A follow-up study of 1966 patients with insulin-dependent diabetes mellitus (IDDM) who were diagnosed at Children's Hospital of Pittsburgh (CHP) between 1950 and 1981 has been completed. The mean age of the population at follow-up was 21.2 yr with a mean duration of IDDM of 12.9 yr. Nine percent of the patients were deceased, a sevenfold excess in mortality compared with the U.S. population. The relative increase in mortality was greater for females than males and greater for blacks than whites. Before age 20, the primary excess in mortality was at onset of IDDM, or within 6 mo after onset, and was due to acute diabetic complications. After age 20, the annual mortality risk was approximately 2%, which was more than 20 times greater than for the U.S. population. Renal disease was responsible for the majority of these deaths. There was a reduced risk of dying for diabetic patients who were diagnosed between 1966 and 1971 compared with patients diagnosed during earlier years.

R E S U LT S -Patients who re p o rted receiving specialist care were more likely to be female, to have an education level beyond high school, to have an annual household income $ 2 0 , 0 0 0 , and to have health insurance. Additionally, patients receiving specialist care were more likely to have received diabetes education during the previous 3 years, to have knowledge of HbA 1 c t e s ting and to have received that test during the previous 6 months, to have knowledge of the Diabetes Control and Complications Trial results, to self-monitor blood glucose, and to inject insulin more than twice daily. A lower HbA 1 level was associated with specialist care versus generalist care (9.7 vs. 10.3%; P = 0.0006) as were higher education and income levels. Multivariate analyses suggest that the lower HbA 1 levels observed in patients receiving specialist care were restricted to patients with an annual income $ 2 0 , 0 0 0 .

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To ascertain whether the dawn phenomenon occurs in normal adolescents and, if so, to determine its mechanism, we measured nocturnal plasma glucose, insulin, glucagon, growth hormone, cortisol, and adrenocorticotropic hormone (ACTH) levels between 01.00 and 08.00 h in 10 healthy adolsescents. The prehepatic insulin secretion rate was calculated based on C peptide levels. The metabolic clearance rate of insulin (MCRI) was calculated as the ratio of mean insulin secretion rate to mean insulin concentration. There was no change in plasma glucose, insulin, and glucagon between 01.00–04.00 and 05.00–08.00 h (paired t test). The MCRI was higher at 05.00–08.00 h compared to 01.00–04.00 h (9.30 ± 1.50 vs. 4.87 ± 1.11 ml·kg^-1·min^-1; p = 0.008). The prehepatic insulin secretion increased at 05.00–08.00 h relative to 01.00–04.00 h( 1.1 ± 0.2 vs. 0.6 ± 0.1 pmol·kg^-1·min^-1;p= 0.013). Similarly, cortisol and ACTH levels were higher at 05.00–08.00 versus 01.00–04.00 h (323 ± 33 vs. 102 ± 22nmol/l, p < 0.001; 3.6 ± 0.5 vs. 1.8 ± 0.4 pmol/l, p = 0.006, respectively). Growth hormone was higher at 01.00–04.00 versus 05.00–08.00 h (7.6 ± 1.2 and 3.0 ± 0.9 µg/l; p = 0.019). ACTH correlated with MCRI (r = 0.66; p = 0.002) and prehepatic insulin secretion (r = 0.75; p < 0.01). We conclude that (1) the dawn phenomenon, characterized by an increase in MCRI, occurs in healthy adolescents; (2) this increase in MCRI is compensated for by an increase in insulin secretion from the normal pancreas, thus preventing a fall in plasma insulin and a rise in plasma glucose.

Summary. A total community (Allegheny County, Pennsylvania) Type 1 (insulin-dependent) diabetes mellitus registry was examined for evidence of seasonality at onset of the disease. No significant seasonal trend was found if all cases aged < 20 years at onset (n = 901) were considered. However, a significant pattern emerged for the age groups 5 9 years and 10-14 years. Furthermore, sex differences were apparent in that males but not females demonstrated a seasonal pattern (fewer cases in the summer months).