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Recent study shows- most youth do not meet A1C goals

Discussion in 'Parents of Children with Type 1' started by Momontherun, Feb 14, 2013.

  1. C6H12O6

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    Attached is the full text hope it works for everyone who wants to read it

    I can't attach it bc I would have to get it down to 20 KB. It has some graphs
     
    Last edited: Feb 16, 2013
  2. C6H12O6

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    MostYouthWith Type1Diabetes in the
    T1D Exchange Clinic Registry Do Not
    Meet American Diabetes Association or
    International Society for Pediatric and
    Adolescent Diabetes Clinical Guidelines
    JAMIE R. WOOD, MD
    1
    KELLEE M. MILLER, MPH
    2
    DAVID M. MAAHS, MD, PHD
    3
    ROY W. BECK, MD, PHD
    1
    LINDA A. DIMEGLIO, MD, MPH
    4
    INGRID M. LIBMAN, MD, PHD
    5
    MARYANNE QUINN, MD
    6
    WILLIAM V. TAMBORLANE, MD
    7
    STEPHANIE E. WOERNER, FNP
    4
    FOR THE T1D EXCHANGE CLINIC
    NETWORK*
    OBJECTIVEdTo assess the proportion of youth with type 1 diabetes under the care of pediatric
    endocrinologists in the United States meeting targets for HbA1c, blood pressure (BP), BMI,
    and lipids.
    RESEARCH DESIGNANDMETHODSdData were evaluated for 13,316 participants in
    the T1D Exchange Clinic Registry younger than 20 years old with type 1 diabetes for $1 year.
    RESULTSdAmerican Diabetes Association HbA1c targets of ,8.5% for those younger than 6
    years, ,8.0% for those 6 to younger than 13 years old, and ,7.5% for those 13 to younger than
    20 years old were met by 64, 43, and 21% of participants, respectively. The majority met targets
    for BP and lipids, and two-thirds met the BMI goal of ,85th percentile.
    CONCLUSIONSdMost children with type 1 diabetes have HbA1c values above target levels.
    Achieving American Diabetes Association goals remains a significant challenge for the majority of
    youth in the T1D Exchange registry.
    The Diabetes Control and Complications
    Trial and Epidemiology of
    Diabetes Interventions and Complications
    study, has demonstrated in adolescents
    and adults that intensive
    diabetes management significantly reduces
    the risk of vascular complications
    in type 1 diabetes (1,2) and that this
    benefit is sustained over time (3). In addition
    to glucose control, hypertension,
    dyslipidemia, and obesity (4?7) increase
    risk for future vascular disease,
    and these risk factors can be present
    in youth with type 1 diabetes. Both
    the American Diabetes Association
    (ADA) (8?10) and the International Society
    for Pediatric and Adolescent Diabetes
    (ISPAD) (11) have established
    targets for HbA1c, blood pressure (BP),
    lipids, and BMI for youth with type 1
    diabetes. The T1D Exchange clinic registry
    provides an opportunity to assess
    the frequencies of youth meeting these
    targets.
    RESEARCH DESIGN AND
    METHODSdThe T1D Exchange
    Clinic Network includes 67 United
    States?based pediatric or adult endocrinology
    practices. A registry of individuals
    with type 1 diabetes commenced enrollment
    in September 2010 (12). Each clinic
    received approval from an institutional
    review board (IRB). Informed consent
    was obtained according to IRB requirements
    from adult participants and parents
    or guardians of minors, and assent
    was obtained from minors. This report
    includes 13,316 participants from 67
    sites enrolled through 1 August 2012,
    who were younger than 20 years old at
    enrollment with type 1 diabetes for .1
    year.
    Data were collected for the registry?s
    database from the participant?s medical
    record and by having the participant or
    parent complete a comprehensive questionnaire
    (12). A recent HbA1c value
    (within 6 months before enrollment)
    was available for 99% (N = 13,226) of
    participants (82% obtained using DCA,
    3% from another point-of-care device,
    12% from a laboratory, 3% by an unrecorded
    method). Data for BP and BMI
    were available for 12,664 (95%) and
    13,045 (98%) participants. Among the
    12,639 participants age 6 years or older,
    fasting LDL, HDL, and fasting triglycerides
    were available for 2,928 (23%),
    8,693 (69%), and 2,387 (19%) participants,
    respectively (lipid results are not
