Lipid Profile in a Cohort of Patients Aged between 3 and 18 with Type 1 Diabetes. Correlation with Homologous Age Range of the General Population

  

    
 
    
 
    
T1D patients 
    
Control group 
  
  

    
N    Subjetcs 
    
  
    
65 
    
44 
  
  

    
TG    10-18 years 
    
Acceptable: <90mg/dL 
    
58 ( 89.3%) 
    
36 (81.8%) 
  
  

    
Borderline: 90-129 mg/dL 
    
6 ( 9.2%) 
    
4 (9.1%) 
  
  

    
High: =130mg/dL 
    
1 (1.5%) 
    
4 (9.1%) 
  

Table 5: TG levels (10-18 years) in the T1D patient group and control group.

Discussion

Before the discovery of insulin, survival after the diagnosis of T1 was extremely short: about half of the patients died within the first 20 months of diagnosis and less than 10% survived to 5 years.

Thanks to the introduction of insulin therapy, mortality and morbidity have been significantly reduced in diabetic patients and today this therapy remains the irreplaceable cure for patients with type 1 diabetes.

If it is true that the cornerstone of therapy remains insulin, with different modes of action and administration, it is equally true that over the years the awareness of the importance of motor activity, nutrition and above all self-control has grown while the ideal values of HbA1c and glycemic range for a metabolic control to be considered satisfactory over the years have become tighter.

All this in order to make the long-term life prospect better and reduce the possible complications related to the disease and poor control of it.

As part of the prevention of medium and long-term cardiovascular risk, it is essential to carry out the complete lipid profile in young diabetics, at least annually, with intensification of checks in the event of unsatisfactory results.

In our group of pediatric T1D patients, only less than half (47.2%) of the sample managed to reach the recommended TC target (<170mg/dL), while 19.1% of the sample had elevated values (≥200mg/dL).

Dyslipidemia, especially LDL-C, seems to be the main cause of the extent and severity of atherosclerosis in children and adolescents and therefore its prevention must become a target for all diabetics.

The NCEP guidelines [5] recommend maintaining LDL-C levels below 110mg/dL in children and adolescents; however, in the case of patients with T1D the recent ESC-EASD guidelines [7] focus attention on the CV risk of diabetic patients.

In the case of subjects with T1D and age <35 years, with T1D of duration <10 years, without other risk factors, it is recommended to further reduce LDL-C levels below 100mg/dL.

In our sample of young diabetic patients only 44.9% succeeds in reaching this target, while in the remaining 55.1% values ≥100mg/dL are recorded.

A US study evaluated the daily calorie intake of young patients with T1D [8]. It has been observed that total fat intake, especially saturated fat, is higher than the recommended levels for young people with T1D. The lower percentage of total energy coming from carbohydrates seems to be compensated by a greater consumption of saturated fats which, as known, do not cause an immediate rise in blood sugar. Parents of young diabetic patients report that their children demonstrate a preference for foods from the food industry and provided for labels, such as processed and prepackaged foods, which allow them to calculate more precisely the amount of carbohydrates introduced and consequently the insulin dose [9].

However, the most common processed foods are known to be higher in saturated fat than unprocessed foods.

When LDL-C values are higher than 100 mg / dL it is therefore necessary to intervene with the support of nutrition specialists, in order to encourage the adoption of correct eating habits, also recommending the patient to exercise more.

Also, in the control group there is a situation of dyslipidemia that absolutely should not be underestimated.

A study conducted by 69 pediatricians in the provinces of Milan and Bergamo examined the lipid profile of 1910 children not suffering from chronic or acute diseases, concluding that 4.5% of the subjects had hypercholesterolemia, that is TC level s >200mg/dL; 3.3% of the sample had low HDL-C levels (<40mg/dL) and 23.5% high triglyceride levels (≥100mg/dL under 10 years of age, or ≥130mg/dL in patients over 10 years) [10]. Comparing this data with those of our control group of 89 subjects, we find in our experience higher percentages of hypercholesterolemia (21.3%) and low levels of HDL-C (4.5%) while in a lower percentage values of triglycerides above the control range (12.5%).

To our knowledge, few other Italian studies have measured plasma lipid concentrations in the general pediatric population.

A US study, conducted on children and adolescents aged between 6 and 19 years, in which the same cut-offs were used for the definition of high levels of TC and low levels of HDL-C, found hypercholesterolemia and HDL-C levels <40mg/dL in 7.4% and 13.4% of the sample, respectively [11].

We can therefore affirm that the prevalence of dyslipidemia in our group of control patients is considerable if compared with the available experiences and this data confirms the importance of nutrition education as a fundamental preventive activity by pediatrics, given the increasingly frequent trend in population pediatric in general to an unbalanced diet and less and less regular physical activity.

There are obvious differences in the management of the disease between children, adolescents and adults.

As already mentioned, diabetic patients treated at the Complex Structure of Pediatrics and Neonatology, San Paolo Hospital in Savona, are followed in their path of disease management by a multidisciplinary team in order to prevent complications and allow better management of the disease. Acceptance of the disease can be difficult for the young diabetic patient as it tends to focus on the limitations that it undoubtedly imposes on a social and educational level.

It is essential to set up and personalize, with the figure of the dietician or nutritionist, a diet based on the preferences of the child without forgetting the basic pathology and age recommendations.

In the last 20 years, the incidence of overweight and obese children and adolescents with T1D has increased, so the importance of assessing the BMI at each check-up and reporting it in the reference centiles for age and sex is emphasized.

In fact, excess weight further prevents the achievement of therapeutic goals.

At the same time as the lipid control, the HbA1c value was measured in diabetic patients. The American Diabetes Association (ADA) confirms that for young patients with diabetes, regardless of age group, HbA1c values <7% represent an indication of good glycemic control over time [12].

In our study, the percentage of pediatric subjects in which HbA1c ≥8% was recorded was 52.8%, while the remaining 47.2% had HbA1c ≤7%.

The mean HbA1c value in the group of 89 diabetic subjects was 8.2 ± 1.3 with a mean duration of the disease of 4.5 years.

In 2005, a survey conducted by the National Pediatric Diabetes Centers (MCDC) showed that the average of HbA1c in the Italian pediatric population stood at around 8.8% [13].

An international multicenter study, conducted on a series of about 142,000 T1D patients from 13 countries, including Italy, showed that well over 26% of patients had HbA1c values >9% [14].

It is essential, during the year, to check the HbA1c value on a regular basis.

Diabetic patients, treated at the Day Hospital of the San Paolo Hospital in Savona, go to the Department about every 3 months to perform the HbA1c dosage and when values ≥ 8% are recorded, it is necessary to intervene in a timely manner to try to reach the therapeutic goal again.

It is important to emphasize the individualization of glycemic goals: successful management of diabetes in the pediatric age needs to set realistic targets, which take into account the age, stage of pubertal development and the emotional impact of the disease as there are significant differences in the management of the disease between children, adolescents and adults.

An overall evaluation of the data in our possession can lead to the conclusion that probably the diet of diabetic patients in followup at the Day Hospital of the San Paolo Hospital in Savona is not optimal, even when compared to literature data and this confirms the importance of a multidisciplinary team. Coordinated in which the role of the dietician / nutritionist is fundamental, the carbohydrate count as a necessary but not sufficient prevention weapon.

Unfortunately, the data from the control group are not very comforting in relation to the lipid structure and are an alarm bell that should not be underestimated by Pediatrics as a whole.

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