measurements daily into the sensor for calibration. Detailed logs of food intake, exercise, and hypoglycemic symptoms were also recorded. Results: Hemoglobin A1c (HbA1C) was reduced (p < 0.007) following 3 months of insulin pump therapy. Post‐CSII continuous glucose profiles demonstrated an overall improvement in hourly mean glucose over a 24‐h period (p < 0.001) as well as a reduction in the area under the curve for glucose (27 ± 4 prepump vs. 8.6 ± 1.4 mg/dL/d postpump, p < 0.004). This improvement was a result of an attenuation of the maximal postprandial glycemic excursions. Postbreakfast 349 ± 24 vs. 267 ± 16 mg/dL, p < 0.003; lunch 340 ± 16 vs. 217 ± 20 mg/dL, p < 0.003. Postdinner average similarly decreased after 3 months of CSII by 22%, p < 0.04. Conclusions: Pump therapy specifically improved the postprandial glucose excursions in children.     

Insulin resistance in newly diagnosed type 1 diabetic children and adolescents

The aim of this study was to estimate insulin resistance in newly diagnosed type 1 diabetic children and adolescents and to analyse the correlation between insulin secretion and impaired insulin action. 37 patients with type 1 diabetes mellitus aged 12.9 +/- 3 years were included in the study. Duration of diabetes was 6 months. Euglycemic-hyperinsulinemic clamp was performed to estimate insulin resistance. Glucose disposal rate was calculated as index M - mg/kg/min. Insulin secretion was measured by glucagon test. The serum level of cholesterol, HDL-Ch, triglycerides and HbA1 was examined. The height, weight, skinfold, waist and hip circumference were measured. Body mass index and waist/hip ratio were calculated. In children and adolescents with type1 diabetes mellitus insulin resistance of various degree was observed. The glucose disposal rate (M index) was 3.2 - 11.8 mg/kg/min., mean 7.08 +/- 2.5 mg/kg/min. The insulin resistance depended on patients' age (r= - 0.3, p<0.05,) and the stage of puberty. There was no difference in insulin secretion in insulin-resistant and insulin-sensitive subjects. The insulin resistance was related to BMI (r=-0.33; p=0.04), and with skinfold thickness (r=-0.59; p=0.001). In insulin-sensitive children the insulin dose was lower (0.45: 0.67; p<0.02). No influence of insulin resistance on metabolic control was observed. Insulin resistance is observed in newly diagnosed type 1 diabetic children and adolescents. No relationship between insulin secretion and impaired insulin action was found. Insulin resistance was greater during III Tanner stage of puberty and in obese children.     

Driving safety: concerns and experiences of parents of adolescent drivers with type 1 diabetes

Driving is a dangerous activity for adolescents, perhaps being even more precarious for adolescents with type 1 diabetes due to the possibility of extreme blood glucose (BG). There is no available data on adolescent driving safety concerns and type 1 diabetes. To begin addressing this issue, we surveyed parents regarding their observations and concerns. Seventy‐two parents (87.5% mothers) of adolescent drivers aged 16–19 with type 1 diabetes provided analyzable data. Females comprised 36% of their adolescents, with 74% using pump therapy. In the past year, 13 and 84% of parents reported that their adolescent had experienced severe or moderate disruptive hypoglycemia, respectively. Over half (56%) of the parents reported moderate to extreme worry about how diabetes impacted their adolescent's driving, while only 21% of parents thought their adolescents had similar concerns (p = 0.037). Almost one third (31%) of parents thought their adolescent need not treat low BG until it fell below 70 mg/dL, 13% thought their adolescent could safely drive with BG below 65 mg/dL. And, 31 and 14% of parents, respectively, reported their adolescent had been in a collision or stopped by the police in the past year, which they attributed to both hypo‐ and hyperglycemia. Adolescents reportedly took steps to prevent hypo‐ and hyperglycemia while driving, but more aggressively avoided hypoglycemia (p < 0.001). While this data is limited, lacking a non‐diabetic control group and randomized sample, it does suggest that driving and adolescent type 1 diabetes deserve further attention and investigation.     

