NPDA 2021-22 Extended Analysis
Source: data.gov.uk (2024-05-31)

National Paediatric Diabetes Audit 2021 - 2022. The excel file contains unit, regional and national level data obtained from the National Paediatric Diabetes Audit 2021-2022.
Specifically, it includes information on patient characteristics, completion of health checks and outcomes achieved (as recommended by the National Institute for Clinical Excellence) for infants, children and young people with type 1 diabetes, under the age of 25, who attended paediatric diabetes units in England and Wales between 1 April 2021 and the 31 March 2022.
Data are included for the seven key health checks:
• Glycated Haemoglobin A1c (HbA1c)
• Body Mass Index (BMI)
• Thyroid
• Blood pressure
• Urinary albumin
• Foot examination
• Eye screening.

Data on other health checks include:
• Psychological assessment
• Offering of immunisation against influenza
• Advice about managing diabetes (‘sick-day rules’)
• Using (or trained to use) blood ketone testing strips and a meter
• Cholesterol
• Additional dietetic support

Data are included for health checks at diagnosis
• Screening for autoimmune disease (coeliac and thyroid disease) 
• Provision of Level 3 carbohydrate-counting education

Data on outcomes of care include:
• HbA1c target measurements
• Small vessel (microvascular) disease
• Large vessel (macrovascular) disease
• Autoimmune disease (coeliac and thyroid disease)

The data were first published in 2023 alongside the National Paediatric Diabetes Audit Report 2021-2022 Data suppressed due to small numbers (<5).

For further information and details on the audit please refer to:
• National Paediatric Diabetes Audit Annual Reports: https://www.rcpch.ac.uk/resources/npda-annual-reports
• NPDA results online: http://npda-results.rcpch.ac.uk/default.aspx
• The RCPCH website: https://www.rcpch.ac.uk/npda

Annual report 2021-22:
Care processes and outcomes
Appendix 1 - full audit analysis

NPDA National report 2021/22:
Care processes and outcomes
Appendix 1: Full audit analysis

2.1.6.2 Level 3 carbohydrate counting
33
2.2
Health checks for children and
young people with Type 2 diabetes 34
2.2.1
Completion of key health checks
35
2.2.2 Number of HbA1c measurements 36
2.2.3 Completion of all other
health checks
37
3.
Outcomes
38
3.1
HbA1c
38
3.2
HbA1c outcomes of children
and young people with all types
of diabetes
38
3.3
HbA1c outcomes of children and
young people with Type 1 diabetes 39
3.3.1
National and regional unadjusted
HbA1c results
39
3.3.2 HbA1c outcomes by sex
43
3.3.3 HbA1c outcomes by age
and duration of diabetes
43
3.3.4 HbA1c outcomes by ethnicity
44
3.3.5 HbA1c outcomes by
deprivation quintile
46
3.3.6 HbA1c outcomes across PDUs
in England and Wales
48
3.4
HbA1c outcomes of children and
young people with Type 2 diabetes 49
3.4.1
HbA1c outcomes by sex
50
3.4.2 HbA1c outcomes by duration
of Type 2 diabetes
50
3.4.3 HbA1c outcomes by
deprivation quintile
51
3.4.4 HbA1c outcomes by
ethnic category
51
3.5
Small vessel (microvascular)
disease
52
3.5.1
Diabetic kidney disease
52
3.5.1.1 Albuminuria in young people
with Type 1 diabetes
52
3.5.1.2 Albuminuria in children and young
people with Type 2 diabetes
56
3.5.2 Eye disease
57
Contents
1.
Characteristics, prevalence,
and incidence
5
1.1
Audit cohort
5
1.2
Characteristics of children and
young people with Type 1 diabetes
5
1.2.1
Age and sex
5
1.2.2
Regional distribution
6
1.2.3
Ethnicity
7
1.2.4
Deprivation
8
1.3
Prevalence and incidence of
Type 1 diabetes
9
1.3.1
Prevalence
9
1.3.2
Incidence
10
1.4
Characteristics of children and
young people with Type 2 diabetes 15
1.4.1
Age and sex
15
1.4.2
Regional distribution
16
1.4.3
Ethnicity
17
1.4.4 Deprivation
18
2.
Completion of annual
health checks
18
2.1
Completion of health checks
for children and young people
with Type 1 diabetes
18
2.1.1
Completion of key health checks
18
2.1.1.1 Retinopathy screening
21
2.1.2
Variation in key health
check completion
22
2.1.2.1  Variation in completion rates
nationally and regionally
22
2.1.2.2  Variation in completion
rates across PDUs
24
2.1.3
Number of HbA1c
measurements recorded
27
2.1.4
Nutrition and lifestyle
education and support
29
2.1.5
Completion of all other
annual health checks
31
2.1.6
Care at diagnosis
32
2.1.6.1  Screening for autoimmune
conditions
32

4.3
Assessing the probability of achieving
HbA1c targets using multivariate
analyses including treatment regimen,
use of technology, demographic and
socio-economic factors
86
4.3.1
Introduction
86
4.3.2 What the models tell us about the
impact of technology on achieving
an HbA1c ≤48 mmol/mol
87
4.3.3 What the models tell us about the
impact of technology on achieving
an HbA1c <58 mmol/mol
87
4.3.4 What the models tell us about
the overall relationship

88
5.
Thyroid and
coeliac disease
90
5.1
Thyroid and coeliac disease
amongst children and young
people with Type 1 diabetes
90
6.
List of Tables
94
7.
List of Figures
96
8.
References
100
3.5.2.1 Retinopathy in young people
with Type 1 diabetes
57
3.5.2.2 Retinopathy in young people
with Type 2 diabetes
58
3.6
Large vessel disease - Cardiovascular
Disease (CVD) risk factors
59
3.6.1 Blood pressure and cholesterol
59
3.6.1.1 Blood pressure and cholesterol in
young people with Type 1 diabetes 59
3.6.1.2 Blood pressure and cholesterol
in young people with Type 2
diabetes
62
3.6.2 Body Mass Index
63
3.6.2.1 Body Mass Index and
Type 1 diabetes
63
3.6.2.2 Body Mass Index and
Type 2 diabetes
67
3.7
Psychological assessment
68
3.7.1 Psychological outcomes of
children and young people
with Type 1 diabetes
68
3.7.2 Psychological outcomes of
children and young people
with Type 2 diabetes
70
3.8
Hospital admissions
70
3.8.1
Type 1 diabetes-related
admissions
70
3.8.2 DKA at diagnosis
72
4.
Treatment regimen and
diabetes monitoring
72
4.1
Treatment regimens
73
4.1.1
Treatment regimens of
children and young people
with Type 1 diabetes
73
4.1.2
Treatment regimens of
children and young people
with Type 2 diabetes
77
4.2
Glucose monitoring devices
78
4.2.1
Usage of glucose monitoring devices
among children and young people
with Type 1 diabetes
78

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NPDA National report 2021/22: Care processes and outcomes
1.
Characteristics, prevalence,
and incidence
1.1
Audit cohort

A total of 33,251 children and young people with diabetes were included in the 2021/22 audit. All
paediatric diabetes units (PDUs) in England and Wales participated.

Table 1 shows the breakdown of this cohort by age group and type of diabetes.

Table 1: Number of children and young people with diabetes by age-group and type of diabetes,
2021/22
0-4
years
5-9
years
10-14
years
15-19
years++
20-24
years ++
Total
% of
cohort
Type 1 diabetes
1,774
6,475
13,261
9,779
60
31,349
94.3%
Type 2 diabetes
4
24
452
664+
1,144
3.4%
Cystic fibrosis-related diabetes
0
15
83
91
0
189
0.6%
Monogenic forms of diabetes
17
25
73
65
0
180
0.5%
Other specified diabetes mellitus
35
50
121
114+
320
1.0%
Not specified diabetes mellitus
20+
34
15
0
69
0.2%

+Results merged to mask number <4

++The NPDA recognises that transition to adult diabetes services usually starts in a patient’s late teenage years. The numbers presented in
these columns represents the number still receiving care from a PDU and do not represent the total number of young people with
diabetes in these age groups in England and Wales.
1.2 Characteristics of children and young people
with Type 1 diabetes
1.2.1 Age and sex

Figure 1 shows the number of children and young people with Type 1 diabetes by sex and age in
whole years at the beginning of the audit period.

The distribution by age and sex is consistent with previous years. The number of children increases
up to 14-15 years, when many young people start to transition to adult services. Boys account for
52.7% of the sample.

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NPDA National report 2021/22: Care processes and outcomes
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19+
Boys
63
106
190
247 344
433
530
651
788 890 1090 1210 1423 1535 1631 1618 1567 1311
744
132
Girls
33
111
191
218
269
388
507
633
xx-xxxx-xxxx
1159 1271 1425 1401 1318 1317 1079 598
147
2021/22
96
217
381
465
613
821 1037 1284 1486 1834 2191 2369 2694 2960 3032 2936 2884 2390 1342 279
2020/21
78
180
307
418
586
787 1018 1199 1493 1821 2011 2388 2647 2792 2746 2870 2712 2271 1278 252
0
400
800
1200
1600
2000
2400
2800
3200
Number of children and young people
with Type 1 diabetes reported to the audit
Age, sex and audit year

Figure 1: Total number of children and young people with Type 1 diabetes broken down by age and
sex 2020/21 - 2021/22
1.2.2 Regional distribution

Table 2 shows the number of children and young people with Type 1 diabetes by age category
included in the 2021/22 audit overall and by country and regional network. Children and young
people were allocated to a region and country based on the last paediatric diabetes unit (PDU)
that they attended within the audit year. Table 3 displays equivalent data for the seven NHS
England newly defined regions (https://www.england.nhs.uk/about/regional-area-teams/).

