Ronny A. Bell

The SEARCH for Diabetes in Youth study: rationale, findings, and future directions.

The SEARCH for Diabetes in Youth (SEARCH) study was initiated in 2000, with funding from the Centers for Disease Control and Prevention and support from the National Institute of Diabetes and Digestive and Kidney Diseases, to address major knowledge gaps in the understanding of childhood diabetes. SEARCH is being conducted at five sites across the U.S. and represents the largest, most diverse study of diabetes among U.S. youth. An active registry of youth diagnosed with diabetes at age <20 years allows the assessment of prevalence (in 2001 and 2009), annual incidence (since 2002), and trends by age, race/ethnicity, sex, and diabetes type. Prevalence increased significantly from 2001 to 2009 for both type 1 and type 2 diabetes in most age, sex, and race/ethnic groups. SEARCH has also established a longitudinal cohort to assess the natural history and risk factors for acute and chronic diabetes-related complications as well as the quality of care and quality of life of persons with diabetes from diagnosis into young adulthood. Many youth with diabetes, particularly those from low-resourced racial/ethnic minority populations, are not meeting recommended guidelines for diabetes care. Markers of micro- and macrovascular complications are evident in youth with either diabetes type, highlighting the seriousness of diabetes in this contemporary cohort. This review summarizes the study methods, describes key registry and cohort findings and their clinical and public health implications, and discusses future directions.

Glycemic control in youth with diabetes: the SEARCH for diabetes in Youth Study.

OBJECTIVE To assess correlates of glycemic control in a diverse population of children and youth with diabetes. STUDY DESIGN This was a cross-sectional analysis of data from a 6-center US study of diabetes in youth, including 3947 individuals with type 1 diabetes (T1D) and 552 with type 2 diabetes (T2D), using hemoglobin A(1c) (HbA(1c)) levels to assess glycemic control. RESULTS HbA(1c) levels reflecting poor glycemic control (HbA(1c) >or= 9.5%) were found in 17% of youth with T1D and in 27% of those with T2D. African-American, American Indian, Hispanic, and Asian/Pacific Islander youth with T1D were significantly more likely to have higher HbA(1c) levels compared with non-Hispanic white youth (with respective rates for poor glycemic control of 36%, 52%, 27%, and 26% vs 12%). Similarly poor control in these 4 racial/ethnic groups was found in youth with T2D. Longer duration of diabetes was significantly associated with poorer glycemic control in youth with T1D and T2D. CONCLUSIONS The high percentage of US youth with HbA(1c) levels above the target value and with poor glycemic control indicates an urgent need for effective treatment strategies to improve metabolic status in youth with diabetes.

Disparities in HbA1c levels between African-American and non-Hispanic white adults with diabetes: a meta-analysis.

OBJECTIVE—Among individuals with diabetes, a comparison of HbA1c (A1C) levels between African Americans and non-Hispanic whites was evaluated. Data sources included PubMed, Web of Science, the Cumulative Index to Nursing and Allied Health, the Cochrane Library, the Combined Health Information Database, and the Education Resources Information Center. RESEARCH DESIGN AND METHODS—We executed a search for articles published between 1993 and 2005. Data on sample size, age, sex, A1C, geographical location, and study design were extracted. Cross-sectional data and baseline data from clinical trials and cohort studies for African Americans and non-Hispanic whites with diabetes were included. Diabetic subjects aged <18 years and those with pre-diabetes or gestational diabetes were excluded. We conducted a meta-analysis to estimate the difference in the mean values of A1C for African Americans and non-Hispanic whites. RESULTS—A total of 391 studies were reviewed, of which 78 contained A1C data. Eleven had data on A1C for African Americans and non-Hispanic whites and met selection criteria. A meta-analysis revealed the standard effect to be 0.31 (95% CI 0.39–0.25). This standard effect correlates to an A1C difference between groups of ∼0.65%, indicating a higher A1C across studies for African Americans. Grouping studies by study type (cross-sectional or cohort), method of data collection for A1C (chart review or blood draw), and insurance status (managed care or nonmanaged care) showed similar results. CONCLUSIONS—The higher A1C observed in this meta-analysis among African Americans compared with non-Hispanic whites may contribute to disparity in diabetes morbidity and mortality in this population.

Prevalence and Correlates of Depressed Mood Among Youth With Diabetes: The SEARCH for Diabetes in Youth Study

