Characteristics of Children with Type 1 Diabetes and Persistent Suboptimal Glycemic Control

Characteristics of Children with Type 1 Diabetes and Persistent Suboptimal Glycemic ControlOri gi nal Ar tic le 8 2 In tro duc ti onSuccessful management of type 1 diabetes mellitus (T1DM) requires sustained collaboration involving the patient, family, caregivers, and the multidisciplinary diabetes team.Near normalization of blood glucose often fails even in patients and families who consistently perform self-care skills including the prescribed insulin regimen and diet (1).Children and adults with well-managed diabetes typically have hemoglobin A1c (HbA1c) levels in the range of 6-8%, approximately equivalent blood glucose levels in the range of 120-180 mg/dL.On the other hand, patients with poor diabetes management have a much higher HbA1c level, typically ≥10%.These high values are estimated to reflect a 2-3 month blood sugar average of ≥240 mg/dL.Children with T1DM present unique challenges due to problems in diabetes self-care responsibilities which arise between the ages of 10 and 15, often resulting in deterioration of glycemic control.Factors which have been found to be predictive of HbA1c levels include age (2) and gender (3), regularity of clinic attendance (4), frequency of blood glucose monitoring (5,6), number of insulin injections (7), and the duration of diabetes (8) Diabetes self-management occurs within the home environment and is consequently influenced by social and economic stressors.Family factors (9), psychological characteristics (10), and economic issues (11) all may influence glycemic control.These identified factors, however, have not been well studied in the subgroup of children with T1DM who have persistent difficulty with their diabetes management.Noting that this particular group of patients is at higher risk for long-ABS TRACT Ob jec ti ve: This study aims to determine the relationship between the duration of persistent poor glycemic control in type 1 diabetes mellitus (T1DM) children and the likelihood of subsequent improvement.Met hods: A retrospective cohort study was conducted on T1DM patients aged 6-18 years, followed for at least six visits at Children's National Medical Center (Washington, DC) with at least one hemoglobin A1c (HbA1c) ≥10% after the first year since the initial visit (n=151).Medical records of patients with subsequently improved glycemic control were reviewed (n=39).Re sults: Patients aged 12-18 years, females, and Medicaid patients were twice as likely to be in persistently poor control as patients aged 6-11 years, males, and privately insured patients, respectively.Each additional visit with HbA1c ≥10% and one percentage point increase in the mean HbA1c reduced the likelihood of subsequent improvement by 20% and 50%, respectively.Of the 39 patients with improved control, only 5 (13%) sustained their improvement for ≥2 years.Multiple contributing factors for improved control were identified, but no one factor explained improved control in >25% of patients.Conc lu si on: This study suggests that the longer the duration of poor control, the more difficult it is to reverse the underlying factors of poor diabetes management.Strategies to improve regular clinic attendance along with reinforcement of changes which resulted in improved control are critical.Adolescents, females, and Medicaid patients in particular should be targeted for sustained intervention.