Management of Hypertension and High LDL in Pediatric Type 1 Diabetes

Abstract

Objective

To evaluate hypertension and hyperlipidemia management patterns in youth with type 1 diabetes and to. assess perceived effectiveness of management strategies and barriers to management.

Study design

An electronic survey, including clinical scenarios, fielded to pediatric providers (members of the American Diabetes Association Diabetes in Youth Interest Group, Pediatric Endocrine Society, or Type 1 Diabetes Exchange).

Results

Respondents (N=207, 86% MDs, 68% female) were practicing clinicians for youth with type 1 diabetes. As an initial recommendation, the overwhelming majority of respondents (83–99%) endorsed lifestyle and nonmedical recommendations (e.g. improve glycemic control) for hypertension and hyperlipidemia. Yet, few (6–17%) reported these recommendations as effective. Many respondents (57%) reported referring to another specialist for hypertension whereas few (8%) reported referring to another specialist for hyperlipidemia management. About one-fifth (21%) of respondents never initiate antihypertensive medications whereas only 8% never initiate lipid-lowering medication. Among prescribers, the majority of respondents only started antihypertensive or lipid-lowering medications after persistent elevations and in the setting of either ineffective lifestyle or non-medical interventions or additional cardiovascular risk factors. More than two-thirds of respondents endorsed medications as often effective for hypertension and hyperlipidemia (68% and 69% respectively).

Conclusions

Pediatric diabetes providers commonly defer prescribing antihypertensive and lipid-lowering medications until non-medication interventions have been ineffective. Most providers describe medications, but not lifestyle interventions, as often effective. Efforts to align clinical practice with clinical guidelines are needed.

Cardiovascular disease (CVD) affects persons with type 1 diabetes more frequently(1), at younger ages(2), and with greater mortality(3, 4) than persons without type 1 diabetes. Childhood CVD risk factors such as elevated LDL cholesterol or blood pressure (BP) directly relate to early atherosclerosis in young adulthood(5). Given elevated future CVD risk in children with type 1 diabetes, national guidelines for the management of hypertension and hyperlipidemia recommend more aggressive management in youth with type 1 diabetes than in youth without type 1 diabetes(6–8).

Previous studies describe a gap between clinical guideline recommendations and clinical management of CVD risk factors in youth with(9, 10) and without type 1 diabetes(11–13). However, it is unclear whether differences between clinical guidelines and clinical practice result from an inadvertent gap between intention and actual practice or whether pediatric diabetes providers’ treatment paradigms differ from current guidelines. Further, pediatric diabetes providers’ perceptions of the effectiveness of management strategies for hypertension and hyperlipidemia and barriers to management have been incompletely described.

By surveying a broad sample of pediatric diabetes providers, we aimed to assess providers’ current management strategies for hypertension and hyperlipidemia in youth with type 1 diabetes. We also aimed to describe the perceived effectiveness of various management strategies and the barriers that prevent optimal management of hypertension and hyperlipidemia in youth with type 1 diabetes.

Methods

This provider survey focused on current management practices for hypertension and hyperlipidemia (high LDL) in youth with type 1 diabetes including strategies for and barriers to optimal management. The survey was developed with an initial literature review and then questions were drafted by pediatric endocrinologists with input from a multidisciplinary team including physicians, nurse practitioners, nurse educators, nutritionists, and mental health professionals, all with pediatric type 1 diabetes expertise. Areas surveyed included provider and practice demographic information, work-up for hypertension, management recommendations for hypertension and hyperlipidemia, medication use in these conditions, perceived effectiveness of management recommendations, and barriers to treatment in youth with type 1 diabetes and hypertension or hyperlipidemia. Because we intended to determine how current management compares with commonly referenced guidelines, we specifically queried recommendations and clinical scenarios that related to popular guidelines as well as other clinical scenarios where medication initiation might reasonably be considered. The guidelines used for comparison were Standards of Medical Care in Diabetes–2016 from the American Diabetes Association (ADA guidelines(6)), the National Heart, Lung, and Blood Institute Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents Summary Report (NHLBI guidelines(7)), and Cardiovascular risk reduction in high-risk pediatric patients: a scientific statement from the American Heart Association Expert Panel on Population and Prevention Science; the Councils on Cardiovascular Disease in the Young, Epidemiology and Prevention, Nutrition, Physical Activity and Metabolism, High Blood Pressure Research, Cardiovascular Nursing, and the Kidney in Heart Disease; and the Interdisciplinary Working Group on Quality of Care and Outcomes Research (AHA guidelines(8)). Guideline recommendations for youth with type 1 diabetes are summarized in Table I (available at www.jpeds.com). Cognitive interviewing was conducted with 2 nurse practitioners and 2 physicians and the survey was revised iteratively in response to their feedback.