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NPDA National report 2021/22: Care processes and outcomes

Table 2: Number of children and young people with Type 1 diabetes by country, region and age
group, 2021/22
Region/Country
0-4
years
5-9
years
10-14
years
15-19
years
20-24
years
Total
(% of
cohort)
England and Wales
1,774
6,475
13,261
9,779
60
31,349
100.0%
England
1,693
6,151
12,564
9,370
60
29,778
95.2%
Wales
81
324
697
409
0
1,511
4.8%
East Midlands
133
482
934
659
0
2,208
7.1%
East of England
204
711
1,450
1021+
3,383
10.8%
London and South East
377
1,362
2,896
2,252
10
6,887
22.0%
North East and North Cumbria
104
390
741
539
0
1,774
5.7%
North West
210
772
1,635
1,219
15
3,836
12.3%
South Central
168
670
1,218
889+
2,944
9.4%
South West
146
494
1,062
736+
2,436
7.8%
West Midlands
186
660
1,394
1,061
22
3,301
10.6%
Yorkshire and Humber
165
610
1234
1,000
7
3,009
9.6%

+ Results merged to mask numbers <4

Table 3: Number of children and young people with Type 1 diabetes by NHS England region and
age group, 2021/22
NHS England region
0-4
years
5-9
years
10-14
years
15-19
years
20-24
years
Total
(% of
cohort)
East of England
214
760
1,530
1040+
3,541
11.3%
London
231
859
1,901
1,517
10
4,508
14.4%
Midlands
319
1,142
2,328
1,720
22
5,509
17.6%
North East and Yorkshire
269
1,000
1,975
1,539
7
4,783
15.3%
North West
210
772
1,635
1,219
15
3,836
12.3%
South East
282
991
1,919
1466+
4,657
14.9%
South West
168
627
1,276
875+
2,944
9.4%

+ Results merged to mask numbers <4
1.2.3 Ethnicity

The ethnic breakdown of children and young people with Type 1 diabetes reported to the 2021/22
audit is shown in Table 4. Percentages are also shown excluding ‘not stated’ and ‘unknown’
categories to allow for comparison with the United Kingdom 2021 census data (https://census.gov.
uk/). The distribution of Type 1 diabetes by ethnic status is similar to the background population.

8
NPDA National report 2021/22: Care processes and outcomes

Table 4: Ethnic groups of children and young people with Type 1 diabetes in England and Wales,
2021/22
No. of children and
young people with
T1 diabetes
Total
(% of cohort)
% of total with
known and
stated ethnicity
% of total
population**
White
24,879
79.4%
82.9%
81.7%
Asian
2,059
6.6%
6.9%
8.5%
Black
1,287
4.1%
4.3%
4.0%
Mixed
1,007
3.2%
3.4%
2.9%
Other
769
2.5%
2.6%
2.8%
Not stated
40
0.1%
-
-
Not known
1,308
4.2%
-
-

* Percentage of total population in 2021 England and Wales Census

** Chinese ethnicity census data has been included in the “Other” category to align with NHS data dictionary standards
1.2.4 Deprivation

Table 5 shows the number and percentages of children and young people with Type 1 diabetes by
deprivation quintile in 2021/22 based on patient postcode and the English and Welsh indices of
multiple deprivation (ONS, 2020a). Percentages are also shown excluding missing values to allow
for comparison with the breakdown of the general population aged 0 to 19 years old in England
and Wales (ONS, 2020b).

The deprivation breakdown shows a higher proportion of children and young people with Type 1
diabetes living in the most deprived quintile. This is consistent with the distribution of the general
population aged 0 to 19 years old in England and Wales.

Table 5: Percentage and number of children and young people with Type 1 diabetes by deprivation
quintile, 2021/22
Deprivation
quintile
Total
% of cohort
% of total
with known
deprivation
quintile
% of children and
young people
aged 0-19 yrs old
(England and
Wales)+
Most deprived
7,164
22.9%
22.9%
23.7%
Second most deprived
6,301
20.1%
20.1%
20.7%
Third least deprived
5,995
19.1%
19.1%
19.0%
Second least deprived
5,962
19.0%
19.0%
18.1%
Least deprived
5,887
18.8%
18.8%
18.5%
Missing
40
0.1%
-
-

+Percentage of general population aged 0 to 19 years old in England and Wales. Calculations made using the “Lower layer Super Output
Area population estimates” from the Office for National Statistics, mid-year 2020

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NPDA National report 2021/22: Care processes and outcomes
1.3 Prevalence and incidence of Type 1 diabetes
1.3.1 Prevalence

Figure 2 and Figure 3 show the prevalence rates of Type 1 diabetes in children and young people
aged 15 and below by sex and by age group over the last nine audit years, respectively.

The estimated prevalence rate of Type 1 diabetes in England and Wales was 213.9 per 100,000 of the
general population. It was slightly higher among boys (217.8 per 100,000) compared to girls (209.8
per 100,000), with no appreciable change over the last nine audit years.
2013/14
2014/15
2015/16
2016/17
2017/18
2018/19
2019/20
2020/21
2021/22
Boys
199.8
194.9
190.8
196.1
198.1
198.1
199.0
208.3
217.8
Girls
175.3
187.2
190.6
192.2
193.8
194.6
197.6
200.4
209.8
All
187.7
192.0
195.0
194.2
196.0
196.4
198.3
204.5
213.9
0
50
100
150
200
250
Prevalence per 100,000 general population
0-15 years old
Sex and audit year

Figure 2: Prevalence of Type 1 diabetes per 100,000 general population among children aged 0-15
years by age and sex, 2013/14 to 2021/22

10
NPDA National report 2021/22: Care processes and outcomes
0
50
100
150
200
250
300
350
400
0-4
5 - 9
10 - 14
0 - 4
5 - 9
10 - 14
0 - 4
5 - 9
10 - 14
Boys
Girls
All
Prevalence per 100,000 general
population
Age group, sex and audit year
2013/14
2014/15
2015/16
2016/17
2017/18
2018/19
2019/20
2020/21
2021/22

Figure 3: Prevalence of Type 1 diabetes per 100,000 general population by age group and sex,
2013/14 to 2021/22
1.3.2 Incidence

In 2021/22 there were 3,883 children and young people newly diagnosed with Type 1 diabetes, of
whom 3,730 (96.1%) were aged 0 to 15 years old. This is 884 more than the average number newly
diagnosed per annum being managed in a PDU between 2013/14-2020/21 (2,999).

Figure 4 shows the incidence of Type 1 diabetes among boys and girls aged 0-15 years, from 2013/14
to 2021/22. It shows an increase in both girls and boys in 2021/22 (a marginal increase of 0.4% in boys
and a more substantial 12.9% increase in girls) compared to 2020/21.

11
NPDA National report 2021/22: Care processes and outcomes
2013/14
2014/15
2015/16
2016/17
2017/18
2018/19
2019/20 2020/21
2021/22
Boys
24.8
28.0
24.8
25.9
26.0
25.8
27.0
33.9
34.1
Girls
20.8
24.4
20.8
24.4
24.2
23.3
24.3
27.7
31.3
All
22.8
26.5
22.8
25.4
25.1
24.6
25.7
30.9
32.7
0
5
10
15
20
25
30
35
40
Incidence per 100,000 general
population 0-15 years old
Sex and audit year

Figure 4: Incidence of Type 1 diabetes per 100,000 general population among children aged 0-15
years by sex, 2013/14 to 2021/22

Figure 5 shows that the consistent seasonal pattern of new diagnoses of Type 1 diabetes amongst
all children and young people receiving care from a PDU observed in previous audit years has
largely re-emerged since its disruption in 2020/21, albeit at a higher base rate.

12
NPDA National report 2021/22: Care processes and outcomes
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
2013/14
252
225
190
186
208
245
249
242
224
258
202
134
2014/15
262
224
188
181
213
241
245
207
253
293
236
182
2015/16
240
237
205
224
234
304
296
248
264
300
258
161
2016/17
278
243
227
192
259
264
278
262
251
294
210
180
2017/18
242
253
214
223
243
272
275
216
243
309
229
198
2018/19
245
215
217
203
248
258
274
265
222
312
231
205
2019/20
241
251
221
217
231
268
256
270
293
286
257
146
2020/21
194
281
308
316
302
339
379
320
296
287
301
339
2021/22
377
382
332
304
291
348
351
328
288
321
280
281
0
50
100
150
200
250
300
350
400
Number of children diagnosed with
Type 1 diabetes
Month of diagnosis

Figure 5: Number of new cases of Type 1 diabetes amongst children and young people receiving
care from a PDU by month, 2013/14-2021/22

Figure 6 shows the breakdown of the age at diagnosis for both boys and girls with Type 1 diabetes
in 2021/22.

