liu.seSearch for publications in DiVA
Change search
CiteExportLink to record
Permanent link

Direct link
Cite
Citation style
  • apa
  • harvard1
  • ieee
  • modern-language-association-8th-edition
  • vancouver
  • oxford
  • Other style
More styles
Language
  • de-DE
  • en-GB
  • en-US
  • fi-FI
  • nn-NO
  • nn-NB
  • sv-SE
  • Other locale
More languages
Output format
  • html
  • text
  • asciidoc
  • rtf
On Severe Hypoglycaemia in Children and Adolescents with Type 1 Diabetes
Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Local Health Care Services in Central Östergötland, Department of Child and Adolescent Psychiatry.
2000 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: For people with type 1 diabetes, there is no alternative to treatment with insulin. The major side effect of insulin is severe hypoglycaemia (SH), when the patient needs help or even becomes unconscious.

Material: We have studied a geographic population of yearly 130-140 unselected type 1 diabetes patients aged 1-18 years during 1992-1999. They were intensively treated with 87-96% on 4-7 daily insulin doses, combined with active self-control, psychosocial support and problem-based education from onset. Average HbA1c was 6.5 with Mono-S standard (1.15% beow DCCT level).

Methods: We evaluated use of a prospective patient questionnaire for continuous long-term registration of treatment and outcome data and analysed HbA1c, SH and other variables. Over years, 95-100% response rate was achieved. We used also temporary questionnaries.

Results: We found SH with unconsciousness reported from on average 11% of patients yearly, SH without unconsciousness but needing assistance from on average 36% yearly and weak associations to HbA1c, such as reletive risk of SH 1.24 for yearly mean HbA1c <7.0% compared to ≥7.0% There was a seasonal variation in HbA1c (p=0.023) and incidence of SH. The strongest predictor for SH was SH during the previous year (r=9.38, p<0.0001).

The impact from SH showed great variation, and 20-30% of events led to practical disturbancies for parents and/or other people. Hospital visits took place only at 5% and hospitalisations at 3% of events. Social activities for patients were cancelled after 10% of events. Increased worry for patients was reported after 8% of events, bad sleep after 7%. We estimated the average socio-economic cost for SH at EURO 239 per event of SH with unconsciousness, and EURO 63 per event of SH without unconsciousness but needing assistance.

Mass-distributed self-study material (brochures and videos) aimed at the prevention of SH without compromising metabolic control reached high dissemination and was widely appreciated by patients. The material copy cost was only EURO 7 per patient. It also seems to have contributed to a decrease in SH with unconsciousness from yearly 13% of patients before to 9% after intervention (3-years average), but controlled studies are needed.

Conclusions: We conclude that SH remains a very serious problem of multifactorial aethiology. It causes considerable discomfort and costs. Systematic patient education mgiht reduce the incidence. Interventions using mass-distribution of high quality self-study material such as videos and brochures seem to have a potential to be cost-effective. There is a great patient/consumer interest in high quality- and advanced information/education materials.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2000. , 67 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 648
Keyword [en]
Severe hypoglycaemia, SH, diabetes, insulin, HbA1c, aethiology
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-5018ISBN: 91-7219-749-8 (print)OAI: oai:DiVA.org:liu-5018DiVA: diva2:20952
Public defence
(English)
Available from: 2000-11-29 Created: 2000-11-29 Last updated: 2012-01-24Bibliographically approved
List of papers
1. Increasing response rate in data registration and follow-up of type 1 diabetes children and adolescents: A prospective population study 1992–97
Open this publication in new window or tab >>Increasing response rate in data registration and follow-up of type 1 diabetes children and adolescents: A prospective population study 1992–97
1999 (English)In: Practical Diabetes International, ISSN 1357-8170, Vol. 16, no 4, 101-106 p.Article in journal (Refereed) Published
Abstract [en]

Aims: This study considers how a local diabetes team can develop a system for patient data registration and follow-up to enhance quality control and health economic analysis, and how a high response rate for patient data can be achieved.

