Obesity in Youth with Type 1 Diabetes in Germany, Austria, and the

United States
Stephanie N. DuBose, MPH1, Julia M. Hermann, MS2, William V. Tamborlane, MD3, Roy W. Beck, MD, PhD1, Axel Dost, MD4,
Linda A. DiMeglio, MD, MPH5, Karl Otfried Schwab, MD6, Reinhard W. Holl, MD2, Sabine E. Hofer, MD7,*,
and David M. Maahs, MD, PhD8,*, on behalf of the
Type 1 Diabetes Exchange Clinic Network and Diabetes Prospective Follow-up Registry†

Objective To examine the current extent of the obesity problem in 2 large pediatric clinical registries in the US and
Europe and to examine the hypotheses that increased body mass index (BMI) z-scores (BMIz) are associated with
greater hemoglobin A1c (HbA1c) and increased frequency of severe hypoglycemia in youth with type 1 diabetes (T1D).
Study design International (World Health Organization) and national (Centers for Disease Control and Prevention/
German Health Interview and Examination Survey for Children and Adolescents) BMI references were used to
calculate BMIz in participants (age 2-<18 years and $1 year duration of T1D) enrolled in the T1D Exchange
(n = 11 435) and the Diabetes Prospective Follow-up (n = 21 501). Associations between BMIz and HbA1c and se-
vere hypoglycemia were assessed.
Results Participants in both registries had median BMI values that were greater than international and their
respective national reference values. BMIz was significantly greater in the T1D Exchange vs the Diabetes Prospec-
tive Follow-up (P < .001). After stratification by age-group, no differences in BMI between registries existed for chil-
dren 2-5 years, but differences were confirmed for 6- to 9-, 10- to 13-, and 14- to 17-year age groups (all P < .001).
Greater BMIz were significantly related to greater HbA1c levels and more frequent occurrence of severe hypogly-
cemia across the registries, although these associations may not be clinically relevant.
Conclusions Excessive weight is a common problem in children with T1D in Germany and Austria and, espe-
cially, in the US. Our data suggest that obesity contributes to the challenges in achieving optimal glycemic control
in children and adolescents with T1D. (J Pediatr 2015;-:---).

H
istorically, obesity was rare in people with type 1 diabetes (T1D) because of the ineffective methods to achieve
glucose control. In 1993, the Diabetes Control and Complications Trial (DCCT) established the importance of inten-
sive diabetes management in adults and adolescents with T1D,1,2 but this therapy paradigm was accompanied by
increased weight gain in intensively treated participants.3,4 In the follow-up to the DCCT, the Epidemiology of Diabetes In-
terventions and Complications (EDIC) study, increased body mass index (BMI) was associated with increased cardiovascular
disease risk factors and markers of atherosclerosis (coronary artery calcification and carotid intima media thickness).5 In a
similar time period as the transition to intensive therapy for patients with T1D, Western countries have experienced an
epidemic of pediatric obesity,6 and youth with T1D are unlikely to have been spared from these effects. Increased BMI
in youth with T1D has been reported in clinic-based and national cohorts7-
14
and is associated with a more atherogenic cardiovascular disease risk pro-
file.11,13,15 Increased BMI increases insulin resistance; however, the association
1
From the Jaeb Center for Health Research, Tampa, FL;
of BMI, insulin resistance, hemoglobin A1c (HbA1c), severe hypoglycemia, and 2
Institute for Epidemiology and Medical Biometry,
3
daily insulin doses is complex. International data comparing BMI in youth ZIBMT, University of Ulm, Ulm, Germany; Yale
4
University, New Haven, CT; Department of Pediatrics,
with T1D and the association of BMI with glucose control across countries University Children’s Hospital Jena, Jena, Germany;
5
Indiana University School of Medicine, Indianapolis, IN;
do not exist. 6
University Children’s Hospital Freiburg, Freiburg,
7
Germany; Department of Pediatrics, Medical University
The T1D Exchange (T1DX) registry in the US and the Diabetes Prospective of Innsbruck, Innsbruck, Austria; and Barbara Davis 8

Follow-up (DPV) registry in Germany and Austria are 2 large consortia of Center for Childhood Diabetes, Aurora, CO
*Contributed equally.

†List of members of T1D Exchange Clinic Network and

BMI Body mass index HbA1c Hemoglobin A1c Diabetes Prospective Follow-up Registry study group
members is available at www.jpeds.com (Appendix).
BMIz BMI z-scores IRB Institutional review board
Supported by the Leona M. and Harry B. Helmsley
CDC Centers for Disease Control and KiGGS German Health Interview and Charitable Trust, and the German Federal Ministry of
Prevention Examination Survey for Children Education and Research Competence Net Diabetes
Mellitus (which is integrated into the German Center for
DCCT Diabetes Control and Complications and Adolescents Diabetes Research as of January 2015; FKZ 01GI1106),
Trial T1D Type 1 diabetes and the European Foundation for the Study of Diabetes.
The authors declare no conflicts of interest.
DPV Diabetes Prospective Follow-up T1DX T1D Exchange
EDIC Epidemiology of Diabetes WHO World Health Organization 0022-3476/$ - see front matter. Copyright ª 2015 Elsevier Inc. All
Interventions and Complications rights reserved.
http://dx.doi.org/10.1016/j.jpeds.2015.05.046

