Treatment regimens and glycaemic outcomes in more than 100 000 children with type 1 diabetes (2013-22): a longitudinal analysis of data from paediatric diabetes registries

Anthony T Zimmermann¹, Stefanie Lanzinger², Siv Janne Kummernes³, Nicolai A Lund-Blix³, Reinhard W Holl², Elke Fröhlich-Reiterer⁴, David M Maahs⁵, Osagie Ebekozien⁶, Saketh Rompicherla⁷, Justin T Warner⁸, Saira Pons Perez⁹, Holly Robinson¹⁰, Maria E Craig¹¹, Stephanie Johnson¹², Karin Akesson¹³, Alexander Thorén¹⁴, Katarina Eeg-Olofsson¹⁵, Ajenthen G Ranjan¹⁶, Mette Madsen¹⁷, Michael Witsch¹⁸, Heiko Bratke¹⁹, G Todd Alonso²⁰, Zdenek Sumnik²¹, Vit Neuman²¹, Ondrej Cinek²¹, Torild Skrivarhaug²², Jannet Svensson²³

Affiliations

¹ Division of Medicine, Lyell McEwin Hospital, Adelaide, SA, Australia. Electronic address: anthony.zimmermann@sa.gov.au.
² Institute of Epidemiology and Medical Biometry, Computer Assisted Quality Management, Ulm University, Ulm, Germany; German Center for Diabetes Research, Munich-Neuherberg, Munich, Germany.
³ The Norwegian Childhood Diabetes Registry, Division of Childhood and Adolescent Medicine, Oslo University Hospital, Oslo, Norway.
⁴ Department of Paediatric and Adolescent Medicine, Medical University of Graz, Graz, Austria.
⁵ Department of Pediatrics, Division of Endocrinology, Stanford University School of Medicine, California, CA, USA.
⁶ T1D Exchange, Boston, MA, USA; School of Medicine, University of Mississippi, Jackson, MI, USA.
⁷ T1D Exchange, Boston, MA, USA.
⁸ National Paediatric Diabetes Audit, Noah's Ark Children's Hospital for Wales, Cardiff, UK.
⁹ National Paediatric Diabetes Audit, Royal College of Paediatrics and Child Health, London, UK.
¹⁰ Royal College of Paediatrics and Child Health, London, UK.
¹¹ Paediatrics and Child Health, University of New South Wales, Sydney, NSW, Australia; Charles Perkins Centre Westmead, University of Sydney, Sydney, NSW, Australia.
¹² Department of Endocrinology, Queensland Children's Hospital, Brisbane, QLD, Australia.
¹³ The Swedish National Diabetes Register, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden; Department of Pediatrics, Ryhov County Hospital, Jönköping, Sweden; The Swedish National Diabetes Register, Center of Registers, Gothenburg, Sweden.
¹⁴ The Swedish National Diabetes Register, Center of Registers, Gothenburg, Sweden.
¹⁵ The Swedish National Diabetes Register, Center of Registers, Gothenburg, Sweden; Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden.
¹⁶ Steno Diabetes Center Copenhagen, Herlev, Denmark.
¹⁷ Steno Diabetes Center North Denmark, Aalborg University Hospital, Aalborg, Denmark; Department of Pediatrics and Adolescent Medicine, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Gistrup, Denmark.
¹⁸ Centre Hospitalier de Luxembourg, Luxembourg City, Luxembourg.
¹⁹ Department of Pediatrics, Haugesund Hospital, Fonna Health Trust, Haugesund, Norway.
²⁰ Barbara Davis Center, University of Colorado, Aurora, CO, USA.
²¹ Department of Pediatrics, 2nd Faculty of Medicine, Motol University Hospital, Charles University, Prague, Czechia.
²² The Norwegian Childhood Diabetes Registry, Division of Childhood and Adolescent Medicine, Oslo University Hospital, Oslo, Norway; Oslo Diabetes Research Center, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.
²³ Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden; Steno Diabetes Center Copenhagen, Herlev, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.

PMID: 39622257
DOI: 10.1016/S2213-8587(24)00279-1

Treatment regimens and glycaemic outcomes in more than 100 000 children with type 1 diabetes (2013-22): a longitudinal analysis of data from paediatric diabetes registries

Anthony T Zimmermann et al. Lancet Diabetes Endocrinol. 2025 Jan.

. 2025 Jan;13(1):47-56.

doi: 10.1016/S2213-8587(24)00279-1. Epub 2024 Nov 29.

