Heather J. Dean

Evaluation of a Systems Navigator Model for Transition From Pediatric to Adult Care for Young Adults With Type 1 Diabetes

OBJECTIVES— To determine whether a systems navigator service, The Maestro Project, could increase medical surveillance for young adults with type 1 diabetes who transfer from pediatric to adult care. RESEARCH DESIGN AND METHODS— There were two cohorts of participants: 1) a younger group (aged 18 years, n = 82) who had the assistance of the navigator as they graduated from pediatric care and 2) an older group (aged 19–25 years) who were transferred to adult care without this initial support but later enrolled in the program. RESULTS— Of the older group (who did not have initial access to the navigator), 40% dropped out of adult medical care, compared with a dropout rate of 11% for the younger group, who had access to the navigator at the time of transfer from pediatric care. CONCLUSIONS— The systems navigator helped improve medical surveillance for both groups, although there was no evidence of improved short-term medical outcomes.

Incidence and Prevalence of Diabetes in Manitoba, 1986–1991

OBJECTIVE To estimate the incidence and prevalence of diabetes among adults in Manitoba, Canada, from 1986 to 1991. RESEARCH DESIGN AND METHODS A population-based database of individuals diagnosed with diabetes (Manitoba Diabetes Database) was created using data from Manitoba Healths comprehensive insurance system. Using this database, estimates of the annual incidence and prevalence of diabetes among Manitoba adults aged ≥25 years were made for the years 1986–1991. Age-specific and age-adjusted rates were calculated separately for men and women. RESULTS The prevalence of diabetes in 1991 was 66.9/1,000 among adults ≥25 years. Between 1986 and 1991 the age-adjusted prevalence rose steadily among both men and women. In 1991, the incidence of diabetes was 5.6/1,000. After an observed decline prior to 1989, the annual incidence of diabetes appears to be relatively stable. CONCLUSIONS The prevalence of diabetes is increasing steadily despite relatively stable incidence rates. Population-based data are required for projecting future trends and are an important tool for planning the required health resources.

Type 2 Diabetes, Medication-Induced Diabetes, and Monogenic Diabetes in Canadian Children: A Prospective National Surveillance Study

OBJECTIVE To determine in Canadian children aged <18 years the 1) incidence of type 2 diabetes, medication-induced diabetes, and monogenic diabetes; 2) clinical features of type 2 diabetes; and 3) coexisting morbidity associated with type 2 diabetes at diagnosis. RESEARCH DESIGN AND METHODS This Canadian prospective national surveillance study involved a network of pediatricians, pediatric endocrinologists, family physicians, and adult endocrinologists. Incidence rates were calculated using Canadian Census population data. Descriptive statistics were used to illustrate demographic and clinical features. RESULTS From a population of 7.3 million children, 345 cases of non–type 1 diabetes were reported. The observed minimum incidence rates of type 2, medication-induced, and monogenic diabetes were 1.54, 0.4, and 0.2 cases per 100,000 children aged <18 years per year, respectively. On average, children with type 2 diabetes were aged 13.7 years and 8% (19 of 227) presented before 10 years. Ethnic minorities were overrepresented, but 25% (57 of 227) of children with type 2 diabetes were Caucasian. Of children with type 2 diabetes, 95% (206 of 216) were obese and 37% (43 of 115) had at least one comorbidity at diagnosis. CONCLUSIONS This is the first prospective national surveillance study in Canada to report the incidence of type 2 diabetes in children and also the first in the world to report the incidence of medication-induced and monogenic diabetes. Rates of type 2 diabetes were higher than expected with important regional variation. These results support recommendations that screening for comorbidity should occur at diagnosis of type 2 diabetes.

