Introduction
It is now well accepted that early glycaemic control in adolescents
with type 1 diabetes mellitus (Type1 DM) is crucial to prevent both
microvascular and macrovascular complications [1,2]. However, average
HbA1c in this age group remains unacceptably high [3] secondary to
psychological and behavioral barriers. This makes adherence to strict
glycaemic control challenging [4,5], and contributes to long-term
morbidity and mortality [6].
Deterioration in glycaemic control following transfer of patients with
diabetes to adult care has been reported [7], particularly in cases of early
transfer [8], which can be due to lack of engagement [9]. Despite concerns
regarding the myriad of problems associated with transfer of care, there
are very few studies investigating its effect on glycaemic control or clinic
attendance [10].
Our aims were to:1) investigate glycaemic control, markers of
microvascular and macrovascular complications in young adults
with Type1 DM 2) understand trends in glycaemic control and clinic
attendance in a subset of patients transferred from transition clinic to
young adult clinic.
Methods
Study design
A retrospective cohort study of all adolescents and young adults, with
childhood onset Type1 DM, attending the transition clinic and young
adult clinic at Leeds Teaching Hospitals NHS Trust; Patients transferred
from transition clinic to young adult clinic within our Trust during a
3 year period (August 2009 and August 2012) were included. Young
adults transferred from other paediatric or transition clinics and those
transferred out of the region for adult care were excluded due to incomplete
data on these patients. Data was obtained from the electronic Diabetes
Management System (DMS) and the study was cleared by the local ethical
committee and in accordance with the Declaration of Helsinki.
Clinic set up
Young adults aged 16-18 years were seen in a transition clinic held in the paediatric diabetes centre where patients are seen jointly by paediatric
and adult team. Young adults are subsequently transferred to a young adult
clinic when deemed appropriate by the treating clinician. The young adult
clinic is held in the adult diabetes centre and patients are seen by an adult
diabetes physician. The transition clinic offered 3 monthly appointments
and the young adult clinic 4 monthly, although more frequent reviews
were provided in both units according to patient need.
Data collection
HbA1c was checked at each clinic visit in the transition clinic using the
DCA 2000 analyser. Each patient also had a laboratory assay annually. In
young adult clinics a laboratory assay was performed prior to each visit at
the same local laboratory. Both methods were IFCC aligned. All patients
had weight and blood pressure checked at each visit. Screening for
retinopathy, dyslipidemia (random lipid profile) and microalbuminuria
was performed annually.
Systolic blood pressure (SBP)>140 mmHg and diastolic blood
pressure (DBP)>85 mmHg was classed as hypertension. We defined
microalbuminuria as a urinary albumin creatinine ratio >2.5 mg/mmol
in males and >3.5 mg/mmol in females, on at least two occasions.
Patients were classed as having retinopathy if changes were detected on
at least one screening. Retinopathy screening was undertaken by trained
Ophthalmologists and screening was graded according to the UK National
Screening Committee recommendations.
Email support
All patients with suboptimal diabetes control in the adult diabetes
service were offered email support by the attending physician. Patients
were never prompted and the role of physician was restricted to replying
to patient emails.
Statistical analysis
Statistical software SPSS version 21 was used. Unpaired t-test was
used to compare HbA1c between the transition clinic and young adult
clinic groups. Paired t-test was used in the latter group to compare pre
and post transfer HbA1c.
Results
Glycaemic control and treatment
A total of 104 patients (male=55) with a mean age of 19.5 years were
identified. Fifty four patients were in the transition clinic and fifty who
were transferred to adult care. Mean age at diagnosis was 9.2 ± 3.8 years
and duration of diabetes 9.4 ± 3.9 years. The majority of patients (66.3%)
were on multiple daily injections (MDI), with 27.9% on continuous
subcutaneous insulin infusion (CSII) and a minority (5.8%) on twice daily
(BD) injection regimen. Two patients were commenced on metformin
following transfer to adult care. Mean HbA1c in the whole population was
77 ± 18 mmol/mol. The mean HbA1c in females was slightly higher at 81
± 17 mmol/mol compared to males at 74 ± 18 mmol/mol, however this
was not statistically significant (p=0.04).