    reported for participants age 1 to younger
    than 6 years because of the small amount
    of data). Data were categorized according
    to the following ADA and ISPAD targets:
    HbA1c (ADA ,8.5% for those younger
    than 6 years of age, ,8.0% for those 6
    to younger than 13 years of age, and
    ,7.5% for those 13 to younger than 20
    years of age; ISPAD #7.5% for all ages);
    BP ,90th percentile for age, sex, and
    height; BMI ,85th percentile for age
    and sex; LDL ,100 mg/dL (,2.6
    mmol/L); HDL (ADA .35 mg/dL; ISPAD
    c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c
    From the 1Children?s Hospital Los Angeles, Los Angeles, California; the 2Jaeb Center for Health Research,
    Tampa, Florida; the 3Barbara Davis Center for Childhood Diabetes, Aurora, Colorado; the 4Indiana University
    School of Medicine, Indianapolis, Indiana; the 5Children?s Hospital of Pittsburgh, Pittsburgh,
    Pennsylvania; the 6Children?s Hospital of Boston, Boston, Massachusetts; and the 7Yale University, New
    Haven, Connecticut.
    Corresponding author: Kellee M. Miller, t1dstats@jaeb.org.
    Received 25 September 2012 and accepted 28 December 2012.
    DOI: 10.2337/dc12-1959
    *A complete list of the members of the T1D Exchange Clinic Network can be found at http://care
    .diabetesjournals.org/lookup/suppl/doi:10.2337/dc12-1959/-/DC1.
    ? 2013 by the American Diabetes Association. Readers may use this article as long as the work is properly
    cited, the use is educational and not for profit, and the work is not altered. See http://creativecommons.org/
    licenses/by-nc-nd/3.0/ for details.
    care.diabetesjournals.org DIABETES CARE 1
    E p i d e m i o l o g y / H e a l t h S e r v i c e s R e s e a r c h
    B R I E F R E P O R T
    Diabetes Care Publish Ahead of Print, published online January 22, 2013
    .1.1 mmol/ L); and triglycerides ,150
    mg/dL (,1.7 mmol/L).
    The proportion of participants meeting
    ISPAD and ADA targets for HbA1c, BP,
    lipids, and BMI were tabulated according
    to age group. Differences in the characteristics
    of participants meeting HbA1c targets
    were evaluated through logistic
    regression models adjusted for potential
    confounders. In view of the large sample
    size only P , 0.01 was considered statistically
    significant.
    RESULTSdAmong the 13,316 pediatric
    participants, 677 (5%) were 1 to younger
    than 6 years of age, 5,336 (40%) were 6 to
    younger than 13 years of age, and 7,303
    (55%) were 13 to younger than 20 years
    of age (mean age, 12.7 years; mean diabetes
    duration, 5.6 years; 48% female; 78%non-
    Hispanic white). An insulin pump was
    used by 55% of participants and a continuous
    glucosemonitor was used by 3%. The
    median (25th and 75th percentile) number
    of self-reported self-monitoring of blood
    glucose per day was 5 (4,7).
    The ISPAD and ADA targets for HbA1c,
    BP, BMI, and lipids are shown according to
    age in Fig. 1. Mean 6 SD for HbA1c was
    8.2 6 1.1% in those 1 to younger than 6
    years old, 8.361.2% in those 6 to younger
    than 13 years old, and 8.8 61.7% in those
    13 to younger than 20 years old. The agespecific
    ADA HbA1c target was met by 32%
    of participants and the ISPAD HbA1c target
    of #7.5% was met by 25% of participants.
    The percentage meeting ADA and ISPAD
    HbA1c targets was higher in the younger
    age groups compared with the group 13
    to younger than 20 years old (P , 0.001
    for ADA and ISPAD). Among pump users 1
    to younger than 6 years old, the proportions
    of participantsmeeting the ADA and ISPAD
    HbA1c targets were 79 and 37% compared
    with 50 and 17% among injection users
    (P , 0.001, adjusted for diabetes duration,
    race/ethnicity, household income, insurance,
    and self-monitoring of blood glucose
    per day). In those 6 to younger than 13
    years old, 50 and 32% of insulin pump
    users met the ADA and ISPAD HbA1c targets
    comparedwith 34 and 20%of injection
    users (P , 0.001). There was not a significant
    difference in the percentage meeting
    HbA1c targets between insulin pump users
    and injection users among the group 13 to
    younger than 20 years old (24 and 27% of
    Figure 1dA: Proportion of participants meeting HbA1c targets (N = 13,226). ADA (black bars) ,8.5% for those 1 to younger than 6 years of age,