NIDDM-Y in First Nation Children in Canada

Prevalence of NIDDM-Y in children in many First Nations communities in Manitoba and northwestern Ontario is now severalfold greater than the prevalence of IDDM in the general pediatric population. Rates vary among First Nations communities in Canada owing to inconsistent screening programs and different genetic risk. The number of undiagnosed, asymptomatic cases is predicted to be at least 2× greater than the known cases. Serious complications of diabetes are known to occur in the early third decade of life and within 10 years of diagnosis. Long-term follow-up data are scarce. Nonpharmacologic management in youths has been successful in short-term studies but generally unsuccessful in achieving long-term acceptable glycemic control. The safety and efficacy of pharma cologic interventions have not been proven in this age group, particularly the prepubertal group. NIDDM-Y fits the WHO criteria for a disease appropriate for screening. There is an urgent need for consistent community-based screening programs and randomized controlled trials of pharmacologic interventions to test the safety and efficacy of these agents in primary prevention and secondary prevention of complications in youths. Clin Pediatr. 1998;37:89-96

Screening for type-2 diabetes in aboriginal children in northern Canada

The numbers of cases of type-2 diabetes among aboriginal children in Canada is increasing. There is strong evidence that this increase is due to increased case finding and decreasing age of onset in high-risk populations. The longer duration of the disease increases the likelihood of complications occurring earlier. Prevalence and age-of-onset data must be collected to develop rational population-based screening programme for the earlier detection and intervention. We carried out a cross-sectional survey of schoolchildren aged 4–19 years of anthropometry and fasting serum concentrations of glucose and insulin during 1996–97 in the remote northern Ojibwa-Cree community of St Theresa Point First Nation. We did the survey at the request of the community for a diabetes screening programme. Of the 873 children registered at the school, 717 (82%) had standing height, weight, fasting serum glucose, and insulin measured following the American Diabetes Association diagnostic criteria (fasting blood glucose 7·0 mmol/L for diabetes, and 6·0–6·9 mmol/L for impaired fasting glucose). RESEARCH LETTERS

Earlier onset of complications in youth with type 2 diabetes

OBJECTIVE To evaluate the risk of complications in youth with type 2 diabetes. RESEARCH DESIGN AND METHODS Population-based cohorts of 342 youth (1–18 years of age) with prevalent type 2 diabetes, 1,011 youth with type 1 diabetes, and 1,710 nondiabetic control youth were identified between 1986 and 2007 from a clinical registry and linked to health care records to assess long-term outcomes using ICD-9CM and ICD-10CA codes. RESULTS Youth with type 2 diabetes had an increased risk of any complication (hazard ratio 1.47 [95% CI 1.02–2.12]). Significant adverse clinical factors included age at diagnosis (1.08 [1.02–2.12]), HbA1c (1.06 [1.01–1.12]), and, surprisingly, renin-angiotensin-aldosterone system (RAAS) inhibitor use (1.75 [1.27–2.41]). HNF-1α G319S polymorphism was protective in the type 2 diabetes cohort (0.58 [0.34–0.99]). Kaplan-Meier statistics revealed an earlier diagnosis of renal and neurologic complications in the type 2 diabetes cohort, manifesting within 5 years of diagnosis. No difference in retinopathy was seen. Cardiovascular and cerebrovascular diseases were rare; however, major complications (dialysis, blindness, or amputation) started to manifest 10 years after diagnosis in the type 2 diabetes cohort. Youth with type 2 diabetes had higher rates of all outcomes than nondiabetic control youth and an overall 6.15-fold increased risk of any vascular disease. CONCLUSIONS Youth with type 2 diabetes exhibit complications sooner than youth with type 1 diabetes. Younger age at diagnosis is potentially protective, and glycemic control is an important modifiable risk factor. The unexpected adverse association between RAAS inhibitor use and outcome is likely a confounder by indication; however, further evaluation in young people is warranted.