Gestational diabetes mellitus and glucose intolerance among Mexican pregnant adolescents

There is an increasing incidence of type 2 diabetes mellitus (DM) among adolescents (especially females), and the serum glucose concentrations in pregnant women <25 years during a 3-h oral glucose tolerance test (3-h OGTT) seem to be lower than those of pregnant women >25 years. Among 115 Mexican pregnant adolescents (<18 years) we analyzed their serum glucose concentrations during: a) 1-h 50-g glucose challenge test (GCT) performed at 24-28 weeks of gestation (n = 103) or at 29-35 weeks of gestation (n = 12); b) A standard 3-h OGTT performed 3-5 days later. Eight adolescents had an abnormal GCT, three of whom also had an abnormal 3-h OGTT. Sixteen adolescents (13 with previously normal GCT) had an abnormal 3-h OGTT, 15 classified as GGI and one as gestational DM (GDM). Serum glucose concentrations in adolescents with GGI were higher than in adolescents with normal 3-h OGTT: a) at 60 and 120 min during the 3-h OGTT (p < 0.001); and b) when expressed as the area under the glucose curve (p < 0.001). Adolescents with GGI had serum glucose concentrations during the 3-h OGTT similar to adult, non-diabetic pregnant Mexican women. It is suggested that GGI in pregnant adolescents may represent an early sign of a future deterioration in glucose metabolism, leading to a higher risk for GDM in future pregnancies and/or type 2 DM in adulthood. Thus, the current criteria to diagnose GDM in adults may not completely apply to adolescents, especially in ethnic groups with high risk for glucose abnormalities and considering the frequency of multiparous adolescents, especially in developing countries.     

Characteristics of glycemic control in young children with type 1 diabetes

Abtract: Background: The Diabetes Control and Complications Trial (DCCT) demonstrated that the rate-limiting step to the intensification of diabetes management in adolescents and adults was hypoglycemia. Young children were presumed to be at even greater risk for hypoglycemia with severe consequences, particularly if they had HbA1c levels < 8%.
Subjects: A retrospective chart review was performed on 148 patients with type 1 diabetes on insulin injection therapy who were < 8 yr of age (mean age 5.7 ± 1.5, mean diabetes duration 3.0 ± 1.4 yr) followed quarterly from July 1999 to June 2001.
Methods:  The subjects were divided into two groups based on their mean HbA1c values (< 8 vs. ≥ 8%) averaged over the 2-yr time period. The following variables were analyzed comparing the two groups: age, duration of diabetes, insulin dose, severe hypoglycemic episodes, episodes of diabetic ketoacidosis (DKA), percentage of glucose levels above, within, and below the target range, and number of diabetes home-management competencies obtained.
Results:  Patients with HbA1c < 8% spent more time within target range (40.0 vs. 29.5%, p = 0.0001) and less time above their target range (36.9 vs. 51.2%, p = 0.0003). There was no difference in the percentage of glucose levels below target (23.2 vs. 19.4%, p = NS), percentage of severe hypoglycemic episodes (3 vs. 7 episodes per 100 patient-yr, p = NS), or episodes of DKA (1 vs. 3 episodes per 100 patient-yr, p = NS) between the two groups. Subjects with lower HbA1c levels had acquired more home-management competencies (4.0 vs. 3.5, p = 0.01).
Conclusions:  If families are competent in fundamental diabetes management, young children can achieve HbA1c levels < 8.0% without increasing the risk of hypoglycemia.     

Hypertension and hypercholesterolemia aggregate in nondiabetic children and adolescents with higher fasting plasma glucose levels

Li H‐Y, Wei J‐N, Ma W‐Y, Sung F‐C, Lin M‐S, Lin C‐H, Chiang C‐C, Chuang L‐M. Hypertension and hypercholesterolemia aggregate in nondiabetic children and adolescents with higher fasting plasma glucose levels. Objective: To investigate how hypertension and hypercholesterolemia aggregate at different fasting plasma glucose (FPG) levels in children aged 6–16 yr. Research design and methods: In a nationwide survey conducted between 1992 and 2000, all schoolchildren aged 6–18 yr with abnormal results in repeated urine samples were included. In this study, we recruited 27 535 students aged 6‐ to 16‐yr whose FPG levels were 90–125 mg/dL. Another 17 907 children were randomly selected as control from schoolchildren with FPG <90 mg/dL by stratification to reflect the age‐ and sex‐specific proportion of the whole student population. Results: The risk of having hypertension or hypercholesterolemia increased at FPG level above 90 mg/dL compared with children with FPG <90 mg/dL [6–10 yr, odd ratios (OR) = 1.51 and 1.82 for FPG 90–99 and 100–125 mg/dL for girls, OR = 1.35 and 2.03 for FPG 90–99 and 100–125 mg/dL for boys; 10–16 yr, OR = 1.24 and 1.66 for FPG 90–99 and 100–125 mg/dL for girls, OR = 1.17 and 1.41 for FPG 90–99 and 100–125 mg/dL for boys, all p < 0.05]. The risk of having both hypertension and hypercholesterolemia elevated at FPG 100–125 mg/dL (6–10 yr, OR = 2.76 for girls and 2.75 for boys; 10–16 yr, OR = 2.19 for girls and 1.74 for boys, all p < 0.05). Conclusions: Aggregation of hypertension, hypercholesterolemia, and abnormal glycemia was found at FPG level above 100 mg/dL, which supported the definition of abnormal glycemia in metabolic syndrome by the International Diabetes Federation in 10‐ to 16‐yr‐old children. These findings also suggest that this FPG cutoff is reasonable for 6‐ to 10‐yr‐old children.     

