Tip 1 Diyabetli Çocuklarda Glisemik Kontrolü Etkileyen Faktörler

Öz

Giriş: Tip 1 diyabetli hastalarda glisemik kontrol etkileyen çok sayıda faktör söz konusudur. Bu çalışmada, tip 1 diabetes mellituslu DM çocuklarda metabolik kontrolü etkileyen faktörleri belirlemek amaçlanmıştır. Gereç ve Yöntem: Tip 1 DM tanısı ile takip edilen 0-18 yaş arasında 200 hastaya sosyodemografik özelliklerini ve hastalıkla ilgili bilgilerini içeren sorulardan oluşan biranket formu uygulanmış ve hasta dosyaları geriye dönük olarak incelenerek hastaların laboratuvar bulguları ve tıbbi tedavi bilgileri elde edilmiştir.Bulgular: Çalışmaya 104 %52 kız ve 96 %48 erkek olmak üzere toplam 200 tip 1 diyabetli çocuk dahil edilmiştir. Hastaların ortalama HbA1c değeri %8,8 , ortalama yaşı 11,7 ±4,26 yıl ve ortalama diyabet süresi 3,8 yıl 6 ay-14 yıl olarak bulunmuştur. Tüm hastaların %89’u, 12-18 yaş arası hastaların ise tamamı yoğun insülin tedavisi kullanmakta idi. Ortalama insülin dozu 0,84±0,19 ü/kg/gün ve vücut kitle indeksi VKİ z-skor ortalaması -0,06±1,19 olarak saptandı. HbA1c ile insülin dozu arasındapozitif korelasyon olduğu r=0,27 p< 0,01 saptanırken HbA1c ile diyabet süresi ve yaşarasında korelasyon olmadığı saptandı. Yoğun tedavinin HbA1c değerini ve ağır hipoglisemi sıklığını düşürmediği saptandı. Ancak geleneksel tedaviden yoğun tedaviye geçen 72 %36 hastanın HbA1c değerinde düşme saptandı p< 0,05 . Evde dörttenfazla birey olanlarda, poliklinik kontrolüne uzun süredir gelmeyen ve ayda bir gelenhastalarda, diyetine tam uymayan hastalarda, 6 ay içerisinde 3’ten fazla semptomatik hipoglisemi olanlarda, diyabetik ketoasidoz DKA atağı olanlarda, tanı sırasındaadölesan olanlarda, tanıda DKA ile başvuranlarda HbA1c düzeyi yüksek saptandı p< 0,05 . İnsülin dozu ile diyabet süresi arasında korelasyon mevcutken r=0,45 p< 0,05 , VKİ z-skoru arasında ilişki saptanmadı r=0,075 p=0,29 . Tedavi sonrası ortalama VKİ z-skoru tedavi öncesine göre anlamlı olarak yüksek saptandı p< 0,01 .Sonuç: Tip 1 DM’de iyi bir metabolik kontrol elde etmek birçok faktöre bağlıdır. Bu çalışmada kötü metabolik kontrol için en önemli risk faktörlerinin diyabet süresinin 5 yıldan fazla olması, insülin dozu ihtiyacının artması, kalabalık aile, düzensiz poliklinikkontrolü, diyetine uymamak, semptomatik hipoglisemi varlığı, DKA ataklarının varlığı,tanıda DKA varlığı ve tanı sırasında hastanın adölesan olması olduğu ortaya konmuştur