1
THE JOURNAL OF PEDIATRICS  www.jpeds.com
pediatric diabetes centers that were established with an objec-
tive of improving the care of children with T1D through
sharing of best practices and the collection of clinical
outcome data in large numbers of patients. In this collabora-
tive study, both T1DX and DPV used queries of their data-
bases to describe the prevalence of increased BMI z-scores
(BMIz) in youth with T1D who were 2 to <18 years of age
and had $1 year duration of diabetes. In addition, we tested
the hypothesis that increased BMIz was associated with
poorer metabolic control (greater HbA1c and increased fre-
quency of severe hypoglycemia) in both registries.
Methods
The T1DX Clinic Network includes 70 US-based pediatric and
adult endocrinology practices in 34 states. A registry of more
than 26 000 individuals with T1D commenced enrollment in
September 2010.16 Each clinic received approval from a local
institutional review board (IRB). Informed consent was ob-
tained according to IRB requirements. Data were collected
for the registry’s central database from the participant’s med-
ical record and by having the participant or parent complete a
comprehensive questionnaire, as previously described.16
The DPV registry is a prospective longitudinal, standard-
ized, and computer-based documentation system for patients
with all types of diabetes. Currently, more than 90% of
German and more than 70% of Austrian children with dia-
betes are included in the registry. Data are documented
locally by the 391 participating centers in an electronic health
record. Twice yearly, anonymized data are exported and
transmitted for central analyses. Missing and inconsistent
data are reported back to the centers for correction. Data
collection is approved by the ethics committee at Ulm Uni-
versity and by the IRBs at the participating centers.17,18
This report includes data on 32 936 children 2 to <18 years
of age with a T1D duration of at least 1 year and available
height and weight data; 11 435 participants enrolled in the
T1DX from September 2010 to August 2012 at 59 sites who
care for pediatric patients and 21 501 patients from 262 sites
in the DPV who had at least one office visit in either 2011 or
2012. All eligible T1DX and DPV participants were included
in this analysis. Median HbA1c over the year before the reg-
istry assessment, calculated from all available for the previous
year but excluding any values obtained within 3 months of
diagnosis, was used to represent HbA1c in this analysis. For
both the T1DX and DPV, all HbA1c values were DCCT-stan-
dardized.19,20 Severe hypoglycemia was defined by both reg-
istries as a hypoglycemic event in which seizure or loss of
consciousness occurred. The numbers given correspond to
the percent of patients with at least one severe hypoglycemia
event during the previous year. BMI percentiles and z-scores
were calculated from height and weight and adjusted for age
and sex, using both international (World Health Organiza-
tion [WHO]) and national (Centers for Disease Control
and Prevention [CDC] for T1DX and German Health Inter-
view and Examination Survey for Children and Adolescents
2 DuBose et al
Vol. -, No. -
[KiGGS] for DPV) reference tables.21-26 Extreme BMIz
< 3 and >+3 were truncated. In the WHO and the national
reference populations, a BMIz of 0 represents the mean value
of the population; values above the mean are positive and
values below the mean are negative. BMI categories were
defined using BMIz according to pediatric standards for
each source.22,26,27 Underweight individuals were excluded
from analyses that assessed glucose control, because under-
weight status in adolescents with T1D often is caused by
eating disorders, and psychiatric disorders have a strong
impact on HbA1c and severe hypoglycemia.
In the T1DX, data were obtained through a combination
of clinic and participant-report. Method of insulin delivery
(pump/injection), height, weight, HbA1c values, and fre-
quency of severe hypoglycemia were extracted retrospectively
from the medical chart. Rates of self-monitoring of blood
glucose and insulin dose were obtained from participant
report via completion of a questionnaire. Conversely, all
data from the DPV were extracted from the electronic med-
ical record, as documented by members of the local diabetes
team during routine patient care. All data from T1DX were
obtained at the enrollment visit and data from DPV were
collected from office visits that occurred during 2011 or
2012 (a similar time period as T1DX enrollment).
Statistical Analyses
To compare BMI between the 2 registries, a mixed model was
used with BMIz calculated from the WHO reference tables.
The model accounted for site differences and adjusted for
T1D duration, sex, age group, and the interaction between
registry and age group. Mixed models also were used to assess
whether BMI was associated with HbA1c or severe hypogly-
cemia, overall (WHO reference and adjusted for T1D dura-
tion, sex, age group, registry, and random site effect) and
within each registry (CDC or KiGGS reference and adjusted
for T1D duration, sex, age group, and random site effect).
Tests of significance were reported from models using
BMIz as a continuous variable; adjusted means were reported
from models using BMI as a categorical variable. Under-
weight individuals (based on corresponding cutoffs for un-
derweight categorization) were excluded from these
analyses. Although BMIz adjusts an individual BMI value
for age and sex of the reference population, these factors
were not fully adjusted for in our population and thus were
included in the statistical models to account for residual con-
founding that could be present in this analysis cohort. All sta-
tistical analyses were performed using SAS 9.4 (SAS Institute,
Cary, North Carolina). All P values are 2-sided. A priori, in
view of the large sample size and multiple comparisons,
only P values <.01 were considered statistically significant.
Results
Participant characteristics of children in the T1DX and DPV
registries can be found in Table I. Children in both registries
were similar with respect to sex, total daily insulin dose per
- 2015 ORIGINAL ARTICLES

Table I. Participant characteristics of T1DX and DPV

Overall, N = 32 936 T1DX, n = 11 435 DPV, n = 21 501
Male, % 52% 51% 52%
Age (years), median (25th, 75th percentile) 12.6 (9.5, 15.1) 12.8 (9.9, 15.3) 12.4 (9.2, 15.0)
T1D duration (years), median (25th, 75th percentile) 4.0 (1.9, 7.0) 4.0 (2.0, 7.0) 3.6 (1.4, 6.7)
BMIz (WHO) (years), median (25th, 75th percentile) 0.70 (0.07, 1.36) 0.78 (0.16, 1.47) 0.65 (0.02, 1.30)
BMIz (CDC and KiGGS) (years), median (25th, 75th percentile) N/A 0.74 (0.18, 1.30) 0.33 ( 0.24, 0.89)
Insulin pump use, % 49% 56% 45%
HbA1c, %, mean  SD, 8.1  1.4% 8.5  1.4% 7.9  1.4%
mmol/mol 65.1  15.2 68.9  15.1 63.1  14.9
Frequency of self-monitoring of blood glucose, median (25th, 75th percentile) 6 (5, 8) 6 (4, 7) 6 (5, 8)
Total daily insulin dose (units/kg body weight), median (25th, 75th percentile) 0.82 (0.65, 1.02) 0.82 (0.64, 1.03) 0.82 (0.66, 1.02)
Percent prandial insulin, median (25th, 75th percentile) 57% (48%, 65%) 56% (47%, 65%) 57% (48%, 65%)
$1 Severe hypoglycemic event* in past 12 months, % 2.5% 2.4% 2.5%

N/A, not applicable.

Data shown are unadjusted percentages, mean  SD, or median and IQR (25th, 75th percentile).
*Resulting in seizure/loss of consciousness.

kilogram, and frequency of severe hypoglycemia, but a
greater percentage of children in T1DX were using an
insulin pump (56% vs 45%). Children in T1DX also had a
greater mean HbA1c level (8.5% vs 7.9%) than those in DPV.
Children in both registries had an increased BMI
compared with international reference values (unadjusted
median BMIz 0.78 for T1DX and 0.65 for DPV) and their
respective national reference values (unadjusted median
BMIz 0.74 for T1DX and 0.33 for DPV) (Table I). Overall,
by the WHO, 12% (n = 3977) of children in both registries
combined were considered obese, 24% (n = 7825)
overweight, 64% (n = 20 942) normal weight, and <1%
(n = 192) underweight (Table II).
When comparing BMIz between the registries using WHO
reference tables, BMI was significantly greater in T1DX than
in DPV (P < .001; Table I). Differences in least squares mean
BMIz by age group are shown in Figure 1, adjusted for T1D
duration, sex, age group, and the interaction between registry
and age group. No significant difference in BMIz was found
in the 2- to <6-year-old group (P = .10), but children in
T1DX had greater BMIz than DPV children in all other age
groups (P < .001 for all).
Overall, greater BMIz (WHO) was associated with greater
HbA1c, adjusted for T1D duration, sex, age group, and registry
(P < .001; Figure 2, A). When we looked at the registry-specific
BMIz (CDC or KiGGS), greater BMI also was associated with

Table II. BMI categories* overall and by registry, according to each reference table
Overall, N = 32 936 T1DX, n = 11 435 DPV, n = 21 501
WHO reference
Underweight, n (%) 192 (<1%) 61 (<1%) 131 (<1%)
Normal weight, n (%) 20 942 (64%) 6844 (60%) 14 098 (66%)
Overweight, n (%) 7825 (24%) 2791 (24%) 5034 (23%)
Obese, n (%) 3977 (12%) 1739 (15%) 2238 (10%)
CDC reference
Underweight, n (%) 317 (1%) 86 (<1%) 231 (1%)
Normal weight, n (%) 22 629 (69%) 7228 (63%) 15 401 (72%)
Overweight, n (%) 6599 (20%) 2547 (22%) 4052 (19%)
Obese, n (%) 3391 (10%) 1574 (14%) 1817 (8%)
KiGGS reference
Underweight, n (%) 988 (3%) 311 (3%) 677 (3%)
Normal weight, n (%) 27 178 (83%) 9142 (80%) 18 036 (84%)
Overweight, n (%) 3507 (11%) 1392 (12%) 2115 (10%)
Obese, n (%) 1263 (4%) 590 (5%) 673 (3%)
*BMI categories defined as follows:

WHO: Underweight: Z-score < 1.881 (<3rd percentile).