Table 1.

online only. Summary of guideline recommendations for youth with type 1 diabetes.

Guideline	Lifestyle Intervention Threshold	Initial Treatment	Medication Threshold	Medication Target
Blood Pressure
American Diabetes Association(6)	Prehypertension	Prehypertension: Dietary changes, increased exercise if appropriate Hypertension: Medication	Prehypertension: Consider if not successful with 3–6 months lifestyle change Hypertension: As soon as diagnosis confirmed	Below prehypertensive range
National Heart, Lung, and Blood Institute (Chapter 8)(7)	Prehypertension	Prehypertension/Stage 1 hypertension: Dietary changes, increased activity, weight management if indicated Stage 2 Hypertension: Medication or referral	Hypertension: If unsuccessful with 3–6 months of lifestyle change Stage 2 Hypertension or left ventricular hypertrophy: Treat immediately	Below prehypertensive range
American Heart Association(8)	Prehypertension	Prehypertension: Decrease calories, increase activity for 6 months Hypertension: Medication	Hypertension: As soon as diagnosis confirmed	Below prehypertensive range or <130/80 mmHg whichever is lower
American Academy of Pediatrics (16)*		Hypertension: Medication	Hypertension: As soon as diagnosis confirmed	<90th %tile or <130/80 mmHg whichever is lower
Lipids (LDL)
American Diabetes Association(6)	LDL ≥100 mg/dl	Nutrition therapy emphasizing decreasing saturated fat. Optimizing glycemic control.	If >10 years of age and counselling attempted if LDL >160 mg/dl, or LDL >130 mg/dl with other cardiovascular disease risk factors	LDL <100 mg/dl
National Heart, Lung, and Blood Institute (Chapter 9)(7)	LDL ≥130 mg/dl	Lifestyle therapy focused on limiting fats, especially saturated and trans fat, physical activity, and possible plant sterol esters	If >10 years of age and if LDL ≥160 mg/dl after 6 months of lifestyle change, or if LDL ≥130 mg/dl with ≥2 moderate risk factors or 1 additional high risk factor	LDL <130 mg/dl
American Heart Association(8)	LDL ≥100 mg/dl	Intensive glucose management to attain A1c <7.0%, nutritionist training on limiting fats, especially saturated and trans fat	If >10 years of age and LDL ≥100 mg/dl after 6 months of lifestyle change	LDL ≤100 mg/dl

^*American Academy of Pediatrics guideline not published when survey fielded.

The survey initially included 36 main items and then was consolidated to 33 items to ease respondent burden given the similarity of responses for barriers to hypertension and hyperlipidemia management. A small number of sections employed adaptive questioning to reduce the length of the survey and allow respondents to view only relevant questions. Response options included a 5-point Likert Scale (Never, Rarely, Sometimes, Often, Always), forced choice, or multiple responses allowed depending upon the question. Questions included an “Other” response with the option for free text if respondents chose. The survey required less than ten minutes to complete. The full survey is available (Appendix; available at www.jpeds.com).

The survey was fielded electronically via RedCap (Research Electronic Data Capture)(14) to members of the American Diabetes Association (ADA) Diabetes in Youth Interest Group, Pediatric Endocrine Society (PES), and investigators and coordinators of the Type 1 Diabetes Exchange with majority pediatric patients between January 2016 and January 2017. An introductory information letter provided details on survey purpose, anonymity of responses, and the option for nonparticipation with consent implied when respondents opted to proceed with the survey. The invitation to complete the survey was sent via email with a follow-up email sent approximately 2 weeks later with direction to only complete the survey once. Participation was also encouraged at the Diabetes in Youth Interest Group session at the ADA Scientific Sessions in New Orleans, 2016. Physicians, nurse practitioners, physician’s assistants, nurses, or dieticians who cared for more than 10 patients aged 0–25 with diabetes annually were eligible to participate. A $5 donation to ADA, PES, or Life for a Child of the International Diabetes Federation (for Type 1 Diabetes Exchange participants) was used to recognize respondents for completing the survey. Before fielding the survey, Institutional Review Board approval was obtained.

