Cluster analysis of Thai patients with newly diagnosed type 2 diabetes mellitus to predict disease progression and treatment outcomes : A prospective cohort study.

INTRODUCTION: Type 2 diabetes mellitus (T2D) is highly heterogeneous in disease progression and risk of complications. This study aimed to categorize Thai T2D into subgroups using variables that are commonly available based on routine clinical parameters to predict disease progression and treatment outcomes. RESEARCH DESIGN AND METHODS: This was a cohort study. Data-driven cluster analysis was performed using a Python program in patients with newly diagnosed T2D (n=721) of the Siriraj Diabetes Registry using five variables (age, body mass index (BMI), glycated hemoglobin (HbA1c), triglyceride (TG), high-density lipoprotein cholesterol (HDL-C)). Disease progression and risk of diabetic complications among clusters were compared using the Χ2 and Kruskal-Wallis test. Cox regression and the Kaplan-Meier curve were used to compare the time to diabetic complications and the time to insulin initiation. RESULTS: The mean age was 53.4±11.3 years, 58.9% were women. The median follow-up time was 21.1 months (9.2-35.2). Four clusters were identified: cluster 1 (18.6%): high HbA1c, low BMI (insulin-deficiency diabetes); cluster 2 (11.8%): high TG, low HDL-C, average age and BMI (metabolic syndrome group); cluster 3 (23.3%): high BMI, low HbA1c, young age (obesity-related diabetes); cluster 4 (46.3%): older age and low HbA1c at diagnosis (age-related diabetes). Patients in cluster 1 had the highest prevalence of insulin treatment. Patients in cluster 2 had the highest risk of diabetic kidney disease and diabetic retinopathy. Patients in cluster 4 had the lowest prevalence of diabetic retinopathy, nephropathy, and insulin use. CONCLUSIONS: We were able to categorize Thai patients with newly diagnosed T2D into four clusters using five routine clinical parameters. This clustering method can help predict disease progression and risk of diabetic complications similar to previous studies using parameters including insulin resistance and insulin sensitivity markers.

Clinical Characteristics, Glycemic Control, and Microvascular Complications Compared Between Young-Onset Type 1 and Type 2 Diabetes Patients at Siriraj Hospital - A Tertiary Referral Center.

Purpose: This study aimed to investigate the clinical characteristics, glycemic control, and microvascular complications compared between young-onset type 1 (T1DM) and type 2 diabetes (T2DM) patients at Siriraj Hospital. Patients and Methods: We collected demographic, clinical, glycemic control, and microvascular complication data of young-onset (onset <30 years of age) T1DM and T2DM patients at our center using February 2019-December 2020 data from the Thai Type 1 Diabetes and Diabetes diagnosed Age before 30 years Registry, Care and Network (T1DDAR CN). Results: Of 396 patients, 76% had T1DM and 24% had T2DM. At diagnosis, T1DM were significantly younger (9.7±5.4 vs 16.9±6.4 years, p<0.001), had a lower body mass index (17.2±4.1 vs 30.8±7.9 kg/m2, p<0.001), higher prevalence of diabetic ketoacidosis (DKA) (66.1% vs 13.7%, p<0.001), and higher HbA1c level (12.8±2.6% vs 10.9±3.1%, p=0.002) compared to T2DM. Regarding glycemic control, the mean HbA1c at registry enrollment did not differ between groups (T1DM 8.3±1.8% vs T2DM 8.1±2.2%, p=0.303), but T1DM achieved HbA1c <7% significantly less than T2DM (19.3% vs 47.8%, p<0.001). T1DM showed deterioration of glycemic control during 10-20 years of age, and gradually improved during 20-30 years of age, whereas patients with T2DM showed progressive worsening of glycemic control over time. Concerning microvascular complications, the prevalence of diabetic retinopathy (10.6% vs 9%, p=0.92) and diabetic neuropathy (3.4% vs 5.5%, p=0.514) between T1DM and T2DM was not significantly different. However, T2DM had a significantly higher prevalence of diabetic nephropathy (T1DM 10.1% vs T2DM 40.2%, p<0.001) that developed within a significantly shorter duration of diabetes (T1DM 11.0±6.8 vs T2DM 4.3±5.1 years, p<0.001) compared to T1DM. Conclusion: T1DM had a significantly high prevalence of DKA at presentation, and most T1DM did not achieve the glycemic target, especially during adolescence. T2DM had a significantly higher prevalence of diabetic nephropathy that developed within a shorter duration of diabetes compared to T1DM.

