Glycemic Control and Long-term Complications in Pediatric Onset Type 1 Diabetes Mellitus: A Single-center Experience from Northern India

Objective: To study glycemic control, mortality and long-termcomplications in children with type 1 diabetes (T1D).Design: Cross-sectional study.Setting: Referral centre at a government teaching hospital.Participants: Patients with T1D with age ≤18 years at onset.Methods: We retrospectively collected demographic data fromcomputer records from 1991 to 2015. Prospective study foroutcomes was conducted between 2012 and 2016.Main outcome measures: Mortality rate, glycosylatedhemoglobin (HbA1c), and microvascular complication rate.Results: The proportion of T1D patients (n=512) <5 years of ageat onset was 18.6% between 1995 and 2004, and 24.2% in2005-2014 (P<0.001). Twenty eight patients had died out of 334whose living status was known (mortality 1.1 per 100 patient-years over 2549 patient-years follow up). Median (range)HbA1c (n=257) was 8.3% (5.1-15.0%). At least one episode ofsevere hypoglycemia (coma/seizure/inability to assist self) hadoccurred in 22.8% patients over two years. Hypertension waspresent in 11.7% patients. Microvascular complications screenin 164 eligible patients [median (range) age 20 (8-45) y andduration of diabetes 9.1 (5-30) y] showed diabetic nephropathy in3.0%, proliferative retinopathy in 3.6% and LDL cholesterol >100mg/dL in 34% patients.Conclusion: The mortality rate and prevalence of hypertensionwere high, given the short duration of diabetes of the patients.The proportion of patients with age ≤5 years at onset of diabeteshas increased at our center.

High direct costs of medical care in patients with Type 1 diabetes attending a referral clinic in a government-funded hospital in Northern India.

Background. There is little information regarding costs of managing type 1 diabetes mellitus (T1DM) from low- and middle-income countries. We estimated direct costs of T1DM in patients attending a referral diabetes clinic in a governmentfunded hospital in northern India. Methods. We prospectively enrolled 88 consecutive T1DM patients (mean [SD] age 15.3 [8] years) with age at onset <18 years presenting to the endocrine clinic of our institution. Data on direct costs were collected for 12 months—6 months retrospectively followed by 6 months prospectively. Results. Patients belonged predominantly (77%) to the middle socioeconomic strata (SES); 81% had no access to government subsidy or health insurance. The mean direct cost per patient-year of T1DM was `27 915 (inter-quartile range [IQR] `19 852–32 856), which was 18.6% (7.1%–30.1%) of the total family income. A greater proportion of income was spent by families of lower compared to middle SES (32.6% v. 6.6%, p<0.001). The mean out-of-pocket payment for diabetes care ranged from 2% to 100% (mean 87%) of the total costs. The largest expenditure was on home blood glucose monitoring (40%) and insulin (39.5%). On multivariate analysis, total direct cost was associated with annual family income (β=0.223, p=0.033), frequency of home blood glucose monitoring (β=0.249, p=0.016) and use of analogue insulin (β=0.225, p=0.016). Conclusions. Direct costs of T1DM were high; in proportion to their income the costs were greater in the lower SES. The largest expenditure was on home blood glucose monitoring and insulin. Support for insulin and glucose testing strips for T1DM care is urgently required. Natl Med J India 2016;29:64–7

Growth and obesity status of children from the middle socioeconomic group in Lucknow, northern India: A comparison with studies on children from the upper socioeconomic group.

Background. Children from the upper socioeconomic group in India currently show a modest positive secular trend in height, accompanied by a high prevalence of obesity. We examined the anthropometric pattern among children from the middle socioeconomic group. Methods.A cross-sectional study of anthropometry in 3794 schoolchildren from the middle socioeconomic group in the city of Lucknow, Uttar Pradesh, India. Results. Results. A comparison with the data of a 20-year-old study of children from the upper socioeconomic group showed that the height of boys in our study was at par with or higher than that of boys of the same (Lucknow–Allahabad–Varanasi) region or national data, at all centiles. In contrast, girls in our study were shorter than national data at all centiles and shorter than girls of the same region at the 3rd centile. Children from the middle socioeconomic group did not show the large increase in weight centiles seen in the recent data of the upper socioeconomic group. The values of body mass index at the 85th and 95th percentile at 17 or 18 years of age in girls and boys were 23 and 25 kg/m2, respectively. Obesity was prevalent in 1% of children of the middle socioeconomic group and an additional 5.7% were overweight. Conclusions.Children from the middle socioeconomic group in Lucknow have grown taller than their 20-year-old counterparts from the upper socioeconomic group. Boys have fared better than girls. Children from the middle socioeconomic group in Lucknow are at present spared from the epidemic of obesity.

