Juvenile Diabetes

Diabetes is the most common metabolic disease in young people
Diabetes is the most common metabolic disease in young people

Juvenile diabetes refers to diabetes in the young. Type 1 diabetes effects 90% of people younger than 25 who have diabetes.

Diabetes is the most common metabolic disease in the young.

There is no agreed definition of what is meant by a young person in this context, however most people would refer to a young person as being under 16 or 18 years of age.

Various age ranges have been used in the literature.

Diagnosis and epidemiology

The Scottish Study Group for the Care of the Diabetes in the Young showed that currently there are nearly 2000 people with diabetes aged under 16 years in Scotland, with an annual incidence of 25 per 100,000 population and a near tripling of new cases in the last 30 years.

Type 1 diabetes, resulting from beta-cell destruction and absolute insulin deficiency, accounts for over 90% of diabetes in young people younger than 25, and is autoimmune in origin.

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Non-type 1 diabetes is recognised with increasing frequency, particularly emerging molecular forms of diabetes, diabetes secondary to pancreatic disease and a rise in type 2 diabetes and other insulin resistance syndromes in the young.

Type 1 diabetes

12-15% of young people under the age of 15 with diabetes mellitus have an affected first degree relative (a positive family history).

Children are thrice as likely to develop diabetes if their father has diabetes rather than their mother.

While there are known antibody markers of prediction in high-risk subjects, there is no evidence for effective methods of prevention of diabetes.

Screening is currently considered unethical except in the context of a trial.

There are several randomised trials in progress (e.g. ENDIT, DPT-1, DIPP) investigating different therapies for the prevention of type 1 diabetes. It is anticipated that results will be available in the next five years.

Diabetes and cystic fibrosis

20% of patients with cystic fibrosis develop secondary diabetes by the age of 20, with an incidence which increases thereafter to 80% by the of age 35.

Limited data suggest that clinical symptoms deteriorate when diabetes develops in cystic fibrosis, although no evidence exists that the presence of diabetes or its treatment affects long-term survival.

Initiating therapy at diagnosis

Home-based instruction of the newly diagnosed child or young person appears to be at least as effective as inpatient instruction in terms of glycaemic control and family acceptability over a two-year period. Management in the community using a home-based education programme for patients with newly diagnosed diabetes has been shown also to be cost-effective.

The evidence on the role of the intensification of therapy in the attempt to achieve as rapid as possible normoglycaemia is inconsistent. In particular, there is no evidence of a sustained effect of any specific insulin therapy on glycaemic control during the first few months after diagnosis.

Therefore, no recommendation can be given for the most appropriate insulin therapy at diagnosis.

Continuing management

There is at present no evidence for the effectiveness of any medication other than insulin in the management of type 1 diabetes in the young.

Insulin regimen

Conventional therapy for type 1 diabetes (twice daily insulin with support from a multidisciplinary healthcare team and regular diabetes and health monitoring) is associated with variable results.

Limited data support an improvement in glycaemic control using three rather than two injections per day.

Evidence regarding the impact of an intensive insulin regimen upon long term control is derived principally from the Diabetes Control and Complication Trial (DCCT) which also involved a comprehensive patient support element (diet and exercise plans, monthly visits to the health care team etc).

Intensive insulin therapy (four injections or more per day or pump insulin) significantly improves glycaemic control over a sustained period compared with conventional insulin therapy (two injections per day). DCCT did not include children aged less than 13, due to the study design, it is impossible to separate the benefits of intensive insulin therapy from intensive support.

While there is no evidence on the most effective form of support package, in general this refers to increased contact between patients and their families with a local multidisciplinary team of health professionals delivering specific health care strategies

.The risk of hypoglycemia increases with intensive therapy but rapid acting insulin analogues, as part of a three or four injection regimen can reduce hypoglycaemia.

Diet control

A discipline that includes diet control improves glycaemic control. Limited evidence was identified concerning the optimal type of dietary therapy.

There is a lack of evidence to recommend either a qualitative or quantitative approach as the most effective mode of dietary therapy.

Psychological factors

Specifics that contribute to an increased risk of young people with diabetes developing psychological problems include:

  • a reluctance to cope with the situation
  • too great an onus placed on the child
  • family difficulties
  • lack of communication, both within families and with the diabetes team
  • low socio-economic status
  • non-traditional family structure
  • poor maternal health, especially depression.

Eating disorders are more prevalent in adolescents with diabetes compared with non-diabetic peers, and adversely affect glycaemic control.

Specific psychological problems (e.g. maladaptive coping strategies) linked to future glycaemic control, can be identified at diagnosis and 1-2 years later, using validated tools performed by a trained practitioner.

Psychological or educational interventions have positive effects on psychological outcomes, knowledge about diabetes and glycaemic control. Maintaining parental involvement improves glycaemic control. Interventions which promote diabetes-specific coping skills are effective and add to the effectiveness of intensive management.

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