High Burden of Kidney Disease in Youth-Onset Type 2 Diabetes

OBJECTIVE To evaluate renal outcomes and survival in youth with type 2 diabetes (T2DM) versus type 1 diabetes (T1DM) versus nondiabetic control subjects. RESEARCH DESIGN AND METHODS In total, 342 prevalent youth (aged 1–18 years) with T2DM, 1,011 youth with T1DM, and 1,710 control subjects identified from 1986 to 2007 were anonymously linked to health care records housed at the Manitoba Centre for Health Policy to assess long-term outcomes using ICD codes. RESULTS Youth with T2DM were found to have a fourfold increased risk of renal failure versus youth with T1DM. Risk factors associated with renal failure were renin angiotensin aldosterone system inhibitor use and albuminuria in adolescence. Compared with control subjects (age, sex, and postal code matched), youth with T2DM had a 23-fold increased risk of renal failure and a 39-fold increased risk of dialysis. Kaplan-Meier survival at 10 years was 91.4% in the type 2 diabetic group versus 99.5% in the type 1 diabetic group (P < 0.0001). Renal survival was 100% at 10 years in both groups. It decreased to 92.0% at 15 years and 55.0% at 20 years in the type 2 diabetic group but remained stable in the type 1 diabetic group (P < 0.0001). CONCLUSIONS Youth with T2DM are at high risk of adverse renal outcomes and death. Albuminuria and angiotensin aldosterone system inhibitor use, which may be a marker of severity of disease, are associated with poor outcomes in early adulthood.

Reference ranges for serum cortisol and 17-hydroxyprogesterone levels in preterm infants

Abstract Reference ranges for cortisol and 17-hydroxyprogesterone were developed with sera from 39 healthy preterm infants less than 31 weeks of gestational age, collected weekly until 37 weeks of corrected age. (J P EDIATR 1995;126:985-7)

Physical activity for the prevention and management of youth-onset type 2 diabetes mellitus: focus on cardiovascular complications

With the growing prevalence of childhood obesity and type 2 diabetes mellitus (T2DM) in youth, the challenge of cardiovascular disease risk management has entered the paediatric realm, affecting specialists, family physicians and allied healthcare professionals alike. Currently, there is little evidence to support optimal strategies for management of T2DM in youth and the associated cardiovascular complications. Physical activity plays a powerful role in the prevention and management of T2DM and cardiovascular disease in adults. This review will focus on the role of physical activity for the prevention of T2DM in youth and its associated cardiovascular complications. The first part describes the prevalence of cardiovascular risk factors in this cohort. The second part focuses on the role of physical activity in the prevention and management of T2DM in youth. Collectively, the limited intervention and observation studies published to date suggest that daily targets of 60–90 minutes of physical activity and less than 60 minutes of screen time (i.e. time spent in front of a television, computer or video games) are required for the prevention and management of T2DM in youth. Large-scale intervention studies are needed to determine the most effective physical activity strategies for the prevention and management of T2DM in youth.

Incidence and Prevalence of Diabetes in Children Aged 0–14 Years in Manitoba, Canada, 1985–1993

OBJECTIVE To estimate the incidence and prevalence of type I diabetes among Manitoba children aged 0–14 years from 1985–1993. RESEARCH DESIGN AND METHODS The Manitoba Diabetes Database (a population-based database of individuals diagnosed with diabetes based on Manitobas health insurance system) was used to estimate the annual incidence of diabetes for the years 1985–1993 and the point prevalence of diabetes at 31 March 1993 for Manitoba children aged 0–14 years. The Diabetes Education Resource for Children and Adolescents program database was used to correct incidence and prevalence rates for ascertainment using the two-source capture-recapture method. RESULTS The overall ascertainment rate of the Manitoba Diabetes Database was 95% for incident cases and 93% for prevalent cases. The average annual incidence was 20.4 per 100,000 for children aged 0–14 years. The annual incidence appears to be stable for all age-groups 0–14 years over the past decade. The point prevalence of diabetes among children was 120.4 per 100,000. CONCLUSIONS The incidence of type I diabetes in children aged 0–14 years in Manitoba is higher than reported previously in other urban regions of Canada, but similar to population-based estimates from Prince Edward Island. The incidence appears stable in Manitoba over the past decade even in the 0–4 year age-group. The Manitoba Diabetes Database appears to be a highly accurate population-based source of data on the epidemiology of diabetes in children.