OBJECTIVE.The objective of this study was to determine if depressed mood among youth with diabetes was associated with type and duration of diabetes, mean glycosylated hemoglobin (HbA1c) level, and the frequency of diabetic ketoacidosis (DKA) and hypoglycemic episodes, hospitalizations, and emergency department (ED) visits. METHODS.A total of 2672 youth (aged 10–21 years) who had diabetes for a mean duration of 5 years completed a SEARCH study visit, in which their HbA1c was measured and information about their demographic characteristics, diabetes type and duration, and episodes of DKA, hypoglycemia, hospitalizations, and ED visits over the previous 6 months was collected. Their level of depressed mood was measured using the Center for Epidemiologic Studies Depression Scale (CES-D). RESULTS.Among these youth, 14% had mildly (CES-D 16–23) and 8.6% had moderately or severely (CES-D ≥24) depressed mood. Females had a higher mean CES-D score than males. After adjusting for demographic factors, and duration of diabetes, we found the prevalence of depressed mood to be higher among males with type 2 diabetes than those with type 1 diabetes and to be higher among females with comorbidities than those without comorbidities. Higher mean HbA1c and frequency of ED visits were associated with depressed mood. The prevalence of depressed mood among youth with diabetes was similar to that of published estimates of depressed mood among youth without diabetes. CONCLUSIONS.Physicians and other health care professionals should consider screening youth with diabetes for depressed mood in clinical settings, particularly youth with poor glycemic control, those with a history of frequent ED visits, males with type 2 diabetes, and females with comorbidities.

Prevalence of Cardiovascular Disease Risk Factors in U.S. Children and Adolescents With Diabetes The SEARCH for Diabetes in Youth Study

OBJECTIVE—The purpose of this study was to determine the prevalence and correlates of selected cardiovascular disease (CVD) risk factors among youth aged <20 years with diabetes. RESEARCH DESIGN AND METHODS—The analysis included 1,083 girls and 1,013 boys examined as part of the SEARCH for Diabetes in Youth study, a multicenter, population-based study of youth 0–19 years of age with diabetes. Diabetes type was determined by a biochemical algorithm based on diabetes antibodies and fasting C-peptide level. CVD risk factors were defined as follows: HDL cholesterol <40 mg/dl; age- and sex-specific waist circumference >90th percentile; systolic or diastolic blood pressure >90th percentile for age, sex, and height or taking medication for high blood pressure; and triglycerides >110 mg/dl. RESULTS—The prevalence of having at least two CVD risk factors was 21%. The prevalence was 7% among children aged 3–9 years and 25% in youth aged 10–19 years (P < 0.0001), 23% among girls and 19% in boys (P = 0.04), 68% in American Indians, 37% in Asian/Pacific Islanders, 32% in African Americans, 35% in Hispanics, and 16% in non-Hispanic whites (P < 0.0001). At least two CVD risk factors were present in 92% of youth with type 2 and 14% of those with type 1A diabetes (P < 0.0001). In multivariate analyses, age, race/ethnicity, and diabetes type were independently associated with the odds of having at least two CVD risk factors (P < 0.0001). CONCLUSIONS—Many youth with diabetes have multiple CVD risk factors. Recommendations for weight, lipid, and blood pressure control in youth with diabetes need to be followed to prevent or delay the development of CVD as these youngsters mature.

Diabetes in Non-Hispanic White Youth Prevalence, incidence, and clinical characteristics: the SEARCH for Diabetes in Youth Study

OBJECTIVE—To investigate the incidence, prevalence, and clinical characteristics of diabetes among U.S. non-Hispanic white (NHW) youth. RESEARCH DESIGN AND METHODS—Data from the SEARCH for Diabetes in Youth Study (SEARCH study), a multicenter study of diabetes among youth aged 0–19 years, were examined. Incidence rates were calculated per 100,000 person-years across 4 incident years (2002–2005), and prevalence in 2001 was calculated per 1,000 youths. Information obtained by questionnaire, physical examination, and blood and urine collection was analyzed to describe the characteristics of youth who completed an in-person visit. RESULTS—The prevalence of type 1 diabetes (at ages 0–19 years) was 2.00/1,000, which was similar for male (2.02/1,000) and female (1.97/1,000) subjects. The incidence of type 1 diabetes was 23.6/100,000, slightly higher for male compared with female subjects (24.5 vs. 22.7 per 100,000, respectively, P = 0.04). Incidence rates of type 1 diabetes among youth aged 0–14 years in the SEARCH study are higher than all previously reported U.S. studies and many European studies. Few cases of type 2 diabetes in youth aged <10 years were found. The prevalence of type 2 diabetes (at ages 10–19 years) was 0.18/1,000, which is significantly higher for female compared with male subjects (0.22 vs. 0.15 per 1,000, P = 0.01). Incidence of type 2 diabetes was 3.7/100,000, with similar rates for female and male subjects (3.9 vs. 3.4 per 1,000, respectively, P = 0.3). High levels of abnormal cardiometabolic and behavioral risk factor profiles were common among youth with both type 1 and type 2 diabetes. For example, within each of four age-groups for youth with type 1 diabetes and two age-groups for youth with type 2 diabetes, >40% had elevated LDL cholesterol, and <3% of youth aged >10 years met current recommendations for intake of saturated fat. Among youth aged ≥15 years, 18% with type 1 and 26% with type 2 diabetes were current smokers. CONCLUSIONS—The SEARCH study is one of the most comprehensive studies of diabetes in NHW youth. The incidence of type 1 diabetes in NHW youth in the U.S. is one of the highest in the world. While type 2 diabetes is still relatively rare, rates are several-fold higher than those reported by European countries. We believe efforts directed at improving the cardiometabolic and behavioral risk factor profiles in this population are warranted.