Normal weight: 1.881 # Z-score # 1.036 (3rd-85th percentile).
Overweight: 1.036 < Z-score # 1.881 (>85th-97th percentile).
Obesity: Z-score > 1.881 (>97th percentile).
CDC: Underweight: Z-score < 1.645 (<5th percentile).
Normal weight: 1.645 # Z-score < 1.036 (5th-<85th percentile).
Overweight: 1.036 # Z-score < 1.645 (85th-<95th percentile).
Obesity: Z-score $ 1.645 ($95th percentile).
KiGGS: Underweight: Z-score < 1.282 (<10th percentile).
Normal weight: 1.282 # Z-score # 1.282 (10th-90th percentile).
Overweight: 1.282 < Z-score # 1.881 (>90th-97th percentile).
Obesity: Z-score > 1.881 (>97th percentile).

Obesity in Youth with Type 1 Diabetes in Germany, Austria, and the United States 3
THE JOURNAL OF PEDIATRICS  www.jpeds.com
Figure 1. Mean BMIz in T1DX (black bars) vs DPV (white bars)
by age. Error bars show 95% CI. BMIz of 0 is equivalent to the
mean value of the WHO reference population.
greater HbA1c within each registry (P < .001 for both, adjusted
for T1D duration, sex, and age group). Similarly, greater BMIz
(WHO) was associated with increased frequency of at least one
severe hypoglycemia event in the past year, adjusted for T1D
duration, sex, age group, and registry (P < .001, Figure 2, B).
However, when we examined registry-specific BMIz (CDC or
KiGGS), greater BMIz was significantly associated with severe
hypoglycemia within DPV (P = .004) but only marginally
within T1DX (P = .05).
Discussion
In contrast to historic experience, our data demonstrate that
youth with T1D have increased BMIz compared with the in-
ternational norms developed by the WHO and the respective
national norms for youth in the US and in Germany/Austria.
These data extend the findings of recent reports from the
DCCT/EDIC study to highlight the consistency of increased
BMI in Western countries in which intensive management
of T1D is standard of care.5 Of particular concern, our
cross-sectional data also demonstrate that greater weight in
youth with T1D may be inversely associated with achieving
the goals of intensive treatment, because increased BMIz
Figure 2. A, Mean HbA1c by BMI category. B, Percent with $1 severe hypoglycemia event (seizure/loss of consciousness) in
the past year. Error bars show 95% CI. Underweight individuals were excluded.
4 DuBose et al
Vol. -, No. -
was associated with greater HbA1c in both registries. This
relationship between HbA1c and BMI was not found by
Redondo et al,28 but those authors assessed a cohort of
newly diagnosed patients with T1D, whereas our report
was limited to participants with at least 1 year T1D duration
(mean duration 4.8  3.5 years). Increased BMIz was
associated with a greater risk of severe hypoglycemia in the
DPV cohort, but an association between BMI and severe
hypoglycemia was not found in the T1DX registry. These
differences in HbA1c and severe hypoglycemia between
BMI groups, however, were small and may not be
clinically relevant. Further, the cause-effect relationship of
the association between severe hypoglycemia and BMI is
uncertain.
Compared with international WHO BMI standards, youth
in the T1DX were more obese than youth in the DPV, except
in the 2- to <6-year old group. It is likely that the differences
in lifestyle and nutrition that contribute to increased rates of
obesity in children without diabetes in the US compared with
Europe also contribute to the different prevalence of over-
weight and obesity in youth with T1D. Whether differences
in nutritional counseling and carbohydrate counting recom-
mendations for patients with T1D between US and Europe
also contribute to these trans-Atlantic differences in BMI re-
mains to be determined.
Healthy weight is an important component of care for
youth with T1D but how to achieve this goal while maintain-
ing glucose and HbA1c levels as close to normal as possible
with intensive insulin therapy has not been established.
Greater attention to avoidance of excessive caloric intake
and better food choices early in the treatment of T1D,
encouragement of regular physical activity, reduced screen
time, and the elimination of unnecessary snacks are among
the factors that could play roles in achieving and maintaining
healthy weights in this population. Given the challenges of
preventing and treating obesity in youth with T1D who
receive intensive treatment, adjunctive therapies to insulin,
like metformin, glucagon-like peptide 1 agonists and
sodium-glucose cotransporter-2 inhibitors that have been
shown to lower HbA1c and body weight in adults with
- 2015
T2D, could be important additions to current options for
care in youth with T1D.29,30
Recent studies indicate that the benefits of limiting exces-
sive weight gain in children and adolescents with T1D extend
beyond improvements in body image and psychosocial well-
being to include a reduction in insulin resistance and cardio-
vascular risk factors. Insulin resistance is increased in youth
with T1D compared with youth without diabetes of similar
age, sex, and BMIz, especially in children who fail to achieve
target HbA1c levels.31,32 As insulin resistance increases so do
cardiovascular disease risk factors.33 Similarly, data from the
DCCT/EDIC study in adults with T1D indicate that excessive
weight gain is associated with insulin resistance, hyperten-
sion, dyslipidemia, central obesity, and more extensive
atherosclerosis (as assessed by coronary artery calcium and
carotid intima media thickness).5 Further studies on the
magnitude of the association of obesity with vascular disease
risk factors in youth with T1D are needed.34
As with any comparison between 2 large clinical registries,
differences in the data collection methods are a potential lim-
itation. Severe hypoglycemia events were clinic-reported for
both registries; however, the type of data extraction—manual
for T1DX and automatic for DPV—may have led to under-
reporting of events within T1DX. For this report, although
there may be some differences in the collection of height
and weight measurements across the clinics, it is highly un-
likely that all errors are in the same direction, thus reducing
the possibility of systematic bias. In addition, standardized
measurements of height and weight via the use of calibrated
devices and trained personnel are standard in pediatric endo-
crine/diabetes clinics taking care of children with T1D.
Regarding possible differences in HbA1c measurements, we
have reported previously that in both registries HbA1c
methods are DCCT standardized and 3 different sensitivity
analyses did not change results in a comparison focused on
between-registry HbA1c differences in children <6 years of
age.19 It is possible, however, that assay variation may mask
relationships with HbA1c. As noted previously, the very large
sample sizes of the 2 registries may result in associations that
are statistically significant but not clinically important.
It also should be noted that the reference tables used to
calculate BMIz are somewhat outdated, particularly CDC
data, which was collected before 2000. The KiGGS reference
