Jane L. Chiang

Type 1 Diabetes Through the Life Span: A Position Statement of the American Diabetes Association

Type 1 diabetes is characterized by an immune-mediated depletion of β-cells that results in lifelong dependence on exogenous insulin. While both type 1 and type 2 diabetes result in hyperglycemia, the pathophysiology and etiology of the diseases are distinct and require us to consider each type of diabetes independently. As such, this position statement summarizes available data specific to the comprehensive care of individuals with type 1 diabetes. The goal is to enhance our ability to recognize and manage type 1 diabetes, to prevent its associated complications, and to eventually cure and prevent this disease. The exact number of individuals with type 1 diabetes around the world is not known, but in the U.S., there are estimated to be up to 3 million (1). Although it has long been called “juvenile diabetes” due to the more frequent and relatively straightforward diagnosis in children, the majority of individuals with type 1 diabetes are adults. Most children are referred and treated in tertiary centers, where clinical data are more readily captured. The SEARCH for Diabetes in Youth study estimated that, in 2009, 18,436 U.S. youth were newly diagnosed with type 1 diabetes (12,945 non-Hispanic white, 3,098 Hispanic, 2,070 non-Hispanic black, 276 Asian-Pacific Islander, and 47 American Indian) (2). Worldwide, ∼78,000 youth are diagnosed with type 1 diabetes annually. Incidence varies tremendously among countries: East Asians and American Indians have the lowest incidence rates (0.1–8 per 100,000/year) as compared with the Finnish who have the highest rates (>64.2 per 100,000/year) (3). In the U.S., the number of youth with type 1 diabetes was estimated to be 166,984 (4). The precise incidence of new-onset type 1 diabetes in those over 20 years of age is unknown. This may be due to the prolonged phase of onset and the subtleties in distinguishing the different …

Diabetic Kidney Disease: A Report From an ADA Consensus Conference

The incidence and prevalence of diabetes mellitus have grown significantly throughout the world, due primarily to the increase in type 2 diabetes. This overall increase in the number of people with diabetes has had a major impact on development of diabetic kidney disease (DKD), one of the most frequent complications of both types of diabetes. DKD is the leading cause of end-stage renal disease (ESRD), accounting for approximately 50% of cases in the developed world. Although incidence rates for ESRD attributable to DKD have recently stabilized, these rates continue to rise in high-risk groups such as middle-aged African Americans, Native Americans, and Hispanics. The costs of care for people with DKD are extraordinarily high. In the Medicare population alone, DKD-related expenditures among this mostly older group were nearly

BMI Cut Points to Identify At-Risk Asian Americans for Type 2 Diabetes Screening

25 billion in 2011. Due to the high human and societal costs, the Consensus Conference on Chronic Kidney Disease and Diabetes was convened by the American Diabetes Association in collaboration with the American Society of Nephrology and the National Kidney Foundation to appraise issues regarding patient management, highlighting current practices and new directions. Major topic areas in DKD included 1) identification and monitoring, 2) cardiovascular disease and management of dyslipidemia, 3) hypertension and use of renin-angiotensin-aldosterone system blockade and mineralocorticoid receptor blockade, 4) glycemia measurement, hypoglycemia, and drug therapies, 5) nutrition and general care in advanced-stage chronic kidney disease, 6) children and adolescents, and 7) multidisciplinary approaches and medical home models for health care delivery. This current state summary and research recommendations are designed to guide advances in care and the generation of new knowledge that will meaningfully improve life for people with DKD.

Staging Presymptomatic Type 1 Diabetes: A Scientific Statement of JDRF, the Endocrine Society, and the American Diabetes Association