Anahtar Kelimeler

• HbA1c,tip 1 diabetes mellitus,metabolik kontrol

Factors Influencing Glycemic Control in Children with Type 1 Diabetes

Öz

There are a plenty of factors influencing glycemic control in children with type 1 diabetes mellitus DM . The aim of this study was to determine the factors influencing metabolic control in children with type 1 DM. Materials and Method: The study was performed in 200 children with type 1 DM between the ages 6 months to 18 years. This study was conducted by interviewing individually with the children and their families and completing the questionnaires related to their demographic features and data associated with their illness. The laboratory findings and medical information of the patients from the charts were also retrospectively recorded. Results: There were a total of 200 patients including 104 52% girls and 96 48% boys. The mean age of the patients was 11.7 ±4.26 years. The mean duration of diabetes was 3.8 years 6 months to 14 years . Eighty-nine percent of all patients and all of the patients between 12 and 18 years of age were on intensive insulin therapy. Mean insulin dose was 0.84±0.19 units/kg/day. The mean HbA1c value was 8.8%. Body mass index BMI mean z-score was -0.06±1.19. There were no correlations between HbA1c and the duration of diabetes or age although a positive correlation was found with insulin dose r=0.27 p< 0.01 . It was found that intensive therapy did not lower HbA1c values or the risk of severe hypoglycemia. Nevertheless, there was a decrease in HbA1c values of 72 36% patients whose therapy was converted from conventional therapy to intensive therapy p< 0.05 . HbA1c values were found to be higher in patients who lived with more than 4 persons in the house, who were non-compliant to follow-up or diet, who had more than 3 symptomatic hypoglycemia in the last 6 months, who had episodes of diabetic ketoacidosis DKA , who were adolescent at the time of diagnosis, and who were admitted with diabetic ketoacidosis at the time of diagnosis p< 0.05 . Although there was a correlation between insulin doses and durations of diabetes r=0.45 p< 0.05 , no correlation was determined with BMI z-score r=0.075 p=0.29 . The BMI z-score was significantly higher after therapy compared with the value before therapy p< 0.01 . Conclusion: In type 1 DM, obtaining a good metabolic control depends on many factors. In this study, duration of diabetes longer than 5 years, crowded families, irregular follow-up visits, poor compliance to diet, presence of symptomatic hypoglycemia, presence of episodes of DKA, presence of DKA at diagnosis, and being an adolescent at the time of diagnosis were found to be the risk factors that associated with poor metabolic control.

Anahtar Kelimeler

• HbA1c,type 1 diabetes mellitus,metabolic control

Kaynakça

1. 1. Rosenbloom AL, Winter WE, Escobar O, Diabetes Mellitus. In: Lifshitz F, (ed.), Pediatric Endocrinology, 5th edition. New York: Informa Health Care 2007;57-202.
2. 2. American Diabetes Association. Diagnosis and Classificati￾on of Diabetes Mellitus. Diabetes Care 2006;27:43-8.
3. 3. ISPAD Clinical Practice Consensus Guidelines 2006-2007. Assessment and monitoring of glycemic control in children and adolescents with diabetes. Pediatric Diabetes 2007;8:408-18.
4. 4. Saka HN. Diabetes Mellitus. In: Günöz H, Öcal G, Yordam N, Kurto¤lu S (eds). Pediatrik Endokrinoloji. 1. Bask›. Pediatrik Endokrinoloji ve Oksoloji Derne¤i Yay›nlar›, Ankara: Kalkan Matbaac›l›k; 2003. p. 415-55.
5. 5. The DIAMOND Project Group. Incidence and trends of child￾hood Type 1 diabetes worldwide 1990-1999. Diabetic Medici￾ne 2006;23:857-66.
6. 6. DCCT Research Group: The Effect of Intensive Treatment of Diabetes on the Development and Progression of Long-term Complication in Insulin-dependent Diabetes Mellitus. N Engl J Med 1993;329:977-86.
7. 7. Chandalia HB, Krishnaswamy PR. Glycated hemoglobin. Cur￾rent Science 2002;83:1522-32.
8. 8. The French Pediatric Diabetes Group. Factors Associated With Glycemic Control; A cross-sectional nationwide study in 2,579 French children with type 1 diabetes. Diabetes Care 1998;7:1146-53.