In order for survey responses to be included for analysis, demographic questions and the initial question on evaluation of hypertension must have been answered. For analysis, the 5-point Likert scale was consolidated to a 3-point Likert scale. The categories of Never and Rarely are referred to as “Rarely,” the category of Sometimes remains as “Sometimes,” and the categories of Often and Always are referred to as “Often.” In order to combine the questions on barriers for hypertension and hyperlipidemia in the 35 individuals who answered the longer survey with separate barrier questions for each condition, responses were maintained for respondents who answered similarly for both conditions (65% of responses). If respondents answered oppositely for hypertension and hyperlipidemia (Rarely versus Often) then the responses were excluded (7%). If respondents answered either Rarely or Often for one condition and Sometimes for the other condition then Sometimes was kept as the response (28%).

If respondents utilized the “Other” response option and entered free text, the study team categorized and tabulated responses by consensus. Responses that were highly similar to existing response options were recategorized to the existing option. Free text responses written by ≥5% of respondents to a question are reported in the text.

Analyses were conducted in SAS version 9.4 (Cary, North Carolina). Descriptive analyses were completed for all questions. We conducted chi-squared analyses to determine if differences in provider or medication barriers varied by provider demographic characteristics (provider age, practice setting, years since training completion, sex, and number of patients under provider’s care). P < .05 was considered significant.

Results

The survey was fielded to the 1361 members from American Diabetes Association Diabetes in Youth Interest Group, the 1368 members from Pediatric Endocrine Society and the 754 pediatric providers from Type 1 Diabetes Exchange. Of the 260 individuals who opened the survey from the three organizations, 16 did not meet inclusion criteria to complete the survey, and 37 were excluded because they provided only demographic information without completing additional survey questions. There was a total of 207 respondents.

Two-thirds of the respondents were female and 19% were nonwhite. Almost all (95%) resided in the United States and were well-distributed throughout different regions (Table 2). 48% of respondents were ≤45 years; 52% were ≥46 years of age.

Table 2.

Respondent Demographic and Practice Characteristics

Provider
Physician	86%
Nurse Practitioner/Physician’s Assistant	7%
Registered Nurse/Dietitian	6%
Sex (% Female)	68%
Race/Ethnicity (% Nonwhite)	19%
Age
≤35 years	19%
36–45 years	29%
46–55 years	22%
56–65 years	23%
≥66 years	7%
Years since training completed
≤4 years	25%
5–9 years	18%
10–20 years	25%
>20 years ago	32%
United States residence	95%
Northeast	23%
Midwest	26%
South	31%
West	20%
Geographic location
Urban	73%
Suburban/Rural	27%
Practice setting
Academic Medical Center	77%
Other (community hospital, group/solo practice)	23%
Youth ≤25 years with type 1 diabetes in practice group
<100	7%
100–250	13%
251–500	15%
501–1000	29%
>1000	37%
Youth ≤25 years old with type 1 diabetes provider cares for annually
11–50	19%
51–100	21%
101–250	41%
>250	19%
Primary Focus Area
Clinic	72%
Research/Teaching/Administration	28%

Respondents were 86% physicians and the remainder were nurse practitioners, physician’s assistants, nurses, and nutritionists (Table 2). Two-thirds of respondents endorsed participating in practice groups that treated at least 500 youth 0–25 years with type 1 diabetes and 60% cared for over 100 youth with type 1 diabetes themselves. About three-quarters of respondents practiced in an academic medical center and 72% focused primarily on clinical practice. The majority (57%) completed their training greater than 10 years ago.

Evaluation strategies for youth with hypertensive-range BPs on 2–3 occasions varied among respondents. Most respondents often obtain laboratory studies (71% often obtain a urinalysis and 65% often obtain a BUN and creatinine). Additionally, 7% of respondents wrote in via free text that they would obtain a urine albumin to creatinine ratio and 15% wrote in that they would refer to a specialist. Many do not perform an extensive work-up; 21% often obtain a sleep history, 13% a renal ultrasound, 9% four extremity BPs, and 7% a cardiac ultrasound.