Patients and methods: A geographic population of yearly 120-130 intensively treated type 1 diabetes children. <19 years of age was studied. A prospective patient questionnaire monitored: blood glucose and urine testing, insulin doses, acute complications, medications for hypertension and epilepsy, tobacco and snuff use, and any open questions and needs of the patient. This was completed before every visit to the out-patient department and used as a database for consultation. Data were thereafter registered in regular computer software, and analysed on a yearly basis.

Results: Response rate increased with time to near 100%. There was a time gain for diabetes nurse and physician. Many patients found the questionnaire good for overviewing treatment and easy to complete, whereas some found it was irksome and boring. The total cost of the method was <160 SEK/patient year.

Conclusions: A very high patient data response rate can be achieved over years by a patientsupportive questionnaire integrated in the treatment program. Treatment and outcome analysis can then be performed locally at low costs. The combination of a patient questionnaire with regular hard- and software is easy to create, manage and develop. Benefits for diabetes team and patients exceed the total cost.

Keyword
adolescent, child, data registration, information system, evaluation, questionnaire, health economy, quality of life, diabetes mellitus
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-13554 (URN)10.1002/pdi.1960160406 (DOI)
Available from: 2000-11-29 Created: 2000-11-29 Last updated: 2009-08-20
2. Severe hypoglycemia in children with IDDM: A prospective population study, 1992-1994
Open this publication in new window or tab >>Severe hypoglycemia in children with IDDM: A prospective population study, 1992-1994
1997 (English)In: Diabetes Care, ISSN 0149-5992, Vol. 20, no 4, 497-503 p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: Is an increased incidence of severe hypoglycemia an unavoidable effect of improved metabolic control? And, if so, to what extent? RESEARCH DESIGN AND METHODS: In 1992-1994, severe hypoglycemia was prospectively registered in our intensively treated IDDM population, 146 children 1-18 years of age with > 90% of the patients on > or = 4 insulin injections per day. The two categories, "severe hypoglycemia with unconsciousness" (U hypoglycemia) and "severe hypoglycemia without unconsciousness but needing the assistance of another person" (NU hypoglycemia), were analyzed in relation to yearly mean HbAlc levels, insulin doses and proportion of short-acting insulin, age at onset, duration of diabetes, age, sex, and weight-to-height ratio. RESULTS: Yearly mean HbAlc levels improved from 8.1 +/- 1.6% in 1992 to 6.9 +/- 1.3% in 1994. The yearly incidence of U hypoglycemia was 0.15-0.19 events per patient-year, seen in 10-16% of patients, showing no significant increase from 1992-1994. For NU hypoglycemia, slightly increasing figures from 1.01 to 1.26 events per patient-year, seen in 27-38% of patients yearly, were reported. There was no significant correlation between severe (U or NU) hypoglycemia and HbAlc, but still an association was seen in certain calculations. In multiple regression analysis, U hypoglycemia was not related to any factor, but the square root of the rate of NU hypoglycemia was related to lower HbAlc levels (P = 0.0003), higher insulin doses (IU.kg-1.24 h-1) (P = 0.0024), and a lower proportion of short-acting insulin out of the total daily insulin dose (P = 0.031). CONCLUSIONS: Multiple-dose insulin therapy with rather low yearly mean HbAlc values causes a slight increase of NU hypoglycemia but no increase of U hypoglycemia in our population of children with IDDM. Near physiological HbAlc levels may be achieved without any pronounced risk of increasing the incidence of severe hypoglycemia when multiple-injection insulin therapy is combined with adequate self-control based on psychosocial support and active education.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-13555 (URN)
Available from: 2000-11-29 Created: 2000-11-29 Last updated: 2009-08-20
3. Adverse events in intensively treated children and adolescents with type 1 diabetes
Open this publication in new window or tab >>Adverse events in intensively treated children and adolescents with type 1 diabetes
1999 (English)In: Acta Paediatrica, ISSN 0001-656X, Vol. 88, no 11, 1184-1193 p.Article in journal (Refereed) Published
Abstract [en]