13
NPDA National report 2021/22: Care processes and outcomes
397
647
841
198
359
652
649
134
0
200
400
600
800
1000
0 to 4 years
5 to 9 years
10 to 14 years
15+
Newly diagnosed children and young
people with Type 1 diabetes
Sex and age group
Boys
Girls

Figure 6: Newly diagnosed children and young people with Type 1 diabetes by age group and sex,
2021/22

Figure 7 shows the incidence of Type 1 diabetes among boys and girls different age groups, from
2013/14 to 2021/22. It shows an increase in incidence in every age group for both boys and girls
compared to 2020/21, with the exception of boys aged 10-14, where a slight decrease is observed.
0
5
10
15
20
25
30
35
40
45
50
0 - 4
5 - 9
10 - 14
0 - 4
5 - 9
10 - 14
0 - 4
5 - 9
10 - 14
Boys
Girls
All
Incidence per 100,000 general population
Age group, sex and audit year
2013/14
2014/15
2015/16
2016/17
2017/18
2018/19
2019/20
2020/21
2021/22

Figure 7: Incidence of Type 1 diabetes per 100,000 general population by age group and sex, 2013/14
to 2021/22

14
NPDA National report 2021/22: Care processes and outcomes

Though incidence of Type 1 diabetes among children and young people has increased, Figure 8
shows that the age profile of new patients largely mirrors that seen in 2020/21.
0
50
100
150
200
250
300
350
400
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
Numbers of new cases of Type 1
diabetes
Age

Figure 8: Numbers of new cases of Type 1 diabetes presenting in 2020/21 and 2021/22 by age at the
beginning of the audit year

Figure 9 shows the incidence per 100,000 of Type 1 diabetes by NHS network in England and Wales.

Figure 9: Incidence of Type 1 diabetes amongst children and young people aged 0-15 years per
100,000 by NHS network.

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NPDA National report 2021/22: Care processes and outcomes
1.4 Characteristics of children and young people
with Type 2 diabetes

In 2021/22, there were 1,144 children and young people with Type 2 diabetes being cared for in a
PDU, of whom 281 (24.6%) were newly diagnosed within the audit year. Prevalence and/or incidence
rates of Type 2 diabetes cannot be accurately calculated from NPDA data as an unknown number
of children and young people are treated for Type 2 diabetes in primary care and will therefore not
be included in the paediatric audit. However, there appears to be a year-on-year increase in the
number of children and young people with Type 2 diabetes being managed within PDUs. For
instance, in 2021/22 there was an increase of 171 (17.6%) compared to the total number reported for
the 2020/21 audit year. Figure 10 shows the numbers of children and young people with Type 2
diabetes being managed within a PDU since 2011/12.
2011/12
2012/13
2013/14
2014/15
2015/16
2016/17
2017/18
2018/19
2019/20
2020/21
2021/22
Type 2 diabetes
448
326
340
544
621
715
745
790
866
973
1144
% Total cohort
1.8%
1.3%
1.3%
2.0%
2.2%
2.5%
2.5%
2.6%
3.0%
3.1%
3.4%
448
326
340
544
621
715
745
790
866
973
1144
0.0%
0.5%
1.0%
1.5%
2.0%
2.5%
3.0%
3.5%
0
200
400
600
800
1000
1200
1400
Percentage of total NPDA cohort
Number of children and young people
with Type 2 diabetes

Figure 10: Numbers of children and young people with Type 2 diabetes included in the NPDA,
2011/12- 2021/22
1.4.1 Age and sex

Figure 11 shows the age and sex breakdown of children and young people with Type 2 diabetes. The
numbers start to fall from the age of 16 likely due to transitioning to adult services. In every age
category there is a higher proportion of girls with Type 2 diabetes. Figure 12 also shows that there
were higher numbers of young people with Type 2 diabetes aged 16-18 receiving care from PDUs in
2021/22 compared to 2020/21.

16
NPDA National report 2021/22: Care processes and outcomes
0-9
10
11
12
13
14
15
16
17
18+
Boys
11
6
16
28
39
79
76
83
68
43
Girls
17
22
35
44
85
97
104
129
99
61
2021/22
28
28
51
72
124
176
180
212
167
104
2020/21
17
24
41
71
108
123
186
191
115
96
0
50
100
150
200
250
Number of children and young people with
Type 2 diabetes
Age and sex

Figure 11: Numbers of children and young people with Type 2 diabetes by sex, 2021/22 and changes
in numbers between 2020/21 and 2021/22.
1.4.2 Regional distribution

Table 6 shows the number of children and young people with Type 2 diabetes by country, region
and NHS England region, based on PDU location.

Table 6: Number of children and young people with Type 2 diabetes by country, region and NHS
England region, 2021/22
Region/Country
5-9 years
10-14
years
15-19
years
20-24
years
Total
(% of
cohort)
England and Wales
24
452
664+
1,144
100%
England
24
439
649+
1,116
98%
Wales
0
13
15
0
28
2%
Regional Network
East Midlands
4
31
36
0
71
6%
East of England
0
37
40
0
79
7%
London and South East
7
143
238+
390
34%
North East and North
0
20
30
0
50
4%
North West
8
55
72
0
135
12%
South Central
40+
30
0
70
6%
South West
0
17
31
0
48
4%
West Midlands
50+
105
0
155
14%
Yorkshire and Humber
51+
67
0
118
10%

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NPDA National report 2021/22: Care processes and outcomes
Region/Country
5-9 years
10-14
years
15-19
years
20-24
years
Total
(% of
cohort)
NHS England region
East of England
0
48
41
0
91
8%
London
6
120
211+
337
29%
Midlands
5
80
141
0
226
20%
North East and Yorkshire
71+
97
0
168
15%
North West
8
55
72
0
135
12%
South East
50+
53
0
105
9%
South West
0
20
34
0
54
5%

+Results merged to mask numbers <4
1.4.3 Ethnicity

Table 7 shows the breakdown of children and young people with Type 2 diabetes by ethnic category.
The percentage of the general population in each ethnic category according to the most recent
census is presented to enable comparison of prevalence of Type 2 diabetes within each category.
Most children and young people with Type 2 diabetes were of non-White ethnicity, and the
prevalence of Type 2 diabetes in children of non-White ethnicity is disproportionately higher than
the prevalence of non-White ethnicity in the general population. The breakdown in 2021/22 was
similar compared to 2020/21.

Table 7: Children and young people with Type 2 diabetes in England and Wales by ethnic group,
2021/22
Ethnicity
Total
% of cohort
% of total with
stated ethnicity
% of total
population*
White
398
34.8%
37.8%
81.7%
Asian
380
33.2%
36.1%
8.5%
Black
163
14.2%
15.5%
4.0%
Mixed
58
5.1%
5.5%
2.9%
Other
54
4.7%
5.1%
2.8%
Not stated
91
8.0%
-
-

*Percentage of total population in 2021 England and Wales Census

** Chinese ethnicity census data has been included in the “Other” category to align with NHS data dictionary standards

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NPDA National report 2021/22: Care processes and outcomes
1.4.4 Deprivation

Table 8 shows that there were a disproportionate number of children and young people with Type
2 diabetes living in the most deprived areas compared to the least deprived. This trend was
observed in previous audit years.

Table 8: Numbers and percentages of children and young people with Type 2 diabetes by
deprivation quintile, 2021/22
Deprivation quintile
Total
% of cohort
% of total with
known
deprivation*
% of children and
young people
aged 0-19 years
old (England and
Wales)**
Most deprived
493
43.1%
43.2%
23.7%
Second most deprived
305
26.7%
26.8%
20.7%
Third least deprived
177
15.5%
15.5%
19.0%
Second least deprived
91
8.0%
8.0%
18.1%
Least deprived
74
6.5%
6.5%
18.5%
Missing
4
0.3%
-
-

* Percentages within deprivation quintiles have been calculated excluding those without an allocated quintile due to missing data, to
allow comparison to the age group 0-19 years old in England and Wales, 2020.

** Percentage of general population aged 0 to 19 years old in England and Wales. Calculations made using the “Lower layer Super Output
Area population estimates” from the Office for National Statistics, mid-year 2020.
2. Completion of annual health checks
2.1 Completion of health checks for children and
young people with Type 1 diabetes
2.1.1 Completion of key health checks

Health checks recommended by NICE for children and young people with Type 1 diabetes (NG18,
NICE 2015; NG19, 2015) should be performed at least once annually.

Prior to 2020/21 the NPDA reported on the following seven to be the ‘key’ annual checks:
•
Glycated Haemoglobin A1c (HbA1c) (blood test for diabetes control)
•
Body Mass Index (BMI) (measure of cardiovascular risk)
•
Blood pressure (measure of cardiovascular risk)
•
Urinary albumin (urine test for kidney function)
•
Thyroid screen (blood test for hyper/hypothyroidism)
•
Eye screening (photographic test for eye disease risk)
•
Foot examination (foot examination for ulcer risk)

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NPDA National report 2021/22: Care processes and outcomes

From the 2020/21 audit year onwards, retinopathy screening reduced from an annual to a biennual
schedule, unless retinopathy was observed at a previous screen, for many services in England. In
view of this change, and in line with the 2020/21 audit, the NPDA describes six ‘key annual checks’,
excluding retinopathy screening. Guidelines specify a starting age of 12 years for commencing all
checks except for HbA1c and measurement of height and weight, which should be recorded in all
ages of children and young people with Type 1 diabetes, and thyroid screening, which should be
performed at diagnosis and annually thereafter.