tables are also somewhat dated, because the normative data
were collected from 2003 to 2006. However, for the aim of
comparing BMI between the registries, the potentially
outdated reference tables are not a limitation. Finally, the
DPV registry is a population-based sample that included
70%-90% of all potential patients in Germany and Austria
whereas the T1DX registry is a sample of patients from
participating pediatric diabetes centers staffed by pediatric
endocrinologists and only includes the children of families
who volunteered to participate. The T1DX registry partici-
pants represent about one-fourth of the patients with T1D
who are followed at a T1D Exchange Clinic Network site16;
thus, the T1DX data may not be representative of all youth
with T1D in the US. Although it is difficult to compare socio-
Obesity in Youth with Type 1 Diabetes in Germany, Austria, and the United States
ORIGINAL ARTICLES
economic status between the 2 registries, the proportion of
minorities was similar for each group—21% of T1DX partic-
ipants were not non-Hispanic white and 20% of DPV partic-
ipants had a history of migration (defined as at least one
parent born outside of Germany or Austria).
In conclusion, the obesity epidemic has not spared youth
with T1D, because youth in both the T1DX and DPV regis-
tries have increased BMIz, with youth in the T1DX being
more obese than those in DPV. Increased obesity in youth
with T1D has negative implications for glucose control,
vascular disease risk factors, and future health outcomes.
Data from large registries such as the T1DX and the DPV
allow for a comparison of diabetes care and the opportunity
to focus clinical care to improve outcomes for people with
T1D. An important future direction is to further delve into
how practices differ between countries in an effort to discover
which diabetes care strategies are most effective for youth
with T1D. n
Submitted for publication Nov 19, 2014; last revision received Apr 28, 2015;
accepted May 22, 2015.
Reprint requests: Stephanie N. DuBose, MPH, Jaeb Center for Health
Research, 15310 Amberly Drive, Suite 350, Tampa, FL 33647. E-mail:
T1DStats@jaeb.org
References
1. The Diabetes Control and Complications Trial Research Group. The ef-
fect of intensive treatment of diabetes on the development and progres-
sion of long-term complications in insulin-dependent diabetes mellitus.
N Engl J Med 1993;329:977-86.
2. The Diabetes Control and Complications Trial Research Group. Effect of
intensive diabetes treatment on the development and progression of
long-term complications in adolescents with insulin-dependent diabetes
mellitus: Diabetes Control and Complications Trial. J Pediatr 1994;125:
177-88.
3. The Diabetes Control and Complications Trial Research Group. Weight
gain associated with intensive therapy in the diabetes control and com-
plications trial. Diabetes Care 1988;11:567-73.
4. Purnell JQ, Dev RK, Steffes MW, Cleary PA, Palmer JP, Hirsch IB, et al.
Relationship of family history of type 2 diabetes, hypoglycemia, and au-
toantibodies to weight gain and lipids with intensive and conventional
therapy in the Diabetes Control and Complications Trial. Diabetes
2003;52:2623-9.
5. Purnell JQ, Zinman B, Brunzell JD. The effect of excess weight gain with
intensive diabetes mellitus treatment on cardiovascular disease risk fac-
tors and atherosclerosis in type 1 diabetes mellitus: results from the Dia-
betes Control and Complications Trial/Epidemiology of Diabetes
Interventions and Complications Study (DCCT/EDIC) study. Circula-
tion 2013;127:180-7.
6. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and
adult obesity in the United States, 2011-2012. JAMA 2014;311:806-14.
7. Frohlich-Reiterer EE, Rosenbauer J, Bechtold-Dalla Pozza S, Hofer SE,
Schober E, Holl RW. Predictors of increasing BMI during the course
of diabetes in children and adolescents with type 1 diabetes: data from
the German/Austrian DPV multicentre survey. Arch Dis Child 2014;
99:738-43.
8. Kapellen TM, Gausche R, Dost A, Wiegand S, Flechtner-Mors M,
Keller E, et al. Children and adolescents with type 1 diabetes in Germany
are more overweight than healthy controls: results comparing DPV data-
base and CrescNet database. J Pediatr Endocrinol Metab 2014;27:209-14.
9. Knerr I, Wolf J, Reinehr T, Stachow R, Grabert M, Schober E, et al. The
’accelerator hypothesis’: relationship between weight, height, body mass
5
THE JOURNAL OF PEDIATRICS  www.jpeds.com
index and age at diagnosis in a large cohort of 9,248 German and Aus-
trian children with type 1 diabetes mellitus. Diabetologia 2005;48:
2501-4.
10. Liu LL, Lawrence JM, Davis C, Liese AD, Pettitt DJ, Pihoker C, et al.
Prevalence of overweight and obesity in youth with diabetes in USA:
the SEARCH for Diabetes in Youth study. Pediatr Diabetes 2010;11:4-11.
11. Meissner T, Wolf J, Kersting M, Frohlich-Reiterer E, Flechtner-Mors M,
Salgin B, et al. Carbohydrate intake in relation to BMI, HbA1c and lipid
profile in children and adolescents with type 1 diabetes. Clin Nutr 2014;
33:75-8.
12. Schwab KO, Doerfer J, Hecker W, Grulich-Henn J, Wiemann D,
Kordonouri O, et al. Spectrum and prevalence of atherogenic risk factors
in 27,358 children, adolescents, and young adults with type 1 diabetes:
cross-sectional data from the German diabetes documentation and qual-
ity management system (DPV). Diabetes Care 2006;29:218-25.
13. Schwab KO, Doerfer J, Naeke A, Rohrer T, Wiemann D, Marg W, et al.
Influence of food intake, age, gender, HbA1c, and BMI levels on plasma
cholesterol in 29,979 children and adolescents with type 1 diabetes—
reference data from the German diabetes documentation and quality
management system (DPV). Pediatr Diabetes 2009;10:184-92.
14. Wood JR, Miller KM, Maahs DM, Beck RW, Dimeglio LA, Libman IM,
et al. Most youth with type 1 diabetes in the T1D Exchange Clinic Reg-
istry do not meet American Diabetes Association or International Soci-
ety for Pediatric and Adolescent Diabetes clinical guidelines. Diabetes
Care 2013;36:2035-7.
15. Mangge H, Schauenstein K, Stroedter L, Griesl A, Maerz W,
Borkenstein M. Low grade inflammation in juvenile obesity and type 1
diabetes associated with early signs of atherosclerosis. Exp Clin Endocri-
nol Diabetes 2004;112:378-82.
16. Beck RW, Tamborlane WV, Bergenstal RM, Miller KM, DuBose SN,
Hall CA. The T1D Exchange Clinic Registry. J Clin Endocrinol Metab
2012;97:4383-9.
17. Gerstl EM, Rabl W, Rosenbauer J, Grobe H, Hofer SE, Krause U, et al.
Metabolic control as reflected by HbA1c in children, adolescents and
young adults with type-1 diabetes mellitus: combined longitudinal anal-
ysis including 27,035 patients from 207 centers in Germany and Austria
during the last decade. Eur J Pediatr 2008;167:447-53.
18. Grabert M, Schweiggert F, Holl RW. A framework for diabetes
documentation and quality management in Germany: 10 years of
experience with DPV. Comput Methods Programs Biomed 2002;69:
115-21.
19. Maahs DM, Hermann JM, DuBose SN, Miller KM, Heidtmann B,
DiMeglio LA, et al. Contrasting the clinical care and outcomes of