Efficacy of orlistat as an adjunct to behavioral treatment in overweight African American and Caucasian adolescents with obesity-related co-morbid conditions

This pilot study compared the efficacy of orlistat as an adjunctive treatment for obesity between African American and Caucasian adolescents. Twenty obese adolescents with obesity-related co-morbid conditions underwent measurements of body composition, glucose homeostasis by frequently sampled intravenous glucose tolerance test (FSIGT), and fasting lipids before and after 6 months treatment with orlistat 120 mg tid in conjunction with a comprehensive behavioral program. Weight (p < 0.05), BMI (p < 0.001), total cholesterol (p < 0.001), LDL cholesterol (p < 0.001), fasting insulin (p < 0.02) and fasting glucose (p < 0.003) were lower after treatment. Insulin sensitivity, measured during the FSIGT, improved significantly (p < 0.02), as did fasting indices such as the homeostasis model assessment for insulin resistance (p < 0.01). African American subjects exhibited significantly less improvement in weight (p < 0.05), BMI (p < 0.01), waist circumference (p = 0.03), and insulin sensitivity (p = 0.05). Improvements in cholesterol were not significantly different between African Americans and Caucasians. We conclude that Caucasians lost more weight and had greater improvements in insulin sensitivity than African Americans, but both exhibited improvements in plasma lipids. The true benefit of orlistat treatment over a comprehensive behavioral program remains to be determined in placebo-controlled trials.     

Exaggerated epinephrine responses to hypoglycemia in normal and insulin-dependent diabetic children

To determine whether children with insulin-dependent diabetes mellitus (IDDM) might have exaggerated hormonal responses to hypoglycemia, the euglycemic-hypoglycemic glucose clamp procedure was used to provide a uniform hypoglycemic stimulus (plasma glucose kept at 90 mg/dL for 2 hours, then reduced to 50 to 55 mg/dL for 1 hour) in children and adults with and without IDDM. The chidren with IDDM showed an exaggerated rise in plasma epinephrine levels (625 +/- 112 pg/mL) compared with adults with IDDM (259 +/- 57 pg/mL, P less than 0.02); the same was true for children and adults without IDDM (811 +/- 100 vs 458 +/- 85 pg/mL, P less than 0.05). Among the children, the increase in epinephrine during hypoglycemia was similar in prepubertal and pubertal patients. Children with IDDM showed a greater rise in plasma norepinephrine than did adults with IDDM (P less than 0.001), and both diabetic groups failed to mount a glucagon response. Growth hormone and cortisol responses were unaffected by either childhood or diabetes. Enhanced secretion of epinephrine, induced by mild reductions in plasma glucose, may contribute to the management difficulties characteristically observed in the young patient with diabetes.     

Ketoacidosis at onset of type 1 diabetes mellitus in children--frequency and clinical presentation

Abstract: Background: Since 1987, patients with newly diagnosed diabetes mellitus type 1 under 15 yr of age have been registered in Baden‐Wuerttemberg (BW), Germany. Aim: Our aim was to describe the frequency and the clinical presentation of diabetic ketoacidosis (DKA) at onset of type 1 diabetes mellitus in children. Methods: All 31 pediatric departments in BW and one diabetes center participated in this study. Hospital records of 2121 children below 15 yr of age were examined retrospectively. DKA was defined as glucose > 250 mg/dL, pH < 7.30 or bicarbonate < 15 mmol/L and ketonuria. Statistical analysis was done after logarithmic transformation. Results: 26.3% (n = 558) of all patients presented with DKA. The mean age of these patients was 7.9 yr. The frequency of DKA is higher in girls than in boys (28.9 vs. 23.8%; p = 0.0079). Those aged 0–4 yr suffered most frequently (p < 0.0001) from ketoacidosis (36.0%). The percentage of DKA in newly diagnosed cases was constant over 10 yr. 23.3% of all patients with DKA presented with an altered level of consciousness; 10.9% of these had clinical signs of coma. No deaths occurred. The proportion of ketoacidosis does not increase concurrently with the number of diabetes manifestations in winter. Conclusion: The proportion of DKA in children with newly diagnosed diabetes mellitus is significant. In particular, children < 5 yr and girls face an increased risk. DKA may be the result of a particularly aggressive subtype of diabetes.     

