Are Youth With Diabetes at Risk for Cardiovascular Disease?
By Michael Howerton
More children are being diagnosed with both type 1 and type 2 diabetes, increasing the need to identify risk factors for, and prevent, serious health complications. Pediatric experts recently presented findings on risks and development of novel biomarkers for cardiovascular disease among youth with diabetes.
The rising rate of diagnosis, complications and risk factors for cardiovascular disease in children, both those with type 1 and type 2 diabetes, was the subject of a wide ranging and dire symposium at the 59th EASD sessions in Hamburg, Germany. The panel of expert researchers from the United States sounded the alarm, saying a greater focus on risk prevention and finding new biomarkers to better identify risk in children would save and lengthen lives.
“There is a rising incidence of youth onset type 1 and type 2 diabetes and it’s clearly a growing public health concern,” said Dr. Amy Mottl, from the University of North Carolina. And with the rise of diabetes in youth, the increase of health complications in the young, particularly relating to cardiovascular disease, which is the most deadly complication for those with diabetes, has become more apparent and distressing.
Youth with diabetes at high risk for complications
Mottl presented combined findings from two U.S.-based pediatric longitudinal studies looking at complications and glycemic control in children with type 1 and type 2 diabetes to highlight the dangers of adverse vascular outcomes in that population.
The TODAY-2 study from 2020 was a longitudinal follow-up study to the TODAY (Treatment Options for Type 2 Diabetes in Adolescents and Youth) study, which took place from 2011-2014, to track the development of vascular complications and risk factors for complications, as well as glycemic control, among youth with type 2 diabetes. The results showed poor glycemic control and an increased risk of complications over time, particularly among those from minority groups.
The other study, SEARCH for Diabetes in Youth (SEARCH) study, studied a longitudinal cohort to assess risk factors for acute and chronic diabetes-related complications, quality of care and quality of life from diagnosis into young adulthood, in both types 1 and 2 diabetes. Those results showed that young people with type 1 diabetes were at lower risk of diabetes-related complications during the study, but the prevalence was substantial in both groups.
Approximately 1 in 3 teenagers and young adults with type 1 diabetes (32%) and almost 3 of 4 of those with type 2 diabetes (72%) had at least 1 complication or comorbidity. She added that about half of those with type 2 diabetes had two or more complications.
“Glycemia really is the key to all this,” Mottl said. “In those with type 1, we saw it get worse in adolescence. Among those with type 2, it got slightly better, but not significantly so. We know that glycemic control is so difficult in childhood and young adulthood, but it’s important to realize that it’s not true for everyone.”
Social determinants of health, such as neighborhood, living conditions, race, access to technology, insurance, and food security are key to understanding which children are at-risk for complications. Mottl said she was particularly surprised by research that found that food insecurity was a factor in poor glycemic control for 19% of youth and young adults with type 1 diabetes and for 31% of those with type 2 diabetes.
The complication of retinopathy is equally prevalent in youth with either type of diabetes, with about half of youth and young adults showing signs of the complication 12 years after diagnosis. Albuminuria, a sign of kidney disease, is more common among adolescents with type 2 (27%) than those with type 1 (10%). Although major clinical events such as dialysis, blindness and major adverse cardiovascular events are rare in children, they do happen.
“When one complication is present, most likely another is also present,” Mottl said. “Glycemic control is a main driver of complications and is tightly linked with socioeconomic disparities.”
The hope in this otherwise dour news is that if families can find the right care for children with diabetes, find the therapies and technology that are available, then they can control the risk factors for serious complications.
“If they do that, they have the power to completely change their future outcomes,” Mottl said. “It is terrifying, and as a parent myself, I completely understand that terror, but I think that we can convert that fear into action and really change outcomes for children.”
Early prevention is key, starting with lifestyle change
Dr. Elaine Urbina, a researcher at Cincinnati Children's Hospital studying cardiac damage in young adults with youth-onset diabetes, echoed the sentiment that common sense steps can reduce cardiovascular disease risk in young patients. That’s why endocrinologists and parents should pay close attention to identifying the early signs of cardiovascular disease in pediatric patients.
“As a pediatric preventive cardiologist, I’m passionate about primordial prevention,” Urbina said, “which means the prevention of the acquisition of cardiovascular risk factors, which are mostly driven by obesity, even if you have type 1 diabetes.”
Since 68% of people with diabetes over the age of 65 die from some sort of heart disease, she said, the earlier we can identify and prevent it, the better and longer their lives.
“Everything your grandma told you was correct,” Urbina said. “Get enough sleep, go out and exercise and eat a healthy diet.”
More research is needed to identify risk factors in childhood
Dr. Janet Snell-Bergeon, with the Barbara Davis Center for Childhood Diabetes and the University of Colorado School of Medicine, echoed the call to identify risks for cardiovascular disease complications as early as possible and to treat them early. The trend of earlier diagnosis for type 2 diabetes was troubling, she cautioned, citing studies that showed a loss of life expectancy of 14-16 years for those diagnosed at 30 years of age, as opposed to just 6 years for those diagnosed at 50.
“We need to do a better job at preventing mortality in these people,” Snell-Bergeon said. “Better glycemic control is really critical to prevention.”
One encouraging finding was that children who are introduced early to diabetes technology, especially the use of CGMs, show better glycemic control as adolescents and young adults. The earlier they start using technology, the better their outcomes. The challenge is making sure everyone who needs technology has access to it, she said.
Snell-Bergeon noted that traditional risk factors, including glycemic control, blood pressure and cholesterol, remain important targets for reducing CVD, but they don’t account for all the excess risk of having diabetes. That’s why, she said, new measures are needed to further identify risk levels among children. She had been studying various new methods of identifying risk factors earlier.
“Early intervention is the key, as abnormalities in vascular health are evident early in life,” she said. “Novel biomarkers could help identify risk.“
Symposium co-chair Aaron Kowalski, CEO of JDRF, said the research presented made it clear that the quest of identifying and preventing complications, especially cardiovascular, in children and young adults with diabetes is far from complete.
“The fact that you’re seeing the development of complications in young children means we need new therapies,” Kowalski said. “We need to drive better glucose control. We need better equity in therapies in underserved populations. The opportunity with some of these novel agents, particularly with incretins and GLP-1 agonists, hold incredible potential, both in glycemic control and from the complications-reduction perspective. The fight isn’t over. We have to keep pushing.”