Epidemiology and phenotypes of diabetes in children and adolescents in non-European-origin populations in or from Western Pacific region.

BACKGROUND: Type 1 diabetes (T1D) incidence varies substantially between countries/ territories, with most studies indicating increasing incidence. In Western Pacific region (WPR), reported rates are much lower than European-origin populations. In contrast, there are reports of substantial numbers of young people with type 2 diabetes (T2D). A deeper understanding of T1D and T2D in the WPR may illuminate factors important in pathogenesis of these conditions. Furthermore, with varying resources and funding for diabetes treatment in this region, there is a need to more clearly determine the current burden of disease and also any gaps in knowledge. AIM: To compile and summarise published epidemiologic and phenotypic data on childhood diabetes in non-European populations in and from WPR. METHODS: Research articles were systematically searched from PubMed (MEDLINE), Embase, Cochrane library, and gray literature. Primary outcome measures were incidence and prevalence, with secondary measures including phenotypic descriptions of diabetes, including diabetes type categorization, presence of diabetic ketoacidosis (DKA) at onset, autoantibody positivity, C-peptide levels, and human leucocyte antigen phenotype. Extracted data were collected using a customized template. Three hundred and thirty relevant records were identified from 16 countries/territories, with analysis conducted on 265 (80.3%) records published from the year 2000. RESULTS: T1D incidence ranged from < 1-7.3/100000 individuals/year, rates were highest in emigrant/ mixed populations and lowest in South-East Asia, with most countries/territories (71.4%) having no data since 1999. Incidence was increasing in all six countries/territories with data (annual increases 0.5%-14.2%, highest in China). Peak age-of-onset was 10-14 years, with a female case excess. Rate of DKA at onset varied from 19.3%-70%. Pancreatic autoantibodies at diagnosis were similar to European-origin populations, with glutamic acid decarboxylase-65 autoantibody frequency of 44.1%-64.5%, insulinoma-associated 2 autoantibody 43.5%-70.7%, and zinc transporter-8 autoantibody frequency 54.3% (one study). Fulminant T1D also occurs. T2D was not uncommon, with incidence in Japan and one Chinese study exceeding T1D rates. Monogenic forms also occurred in a number of countries. CONCLUSION: T1D is less common, but generally has a classic phenotype. Some countries/ territories have rapidly increasing incidence. T2D is relatively common. Registries and studies are needed to fill many information gaps.

Young-onset diabetes patients in Thailand: Data from Thai Type 1 Diabetes and Diabetes diagnosed Age before 30 years Registry, Care and Network (T1DDAR CN).

AIMS/INTRODUCTION: There is a lack of current information regarding young-onset diabetes in Thailand. Thus, the objectives of this study were to describe the types of diabetes, the clinical characteristics, the treatment regimens and achievement of glycemic control in Thai patients with young-onset diabetes. MATERIALS AND METHODS: Data of 2,844 patients with diabetes onset before 30 years-of-age were retrospectively reviewed from a diabetes registry comprising 31 hospitals in Thailand. Gestational diabetes was excluded. RESULTS: Based on clinical criteria, type 1 diabetes was identified in 62.6% of patients, type 2 diabetes in 30.7%, neonatal diabetes in 0.8%, other monogenic diabetes in 1.7%, secondary diabetes in 3.0%, genetic syndromes associated with diabetes in 0.9% and other types of diabetes in 0.4%. Type 1 diabetes accounted for 72.3% of patients with age of onset <20 years. The proportion of type 2 diabetes was 61.0% of patients with age of onset from 20 to <30 years. Intensive insulin treatment was prescribed to 55.2% of type 1 diabetes patients. Oral antidiabetic agent alone was used in 50.8% of type 2 diabetes patients, whereas 44.1% received insulin treatment. Most monogenic diabetes, secondary diabetes and genetic syndromes associated with diabetes required insulin treatment. Achievement of glycemic control was identified in 12.4% of type 1 diabetes patients, 30% of type 2 diabetes patients, 36.4% of neonatal diabetes patients, 28.3% of other monogenic diabetes patients, 45.6% of secondary diabetes patients and 28% of genetic syndromes associated with diabetes patients. CONCLUSION: In this registry, type 1 diabetes remains the most common type and the prevalence of type 2 diabetes increases with age. The majority of patients did not achieve the glycemic target, especially type 1 diabetes patients.