Questions regarding any detailed medical evaluation for hyperlipidemia were not asked although the survey addressed steps that providers would take prior to starting a statin such as repeating a lipid profile, nutritional advice, or improving glycemic control.

Respondents overwhelmingly endorsed lifestyle modification as their initial recommendation for confirmed primary hypertension or hyperlipidemia (LDL ≥130 mg/dl, ≥3.37 mmol/l) in youth with type 1 diabetes. Over 80% of respondents endorsed often providing counselling on healthy eating, increasing physical activity, and losing weight (if patient was overweight/obese) (Table 3). Respondents also commonly reported recommending improvements to glycemic control (≥95% responded often), repeating BP in other settings (81% responded often), and repeating lipid levels (52% responded often). The majority often referred to a nutritionist; 61% for HTN, 85% for hyperlipidemia. For hypertension, over half of respondents (57%) often initially referred to another specialist and 27% often started a medication for confirmed primary hypertension. For hyperlipidemia, only 8% often refer to a lipid specialist and 15% started a medication in their initial management of LDL ≥130 mg/dl (≥3.37 mmol/l).

Table 3.

Initial Provider Recommendations for Hypertension or LDL ≥130 mg/dl and Effectiveness of Recommendations

	Often/AlwaysRecommend for Confirmed Hypertension	Often/Always Recommend for LDL ≥130 mg/dl	Often/Always Effective for Confirmed Hypertension	Often/Always Effective for LDL ≥130 mg/dl
Lose weight	97%	96%	12%	13%
Improve glycemic control	95%	99%	12%	17%
General health eating	86%	95%	6%	8%
Increase physical activity	83%	93%	7%	9%
Refer to dietitian	61%	85%	9%	15%
Referral to specialist	57%	8%	68%	38%
Start a medication	27%	15%	68%	69%
Repeat BP in a new setting	81%	–	–	–
Limit salt intake	36%	–	5%	–
Increase dietary fiber	–	45%	–	4%
Increase omega-3 fatty acids	–	32%	–	8%
Repeat lipids (+/− fasting)	–	52%	–	–

LDL 130 mg/dl = 3.37 mmol/l

Twenty-one percent of respondents endorsed never prescribing medication for BP (Table 4). Among the remaining 79% of prescribers, respondents varied in the circumstances warranting medication to treat BP in a teenager with type 1 diabetes. Of the respondents who did prescribe medication, 73% would prescribe medications for hypertensive-range blood pressure on 2–3 occasions where lifestyle changes were not effective and 64% would prescribe medication for hypertensive-range blood pressures on 2–3 occasion with other CVD risk factors present. Fewer would prescribe medication for hypertensive-range blood pressures on 2–3 occasions (without either a trial of lifestyle change or additional CVD risk factors) or for prehypertension (Table 4).

Table 4.

Proportion of Respondents Starting an Anti-hypertensive or Lipid-lowering Medication in Various Scenarios

	% of Respondents
Hypertension
% respondents who never initiate medication for hypertension	21%
Among those that do:
% for prehypertension that persists for ≥6 months and additional CVD risk factors present	34%
% for prehypertension that persists for ≥6 months despite lifestyle recommendations*	41%
% for hypertensive BP on ≥2–3 occasions*†	41%
% for hypertensive BP on ≥2–3 occasions and lifestyle changes not effective*†	73%
% for hypertensive BP on ≥2–3 occasions and additional CVD risk factors present*†	64%
% for severe/stage 2 hypertension*†	59%
Hyperlipidemia
% of respondents who never initiate medication for high LDL	8%
Among those that do:
% immediately if LDL ≥160 mg/dl	21%
% if LDL ≥160 mg/dl and persists 6–12 months despite non-medication interventions*†	76%
% if LDL ≥130 (and <160) mg/dl and persists over 6–12 months despite non-medication intervention†	49%
% if LDL ≥130 (and <160) mg/dl and persists over 6–12 months, despite non-medication intervention, and additional CVD risk factors present*†	56%
% if LDL ≥100 (and <130) mg/dl and persists over 6–12 months despite non-medication intervention†	11%
% if LDL ≥100 (and <130) mg/dl and persists over 6–12 months despite non-medication intervention, and additional CVD risk factors present†	23%