Newborn Screening for Congenital Hypothyroidism, Galactosemia and Biotinidase Deficiency in Uttar Pradesh, India.

Objective: To assess feasibility and recall rates for newborn screening for congenital hypothyroidism, galactosemia and biotinidase deficiency in a predominantly rural and inner city population in and around the city of Lucknow in Uttar Pradesh, India. Design: Prospective observational study. Setting: Two tertiary-care and 5 district hospitals in and around Lucknow. Participants: All babies born in above hospitals during the study period. Methods: Heel prick samples were collected after 24 hours of life. Dried blood spot TSH, total galactose and biotinidase were assayed by immunofluorometry. Age related cut-offs were applied for recall for TSH. For galactosemia and biotinidase deficiency, manufacturer-suggested recall cut-offs used initially were modified after analysis of initial data. Main outcome measure: Recall rate for hypothyroidism, galactosemia and biotinidase deficiency. Results: Screening was carried out for 13426 newborns, 73% of all deliveries. Eighty-five percent of those recalled for confirmatory sampling responded. Using fixed TSH cut off of 20 mIU/L yielded high recall rate of 1.39%, which decreased to 0.84% with use of age-related cut-offs. Mean TSH was higher in males, and in low birth weight and vaginally delivered babies. Eleven babies had congenital hypothyroidism. Recall rates with modified cut-offs for galactosemia and biotinidase deficiency were 0.32% and 0.16%, respectively. Conclusion: An outreach program for newborn screening can be successfully carried out in similar socio-cultural settings in India. For hypothyroidism, the high recall rate due to early discharge was addressed by age-related cut-offs.

Corticosteroid physiology and principles of therapy.

The adrenal cortex secretes glucocorticoids (GC), mineralocorticoids (MC) and androgens. GC maintain homeostasis, MC regulate fluid and electrolyte balance and adrenal androgens contribute to development of secondary sexual characteristics. Pharmacologic GC therapy is frequently indicated in the pediatric age group. Besides having many important side effects, prolonged high dose systemic GC therapy has a suppressive effect on endogenous steroid production. Therefore, GC therapy should be withdrawn gradually and stopped based on assessment of hypothalamo-pituitary-adrenal (HPA) axis recovery. Patients with HPA axis suppression require physiological replacement of GC along with enhancement of doses during periods of stress. Due to its immunosuppressive effects, issues about safety and efficacy of live virus vaccines in patients receiving systemic high dose GC therapy must be borne in mind.

IAP National Task Force for Childhood Prevention of Adult Diseases: insulin resistance and Type 2 diabetes mellitus in childhood.

Type 2 diabetes mellitus (DM) has traditionally been considered a disease of adults. However, in the last 2 decades, it is increasingly being reported in children and adolescents. Obesity is a strong correlate, and the increasing prevalence of obesity and poor physical activity is precipitating type 2 DM at younger ages in the ethnic groups at risk.Indians and other South Asians are among the ethnic groups particularly prone to insulin resistance and type 2 DM, the other racial groups being some American Indian tribes like the Pima Indians, Mexican Americans,Pacific Islanders and African Americans,among others. The WHO has predicted that India will have the greatest number of diabetic individuals in the world by the year 2025.Type 2 DM starting during adolescence puts the individual at risk for major morbidity and even mortality right during the productive years of life. The microvascular complications of DM (nephropathy, retinopathy, neuropathy) are brought on at an early age. In addition, type 2 DM and obesity are two components of a metabolic syndrome of insulin resistance, the other features of which include hypertension, dyslipidemia and hypercoagulability of blood. All these conditions together increase the risk for cardiovascular and cerebrovascular mortality and morbidity (i.e., myocardial infarction and stroke). The resulting economic burden will be enormous.Type 2 DM and the insulin resistance syndrome are to a large extent preventable.Adoption of a healthy eating and physical activity pattern has resulted in decreasing the development of DM in a few recent studies from various parts of the world. A concerted,multi-pronged effort is needed, involving the general public, pediatricians and general physicians, teachers and schools, the media,the government and professional medical bodies, to generate a momentum towards the goal of prevention of type 2 DM and the insulin resistance syndrome in the young population of India.