Type 1 diabetes management and outcomes: A multicenter study in Thailand.

AIMS/INTRODUCTION: The Thai Type 1 Diabetes and Diabetes Diagnosed Before Age 30 Years Registry, Care and Network was established in 2014 and involved 31 hospitals. The objective of the registry was to evaluate glycemic control and complications of patients with type 1 diabetes. MATERIALS AND METHODS: Patients' demographics, clinical data, frequencies of daily self-monitoring of blood glucose (SMBG), glycemic control and complications were collected. RESULTS: Among the 1,907 type 1 diabetes patients, the mean age was 21.2 ± 11.3 years. The mean glycated hemoglobin level was 9.35 ± 2.41%, with significant variations among age groups (P < 0.001). Conventional insulin treatment and intensive insulin treatment were used in 43 and 57% of patients, respectively. Mean glycated hemoglobin levels were significantly higher in patients treated with conventional insulin treatment compared to those treated with intensive insulin treatment (9.63 ± 2.34 vs 9.17 ± 2.46%, P = 0.002). Compared to the conventional insulin treatment group, significantly more patients in the intensive insulin treatment group achieved good glycemic control (P < 0.001), and fewer had diabetic retinopathy (P = 0.031). The prevalence of microvascular complications increased significantly with age (P < 0.001). Multivariate analysis showed good glycemic control to be associated with age 25 to <45 years, intensive insulin treatment with SMBG three or more times daily and diabetes duration of 1 to <5 years. CONCLUSIONS: Most Thai type 1 diabetes patients were not meeting the recommended glycemic target. As a result of this study, the national program to improve the quality of diabetes treatment and education has been implemented, and the results are ongoing.

The obstacles to diabetes self-management education and support from healthcare professionals' perspectives: a nationwide survey.

Purpose: This study identified the obstacles to diabetes self-management education and support (DSMES) from healthcare professionals' perspectives in Thailand. Patients and methods: A cross-sectional survey was conducted at 613 hospitals throughout Thailand from December 2016 to March 2017. A self-completion questionnaire on the characteristics of, and obstacles to, diabetes education was sent to administrators, doctors, and diabetes educators (DEs). The views of DEs at public and private hospitals on the characteristics of diabetes education were compared. The obstructing factors reported by administrators, doctors, and DEs were also analyzed. Results: The overall response was 76.6%; the response rates of DEs, doctors, and administrators were 85.6%, 58.9%, and 46.5%, respectively. Although the respondents reported that 75% of patients received diabetes education, only 30% of the DEs believed it was successful. An individual-patient education approach was used by 95.1% of public and 81.4% of private hospitals. The median durations of the individual education sessions were 15 (IQR 10, 28) and 30 (IQR 15, 30) minutes for public and private hospitals, respectively. The DE workload at public hospitals was 3 times heavier than at private hospitals (60 [IQR 30, 140] vs 20 [IQR 10, 33] patients per week; p<0.001). Obstacles to diabetes education were a lack of time due to other duties, a lack of skills in assisting patients with behavior change, inadequate DE numbers, patient disinterest in diabetes education, and patient reluctance to change unhealthy behaviors. Conclusions: High workloads, unclear DE roles, and a lack of DE skills to support patients with behavior change are the primary obstacles to diabetes education.

Corrigendum to: Increased high molecular weight adiponectin, but decreased total adiponectin and kisspeptin, in central precocious puberty compared with aged-matched prepubertal girls.

