Journal of General Internal Medicine

, Volume 34, Issue 7, pp 1244–1250 | Cite as

The Incidence of Diabetic Ketoacidosis During “Emerging Adulthood” in the USA and Canada: a Population-Based Study

  • Adam GaffneyEmail author
  • Andrea ChristopherEmail author
  • Alan Katz
  • Dan Chateau
  • Chelsey McDougall
  • David Bor
  • David Himmelstein
  • Steffie Woolhandler
  • Danny McCormick
Original Research



As children with diabetes transition to adulthood, they may be especially vulnerable to diabetic ketoacidosis (DKA). Cross-national comparisons may inform efforts to avoid this complication.


To compare DKA hospitalization rates in the USA and Manitoba, Canada, during the vulnerable years known as “emerging adulthood.”


Cross-sectional study using inpatient administrative databases in the USA (years 1998–2014) and Manitoba, Canada (years 2003–2013).


Individuals aged 12–30 years hospitalized with DKA, identified using ICD-9 (USA) or ICD-10 codes (Manitoba).

Main Measures

DKA hospitalization rates per 10,000 population by age (with a focus on those aged 15–17 vs. 19–21). Admissions were characterized by gender, socioeconomic status, year of hospitalization, and mortality during hospitalization.

Key Results

The DKA rate was slightly higher in the USA among those aged 15–17: 4.8 hospitalizations/10,000 population vs. 3.7/10,000 in Manitoba. Among those aged 19–21, the DKA hospitalization rate rose 90% in the USA to 9.2/10,000, vs. 23% in Manitoba, to 4.5/10,000. In both the USA and Manitoba, rates were higher among those from poorer areas, and among adolescent girls compared with adolescent boys. DKA admissions rose gradually during the period under study in the USA, but not in Manitoba.


In years of “emerging adulthood,” the Canadian healthcare system appears to perform better than that of the USA in preventing hospitalizations for DKA. Although many factors likely contribute to this difference, universal and seamless coverage over the lifespan in Canada may contribute.


healthcare access diabetic ketoacidosis, emerging adulthood 



The authors acknowledge Carole Taylor for her analysis of the Manitoba data.


The Manitoba researchers were supported through a contract with the Manitoba Government. Dr. Christopher received funding support from an Institutional National Research Service Award (T32HP12706) and the Ryoichi Sasakawa Fellowship Fund.

Compliance with Ethical Standards

Conflict of Interest

The authors report no conflicts of interest with any relevant commercial entities. Drs. Gaffney, McCormick, Himmelstein, and Woolhandler are leaders of Physicians for a National Health Program, a non-profit organization that favors coverage expansion through a single-payer program, and Drs. Bor and Christopher are members of that organization. None of them receive any compensation from that group. Although Adam Gaffney is reimbursed for some of his travel on behalf of the organization. Dr. Katz is supported through the Manitoba Health Research Council Chair in Primary Prevention.


The authors acknowledge the Manitoba Centre for Health Policy for use of data contained in the Manitoba Population Research Data Repository under project no. 2014-028 (HIPC no. 2014/2015 - 39). The results and conclusions are those of the authors and no official endorsement by the Manitoba Centre for Health Policy, Manitoba Health, Seniors and Active Living, or other data providers is intended or should be inferred. Data used in this study are from the Manitoba Population Research Data Repository housed at the Manitoba Centre for Health Policy, University of Manitoba, and were derived from data provided by Manitoba Health, Seniors and Active Living.

Supplementary material

11606_2019_5006_MOESM1_ESM.docx (34 kb)
ESM 1 (DOCX 34 kb)