The main objective of this study was to examine the relation between adverse events and degree of metabolic control and multiple-dose treatment. A total of 139 children, aged between 1 and 18 y, prospectively registered severe hypoglycaemia with or without unconsciousness, as well as hospitalized ketoacidosis, during 1994-95. Treatment from onset was multiple-dose insulin (> 95% > or = 4 doses) combined with intense training and psychosocial support. Median HbA1c was 6.9% (ref. 3.6-5.4%). The incidence of severe hypoglycaemia with unconsciousness was 0.17 events per patient-year, having decreased from the 1970s to the 1990s, parallel to a change from 1-2 to > or = 4 doses per day. There was no correlation or association to the year mean HbA1c for severe hypoglycaemia. Severe hypoglycaemic episodes in 1995 correlated to severe hypoglycaemic episodes in 1994 (r=0.38; p<0.0001). Severe hypoglycaemia with unconsciousness increased during the spring season, and according to case records the assumed causes were mainly mistakes with insulin, food and exercise. Ketoacidosis was rare: 0.015 episodes per patient-year. We conclude that multiple-dose insulin therapy from the very onset of diabetes, combined with adequate self-control, active problem-based training and psycho-social support, may limit severe hypoglycaemia and ketoacidosis. Strategies aimed at minimizing severe hypoglycaemia without compromising metabolic control need to be evaluated.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-13556 (URN)
Available from: 2000-11-29 Created: 2000-11-29 Last updated: 2009-08-20
4. Seasonal variation of HbA1c in intensive treatment of children with type 1 diabetes
Open this publication in new window or tab >>Seasonal variation of HbA1c in intensive treatment of children with type 1 diabetes
2000 (English)In: Journal of pediatric endocrinology and metabolism, ISSN 0334-018X, Vol. 13, no 5, 529-535 p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: The aim of this study was to measure whether there is a seasonal variation in glycosylated haemoglobin concentrations and insulin dose used in the intensive treatment of children with type 1 diabetes, and whether such variation is related to severe hypoglycaemia.

PATIENTS: A geographic population of 114 intensively treated type 1 diabetic patients < 19 years of age, mean 12.7 (SD 4.3) years, with diabetes onset before 1995, were studied in a cohort 1995-96.

METHODS: HbA1c, insulin doses and severe hypoglycaemia were registered at regular visits scheduled quarterly, but not standardised in time. Seasonal mean values were calculated for HbA1c and insulin dose.

RESULTS: Lower HbA1c was seen in spring and summer, and higher in autumn and winter (p=0.023). Patients reporting severe hypoglycaemia had a seasonal variation in HbA1c (p=0.019) and a tendency to seasonal variation in insulin dose, while patients not reporting severe hypoglycaemia did not vary in HbA1c or insulin dose.

CONCLUSIONS: Self-control and adjustment of insulin doses to seasonal change need to be improved also in intensively treated children, with regard to the risk for worsened metabolic control after the summer and increased severe hypoglycaemia in spring and early summer. The findings have important implications for design of short-term studies of metabolic control.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-13557 (URN)
Available from: 2000-11-29 Created: 2000-11-29 Last updated: 2009-08-20
5. Short-term effects of severe hypoglycaemia in children and adolescents with type 1 diabetes. A cost-of-illness study
Open this publication in new window or tab >>Short-term effects of severe hypoglycaemia in children and adolescents with type 1 diabetes. A cost-of-illness study
2001 (English)In: Acta Paediatrica, ISSN 0001-656X, Vol. 90, no 2, 137-142 p.Article in journal (Refereed) Published
Abstract [en]