In 2021/22, there were 24,989 children and young people with Type 1 diabetes who completed a full
year of care (i.e. who did not transition to adult services, did not die, and were not diagnosed within
the audit year), of whom 15,009 (60.1%) were aged 12 and above. Table 9 shows the percentage of
children and young people recorded as receiving essential healthcare checks in the audit year,
from 2015/16 to 2021/22.

Table 9: Percentage of children and young people with Type 1 diabetes who completed a full year
of care recorded as receiving health checks, 2015/16 to 2021/22
Age
Health check completion
Audit year
2015/16
2016/17
2017/18
2018/19
2019/20 2020/21
2021/22
All
ages
No. of children and young
people with T1 diabetes (n)
22,567
22,933
23,130
23,223
22,638
24,138
24,989
HbA1c (%)
99.2
99.5
99.4
99.4
99.7
90.6
98.3
BMI (%)
97.9
98.7
98.9
99.2
99.3
78.6
96.7
Thyroid (%)
77.7
81.8
84
87.2
87.8
77.9
84.1
Aged
12 and
above
No. of young people with
T1 diabetes (n)
13,313
13,437
13,363
13,391
13,266
14,449
15,009
Blood pressure (%)
90.8
92.7
94.6
96.2
96.5
70.4
92.4
Urinary albumin (%)
66.0
68.7
74.3
78.3
79.1
64.4
75.5
Foot Exam (%)
65.8
72.8
78.2
82.5
84.3
57.1
78.7
All seven health checks* (%)
35.5
43.5
49.8
55.2
54.4
-
-
All six health checks (%)*
40.2
59.7

* Includes retinal screening – one of the key annual checks until 2020/21

** Excludes retinal screening due to change in screening interval for 2020/21 and 2021/22

Figure 12 shows completion rates from 2004/05 up until 2021/22. Comparisons of completion rates
prior to 2015/16 should be reviewed with caution as they included both Type 1 and Type 2 diabetes.
However, given that most children and young people reported to the audit have Type 1 diabetes,
the improvements in completion rates are likely to reflect real improvements in health check
completion and/or completeness of data submitted to the NPDA.

Figure 12 shows that the decline in health check completion rates recorded in the 2020/21 audit has
largely reversed, although each rate remains below its pre-pandemic peak.

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NPDA National report 2021/22: Care processes and outcomes
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2004/05
2005/06
2006/07
2007/08
2008/09
2009/10
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
2016/17
2017/18
2018/19
2019/20
2020/21
2021/22
All types of diabetes
Type 1 only**
% of children and young people who completed
a full year of care
Audit year
HbA1c
Blood pressure*
BMI
Urinary albumin*
Cholesterol*
Eye screen*
Foot Exam*
Thyroid

* health checks completed on children and young people aged 12 or older

Figure 12: Percentage of children and young people who completed a full year of care recorded as
receiving individual health checks, 2004/05 to 2021/22

Figure 13 shows a strong recovery in the proportion of all children with Type 1 diabetes who
completed a year of care in 2021/22 receiving all six key annual healthcare checks, surpassing the
percentage receiving all seven health checks in the years prior to the pandemic (when retinopathy
screening was included).

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NPDA National report 2021/22: Care processes and outcomes
2.0% 2.6% 3.6% 5.0% 5.2% 4.1% 5.8% 6.7%
12.1%
16.1%
25.4%
35.5%
43.5%
49.8%
55.2% 54.4%
40.2%
59.7%
0%
10%
20%
30%
40%
50%
60%
70%
2004/05
2005/06
2006/07
2007/08
2008/09
2009/10
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
2016/17
2017/18
2018/19
2019/20
2020/21
2021/22
All types of diabetes
Type 1 only
Type 1
only-
six
checks*
% of young people aged 12 or older who completed a full
year of care
Audit year

* Retinopathy screening was removed from the ‘seven key health checks’ analysis in 2020/21 due to changes in frequency of screening
during this audit year. The percentage receiving all of the remaining six key annual checks is presented instead for these audit years.

Figure 13: Percentage of young people aged 12 or above who completed a full year of care recorded
as receiving all seven/six key health checks, 2004/05 to 2021/22

2.1.1.1 Retinopathy screening

Retinopathy screening intervals changed for many services in England in 2020/21. Rather than
screening all those with diabetes aged 12 and above annually, many were advised to screen
biennially unless an abnormal result was observed at a previous annual screen. In 2021/22, 62.6% of
children and young people with Type 1 diabetes aged 12 and above received a screen, an increase
from 24.3% in 2020/21.

In 2020/21, 720 young people with Type 1 diabetes had an abnormal eye screen recorded, of whom
570 were also captured in the 2021/22 audit dataset. Figure 14 shows that 59.5% of those who had
an abnormal eye screen result in 2020/21 had an eye screen in 2021/22. This percentage is similar to
the percentage of those with a normal retinopathy result recorded in 2020/21 who also received an
eye screen in 2021/22, and is well below the target (100%) screening rate for those with known
retinopathy.

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NPDA National report 2021/22: Care processes and outcomes
39.9%
40.5%
60.1%
59.5%
0%
20%
40%
60%
80%
100%
Normal eye screen results in
2020/21 and captured in 2021/22
dataset (n=3,113)
Abnormal eye screen results in
2020/21 and captured in 2021/22
dataset (n=570)
Didn't have eye screen in 2021/22
Had eye screen in 2021/22

Figure 14: Percentage of children and young people aged 12 and above in 2020/21 receiving
retinopathy screening in 2021/22, by screening result in 2020/21
2.1.2 Variation in key health check completion

2.1.2.1 Variation in completion rates nationally and regionally

Table 10 and Table 11 provide a breakdown of the health checks recorded for children and young
people with Type 1 diabetes with a complete year of care in 2021/22 by regional network, NHS
England region, country and overall, in England and Wales. Table 10 contains data on the health
checks received by all children and young people with Type 1 diabetes and Table 11 contains data
on the health checks received by those aged 12 and above.

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NPDA National report 2021/22: Care processes and outcomes

Table 10: Percentage of children and young people of all ages with Type 1 diabetes who completed
a full year of care recorded as having received health checks by country, region and NHS England
region, 2021/22
Country/Region
No. of children
and young
people with
Type 1 diabetes
Percentage completing health checks
HbA1c (%)
BMI (%)
Thyroid (%)
England and Wales
24,989
98.3
96.7
84.1
England
23,800
98.2
96.8
83.8
Wales
1,189
99.2
95.5
89.1
Regional Network
East Midlands
1,739
99.8
97.0
87.9
East of England
2,793
98.7
97.4
79.3
London and South East
5,539
96.6
95.8
78.9
North East and North Cumbria
1,422
99.2
97.8
91.1
North West
3,083
98.0
96.9
86.9
South Central
2,261
98.6
98.3
86.6
South West
1,960
99.2
98.2
84.3
West Midlands
2,620
98.0
95.1
82.1
Yorkshire and Humber
2,383
99.1
96.8
88.4
NHS England region
East of England
2,915
98.0
96.8
79.4
London
3,693
95.4
95.1
79.3
Midlands
4,359
98.7
95.8
84.4
North East and Yorkshire
3,805
99.1
97.2
89.4
North West
3,083
98.0
96.9
86.9
South East
3,602
99.3
98.2
82.2
South West
2,343
99.2
98.3
85.0

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NPDA National report 2021/22: Care processes and outcomes

Table 11: Percentage of young people aged 12 and above with Type 1 diabetes who completed a full
year of care recorded as having received health checks by country and region, 2021/22
Country/Region
No. of young
people aged 12
and above with
Type 1 diabetes
Percentage completing health checks
Foot
exam (%)
Blood
pressure
(%)
Urinary
albumin
(%)
All six
(%)
England and Wales
15,009
78.7
92.4
75.5
59.7
England
14,302
78.4
92.5
75.0
59.1
Wales
707
84.9
90.5
83.9
72.0
Regional Network
East Midlands
1,021
79.5
95.3
82.2
66.3
East of England
1,665
74.0
94.5
68.5
50.9
London and South East
3,358
74.4
90.6
72.2
53.5
North East and North Cumbria
857
76.3
93.6
83.8
63.8
North West
1,910
79.5
92.1
73.7
58.5
South Central
1,279
75.8
89.7
77.3
59.1
South West
1,158
73.7
93.5
71.5
54.5
West Midlands
1,571
84.7
91.9
72.1
63.0
Yorkshire and Humber
1,483
90.3
94.9
84.4
73.2
NHS England region
East of England
1,731
72.1
91.8
68.5
49.3
London
2,289
69.9
91.3
72.9
53.4
Midlands
2,592
82.7
93.2
76.1
64.3
North East and Yorkshire
2,340
85.2
94.4
84.1
69.7
North West
1,910
79.5
92.1
73.7
58.5
South East
2,066
82.4
91.3
73.7
58.2
South West
1,374
72.8
93.2
73.4
54.9

2.1.2.2 Variation in completion rates across PDUs

Figure 15 shows the percentage of eligible children and young people with Type 1 diabetes receiving
each specific key annual health check against PDU from least to most completed in 2021/22.