2,622 children with type 1 diabetes less than 6 years of age in the United
States T1D Exchange and German/Austrian DPV registries. Diabetologia
2014;57:1578-85.
20. Rosenbauer J, Dost A, Karges B, Hungele A, Stahl A, Bachle C, et al.
Improved metabolic control in children and adolescents with type 1 dia-
betes: a trend analysis using prospective multicenter data from Germany
and Austria. Diabetes Care 2012;35:80-6.
6 DuBose et al
Vol. -, No. -
21. Butte NF, Garza C, de Onis M. Evaluation of the feasibility of interna-
tional growth standards for school-aged children and adolescents.
J Nutr 2007;137:153-7.
22. Kromeyer-Hauschild K, Wabitsch M, Kunze D, Geller F, Greib HC,
Hesse V, et al. Perzentile f€ ur den Body-Mass-Indes f€ ur das Kindes-
und Jugendalter unter Heranziehung verschiedener deutscher Stichpro-
ben. Monatsschrift Kinderheilkunde 2001;149:807-18.
23. Kuczmarski RJ, Ogden CL, Guo SS, Grummer-Strawn LM, Flegal KM,
Mei Z, et al. 2000 CDC growth charts for the United States: nethods
and development. Vital Health Stat 11 2002;8:1-190.
24. Kurth BM, Schaffrath Rosario A. The prevalence of overweight and
obese children and adolescents living in Germany. Results of the German
Health Interview and Examination Survey for Children and Adolescents
(KiGGS) [in German]. Bundesgesundheitsblatt Gesundheitsforschung
Gesundheitsschutz 2007;50:736-43.
25. World Health Organization. Growth reference data for 5-19 years,
http://www.who.int/growthref/en/; 2013. Accessed May 29, 2015.
26. World Health Organization. Child growth standards- BMI for age,
http://www.who.int/childgrowth/standards/bmi_for_age/en/; 2014. Ac-
cessed May 29, 2015.
27. Centers for Disease Control and Prevention NCfHS. CDC growth charts:
United States, http://www.cdc.gov/growthcharts/charts.htm; 2000. Ac-
cessed May 29, 2015.
28. Redondo MJ, Connor CG, Ruedy KJ, Beck RW, Kollman C, Wood JR,
et al. Pediatric Diabetes Consortium Type 1 Diabetes New Onset
(NeOn) Study: factors associated with HbA1c levels one year after diag-
nosis. Pediatr Diabetes 2014;15:294-302.
29. Konrad K, Datz N, Engelsberger I, Grulich-Henn J, Hoertenhuber T,
Knauth B, et al. Current use of metformin in addition to insulin in
pediatric patients with type 1 diabetes mellitus: an analysis based on a
large diabetes registry in Germany and Austria. Pediatr Diabetes 2014
[Epub ahead of print] http://dx.doi.org/10.1111/pedi.12203.
30. Reinehr T, Holl RW, Roth CL, Wiesel T, Stachow R, Wabitsch M, et al.
Insulin resistance in children and adolescents with type 1 diabetes mel-
litus: relation to obesity. Pediatr Diabetes 2005;6:5-12.
31. Amiel SA, Sherwin RS, Simonson DC, Lauritano AA, Tamborlane WV.
Impaired insulin action in puberty. A contributing factor to poor glyce-
mic control in adolescents with diabetes. N Engl J Med 1986;315:215-9.
32. Nadeau KJ, Regensteiner JG, Bauer TA, Brown MS, Dorosz JL, Hull A,
et al. Insulin resistance in adolescents with type 1 diabetes and its rela-
tionship to cardiovascular function. J Clin Endocrinol Metab 2010;95:
513-21.
33. Specht BJ, Wadwa RP, Snell-Bergeon JK, Nadeau KJ, Bishop FK,
Maahs DM. Estimated insulin sensitivity and cardiovascular disease
risk factors in adolescents with and without type 1 diabetes. J Pediatr
2013;162:297-301.
34. Maahs DM, Daniels SR, de Ferranti SD, Dichek HL, Flynn J,
Goldstein BI, et al. Cardiovascular disease risk factors in youth with
diabetes mellitus: a scientific statement from the American Heart Asso-
ciation. Circulation 2014;130:1532-58.
- 2015
Appendix
Additional members of T1DX include (clinic network sites
with participating principal investigators [PI], coinvestiga-
tors [I], and coordinators [C] ordered by the number of par-
ticipants recruited per site as of August 1, 2012):
Children’s Hospital of Philadelphia, Philadelphia, PA
(n = 1451): Steven Willi (PI); Terri Lipman (I); Tammy Cal-
vano (C); Olena Kucheruk (C); Pantea Minnock (C); Chau
Nguyen (C).
Barbara Davis Center for Childhood Diabetes, Aurora, CO
(n = 1440): Georgeanna Klingensmith (PI); Carolyn Banion
(I); Jennifer Barker (I); Cindy Cain (I); Peter Chase (I); Sandy
Hoops (I); Megan Kelsy (I); Georgeanna Klingensmith (I);
David Maahs (I); Cathy Mowry (I); Kristen Nadeau (I); Jen-
nifer Raymond (I); Marian Rewers (I); Arleta Rewers (I);
Robert Slover (I); Andrea Steck (I); Paul Wadwa (I); Philippe
Walravens (I); Philip Zeitler (I); Heidi Haro (C); Katherine
Manseau (C).
SUNY Upstate Medical University, Syracuse, NY
(n = 1301): Ruth Weinstock (PI); Roberto Izquierdo (I);
Umair Sheikh (I); Patricia Conboy (C); Jane Bulger (C); Su-
zan Bzdick (C).
Naomi Berrie Diabetes Center, Columbia University P&S,
New York City, NY (n = 1249): Robin Goland (PI); Rachelle
Gandica (I); Lindsay Weiner (I); Steve Cook (C); Ellen
Greenberg (C); Kevin Kohm (C); Sarah Pollack (C).
University of Michigan, Ann Arbor, MI (n = 927): Joyce
Lee (PI); Brigid Gregg (I); Meng Tan (I); Kimberly Burgh
(C); Ashley Eason (C).
University of Colorado/Denver, Barbara Davis Center for
Childhood Diabetes, Aurora, CO (n = 897): Satish Garg
(PI); Aaron Michels (I); Lisa Myers (C).
Riley Hospital for Children, Indiana University School of
Medicine, Indianapolis, IN (n = 859): Linda DiMeglio (PI);
Tamara Hannon (I); Donald Orr (I); Christy Cruz (C); Ste-
phanie Woerner (C).
Children’s Hospital Boston, Boston, MA (n = 836): Joseph
Wolfsdorf (PI); Maryanne Quinn (I); Olivia Tawa (C).
Harold Schnitzer Diabetes Health Center at Oregon
Health and Science University, Portland, OR (n = 793): An-
drew Ahmann (PI); Jessica Castle (I); Farahnaz Joarder (I);
Chris Bogan (C); Nancy Cady (C); Jennifer Cox (C); Amy
Pitts (C); Rebecca Fitch (C); Brad White (C); Bethany Wol-
lam (C).
Atlanta Diabetes Associates, Atlanta, GA (n = 742): Bruce
Bode (PI); Katie Lindmark (C); RaShonda Hosey (C).
University Pediatric Associates, Buffalo, NY (n = 673):
Kathleen Bethin (PI); Teresa Quattrin (I); Michelle
Ecker (C).
Children’s Hospital Los Angeles, Los Angeles, CA
(n = 605): Jamie Wood (PI); Lily Chao (I); Clement Cheung
(I); Lynda Fisher (I); Debra Jeandron (I); Francine Kaufman
(I); Mimi Kim (I); Brian Miyazaki (I); Roshanak Monzavi (I);
Payal Patel (I); Pisit Pitukcheewanont (I); Anna Sandstrom
(I); Marisa Cohen (C); Brian Ichihara (C); Megan Lipton (C).
Obesity in Youth with Type 1 Diabetes in Germany, Austria, and the United States
ORIGINAL ARTICLES
Helen DeVos Children’s Hospital Endocrinology and
Diabetes, Grand Rapids, MI (n = 576): Ayse Cemeroglu
(PI); Yaw Appiagyei-Dankah (I); Maala Daniel (I); Daniel
Postellon (I); Michael Racine (I); Michael Wood (I); Lora
Kleis (C).
University of Washington, Diabetes Care Center, Seattle,
WA (n = 569): Irl Hirsch (PI); Anthony DeSantis (I); DC
Dugdale (I); R Alan Failor (I); Lisa Gilliam (I); Carla Green-
baum (I); Mary Janci (I); Peggy Odegard (I); Dace Trence (I);
Brent Wisse (I); Emily Batts (C); Angela Dove (C); Deborah
Hefty (C); Dori Khakpour (C); Jani Klein (C); Kristen Kuhns
(C); Marli McCulloch-Olson (C); Christina Peterson (C);
