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Diabetes: incidence of childhood type 1

diabetes: a worrying trend.

ARTICLE in NATURE REVIEWS ENDOCRINOLOGY · OCTOBER 2009

Impact Factor: 12.96 · DOI: 10.1038/nrendo.2009.180 · Source: PubMed

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diabetes
Incidence of childhood type 1 diabetes:
a worrying trend
Ronald C. W. Ma and Juliana C. N. Chan
Much attention has focused on the increasing prevalence of childhood type 2 diabetes mellitus. However,
considerable evidence suggests that the incidence of childhood type 1 diabetes mellitus is also increasing.
the results of a multicenter registration study from europe confirm this alarming trend, which has important
health-care implications.
Diabetes mellitus is a common chronic
disease that affects children. although
the emergence of type 2 diabetes mellitus
(t2Dm) in children and adolescents has
attracted much attention, type 1 diabetes
mellitus (t1Dm) remains the predominant
form during childhood in many countries.
the incidence of t1Dm varies markedly in
different geographic locations, but seems to
be increasing globally. Data from Finland,
which has one of the highest incidences
of t1Dm, suggest an “accelerating” epi­
demic, with the rate of increase exceeding
previous estimates.1 similar data has been
obtained from different countries includ­
ing the uK, although the latest results
from the euroDiaB (the epidemiology
and Prevention of Diabetes) study group2
provide one of the most comprehensive
sources of epidemiological data regard­
ing the incidence of t1Dm in europe and
serves as a useful pointer to the future
burden of t1Dm.
the euroDiaB register is an inter­
national collaborative effort, which encom­
passes population­based registers of new
cases of t1Dm in children aged <15 years
from 20 centers, distributed across 17 coun­
tries in europe. Given the diverse regional
incidence of t1Dm, the euroDiaB
centers are split into five regions accord­
ing to geography, with fairly homogenous
incidence rates within each region. in the
article by Patterson et al.,2 the incidence
data for t1Dm during a 15­year period
(1989–2003) were analyzed according to
the individual regions as well as together.
although the standardized incidence in
the period 1989–1993 varied from 4.7 cases
per 100,000 in romania to 39.9 cases per
100,000 in Finland, the rise in incidence rate
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news & views
Perinatal and intrauterine factors
Transplacental transmission of antibodies
Cesarean deliveries
Birthweight
Interplay between maternal age and birth order
Prenatal factors Islet autoimmunity Postnatal factors
Genetic factors Breastfeeding
HLA genotype Cow’s milk exposure
Vitamin D intake
Clinical type 1 Childhood infections
diabetes mellitus Obesity
Viral infections
Other dietary factors
Figure 1 | Prenatal, perinatal and postnatal factors implicated in the development of
autoimmune type 1 diabetes mellitus. Apart from genetic factors, environmental factors such as
delivery by Cesarean section, high birthweight, vitamin D deficiency, viral infections and obesity
may interact in a complex manner to cause autoimmunity and clinical type 1 diabetes mellitus.
Abbreviation: HLA, human leukocyte antigen.
in individual countries during the 15­year of t1Dm in europe in 2005, and project
period was inversely associated with the a marked increase to 24,400 new cases by
average rate during the same period. in 2020. For children aged <5 years, they pre­
other words, over the study period, the rise dict incidence to double over that period.
in incidence was most accelerated among with a younger age of onset, the prevalence
countries that initially had the lowest inci­ of t1Dm in children <15 years would also
dence. thus, with time, different regions increase markedly, and is predicted to rise
within europe may exhibit less hetero­ from 94,000 in 2005 to 160,000 in 2020, with
geneity for prevalence of childhood t1Dm considerable health­care implications.2
than today. Despite a strong genetic component to
strikingly, the greatest increase in inci­ the susceptibility of t1Dm, this marked
dence rate was seen in the youngest age group. increase in incidence in different popula­
the overall annual increase in incidence for tions within a short period of time cannot
all centers was estimated to be 3.9% (95% Ci be explained by increased transmission of
3.6–4.2), and incidence rises for the different t1Dm susceptibility genes. so what is the
age groups were 5.4% (0–4 years), 4.3% cause? in children with human leukocyte
(5–9 years), and 2.9% (10–14 years). this antigen (Hla)­conferred susceptibility to
rapid rise of t1Dm among the youngest t1Dm, environmental factors trigger the
age group was particularly marked for process of β­cell autoimmunity followed by
regions in Central and eastern europe. on progressive β­cell destruction, and even­
the basis of these results, the investigators tually, development of clinical t1Dm. in
estimate that there were 15,000 new cases this context, several theories have been put
volume 5 | oCtoBer 2009 | 529
 news & views

