Diabetologia

, Volume 61, Issue 6, pp 1354–1361 | Cite as

Impact of long-term air pollution exposure on metabolic control in children and adolescents with type 1 diabetes: results from the DPV registry

  • Stefanie Lanzinger
  • Joachim Rosenbauer
  • Dorothea Sugiri
  • Tamara Schikowski
  • Birgit Treiber
  • Daniela Klee
  • Wolfgang Rathmann
  • Reinhard W. Holl
Article

Abstract

Aims/hypothesis

Studies on the association between air pollution and metabolic control in children and adolescents with type 1 diabetes are rare and findings are inconsistent. We examined the relationship between air pollution variables (particulate matter with an aerodynamic diameter <10 μm [PM10], NO2 and accumulated ozone exposure [O3-AOT]) and metabolic variables (HbA1c and daily insulin dose [U/kg body weight]) in children and adolescents with type 1 diabetes.

Methods

We investigated 37,372 individuals with type 1 diabetes aged <21 years, documented between 2009 and 2014 in 344 German centres of the prospective diabetes follow-up registry (Diabetes-Patienten-Verlaufsdokumentation [DPV]). Long-term air pollution exposure (annual and quinquennial means) data were linked to participants via the five-digit postcode areas of residency. Cross-sectional multivariable regression analysis was used to examine the association between air pollution and metabolic control.

Results

After comprehensive adjustment, an interquartile range increase in O3-AOT was associated with a lower HbA1c (−3.7% [95% CI −4.4, −3.0]). The inverse association between O3-AOT and HbA1c persisted after additional adjustment for degree of urbanisation or additional adjustment for PM10. Moreover, the inverse association remained stable in further sensitivity analyses. No significant associations between HbA1c and PM10 or NO2 were found. No association was observed between any of the three air pollutants and insulin dose.

Conclusions/interpretation

The inverse association between O3-AOT and HbA1c could not be explained by regional differences in diabetes treatment or by other differences between urban and rural areas. Furthermore, our results remained stable in sensitivity analyses. Further studies on the association between air pollution and HbA1c in children and adolescents with type 1 diabetes are needed to confirm our observed association and to elucidate underlying mechanisms.

Keywords

Air pollution HbA1c Insulin Metabolic control Ozone Particulate matter Type 1 diabetes 

Abbreviations

25(OH)D

25-Hydroxyvitamin D

DPV

Diabetes-Patienten-Verlaufsdokumentation

IQR

Interquartile range

KiGGS

German Health Interview and Examination Survey for Children and Adolescents

KORA

Cooperative Health Research in the Region of Augsburg, Germany

O3-AOT

Accumulated ozone exposure

PM10

Particulate matter with an aerodynamic diameter <10 μm

SDS

Standard deviation score

Notes

Acknowledgements

The authors thank all participating centres of the DPV Initiative, especially those collaborating in this investigation (listed in the ESM). We thank the German Federal Environmental Agency (Umweltbundesamt [UBA], Department II 4.2) for providing the air pollution data.

Contribution statement

SL contributed to data management, data analysis and manuscript writing and editing. JR contributed to data analysis and manuscript writing and editing. DS and TS contributed to data analysis and manuscript editing. BT, DK and WR reviewed the manuscript and contributed to interpretation of data and manuscript editing. RWH is the principal investigator of the study and contributed to data analysis and manuscript writing and editing. All co-authors approved the final version to be published. RWH is the guarantor of this work and, as such, had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Funding

The study was financially supported by the Federal Ministry of Education and Research within the German Competence Network Diabetes Mellitus (grant 01GI1106), which was integrated into the German Centre for Diabetes Research (DZD) as of January 2015. This project has received funding from the Innovative Medicines Initiative 2 Joint Undertaking under grant agreement no. 115797 (INNODIA). This joint undertaking receives support from the Union’s Horizon 2020 research and innovation programme and ‘EFPIA’, ‘JDRF’ and ‘The Leona M. and Harry B. Helmsley Charitable Trust’. Additional support was provided by the German Diabetes Association (DDG). Sponsors were not involved in data acquisition or analysis.

Duality of interest

The authors declare that there is no duality of interest associated with this manuscript.