Mary Ramey (C); Marissa St. Marie (C); Pam Thomson
(C); Christine Webber (C).
Rocky Mountain Diabetes & Osteoporosis Center, Idaho
Falls, ID (n = 557): David Liljenquist (PI); Mark Sulik (PI);
Carl Vance (PI); Tiffany Coughenour (I); Chris Brown (C);
Jean Halford (C); Andrea Prudent (C); Shanda Rigby (C);
Brandon Robison (C).
BD Diabetes Center at Goryeb Children’s Hospital, Mor-
ristown, NJ (n = 542): Harold Starkman (PI); Tymara Berry
(I); Barbara Cerame (I); Daisy Chin (I); Laurie Ebner-Lyon
(I); Frances Guevarra (I); Kristen Sabanosh (I); Lawrence Sil-
verman (I); Christine Wagner (I); Marie Fox (C).
Stanford University School of Medicine, Division of Pedi-
atric Endocrinology, Stanford, CA (n = 525): Bruce Bucking-
ham (PI); Avni Shah (I); Kimberly Caswell (C); Breanne
Harris (C).
International Diabetes Center/Park Nicollet Adult Endo-
crinology, Minneapolis, MN (n = 514): Richard Bergenstal
(PI); Amy Criego (I); Greg Damberg (I); Glenn Matfin (I);
Margaret Powers (I); David Tridgell (I); Cassie Burt (C);
Beth Olson (C); LeeAnn Thomas (C).
Joslin Diabetes Center-Pediatric, Boston, MA (n = 451):
Sanjeev Mehta (PI); Michelle Katz (I); Lori Laffel (I); Joanne
Hathway (C); Roxanne Phillips (C).
Yale Pediatric Diabetes Program, New Haven, CT
(n = 398): Eda Cengiz (PI); William Tamborlane (I); Darryll
Cappiello (C); Amy Steffen (C); Melinda Zgorski (C).
University of Southern California-Community Diabetes
Initiatives, Los Angeles, CA (n = 365): Anne Peters (PI); Val-
erie Ruelas (C).
Duke University Medical Center - Pediatric Endocrine Di-
vision, Durham, NC (n = 364): Robert Benjamin (PI);
Deanna Adkins (I); Juanita Cuffee (C); Amber Spruill (C).
International Diabetes Center/Park Nicollet Pediatric
Endocrinology, Minneapolis, MN (n = 357): Richard Bergen-
stal (PI); Amy Criego (I); Greg Damberg (I); Glenn Matfin
(I); Margaret Powers (I); David Tridgell (I); Cassie Burt
(C); Beth Olson (C); LeeAnn Thomas (C).
Northwestern University, Chicago, IL (n = 352): Grazia
Aleppo-Kacmarek (PI); Teresa Derby (C); Elaine Massaro
(C); Kimberly Webb (C).
University of Virginia Health System, Charlottesville, VA
(n = 342): Christine Burt Solorzano (PI); Mark DeBoer (I);
Helen Madison (C).
6.e1
THE JOURNAL OF PEDIATRICS  www.jpeds.com
Washington University, St. Louis, MO (n = 342): Janet
McGill (PI); Lori Buechler (C); Mary Jane Clifton (C); Stacy
Hurst (C); Sarah Kissel (C); Carol Recklein (C).
University of Iowa Children’s Hospital, Iowa City, IA
(n = 327): Eva Tsalikian (PI); Michael Tansey (I); Joanne
Cabbage (C); Julie Coffey (C); Sarah Salamati (C).
Children’s Mercy Hospital, Kansas City, MO (n = 323):
Mark Clements (PI); Sripriya Raman (I); Angela Turpin
(I); Jennifer Bedard (C); Cyndy Cohoon (C); Aliza Elrod
(C); Amanda Fridlington (C); Lois Hester (C).
Henry Ford Health System, Detroit, MI (n = 316): Davida
Kruger (PI); Andreana Tassopoulos. University of Florida,
Gainesville, FL (n = 306): Desmond Schatz (PI); Michael
Clare-Salzler (I); Kenneth Cusi (I); Colleen Digman (I);
Becky Fudge (I); Mike Haller (I); Collette Meehan (I); Henry
Rohrs (I); Janet Silverstein (I); Sujata Wagh (I); Miriam Cin-
tron (C); Eleni Sheehan (C); Jamie Thomas (C).
Children’s Hospital of Orange County, Orange, CA
(n = 305): Mark Daniels (PI); Susan Clark (I); Timothy Flan-
nery (I); Nikta Forghani (I); Ajanta Naidu (I); Christina Reh
(I); Peggy Scoggin (I); Lien Trinh (I); Natalie Ayala (C); Re-
beca Quintana (C); Heather Speer (C).
Central Ohio Pediatrics Endocrinology and Diabetes Ser-
vices, Columbus, OH (n = 303): William Zipf (PI); Diane
Seiple (C).
Avera Research Institute, Sioux Falls, SD (n = 281) Julie
Kittelsrud (PI); Ashutosh Gupta (I); Vikki Peterson (C); Ash-
ley Stoker (C).
University of California, San Diego, CA (n = 280): Michael
Gottschalk (PI); Marla Hashiguchi (C); Katheryn Smith (C).
University of South Florida Diabetes Center, Tampa, FL
(n = 276): Henry Rodriguez (PI); Craig Bobik (C); Danielle
Henson (C).
Vanderbilt Eskind Diabetes Clinic, Nashville, TN
(n = 276): Jill Simmons (PI); Amy Potter (I); Margo Black
(C); Faith Brendle (C).
Case Western Reserve University, Cleveland, OH
(n = 251): Rose Gubitosi-Klug (PI); Beth Kaminski (I); Susan
Bergant (C); Wendy Campbell (C); Catherine Tasi (C).
University of Oklahoma Health Sciences Center Dept. of
Pediatric Diabetes and Endocrinology, Oklahoma City, OK
(n = 243): Kenneth Copeland (PI); Joni Beck (I); Joane
Less (C); Jill Schanuel (C); Jennifer Tolbert (C).
University of California, San Francisco Medical Center
(UCSF), San Francisco, CA (n = 237): Saleh Adi (PI); Andrea
Gerard-Gonzalez (I); Stephen Gitelman (I); Nassim Chettout
(C); Christine Torok (C).
Seattle Children’s Hospital, Seattle, WA (n = 226): Cather-
ine Pihoker (PI); Joyce Yi-Frazier (I); Susan Kearns (C).
Children’s Hospital of Pittsburgh of UPMC, Pittsburgh,
PA (n = 217): Ingrid Libman (PI); Vicky Bills (C); Ana
Diaz (C); Julie Duke (C).
University of Minnesota, Minneapolis, MN (n = 204):
Brandon Nathan (PI); Antoinette Moran (I); Melena Bellin
(I); Shannon Beasley (C); Anne Kogler (C); Janice Leschy-
shyn (C); Kara Schmid (C); Anne Street (C).
6.e2
Vol. -, No. -
Greenville Hospital System Pediatric Endocrinology,
Greenville, SC (n = 196): Bryce Nelson (PI); Carrie Frost
(C); Erin Reifeis (C).
Baylor College of Medicine/Texas Children’s Hospital,
Houston, TX (n = 187): Morey Haymond (PI); Fida Bacha
(I); Maria Caldas-Vasquez (I); Sara Klinepeter (I); Maria Re-
dondo (I); Rosa Berlanga (C); Teresa Falk (C); Elizabeth
Garnes (C); Janette Gonzalez (C); Cecilia Martinez (C); Ma-
riam Pontifes (C); Ronald Yulatic (C).
The Diabetes Center, PLLC, Ocean Springs, MS (n = 187):
Kathleen Arnold (PI); Traci Evans (I); Sharon Sellers (C).
University of Utah-Utah Diabetes Center, Salt Lake City,
UT (n = 181): Vandana Raman (PI); Carol Foster (I); Mary
Murray (I); Vandana Raman (I); Trina Brown (C); Hillarie
Slater (C); Karen Wheeler (C).
University of Massachusetts Medical School, Worcester,
MA (n = 179): David Harlan (PI); Mary Lee (I); John-Paul
Lock (I); Celia Hartigan (C); Lisa Hubacz (C).
University of North Carolina Diabetes Care Center,
Durham, NC (n = 179): John Buse (PI); Ali Calikoglu (I); Jo-
seph Largay (I); Laura Young (I); Helen Brown (C); Vinnie
Duncan (C); Michelle Duclos (C); Julie Tricome (C).
Sanford Research/USD, Sioux Falls, SD (n = 178): Ver-
dayne Brandenburg (PI); Julie Blehm (I); Julie Hallanger-
Johnson (I); Dawn Hanson (C); Corliss Miller (C); Jennifer
Weiss (C).
The Research Institute at Nationwide Children’s Hospital,
Columbus, OH (n = 168): Robert Hoffman (PI); Monika
Chaudhari (I); David Repaske (I); Elizabeth Gilson (C); Jesse
Haines (C).
St. Vincent Healthcare/Internal Medicine and Diabetes,
Billings, MT (n = 165): Justen Rudolph (PI); Charles
McClave (I); Doris Biersdorf (C).
Medcenter One, Bismarck, ND (n = 156): Anthony Tello
(PI); Julie Blehm (I); Donna Amundson (C); Rhonda Ward
(C).
University of Pennsylvania School of Medicine/Rode-
baugh Diabetes Center, Philadelphia, PA (n = 156): Michael