25
NPDA National report 2021/22: Care processes and outcomes
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Percentage of children and young peopke with Type 1
diabetes receivimg each health check per PDU
PDUs
HbA1c 1+ in audit
Thyroid
Body mass index
Blood pressure (aged 12+)
Albuminuria (aged 12+)
Foot examination (aged 12+)

Figure 15: Percentage of children and young people with Type 1 diabetes receiving each key health
check by PDU, 2021/22

Figure 16 shows the variation by PDU in the percentage of young people aged 12 years and older
who were recorded to have received all six key health checks in 2021/22. The horizontal navy line
shows the mean completion rate for England and Wales, and the dotted lines indicate PDUs whose
results are within two standard deviations (dashes) or three standard deviations (dots) of the mean.
There remains considerable variation in percentage of young people receiving all six health checks
across PDUs.

26
NPDA National report 2021/22: Care processes and outcomes
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0
50
100
150
200
250
300
350
% of young people with Type 1 diabetes aged 12
and above receiving all six healthchecks
Number of young people with Type 1 diabetes aged 12 and above who completed
a full year of care
English PDUs
Welsh PDUs
95% level (2 SD)
99% level (3 SD)
Mean (England and Wales)

Figure 16: Percentage of young people aged 12 years and above with Type 1 diabetes who completed
a full year of care recorded as receiving all six health checks by unit, 2021/22

Figure 17 plots the overall PDU health check completion rates against the total number of young
people with Type 1 diabetes aged 12 and above who completed a full year of care in each unit. The
health check completion rate is calculated by dividing the sum of the number of health checks
received by young people with Type 1 diabetes aged 12 and above who completed a full year of care
by the sum of the total expected number of health checks. The total expected number of health
checks is equal to the number of young people, with Type 1 diabetes aged 12 and above who
completed a full year of care, multiplied by six (i.e., the number of health checks that they should have
received within the audit year). This metric is used in the NPDA to determine outlier status, with
PDUs below the bottom dotted line (>3SD) considered ‘alarm’ outliers, as they were recording
significantly fewer key health checks than other PDUs in England and Wales.

27
NPDA National report 2021/22: Care processes and outcomes


55%
60%
65%
70%
75%
80%
85%
90%
95%
100%
0
50
100
150
200
250
300
350
Health check completion rate
Number of young people with Type 1 diabetes aged 12 and above who completed
a full year of care 2021/22
English PDUs
Welsh PDUs
95% level (2 SD)
99% level (3 SD)
Mean (England and Wales)
Figure 17: Funnel plot of key health check completion rates for young people aged 12 years and
above with Type 1 diabetes who completed a full year of care 2021/22, by PDU
2.1.3 Number of HbA1c measurements received

NICE (NG18) recommends that a minimum of four HbA1c measurements are offered to children
and young people with Type 1 diabetes per annum (NICE, 2015). Figure 18 shows the percentage of
children and young people with Type 1 diabetes receiving a full year of care by number of HbA1c
measurements received in the audit year. It shows that the percentage of children and young
people with Type 1 diabetes receiving four or more measurements (28.8%) was close to half that
recorded in 2019/20 (53.1%).

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NPDA National report 2021/22: Care processes and outcomes
2016/17
2017/18
2018/19
2019/20
2020/21
2021/22
0
0.5%
0.6%
0.6%
0.3%
9.4%
1.7%
1
4.5%
4.3%
3.7%
3.6%
26.0%
9.2%
2
12.9%
11.4%
10.6%
11.7%
28.3%
19.3%
3
29.1%
29.0%
27.7%
31.2%
21.4%
29.2%
4 or more
52.9%
54.6%
57.5%
53.1%
14.9%
28.8%
0%
10%
20%
30%
40%
50%
60%
70%
% of children and young people with Type 1 diabetes who completed a full year of
care

Figure 18: Percentage of children and young people with Type 1 diabetes who completed a full year of
care by number of HbA1c measurements recorded per child or young person, 2016/17 to 2021/22

Table 12 shows the percentage of children and young people with Type 1 diabetes receiving a full
year of care by number of HbA1c measurements in each country and region.

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NPDA National report 2021/22: Care processes and outcomes

Table 12: Percentage of children and young people with Type 1 diabetes who completed a full year
of care by number of HbA1c measurements recorded in 2021/22, by country, region and NHS
England region
Country/Region
Total
None (%)
One (%)
Two (%)
Three (%)
Four (%)
England and Wales
24,989
1.7
9.2
19.3
29.2
40.6
England
23,800
1.8
9.4
19.4
28.9
40.4
Wales
1,189
0.8
4.9
16.7
33.6
44.0
Regional Network
East Midlands
1,739
0.2
4.0
10.9
25.2
59.6
East of England
2,793
1.3
13.8
23.4
25.3
36.2
London and South East
5,539
3.4
11.5
21.1
28.0
36.0
North East and North Cumbria
1,422
0.8
4.6
15.5
34.7
44.4
North West
3,083
2.0
12.3
27.1
30.7
27.9
South Central
2,261
1.4
6.4
10.6
27.5
54.1
South West
1,960
0.8
6.3
20.0
33.3
39.6
West Midlands
2,620
2.0
11.3
20.6
29.1
37.1
Yorkshire and Humber
2,383
0.9
5.7
16.0
30.0
47.3
NHS England region
East of England
2,915
2.0
15.8
22.6
24.6
35.0
London
3,693
4.6
13.4
21.1
27.8
33.1
Midlands
4,359
1.3
8.4
16.7
27.6
46.0
North East and Yorkshire
3,805
0.9
5.3
15.8
31.8
46.2
North West
3,083
2.0
12.3
27.1
30.7
27.9
South East
3,602
0.7
5.7
16.0
28.3
49.3
South West
2,343
0.8
5.5
19.0
32.7
42.0
2.1.4 Nutrition and lifestyle education and support

NICE (NG18) recommends offering children and young people with diabetes dietetic support to
help optimise body weight and blood glucose control (NICE, 2015), and NHS England’s Best Practice
Tariff criteria for paediatric diabetes care (NHS England, 2020) include the offering of an additional
dietetic appointment outside of MDT clinic meetings. A lower take up rate of dietetic appointments
outside of appointments with the rest of the MDT should be interpreted with caution, as it could
reflect satisfaction with the advice shared during routine MDT appointments rather than a lack of
engagement with the service.

Of those children and young people with Type 1 diabetes who completed a full year of care, 87.8%
were offered an additional dietetic appointment, compared to 82.5% in 2020/21. Table 13 shows the
percentages who were offered an additional appointment and attended the offered appointment
within the audit year by country, region and NHS England region.

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NPDA National report 2021/22: Care processes and outcomes

Table 13: Percentage of children and young people with Type 1 diabetes who completed a full year
of care who were offered and/or attended an additional dietetic appointment by country and
region, 2021/22
Country/Region
Total
Appointment
offered
Appointment
attended
England and Wales
24,989
87.8
53.1
England
23,800
88.6
53.6
Wales
1,189
71.7
42.9
Regional Network
East Midlands
1,739
70.7
55.3
East of England
2,793
84.9
55.0
London and South East
5,539
90.2
53.7
North East and North Cumbria
1,422
88.5
63.0
North West
3,083
88.0
62.0
South Central
2,261
91.4
49.4
South West
1,960
90.8
44.2
West Midlands
2,620
95.7
57.2
Yorkshire and Humber
2,383
91.1
41.8
NHS England region
East of England
2,915
84.3
54.6
London
3,693
90.9
50.3
Midlands
4,359
85.8
56.4
North East and Yorkshire
3,805
90.2
49.7
North West
3,083
88.0
62.0
South East
3,602
90.8
52.8
South West
2,343
90.9
48.7

The percentage of appointments attended decreased with age and duration of diabetes, from
62.3% of those four years old or younger to 47% in the group aged 15 years old or older (Figure 19).
62.3%
56.3% 54.7%
47.0%
62.9%
56.1%
52.1% 49.2% 46.8%
41.8%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
0 to 4 5 to 9
10 to
14
15 to
19
Less
than 1
year
1-2
years
3-4
years
5-9
years
10-14
years
15+
years
Age group
Duration of diabetes
Offered dietetic appointments
attended

Figure 19: Percentage of offered dietetic appointments attended by age group and duration of
diabetes, 2021/22

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NPDA National report 2021/22: Care processes and outcomes
2.1.5 Completion of all other annual health checks

The NPDA also collects data on four additional health checks for children and young people with
Type 1 diabetes as recommended by NICE 2015 (NG18):
•
Psychological assessment (assessment for need of psychological support)
•
Offering of immunisation against influenza
•
Advice about managing diabetes (‘sick-day rules’)
•
Using (or trained to use) blood ketone testing strips and a meter
•
Smoking status check

Results are shown in Table 14.