    ,8.0% for those 6 to younger than 13 years of age, and ,7.5% for those 13 to younger than 20 years of age. ISPAD (striped bars) ,7.5%.
    B: Proportion of participants meeting BP target (N = 12,664) ,90th percentile for age, sex, and height. C: Proportion of participants meeting BMI
    target (N = 13,045) ,85th percentile for age and sex. BMI percentile was not calculated for those younger than 2 years of age. D: Proportion of
    participants meeting fasting LDL target (N = 3,010) ,100 mg/dL (,2.6 mmol/L). E: Proportion of participants meeting HDL target (N = 8,938).
    ADA (black bars) .35 mg/dL; ISPAD (striped bars) .1.1 mmol/L. F: Proportion of participants meeting triglycerides target (N = 2,454) ,150 mg/dL
    (,1.7 mmol/L)
    2 DIABETES CARE care.diabetesjournals.org
    Clinical targets in youth with type 1 diabetes
    pump users vs. 18 and 20% of injection
    users; P = 0.11 and 0.02). Only 14% of
    non-Hispanic black participants met the
    ADA HbA1c target compared with 34 and
    28% in non-Hispanic white and Hispanic
    participants (adjusted P , 0.001). Among
    participants with available data, 95 and
    86% met ADA and ISPAD HDL targets;
    78, 63, 65, and 90% met BP, BMI, LDL,
    and triglycerides targets.
    CONCLUSIONSdThese data from
    the T1D Exchange describe how frequently
    ADA and ISPAD targets are met
    in the largest reported sample (N =
    13,316) of youth with type 1 diabetes in
    the United States. Only approximately
    one-third of participants met the agespecific
    ADA and ISPAD targets for
    HbA1c. Although the majority of participants
    did meet BP, lipid, and BMI
    targets, the frequency of abnormalities
    for these vascular disease risk factors is
    concerning (13).
    Because the clinic registry is not a
    population-based study, these results
    may not be representative of all youth
    with type 1 diabetes. However, participant
    characteristics were similar to those
    of patients not enrolled into the registry at
    the 67 clinics and when compared with
    the SEARCH for Diabetes in Youth Study
    (12). Comparisons with DPV German
    registry are difficult because of differences
    in target definitions (14). Another limitation
    is the number of participants missing
    fasting lipid results and with HbA1c results
    obtained from point of care.
    Despite advances in technologies and
    strategies for care, achieving HbA1c targets
    remains a significant challenge for
    the majority of youth in the T1D Exchange
    registry. Moreover, a large number
    of youth with diabetes already have
    additional vascular disease risk factors
    at a young age. This analysis suggests further
    transformations to improve pediatric
    diabetes care are needed to prevent future
    complications of diabetes.
    AcknowledgmentsdFunding was provided
    by the Leona M. and Harry B. Helmsley
    Charitable Trust.
    J.W. has received consultant payments from
    Medtronic.
    No other potential conflicts of interest relevant
    to this article were reported.
    J.R.W. initiated the idea, wrote the manuscript,
    contributed to discussion, and reviewed
    and edited the manuscript. K.M.M.
    performed statistical analysis, wrote the manuscript,
    contributed to discussion, and reviewed
    and edited the manuscript. D.M.M.
    initiated the idea, wrote the manuscript, contributed
    to discussion, and reviewed and
    edited the manuscript. R.W.B. wrote the
    manuscript, contributed to discussion, and
    reviewed and edited the manuscript. L.A.D.
    contributed to discussion and reviewed and
    edited the manuscript. I.M.L. contributed to
    discussion and reviewed and edited the manuscript.
    M.Q. contributed to discussion and
    reviewed and edited manuscript. W.V.T.
    contributed to discussion and reviewed and
    edited the manuscript. S.E.W. contributed to
    discussion and reviewed and edited the manuscript.
    R.W.B. is the guarantor of this work
    and, as such, had full access to all the data in
    the study and takes responsibility for the integrity
    of the data and the accuracy of the data
    analysis.
    These data have been presented in part at
    the 72nd Scientific Sessions of the American
    Diabetes Association, Philadelphia, Pennsylvania,
    8?12 June 2012 and at the 2011 International
    Society for Pediatric and Adolescent Diabetes
    Meeting, Miami Beach, Florida, 19?22 October
    2011.
     