Rickels (PI); Cornelia Dalton-Bakes (C); Eileen Markman
(C); Amy Peleckis (C); Nora Rosenfeld (C).
Cincinnati Children’s Hospital Medical Center, Cincin-
nati, OH (n = 148): Lawrence Dolan (PI); Sarah Corathers
(I); Jessica Kichler (I); Holly Baugh (C); Debbie Standiford
(C).
Rockwood Research Center, PS, Spokane, WA (n = 132):
Jeanne Hassing (PI); Jennifer Jones (I); Stephen Willis (I);
Stephen Willis (I); Carol Wysham (I); Lisa Davis (C).
Johns Hopkins University Pediatric Endocrinology, Balti-
more, MD (n = 120): Scott Blackman (PI); Kimber-Lee Abel
(C); Loretta Clark (C); Andrea Jonas (C); Ellie Kagan (C).
University of Miami, Diabetes Research Institute, Miami,
FL (n = 119): Jay Sosenko (PI); Carlos Blashke (C); Della
Matheson (C).
Regional Health Clinical Research, Rapid City, SD
(n = 118): Rachel Edelen (PI); Thomas Repas (I); Denise
Baldwin (C); Trista Borgwardt (C); Christina Conroy (C);
DuBose et al
- 2015
Kelly DeGrote (C); Rod Marchiando (C); Michelle Wasson
(C).
Nemours Children’s Clinic, Jacksonville, FL (n = 116):
Larry Fox (PI); Nelly Mauras (I); Ligeia Damaso (C); Kim
Englert (C).
Cleveland Clinic Department of Endocrinology, Diabetes
and Metabolism, Cleveland, OH (n = 111): Marwan Hamaty
(PI); Laurence Kennedy (I); Michelle Schweiger (I); Pantelis
Konstantinopoulos (C); Carolyn Mawhorter (C); Amy Or-
asko (C); Denise Rose (C).
Tallahassee Memorial Diabetes Center, Tallahassee, FL
(n = 108): Larry Deeb (PI); Kim Rohrbacher (C).
Blanchard Valley Medical Associates, Findlay, OH
(n = 100): Leroy Schroeder (PI); Amanda Roark (C).
The Medical College of Wisconsin/Children’s Hospital of
WI, Milwaukee, WI (n = 99): Omar Ali (PI); Joanna Kramer
(C); Donna Whitson-Jones (C).
Vanderbilt Eskind Diabetes Clinic, Nashville, TN (n = 98):
Amy Potter (PI); Margo Black (C); Faith Brendle (C).
Kaiser Permanente, Vallejo, CA (n = 74): Heidi Gassner
(PI); Sobha Kollipara (I); Vicky Bills (C); Julie Duke (C).
St. Joseph’s Children’s Hospital, Paterson, NJ (n = 53):
Katerina Harwood (PI); Vijaya Prasad (I); Judy Brault (C).
DPV sites contributing data include:
Aachen - Uni-Kinderklinik RWTH, Aalen Kinderklinik,
Ahlen St. Franziskus Kinderklinik, Amstetten Klinikum
Mostviertel Kinderklinik, Arnsberg-H€ usten Karolinenhosp.
Kinderabteilung, Aue Helios Kinderklink, Augsburg Kind-
erklinik Zentralklinikum, Aurich Kinderklinik, Bad Aibling
Internist. Praxis, Bad Hersfeld Kinderklinik, Bad K€ osen
Kinder-Rehaklinik, Bad Mergentheim - Diabetesfachklinik,
Bad Mergentheim - Gemeinschaftspraxis DM-dorf Althau-
sen, Bad Oeynhausen Herz-und Diabeteszentrum NRW,
Bad Salzungen Kinderklinik, Bautzen Oberlausitz KK, Ber-
lin DRK-Kliniken, Berlin Endokrinologikum, Berlin
Lichtenberg - Kinderklinik, Berlin Virchow-Kinderklinik,
Bielefeld Kinderklinik Gilead, Bocholt Kinderklinik,
Bochum Universit€atskinderklinik St. Josef, Bonn
Uni-Kinderklinik, Braunschweig Kinderarztpraxis, Bremen
- Kinderklinik Nord, Bremen Prof. Hess Kinderklinik, Bre-
merhaven Kinderklinik, B€ oblingen Kinderklinik, Chemnitz
Kinderklinik, Coesfeld Kinderklinik, Darmstadt Kinderkli-
nik Prinz. Margaret, Datteln Vestische Kinderklinik,
Deggendorf Medizinische Klinik II, Delmenhorst Kinder-
klinik, Dessau Kinderklinik, Dornbirn Kinderklinik,
Dortmund Kinderklinik, Dresden Neustadt Kinderklinik,
Dresden Uni-Kinderklinik, Duisburg Kinderklinik, D€ uren-
Birkesdorf Kinderklinik, D€ usseldorf Uni-Kinderklinik,
Erfurt Kinderklinik, Erlangen Uni-Kinderklinik, Essen Eli-
sabeth Kinderklinik, Essen Uni-Kinderklinik, Esslingen
Klinik f€ur Kinder und Jugendliche, Eutin Kinderklinik,
Feldkirch Kinderklinik, Frankenthal Kinderarztpraxis,
Frankfurt Uni-Kinderklinik, Freiburg Kinder-MVZ, Frei-
burg St. Josef Kinderklinik, Freiburg Uni-Kinderklinik,
Fulda Kinderklinik, F€ urth Kinderklinik, Gaissach Fachkli-
nik der Deutschen Rentenversicherung Bayern S€ ud,
Obesity in Youth with Type 1 Diabetes in Germany, Austria, and the United States
ORIGINAL ARTICLES
Garmisch-Partenkirchen Kinderklinik, Gelnhausen Kind-
erklinik, Gelsenkirchen Kinderklinik Marienhospital, Gera
Kinderklinik, Gießen Uni-Kinderklinik, Graz Uni-
versit€ats-Kinderklinik, G€
oppingen Kinderklinik am Ei-
chert, G€ ottingen Uni-Kinderklinik, Hagen Kinderklinik,
Halle Uni-Kinderklinik, Hamburg Altonaer Kinderklinik,
Hamburg Kinderklinik Wilhelmstift, Hamburg-Nord
Kinder-MVZ, Hameln Kinderklinik, Hamm Kinderklinik,
Hanau Kinderklinik, Hannover Kinderklinik MHH, Hann-
over Kinderklinik auf der Bult, Haren Kinderarztpraxis,
Heide Kinderklinik, Heidelberg Uni-Kinderklinik, Heiden-
heim Kinderklinik, Heilbronn Kinderklinik, Herdecke
Kinderklinik, Herford Kinderarztpraxis, Herford Klinikum
Kinder & Jugendliche, Heringsdorf Inselklinik, Hildesheim
Kinderarztpraxis, Hof Kinderklinik, Homburg Uni-
Kinderklinik Saarland, Innsbruck Universit€atskinderklinik,
Itzehoe Kinderklinik, Jena Uni-Kinderklinik, Kaiserslau-
tern-Westpfalzklinikum Kinderklinik, Karlsburg Klinik
f€
ur Diabetes & Stoffwechsel, Karlsruhe St€adtische Kinder-
klinik, Kassel Klinikum Kinder- und Jugendmedizin, Kiel
St€adtische Kinderklinik, Kiel Universit€ats-Kinderklinik,
Kirchen DRK Klinikum Westerwald, Kinderklinik, Ko-
blenz Kinderklinik Kemperhof, Konstanz Kinderklinik,
Krefeld Kinderklinik, K€ oln Kinderklinik Amsterdamer-
strasse, K€ oln Uni-Kinderklinik, Landshut Kinderklink,
Lappersdorf Kinderarztpraxis, Leipzig Uni-Kinderklinik,
Leoben LKH Kinderklinik, Leverkusen Kinderklinik, Lienz
BKH P€adiatrie, Lingen Kinderklinik St. Bonifatius, Linz
Krankenhaus der Barmherzigen Schwestern Kinderklinik,
Linz Landes-Kinderklinik, Lippstadt Evangelische
Kinderklinik, Ludwigsburg Kinderklinik, Ludwigshafen
Kinderklinik St. Anna-Stift, L€ ubeck Uni-Kinderklinik,
L€udenscheid M€arkische Kliniken - Kinder & Jugendmedi-
zin, Magdeburg Uni-Kinderklinik, Mainz Uni-
Kinderklinik, Mannheim Uni-Kinderklinik, Mechernich
Kinderklinik, Memmingen Kinderklinik, Minden Kinder-
klinik, Moers Kinderklinik, Mutterstadt Kinderarztpraxis,
M€ odling Kinderklinik, M€ onchengladbach Kinderklinik
Rheydt Elisabethkrankenhaus, M€ uhldorf Gemeinschaft-
spraxis, M€ unchen 3. Orden Kinderklinik, M€unchen Kind-
erarztpraxis diabet. SPP, M€ unchen von Haunersche
Kinderklinik, M€unchen-Gauting Kinderarztzentrum,
M€ unchen-Harlaching Kinderklinik, M€ unchen-Schwabing
Kinderklinik, M€ unster St. Franziskus Kinderklinik,
M€ unster Uni-Kinderklinik, Neuburg Kinderklinik, Neu-
nkirchen Marienhausklinik Kohlhof Kinderklinik, Neuss
Lukaskrankenhaus Kinderklinik, Neuwied Kinderklinik
Elisabeth, N€ urnberg Cnopfsche Kinderklinik, N€ urnberg
Zentrum f Neugeb., Kinder & Jugendl., Oberhausen Kind-
erklinik, Oberhausen Kinderpraxis, Offenbach/Main Kind-
erklinik, Offenburg Kinderklinik, Oldenburg Kinderklinik,
Oldenburg Schwerpunktpraxis, Osnabr€ uck Christliches
Kinderhospital, Paderborn St. Vincenz Kinderklinik,
Papenburg Marienkrankenhaus Kinderklinik, Passau Kind-
erarztpraxis, Passau Kinderklinik, Pforzheim Kinderklinik,
Plauen Vogtlandklinikum, Ravensburg Kinderklink St.
6.e3
THE JOURNAL OF PEDIATRICS  www.jpeds.com Vol. -, No. -