Practice points markers of islet cell autoimmunity and

modify the development of preclinical
■ incidence of type 1 diabetes mellitus in children aged <15 years is increasing in europe,
especially in countries with low incidence rates and among young children t1Dm in infants at increased risk of the
disease. in this regard, a large randomized
■ Data from the large population-based eURODiAB register predicts a doubling in the number
of new cases in children aged <5 years from 2005 to 2020 trial is now underway to address the role of
early breastfeeding on risk of development
■ These predicted changes will considerably increase the prevalence of T1DM, with important
implications on health-care resources of t1Dm.10
these large studies with long periods
■ Given the global epidemic of childhood obesity, which may accelerate β-cell apoptosis in
predisposed individuals, similar data is urgently needed in other world regions and countries
of follow­up will provide important pieces of
to improve our understanding of the disease and guide policy makers to formulate prevention the jigsaw needed to gain a better under­
and treatment strategies standing of how to reduce the burden of
t1Dm. meanwhile, an urgent need exists
for government policies that raise public
forward to explain the recent increase in taken together, data from this compre­ and professional awareness and create an
incidence of childhood t1Dm in developed hensive euroDiaB register raise alarm environment conducive to the promotion of
countries. these include increasing rates bells regarding the potential impact of a healthy lifestyles. Furthermore, reform of the
of Cesarean sections, dietary factors (for rapid transition in nutrition and rising health­care system is needed to encourage
example, vitamin D deficiency, or exposure childhood obesity on the burden of young practice of preventive care.
to cow’s milk protein or cereals), reduced onset diabetes mellitus, including t1Dm,
Department of Medicine and Therapeutics, The
exposure to childhood infections and especially in developing areas of the world
Chinese University of Hong Kong, The Prince of
increased childhood obesity (Figure 1). that are undergoing rapid modernization Wales Hospital, Shatin, Hong Kong SAR, China
the hygiene hypothesis, for example, but have the least resources to deal with the (R. C. W. Ma, J. C. N. Chan).
postu lated that decreased exposure to health consequences. Correspondence: J. C. N. Chan, Department of
pathogens in childhood may lead to obesity and diabetes are now global epi­ Medicine and Therapeutics, The Chinese
increased atopy, asthma and autoimmune demics, and affect an increasingly young University of Hong Kong, The Prince of Wales
diseases such as t1Dm. of particular population. with better understanding of Hospital, Shatin, Hong Kong SAR, China
jchan@cuhk.edu.hk
concern is the risk association of t1Dm the multiple etiologies of insulin deficiency
with high birthweight and early weight and insulin resistance, the distinc tion doi:10.1038/nrendo.2009.180
gain. 3 the accelera tor hypothesis put between t1Dm and t2Dm also becomes competing interests
forward by wilkin4 postulates that increased increasingly blurred. During the past two The authors declare no competing interests.
childhood obesity, with decades, consider able
1. Harjutsalo, v., sjöberg, L. & Tuomilehto, J. Time
its associated insulin advances have been made trends in the incidence of type 1 diabetes in
resistance and inflamma­ in our understanding of Finnish children: a cohort study. Lancet 371,
tion, may lead to acceler­ …prevalence of the natural history and 1777–1782 (2008).
2. Patterson, C. C. et al. incidence trends for
ated β­cell apoptosis, and T1DM in children pathogenesis of t2Dm, childhood type 1 diabetes in europe during
thus earlier manifesta­ including the role of 1989–2003 and predicted new cases
tion of t1Dm in indivi­ … is predicted to obesity­induced insulin 2005–20: a multicentre prospective registration
study. Lancet 373, 2027–2033 (2009).
duals who have increased rise from 94,000 in resistance, identi fica­ 3. stene, L. C. et al. Birth weight and childhood
genetic susceptibility. tion of indivi duals with
although the validity of
2005 to 160,000 impaired glu cose toler­
onset type 1 diabetes: population based cohort
study. BMJ 322, 889–892 (2001).
this hypothesis remains in 2020… ance, and beneficial effects
4. wilkin, T. J. The accelerator hypothesis: weight
gain as the missing link between type i and
to be tested,5 the acceler­ of lifestyle modification type ii diabetes. Diabetologia 44, 914–922
ated increase in incidence on prevention of t2Dm. (2001).
5. Gale, e. A. To boldly go—or to go too boldly?
of t1Dm against the with this rising tide of The accelerator hypothesis revisited.
backdrop of rising prevalence of childhood t1Dm, concerted effort is needed to iden­ Diabetologia 50, 1571–1575 (2007).
obesity in europe provides some support tify environmental factors that trigger and 6. Knai, C., suhrcke, M. & Lobstein, T. Obesity in
eastern europe: an overview of its health and
for this theory.6 in an editorial that accom­ perpetuate the autoimmune destruction of
economic implications. Econ. Hum. Biol. 5,
panied the euroDiaB article, Dabelea7 β­cells, especially in predisposed indivi­ 392–408 (2007).
pointed out the scarcity of incidence data duals. the environmental Deter minants 7. Dabelea, D. The accelerating epidemic of
on t1Dm in developing areas such as asia, of Diabetes in the Youth (teDDY) study childhood diabetes. Lancet 372, 1999–2000
(2009).
africa and south america. some of these Consortium,9 which involves six centers in 8. Chan, J. C. et al. Diabetes in Asia:
countries, for example China and india, the usa and europe, has embarked on an epidemiology, risk factors, and pathophysiology.
face major epidemics of childhood obesity, effort to identify possible environmental JAMA 301, 2129–2140 (2009).
9. TeDDY study group. The environmental
and here autoimmunity, obesity and genetic triggers and protective factors for t1Dm Determinants of Diabetes in the Young (TeDDY)
factors may all contribute to the increas­ in several thousand newborn babies with study. Ann. NY Acad. Sci. 1150, 1–13 (2008).
ingly young age of onset of t2Dm; concern susceptible Hla genotypes.9 Pilot studies 10. Akerblom, H. K. et al. Dietary manipulation of
beta cell autoimmunity in infants at increased
exists that increased onset of t1Dm will of dietary intervention have shown that risk of type 1 diabetes: a pilot study.
follow suit.8,9 it is possible to reduce the appearance of Diabetologia 48, 829–837 (2005).

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