  1. 1.
    Weissberg-Benchell J, Wolpert H, Anderson BJ. Transitioning from pediatric to adult care: A new approach to the post-adolescent young person with type 1 diabetes. Diabetes Care. 2007;30(10):2441–2446.CrossRefGoogle Scholar
  2. 2.
    Peters A, Laffel L. Diabetes Care for Emerging Adults: Recommendations for Transition From Pediatric to Adult Diabetes Care Systems. Diabetes Care. 2011;34(11):2477–2485.CrossRefGoogle Scholar
  3. 3.
    Arnett JJ. Emerging adulthood. A theory of development from the late teens through the twenties. Am Psychol. 2000;55(5):469–480.CrossRefGoogle Scholar
  4. 4.
    American Diabetes Association. Standards of medical care in diabetes - 2017: 12. Children and adolescents. Diabetes Care. 2017;40(Supplement 1):S105-S113.CrossRefGoogle Scholar
  5. 5.
    Nakhla M, Daneman D, To T, Paradis G, Guttmann A. Transition to adult care for youths with diabetes mellitus: findings from a universal health care system. Pediatrics. 2009;124(6):e1134–1141.CrossRefGoogle Scholar
  6. 6.
    Jefferies CA, Nakhla M, Derraik JG, Gunn AJ, Daneman D, Cutfield WS. Preventing diabetic ketoacidosis. Pediatr Clin North Am. 2015;62(4):857–871.CrossRefGoogle Scholar
  7. 7.
    Saydah S, Imperatore G, Cheng Y, Geiss LS, Albright A. Disparities in diabetes deaths among children and adolescents - United States, 2000-2014. MMWR Morb Mortal Wkly Rep. 2017;66(19):502–505.CrossRefGoogle Scholar
  8. 8.
    Laing SP, Swerdlow AJ, Slater SD, Botha JL, Burden AC, Waugh NR, et al. The British Diabetic Association Cohort Study, II: cause-specific mortality in patients with insulin-treated diabetes mellitus. Diabet Med. 1999;16(6):466–471.CrossRefGoogle Scholar
  9. 9.
    Weissman JS, Gatsonis C, Epstein AM. Rates of avoidable hospitalization by insurance status in Massachusetts and Maryland. JAMA. 1992;268(17):2388–2394.CrossRefGoogle Scholar
  10. 10.
    Table 1. AHRQ quality indicators selected for the national healthcare quality report, 2008. Rockville, MD. March, 2009. Accessed January 16, 2019. Available at:
  11. 11.
    International Statistical Classification of Diseases and Related Health Problems: Tenth Revision. Ottawa, Ontario, Canada: Canadian Institute for Health Information; 2009. Accessed January 16, 2019. Available at:
  12. 12.
    Organisation for Economic Co-Operation and Development. OECD Health Statistics 2017. Accessed January 16, 2019. Available at:
  13. 13.
    International Diabetes Federation. IDF diabetes atlas - 8th edition. 2017. Accessed January 16, 2019: Available at:
  14. 14.
    Pettitt DJ, Talton J, Dabelea D, Divers J, Imperatore G, Lawrence JM, et al. Prevalence of diabetes in U.S. youth in 2009: the SEARCH for diabetes in youth study. Diabetes Care. 2014;37(2):402–408.CrossRefGoogle Scholar
  15. 15.
    Chapter 1: Diabetes in Canada: Facts and figures from a public health perspective - Burden. Accessed January 16, 2019. Available at:
  16. 16.
    Patterson C, Guariguata L, Dahlquist G, Soltész G, Ogle G, Silink M. Diabetes in the young - a global view and worldwide estimates of numbers of children with type 1 diabetes. Diabetes Res Clin Pract. 2013;103(2):161–175.CrossRefGoogle Scholar
  17. 17.
    Rudowitz R, Artiga S, Arguello R. Children’s Health Coverage: Medicaid, CHIP and the ACA. Kaiser Family Foundation. Accessed January 16, 2019. Available at:
  18. 18.
    Paradise J. Medicaid Moving Forward. Kaiser Family Foundation. Accessed January 16, 2019. Available at:
  19. 19.
    Barnett JC, Berchick ER. Health Insurance Coverage in the United States: 2016. Current Population Reports. Washington DC: US Government Printing Office; 2017.Google Scholar
  20. 20.
    Sommers BD, Gourevitch R, Maylone B, Blendon RJ, Epstein AM. Insurance churning rates for low-income adults under health reform: lower than expected but still harmful for many. Health Aff (Millwood). 2016;35(10):1816–1824.CrossRefGoogle Scholar
  21. 21.
    Davies MJ, Gagliardino JJ, Gray LJ, Khunti K, Mohan V, Hughes R. Real-world factors affecting adherence to insulin therapy in patients with Type 1 or Type 2 diabetes mellitus: a systematic review. Diabet Med. 2013;30(5):512–524.CrossRefGoogle Scholar
  22. 22.