Table 14: Percentage of children and young people with Type 1 diabetes who completed a full year
of care recorded as receiving health checks by region and country, 2021/22
Country/Region
Total
Flu
vaccine
(%)
Sick day
rules (%)
Blood
ketone
testing
(%)
Psycholog­
ical
assess­
ment (%)
Smoking
health
check
(%)*
England and Wales
24,989
87.2
88.0
91.0
80.3
90.0
England
23,800
86.9
87.7
90.7
80.5
89.6
Wales
1,189
93.1
94.1
97.3
75.3
99.6
Regional Network
East Midlands
1,739
95.9
97.6
98.3
77.5
92.4
East of England
2,793
74.3
86.8
83.2
66.2
80.6
London and South East
5,539
82.6
87.5
88.8
80.7
89.4
North East and North Cumbria
1,422
96.2
82.0
90.7
94.4
83.4
North West
3,083
87.0
86.6
92.1
74.6
97.7
South Central
2,261
88.6
82.5
88.1
85.7
86.7
South West
1,960
83.0
83.4
87.1
76.8
86.3
West Midlands
2,620
93.7
93.2
96.5
84.7
94.0
Yorkshire and Humber
2,383
93.2
89.4
95.4
92.0
91.4
NHS Network
East of England
2,915
72.2
84.7
83.9
63.7
78.5
London
3,693
79.4
84.1
86.3
87.1
88.1
Midlands
4,359
94.6
95.0
97.2
81.8
93.4
North East and Yorkshire
3,805
94.3
86.6
93.7
92.9
88.5
North West
3,083
87.0
86.6
92.1
74.6
97.7
South East
3,602
90.0
89.0
90.5
80.7
91.5
South West
2,343
85.4
84.8
87.3
76.1
86.3

* Percentage of young people aged 12 and above with Type 1 diabetes

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NPDA National report 2021/22: Care processes and outcomes

Approximately 2.8% of young people were recorded as smoking within the audit year and of those,
28.6% were offered a referral to smoking cessation services, compared to 39.3% in 2020/21. The
proportion of current smokers was higher in boys (3.1%) than girls (2.5%), and higher among those
living in the least deprived areas (2.9%) than in the most deprived areas (2.2%).

Figure 20 shows a return close to the levels seen immediately prior to the pandemic in the
percentage of children and young people with type 1 diabetes being offered flu vaccination, “Sick
day rules” advice and blood ketone testing.
2017/18
2018/19
2019/20
2020/21
2021/22
Psychological assessment
86.6%
85.7%
84.4%
71.6%
80.3%
Flu vaccine recommended
75.9%
81.2%
87.6%
80.3%
87.2%
‘Sick day rules’
77.4%
83.6%
88.7%
82.1%
88.0%
Blood ketone testing
82.7%
88.0%
91.9%
86.9%
91.0%
50%
55%
60%
65%
70%
75%
80%
85%
90%
95%
100%
% of children and young people
who complete a full year of care

Figure 20: Completion rates for psychological assessment, flu vaccine recommendation, “Sick day
rules” advice and blood ketone testing, for children and young people with Type 1 diabetes who
completed a full year of care, 2017/18 to 2021/22
2.1.6 Care at diagnosis

2.1.6.1 Screening for autoimmune conditions

Children and young people with Type 1 diabetes are at greater risk of having other autoimmune
conditions. NG18 (NICE, 2015) and NG20 (NICE, 2015) recommend screening for thyroid and coeliac
disease at diagnosis.

Figure 21 shows the percentage of children and young people diagnosed more than 90 days before
the end of the audit year (n=2,990), who received screening for coeliac and thyroid disease within
90 days of diagnosis. In 2021/22 completion of both health checks at diagnosis were at their highest
rates seen in recent years.

33
NPDA National report 2021/22: Care processes and outcomes
2015/16
2016/17
2017/18
2018/19
2019/20
2020/21
2021/22
Thyroid
67.8%
78.9%
83.8%
88.8%
85.2%
86.6%
91.2%
Coeliac
62.3%
72.6%
80.2%
82.9%
81.3%
83.8%
87.0%
91.2%
87.0%
0%
20%
40%
60%
80%
100%
% of newly diagnosed children and young people
with Type 1 diabetes

Figure 21: Percentage of newly diagnosed children and young people with Type 1 diabetes who
received screening for thyroid and coeliac disease within 90 days of diagnosis, 2015/16 to 2021/22

2.1.6.2 Level 3 carbohydrate counting

NICE guidance (NG18, NICE 2015) recommends offering level 3 carbohydrate-counting education
to children and young people with Type 1 diabetes from diagnosis.

Figure 22 shows the percentage of children and young people diagnosed more than 14 days before
the end of the audit year (n=3,754) who received level 3 carbohydrate-counting education within 14
days of diagnosis from 2017/18 to 2021/22.

34
NPDA National report 2021/22: Care processes and outcomes
Carb counting %
2017/18
67.6%
2018/19
75.6%
2019/20
82.5%
2020/21
82.1%
2021/22
85.9%
0%
20%
40%
60%
80%
100%
% of newly diagnosed children and young people
with Type 1 diabetes

Figure 22: Percentage of newly diagnosed children and young people with Type 1 diabetes who
received level 3 carbohydrate counting education within 14 days of diagnosis, 2017/18 to 2021/22
2.2 Health checks for children and young people
with Type 2 diabetes

The health checks for children and young people with Type 2 diabetes recommended in NG18 and
NG19 (NICE, 2015) differ slightly from those for Type 1 diabetes. The NPDA includes cholesterol
screening as one of the six essential annual checks for those with Type 2 rather than thyroid
screening. All should be performed annually from diagnosis, except for foot examination, which is
indicated from age 12, and eye screening, which is also indicated from 12, and indicated biannually
from 2020 onwards (previously annually). In 2021/22, there were 694 children and young people
who completed a full year of care (i.e. were not diagnosed, did not die and did not transition to
adult services within the audit year) recorded as having Type 2 diabetes, of whom 654 (94.2%) were
aged 12 years and above.

35
NPDA National report 2021/22: Care processes and outcomes
2.2.1 Completion of key health checks

Figure 23 shows the percentage of children and young people with Type 2 diabetes who completed
a full year of care recorded as receiving each of the six recommended health checks from 2015/16
to 2021/22.
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2015/16
2016/17
2017/18
2018/19
2019/20
2020/21
2021/22
% of children and young people with Type 2 diabetes
who completed a full year of care
Audit year
HbA1c
BMI
Cholesterol
Urinary
albumin
Blood
pressure
Eye screen*
Foot exam*
All 7 care
processes*
All 6 care
processes**

*Health check for those aged 12 and above

**Excludes retinal screening due to a change in screening frequency

Figure 23: Percentage of children and young people with Type 2 diabetes who completed a full
year of care recorded as receiving key health checks, 2015/16 to 2021/22

Table 15 shows the percentage of children and young people with Type 2 diabetes recorded as
receiving recommended health checks in the audit year, from 2015/16 to 2021/22.

36
NPDA National report 2021/22: Care processes and outcomes

Table 15: Percentage of children and young people with Type 2 diabetes who completed a full year
of care recorded as receiving recommended health checks, 2015/16 to 2021/22
Age
Health check
Audit year
2015/16
2016/17
2017/18
2018/19
2019/20
2020/21
2021/22
All ages
No. of children and
young people (n)
412
473
470
501
534
618
694
HbA1c (%)
97.3
96.6
96.8
97.8
95.3
82.7
92.1
BMI (%)
94.4
94.1
94.5
95
94.2
69.1
87.9
Cholesterol (%)
59.2
66.4
67.9
70.5
64.4
58.3
61.10
Aged 12
and
above
No. of young people (n)
390
436
436
470
499
577
654
Urinary albumin (%)
51.7
56.7
58.9
62.1
62.1
48.9
56.1
Blood pressure (%)
85
86
88.5
90.9
89.6
63.1
82.1
Foot Exam (%)
50
50.2
61.7
67
65.1
40.4
44.8
All six health checks (%)
16.7
21.3
25.7
30.9
26.7
24.1
57.2

2.2.2 Number of HbA1c measurements

Figure 24 shows that 26.7% of children and young people with Type 2 diabetes recorded as completing
a full year of care received the recommended four or more HbA1c measurements in the year, a partial
return to the pattern observed prior to the 2020/21 audit year (between 30% and 35%).
2016/17
2017/18
2018/19
2019/20
2020/21
2021/22
None
3.8%
3.2%
2.2%
4.7%
17.3%
7.9%
1
15.4%
18.7%
15.2%
11.6%
34.5%
17.1%
2
22.8%
21.3%
21.2%
24.7%
25.6%
22.0%
3
27.5%
25.7%
26.5%
26.0%
12.0%
26.2%
4+
30.4%
31.1%
34.9%
33.0%
10.7%
26.7%
0%
5%
10%
15%
20%
25%
30%
35%
40%
% of children and young people with Type 2 diabetes
who completed a full year of care

Figure 24: Number of HbA1c measurements recorded for children and young people with Type 2
diabetes receiving a full year of care, 2016/17 – 2021/22

37
NPDA National report 2021/22: Care processes and outcomes
2.2.3 Completion of all other health checks

Table 16 shows the percentage of children and young people with Type 2 diabetes completing a
full year of care (n=694) recorded as being offered and attending an additional dietetic appointment
outside of routine MDT clinics with the rest of the MDT present. Lower uptake may be indicative of
satisfaction with advice provided in routine clinics rather than lack of engagement with dietetic
services.

Table 16: Percentage of children and young people with Type 2 diabetes who completed a full year
of care recorded as being offered and attending an additional dietetic appointment, 2017/18 to
2021/22
England and Wales
2017/18
2018/19
2019/20
2020/21
2021/22
Appointment offered (%)
70.0
80.0
80.0
78.3
78.7
Appointment attended (%)
48.7
48.5
56.0
56.3
57.3

The NPDA also collects data on four additional health checks for children and young people with
Type 2 diabetes:
•
Psychological assessment (assessment for need of psychological support)
•
Offering of immunisation against influenza
•
Advice about managing diabetes during sickness (‘sick day rules’)
•
Smoking status

Results are shown in Table 17 for all children and young people with Type 2 diabetes and a complete
year of care (n= 694).