9. 9. Kaufman FR, Halvorson M, Carpenter S. Association Betwe￾en Diabetes Control and Visits to a Multidisciplinary Pediat￾ric Diabetes Clinic. Pediatrics 1999;103:948-51.
10. 10. Kaufman FR, Austin J, Lloyd J, Halvorson M, Carpenter S, Pi￾tukcheewanont P. Characteristics of glycemic control in yo￾ung children with type 1 diabetes. Pediatric Diabetes 2002;3:179-83.
11. 11. Duke DC, Geffken GR, Lewin AB, Williams LB, Storch EA, Sil￾verstein JH. Glycemic Control in Youth with Type 1 Diabetes: Family Predictors and Mediators. Journal of Pediatric Psychology 2008;33:719-27.
12. 12. American Diabetes Association. Standards of Medical Care in Diabetes-2009. Diabetes Care 2009;32:13-61.
13. 13. Rodrigues TC, Pecis M, Canani LH, Schreiner L, Kramer CK, Biavatti K et al. Characterization of patients with type 1 dia￾betes mellitus in southern Brazil: chronic complications and associated factors. Rev Assoc Med Bras 2010;56:67-73.
14. 14. Chuang LM, Tsai ST, Huang BY, Tai TY; Diabcare-Asia 1998 Study Group. The status of diabetes control in Asia-a cross sectional survey of 24 317 patients with diabetes mellitus in 1998. Diabet Med 2002;19:978-85.
15. 15. Davis Ea, Keating B, Byrne GC, Russell M, Jones TW. Impact of improved glycemic control on rates of hypoglycemia in in￾sulin dependent diabetes mellitus. Arch Dis Child 1998;78:111-5.
16. 16. Chase HP, Lockspeiser T, Peery B, Shepherd M, MacKenzie T, Anderson J et al. The impact of the diabetes control and complications trial and humalog insulin on glycohemoglobin levels and severe hypoglycemia in type 1 diabetes. Diabetes Care 2001;24:430-4.
17. 17. A population-based study (DIABAUD2). Factors Influencing Glycemic Control in Young People with Type 1 Diabetes in Scotland. Diabetes Care 2001;24:239-44.
18. 18. Daneman D, Wolfson DH, Becker DJ, Drash AL. Factors af￾fecting glycosylated hemoglobin values in children with in￾sülin-dependent diabetes. The Journal of Pediatrics 1981;99:847-53.
19. 19. For The Hvidøre Study Group on Childhood Diabetes. Good Metabolic Control Is Associated With Better Quality of Life in 2,101 Adolescents With Type 1 Diabetes. Diabetes Care 2001;24:1923-8.
20. 20. Saunders SA, Wallymahmed M, MacFarlane IA. Glycemic control in a type 1 diabetes clinic for younger adults. Q J Med 2004;97:575-80.
21. 21. Raile K, Galler A, Hofer S, Herbst A, Dunstheimer D, Busch P, et al. Diabetic Nephropathy in 27,805 Children, Adolescents, and Adults with Type 1 Diabetes. Diabetes Care 2007;30:2523-8.
22. 22. Elamin A, Hussein O, Tuvemo T. Growth, puberty, and final height in children with Type 1 diabetes. Journal of Diabetes and Its Complications 2006;20:252-6.
23. 23. Danne T, Kordonouri O, Enders I, Weber B. Factors Influen￾cing Height and Weight Development in Children with Diabe￾tes. Results of the Berlin Retinopathy Study. Diabetes Care 1997;20:281-5.
24. 24. Lebl J, Schober E, Zidek T, Baldis S, Rami B, Pruhova S et al. Growth Data in Large Series of 587 Children and Adoles￾cents with Type 1 Diabetes Mellitus. Endocrine Regulations 2003;37:153-61.