The aim of the present study was to compare serum leptin, kisspeptin, total adiponectin, high molecular weight (HMW) adiponectin and neuropeptide Y (NPY) levels between girls with central precocious puberty (CPP; n=26, 7-9.5 years old) and age-matched controls (n=29) including or excluding obese girls. Leptin and NPY levels were comparable between CPP and control girls. Kisspeptin levels were lower in the CPP than control group, and were positively correlated with oestrogen in the control group and with systolic and diastolic blood pressure in the CPP group. Kisspeptin levels were negatively correlated with FSH and LH in the CPP group. Total adiponectin levels were lower in CPP than control girls, and were negatively correlated with Tanner stage and body mass index, but positively correlated with the quantitative insulin sensitivity check index in the control group. HMW adiponectin was higher in the CPP than control group, and was positively correlated with Tanner stage and LH in all girls. Total adiponectin had a strong positive correlation with HMW adiponectin in the CPP group (r=0.915) compared with the control group (r=0.371). In conclusion, kisspeptin may be associated with increased oestrogen in prepubertal girls, but with increased blood pressure in girls with CPP. In girls entering puberty, HMW adiponectin was increased and associated with reproductive parameters. Based on these observations, HMW adiponectin probably plays an essential role in the initiation of puberty and is a candidate marker for the prediction of CPP.

Increased high molecular weight adiponectin, but decreased total adiponectin and kisspeptin, in central precocious puberty compared with aged-matched prepubertal girls.

The aim of the present study was to compare serum leptin, kisspeptin, total adiponectin, high molecular weight (HMW) adiponectin and neuropeptide Y (NPY) levels between girls with central precocious puberty (CPP; n=26, 7-9.5 years old) and age-matched controls (n=29) including or excluding obese girls. Leptin and NPY levels were comparable between CPP and control girls. Kisspeptin levels were lower in the CPP than control group, and were positively correlated with oestrogen in the control group and with systolic and diastolic blood pressure in the CPP group. Kisspeptin levels were negatively correlated with FSH and LH in the CPP group. Total adiponectin levels were lower in CPP than control girls, and were negatively correlated with Tanner stage and body mass index, but positively correlated with the quantitative insulin sensitivity check index in the control group. HMW adiponectin was higher in the CPP than control group, and was positively correlated with Tanner stage and LH in all girls. Total adiponectin had a strong positive correlation with HMW adiponectin in the CPP group (r=0.915) compared with the control group (r=0.371). In conclusion, kisspeptin may be associated with increased oestrogen in prepubertal girls, but with increased blood pressure in girls with CPP. In girls entering puberty, HMW adiponectin was increased and associated with reproductive parameters. Based on these observations, HMW adiponectin probably plays an essential role in the initiation of puberty and is a candidate marker for the prediction of CPP.

Adiponectin/resistin levels and insulin resistance in children: a four country comparison study.

BACKGROUND: There are few reports on the effects of ethnicity or gender in the association between adipocytokines and insulin resistance in children of different ages. This study assessed associations between serum concentrations of adiponectin/resistin and parameters of insulin resistance in children from 4 different countries. METHODS: A total of 2,290 children were analyzed in this study; each was from one of 4 different countries (Japan, Thailand, Italy and USA), and grouped according to age (8-11 years old in Group 1 and 12-15 years old in Group 2). RESULTS: Adioponectin was higher in female than in male children, and in Group 1 than in Group 2. Generally, adiponectin was lower in Asian as compared to Italian and American children. These tendencies remained even after adjustment for body mass index (BMI) or waist circumstance (WC). Among older children (Group 2), resistin was higher in female than in male children. Significant correlations by non-parametric univariate correlation coefficients and Spearman's rank correlation coefficients were found between adiponectin and homeostasis model assessment of insulin resistance (HOMA-IR), and fasting serum insulin levels in young Japanese, Italian, and American female children(p < 0.01, p < 0.05, p < 0.05, respectively). Correlations between serum adiponectin and HOMA-IR were also found among older male Italian, American, and Thai children (p < 0.05, p < 0.001, p < 0.001, respectively). In multiple regression analysis by forced entry method, adiponectin correlated with HOMA-IR in Italian and American male children, and in all older female children regardless of country of origin. There was no correlation between resistin and markers of insulin resistance in children from any of the countries. CONCLUSIONS: We conclude that serum adiponectin concentrations are lower in Asian as compared to Italian and American children, and that adiponectin but not resistin contributes to differences in markers for insulin resistance in children from different populations.