Table 17: Percentage of young people with Type 2 diabetes who completed a full year of care
recorded as receiving health checks by region and country, 2017/18 to 2021/22
Health checks
England and Wales
2017/18
2018/19
2019/20
2020/21
2021/22
Assessment for need of
psychological support (%)
77.9
75
70.8
60.5
70.5
Flu vaccine recommendation (%)
49.4
69.3
67.8
63.3
70.5
‘Sick day rules’ advice (%)
41.7
51.5
53
48.5
52.7
Smoking status check (%)*
83.3
84.3
85.0
83.7
85.9

*percentage of children and young people age 12 and above

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NPDA National report 2021/22: Care processes and outcomes
3. Outcomes
3.1 HbA1c

HbA1c is a marker of overall diabetes blood glucose levels over the preceding six to eight weeks
and is associated with lifetime risk of microvascular complications. There is clear evidence from
the DCCT trial (The Diabetes Control and Complications Trial Research Group, 1993) and the follow
up EDIC trial (Nathan et al., 2005) that good diabetes management in childhood tracks into
adulthood with a lower risk of developing vascular complications and early mortality in the future.

In 2015, NICE (NG18, 2015) introduced a stricter HbA1c target of 48mmol/mol or less to indicate
excellent diabetes management for both Type 1 and 2 diabetes and requested that providers also
report those achieving a level of 53 mmol/mol or below. To allow historical benchmarking, the
NPDA also reports the numbers achieving the previous NICE (2004) target of 58 mmol/mol or
below and an HbA1c level above 80mmol/mol representing considerable increased risk of both
microvascular diabetic complications (eye disease and kidney disease) and cardiovascular
disease.

Average HbA1c and the proportion of children and young people meeting specific HbA1c targets
vary depending on the type of diabetes. Children and young people with non-Type 1 diabetes
tend to have a lower HbA1c than those with Type 1 diabetes. Some of the data presented below
refer to children and young people with all types of diabetes whilst other sections detail the
results of those with Type 1 or Type 2 diabetes separately. Numbers of children and young people
with other types of diabetes were too low to enable meaningful analysis.

This section of the report seeks to answer the following audit questions:

1. What are the average HbA1c levels and percentage of children and you people with diabetes
hitting targets in England and Wales for 2021/22, and

2. What are the longitudinal changes?
3.2 HbA1c outcomes of children and young people
with all types of diabetes

Figure 25 shows the median HbA1c for children and young people with all types of diabetes, in
England and Wales, from 2009/10 to 2021/22. The timeline below the graph highlights key quality
improvement initiatives implemented in England and Wales over the same period.

39
NPDA National report 2021/22: Care processes and outcomes
Internal and
external peer
reviews of Quality
standards and
on-going
participation in
quality
improvement
methodology
training

60
62
64
66
68
70
72
74
2009/10 2010/11
2011/12 2012/13 2013/14 2014/15 2015/16 2016/17 2017/18 2018/19 2019/20 2020/21 2021/22
Median HbA1c (mmol/mol)
England
Wales
Regional
networks
established,
England

Best
Practice
Tariff
introduced,
England

Quality
Assurance
(peer
review),
England
Diabetes
Delivery
Plans,
England &
Wales
Quality
Assurance
(peer
review),
Wales
Regional
networks
established,
Self-assessment
QA started,
England &
Wales
Updated
Diabetes
Delivery Plan
published
2016, Wales
National
Diabetes QI
Programme
introduced,
England &
Wales

Figure 25: Median HbA1c for children and young people with all types of diabetes in England and
Wales 2009/10 to 2021/22, with associated NHS policy and/or paediatric diabetes delivery structural
changes
3.3 HbA1c outcomes of children and young people
with Type 1 diabetes

The results presented in this section pertain to children and young people with Type 1 diabetes and
show the variation in HbA1c outcomes nationally and regionally as well as by patient characteristics.
3.3.1 National and regional unadjusted HbA1c results

Table 18 shows the unadjusted mean and median HbA1c results for children and young people
with Type 1 diabetes achieved by region and country. The unadjusted mean HbA1c was 63.8 mmol/
mol, which is a decrease of 0.4 mmol/mol from 2020/21. The median HbA1c was 61.0 mmol/mol,
unchanged from 2020/21. Table 19 shows the equivalent data by NHS England region.

40
NPDA National report 2021/22: Care processes and outcomes

Table 18: HbA1c for all children and young people with Type 1 diabetes with one or more valid
HbA1c measurement by country and regional network 2021/22
Country/
Region
No. of children and
young people with
Type 1 diabetes
Mean
mmol/mol
Standard
deviation
mmol/mol
Median
mmol/mol
Interquartile
range mmol/
mol
England and Wales
28,983
63.8
16.2
61.0
17.5
England
27,568
63.7
16.3
61.0
17.0
Wales
1,415
64.9
15.8
62.0
17.0
East Midlands
2,067
61.3
14.6
59.0
15.0
East of England
3,146
64.0
16.9
61.0
18.5
London and South East
6,311
64.9
16.8
62.0
18.0
North East and
North Cumbria
1,661
62.2
15.4
59.5
15.5
North West
3,556
65.2
16.5
62.0
18.0
South Central
2,698
61.6
14.8
59.0
15.5
South West
2,282
62.4
15.6
60.0
16.5
West Midlands
3,033
64.4
16.2
62.0
17.0
Yorkshire and Humber
2,814
63.9
17.0
60.7
17.0

Table 19: HbA1c for all children and young people with Type 1 diabetes with one or more valid
HbA1c measurement by NHS England region 2021/22
NHS England region
No. of children and
young people with
Type 1 diabetes
Mean
mmol/mol
Standard
deviation
mmol/mol
Median
mmol/mol
Interquartile
range mmol/
mol
East of England
3,254
63.8
16.8
61.0
18.0
London
4,107
64.7
17.2
61.5
19.0
Midlands
5,100
63.2
15.6
60.5
17.0
North East and Yorkshire
4,475
63.3
16.4
60.0
16.0
North West
3,556
65.2
16.5
62.0
18.0
South East
4,327
63.4
15.6
61.0
15.4
South West
2,749
62.4
15.4
60.0
16.5

Figure 26 shows the percentages of children and young people with Type 1 diabetes achieving
each of the NICE (2015) treatment targets from 2014/15 to 2021/22. Figure 26 also includes the
percentages of children and young people with Type 1 diabetes who achieved the NICE (2004)
treatment targets of below 58 mmol/mol, between 58 mmol/mol and 80 mmol/mol, and above 80
mmol/mol from 2010/11 to 2013/14. Table 20 displays this information by country and region, and
Table 21 does so by NHS England region.

41
NPDA National report 2021/22: Care processes and outcomes

6.4%
6.5%
7.5%
7.2%
10.3%
10.6%
11.8%
12.2%
6.8%
8.2%
8.8%
8.9%
11.4%
11.4%
12.6%
13.0%
10.3%
11.9%
12.6%
12.5%
14.3%
14.1%
13.4%
14.2%
34.3%
34.8%
34.3%
34.8%
33.3%
33.1%
32.4%
32.1%
13.4%
14.1%
13.7%
13.7%
11.5%
11.5%
10.6%
11.0%
7.5%
6.6%
6.7%
6.5%
5.2%
5.3%
6.3%
5.0%
15.8%
17.4%
15.8%
18.4%
55.5%
57.5%
58.4%
58.3%
28.7%
25.1%
25.9%
23.9%
21.3%
17.9%
16.4%
16.5%
14.1%
14.0%
12.9%
12.5%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
2016/17
2017/18
2018/19
2019/20
2020/21
2021/22
% of children and young people with Type 1 diabetes
≤48 mmol/mol
>48 and ≤53 mmol/mol
>53 and <58 mmol/mol
≥58 and <69 mmol/mol
≥69 and ≤75 mmol/mol
>75 and ≤80 mmol/mol
<58 mmol/mol*
>58 and ≤80 mmol/mol*
>80 mmol/mol
* NICE (2004) treatment targets from 2010/11 to 2013/14

Figure 26: Percentage of children and young people with Type 1 diabetes with an HbA1c result
within current and previous target ranges, 2010/11 - 2021/22

42
NPDA National report 2021/22: Care processes and outcomes

Table 20: Percentage of children and young people with Type 1 diabetes achieving HbA1c targets
by country and regional network, 2021/22
Country/regional
network
≤48
mmol/
mol (%)
≤53
mmol/
mol (%)
<58
mmol/
mol (%)
58-80
mmol/
mol (%)
≥69
mmol/
mol (%)
>75
mmol/
mol (%)
>80
mmol/
mol (%)
England and Wales
12.2
25.2
39.5
48.1
28.4
17.5
12.5
England
12.3
25.4
39.7
47.9
28.3
17.4
12.4
Wales
9.5
21.6
35.0
50.9
31.3
19.2
14.1
East Midlands
13.8
28.4
44.9
46.5
22.9
12.7
8.6
East of England
13.7
26.6
40.4
46.3
29.9
19.0
13.3
London and South East
11.3
23.2
37.1
48.4
31.2
19.5
14.5
North East and North Cumbria
14.3
28.5
43.1
45.6
24.3
14.9
11.3
North West
10.1
22.6
35.2
50.8
32.5
19.6
14.0
South Central
13.7
28.7
44.4
46.6
22.2
13.2
9.0
South West
14.8
28.5
42.4
47.2
25.5
14.9
10.4
West Midlands
10.7
23.3
37.6
49.6
29.8
18.6
12.8
Yorkshire and Humber
12.0
25.0
39.9
47.7
27.3
17.6
12.4