Authors

Affiliations

¹ Division of Medicine, Lyell McEwin Hospital, Adelaide, SA, Australia. Electronic address: anthony.zimmermann@sa.gov.au.
² Institute of Epidemiology and Medical Biometry, Computer Assisted Quality Management, Ulm University, Ulm, Germany; German Center for Diabetes Research, Munich-Neuherberg, Munich, Germany.
³ The Norwegian Childhood Diabetes Registry, Division of Childhood and Adolescent Medicine, Oslo University Hospital, Oslo, Norway.
⁴ Department of Paediatric and Adolescent Medicine, Medical University of Graz, Graz, Austria.
⁵ Department of Pediatrics, Division of Endocrinology, Stanford University School of Medicine, California, CA, USA.
⁶ T1D Exchange, Boston, MA, USA; School of Medicine, University of Mississippi, Jackson, MI, USA.
⁷ T1D Exchange, Boston, MA, USA.
⁸ National Paediatric Diabetes Audit, Noah's Ark Children's Hospital for Wales, Cardiff, UK.
⁹ National Paediatric Diabetes Audit, Royal College of Paediatrics and Child Health, London, UK.
¹⁰ Royal College of Paediatrics and Child Health, London, UK.
¹¹ Paediatrics and Child Health, University of New South Wales, Sydney, NSW, Australia; Charles Perkins Centre Westmead, University of Sydney, Sydney, NSW, Australia.
¹² Department of Endocrinology, Queensland Children's Hospital, Brisbane, QLD, Australia.
¹³ The Swedish National Diabetes Register, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden; Department of Pediatrics, Ryhov County Hospital, Jönköping, Sweden; The Swedish National Diabetes Register, Center of Registers, Gothenburg, Sweden.
¹⁴ The Swedish National Diabetes Register, Center of Registers, Gothenburg, Sweden.
¹⁵ The Swedish National Diabetes Register, Center of Registers, Gothenburg, Sweden; Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden.
¹⁶ Steno Diabetes Center Copenhagen, Herlev, Denmark.
¹⁷ Steno Diabetes Center North Denmark, Aalborg University Hospital, Aalborg, Denmark; Department of Pediatrics and Adolescent Medicine, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Gistrup, Denmark.
¹⁸ Centre Hospitalier de Luxembourg, Luxembourg City, Luxembourg.
¹⁹ Department of Pediatrics, Haugesund Hospital, Fonna Health Trust, Haugesund, Norway.
²⁰ Barbara Davis Center, University of Colorado, Aurora, CO, USA.
²¹ Department of Pediatrics, 2nd Faculty of Medicine, Motol University Hospital, Charles University, Prague, Czechia.
²² The Norwegian Childhood Diabetes Registry, Division of Childhood and Adolescent Medicine, Oslo University Hospital, Oslo, Norway; Oslo Diabetes Research Center, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.
²³ Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden; Steno Diabetes Center Copenhagen, Herlev, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.

PMID: 39622257
DOI: 10.1016/S2213-8587(24)00279-1

Erratum in

Correction to Lancet Diabetes Endocrinol 2025; 13: 47-56.
[No authors listed] [No authors listed] Lancet Diabetes Endocrinol. 2025 Apr;13(4):e7. doi: 10.1016/S2213-8587(25)00032-4. Epub 2025 Feb 17. Lancet Diabetes Endocrinol. 2025. PMID: 39978367 No abstract available.

Abstract

Background: Advances in paediatric type 1 diabetes management and increased use of diabetes technology have led to improvements in glycaemia, reduced risk of severe hypoglycaemia, and improved quality of life. Since 1993, progressively lower HbA_1c targets have been set. The aim of this study was to perform a longitudinal analysis of HbA_1c, treatment regimens, and acute complications between 2013 and 2022 using data from eight national and one international paediatric diabetes registries.

Methods: In this longitudinal analysis, we obtained data from the Australasian Diabetes Data Network, Czech National Childhood Diabetes Register, Danish Registry of Childhood and Adolescent Diabetes, Diabetes Prospective Follow-up Registry, Norwegian Childhood Diabetes Registry, England and Wales' National Paediatric Diabetes Audit, Swedish Childhood Diabetes Registry, T1D Exchange Quality Improvement Collaborative, and the SWEET initiative. All children (aged ≤18 years) with type 1 diabetes with a duration of longer than 3 months were included. Investigators compared data from 2013 to 2022; analyses performed on data were pre-defined and conducted separately by each respective registry. Data on demographics, HbA_1c, treatment regimen, and event rates of diabetic ketoacidosis and severe hypoglycaemia were collected. ANOVA was performed to compare means between registries and years. Joinpoint regression analysis was used to study significant breakpoints in temporal trends.

