July 21, 2017
Young people with type 1 and type 2 diabetes have high rates of neuropathic complications linked to poor glycemic control and risk-factor management, say US researchers in findings that underline the need for closer adherence to best practice recommendations.
In a study of over 2000 young diabetes patients, 7% of those with type 1 diabetes and more than 20% of those with type 2 diabetes had diabetic peripheral neuropathy (DPN), which in turn was significantly associated with modifiable factors such as smoking and dyslipidemia.
The study also showed that the risk of DPN increased with duration of diabetes and was significantly associated with poor glycemic control. The study, by Mamta Jaiswal, MD, of the department of neurology, University of Michigan, Ann Arbor, and colleagues, was published online on July 3, 2017 in Diabetes Care.
"Overall, the results of our study suggest that poor glycemic control over time and traditional cardiovascular risk factors are important risk factors associated with DPN and need to be targeted for the prevention of debilitating consequences of DPN in this young cohort," the team writes.
The "alarming" rise in rates of DPN for every 5-year increase in diabetes duration, "coupled with poor glycemic control and dyslipidemia . . . reinforces the need for clinicians rendering care to youth with diabetes to be vigilant in screening for DPN and identifying any risk factors that could potentially be modified to alter the course of the disease," they add.
The modifiable risk factors that could be targeted in this young population include better glycemic control, treatment of dyslipidemia, and smoking cessation, "approaches that are also part of the Standards of Care recommendation by the American Diabetes Association," stress Dr Jaiswal and coauthors.
DPN Is Twice as Common in Smokers as Nonsmokers
Building on a previous pilot study looking at the prevalence of DPN in young people with diabetes, the researchers examined data on 1734 patients with type 1 diabetes and 258 with type 2 diabetes from the SEARCH for Diabetes in Youth study.
Among those with type 1 diabetes, the mean age was 18.0 years, mean duration of diabetes was 7.2 years, and mean HbA1c was 9.1%. Among those with type 2 diabetes, the mean age was 22.0 years, mean disease duration was 7.9 years, and mean HbA1c was 9.4%.
The prevalence of DPN, defined as a Michigan Neuropathy Screening Instrument score of greater than 2, was 7% among those with type 1 diabetes and 22% in those with type 2 diabetes.
Patients with type 1 diabetes and DPN were significantly older than those without DPN (21 vs 18 years; P < .0001) and had a significantly longer duration of diabetes (8.7 vs 7.8 years; P < .0001).
Patients with type 1 diabetes and DPN also had a higher diastolic blood pressure, at 71 vs 69 mmHg (P = .02) and a higher body mass index, at 26 vs 24 kg/m2 (P < .001), compared with those without DPN. These patients also had higher low-density lipoprotein cholesterol (LDL-C) (101 vs 96 mg/dL; P = .01), higher triglycerides (85 vs 74 mg/dL; P = .005), and lower high-density lipoprotein cholesterol (HDL-C) (51 vs 55 mg/dL; P = .01).
And researchers found that DPN among type 1 diabetes patients was twice as common among current and former smokers than among nonsmokers, at a prevalence of 10% vs 5% (P = .001).
Patterns were similar among patients with type 2 diabetes, as those with DPN were significantly older than those without, at 23 vs 22 years (P = .01). They also had a significantly longer duration of diabetes, at 8.6 vs 7.6 years (P = .002) and lower HDL-C, at 40 vs 43 mg/dL (P = .04).
The prevalence of DPN was significantly higher among male patients with type 2 diabetes than their female counterparts, at 30% vs 18% (P = .02), and again was twice as high in current smokers than nonsmokers and former smokers, at 33% vs 15% and 17%, respectively (P = .01).
Talk About Blood Pressure, Cholesterol, and Smoking Cessation in Diabetes Clinics
The team calculated that there was an approximately two-fold increase in the prevalence of DPN with each 5-year increase in duration of diabetes in both those with type 1 diabetes (P < .0001) and type 2 diabetes (P = .02).
Glycemic control was also significantly associated with the risk of DPN in individuals with type 1 diabetes (adjusted odds ratio [OR] 1.53; P < .0001). However, the association was not significant for type 2 diabetes (OR 1.05; P = .82).
Senior author Eva L Feldman, MD, PhD, professor, department of neurology, University of Michigan, Ann Arbor, told Medscape Medical News that issues such as smoking cessation and lifestyle are at least already on the radar of those treating type 2 diabetes, but she and her colleagues feel that, for young people with type 1 diabetes in particular, there are "clear standards of care that needed to be addressed."
"These children with type 1 diabetes and neuropathy had higher diastolic blood pressure, they were clearly heavier, they had untreated dyslipidemia, and they were smokers, so there are clear recommendations that weren't being met."
She continued, "We feel very strongly about it because, to be frank, many times in type 1 diabetes clinics for children, glycemic control is clearly addressed, but dyslipidemia, smoking, and hypertension are factors that aren't as actively or openly discussed."
She also emphasized that the HbA1c target of less than 7.5% needs to be focused on in children with type 1 diabetes.
She believes that discussion is not taking place for a number of reasons that, in all likelihood, differ from practice to practice and country to country.
However, a common factor is that "probably the time allotted for each appointment is not as great as it needs to be and the practitioners haven't always had the time to address these issues."
Nevertheless, once healthcare professionals are aware of the importance of addressing these issues, she thinks that the time will be found to talk to patients about them.
"Maybe it needs to be carved out in educational sessions, maybe it needs to be carved out with healthcare extenders such as nurse practitioners and nurse educators. And I'm sure that, in all systems where there's a capacity, this will now be done," she concluded.
The SEARCH for Diabetes in Youth study is funded by the National Institute for Health Research and National Institutes of Health (NIH), National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), and supported by the Centers for Disease Control and Prevention (CDC). The authors have reported no relevant financial relationships.