^*Medication initiation consistent with ADA guidelines,

^†Medication initiation consistent with AHA guidelines

LDL 100/130/160 mg/dl = LDL 2.59/3.37/4.14 mmol/l respectively

Sixty-one percent of respondents reported targeting a BP below the hypertensive range for age and sex (Table 5) and 23% of respondents reported targeting a BP below the prehypertensive range (<90^th percentile for age, sex, and height) in youth with type 1 diabetes (ADA guidelines, AHA guidelines, and NHLBI guidelines target).

Table 5.

Goal Blood Pressure or Lipid Level for Medication Titration

Blood Pressure	% of Respondents
Less than 130/90 mmHg	21%
Less than 120/80 mmHg	22%
Below hypertensive range	61%
Below prehypertensive range*	23%
Do not use a goal BP to titrate medications	3%
LDL Level
LDL<160 mg/dl	2%
LDL<130 mg/dl#	36%
LDL<100 mg/dl*	57%
Do not use an LDL target to titrate medications	3%
Other	2%

^*Target consistent with ADA, AHA, and NHLBI (for hypertension only) guidelines

^#Target consistent with NHLBI (Chapter 9) guidelines

LDL 100/130/160 mg/dl = LDL 2.59/3.37/4.14 mmol/l respectively

Respondents were permitted to choose more than one response for BP target.

In contrast to the 21% of respondents who reported never prescribing medication for hypertension management, only 8% of respondents endorsed never prescribing medication for high LDL cholesterol. Among those who initiate medication for high LDL cholesterol, 21% would start medication immediately for LDL ≥160 mg/dl (≥4.14 mmol/l) and 76% would start medication for LDL ≥160 (≥4.14 mmol/l) that persists 6–12 months despite non-medication interventions (lifestyle efforts and/or glycemic management). About half of respondents would start medication for LDL ≥130 (and <160) mg/dl (≥3.37 and <4.14 mmol/l) that persists 6–12 months despite non-medication intervention with or without additional CVD risk factors and most do not prescribe medication for LDL <130 mg/dl (3.37 mmol/l) (Table 5).

Over half of respondents (57%) reported titrating medication to a target LDL <100 mg/dl (<2.59 mmol/l, ADA, and AHA target) and 36% reported targeting LDL <130 mg/dl (<3.37 mmol/l, NHLBI target). Almost all providers (97%) prescribing lipid-lowering medications reported choosing a statin.

Of the possible recommendations provided, the majority of respondents endorsed medications as most likely to be often effective (68% responded often effective for HTN and 69% for hyperlipidemia) (Table 3). The next most effective recommendation was referral to a specialist (68% responded often effective for HTN and 38% for hyperlipidemia). However, few respondents reported that advice to improve glycemic control, recommendations to lose weight, or referral to a dietician were often effective (9–17%; Table 3). Recommendations for general healthy eating, increasing physical activity, increasing dietary fiber, increasing omega-3 fatty acids, or limiting salt were each judged to be often effective by less than 10% of respondents.

There were a number of perceived barriers to effective hypertension or hyperlipidemia management. Respondents endorsed insufficient patient support for lifestyle change, lack of patient motivation to control BP and/or lipid levels, and lack of patient confidence to follow through on lifestyle changes as common patient-related barriers to HTN and/or lipid management (endorsed ‘Often’ a barrier by 69%, 62%, and 61% of respondents respectively, Table 6 [available at www.jpeds.com]). In reflecting on their own barriers to providing care to patients with HTN and/or hyperlipidemia, providers most commonly endorsed insufficient patient education materials, medical visits were too short to focus on diabetes AND HTN and/or hyperlipidemia, and limited provider training on HTN and/or hyperlipidemia management (endorsed ‘Often’ by 40%, 39%, and 33% respectively).

