A new study of the variation in treatment of Type 1 diabetes, appearing in the latest edition of the journal Diabetologia, reveals some surprising and disturbing findings among different geographic regions.
Type 1 diabetes (T1D) is also known as "insulin-dependent" diabetes, since its hallmark is the total or near-total absence of insulin production and secretion by the pancreatic islet cells, due to auto-immune destruction of those endocrine cells, the precise nature of which is still not fully known.
Unlike Type 2 diabetes which often presents in adulthood among overweight or obese people and is not characterized by an absence of insulin but rather its irregular secretion T1D most often starts in infancy or childhood, and its victims tend to be thin. They must be treated regularly with injectable insulin, or metabolic derangements ("ketoacidosis," a life-threatening condition) will occur fairly rapidly.
Rather than administering insulin via three-times- or four-times-daily subcutaneous injections, in recent years technology has advanced to the degree that automated insulin pumps are more and more often used, which can deliver appropriate continuous "basal" insulin doses.
Additional amounts are also given via self-, or caregiver-administered "bolus" doses, for meals or as needed judging by measuring blood sugar levels by finger stick. Longer-term control is assessed by testing the blood levels of HbA1c, glyco-hemoglobin, which reflects blood sugar control over a period of 6-8 weeks.
While the use of insulin pumps in pediatrics has expanded dramatically, there is still considerable variability among countries in the use of pump technology. The present study sought to describe differences in metabolic control and pump use in young people with T1D using data collected from three registries in three separate regions of the world.
Senior authors of this multi-national, multi-center study included Dr. Jennifer L. Sherr of the Dept. of Pediatric Endocrinology, Children s Diabetes Program, Yale School of Medicine; numerous co-researchers affiliated with the T1DX group (T1D Exchange Clinical Network, U.S.); the DPV Initiative (Germany and Austria); and the National Pediatric Diabetes Audit U.K. (NPDA, England and Wales).
Data were collected from the records of 54,410 children and adolescents during the years 2011-12 from the Prospective Diabetes Follow-up Registry (DPV, 26,198), T1D Exchange (T1DX, 13,755) and the National Pediatric Diabetes Audit (NPDA, 14,457). The modality of insulin delivery, based on age, sex and ethnic minority status, and the impact of pump use on HbA1c levels were compared.
The lower the HbA1c levels, the better the overall diabetes control: the goal is to keep it around 7 percent or lower. The overall mean HbA1c level was higher in the NPDA (8.9 percent) than in the DPV (8.0 percent) and T1DX (8.3 percent). Conversely, pump use was much lower in the NPDA (14 percent) than in the DPV (41 percent) and T1DX (47 percent). In all three registries, those with an ethnic minority status were less likely to be treated with a pump (22 percent, vs. 34 percent non-minority), and boys were treated with a pump less often compared with girls (boys 30 percent, girls 34 percent).
The authors concluded that despite similar clinical characteristics and proportion of minority participants, substantial differences in metabolic control exist across the three large transatlantic registries of pediatric patients with Type 1 diabetes, which appears to be due in part to the frequency of insulin pump therapy.
Given the clear superiority of diabetes control via the automated insulin pump, one has to wonder why the American patients received this modality much less often than diabetic patients in Europe? Of course, the ethnic and racial minority effect is another factor that cries out for further exploration and education for doctors and caregivers. Type 1 diabetes is a severe enough burden to bear without equitable access to the best treatment available.