Epidemiology/Health Services/Psychosocial Research

B R I E F R E P O R T

Relationship Between BMI and Age at

Diagnosis of Type 1 Diabetes in a
Mediterranean Area in the Period of
1990 –2004
MARGA GIMÉNEZ, MD1 NURIA DE LARA, BN3 RESULTS — From 1990 to 2004, 222
EVA AGUILERA, MD, PHD2 JOANA NICOLAU, MD1 subjects (6.9%) were diagnosed between
CONXA CASTELL, MD, PHD3 IGNACIO CONGET, MD, PHD1 2 and 4.9 years of age, 638 (19.9%) be-
tween 5 and 9.9 years of age, 877 (27.4%)
between 10 and 14.9 years of age, 713

I
n 2001, Wilkin (1) postulated that type nean subjects in whom diabetes became (22.3%) between 15 and 19.9 years of
1 and type 2 diabetes are mostly the manifest between 1990 and 2004. age, and 753 patients (23.5%) between
same disorder, only distinguished by 20 and 25 years of age. The proportion of
the rate of ␤-cell loss with three different subjects in each group by age at diagnosis
accelerators participating in the process RESEARCH DESIGN AND during the period 1998 –2000 (n ⫽ 579)
(2,3). METHODS — We analyzed data on did not differ greatly from the whole co-
Since 2002, many articles have sup- 3,203 subjects (1,836 male, 2–24 years of hort: 5.9, 19.2, 28.1, 21.4, and 25.4% in
ported the “accelerator hypothesis,” age at diagnosis) with newly diagnosed each different age-group, respectively. In
showing that BMI and changes in weight type 1 diabetes included in the Catalan terms of BMI at diagnosis and age at diag-
are inversely related to age at diagnosis of Registry database for new cases of type 1 nosis, there were no differences between
type 1 diabetes (4 – 6). Recently, Knerr et diabetes between 1990 and 2004 (10). the two cohorts.
al. (7), in a large cohort of children with Data on BMI corresponded to information The patients diagnosed with type 1
type 1 diabetes, concluded that a higher obtained during the 1st week after the di- diabetes had a lower BMI than the refer-
BMI was associated with a younger age at agnosis. The patients were classified into ence population in all groups of age at
diagnosis of type 1 diabetes and that an five groups according to age at diagnosis diagnosis. These results remained un-
increased weight gain could be consid- (2– 4.9, 5–9.9, 10 –14.9, 15–19.9, and changed when data were analyzed by sex
ered a risk factor for early manifestation of 20 –25 years). BMI was compared with or in the 1998 –2000 cohort.
the disease. Dabelea et al. (8) concluded standards from a cross-sectional epidemi- For the period of 1990 –2004, we did
that increasing BMI is associated with ological study of a representative sample not observe any significant change in the
younger age at diagnosis only in subjects of Spanish population (n ⫽ 3,534, 1998 – BMI SD score of either sex regardless of
with a reduced ␤-cell function and hy- 2000, 2–24 years of age) (11). Sex- and the age at diagnosis. In the cohort 1990 –
pothesized that obesity is accelerating the age-adjusted BMI SD scores were calcu- 2004, there was a significant positive cor-
onset of type 1 diabetes at a higher stage in lated. A subgroup of 579 patients diag- relation between patient BMI SD score
the natural history of the disease, after nosed during the period 1998 –2000 was and the age at diagnosis of type 1 diabetes
substantial autoimmune destruction of also selected from the total cohort exactly
(Fig. 1.). Actually, each year increase in
the ␤-cell has occurred. However, as ex- matching the study period of the refer-
age at diagnosis increased BMI SD score
pected, other studies did not agree with ence population.
by 2%. In regard to the relationship be-
the postulate (9). Comparisons between groups of age
tween these two variables in each
Until now, the data testing the accel- at diagnosis and reference values were
age-group, a negative nonsignificant cor-
erator hypothesis comes almost exclu- performed using the Wilcoxon test. Sim-
sively from Anglo-Saxon and central ple correlations (Spearman’s) were calcu- relation was only observed in the young-
European populations. The aim of our lated between age at diagnosis and BMI est group (r ⫽ ⫺0.101). In the remaining
study was to investigate the relationship SD score, as well as a linear regression groups, the correlation between patient
between BMI and the age at onset of type analysis. A P value ⬍0.05 was considered BMI SD score and age at diagnosis was
1 diabetes in a large cohort of Mediterra- statistically significant. also positive (r ⫽ 0.251, r ⫽ 0.228, and
r ⫽ 0.141, respectively, P ⬍ 0.001; and
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● r ⫽ 0.048, P ⫽ 0.219) in each different
From the 1Institut d’Investigacions Biomèdiques August Pi i Sunyer, Hospital Clı́nic I, Universitari, Barce- age-group at diagnosis. The relationship
lona, Spain; the 2Endocrinology Unit, Hospital Germans Trias I Pujol, Badalona, Spain; 3Consell Assessor per between BMI SD score and the age at di-
a la Diabetis a Catalunya, Barcelona, Spain. agnosis did not differ when the analysis
Address correspondence and reprint requests to Dr I. Conget, Endocrinology and Diabetes Unit, Villarroel was performed by sex.
170, 08036 Barcelona, Spain. E-mail: iconget@clinic.ub.es.
Received for publication 20 December 2006 and accepted in revised form 23 February 2007. When the subgroup of subjects diag-
Published ahead of print at http://care.diabetesjournals.org on 19 March 2007. DOI: 10.2337/dc06-2578. nosed between 1998 and 2000 were con-
A table elsewhere in this issue shows conventional and Système International (SI) units and conversion sidered as a whole, a positive correlation
factors for many substances. was again found between BMI SD score
© 2007 by the American Diabetes Association.
The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby and age at diagnosis (r ⫽ 0.147, P ⬍
marked “advertisement” in accordance with 18 U.S.C. Section 1734 solely to indicate this fact. 0.001). A negative nonsignificant correla-

