Repeat DKA more common for younger people, women and those with poor mental health
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Younger adults, women, and those with lower socioeconomic status and poor mental health have a greater likelihood for repeat diabetic ketoacidosis, according to findings from a systematic review published in Diabetic Medicine.
“Considered as a whole, the evidence would seem to suggest that repeat DKA embodies a ‘perfect storm’ of biological, psychological and social issues,” Rose Stewart, BSc, DClinPsy, CPsychol, consultant clinical psychologist and diabetes psychology lead at Betsi Cadwaladr University Health Board in Bangor, United Kingdom, and colleague wrote. “It is most common among adolescents or young adults, who are female, who have backgrounds of lower socioeconomic status and whose psychological well-being is poorer. Indeed, these factors have received the most research attention, and although the methodological quality of the studies from which these findings are derived is variable, the findings are relatively consistent across studies.”
Researchers conducted a systematic review of qualitative and quantitative studies reporting on the association between psychosocial factors and repeat DKA in people with type 1 diabetes. PsycINFO, Web of Science, CINAHL, PubMed and Applied Social Sciences Index and Abstracts (ASSIA) databases were search from inception to Feb. 2, 2020, with a repeat search conducted on April 25, 2020. A meta-analysis was not conducted due to the heterogeneity between the study designs and variance of the psychosocial outcomes.
The review included 22 studies, most from the United States (n = 10) or United Kingdom (n = 6), 11 retrospective studies, seven cross-sectional studies and four prospective studies.
Repeat DKA associated with younger age, women
Most of the studies examined seven psychosocial factors. Twelve investigated the relationship between age and repeat DKA, with eight studies suggesting repeat DKA was more common for adolescents and young adults. For one study focusing on children, youths aged at least 15 had 60% more repeat DKA hospital admissions than those younger than 15 years. Three studies did not find a significant association between age and DKA.
Of 14 studies examining the association between sex and repeat DKA, 11 found repeat DKA was more common for women compared with men, for both children and adults. Three studies found no association between sex and repeat DKA.
Of the 13 studies examining socioeconomic status, 11 found an association between low socioeconomic status and repeat DKA in both children and adults. Most of those studies were based in the U.S.
Ten studies looked at the association between mental health and repeat DKA, with eight finding an association between worse mental health and increased odds of repeat DKA in children and adults. Most of the studies examined mental health in a broad sense rather than specific conditions, according to the researchers.
More research needed on ethnicity, family-related factors
Two other categories in the review had limited findings, according to the researchers, due to a lack of studies and the low quality of the research. Only three studies examined the role of ethnicity in repeat DKA. One study found a higher percentage of non-Hispanic Black participants had a repeat DKA compared with those who had no initial DKA. A second study found Black participants had 80% more repeat DKA admission compared with white individuals. The third study found adults from a migrant background were more likely to experience repeat DKA.
Four studies explored family-related factors and their associations with repeat DKA, with three of them deemed to be of low quality and among the oldest studies included in the review. These studies found repeat DKA was associated with higher levels of family difficulty, indicating greater conflict and problematic parenting styles.
“Future research would benefit from clear and consistent operationalization of variables, as well as aiming to investigate more specifically the nature of psychosocial difficulties that may be associated with repeat DKA, as well as why this may be the case,” the researchers wrote. “In particular, research into the prevalence of specific psychological issues and behaviors in the repeat DKA population is sorely missing. Nevertheless, the existent evidence base may be used to inform enhanced monitoring of ‘at risk’ groups for repeat DKA, as well as to advocate for the importance of professional psychological involvement and recognition of social contexts and needs in type 1 diabetes services.”
Perspective
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Osagie Ebekozien, MD, MPH, CPHQ
I congratulate Allcock and co-authors on the rigorous systemic review. As a diabetes population health researcher, I found their findings insightful.
Although the review period for the study was too early to capture COVID-19-relevant publications on this topic, their analysis is still timely and relevant as the diabetes community seeks to implement practical strategies to reduce the increased rate of diabetic ketoacidosis among patients living with diabetes during the COVID-19 pandemic.
The authors highlight that insulin omission is the leading cause of DKA in people with type 1 diabetes. Nevertheless, I wish the authors elaborated on how access to affordable insulin contributes to insulin omission. In the United States, the cost of insulin and access to quality health insurance directly impact care outcomes. Even though several state mandates have introduced a cap for patient co-pays, this might not be enough to make insulin more accessible and affordable (Chau K, et al. JAMA Pediatr. 2020;doi:10.1001/jamapediatrics.2020.1065.)
The diabetes community must collectively work together to prevent recurrent DKA, and we have the right kind of tools to do better.
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