According to the U.S. Census Bureau, an Asian is a person with origins from the Far East (China, Japan, Korea, and Mongolia), Southeast Asia (Cambodia, Malaysia, the Philippine Islands, Thailand, Vietnam, Indonesia, Singapore, Laos, etc.), or the Indian subcontinent (India, Pakistan, Bangladesh, Bhutan, Sri Lanka, and Nepal); each region has several ethnicities, each with a unique culture, language, and history. In 2011, 18.2 million U.S. residents self-identified as Asian American, with more than two-thirds foreign-born (1). In 2012, Asian Americans were the nation’s fastest-growing racial or ethnic group, with a growth rate over four times that of the total U.S. population. International migration has contributed >60% of the growth rate in this population (1). Among Asian Americans, the Chinese population was the largest (4.0 million), followed by Filipinos (3.4 million), Asian Indians (3.2 million), Vietnamese (1.9 million), Koreans (1.7 million), and Japanese (1.3 million). Nearly three-fourths of all Asian Americans live in 10 states—California, New York, Texas, New Jersey, Hawaii, Illinois, Washington, Florida, Virginia, and Pennsylvania (1). By 2060, the Asian American population is projected to more than double to 34.4 million, with its share of the U.S. population climbing from 5.1 to 8.2% in the same period (2). Although it is clear that increased body weight is a risk factor for type 2 diabetes, the relationship between body weight and type 2 diabetes is more properly attributable to the quantity and distribution of body fat (3–5). Abdominal circumference and waist and hip measurements, although highly correlated with cardiometabolic risk (6,7), do not differentiate subcutaneous from visceral adipose abdominal depots and are subject to interobserver variability. Imaging and other approaches can be used to more accurately assess fat distribution and quantify adiposity (4,8), but they are not readily available, economical, or useable on …

Youth-Onset Type 2 Diabetes Consensus Report: Current Status, Challenges, and Priorities

Insights from prospective, longitudinal studies of individuals at risk for developing type 1 diabetes have demonstrated that the disease is a continuum that progresses sequentially at variable but predictable rates through distinct identifiable stages prior to the onset of symptoms. Stage 1 is defined as the presence of β-cell autoimmunity as evidenced by the presence of two or more islet autoantibodies with normoglycemia and is presymptomatic, stage 2 as the presence of β-cell autoimmunity with dysglycemia and is presymptomatic, and stage 3 as onset of symptomatic disease. Adoption of this staging classification provides a standardized taxonomy for type 1 diabetes and will aid the development of therapies and the design of clinical trials to prevent symptomatic disease, promote precision medicine, and provide a framework for an optimized benefit/risk ratio that will impact regulatory approval, reimbursement, and adoption of interventions in the early stages of type 1 diabetes to prevent symptomatic disease.

Defining Pathways for Development of Disease-Modifying Therapies in Children With Type 1 Diabetes: A Consensus Report

Type 2 diabetes is a significant and increasing burden in adolescents and young adults. Clear strategies for research, prevention, and treatment of the disease in these vulnerable patients are needed. Evidence suggests that type 2 diabetes in children is different not only from type 1 but also from type 2 diabetes in adults. Understanding the unique pathophysiology of type 2 diabetes in youth, as well as the risk of complications and the psychosocial impact, will enable industry, academia, funding agencies, advocacy groups, and regulators to collectively evaluate both current and future research, treatment, and prevention approaches. This Consensus Report characterizes type 2 diabetes in children, evaluates the fundamental differences between childhood and adult disease, describes the current therapeutic options, and discusses challenges to and approaches for developing new treatments.

Care of Young Children With Diabetes in the Child Care Setting: A Position Statement of the American Diabetes Association

Emerging data suggest that type 1 diabetes is a more aggressive disease in children than in adults, with important differences in pathophysiology and clinical course. Therefore, the efficacy of disease-modifying therapies may be different in the two populations. Understanding the developmental and regulatory pathways for type 1 diabetes–modifying therapies in children will enable industry, academia, funders, advocacy groups, and regulators to translate new science to clinical care. This consensus report characterizes the fundamental differences in type 1 diabetes between children and adults and proposes a thoughtful approach to better understand the development and regulatory pathways for type 1 diabetes therapies.

Diabetes Care in the School Setting: A Position Statement of the American Diabetes Association

Diabetes is a relatively common chronic disease of childhood (1); however, capturing prevalence data in children with type 1 and type 2 diabetes has been challenging. The comprehensive SEARCH for Diabetes in Youth (SEARCH) study has made significant strides in better understanding disease prevalence in the pediatric population. A recent SEARCH study found that 1.93 per 1,000 youth (aged <20 years) were diagnosed with type 1 diabetes (2), an increase of 21.1% from 2001 to 2009, with increases seen in all ethnic groups but with non-Hispanic whites disproportionately affected (3). For type 2 diabetes, the SEARCH study reported a prevalence of 0.46 per 1,000 youth (aged 10–20 years), an increase of 30.5% from 2001 to 2009 in all ethnicities (3). As youth rarely die of diabetes, the increase in prevalence is most likely attributed to increased incidence. An annual increase of 2.3% in type 1 diabetes incidence has been reported in children, with children aged <5 years experiencing the greatest increase relative to all children (4). As type 2 diabetes is rarely seen in children younger than 10 years of age (3), this Position Statement will primarily focus on type 1 diabetes. The primary objective of this Position Statement is to explain that young children (aged ≤5 years) are a vulnerable population and have unique diabetes management needs. Our goal is to describe the diabetes management recommendations in the child care setting. The child care setting includes day care, camp, and other programs where young children with diabetes are enrolled. This Position Statement is meant to guide child care providers in caring for young children with diabetes and is not intended to provide specific advice on the medical management for this population. While Position Statements contain evidence-based recommendations, all of the information that pertains to young children is expert opinion …