Diabetes in African American Youth: Prevalence, incidence, and clinical characteristics: the SEARCH for Diabetes in Youth Study

OBJECTIVE—To report the prevalence and incidence of type 1 and type 2 diabetes among African American youth and to describe demographic, clinical, and behavioral characteristics. RESEARCH DESIGN AND METHODS—Data from the SEARCH for Diabetes in Youth Study, a population-based, multicenter observational study of youth with clinically diagnosed diabetes aged 0–19 years, were used to estimate the prevalence for calendar year 2001 (692 cases) and incidence based on 748 African American case subjects diagnosed in 2002–2005. Characteristics of these youth were obtained during a research visit for 436 African American youth with type 1 diabetes and 212 African American youth with type 2 diabetes. RESULTS—Among African American youth aged 0–9 years, prevalence (per 1,000) of type 1 diabetes was 0.57 (95% CI 0.47–0.69) and for those aged 10–19 years 2.04 (1.85–2.26). Among African American youth aged 0–9 years, annual type 1 diabetes incidence (per 100,000) was 15.7 (13.7–17.9) and for those aged 10–19 years 15.7 (13.8–17.8). A1C was ≥9.5% among 50% of youth with type 1 diabetes aged ≥15 years. Across age-groups and sex, 44.7% of African American youth with type 1 diabetes were overweight or obese. Among African American youth aged 10–19 years, prevalence (per 1,000) of type 2 diabetes was 1.06 (0.93–1.22) and annual incidence (per 100,000) was 19.0 (16.9–21.3). About 60% of African American youth with type 2 diabetes had an annual household income of <

Disparities in A1C Levels Between Hispanic and Non-Hispanic White Adults With Diabetes: A meta-analysis

25,000. Among those aged ≥15 years, 27.5% had an A1C ≥9.5%, 22.5% had high blood pressure, and, across subgroups of age and sex, >90% were overweight or obese. CONCLUSIONS—Type 1 diabetes presents a serious burden among African American youth aged <10 years, and African American adolescents are impacted substantially by both type 1 and type 2 diabetes.

Transition From Pediatric to Adult Care for Youth Diagnosed With Type 1 Diabetes in Adolescence

OBJECTIVE—Hispanics have higher rates of diabetes and diabetes-related complications than do non-Hispanic whites. A meta-analysis was conducted to estimate the difference between the mean values of A1C for these two groups. RESEARCH DESIGN AND METHODS—We executed a PubMed search of articles published from 1993 through July 2007. Data sources included PubMed, Web of Science, Cumulative Index to Nursing and Allied Health, the Cochrane Library, Combined Health Information Database, and Education Resources Information Center. Data on sample size, age, sex, A1C, geographical location, and study design were extracted. Cross-sectional data and baseline data from clinical trials and cohort studies for Hispanics and non-Hispanic whites with diabetes were included. Studies were excluded if they included individuals <18 years of age or patients with pre-diabetes or gestational diabetes. RESULTS—A total of 495 studies were reviewed, of which 73 contained data on A1C for Hispanics and non-Hispanic whites, and 11 met the inclusion criteria. Meta-analysis revealed a statistically significant mean difference (P < 0.0001) of −0.46 (95% CI −0.63 to −0.33), correlating to an ∼0.5% higher A1C for Hispanics. Grouping studies by design (cross-sectional or cohort), method of data collection for A1C (chart review or blood sampling), and care type (managed or nonmanaged) yielded similar results. CONCLUSIONS—In this meta-analysis, A1C was ∼0.5% higher in Hispanic patients with diabetes than in non-Hispanic patients. Understanding the reasons for this disparity should be a focus for future research.

Racial differences in knowledge, attitudes, and cancer Screening practices among a triracial rural population

OBJECTIVE: Youth with type 1 diabetes mellitus are at risk for poor glycemic control as they age into adulthood. The aim of this study was to describe sociodemographic and clinical correlates of poor glycemic control associated with the transfer of care from pediatric to adult diabetes providers among a cohort of youth with type 1 diabetes diagnosed in adolescence. METHODS: Analyses included 185 adolescent participants with recently diagnosed type 1 diabetes in the SEARCH for Diabetes in Youth Study with pediatric care at baseline who were age ≥18 years at follow-up. Demographic and clinical factors were measured by survey and laboratory results. Survival analysis was used to estimate the age of transition. Logistic regression analysis assessed the association of demographic and clinical factors with the transition of care and poor glycemic control at follow-up. RESULTS: Fifty-seven percent of participants had transitioned to adult diabetes care providers by the follow-up visit. The estimated median age of transition of care was 20.1 years (95% confidence interval 19.8–20.4). Older age, lower baseline glycosylated hemoglobin, and less parental education were independently associated with increased odds of transition. The odds of poor glycemic control at follow-up were 2.5 times higher for participants who transitioned to adult care compared with those who remained in pediatric care. CONCLUSIONS: Transferring from pediatric to adult care, experienced by more than half the sample, was associated with an increased risk of poor glycemic control at follow-up. These findings suggest that young adults need additional support when moving to adult care.