Table 6.

online only. Barriers to Blood Pressure and/or Lipid Management

Patient barriers	Never/Rarely	Sometimes	Often/Always
Do not have sufficient support for successful lifestyle changes	3%	28%	69%
Are not motivated to control blood pressure and/or lipid levels	4%	34%	62%
Are not confident that they can follow-through with lifestyle changes	3%	35%	61%
Are resistant to start a medication that may be life-long	13%	43%	44%
Do not understand that untreated blood pressure or elevated lipid levels may increase risk of diabetes complications	16%	41%	43%
Are focused on diabetes management and cannot add another condition	14%	49%	37%
Do not believe blood pressure and/or lipid medications are important in youth with diabetes	34%	38%	28%
Medical barriers
Insufficient patient education materials on hypertension and/or hyperlipidemia for these youth	21%	40%	40%
Visits too short to focus on diabetes AND hypertension and/or hyperlipidemia	19%	42%	39%
Limited provider training on hypertension and/or hyperlipidemia management in youth with type 1 diabetes	34%	33%	33%
Insufficient evidence for hypertension and/or lipid management in youth	51%	31%	18%
Practice systems make it difficult to recognize when BP or lipid levels need intervention	53%	32%	14%
Lack of familiarity with practice guidelines	56%	31%	13%
Do not want to distract from blood glucose management	56%	33%	11%
Lack of local subspecialists for referral for hypertension and/or lipid management appropriate for youth with type 1 diabetes	71%	20%	9%
Discomfort discussing complication risk with concurrent diabetes and hypertension and/or hyperlipidemia	73%	20%	7%
Prescription barriers
Concerns about pregnancy (in females)	26%	39%	35%
Concerns about patient adherence	24%	44%	32%
Lack of expertise in this area	39%	39%	23%
Hesitancy to start a medication that may be life-long	47%	33%	21%
Limited evidence in youth with type 1 diabetes	39%	43%	18%

Provider endorsement of barriers differed by age and experience. Providers who completed training <10 years ago versus ≥10 years ago more commonly endorsed lack of familiarity with practice guidelines (22% versus 7%, p= .03), lack of expertise prescribing medication (35% versus 13%, p=.005), and concerns about patient adherence (44% versus 24%, p= .02) as often barriers to managing HTN or hyperlipidemia. Similarly, providers ≤45 years old versus >45 years old more commonly endorsed lack of familiarity with practice guidelines (21% versus 7%, p=.04) and lack of expertise prescribing medication (30% versus 16%, p=.06) as often barriers to managing HTN or hyperlipidemia. Providers who practiced outside of an academic setting more frequently cited lack of specialists for referral as a barrier (23% versus 5%, p=.007). There were no differences according to number of patients cared for or according to sex.

Discussion

Although CVD is recognized as the leading cause of morbidity and premature mortality in type 1 diabetes, addressing CVD risk factors in young persons with type 1 diabetes is an understudied area. This study has evaluated provider practices in managing CVD risk factors in type 1 diabetes. Although most respondents report lifestyle counselling for initial management of both hypertension and hyperlipidemia, they described this counselling as often ineffective. Respondents reported more frequent referrals for hypertension and more frequently initiating medications for hyperlipidemia.

Studies document widespread under-diagnosis of pediatric hypertension in general (11) and in youth with type 1 diabetes in particular (9, 15). Even when provided with the diagnosis of “confirmed primary hypertension” as stated in our survey, providers infrequently followed national evaluation and recommendation guidelines. (However, just over half of respondents refer to hypertension specialists who may then follow recommended evaluations and treatments, although this was not assessed.) Pediatric diabetes providers often did not perform extensive diagnostic evaluations for secondary hypertension or to assess end organ damage. Between survey fielding and manuscript publication, new pediatric hypertension guidelines were published by the American Association for Pediatrics that reduced the need to perform such evaluations (16). Thus, clinical practice anticipated guideline revision in this circumstance.

Pediatric diabetes specialists responding to this survey described treatment for hypertension that was less aggressive than commonly referenced guidelines. For example, only 15% of providers (excluding those who would never prescribe) would prescribe medication in ALL situations recommended by ADA guidelines. As AHA and NHLBI guidelines differ from ADA and are less aggressive, about 30–50% of respondents would be in compliance with these recommendations. ADA, AHA, and NHLBI guidelines recommend a BP target below the prehypertensive range for youth with diabetes; however most pediatric diabetes providers are less aggressive, targeting below the hypertensive range rather than the prehypertensive range when titrating antihypertensive medications. Although pediatric diabetes providers are presumably comfortable with prescribing ACE inhibitors or angiotensin receptor blocks to treat elevated urinary albumin excretion(17), this familiarity has not transferred to comfort with treating elevated BP using these same classes of medications.

