Sex differences over time for glycemic control, pump use and insulin dose in patients aged 10-40 years with type 1 diabetes: a diabetes registry study.

INTRODUCTION: To evaluate sex differences in people with type 1 diabetes concerning changes in glycemic control and trends in insulin pump use and insulin dose over two decades in adolescents and one-and-a-half decades in adults. RESEARCH DESIGN AND METHODS: People aged 10-20 years (data years 1999-2018) and 21-40 years (data years 2004-2018) with type 1 diabetes were identified in the Diabetes Prospective Follow-up Registry (DPV). All available patients' data sets of the respective period were used for linear regression analyses to investigate trends in HbA1c, pump use, insulin doses and body mass index SD scores (BMI-SDS) in females and males. In addition, stratification by migrant background was made for the adolescent group. RESULTS: In the youth group (n=68 662), both boys and girls showed an HbA1c decrease over the period examined. After stratification for migrant background, an HbA1c convergence between boys and girls was seen in those without migrant background as of 2016. Usage of insulin pumps increased continuously from 3% (boys and girls) to 47% (boys) and 54% (girls), respectively. The daily insulin dose in units per kilogram body weight and day increased continuously from 1999 to 2018. An insulin dose leveling between boys and girls occurred. BMI-SDS consistently increased in girls whereas only slight variations were observed in boys.The adult group (n=15 380) showed constant HbA1c sex differences from 2004 to 2018 with lower HbA1c level in females. The use of insulin pump therapy rose from 18% to 35% (males) and 30% to 50% (females). CONCLUSIONS: The gap in metabolic control between boys and girls with type 1 diabetes seems to close, but predominantly in adolescents without a migrant background. Improved HbA1c was associated with increased insulin pump use, especially in girls.In adult patients, sex differences in metabolic control and insulin pump use persist: women show constantly lower HbA1c values and higher insulin pump use.

Mediating Effects of Mental Health Problems in a Clinical Sample of Adolescents with Obesity.

INTRODUCTION: The prevalence rates of obesity have increased in recent decades; despite leveling off in recent German studies among children and adolescents, obesity rates remain high. Psychosocial factors have an adverse impact on the maintenance of obesity. Hence, this study examined the mediating effects of mental health problems on the relation between the body mass index standard deviation score (BMI-SDS) and global health-related quality of life (HRQoL) among adolescent inpatients with obesity while controlling for gender and age-group. METHODS: Three simple mediation analyses with gender and age-group as covariates were conducted for n = 313 adolescents with obesity (nfemale = 193, 61.7%) aged 12-17 (M = 14.19, SD = 1.52; BMI-SDS: M = 2.67, SD = 0.52). The adolescents were asked to report their global HRQoL at admission, and their parents estimated the children's mental health problems at home prior to inpatient rehabilitation. RESULTS: Emotional, peer-related, and conduct problems mediated the unfavorable effects of BMI-SDS on global HRQoL, showing high, moderate, and small effect sizes, respectively (completely standardized indirect effect of emotional problems: ß = -0.09, SE = 0.03, 95% B-CI = -0.15 to -0.04; conduct problems: ß = -0.03, SE = 0.02, 95% B-CI = -0.06 to -0.01; peer-related problems: ß = -0.10, SE = 0.03, 95% B-CI = -0.16 to -0.05). CONCLUSION: Mental health problems may be one salient pathway through which BMI-SDS impairs global HRQoL among adolescents with obesity. Hence, inpatient rehabilitation programs for adolescents with obesity should increase their focus more on the development of psychosocial skills. Thus, the promotion of emotion regulation and social-emotional competencies is suggested.

Inpatient Rehabilitation for Children and Adolescents With Diabetes in Germany Between 2006 and 2013.

