From 1998 to 2012, the incidence of diabetic ketoacidosis in children in Colorado at the time type 1 diabetes was diagnosed increased by 55%, researchers reported in JAMA.

Though recognized as a serious complication of diabetes that can have detrimental effects in the long term, little is known about the long-term trends of diabetic ketoacidosis in the United States, according to background information in the research letter.

In the current study, Arleta Rewers, MD, PhD, of the University of Colorado School of Medicine in Aurora, and colleagues evaluated trends and factors associated with diabetic ketoacidosis at type 1 diabetes diagnosis between 1998 and 2012 in Colorado.

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During this time period, youths diagnosed with type 1 diabetes before age 18 years at any medical facility were included in the study if they were a Colorado resident and followed up at the Barbara Davis Center for Diabetes in Denver.

Of 3,439 youths with type 1 diabetes, 1,339 (38.9%) had diabetic ketoacidosis at time of diagnosis. Among those with diabetic ketoacidosis, median age was 9.4 years, 53.8% were boys and 75.7% were white, according to the data.

During the study period, the researchers observed a significant increase, particularly after 2007, in the proportions of patients with diabetic ketoacidosis, with percentages rising from 29.9% in 1998 to 35.0% in 2007 to 46.2% in 2012 (P for trend <.001).

“This incidence is consistent with incidences in countries with poor access to health care and low community and physician awareness of diabetes, and is much higher than incidences reported in Canada or the United Kingdom,” the researchers wrote.

Over time, the only characteristic that changed was insurance. The proportion of patients covered by public insurance increased from 17.1% in 2007 to 37.5% in 2012 (P<.001), the researchers reported.

Results also linked younger age (OR=1.80; 95% CI, 1.41-2.31) and African-American race (OR=1.80; 95% CI, 1.24-2.62) with a higher risk for diabetic ketoacidosis. Conversely, private insurance (OR=0.37; 95% CI, 0.29-0.49) and history of type 1 diabetes in a first-degree relative (OR=0.35; 95% CI, 0.26-0.48) were associated with lower risk for the condition.

Some of the factors associated with diabetic ketoacidosis at type 1 diabetes diagnosis are potentially modifiable, the researchers noted, but others, such as economic factors, are more difficult to change.

“Increasing incidence of [diabetic ketoacidosis] correlated temporally with an increase in Colorado child poverty prevalence from 10% in 2000 to 18% in 2012. The recent increase of [diabetic ketoacidosis] incidence among youth with private insurance may be related to proliferation of high-deductible health plans,” they wrote.

“To our knowledge, this is the only report of increasing incidence of DKA in the developed world. Further research on the reasons for the increase and interventions to decrease the incidence are warranted.”


  1. Rewers A et al. JAMA. 2015;313(15):1570-1572.