Nikolaus, Regensburg Kinderklinik St. Hedwig, Rendsburg
Kinderklinik, Reutlingen Kinderarztpraxis, Reutlingen
Kinderklinik, Rheine Mathiasspital Kinderklinik, Rose-
nheim Kinderklinik, Rostock Uni-Kinderklinik, Roten-
burg/W€ umme Kinderklinik, R€ usselsheim Kinderklinik,
Saarbr€
ucken Kinderklinik Winterberg, Saarlouis Kinderkli-
nik, Salzburg Kinderklinik, Scheidegg Prinzregent Luit-
pold, Schw. Gm€ und Stauferklinik Kinderklinik,
Schweinfurt Kinderklinik, Schwerin Kinderklinik,
Schw€abisch Hall Diakonie Kinderklinik, Siegen Kinderkli-
nik, St. Augustin Kinderklinik, St. P€ olten Kinderklinik,
Stade Kinderklinik, Stolberg Kinderklinik, Stuttgart Olga-
hospital Kinderklinik, Suhl Kinderklinik, Sylt Rehaklinik,
Trier Kinderklinik der Borrom€aerinnen, T€ ubingen
Uni-Kinderklinik, Ulm Endokrinologikum, Ulm Uni-
Kinderklinik, Vechta Kinderklinik, Viersen Kinderkrankenhaus
St. Nikolaus, Villach Kinderklinik, Villingen-Schwenningen
Diabetesschule, Waiblingen Kinderklinik, Waldshut Kind-
erpraxis, Waldshut-Tiengen Kinderpraxis Biberbau,
Waren-M€ uritz Kinderklinik, Weingarten Kinderarztpraxis,
Wien Preyersches Kinderspital, Wien Rudolfstiftung,
Wien SMZ Ost Donauspital, Wien Uni-Kinderklinik,
Wiesbaden Horst-Schmidt-Kinderkliniken, Wiesbaden
Kinderklinik DKD, Wilhelmshaven Reinhard-Nieter-
Kinderklinik, Wittenberg Kinderklinik, Worms Kinderkli-
nik, Wuppertal Kinderklinik.

6.e4 DuBose et al