  3. C6H12O6

    C6H12O6 Approved members

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    I think they are referring to falling below the 85th percentile as not meeting the BMI target. They are not referring to being overweight or obese because poor control is associated with being low weight in T1
     
  4. TheFormerLantusFiend

    TheFormerLantusFiend Approved members

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    My endo wants my A1c below 7%. He says that with my history of hypoglycemia and my demonstrated c-peptide of 0, it's not really practical to aim lower. And he's very much convinced that risk of severe complication goes up sharply around 7% even though it continues to rise and fall throughout the entire A1c spectrum.
    However, he has been happy with all of my A1cs, from the 6.1 to the 7.2, because he recognizes what else has been going on in my life at those times. He has suggested more aggressive hypoglycemia treatment if both:
    a) I've had a severe hypo recently, and
    b) my A1c is below 6.5%, indicating that we can pretty safely let it rise a bit.

    Overall I don't think he focuses on the A1c as much as he focuses on what I tell him is happening with my bg, because my A1cs have never been really crazy (except at dx, and that was before he met me).

    P.S. I never had a honeymoon. My diabetes has become easier to manage in the last year especially which I attribute mostly to finally really being out of puberty. My insulin needs have been dropping since late 2008 and continue to drop slowly.
     
    Last edited: Feb 17, 2013
  5. Mom211

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    Thank you for posting this - it makes me feel not so alone. My dd seems to be much like yours and it can be very discouraging sometimes.
     
  6. acjsmom

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    Yes! We haven't met the five year mark yet, but dd was five and half when she was diagnosed. Now, at almost nine and a half, we are constantly chasing high numbers because of growth spurts, puberty, etc.
     
  7. Danielle2008

    Danielle2008 Approved members

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    I can't imagine how difficult teenage years can be...for both child and parent. I'd say, knowing my teen was testing, counting carbs, and taking insulin is goal number one...no matter where their A1C actually falls.

    As an adult, I don't have puberty and hormones to contend with at the level most teens do(with the insulin resistance etc.). However, there are other challenges...balancing work, social life, activities etc.

    My last A1C was 6.7(or around there). The one previous to that was 7.8, and before that 8.4 . So steady improvements (utilizing the Dex again fulltime has helped immensely). I wasn't proud of the 8.4, but at that time there had been a lot of things going on in my personal life between family issues, work issues etc. It reflected, quite honestly, in my A1C.

    My Endo wants you under 7% as well, but his job is not to pitchfork you when you go out of the 'guidelines'...he is simply there to help adjust you insulin, so you can keep doing what you do.

    This Diabetes thing really is a 24/7 job. You certainly want to live a long healthy life, but on the otherhand....life itself is not always peachy keen and balanced either. As we say about individual BG numbers...it is there as a guideline to help suggest our next move. Not a number that dictates if you are a failure or not.
     

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