25. 25. Springer D, Dziura J, Tamborlane WV, Steffen AT, Ahern JH, Vincent M, et al. Optimal Control Type 1 Diabetes Mellitus in Youth Receiving Intensive Treatment. J Pediatr 2006;149:227- 32.
26. 26. Fluck CE, Kuhlmann BV, Mullis PE. Metabolic Control in Chil￾dren and Adolescents with Diabetes Mellitus Type 1 in Ber￾ne: A Cross-Sectional Study. Schweiz Med. Wochenschr 1999;129:1650-5.
27. 27. Diabetes Control and Complications Trial Research Group. Effect of intensive diabetes treatment on the development and progression of long-term complications in adolescents with insulin-dependent diabetes mellitus: Diabetes Control and Complications Trial. J Pediatr 1994;125:177-88.
28. 28. The Diabetes Control and Complications Trial (DCCT) Rese￾arch Group. The relationship of glycemic exposure (HbA1c) to the risk of development and progression of retinopathy in the Diabetes Control and Complications Trial. Diabetes 1995;44:968-83.
29. 29. Bognetti F, Brunelli A, Meschi F, Viscardi M, Bonfanti R, Chi￾umello G. Frequency and correlates of severe hypoglycemi￾a in children and adolescents with diabetes mellitus. Eur J Pediatr 1997;156:589-91.
30. 30. Tan CY, Wilson DM, Buckingham B. Initiation of insulin glar￾gine in children and adolescents with type 1 diabetes. Pedi￾atric Diabetes 2004;5:80-6.
31. 31. For The U.S. Study Group Of Insulin Glargine in Type 1 Diabe￾tes. Less Hypoglycemia with Insulin Glargine in Intensive In￾sulin Therapy for Type 1 Diabetes. Diabetes Care 2000;23:639-43.
32. 32. Murphy NP, Keane SM, Ong KK, Ford-Adams M, Edge JA, Acerini CL et al. Randomized Cross-Over Trial of Insulin Glar￾gine Plus Lispro or NPH Insulin Plus Regular Human Insulin in Adolescents With Type 1 Diabetes on Intensive Insulin Re￾gimens. Diabetes Care 2003;26:799-804.
33. 33. Alemzadeh R, Berhe T, Wyatt DT. Flexible Insulin Therapy With Glargine Insulin Improved Glycemic Control and Redu￾ced Severe Hypoglycemia Among Preschool-Aged Children With Type 1 Diabetes Mellitus. Pediatrics 2005;115:1320-4.
34. 34. Çetinkaya E, Kibar AE, Aycan Z, Vidinlisan S, Çak›r B, Gökda¤ B ve ark. Tip 1 Diabetes Mellitus’ta ‹nsülin Glarjin Tedavisine Geçiflin Hipoglisemik Ataklara ve Hemoglobulin A1C Düzey￾lerine Etkisi. Türkiye Çocuk Hast Derg 2008;2:5-10.
35. 35. Mortensen HB, Robertson KJ, Aanstoot HJ, Danne T, Holl RW, Hougaard P et al. Insulin Management and Metabolic Control of Type 1 Diabetes Mellitus in Childhood and Adoles￾cence in 18 Countries. Diabet Med 1998;15:752-9.
36. 36. Rewers A, Chase HP, Mackenzie T, Walravens P, Roback M, Rewers M et al. Predictors of Acute Complications in Chil￾dren with Type 1 Diabetes. JAMA 2002;287:2511-8
37. 37. For The Hv›døre Study Group on Childhood Diabetes. Persis￾tent Differences Among Centers Over 3 Years in Glycemic Control and Hypoglycemia in a Study of 3,805 Children and Adolescents With Type 1 Diabetes From the Hvidøre Study Group. Diabetes Care 2001;24:1342-7.