    Randall L, Begovic J, Hudson M, Smiley D, Peng L, Pitre N, et al. Recurrent diabetic ketoacidosis in inner-city minority patients: behavioral, socioeconomic, and psychosocial factors. Diabetes Care. 2011;34(9):1891–1896.CrossRefGoogle Scholar
  23. 23.
    Wharam J, Zhang F, Eggleston EM, Lu CY, Soumerai S, Ross-Degnan D. Diabetes outpatient care and acute complications before and after high-deductible insurance enrollment: A natural experiment for translation in diabetes (next-d) study. JAMA Intern Med. 2017;177(3):358–368.CrossRefGoogle Scholar
  24. 24.
    Hadley J. Insurance coverage, medical care use, and short-term health changes following an unintentional injury or the onset of a chronic condition. JAMA. 2007;297(10):1073–1084.CrossRefGoogle Scholar
  25. 25.
    Dabelea D, Rewers A, Stafford JM, Standiford DA, Lawrence JM, Saydah S, et al. Trends in the Prevalence of Ketoacidosis at Diabetes Diagnosis: The SEARCH for Diabetes in Youth Study. Pediatrics. 2014;133(4):e938-e945.CrossRefGoogle Scholar
  26. 26.
    Maniatis AK, Goehrig SH, Gao D, Rewers A, Walravens P, Klingensmith GJ. Increased incidence and severity of diabetic ketoacidosis among uninsured children with newly diagnosed type 1 diabetes mellitus. Pediatr Diabetes. 2005;6(2):79–83.CrossRefGoogle Scholar
  27. 27.
    Usher-Smith JA, Thompson MJ, Sharp SJ, Walter FM. Factors associated with the presence of diabetic ketoacidosis at diagnosis of diabetes in children and young adults: a systematic review. BMJ. 2011;343:d4092.CrossRefGoogle Scholar
  28. 28.
    Maahs DM, Hermann JM, Holman N, Foster NC, Kapellen TM, Allgrove J, et al. Rates of diabetic ketoacidosis: international comparison with 49,859 pediatric patients with type 1 diabetes from England, Wales, the U.S., Austria, and Germany. Diabetes Care. 2015;38(10):1876–1882.CrossRefGoogle Scholar
  29. 29.
    Garvey KC, Wolpert HA, Rhodes ET, Laffel LM, Kleinman K, Beste MG, et al. Health care transition in patients with type 1 diabetes: young adult experiences and relationship to glycemic control. Diabetes Care. 2012;35(8):1716–1722.CrossRefGoogle Scholar
  30. 30.
    Child Health Program Winnipeg Regional Health Authority. Diabetes Education Resource for Children & Adolescents (DER-CA): Annual Report 2015. Accessed January 16, 2019. Available at:
  31. 31.
    Van Walleghem N, MacDonald CA, Dean HJ. The Maestro Project: a patient navigator for the transition of care for youth with type 1 diabetes. Diabetes Spectr. 2011;24(1):9–13.CrossRefGoogle Scholar
  32. 32.
    Van Walleghem N, MacDonald CA, Dean HJ. Evaluation of a Systems Navigator Model for Transition From Pediatric to Adult Care for Young Adults With Type 1 Diabetes. Diabetes Care. 2008;31(8):1529–1530.CrossRefGoogle Scholar
  33. 33.
    Fry R. For First Time in Modern Era, Living With Parents Edges Out Other Living Arrangements for 18- to 34-Year-Olds. Pew Research Center. Accessed January 16, 2019. Available at:
  34. 34.
    Statistics Canada. Living arrangements of young adults aged 20 to 29. Accessed January 16, 2019. Available at:
  35. 35.
    Dabelea D, Mayer-Davis EJ, Saydah S, et al. Prevalence of type 1 and type 2 diabetes among children and adolescents from 2001 to 2009. JAMA. 2014;311(17):1778–1786.CrossRefGoogle Scholar
  36. 36.
    Lindner LME, Rathmann W, Rosenbauer J. Inequalities in glycaemic control, hypoglycaemia and diabetic ketoacidosis according to socio-economic status and area-level deprivation in Type 1 diabetes mellitus: a systematic review. Diabet Med. 2017.Google Scholar
  37. 37.
    Stylianou C, Kelnar C. The introduction of successful treatment of diabetes mellitus with insulin. J R Soc Med. 2009;102(7):298–303.CrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2019

Authors and Affiliations

  • Adam Gaffney
    • 1
    Email author
  • Andrea Christopher
    • 2
    Email author
  • Alan Katz
    • 3
  • Dan Chateau
    • 3
  • Chelsey McDougall
    • 3
  • David Bor
    • 1
  • David Himmelstein
    • 1
    • 4
  • Steffie Woolhandler
    • 1
    • 4
  • Danny McCormick
    • 1
  1. 1.Cambridge Health Alliance/Harvard Medical SchoolCambridgeUSA
  2. 2.Boise Veterans Affairs Medical CenterUniversity of Washington School of MedicineSeattleUSA
  3. 3.Manitoba Centre for Health PolicyUniversity of ManitobaWinnipegCanada
  4. 4.City University of New York at Hunter CollegeNew YorkUSA

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