Studies also document the widespread undertreatment of lipid disorders in youth in general(12) and youth with type 1 diabetes (10, 15). In our survey, 44% of respondents (excluding those who never prescribe) would start lipid-lowering medications as recommended by ADA guidelines and only 3% would start medication in all circumstances recommended by AHA guidelines, which are more aggressive. (NHLBI guidelines are intermediate.) Although rates of medication use endorsed by our respondents may be below recommended guidelines, this contrasts with pediatric primary care providers who overwhelmingly endorsed discomfort with lipid disorder management (83%) and who disagreed with using lipid-lowering medication in youth (57%)(18). However, comfort and experience among pediatric diabetes providers may vary geographically and reticence to prescribe may not be limited to the United States. In a recent survey of members of the Association of Children’s Diabetes Clinicians of England, Northern Ireland, and Wales only 14% of clinicians had started a statin in the past 5 years(19).

Providers most strongly endorsed patient-related barriers such as lack of support, motivation, or self-efficacy (confidence) rather than barriers within their practice. A survey of management practices in pediatric type 2 diabetes similarly described difficulties in making lifestyle changes in patients as the most commonly cited barrier for both hypertension and lipid management(20). Only 18% of respondents reported that insufficient evidence for hypertension and/or lipid management in youth was often a barrier. This contrasts with a systematic review reporting limited evidence as to when to initiate lipid-lowering therapy or what cholesterol level to target in pediatric patients(21). Younger (≤45 years), less experienced (<10 years in practice) providers were more likely to cite lack of expertise and/or lack of familiarity with practice guidelines as barriers suggesting education and training opportunities for this demographic.

There are limitations to this survey study. First, the survey had a limited response rate. Part of this low response rate may have resulted from providers receiving this survey from 2–3 organizations due to membership in multiple organizations. In 2011, there were an estimated 893 clinically practicing board-certified pediatric endocrinologists in the United States (22). Although our 207 respondents included some non-MDs (11%) and non-US providers (5%), we captured a respectable proportion of pediatric diabetes physicians practicing in the United States. Other surveys have yielded similar response rates(23). The low response could signify nonresponse bias among providers unlikely to manage CVD risk factors, creating an overestimation of provider management and adherence with guidelines (as diabetes providers with limited knowledge or experience may have been less likely to complete the survey). Second, our survey assessed provider-reported management decisions in response to diagnosed hypertension and hyperlipidemia; it did not discuss provider diagnosis of these conditions. Additional studies might consider assessing healthcare provider criteria for diagnosing hypertension, prehypertension, and hyperlipidemia. Third, our survey captured provider report which may differ from actual practice. Finally, the relatively low adherence to practice guidelines for evaluation of hypertension may have related to the high rates (57%) of referrals.

Our findings suggest providers inconsistently follow practice guidelines, especially with regards to medication initiation and titration. There is greater comfort with managing hyperlipidemia compared with hypertension among pediatric diabetes providers. We speculate that providers may have greater confidence with lipid measurements than BP measurements, which can be highly variable and impacted by measurement technique (manual versus automated methods). Although electronic medical records can flag elevated BP and lipid values, it is unclear how often electronic decision support for management of either or both hypertension and hyperlipidemia is available in current EMRs for teens with type 1 diabetes. Differences among clinical guidelines may contribute to poor adherence with the recommendations. In order to improve hypertension and lipid management for youth with type 1 diabetes, guidelines should be harmonized and the resulting product should be clearly explained at professional conferences, through virtual education efforts, and incorporated into electronic decision support. Finally, the frequent endorsement of patient support, motivation, and self-efficacy as barriers to hypertension and hyperlipidemia management suggests the need for interventions to target these areas in order to motivate behavior change. With dedicated efforts, the management of hypertension and hyperlipidemia in youth with type 1 diabetes will improve.

Abbreviations and Acronyms

CVD

cardiovascular disease

BP

blood pressure

ADA

American Diabetes Association

NHLBI

National Heart, Lung, and Blood Institute

AHA

American Heart Association

PES

Pediatric Endocrine Society