INTRODUCTION: In Germany, inpatient rehabilitation is a well-established additive option in the therapeutic concept for children and adolescents with diabetes. However, its contribution in pediatric diabetes care is not known exactly. Our objective was to analyze inpatient rehabilitation in pediatric diabetes over eight years in Germany. METHODS: We requested secondary data from the German Statutory Pension Insurance Scheme to evaluate all completed inpatient rehabilitations for children and adolescents with diabetes (ICD-code E10-14) reimbursed by this institution between 2006 and 2013. For each type of diabetes, we analyzed the distribution of admissions by year, age-group, sex, nationality, and other documented diagnoses. All analyses were conducted via remote computing with IBM SPSS Version 24. RESULTS: Between 2006 and 2013, 5,403 admissions to inpatient rehabilitation for 4,746 children and adolescents with diabetes were documented. For type 1 diabetes (T1D; 88.5% of admissions), the number of yearly admissions increased from 458 in 2006 to 688 in 2013 (p=0.013), especially for age-group>5-10. The increase for type 2 diabetes (T2D) was not significant. Admissions were more frequent for girls (53.6%, p≤0.001), age>10-15 years (42.8%, p=0.001), and German nationality (98.5%). Obesity (T1D: 11.1%; T2D: 87.9%) and mental disorders (T1D: 11.6%; T2D: 27.4%) were the most frequent documented diagnoses in addition to diabetes. CONCLUSION: This study provides a comprehensive overview of inpatient rehabilitation for children and adolescents with diabetes over many years in Germany. Until 2013, inpatient rehabilitation remained important in pediatric diabetes care, especially for children with mental disorders or obesity.

Rehabilitation in Germany 2004-2016 A Multicenter Analysis Over a Period of 13 Years in Children and Adolescents with Diabetes Mellitus.

In the treatment of children/adolescents with diabetes medical rehabilitation plays an important role. It was the aim of the survey to analyze trends in the number of patients admitted to rehabilitation, the quality of diabetes care, the incidence of acute complications, risk factors for cardiovascular co-morbidities like lipids and blood pressure and the familial status nationwide and over a period of 13 years. METHODS: Currently seven hospitals offer in-patient rehabilitation for children/adolescents with diabetes in Germany. Six hospitals participated in the survey. All children/adolescents (n=7.163) who participated in an in-patient rehabilitation 01/01/2004-31/12/2016 were included. Clinical/familial data were assessed: age, sex, family situation, type/duration of diabetes, insulin dosage, self-monitoring, acute complications, height, body weight, blood pressure and laboratory parameters. For collecting and storage of data the computer software DPV® (Diabetes-Patienten-Verlaufsdokumentation, University of Ulm, Germany) was used. Statistical analyses were performed using the programme SAS (Statistical Analysis Software 9.4, SAS Institute Inc, Cary, North Carolina, USA). RESULTS: During the study period 7.163 patients took part in 10.987 in-patient rehabilitation procedures. The yearly number of patients participating in rehabilitation remained stable. There was no change in the quality of diabetes control (HbA1c: p=0.30, fasting blood glucose: p=0.80). The incidence of severe hypoglycaemia decreased (p<0.001). The incidence of ketacidosis remained stable (p=0.18). The frequency of blood glucose self-monitoring increased (p<0.001). The same was true for patients treated with CSII (p<0.001), whereas the numbers of patients treated with CT or ICT decreased (both p<0.001). There was no change in patients' total insulin dose (p=0.01). There was a decrease of the number of patients living with both parents (p<0.001), the percentage of children/adolescents living with mother or father alone increased (p<0.001). The percentage of children/adolescents living in mixed cultural families or having a background of immigration increased (p<0.001). CONCLUSIONS: There is a change in medical rehabilitation: The number is stable, the proportion of patients using CSII increased, the number of patients living with single parents and the percentage of patients from culturally mixed families increased also.

[Psychological Measures and BMI-SDS among Adolescents with Obesity and Different Motivational Stages in Inpatient Rehabilitation]. / Psychologische Kennwerte und BMI-SDS bei Jugendlichen mit Adipositas und unterschiedlichen Motivationsstadien in der stationären Rehabilitation.

PURPOSE: Obesity is strongly represented in adolescents, showing a high persistency until adulthood. Previous studies displayed short term effects of inpatient rehabilitation, but failed to demonstrate sustainability. Long-term effects might be expected when taking the motivational stage of adolescents into account. However, there is no evidence regarding motivational stages in obese adolescents in German inpatient rehabilitation. The current study investigated psychological measures and the Body-Mass-Index-standard deviation score (BMI-SDS) in obese adolescents related to motivational stages and age. METHODS: A total sample of n=127 adolescents were included in this cross-sectional study during their inpatient rehabilitation intake. Differences in BMI-SDS and self-reported psychological health were analyzed using 2-way analysis of covariance with the factors motivational stage (intender vs. actor) and age (12-14 vs. 15-17 years), and the covariate gender. Motivational stages were assessed using the newly developed questionnaire to classify motivational stages (Fragebogen zur Einteilung in Motivationsstadien; MoS). RESULTS: Intenders reported unfavorable disease management and volitional parameters. Younger participants reported a lower BMI-SDS as well as lower motivational and volitional parameters. A risk profile emerged for younger intenders which was characterized by psychological problems. CONCLUSION: The results provide important insights for the design of motivational stage-based training programs and underpin the need for age-specific therapies during adolescence.

