Expert Comment: NPDA warning over young diabetics' healthFriday 13 March 2015
Ahead of Monday's Diabetes Lecturethon, Dr Denise Roche comments on the 11th annual report of the National Paediatric Diabetes Audit (NPDA), and its warnings about the health of young diabetics.
The latest National Paediatric Diabetes Audit (NPDA), an annual report published by the Royal College of Paediatrics and Child Health, concerning the care of children and young people with mainly type 1 diabetes, was highlighted in the media this week. Some of the more salient findings of the report, fairly emphasised by both the BBC and Diabetes UK, make for troubling reading. Succinctly summarised by a BBC reporter, the predominant outcome was that “a worryingly high number of children with type 1 diabetes [in England and Wales] have warning signs of long-term health complications”.
The ‘warning signs’ identified in the report were early markers of micro- and macroangiopathy, a group of crucial pathogenic indicators used by Paediatric Diabetes Units (PDUs) for detecting the appearance and development of early diabetic complications. These complications in the type 1 diabetic encompass comorbidities such as blindness, nerve damage, heart, kidney and generalised vascular disease and so are of crucial importance to the patient. A closer look at the audit’s statistics leaves me in no doubt that charities, policy makers, healthcare providers, the government and patients themselves ought to be greatly concerned.
Type 1 diabetes, an autoimmune disease that often commences in childhood or the teenage years, causes the destruction of the insulin-secreting b-cells of the pancreas. This leaves the sufferer reliant on multiple exogenous insulin injections every day for the rest of their life for survival. Unfairly for the individual with type 1 diabetes, microvascular complications such as retinopathy, nephropathy, neuropathy and peripheral vascular disease and macrovascular complications such as stroke and heart attack are an almost inevitable consequence of the disease and manifest as disease duration progresses. We might therefore ask how the young patient with type 1 diabetes can reduce their future risk of developing premature complications?
In 1993, a large-scale prospective, randomised - controlled trial, the Diabetes Control and Complications Trial, published unequivocal evidence that stringent glycaemic control deferred the appearance and progression of both micro- and macrovascular diabetic complications. Accordingly, the National Institute for Clinical Excellence (NICE) published guidelines for PDUs to aim for attaining HbA1c levels (glycaemic control over the preceding 6-8 weeks) below a threshold of 58 mmol/mol in order to delay the progression of diabetic complications. In PDUs therefore, it is paramount that glycaemic control is tightly managed from a young age or soon after diagnosis, whilst complications are still treatable.
Whilst this NPDA shows that mean HbA1c levels in children and young people in England and Wales have slightly improved from last year, they are, on average, 71.6 mmol/mol, nowhere near the 58mmol/mol advocated by NICE. More alarming still is that almost a quarter of children and young people in the audit were found to possess ‘very high’ HbA1c levels (> 80 mmol/mol) which NICE describe as the threshold for ‘excess risk’ of developing complications. To further compound the situation, worse glycaemic control is being seen in children from deprived areas and there appears to be much variability between regions.
Such high levels of HbA1c as those identified are indicative of prolonged elevations in circulating blood glucose, a major risk for developing vascular and neural complications. Perhaps not surprisingly then, the NPDA revealed that for 2013/4, in young people over 12 years of age, an alarming proportion are showing one or more early signs of complications ranging from 7.1% for kidney disease to 27.5% for high blood pressure.
The 2013/4 NPDA clearly demonstrates that glycaemic control in England & Wales in the young type 1 diabetic is generally not as good as it should be and it is not comparable to the more favourable levels achieved in other European countries. Reviewing the audit leads me to believe there are other tangible issues with the quality of care for youngsters with type 1 diabetes in this country and wide variations in standards between PDUs and regions.
With a meagre 16.1% of young people aged 12 or over completing all 7 care processes stipulated by NICE at their diabetes clinics, we are falling far short on our care of these vulnerable patients. The PDUs of England and Wales need a fundamental change in priorities, performance and resourcing to ensure youth with type 1 diabetes are given a fighting chance against this malevolent disease.
Dr Denise Roche is Senior Lecturer in Exercise Physiology.