Markers of micro and macrovascular complications
Microalbuminuria was noted in 5.8% (n=6). The incidence in males was
5.4% (n=3) and 6.1% (n=3) in females. Retinopathy was documented in
43.2%. However, only two patients had clinically significant changes (one
female with pre-proliferative and one male with proliferative retinopathy
requiring laser therapy) with the rest having background changes. The
incidence of retinopathy was higher in females at 51% (n=25) compared
to males 36% (n=20).
Mean SBP and DBP were 122 ± 11 and 71 ± 9 mmHg respectively.
Fifteen (14.4 %) patients had raised diastolic blood pressure; none
required treatment as 24h ambulatory BP was normal.
Mean LDL was 2.3 ± 0.67 mmol/L, only one patient required statin
therapy. Sixteen patients were current smokers and five ex-smokers.
The effects of transition on diabetes control
Data were analysed in two groups: Group A, in transition clinic
and Group B who were in the young adult clinic (Table 1). Patients in
the young adult clinic were >1 year but <3 years post transfer from the
transition clinic and the mean age at transfer was 18.5 ± 1.2 years. Mean
HbA1c one year prior to transfer was 78 ± 20 mmol/mol and one year post
transfer was 78 ± 22 mmol/mol (p=0.22) in 47 complete datasets. Analysis
was extended to 3 years before and after transfer. Mean HbA1c 2 years
before and 2 years after transfer (31 data sets) were [79 ± 18 mmol/mol
and 78 ± 18 mmol/mol respectively; p=0.18], whereas 3 years pre and post
transfer (9 data sets) values were [81 ± 22 mmol/mol and 79 ± 18 mmol/
mol respectively; p=0.20] (Figure 1).
A small subset of patients (n=7) who opted for e-mail support provided
by the Consultant in the young adult clinic demonstrated an overall
improvement in the mean HbA1c over one year from 68 ± 8 mmol/mol to
63 ± 10 mmol/mol, (p=0.05). The average number of e-mails was 4.5/year,
in addition to regular clinic attendance.
Clinic attendance and hospital admissions
The average number of transition and young adult clinics attended
per calendar year was 3.2 (range:1-7) and 2.4 (range:0-6) respectively.
No difference in failure to attend rate was observed. Three young adults
were lost to follow up during transfer of care, of whom one returned to
adult services 3 years later. On reengagement with services aged 23, this
patient had developed proliferative retinopathy requiring laser therapy
and dyslipidemia requiring statin therapy
There were a total of 6 hospital admissions (2 diabetic ketoacidosis
(DKA) due to missed insulin, 2 DKA due to illness and 2 were elective
admissions for procedures) in the 3 years prior to transfer and 3 admissions
(1 hypoglycaemia, 1 DKA and 1 elective admission for restabilisation)
post transfer to adult care. No mortality was recorded
Figure 1: Mean HbA1c in the three years preceding and following
transfer from paediatric to adult care. Mean (± SD) HbA1c in the first
year pre and post transfer was 78 ± 20 mmol/mol (9.3 ± 1.9%) and 78
± 22 mmol/mol (9.3 ± 2.1%) respectively and includes 47 data sets.
Mean (± SD) HbA1c in the second year pre and post transfer was
79 ± 18 mmo/mol (9.4 ± 1.7%) and 78 ± 18 mmol/mol (9.3 ± 1.7%)
respectively and includes 31 data sets. Mean (± SD) HbA1c in the third
year pre and post transfer was 81 ± 22 mmol/mol (9.6 ± 2.1%) and 79 ±
18 mmol/mol (9.4 ± 1.7%) respectively and includes 9 data sets.
Discussion
Achieving good glycaemic control in adolescents is challenging. HbA1c
values in our patients are similar to previously published data [3,7,9,11].
However, in contrast to other work [7], there was no deterioration in
glycaemic control following transfer to young adult care, despite reduction
in clinic appointments. Interestingly, email support appeared to improve
diabetes control is a small subset of patients but the numbers are too small
to draw definitive conclusions and further studies are warranted. Patients
taking up the email service had lower baseline HbA1c suggesting they are more motivated and therefore strategies to engage patients with poorer control need to be devised.
The rate of background retinopathy in our cohort was higher than
previously reported [6,11], which may be due to our definition of
retinopathy (changes on any one occasion). However, only two patients
required intervention for retinopathy, which was similar to previously
reported findings [12].
Very few young adults were lost to follow-up in our cohort compared to
previous reports [13], although it should be acknowledged that data on the
minority, who were transferred to other centres, have not been recorded.