Outcomes of group-based treatment program with parental involvement for the management of childhood and adolescent obesity.

OBJECTIVE: An uncontrolled study was conducted to evaluate the effects of a group-based program on weight control, metabolic profiles, and obesity-related complications in obese youth. METHODS: The program consisted of an initial in-patient session and five group sessions, one, two, three, six, and nine months into the study, providing participants and their parents with information about the consequences of obesity and lifestyle modifications. The severity of obesity and obesity-related complications were evaluated at baseline and 12 months after the intervention. The participants' and their parents' perceptions of the program were assessed. RESULTS: Of the obese youth recruited (n=126), 115 completed the study. Their percentage weight for height and percentage body fat decreased significantly (both p<0.001), and their insulin resistance, lipid profiles, and transaminases levels improved (all p<0.01). The prevalence of prediabetes, dyslipidemia, and elevated transaminases decreased significantly (all p<0.05). The participants and their parents perceived the program as valuable. CONCLUSION: A group-based program is effective in managing childhood obesity, improving metabolic profiles, and alleviating certain obesity-related complications. PRACTICE IMPLICATIONS: A group-based program that provides education and raises the awareness of obese children and their parents about the consequences of obesity is an effective model for treating childhood obesity.

Glycemic control, quality of life and self-care behavior among adolescents with type 1 diabetes who attended a diabetes camp.

A prospective study was conducted at the tenth Siriraj diabetes camp with the objectives of evaluating the effectiveness of diabetes camp on 1) glycemic control, 2) knowledge, 3) quality of life, and 4) self-care behavior of adolescents with type 1 diabetes (T1D) who participated in the diabetes camp. During the 5-day camp, twenty-seven participants (mean age 15.6 +/- 2.1 years, mean duration 6.3 +/- 3.0 years) were taught diabetes self-management education (DSME) and engaged in psychosocial support sessions. Post-camp activities were held every 3 months and participants were followed for 12 months post-camp. Glycemic control was assessed prior to the camp, then every 3 months. Knowledge level was assessed prior to the camp, at the end of the camp, and every 3 months. Diabetes self-care behavior and quality of life were evaluated prior to the camp, at 3 months and 12 months after the camp. After attending the camp, participants had improvement in knowledge but there were no changes in HbA1c levels or quality of life scores. Quality of life was not consistently associated with HbA1c. In general, participants did not perceive their quality of life was poor or feel having diabetes affected their social life. The issue participants worried about most was whether they would develop complications from diabetes. There were several weak points found among participant self-care behavior, particularly in diet-related matters. Despite no improvement in glycemic control, participants gained knowledge from attending the camp. Diet related self-care behavior is difficult for teenagers with T1D to be compliant.

Successful strategy to improve glucose tolerance in Thai obese youth.

BACKGROUND: Childhood obesity is an emerging national health problem in Thailand. Our previous study found that one third of obese children and adolescents had impaired glucose tolerance (IGT) and 2.6 percent had already developed type 2 diabetes mellitus. An immediate strategy needs to be established in order to improve these metabolic problems. OBJECTIVE: To determine whether diet and exercise education for lifestyle modification with or without metformin therapy in our diabetes clinic is enable to improve these metabolic problems. MATERIAL AND METHOD: Twenty-six Thai obese children and adolescents with IGT, who received at least 6 months of treatment consisting of lifestyle modification alone or lifestyle modification and metformin (combined treatment) were enrolled into this study. Each patient underwent the second 2-hour oral glucose tolerance test (OGTT). Plasma glucose, insulin levels, HbA1C and lipid profiles were measured. The results were compared with historical pre-treatment data. RESULTS: Approximately 1 year after intervention, 19 out of 26 patients with IGT completed the second 2-hour OGTT. Sixteen patients (84.2%) successfully reversed to be normal glucose tolerance whereas 3 patients (15.8%) remained IGT. Body mass index (BMI), BMISDS, 2-hour plasma glucose, basal insulin level, 2-hour insulin level were significantly decreased after treatment in normal OGTT group (Ps < 0.05). Treatment with lifestyle modification alone and combined treatment indifferently improved the abnormal glucose tolerance in our patient (83.3% vs. 84.6%). CONCLUSION: Impaired glucose tolerance in obese youth is a reversible abnormality by lifestyle modification with or without metformin.

