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. 2024 Dec;67(12):2678-2690.
doi: 10.1007/s00125-024-06273-7. Epub 2024 Sep 13.

Metabolic health in people living with type 1 diabetes in Belgium: a repeated cross-sectional study

Astrid Lavens  1 , Christophe De Block  2 , Philippe Oriot  3 , Laurent Crenier  4 , Jean-Christophe Philips  5 , Michel Vandenbroucke  6 , An-Sofie Vanherwegen  7 , Frank Nobels  8 , Chantal Mathieu  9 ; IQED Group of Experts
Affiliations

Metabolic health in people living with type 1 diabetes in Belgium: a repeated cross-sectional study

Astrid Lavens et al. Diabetologia. 2024 Dec.

Abstract

Aims/hypothesis: Metabolic abnormalities such as central obesity, insulin resistance, dyslipidaemia and hypertension, often referred to as 'the metabolic syndrome' (or 'combined metabolic abnormalities'), are increasingly being identified in people living with type 1 diabetes, accelerating the risk for CVD. As a result, in recent years, treatment in people living with type 1 diabetes has shifted to improving overall metabolic health rather than glucose control alone. In Belgium, diabetes care for people living with type 1 diabetes is centrally organised. The Initiative for Quality Improvement and Epidemiology in Diabetes, imposed by the Belgian health insurance system, has systematically collected data from patients on intensive insulin therapy treated in all 101 diabetes clinics in Belgium since 2001. The aim of this real-world study is to describe the evolution of treatment and metabolic health, including the prevalence of obesity and combined metabolic abnormalities, in people living with type 1 diabetes over the past 20 years, and to compare the treatment and prevalence of complications between those with and without combined metabolic abnormalities.

Methods: We analysed data on adults (≥16 years old) living with type 1 diabetes, who were diagnosed at age ≤45 years and who had a diabetes duration ≥1 year, collected between 2001 and 2022. The evolution of HbA1c, BMI, LDL-cholesterol, systolic BP, lipid-lowering therapy and antihypertensive therapy over time was analysed. The prevalence of individual and multiple metabolic abnormalities according to various definitions of the metabolic syndrome/combined metabolic abnormalities was analysed, and the association between combined metabolic abnormalities and metabolic health indicators, complications and treatment was investigated in the 2022 data.

Results: The final dataset consisted of 26,791 registrations of adults living with type 1 diabetes collected between 2001 and 2022. Although glycaemic and lipid control generally improved over time, the prevalence of obesity strongly increased (12.1% in 2001 vs 21.7% in 2022, p<0.0001), as did the presence of combined metabolic abnormalities (WHO criteria: 26.9% in 2001 vs 42.9% in 2022 in women, p<0.0001; 30.4% in 2001 vs 52.1% in 2022 in men, p<0.0001; WHO criteria without albuminuria: 22.3% in 2001 vs 40.6% in 2022 in women, p<0.0001; 25.1% in 2001 vs 49.2% in 2022 in men, p<0.0001; NCEP-ATPIII criteria: 39.9% in 2005 vs 57.2% in 2022 in women, p<0.0001; 40.8% in 2005 vs 60.9% in 2022 in men, p<0.0001; IDF criteria: 43.9% in 2005 vs 59.3% in 2022 in women, p<0.001; 33.7% in 2005 vs 50.0% in 2022 in men, p<0.0001). People with combined metabolic abnormalities had higher glucose levels compared to those without combined metabolic abnormalities (HbA1c >58 mmol in men: 48.9% vs 36.9%; HbA1c >58 mmol in women: 53.3% vs 41.1%, p<0.0001). People with combined metabolic abnormalities were more often treated with adjunct therapies such as metformin, sodium-glucose transport protein 2 inhibitors and glucagon-like peptide-1 receptor agonists. In both men and women, the presence of combined metabolic abnormalities was strongly related to the presence of eye complications, peripheral neuropathy, chronic kidney disease and CVD, corrected for age, diabetes duration and HbA1c.

Conclusions/interpretation: Overweight, obesity and combined metabolic abnormalities are increasingly being identified in people living with type 1 diabetes, further accelerating the risk of microvascular and macrovascular complications. Early identification of the presence of combined metabolic abnormalities should enable therapeutic interventions to be modified towards multifactorial approaches, with attention to education on avoidance of overweight (e.g. dietary counselling) in addition to strict glycaemic control and intensification of use of antihypertensive agents and statins. Use of adjunct therapies in this population as a tool should be explored more thoroughly to reduce risk of complications.

Keywords: Combined metabolic abnormalities; Diabetes complications; Diabetes treatment; Metabolic health; Metabolic syndrome; Obesity; Real-world data; Type 1 diabetes.

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Conflict of interest statement

Acknowledgements: This article is written on behalf of the IQED Group of Experts. The members of the IQED Group of Experts are L. Crenier, C. De Block, A.-S. Vanherwegen, A. Lavens, C. Mathieu, F. Nobels, J.-C. Philips, P. Oriot, M. Vandenbroucke and V. Vanelshocht. We would like to thank the staff of all Belgian specialised diabetes centres for the data collection. Some of the data were presented as an abstract at the EASD meeting in 2023. Data availability: Data cannot be shared publicly because of the use of pseudonymised person-level data. Readers who wish to access some or all of the data require approval from the Belgian Information Security Committee on Social Security and Health. More information about the access procedure may be obtained by contacting iqed@sciensano.be. Metadata (e.g. overview of variables, legal framework) are available on https://fair.healthdata.be/ . Funding: The IQED programme is funded by the Belgian National Institute for Health and Disability Insurance. Authors’ relationships and activities: The authors declare that there are no relationships or activities that might bias, or be perceived to bias, their work. Contribution statement: AL, CM, PO and CDB developed the concept and design of this study. Data analysis was performed by AL. All authors made substantial contributions to the interpretation of results. AL, CDB, PO and CM drafted the manuscript, and all authors contributed to critical revision of the manuscript for important intellectual content. All authors approved the final manuscript for publication. AL had full access to the data and accepts the responsibility for the integrity of the data and accuracy of the data analysis.

Figures

Fig. 1
Fig. 1
(a) Evolution of the mean HbA1c value (blue circles) and mean BMI value (red circles) over the audit years. (b) Evolution of the mean LDL-cholesterol value (blue circles) and the proportion of people living with type 1 diabetes and treated with lipid-lowering therapy (blue bars) over the audit years. Lipid-lowering therapy was defined as use of statins, fibrates (included in the data collection from 2006) or ezetimibe (included in the data collection from 2011). (c) Evolution of the mean systolic BP value (blue circles) and the proportion of people living with type 1 diabetes and treated with antihypertensive therapy (blue bars) over the audit years. Antihypertensive therapy was defined as use of ACE inhibitors (including sartans) or other antihypertensive drugs (included in the data collection from 2006). The solid lines are the fitted LOESS curves; the shaded bands represent the 95% CI of the fitted LOESS curve. The size of the study population in each audit year is indicated below the graphs. SBP, systolic BP
Fig. 2
Fig. 2
Prevalence of combined metabolic abnormalities in 2001, 2005, 2014 and 2022 for women (a) and men (b), according to the various definitions of the metabolic syndrome/combined metabolic abnormalities. The sizes of the study populations are indicated below the bars. MetS, combined metabolic abnormalities (metabolic syndrome); no alb, no albuminuria
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