Glucose tolerance status in 510 children and adolescents attending an obesity clinic in Central Italy

Brufani C, Ciampalini P, Grossi A, Fiori R, Fintini D, Tozzi A, Cappa M, Barbetti F. Glucose tolerance status in 510 children and adolescents attending an obesity clinic in Central Italy. Childhood obesity is epidemic in developed countries and is accompanied by an increase in the prevalence of type 2 diabetes (T2DM). Aims: Establish prevalence of glucose metabolism alterations in a large sample of overweight/obese children and adolescents from Central Italy. Methods: The study group included 510 overweight/obese subjects (3–18 yr). Oral glucose tolerance test (OGTT) was performed with glucose and insulin determination. Homeostatic model assessment of insulin resistance (HOMA‐IR) and insulin sensitivity index (ISI) were derived from fasting and OGTT measurements. Beta‐cell function was estimated by insulinogenic index. Fat mass was measured by dual‐energy x‐ray absorptiometry. Results: Glucose metabolism alterations were detected in 12.4% of patients. Impaired glucose tolerance (IGT) was the most frequent alteration (11.2%), with a higher prevalence in adolescents than in children (14.8 vs. 4.1%, p < 0.001); silent T2DM was identified in two adolescents (0.4%). HOMA‐IR and glucose‐stimulated insulin levels were higher in patients with IGT than individuals with normal glucose tolerance (HOMA‐IR = 4.4 ± 2.5 vs. 3.4 ± 2.3, p = 0.001). Fat mass percentage and insulinogenic index were not different between the two groups. In multivariate analysis, age, fasting glucose, and insulin resistance influenced independently plasma glucose at 120 min of OGTT. Individuals with combined impaired fasting glucose/IGT (IFG/IGT) and T2DM were older and had reduced plasma insulin values at OGTT when compared to patients with simple IGT. Conclusions: Glucose metabolism alterations are frequently found among children and adolescents with overweight/obesity from Central Italy. Age, fasting glucose, and insulin resistance are main predictors of IGT. We suggest the use of OGTT as a screening tool in obese European adolescents.     

Treatment with insulin glargine reduces asymptomatic hypoglycemia detected by continuous subcutaneous glucose monitoring in children and adolescents with type 1 diabetes

OBJECTIVE: Unsatisfactory basal insulin substitution may lead to asymptomatic hypoglycemia in children and adolescents with type 1 diabetes (T1D). To investigate the effects of multiple daily injections before and after changing to insulin glargine (IG), continuous glucose monitoring system (CGMS) data were used to analyze glycemic control and hypoglycemic episodes during the two different therapy regimens. METHODS: Basal insulin therapy was changed to one daily injection of IG in 30 pediatric patients with T1D (14 boys and 16 girls; age 4.5-18.3 yr, median 14.2 yr; diabetes duration 0.5-15.6 yr, median 4.6 yr) having elevated fasting glucose or recurrent hypoglycemia despite treatment with multiple injection therapy (basal insulin: two to four injections of neutral protamine Hagedorn (NPH) and/or zinc lente insulin). Ambulatory CGMS was applied before and 6-8 wk after treatment change. Frequency of hypoglycemic and hyperglycemic episodes, glucose area under the curve (AUC), and time below 60 mg/dL and above 180 mg/dL, respectively, were calculated from CGMS data during the day (8:00-22:00 hours) and at night (22:00-8:00 hours). RESULTS: Nocturnal hypoglycemia was detected by CGMS in 20 patients before and in 12 patients after the change to IG (p = .039), whereas both, the number of nocturnal and diurnal hypoglycemic episodes, decreased not significantly from 41 to 36 (p = .758) and 48 to 28 (p = .055), respectively. AUC and time below 60 mg/dL as well as hemoglobin A1c (HbA1c) were not significantly different before and after the change to IG. CONCLUSION: Under treatment with IG, asymptomatic hypoglycemia was reduced without increase of HbA1c.     