38. 38. Gallegos-Macias AR, Macias SR, Kaufman E, Skipper B, Ka￾lishman N. Relationship between glycemic control, ethnicity and socioeconomic status in Hispanic and white non-Hispa￾nic youths with type 1 diabetes mellitus. Pediatric Diabetes 2003;4:19-23.
39. 39. Delamater AM, Shaw KH, Applegate EB, Pratt IA, Eidson M, Lancelotta GX et al. Risk for Metabolic Control Problems in Minority Youth with Diabetes. Diabetes Care 1999;22:700-5.
40. 40. Hassan K, Loar R, Anderson BJ, Heptulla RA. The role of so￾cioeconomic status, depression, quality of life, and glycemic control in type 1 diabetes mellitus. J Pediatr 2006;149:526-31.
41. 41. Frey MA, Templin T, Ellis D, Gutai J, Podolski CL. Predicting metabolic control in the first 5 yr after diagnosis for youths with type 1 diabetes: the role of ethnicity and family structu￾re. Pediatric Diabetes 2007;8:220-7.
42. 42. Fettaho¤lu EÇ, Koparan C, Özatalay E, Türkkahraman D. ‹n￾süline Ba¤›ml› Diabetes Mellitus Tan›l› Çocuk Ve Ergenler￾de Gözlenen Ruhsal Güçlükler. Psychiatry in Türkiye 2007;9:32-36.
43. 43. Akbafl S, Karabekiro¤lu K, Özgen T, Böke Ö, Ayd›n M. Tip 1 Diyabet Tan›s› Alan Çocuklar›n Hastal›kla ‹lgili Özellikleri ve Güçlükleri. Türkiye Klinikleri J Endocrin 2008;3:117–21.
44. 44. Sperling MA. Diabetes Mellitus. In: Behrman RE, Kliegman RM, Jenson HB. (eds.), Nelson Textbook of Pediatrics 16th edition. Philadelphia: W.B. Saunders Company, 2000;1:1767-92.
45. 45. Weitgasser R, Schnöll F, Pretsch I, Gruber U, Sailer S. Blood glucose self-monitoring in intensified insulin therapy: accep￾tance of frequent measurements and effect on quality of di￾abetic control. Acta Med Austriaca 1998;25:61-4.
46. 46. Jacobson AM, Hauser ST, Willett J, Wolfsdorf JI, Herman L. Consequences of irregular versus continuous medical fol￾low-up in children and adolescents with insulin-dependent diabetes mellitus. J Pediatr 1997;131:727-33.
47. 47. Dunger DB, Sperling MA, Acerini CL, Bohn DJ, Daneman D, Danne TPA et al. ESPE/LWPES consensus statement on di￾abetic ketoacidosis in children and adolescents. Arch Dis Child 2004;89:188-94.
48. 48. fiimflek E, Karabay M, Kocabay K. Bat› Karadeniz Bölgesin￾de yaflayan çocukluklarda insüline ba¤›ml› diyabetes mellitu￾sun epidemiyolojik özellikleri. Türk Pediatri Arflivi 2003;38:216-22.
49. 49. Özkan B, Tan H, Orbak Z, Döneray H. ‹nsuline Ba¤›ml› Diabe￾tes Mellitus’lu Olgular›n Epidemiyolojik Özellikleri (1990- 1999). Atatürk Üniversitesi Dergisi 1999;31:57-60.
50. 50. Cadario F, Vercelotti A, Trada M, Zaffaroni M, Rapa A, Iafus￾co D et al. Younger age at diagnosis of type 1 diabetes mel￾litus in children of immigrated families born in Italy. J Endoc￾rinol Invest 2004;27:913-8.
51. 51. Güven A, Ayd›n M. Befl yafl›ndan önce tip 1 diyabetes melli￾tus tan›s› alan çocuklarda etiyopatogenezde rol alan faktör￾ler. Çocuk Sa¤l›¤› ve Hastal›klar› Dergisi 2005;48:295-300.
52. 52. Taflk›n E, Y›lmaz E, K›l›ç M, Ertu¤rul S. ‹nsüline Ba¤›ml› Diya￾betes Mellitusun Epidemiyolojik Özellikleri. FÜ Sa¤ Bil Derg 2007;21:75-9.