DIABETES CARE, VOLUME 30, NUMBER 6, JUNE 2007 1593

BMI and age at diagnosis of type 1 diabetes
Figure 1— Relationship between BMI SD score and age at diagnosis of type 1 diabetes (1990 –2004). A: Total cohort. B: Male. C: Female. SDS, SD
score.
tion was only observed in the youngest
group (r ⫽ ⫺0.174). In this cohort, when
weight loss before diagnosis (reported for
each individual subject) was considered
in the analysis, we did not observe any
change in the results.
CONCLUSIONS — Our data, col-
lected from a National registry of newly
diagnosed type 1 diabetes from a Mediter-
ranean area over a period of 15 years
(1990 –2004) indicates that BMI at diag-
nosis of the disease has not substantially
increased. In addition, we found a posi-
tive association between BMI SD score
and the age at diagnosis of type 1 diabetes.
Compared with other geographical
areas, Spain has an intermediate preva-
lence of overweight and obesity in chil-
dren and young adults (11). However,
over the past decades an increased trend
toward higher rates has been observed
(12,13). We did not observe an increase
in BMI or BMI SD score at diagnosis in any
of the age-groups evaluated. In the
present study, a higher BMI SD score at
diagnosis was not associated with a
younger age at onset of type 1 diabetes. To
the contrary, in the whole cohort we
found a positive correlation between
higher BMI SD score and older age at di-
agnosis. However, it should be pointed
out that in both cohorts (1990 –2004 and
1998 –2000) in the 2– 4.9 years of age
group there was a nonsignificant trend to-
ward an association between a higher BMI
SD score and a younger age at diagnosis. It
is well recognized that in type 1 diabetes
the younger the age at diagnosis the lower
the ␤-cell function. In the study by Dabe-
lea et al. (8), 70% of the participants had
fasting C-peptide ⬍0.5 ng/ml with BMI
and a younger age at diagnosis being as-
sociated only in these subjects. It is pos-
1594
sible that the additional metabolic
demands associated with higher BMI can-
not be compensated only in subjects with
a highly diminished ␤-cell function. Un-
fortunately, data concerning ␤-cell func-
tion was not available in our study.
Excluding recent data by Knerr et al.,
previous studies carried out in the U.K.
showing the relationship between
younger age at diagnosis and higher BMI
involved a small number of subjects
(4,5,8). To our knowledge, this is the first
study in a large cohort of a Mediterranean
National Registry for new cases of type 1
diabetes in which the accelerator hypoth-
esis is tested. Our results did not fit with
the hypothesis and point to the heteroge-
neity of the disease in different popula-
tions (14,15). Accordingly, in a recent
study including children who were either
from the U.K. or originally from the south
of Asia, Porter et al. did not confirm the
accelerator hypothesis (9). It is plausible
that this hypothesis does or does not be-
come manifest depending on the genetic
background and environmental factors,
including the prevalence of overweight
and obesity.
Our study has several limitations.
First, it is cross-sectional in nature, it has
a long recruitment period, and influence
by secular trends in BMI cannot be ruled
out. Second, we lack of biological evi-
dence to support diabetes classification in
terms of pancreatic autoantibodies avail-
ability. However, recently, as a part of the
European multicenter study Insulin De-
pendent Diabetes in Young Adults in
Europe (IDA), we investigated the consis-
tency in clinical diagnosis of type 1 diabe-
tes. The percentage agreement between
original classification and reclassification
was 92%. Finally, we are aware that in
order to truly test the accelerator hypoth-
esis, longitudinal studies in risk groups
(i.e., first-degree relatives of type 1 dia-
betic subjects) well before clinical onset
would be needed.
In summary, in our large cohort of
Mediterranean subjects with recently di-
agnosed type 1 diabetes, increasing BMI is
not uniformly associated with younger
age at diagnosis. Although our data did
not agree with the accelerator hypothesis,
the postulate is worthy of interest, mainly
in childhood-onset type 1 diabetes in
Western societies in which obesity has
risen to epidemic proportions in this age-
group.
Acknowledgments — We are indebted to all
of those involved in reporting the data of
newly diagnosed type 1 diabetic subjects to
the National Catalan Registry. The National
Catalan Registry for type 1 diabetes partici-
pates in the EURODIAB study group.
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