Measuring self-reported, health-related, quality of life in adolescents with type 1 diabetes using both generic and disease-specific instruments

AIMS: To describe perceived functional health and well-being and diabetes-related impact, worry and satisfaction with life in relation to demographic and clinical variables in a population of adolescents with type 1 diabetes. To compare perceived functional health and well-being between adolescents with diabetes and a group of healthy controls and to analyse the relationship between generic functional health and well-being and diabetes-related impact, worry and satisfaction with life. METHODS: A total of 130 adolescents were invited to complete the Child Health Questionnaire (CHQ-CF87) and the Diabetes Quality of Life (DQOL) questionnaire modified for youths. A total of 115 (88.5%) subjects participated in the study; mean age 14.5 y (SD 1.86), mean duration of diabetes 6.99 y (SD 3.77, range 1-16 y), mean HbA1c 9.3% (SD 1.62, range 6.2-14.0%). Forty-eight percent of the subjects were girls. RESULTS: When compared with healthy adolescents, subjects with diabetes reported a significantly lower degree of general health. The CHQ-CF87 scales showed that higher age in adolescents with diabetes was associated with lower scores for mental health (p < 0.001), self-esteem (p < 0.001), behaviour (p = 0.004) and general health (p < 0.001). Findings from the DQOL questionnaire showed that older adolescents were more worried (p < 0.001), perceived a greater impact of diabetes on daily life (p = 0.008) and lower diabetes-related life satisfaction (p < 0.001). The scores for girls were lower than those for boys in assessment of mental health (p < 0.001), self-esteem (p = 0.004) and family cohesion (p = 0.002). Girls also reported a greater impact of diabetes (p = 0.028), more worries (p = 0.001) and less satisfaction with life (p = 0.006) than boys. Neither HbA1c, nor other clinical variables could sufficiently explain the variations in DQOL or CHQ-CF87. CONCLUSIONS: Health-related quality of life varied significantly by age and gender, but less so by HbA1c and other clinical variables. Adolescents with diabetes reported a significantly lower degree of general health than that reported by healthy controls. The CHQ-CF87 is a valuable supplement to DQOL, allowing for comparisons with the general population.     

Significance of serum fructosamine in the metabolic control of children and adolescents with type I diabetes mellitus

In 1982 Johnson et al. described a simple colorimetric assay for measuring glycated proteins, termed fructosamine, in the serum of adults with diabetes mellitus and demonstrated this to be a useful index of intermediate glucose control (1-3 weeks). Our study was designed to show this as well in children and adolescents with type I diabetes mellitus. Serum fructosamine was determined in 76 children and adolescents with diabetes mellitus, and 111 age-matched controls. In the controls an age-dependency but not sex-dependency could be demonstrated. In the diabetic patients we found a significant correlation between serum fructosamine and HbA1 values (r = 0.87, p less than 0.001). In 6 patients with newly diagnosed diabetes mellitus serum fructosamine concentrations decreased at a faster rate than HbA1 values. The fructosamine assay is rapid, technically simple and inexpensive, and is at least a useful addition or perhaps an alternative to HbA1 estimation.     

Oral glucose tolerance test in children and adolescents: positives and pitfalls

Objectives:   To describe the glycaemic status (assessed by an oral glucose tolerance test (OGTT)) and associated comorbidities in a cohort of Australian children and adolescents at risk of insulin resistance and impaired glucose homeostasis (IGH).
Methods:   Twenty-one children and adolescents (three male, 18 female) (18 Caucasian, one Indigenous, two Asian) (20 obese, one lipodystrophy) referred to the Paediatric Endocrinology and Diabetes Clinic underwent a 2-h OGTT with plasma glucose and insulin measured at baseline, + 60 and + 120 min. If abnormal, the OGTT was repeated.
Results:   The mean (SD) age was 14.2 (1.6) years, BMI 38.8 (7.0) kg/m² and BMI-SDS 3.6 (0.6). Fourteen patients had fasting insulin levels >21 mU/L. Type 2 diabetes mellitus was diagnosed in one patient, impaired glucose tolerance (IGT) in four patients and impaired fasting glycaemia (IFG) in one patient. Despite no weight loss, only one patient had a persistently abnormal OGTT on repeat testing. Three patients with IGH were medicated with risperidone at the time of the initial OGTT. One patient who had persistent IGT had continued risperidone. The other two patients had initial OGTT results of IGT and diabetes mellitus type 2. They both ceased risperidone between tests and repeat OGTT showed normal glycaemic status.
Conclusions:   Use of fasting glucose alone may miss cases of IGH. Diagnosis of IGT should not be made on one test alone. Interpretation of glucose and insulin responses in young people is limited by lack of normative data. Larger studies are needed to generate Australian screening recommendations. Further assessment of the potential adverse effects of atypical antipsychotic medication on glucose homeostasis in this at-risk group is important.