The aim of this study was to describe costs and other short-term effects of severe hypoglycaemia in children and adolescents with type 1 diabetes. The study comprised a geographic population of 129 patients <19 y of age with families prospectively registering detailed data after self-reported severe hypoglycaemia. In the period Jan.-Dec. 1998, 16 events were reported with unconsciousness and 95 events without unconsciousness but needing the assistance of another person. Of all events, 20-30% had effects requiring the assistance of people other than parents, school absence, parents' absence from work, extra transport and/or telephone calls. Patient (family) activities were cancelled after 10% (5%) of events. Increased worry for parents was reported after 8% and poor sleep after 7% of events. Hospital visits took place at 5% and hospitalizations at 3% of all events. Patients with severe hypoglycaemia indicated lower global quality of life (p=0.0114). The average socio-economic burden for events of severe hypoglycaemia was estimated at EURO 17,400 yearly per 100 type 1 diabetes patients. Average cost was estimated at EURO 239 per event of severe hypoglycaemia with unconsciousness or EURO 478 yearly per patient with unconsciousness, and EURO 63 per event of severe hypoglycaemia without unconsciousness but needing assistance from another person or EURO 307 yearly per patient in this category. These are conservative estimates and do not include unpaid time and other intangibles, possible road traffic accidents, disabling or premature deaths. Conclusions: The results suggest the potential for socio-economic savings and increased quality of life for patients and families from severe hypoglycaemia prevention programs.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-13558 (URN)10.1080/080352501300049244 (DOI)
Available from: 2000-11-29 Created: 2000-11-29 Last updated: 2009-08-20
6. Self-study material to prevent severe hypoglycaemia in children and adolescents with type 1 diabetes: A prospective intervention study
Open this publication in new window or tab >>Self-study material to prevent severe hypoglycaemia in children and adolescents with type 1 diabetes: A prospective intervention study
2002 (English)In: Practical Diabetes International, ISSN 1357-8170, Vol. 19, no 5, 131-136 p.Article in journal (Refereed) Published
Abstract [en]

The aim of this study was to evaluate use of self-study material in diabetes education aimed at prevention of severe hypoglycaemia. Targeted self-study brochures (and video programs) regarding diabetes self-care and prevention of severe hypoglycaemia were mailed to all patients in early 1997 (and in 1999): a geographic population of 122-139 intensively treated type 1 diabetes patients yearly, aged 1-18 years (mean 12.2, SD 4.3), between 1994 and 1999. Yearly mean HbA1c (1.15% below DCCT level) ranged from 4.1 to 11.6% (mean 6.6, SD 1.1), age at onset 0.5-17.4 years (mean 7.6, SD 4.0) and duration 0.1-16.6 years (mean 4.6, SD 3.7). Main outcomes were patient attitudes to the interventions, perceived benefit, level of use, severe hypoglycaemia, and HbA1c.

Eighty-six percent of responders stated that the video was valuable. Perceived benefit was higher for the hypoglycaemia prevention video than for the brochure (p = 0.016). Those with severe hypoglycaemia the preceding year indicated greater benefit from the hypoglycaemia prevention brochure than others (p = 0.039). Average yearly incidence of severe hypoglycaemia with unconsciousness decreased from 13% in 1994-1996 to 9% (ns) in 1997-1999. The per patient cost of the material was <Euro 10.

Conclusion. Self-study material can reach high dissemination at a low cost. It also seems to have contributed to a decrease in severe hypoglycaemia, but controlled studies are needed. There is a great need for good quality patient/consumer information materials dealing with aspects of general management and risk prevention in diabetes treatment.

Keyword
children and adolescents, education, pedagogical device, prevention, severe hypoglycaemia, type 1 diabetes
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-13559 (URN)10.1002/pdi.363 (DOI)
Available from: 2000-11-29 Created: 2000-11-29 Last updated: 2009-08-20

Open Access in DiVA

fulltext(933 kB)732 downloads
File information
File name FULLTEXT01.pdfFile size 933 kBChecksum SHA-1
2ae0c2a3f4c502be7602fc955914c3536269350fe95ca57529b17e26d1e27ff398277a6f
Type fulltextMimetype application/pdf

Authority records BETA

Nordfeldt, Sam

Search in DiVA

By author/editor
Nordfeldt, Sam
By organisation
Child and Adolescent PsychiatryFaculty of Health SciencesDepartment of Child and Adolescent Psychiatry
Medical and Health Sciences

Search outside of DiVA

GoogleGoogle Scholar
Total: 732 downloads
The number of downloads is the sum of all downloads of full texts. It may include eg previous versions that are now no longer available

isbn
urn-nbn

Altmetric score

isbn
urn-nbn
Total: 449 hits
CiteExportLink to record
Permanent link

Direct link
Cite
Citation style
  • apa
  • harvard1
  • ieee
  • modern-language-association-8th-edition
  • vancouver
  • oxford
  • Other style
More styles
Language
  • de-DE
  • en-GB
  • en-US
  • fi-FI
  • nn-NO
  • nn-NB
  • sv-SE
  • Other locale
More languages
Output format
  • html
  • text
  • asciidoc
  • rtf