Worse Metabolic Control and Dynamics of Weight Status in Adolescent Girls Point to Eating Disorders in the First Years after Manifestation of Type 1 Diabetes Mellitus: Findings from the Diabetes Patienten Verlaufsdokumentation Registry.

OBJECTIVE: To assess indications of eating disorders in girls with type 1 diabetes mellitus (T1DM). STUDY DESIGN: In total 31 556 girls aged >6 months and <23 years of age with T1DM from the Diabetes Patienten Verlaufsdokumentation (DPV) cohort were analyzed including 155 (0.49%) girls with anorexia nervosa, 85 (0.27%) girls with bulimia nervosa, 45 (0.14%) girls with binge eating disorder, and 229 (0.73%) girls with eating disorders not otherwise specified. Patient characteristics, weight changes, numbers of patients with severe hypoglycemia and diabetic ketoacidosis (DKA), changes of glycosylated hemoglobin A1c (HbA1c) levels, use of pumps, and prevalence of celiac disease and autoimmune thyroiditis were compared between girls with and without eating disorders. Multiple logistic regression analyses were performed. RESULTS: Eating disorders were significantly associated with late pubertal age, nonusage of pumps, no migration background, increased HbA1c levels, increased frequencies of DKA and severe hypoglycemia, and celiac disease were not related to eating disorders. Significant differences in HbA1c levels, prevalence of DKA and severe hypoglycemia between girls with and without eating disorders were already detectable in the first years after onset of T1DM. A decrease of body mass index (BMI)-SDS increased the risk for comorbid anorexia nervosa (7.1-fold [95% CI 3.6-14.3] compared with stable BMI-SDS, 6.9-fold [95%CI 3.4-14.1] compared with increase of BMI-SDS). CONCLUSIONS: Poor metabolic control and increased rates of DKA and severe hypoglycemia in the first years after manifestation of T1DM can be hints for eating disorders in girls with T1DM, and weight loss is specific for anorexia nervosa. These clinical features should lead to screening for eating disorders especially at a late pubertal age.

Asthma in children and adolescents with type 1 diabetes in Germany and Austria: Frequency and metabolic control.

OBJECTIVE: To investigate the prevalence of asthma in young patients with type 1 diabetes mellitus (T1D) from Austria and Germany and its influence on their metabolic control. METHODS: This prospective, multicenter observational cohort study was based on the DPV-registry (German/Austrian DPV initiative) including 51 926 patients with T1D (<20 years). All clinical data were documented prospectively. To identify patients with additional asthma, the entry of the diagnosis asthma as well as asthma medication was used for classification. RESULTS: 1755 patients (3.4%) of the cohort had the diagnosis asthma or received asthma-specific drugs. Patients with asthma needed higher insulin doses (0.88 ± 0.3 vs 0.84 ± 0.3 U/kg, P < .01) and had decreased height-standard deviation score (SDS) (-0.002 ± 1.04 vs 0.085 ± 1.02, P < .01); they were more often males (61% vs 52%, P < .01), had an increased body mass index (BMI)-SDS (0.31 ± 0.89 vs 0.28 ± 0.89, P = .04) and experienced more severe hypoglycemia (4.5 [4.2; 4.8] vs 3.2 [3.2; 3.3] events/100 pts. years, P < .01). Glycated hemoglobin A1c (HbA1c) did not differ between patients with and without asthma overall, only sub groups (corticosteroids vs leukotriene antagonist and corticosteroids vs sympatomimetics) revealed differences. No influence of asthma medication on metabolic control or BMI-SDS could be found. CONCLUSION: In our DPV-database, frequency of asthma and T1D seems similar to the prevalence of asthma in the healthy German background population. The concomitant diagnosis of asthma and T1D had minor influence on metabolic control and diabetes complication rate, although there was no difference in HbA1c overall. Patients with both diseases seem to be slightly growth restricted and require slightly higher insulin doses.

Changing Characteristics of Obese Children and Adolescents Entering Pediatric Lifestyle Intervention Programs in Germany over the Last 11 Years: An Adiposity Patients Registry Multicenter Analysis of 65,453 Children and Adolescents.

