Elsevier

The Lancet

Volume 355, Issue 9207, 11 March 2000, Pages 873-876
The Lancet

Articles
Variation and trends in incidence of childhood diabetes in Europe

https://doi.org/10.1016/S0140-6736(99)07125-1Get rights and content

Summary

Background

To study the epidemiology of childhood-onset type 1 insulin-dependent diabetes in Europe, the EURODIAB collaborative group established in 1988 prospective geographically-defined registers of new cases diagnosed under 15 years of age. This report is based on 16 362 cases registered during the period 1989–94 by 44 centres representing most European countries and Israel and covering a population of about 28 million children.

Methods

Multiple sources of ascertainment were used in most centres to validate the completeness of registration by the capture-recapture method. Trends in incidence during the period were analysed by Poisson regression, the data from centres within each country being pooled.

Findings

The standardised average annual incidence rate during the period 1989–94 ranged from 3.2 cases per 100 000 per year in the Former Yugoslav Republic of Macedonia to 40.2 cases per 100 000 per year in two regions of Finland. By pooling over centres, the annual rate of increase in incidence was 3.4% (95% Cl 2.5–4.4%), but in some central European countries it was more rapid than this. Pooled over centres and sexes, the rates of increase were 6.3% (4.1–8.5%) for children aged 0–4 years, 3.1% (1.5–4.8%) for 5–9 years, and 2.4% (1.0–3.8%) for 10–14 years.

Interpretation

The results confirm a very wide range of incidence rates within Europe and show that the increase in incidence during the period varied from country to country. The rapid rate of increase in children aged under 5 years is of particular concern.

Introduction

Type 1 insulin-dependent diabetes is generally believed to be due to an immune destruction of pancreatic β cells in genetically susceptible individuals exposed to environmental risk factors. There has been a rapid increase in the incidence of type 1 diabetes in many European countries in the past few decades.1, 2, 3, 4 This increase, in conjunction with the lack of complete concordance in monozygotic twin pairs,5, 6, 7 points to the importance of environmental factors.

Useful clues about these environmental factors may be obtained by studying geographical variation in incidence in relation to the characteristics of different countries. Fundamental to such analyses are high-quality incidence data uniformly collected via a standard protocol from population-based registers. We have previously reported data for the years 1989–90 from 26 registries in the EURODIAB Study Group, and have established that there is a wide range of incidence rates within Europe.8 The network has since expanded to include 44 registries, with representation from most European countries and Israel. Incidence data for the 6-year period 1989–94 are presented in this paper.

Differences in the trends in incidence between countries or age-groups may also provide important clues about environmental factors. Some recent reports suggest a higher rate of increase among children under 5 years of age compared with the age groups 5–9 and 10–14 years,9, 10 which suggests that the environmental factors responsible for the increase may operate early in life. We address this issue in our analysis of the EURODIAB registry data.

Section snippets

Methods

The establishment of the EURODIAB collaborative group of childhood diabetes registers has been described in detail.8, 11 Briefly, in 1988, prospective registers of new cases of insulin-dependent type 1 diabetes mellitus among children aged under 15 years were established in 26 geographically-defined centres in Europe and Israel. Type 1 diabetes was defined on the basis of a clinical diagnosis of idiopathic diabetes made by a physician. Cases secondary to other conditions (having cystic fibrosis

Average annual incidence rates

Table 1 summarises registration for each centre—the number of cases, the standardised average annual incidence rate, and the estimated completeness of ascertainment. Among the 40 centres validating ascertainment, all but four achieved completeness of ascertainment of over 95%. The estimates for some centres exclude the early years of the study period, but estimates for the years 1989–90 have already been published.8 The standardised rates varied from 3.2 cases per 100 000 per year in the Former

Discussion

This multicentre study shows a greater than 10-fold range in incidence rate of childhood diabetes in Europe. Such variation seems unlikely to be explained by genetic differences, since Europeans (except for some outlying populations) are more homogeneous compared with the indigenous populations of other continents.13 Although the independence of primary and secondary sources of ascertainment cannot easily be verified our assessment of completeness is more thorough than in most previous studies

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