Supplementary material

125_2018_4580_MOESM1_ESM.pdf (117 kb)
ESM (PDF 117 kb)

References

  1. 1.
    Rao X, Montresor-Lopez J, Puett R, Rajagopalan S, Brook RD (2015) Ambient air pollution: an emerging risk factor for diabetes mellitus. Curr Diab Rep 15:603-015-0603-8CrossRefGoogle Scholar
  2. 2.
    Thiering E, Heinrich J (2015) Epidemiology of air pollution and diabetes. Trends Endocrinol Metab 26:384–394CrossRefPubMedGoogle Scholar
  3. 3.
    Zanobetti A, Schwartz J (2001) Are diabetics more susceptible to the health effects of airborne particles? Am J Respir Crit Care Med 164:831–833CrossRefPubMedGoogle Scholar
  4. 4.
    Zanobetti A, Schwartz J (2002) Cardiovascular damage by airborne particles: are diabetics more susceptible? Epidemiology 13:588–592CrossRefPubMedGoogle Scholar
  5. 5.
    Brook RD, Rajagopalan S, Pope CA 3rd et al (2010) Particulate matter air pollution and cardiovascular disease: an update to the scientific statement from the American Heart Association. Circulation 121:2331–2378CrossRefPubMedGoogle Scholar
  6. 6.
    Rajagopalan S, Brook RD (2012) Air pollution and type 2 diabetes: mechanistic insights. Diabetes 61:3037–3045CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    American Diabetes Association (2016) Standards of medical care in diabetes-2016. Diabetes Care 39(Suppl 1):1–112Google Scholar
  8. 8.
    Tamayo T, Rathmann W, Kramer U, Sugiri D, Grabert M, Holl RW (2014) Is particle pollution in outdoor air associated with metabolic control in type 2 diabetes? PLoS One 9:e91639CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Yitshak Sade M, Kloog I, Liberty IF, Schwartz J, Novack V (2016) The association between air pollution exposure and glucose and lipids levels. J Clin Endocrinol Metab 101:2460–2467CrossRefPubMedGoogle Scholar
  10. 10.
    Tamayo T, Rathmann W, Stahl-Pehe A et al (2016) No adverse effect of outdoor air pollution on HbA1c in children and young adults with type 1 diabetes. Int J Hyg Environ Health 219:349–355CrossRefPubMedGoogle Scholar
  11. 11.
    Liu C, Yang C, Zhao Y et al (2016) Associations between long-term exposure to ambient particulate air pollution and type 2 diabetes prevalence, blood glucose and glycosylated hemoglobin levels in China. Environ Int 92-93:416–421CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    The European Parliament and the Council of the European Union (2008) Directive 2008/50/EC of the European Parliament and of the Council of 21 May 2008 on ambient air quality and cleaner air for Europe. Available from http://eur-lex.europa.eu/legal-content/EN/TXT/PDF/?uri=CELEX:32008L0050&from=EN. Accessed 11 January 2018
  13. 13.
    German Environment Agency (2010) Informationen zum Luftschadstoff Ozon (O3) Available from www.umweltbundesamt.de/sites/default/files/medien/377/dokumente/infoblatt_ozon.pdf. Accessed 11 January 2018
  14. 14.
    Hofer SE, Schwandt A, Holl RW, Austrian/German DPV Initiative (2016) Standardized documentation in pediatric diabetology: experience from Austria and Germany. J Diabetes Sci Technol 10:1042–1049CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Rosario AS, Kurth BM, Stolzenberg H, Ellert U, Neuhauser H (2010) Body mass index percentiles for children and adolescents in Germany based on a nationally representative sample (KiGGS 2003-2006). Eur J Clin Nutr 64:341–349CrossRefPubMedGoogle Scholar
  16. 16.
    Rosenbauer J, Dost A, Karges B et al (2012) Improved metabolic control in children and adolescents with type 1 diabetes: a trend analysis using prospective multicenter data from Germany and Austria. Diabetes Care 35:80–86CrossRefPubMedGoogle Scholar
  17. 17.
    Eurostat (2015) Glossary: degree of urbanisation. Available from http://ec.europa.eu/eurostat/statistics-explained/index.php/Glossary:Degree%20of%20urbanisation. Accessed 11 January 2018