The etiologies of adrenal insufficiency in 73 Thai children: 20 years experience.

BACKGROUND: Adrenal insufficiency (AI) is an event caused by an inadequate secretion or action of adrenal hormones. It can be classified as primary (1 degree) and secondary (2 degree). AI may result in severe morbidity and mortality when undiagnosed or ineffectively treated. OBJECTIVE: To determine the etiologies of AI in Thai children. MATERIAL AND METHOD: Data of children with AI presented to the authors' pediatric endocrine service between 1982 and 2002 (20 years) were retrospectively collected and analyzed. RESULTS: AI was diagnosed by clinical and laboratory data in 73 children (31 boys and 42 girls). Sixty-two (84.9%) patients had 1degree AI while 11 (15.1%) had 2 degree AI. The majority of patients with 1 degree AI (87.1%) were diagnosed with congenital adrenal hyperplasia (CAH). Other causes of 1 degree AI were uncommon such as ACTH unresponsiveness (4.8%) and no definite diagnosis (8.1%). Most children with 1 degree AI presented with hyperpigmentation. Causes of 2 degree AI were as follows: panhypopituitarism (63.6%), isolated ACTH deficiency (9.1%), and low birth weight (27.3%). CONCLUSION: In the present study, CAH was the most common cause of 1 degree AI while panhypopituitarism was the most common cause of 2 degree AI. Other causes of AI were quite uncommon. Definite causes of AI have not yet been identified in some children. Further clinical observation and special tests including molecular studies in these children are warranted for diagnostic and prognostic importance.

Glycemic control and the psychosocial benefits gained by patients with type 1 diabetes mellitus attending the diabetes camp.

OBJECTIVE: The aim of this study was to evaluate the effectiveness of diabetes camp on glycemic control, knowledge, and psychosocial benefits among patients with type 1 diabetes (T1D). Glycemic control among patients with infrequent and frequent self-monitoring of blood glucose (SMBG) was also compared. METHODS: During a 5-day camp, 60 patients were taught diabetes self-management education (DSME). After camp, patients were divided into two groups based on frequency of SMBG (<3 versus 3-4 times/day) and were followed up until 6-month post-camp. Patients' HbA1c levels and knowledge were assessed at baseline, 3- and 6-month post-camp. Patients' impressions towards camp were assessed. RESULTS: In both SMBG groups, HbA1c levels decreased significantly at 3-month post-camp but did not sustain at 6-month monitoring. The patients with frequent SMBG had a lower mean HbA1c level. A significant improvement in knowledge was noted and sustained up to 6-month post-camp. The patients found diabetes camp of benefit and felt they could better cope with diabetes. CONCLUSIONS: Although the effect of the diabetes camp on glycemic control was short-lived, an improvement in knowledge and a better attitude towards having diabetes were seen among participants. PRACTICE IMPLICATIONS: The psychosocial benefits and knowledge gained by patients attending diabetes camp underline the importance of including a camp in a diabetes management plan. To improve patients' long-term glycemic control, a continuous education is required.

Etiology and glycemic control among Thai children and adolescents with diabetes mellitus.

BACKGROUND: There is little data on etiology and metabolic control in children and adolescents with diabetes in developing countries. OBJECTIVE: Determine the etiology of diabetes in Thai youths and to evaluate their glycemic control. MATERIAL AND METHOD: The authors retrospectively reviewed the case records of 157 patients seen at the Department of Pediatrics, Siriraj Hospital between 2003 and 2004. RESULT: Type 1 diabetes (T1D) comprised 83%, type 2 diabetes (T2D) 13%, and other types 4%. GAD65 and IA-2 antibodies were positive in 63% and 61% of T1D patients, and 0% and 9% of T2D patients, respectively. There were an increasing number of new cases, both T1D and T2D, during the study period compared with a previous study conducted at the hospital. Mean HbA1c in T1D and T2D were 8.9 +/- 2.1% and 6.2 +/- 1.80%, respectively (p < 0.001). CONCLUSION: Based on the present study, glycemic control appeared to be more satisfactory in T2D patients than those with T1D. Glycemic control among T1D patients was comparable to others in developed countries.