In conclusion, our study demonstrates that diabetes control in young
adults with Type1 DM is generally poor. Glycaemic control and clinic
attendance remains stable in patients who transfer through a transition
service. Although a structured approach to transfer of care is believed to
be effective [14-16] there are no proven interventions that help control
glycaemia in this population. Email support may have a role and warrants
further investigation.
|
All (n=104) |
Transition clinic (n=54) |
Young adult clinic(n=50) |
| Mean age (years) |
19.5 ± 1.8 |
17.9 ± 0.6 |
21.2 ± 1.0 |
| Male: Female (n) |
55:49 |
30:24 |
25:25 |
| Mean weight (Kg) |
70.8 ± 13 |
68.8 ± 13.4 |
73 ± 12.5 |
| Mean BMI (Kg/m2) |
24.8 ± 4 |
24.0 ± 3.7 |
25.5 ± 4.2 |
| Mean Diabetes duration (years) |
9.4 ± 3.9 |
8.4 ± 4.2 |
10.6 ± 3.2 |
| Insulin pump therapy (%) |
29 (27.9) |
16 (29.6) |
13 (26) |
| Multiple Daily Injections (%) |
69 (66.3) |
34 (62.9) |
35 (70) |
| BD injections (%) |
6 (5.8) |
4 (7.4) |
2 (4) |
| Mean HbA1c (mmol/mol) |
77 ± 18 |
77 ± 19 |
78 ± 18 |
| Mean HbA1c (%) |
9.2 ± 1.7 |
9.2 ± 1.8 |
9.3 ± 1.7 |
HbA1c ≤ 58 mmol/mol
(7.5%) (%) |
14 (13.5) |
7 (13) |
7 (14) |
HbA1c 59-80 mmol/mol
(7.6-9.5%) (%) |
50 (48) |
30 (55.5) |
20 (40) |
HbA1c ≥ 81 mmol/mol
(9.6%) (%) |
40 (38.5) |
17 (31.5) |
23 (46) |
| Mean SBP (mmHg) |
122 ± 11 |
122 ± 13 |
122 ± 9 |
| Mean DBP (mmHg) |
71 ± 9 |
68 ± 8 |
75 ± 8 |
| Mean total cholesterol mmol/L |
4.4 ± 0.9 |
4.4 ± 1 |
4.5 ± 0.8 |
| Mean LDL mmol/L |
2.37 ± 0.68 |
2.3 ± 0.6 |
2.4 ± 0.7 |
| Mean Triglycerides mmol/L |
1.31 ± 1.1 |
1.3 ± 1.1 |
1.3 ± 1.0 |
| Retinopathy (%) |
45 (43.3) |
29 (53.7) |
16 (32) |
| Microalbuminuria (%) |
6 (5.8) |
3 (5.5) |
3 (6) |
| Hypothyroidism (%) |
7 (6.7) |
2 (3.7) |
5 (10) |
| Coeliac disease (%) |
4 (3.8) |
1 (1.8) |
3 (6) |
Table 1: Glycaemic control and microvascular complications in adolescents
and young adults
Acknowledgements
We would like to thank Elizabeth Adams, Data manager, Paediatric
Diabetes team, Leeds Children’s Hospital, for providing support with data
extraction.
We would also like to thank Julie Cropper, Transition Diabetes
Specialist Nurse, Leeds Teaching Hospitals for reviewing the article.
Funding
None received
Statement of Human and animal rights
This article does not contain any studies with human or animal subjects performed by the any of the authors.
Conflict of interest
Dr S Uday, Dr F Campbell, Dr J Yong and Dr R Ajjan have no conflict of interest to declare.
Contribution statement
S Uday: Design, data acquisition, analysis, reporting, writing and final approval
FM Campbell: Concept, design, revising article and final approval.
J Yong: Revising article and final approval
RA Ajjan: Concept, design, acquisition of data, analysis of data, critical revision of article and final approval.
Article Information
Article Type: Research article
Citation: Uday S, Campbell FM, Yong J, Ajjan RA (2015) Transition and Beyond in Adolescents and Young Adults with Type 1 Diabetes Mellitus. Int J Endocr Metab Disord 1(2): doi http://dx.doi.org/10.16966/2380-548X.106
Copyright:© 2015 Uday S, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Publication history:
Received date: 4 June 2015
Accepted date: 15 July 2015
Published date: 21 July 2015