OBJECTIVE: To examine whether characteristics of children and adolescents who start lifestyle intervention (LI) for obesity in Germany changed over the last decade. METHODS: 65,453 subjects (<21 years) from the APV database (Adiposity Patients Registry) with a BMI ≥ 90th percentile were included (years 2005-2015). Logistic regression models (confounders: age, sex, migration background) were created for overweight, obesity, extreme obesity, and obesity-related comorbidities. Comorbidities were further adjusted for weight category. Results were stratified by inpatient or outpatient care. RESULTS: Extreme obesity was found to be more frequent at the onset of LI (2005: 11.6; 2015: 12.7%) with a similar trend in subgroups (p < 0.001). Obesity increased (2005: 50.3%; 2015: 55.1%), and overweight decreased (2005: 34.1%; 2015: 29.0%) in the whole study population. Trends were similar for inpatient or outpatient care (all p < 0.001). Hypertension increased from 45.7% to 49.2% in the whole study population, and similar data were obtained in the subgroup of inpatients (both p < 0.0001). Dyslipidemia increased in all patients (2005: 21.9%; 2015: 28.0%) and in inpatients (2005: 20.2%; 2015: 25.7%; both p < 0.0001). Abnormal carbohydrate metabolism rose in all patients (from 5.2 to 6.4%; p = 0.0002) without significant trends in subgroups. CONCLUSION: During the last decade, children and adolescents presented with higher BMI SDS at the onset of LI and the proportion with obesity-related comorbidities increased. Particularly the presence of comorbidities differed between outpatients and inpatients.

Predicting weight loss and maintenance in overweight/obese pediatric patients.

BACKGROUND: Pediatric lifestyle interventions have positive short-term effects on obese patients. Studies on long-term effects are still scarce in Europe. We investigated long-term weight patterns and sociodemographic predictors of a weight change in a large Central European (Germany, Austria and Switzerland) overweight pediatric cohort. METHODS: The APV (Adiposity Patients Verlaufsbeobachtung) database was retrospectively analyzed; 157 specialized childhood obesity centers contributed standardized data of 29,181 patients [body mass index (BMI) ≥ 90th percentile; 5-25 years old] presenting between 2000 and 2012. BMI standard deviation scores (BMI-SDS) were analyzed in a 2-year follow-up and grouped according to BMI-SDS changes. Multiple logistic regression analyses were conducted to assess associations between sociodemographic factors and weight patterns. RESULTS: 2-year follow-up data were available in 3,135 patients (54.6% female). Five distinct weight trajectories 'rapid weight loss' (n = 735, 23.4%), 'delayed success' (n = 697, 22.2%), 'cycling weight' (n = 43, 1.4%), 'initial weight loss' and 'weight rebound' (n = 383, 12.2%) and 'no weight loss throughout' (n = 1,277, 40.7%) best characterized long-term BMI-SDS changes. Younger and male patients were more likely to reduce weight and maintain weight loss. CONCLUSIONS: Our results suggest that an intervention before the onset of puberty seems promising for long-term weight maintenance in overweight children. Thus, new concepts are needed to improve long-term treatment success in patients with lower success rates.

Does obesity lead to a specific lipid disorder? Analysis from the German/Austrian/Swiss APV registry.

Overweight and obese youth represent a challenge for the affected individual, the healthcare system as well as society as a whole. Increased long-term cardiovascular risk is one of the major consequences of early-onset obesity, affecting both life expectancy and quality of life. The aim of this report is to study the effects of age, gender and obesity category on the presence of individual components of dyslipidemia using normal-weight subjects from the population-based German KIGGS study including 17,641 randomly selected children and adolescents, aged 0-18 years (11,110 normal-weight subjects with lipid measurements) and the German-Austrian-Swiss APV registry, including 57,239 overweight or obese children, adolescents and young adults from 162 specialized obesity care centers (lipid measurements available in 29,711 subjects). Subjects were classified according to BMI category based on the age- and gender-adjusted BMI-z-scores as recommended by the AGA (German Pediatric Obesity working group). Cut-offs for dyslipidemia were based on the recommendations by the American Heart Association: total cholesterol: > 5.2 mmol/l, HDL-cholesterol < 0.9 mmol/l, LDL-cholesterol > 3.4 mmol/l, triglycerides > 1.7 mmol/l. Using SAS 9.2-software, hierarchic modeling with both linear and logistic regression analysis was applied. Within the group of normal-weight children, fasting triglycerides were elevated in 3.3%, LDL-cholesterol in 7.2% and HDL-cholesterol was reduced in 3.1%. With increasing BMI-category, the prevalence of hypertriglyceridemia and reduced HDL-cholesterol increased rapidly. A weaker relationship was present for LDL-cholesterol and total cholesterol. Among obese youth, 30.5% displayed any dyslipidemia, underlining the importance of adequate screening and intervention.