Professional practice committee

Diabetes is one of the most common chronic diseases of childhood (1). There are approximately 200,000 individuals <20 years of age with diabetes in the U.S. (2). The SEARCH for Diabetes in Youth (SEARCH) study recently reported that 1.93 per 1,000 (aged <20 years) were diagnosed with type 1 diabetes, an increase of 21% from 2001 to 2009. Increases in the prevalence of type 1 diabetes were seen in all ethnic groups, but non-Hispanic whites were disproportionately affected. Because type 2 diabetes rarely occurs in younger children, its prevalence in the population aged <20 years is not readily available. For type 2 diabetes in youth between 10 and 20 years of age, the SEARCH study reported a prevalence of 0.46 per 1,000 youth of all ethnicities, an increase of 31% from 2001 to 2009 (3). These statistics demonstrate the rising prevalence of diabetes in children and the increased need for diabetes management. The majority of young people with diabetes spend many hours at school and/or in some type of child care program. Trained and knowledgeable staff are essential to provide a safe school and child care environment for children with diabetes. This includes the provision of care during the school day, field trips, and all school-sponsored activities in the school setting and in preschool, day care, and camp programs in the child care setting. Staff play a critical role in helping to reduce the risk of short- and long-term complications of diabetes and ensuring that children are well-positioned for academic success and normal growth and development. The child’s parents/guardians and health care provider(s) should work together to provide school systems and child care providers with the information necessary to enable children with diabetes to participate fully and safely in the school and child care setting experiences (4–6). …

Guiding Principles for Diabetes Care

The Professional Practice Committee (PPC) of the American Diabetes Association (ADA) is responsible for the “Standards of Medical Care in Diabetes” position statement, referred to as the “Standards of Care.” The PPC is a multidisciplinary expert committee comprised of physicians, diabetes educators, registered dietitians, and others who have expertise in a range of areas, including adult and pediatric endocrinology, epidemiology, public health, lipid research, hypertension, preconception planning, and pregnancy care. Appointment to the PPC is based on excellence in clinical practice and research. Although the primary role of the PPC is to review and update the Standards of Care, it is also responsible for overseeing the review and revision of ADA’s position statements and scientific statements. The ADA adheres to the Institute of Medicine Standards for Developing Trustworthy Clinical Practice Guidelines. All members of the PPC are required to disclose potential conflicts of interest with industry and/or other relevant organizations. These disclosures are discussed at the onset of each Standards of Care revision meeting. Members of the committee, their employer, and their disclosed conflicts of interest are listed in the “Professional Practice Committee Disclosures” table (see p. S130). For the current revision, PPC members systematically searched MEDLINE for human studies related to each section and published since 1 January 2016. Recommendations were revised based on new evidence or, in some cases, to clarify the prior recommendation or match the strengthof thewording to the strength of theevidence.A table linking the changes in recommendations to new evidence can be reviewed at http://professional .diabetes.org/SOC. As for all position statements, the Standards of Care position statement was approved by the Executive Committee of ADA’s Board of Directors, which includes health care professionals, scientists, and lay people. Feedback from the larger clinical communitywas valuable for the 2017 revision of the Standards of Care. Readers who wish to comment on the 2017 Standards of Care are invited to do so at http://professional.diabetes.org/SOC. The ADA funds development of the Standards of Care and all ADA position statements out of its general revenues and does not use industry support for these purposes. The PPC would like to thank the following individuals who provided their expertise in reviewing and/or consulting with the committee: Conor J. Best, MD; William T. Cefalu, MD; Mary de Groot, PhD; Gary D. Hack, DDS; Silvio E. Inzucchi, MD; Meghan Jardine, MS, MBA, RD, LD, CDE; Victor R. Lavis, MD; Mark E. Molitch, MD; Antoinette Moran, MD; Matt Petersen; Sean Petrie; Louis H. Philipson, MD, PhD; Margaret A. Powers, PhD, RD, CDE; Desmond Schatz, MD; Philip R. Schauer, MD; Sonali N. Thosani, MD; and Guillermo E. Umpierrez, MD.