Findings: In 2022, data were available for 109 494 children from the national registries and 35 590 from SWEET. Between 2013 and 2022, the aggregated mean HbA_1c decreased from 8·2% (95% CI 8·1-8·3%; 66·5 mmol/mol [65·2-67·7]) to 7·6% (7·5-7·7; 59·4mmol/mol [58·2-60·5]), and the proportion of participants who had achieved HbA_1c targets of less than 7% (<53 mmol/mol) increased from 19·0% to 38·8% (p<0·0001). In 2013, the aggregate event rate of severe hypoglycaemia rate was 3·0 events per 100 person-years (95% CI 2·0-4·9) compared with 1·7 events per 100 person-years (1·0-2·7) in 2022. In 2013, the aggregate event rate of diabetic ketoacidosis was 3·1 events per 100 person-years (95% CI 2·0-4·8) compared with 2·2 events per 100 person-years (1·4-3·4) in 2022. The proportion of participants with insulin pump use increased from 42·9% (95% CI 40·4-45·5) in 2013 to 60·2% (95% CI 57·9-62·6) in 2022 (mean difference 17·3% [13·8-20·7]; p<0·0001), and the proportion of participants using continuous glucose monitoring (CGM) increased from 18·7% (95% CI 9·5-28·0) in 2016 to 81·7% (73·0-90·4) in 2022 (mean difference 63·0% [50·3-75·7]; p<0·0001).

Interpretation: Between 2013 and 2022, glycaemic outcomes have improved, parallel to increased use of diabetes technology. Many children had HbA_1c higher than the International Society for Pediatric and Adolescent Diabetes (ISPAD) 2022 target. Reassuringly, despite targeting lower HbA_1c, severe hypoglycaemia event rates are decreasing. Even for children with type 1 diabetes who have access to specialised diabetes care and diabetes technology, further advances in diabetes management are required to assist with achieving ISPAD glycaemic targets.

Funding: None.

Translations: For the Norwegian, German, Czech, Danish and Swedish translations of the abstract see Supplementary Materials section.

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Conflict of interest statement

Declaration of Interests OE has received research grants and speaker's bureaus from Eli Lilly, Lexicon, Sanofi, Vertex, and Medtronic Diabetes paid to their institution. JS has received payment from Novo Nordisk, Rubin Medical, and Medtronic Diabetes for educational events, and insulin and insulin infusion sets for research from Novo Nordisk and Medtronic Diabetes; and is the Secretary General elect for ISPAD and a member of SWEET Advisory Board. DMM has received research grants from NIDDK, NSF, Helmsley Charitable Trust, JDRF, Stanford Human-Centered Artificial Intelligence, and Mannkind paid to their institution; has received CGM materials from Dexcom to institution for the '4T Study’; is the chair for OSMB for NIDDK sponsored GoMoms study; is on the data safety monitoring board for the ATTEMPT and REMODEL studies; and has participated on advisory boards for Medtronic Diabetes, Abbott, Lifescan, Sanofi, Biospex, Provention Bio, Kriya, and Enable Biosciences. MM has been an unpaid board member and head of the society of the Danish Society of Pediatric and Adolescent Diabetes from 2015 to 2024. KA has received speaker's bureaus payment to her institution from Novo Nordisk. MW is contracted with SWEET as an author of the benchmarking report with remuneration received as an annual fee. MW is a member of the executive board of SWEET. GTA has received grants paid to the University of Colorado, to support work in paediatric type 1 diabetes research from the National Institutes of Health/National Institute of Diabetes and Digestive and Kidney Diseases and the Helmsley Foundation; consulting fees from Mannkind; and payments for participation on Data Safety Monitoring Board for the '4T Study', all made to the University of Colorado; and payment for educational events for Children's Diabetes Foundation. HB is a member of the annual Norwegian diabetes meeting program committee. KEO has received consulting fees from Sanofi, Novo Nordisk, Eli Lilly, and Abbott Diabetes Care paid to their institution; and lecture honoraria from Sanofi, Abbott Diabetes Care, and Eli Lilly. KEO is Director for Swedish National Diabetes Register. All other authors declare no conflicts of interest.

Comment in

Achievement of HbA_1c targets: real-world data from international paediatric type 1 diabetes registries.
Karges B, Knip M. Karges B, et al. Lancet Diabetes Endocrinol. 2025 Jan;13(1):6-7. doi: 10.1016/S2213-8587(24)00311-5. Epub 2024 Nov 29. Lancet Diabetes Endocrinol. 2025. PMID: 39622258 No abstract available.

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Treatment regimens and glycaemic outcomes in more than 100 000 children with type 1 diabetes (2013-22): a longitudinal analysis of data from paediatric diabetes registries

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Treatment regimens and glycaemic outcomes in more than 100 000 children with type 1 diabetes (2013-22): a longitudinal analysis of data from paediatric diabetes registries

Authors

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Abstract

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