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  • Incidence of severe hypoglycemia in children with type 1 diabetes in the Nordic countries in the period 2008–2012: association with hemoglobin A 1c and treatment modality

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Pathophysiology/Complications
Incidence of severe hypoglycemia in children with type 1 diabetes in the Nordic countries in the period 2008–2012: association with hemoglobin A 1c and treatment modality
  1. NH Birkebaek1,
  2. AK Drivvoll2,
  3. K Aakeson3,
  4. R Bjarnason4,5,
  5. A Johansen6,
  6. U Samuelsson7,
  7. T Skrivarhaug2,
  8. AV Thorsson4,5,
  9. J Svensson8
  1. 1 Department of Pediatrics, Aarhus University Hospital, Aarhus, Denmark
  2. 2 Norwegian Childhood Diabetes Registry, Division of Pediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
  3. 3 Department of Pediatrics, County Hospital Ryhov, Jönköping, Sweden
  4. 4 Medical Center, Landspitali University Hospital, Reykjavik, Iceland
  5. 5 Department of Pediatrics, University of Iceland, Reykjavik, Iceland
  6. 6 Department of Growth and Reproduction, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
  7. 7 Department of Pediatrics, Linköping University Hospital, Linköping, Sweden
  8. 8 Copenhagen Diabetes Research Center (CPH-DIRECT), Department of Children and Adolescents, Copenhagen University Hospital, Herlev, Denmark
  1. Correspondence to Dr NH Birkebaek; nielbirk{at}rm.dk

Abstract

Objective Treatment of type 1 diabetes has been intensified aiming at normalizing blood glucose, which may increase the risk of severe hypoglycemia (SH). We aimed to compare the incidence of SH events in the four Nordic countries Denmark, Iceland, Norway and Sweden, and to assess the influence of hemoglobin A1c (HbA1c) and treatment modalities on the frequency of SH; particularly, to explore if a HbA1c target ≤6.7% (50 mmol/mol) is feasible.

Research design and methods Data on children below 15 years with a diabetes duration more than 1 year, registered in the national childhood diabetes databases in the four Nordic countries from 2008 to 2012, were compiled. Data completeness was more than 95%.

Results Totally 8806 (48% females) patients with 29 715 person years were included, mean age and diabetes duration were 11 years and 5.1 years, respectively. The overall rate of SH was 6.0 per 100 patient-years, and did not change during the study period. The Swedish population constantly had the lowest SH incidence while it decreased significantly in the Danish population. HbA1c decreased significantly over time (p<0.01), while the number of pump users increased (p<0.01). Stratifying for HbA1c levels showed the lowest risk of SH in patients with HbA1c ≤6.7% (≤50 mmol/mol), but in the statistical models adjusting for possible confounders the difference between the HbA1c groups disappeared. Pump users had the lowest SH risk, also after adjusting for possible confounders.

Conclusions Risk of SH differs between the Nordic countries with the lowest risk in Sweden. Pump therapy was associated with decreased risk of SH. The low HbA1c group had the same or a lower risk of SH compared with the highest HbA1c groups. A target HbA1c ≤6.7% (≤50 mmol/mol) seems achievable without increasing the risk of SH.

  • Severe hypoglycemia
  • Nordic countries
  • HbA1c
  • insulin pump
  • target HbA1c.

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

https://doi.org/10.1136/bmjdrc-2016-000377

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    Footnotes

    • The paper has been presented at The ISPAD 2015 conference - Ped Diabet 2015;16 (Suppl 21):48.

    • Contributors NHB analyzed data, wrote and edited the manuscript and is the guarantor of the work; AKD analyzed data, contributed to the discussion, reviewed and edited the manuscript; KA, RB, AJ, US, TS, AVT, JS contributed to the discussion, reviewed and edited the manuscript. All authors contributed to data collection. US was the guarantor of the Swedish data.

    • Funding This project was supported by the Health Research Fund of Central Denmark Region, and the Swedish Board of Health and Welfare and the Swedish Association of Local Authorities and Regions. The Norwegian Childhood Diabetes Registry is financed by the South-Eastern Norway Regional Health Authority. The Danish registry is funded by the Danish Regions’ Clinical Quality Development Programme. The funding sources had no role in data collection or analysis.

    • Competing interests None declared.

    • Patient consent Only in Norway parents have to provide written informed concent.

    • Ethics approval The project has been approved by the database steering committees of the four countries.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement No additional data are available.