  18. 18.
    Martinez-Sanchez G, Al-Dalain SM, Menendez S et al (2005) Therapeutic efficacy of ozone in patients with diabetic foot. Eur J Pharmacol 523:151–161CrossRefPubMedGoogle Scholar
  19. 19.
    Sagai M, Bocci V (2011) Mechanisms of action involved in ozone therapy: is healing induced via a mild oxidative stress? Med Gas Res 1:29CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Morsy MD, Hassan WN, Zalat SI (2010) Improvement of renal oxidative stress markers after ozone administration in diabetic nephropathy in rats. Diabetol Metab Syndr 2:29CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Beraki A, Magnuson A, Sarnblad S, Aman J, Samuelsson U (2014) Increase in physical activity is associated with lower HbA1c levels in children and adolescents with type 1 diabetes: results from a cross-sectional study based on the Swedish pediatric diabetes quality registry (SWEDIABKIDS). Diabetes Res Clin Pract 105:119–125CrossRefPubMedGoogle Scholar
  22. 22.
    Herbst A, Bachran R, Kapellen T, Holl RW (2006) Effects of regular physical activity on control of glycemia in pediatric patients with type 1 diabetes mellitus. Arch Pediatr Adolesc Med 160:573–577CrossRefPubMedGoogle Scholar
  23. 23.
    Bohn B, Kerner W, Seufert J et al (2016) Trend of antihyperglycaemic therapy and glycaemic control in 184,864 adults with type 1 or 2 diabetes between 2002 and 2014: analysis of real-life data from the DPV registry from Germany and Austria. Diabetes Res Clin Pract 115:31–38CrossRefPubMedGoogle Scholar
  24. 24.
    Karges B, Rosenbauer J, Kapellen T et al (2014) Hemoglobin A1c levels and risk of severe hypoglycemia in children and young adults with type 1 diabetes from Germany and Austria: a trend analysis in a cohort of 37,539 patients between 1995 and 2012. PLoS Med 11:e1001742CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Richter K, Breitner S, Webb AR et al (2014) Influence of external, intrinsic and individual behaviour variables on serum 25(OH)D in a German survey. J Photochem Photobiol B 140:120–129CrossRefPubMedGoogle Scholar
  26. 26.
    Talaat IM, Nasr A, Alsulaimani AA et al (2016) Association between type 1, type 2 cytokines, diabetic autoantibodies and 25-hydroxyvitamin D in children with type 1 diabetes. J Endocrinol Investig 39:1425–1434CrossRefGoogle Scholar
  27. 27.
    Wolf K, Popp A, Schneider A et al (2016) Association between long-term exposure to air pollution and biomarkers related to insulin resistance, subclinical inflammation and adipokines. Diabetes 65:3314–3326CrossRefPubMedGoogle Scholar
  28. 28.
    Hathout EH, Beeson WL, Ischander M, Rao R, Mace JW (2006) Air pollution and type 1 diabetes in children. Pediatr Diabetes 7:81–87CrossRefPubMedGoogle Scholar
  29. 29.
    Gonzalez RN, Torres-Aviles F, Carrasco PE, Salas PF, Perez BF (2013) Association of the incidence of type 1 diabetes mellitus with environmental factors in Chile during the period 2000-2007. Rev Med Chil 141:595–601CrossRefGoogle Scholar
  30. 30.
    Malmqvist E, Larsson HE, Jonsson I et al (2015) Maternal exposure to air pollution and type 1 diabetes--accounting for genetic factors. Environ Res 140:268–274CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Institute of Epidemiology and Medical Biometry, Central Institution for Biomedical Engineering (ZIBMT)University of UlmUlmGermany
  2. 2.German Centre for Diabetes Research (DZD)MünchenGermany
  3. 3.Institute for Biometrics and Epidemiology, German Diabetes CentreLeibniz Centre for Diabetes Research at Heinrich Heine University DüsseldorfDüsseldorfGermany
  4. 4.Leibniz Research Institute for Environmental Medicine (IUF)DüsseldorfGermany
  5. 5.Hospital for Children and Adolescents, Clinical Centre St MarienAmbergGermany
  6. 6.Pediatric PracticeBürstadtGermany

Personalised recommendations