Abstract
Health disparities in the clinical presentation and outcomes among youth with type 1 diabetes exist. Long-term glycemic control patterns in racially/ethnically diverse youth are not well described. To model common trajectories of hemoglobin A1c (HbA1c) among youth with type 1 diabetes and test how trajectory group membership varies by race/ethnicity. Longitudinal cohort study conducted in 5 US locations. The analysis included data from 1313 youths (aged <20 years) newly diagnosed in 2002 through 2005 with type 1 diabetes in the SEARCH for Diabetes in Youth study (mean [SD] age at diabetes onset, 8.9 [4.2] years) who had 3 or more HbA1c study measures during 6.1 to 13.3 years of follow-up. Data were analyzed in 2017. Self-reported race/ethnicity. Hemoglobin A1c trajectories identified through group-based trajectory modeling over a mean (SD) of 9.0 (1.4) years of diabetes duration. Multinomial models studied the association of race/ethnicity with HbA1c trajectory group membership, adjusting for demographic characteristics, clinical factors, and socioeconomic position. The final study sample of 1313 patients was 49.3% female (647 patients) with mean (SD) age 9.7 (4.3) years and mean (SD) disease duration of 9.2 (6.3) months at baseline. The racial/ethnic composition was 77.0% non-Hispanic white (1011 patients), 10.7% Hispanic (140 patients), 9.8% non-Hispanic black (128 patients), and 2.6% other race/ethnicity (34 patients). Three HbA1c trajectories were identified: group 1, low baseline and mild increases (50.7% [666 patients]); group 2, moderate baseline and moderate increases (41.7% [548 patients]); and group 3, moderate baseline and major increases (7.5% [99 patients]). Group 3 was composed of 47.5% nonwhite youths (47 patients). Non-Hispanic black youth had 7.98 higher unadjusted odds (95% CI, 4.42-14.38) than non-Hispanic white youth of being in the highest HbA1c trajectory group relative to the lowest HbA1c trajectory group; the association remained significant after full adjustment (adjusted odds ratio of non-Hispanic black race in group 3 vs group 1, 4.54; 95% CI, 2.08-9.89). Hispanic youth had 3.29 higher unadjusted odds (95% CI, 1.78-6.08) than non-Hispanic white youth of being in the highest HbA1c trajectory group relative to the lowest HbA1c trajectory group; the association remained significant after adjustment (adjusted odds ratio of Hispanic ethnicity in group 3 vs group 1, 2.24; 95% CI, 1.02-4.92). In stratified analyses, the adjusted odds of nonwhite membership in the highest HbA1c trajectory remained significant among male patients and youth diagnosed at age 9 years or younger, but not female patients and youth who were older than 9 years when they were diagnosed (P for interaction = .04 [sex] and .02 [age at diagnosis]). There are racial/ethnic differences in long-term glycemic control among youth with type 1 diabetes, particularly among nonwhite male patients and nonwhite youth diagnosed earlier in life.
Highlights
Type 1 diabetes (T1D) treatment is centered around the improvement and maintenance of tight glycemic control, as assessed by levels of hemoglobin A1c (HbA1c), to prevent acute and chronic diabetes-related complications.[1,2,3] Glycemic control can vary considerably from diabetes onset through adolescence,[4,5,6] where fluctuations are known to occur during puberty[3,4,7,8,9,10,11,12] and during early adulthood
Non-Hispanic black youth had 7.98 higher unadjusted odds than non-Hispanic white youth of being in the highest HbA1c trajectory group relative to the lowest HbA1c trajectory group; the association remained significant after full adjustment
Hispanic youth had 3.29 higher unadjusted odds than non-Hispanic white youth of being in the highest HbA1c trajectory group relative to the lowest HbA1c trajectory group; the association remained significant after adjustment
Summary
Type 1 diabetes (T1D) treatment is centered around the improvement and maintenance of tight glycemic control, as assessed by levels of hemoglobin A1c (HbA1c), to prevent acute and chronic diabetes-related complications.[1,2,3] Glycemic control can vary considerably from diabetes onset through adolescence,[4,5,6] where fluctuations are known to occur during puberty[3,4,7,8,9,10,11,12] and during early adulthood. A constellation of sociodemographic factors related to race/ethnicity and glycemic control have been proposed, ranging from family dynamics, depressive symptoms, and quality of life[13,21,22,23,24,25] to diabetes regimen.[26,27,28] The role of socioeconomic position as a mediator of racial/ethnic associations remains controversial.[28,29,30,31] health care–specific factors such as disparities in health literacy, diabetes-related knowledge, or access to health care are known to contribute to pediatric health disparity but have not been well explored in T1D.32,33
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