Insulin resistance in children and adolescents with type 1 diabetes mellitus: relation to obesity.

BACKGROUND: Insulin resistance is well recognized both in type 1 diabetes mellitus (T1DM) and in obesity. Studies concerning the relation between insulin resistance and overweight in T1DM have not yet been carried out. METHODS: Degree of overweight [standard deviation score-body mass index (SDS-BMI)] and daily insulin doses per weight (ID/kg), per body surface (ID/m2), and per ideal body weight (ID/IW) were recorded in 4124 children aged between 5 and 20 yr with a duration of T1DM of 4-5 yr and an adequate metabolic control [hemoglobin A1c (HbA1c) <8.0%]. SDS-BMI was compared between insulin-resistant (ID/kg > or = 1.0) and insulin-sensitive (ID/kg <1.0) children. The ID/kg, ID/m2, and ID/IW were compared between obese (SDS-BMI >1.9) and non-obese children. Multivariate linear regression analysis was conducted for the dependent variables ID/kg, ID/m2, and ID/IW, including age, gender, SDS-BMI, and HbA1c as independent variables. RESULTS: The 882 insulin-resistant children did not differ significantly (p = 0.447) with respect to SDS-BMI (median +0.38) compared to the 3242 insulin-sensitive children (median SDS-BMI +0.42). The ID/kg was significantly (p = 0.031) lower in the obese children compared to the non-obese children (median 0.80 vs. 0.83), while ID/m2 (median 31.0 vs. 26.2) and ID/IW (median 1.17 vs. 0.85) were significantly (p < 0.001) increased in the obese children. In multivariate linear regression analysis, SDS-BMI was significantly (p < 0.001) associated with an increase in ID/m2 and ID/IW and a decrease in ID/kg. CONCLUSIONS: T1DM children with insulin resistance based on ID/kg are not more overweight than insulin-sensitive children with T1DM. ID/m2 and ID/IW seem to reflect a better tool than ID/kg to describe the influence of overweight on insulin resistance in T1DM.

Medical care of obese children and adolescents. APV: a standardised multicentre documentation derived to study initial presentation and cardiovascular risk factors in patients transferred to specialised treatment institutions.

UNLABELLED: So far in Europe, no studies have been published on the structuring of medical care for obese children and adolescents. Besides anthropometric parameters, evaluations of the cardiovascular risk factors hypertension, dyslipidaemia, impaired glucose metabolism and treatment modalities were documented in a standardised multicentre evaluation survey (APV) of 18 primarily outpatient and nine rehabilitation institutions. In total, 3837 children (aged 2-20 years) took part in the years 2000 up to March 2003, of whom 1985 were treated in outpatient institutions and 1852 in rehabilitation institutions. Of these children, 10% were overweight, 37% obese, 49% extremely obese and 4% of normal weight at initial presentation. The frequencies of diagnostic procedures performed and documented were low (measurement of blood pressure 43%, lipids 40%, glucose metabolism 21%). In the subgroup of obese children who were screened for cardiovascular risk factors, 23% suffered from hypertension, 11% displayed increased cholesterol, 9% increased low-density lipoprotein-cholesterol, 29% increased triglycerides, 11% decreased high-density lipoprotein-cholesterol and 6% had impaired glucose metabolism. CONCLUSION: Despite the high prevalence of cardiovascular risk factors in obese children and adolescents confirmed in this report, diagnostic procedures failed in a considerable percentage even in specialised treatment centres for obese children and adolescents. In future, the feedback based on standardised evaluation of diagnostic and treatment procedures should aim to improve the quality of medical care.

Multimodal patient education program with stress management for childhood and adolescent asthma.

The present study aimed to evaluate a multimodal patient education program carried out during inpatient rehabilitation. The program included cognitive-behavioral stress management training as a main component. The efficacy was examined in comparison to an education program without stress management. In total N=68 patients aged between 8 and 16 years were included in the post-treatment and N=46 patients in the 6 months follow-up assessment. Short- and long-term intervention effects of the multimodal education program were observed in relation to patients' age. The experimental treatment elicited significant improvements in adaptive coping in adolescents aged from 14 to 16 years. In contrast, substantial effects were not yielded for the control treatment. The results suggest that the multimodal patient education training has beneficial effects on stress management in adolescents with asthma. Results are discussed with regard to predictive factors for rehabilitation outcome.