Table 21: Percentage of children and young people with Type 1 diabetes achieving HbA1c targets
by NHS England region, 2021/22
NHS England region
≤48
mmol/
mol (%)
≤53
mmol/
mol (%)
<58
mmol/
mol (%)
58-80
mmol/
mol (%)
≥69
mmol/
mol (%)
>75
mmol/
mol (%)
>80
mmol/
mol (%)
East of England
13.7
26.8
40.6
46.4
29.4
18.7
13.0
London
13.0
25.6
38.7
46.2
31.5
20.4
15.0
Midlands
12.0
25.4
40.6
48.4
27.0
16.2
11.1
North East and Yorkshire
12.9
26.3
41.1
46.9
26.2
16.6
12.0
North West
10.1
22.6
35.2
50.8
32.5
19.6
14.0
South East
10.8
23.8
39.4
49.3
26.5
15.5
11.3
South West
14.7
28.1
42.2
47.5
25.2
14.9
10.3

43
NPDA National report 2021/22: Care processes and outcomes
3.3.2 HbA1c outcomes by sex

Figure 27 shows that the mean HbA1c has decreased at a similar rate for both boys and girls with
Type 1 diabetes over the last 18 years. It also shows that girls have had a consistently higher mean
HbA1c than boys.
2003
/04
2004
/05
2005
/06
2006
/07
2007
/08
2008
/09
2009
/10
2010/
11
2011/1
2
2012/
13
2013/
14
2014/
15
2015/
16
2016/
17
2017/
18
2018/
19
2019/
20
2020
/21
2021/
22
Boys
75.9
73.8
73.5
73.5
73.9
74.2
74.6
73.6
72.9
71.4
70.2
69.8
67.5
66.6
67.0
64.7
64.7
63.7
63.2
Girls
77.1
75.5
75.1
75.3
75.6
75.8
76.4
75.4
74.5
72.8
72.0
71.4
69.1
68.1
68.0
65.4
65.3
64.8
64.4
60
62
64
66
68
70
72
74
76
78
80
Mean HbA1c (mmol/mol)
Boys
Girls

Figure 27: Mean HbA1c for boys and girls with Type 1 diabetes, 2003/04 to 2021/22
3.3.3 HbA1c outcomes by age and duration of diabetes

Figure 28 shows mean unadjusted HbA1c by duration of diabetes in 2021/22. Children and young
people of all age groups had higher HbA1c from two years following diagnosis, with the exception
of those aged 0-4 years. After the first year following diagnosis, those aged 15-19 had consistently
higher HbA1c than other age groups.

44
NPDA National report 2021/22: Care processes and outcomes
Less
than 1
year
1-2 years 2-3 years
3-4
years
4-5
years
5-10
years
10-15
years
15+ years
Age 5 to 9
56.9
59.8
60.2
60.2
59.8
60.5
Age 10 to 14
57.6
63.9
65.7
65.3
64.8
65.0
65.4
Age 15 to 19
56.3
65.6
67.9
70.0
69.3
69.6
69.4
67.7
50
55
60
65
70
75
Mean HbA1c (mmol/mol)

Figure 28: Mean HbA1c for children and young people with Type 1 diabetes in England and Wales
by duration of diabetes and age group, 2021/22
3.3.4 HbA1c outcomes by ethnicity

Figure 29 shows that whilst there have been overall improvements in the average HbA1c amongst
children and young people with Type 1 diabetes in all ethnic categories since 2011/12, there have
been consistent differences in HbA1c outcomes between those in different ethnic categories, with
those of White and Other ethnicities having lower average HbA1cs and those of Black ethnicity
having the highest average HbA1c year on year.

45
NPDA National report 2021/22: Care processes and outcomes


2003/04
2004/05
2005/06
2006/07
2007/08
2008/09
2009/10
2010/11
2011/12
2012/13
2013/14
2014/15
2015/16
2016/17
2017/18
2018/19
2019/20
2020/21
2021/22
White
76.4
74.7
73.9
73.6
74.4
74.4
75.0
73.9
73.2
71.6
70.5
69.9
67.7
66.7
67.0
64.6
64.6
63.9
63.4
Asian
81.5
78.2
77.0
78.3
76.0
76.7
76.3
74.9
74.3
73.1
72.5
72.2
69.3
68.7
68.8
66.2
65.8
65.2
65.0
Black
81.5
80.1
79.8
81.3
80.2
81.3
81.9
81.1
81.0
78.9
78.0
77.8
74.0
74.2
74.9
71.4
71.9
70.9
70.7
Mixed
82.5
80.5
75.5
78.6
79.0
77.8
78.1
78.1
77.0
74.5
73.7
73.3
70.6
68.7
69.6
67.5
67.4
67.2
66.4
Other
75.1
73.8
75.7
75.4
74.0
74.1
77.5
72.9
73.4
73.2
72.1
72.3
69.6
68.2
67.0
63.7
63.0
63.3
62.7
60.0
65.0
70.0
75.0
80.0
85.0
Mean HbA1c (mmol/mol)
White
Asian
Black
Mixed
Other
Figure 29: Mean HbA1c for children and young people with Type 1 diabetes in England and Wales
by ethnic group, 2003/04 to 2021/22

Table 22 provides a breakdown of average HbA1c by ethnic group and deprivation. It shows that
overall, living in a less deprived area was associated with lower HbA1c amongst those of all ethnicities,
except for those of Black ethnicity. It also shows that that the average HbA1c for children and young
people of Black ethnicity living in the least deprived areas was similar to that of children of Asian
and White ethnicity living in the most deprived areas.

Table 22: Mean HbA1c for children and young people with Type 1 diabetes by ethnic category and
deprivation quintile, 2021/22*
Ethnicity
Most
deprived
Second most
deprived
Third least
deprived
Second least
deprived
Least deprived
White
67.2
64.8
63.3
61.7
60.1
Asian
68.3
63.8
62.5
63.4
60.8
Black
71.9
71.2
66.2
70.5
68.6
Mixed
69.2
67.7
67.1
63.5
61.1
Other
64.7
63.5
62.8
60.5
57.4

*The colour scale (red-white-green) indicates mean HbA1c levels (higher-mid-lower).

Figure 30 shows the percentage of children and young people with Type 1 diabetes meeting HbA1c
treatment targets. It shows that results of those of White or Other ethnicity skew towards the lower
targets, whereas those of Black or Mixed ethnicity skew above these targets.

46
NPDA National report 2021/22: Care processes and outcomes
8.9%
10.9%
11.2%
12.3%
11.4%
8.2%
10.4%
9.8%
13.5%
14.2%
9.7%
12.9%
12.6%
14.6%
15.4%
27.8%
31.1%
32.0%
32.5%
33.3%
12.0%
11.1%
15.6%
10.6%
9.5%
8.1%
7.0%
5.8%
4.8%
5.7%
25.4%
16.7%
13.0%
11.8%
10.5%
0%
20%
40%
60%
80%
100%
Black
Mixed
Asian
White
Other
≤48 mmol/mol
>48 and ≤53 mmol/mol
>53 and <58 mmol/mol
≥58 and <69 mmol/mol
≥69 and ≤75 mmol/mol
>75 and ≤80 mmol/mol
>80 mmol/mol

Figure 30: Percentage of children and young people with Type 1 diabetes in England and Wales
achieving HbA1c targets by ethnic group, 2021/22
3.3.5 HbA1c outcomes by deprivation quintile

NPDA results have consistently shown an association between higher HbA1c and living in more
deprived areas. Figure 31 shows that in 2021/22 there was a reduction in mean HbA1c within each
deprivation quintile compared to 2020/21, except for the second most deprived quintile which
remained stable.

47
NPDA National report 2021/22: Care processes and outcomes
2013/14
2014/15
2015/16
2016/17
2017/18
2018/19 2019/20 2020/21 2021/22
Most deprived
74.7
73.7
71.6
70.7
70.9
68.2
68.3
67.8
67.6
Second most deprived
74.0
72.3
69.6
68.7
68.7
66.2
66.1
65.2
65.2
Third least deprived
72.2
70.6
68.1
67.0
67.5
65.0
65.1
64.4
63.3
Second least deprived
70.4
69.0
66.7
65.6
65.9
63.4
62.7
62.3
61.8
Least deprived
69.0
67.2
64.8
64.0
64.2
61.9
62.0
60.7
60.1
60
62
64
66
68
70
72
74
76
Mean HbA1c (mmol/mol)

Figure 31: Mean HbA1c for children and young people with Type 1 diabetes by deprivation quintile,
2013/14 to 2021/22

Figure 32 shows the percentages of children and young people with Type 1 diabetes achieving
treatment targets by deprivation quintile. Results of those in the least deprived areas skewed
towards lower targets, whereas those of children and young people living in the most deprived
areas skewed towards the higher cut offs.
9.2%
10.3%
13.1%
13.6%
15.5%
9.3%
11.6%
14.1%
14.7%
16.3%
11.8%
13.7%
14.0%
15.5%
16.7%
31.9%
32.9%
31.4%
32.6%
31.9%
12.9%
11.8%
10.4%
10.1%
9.2%
6.8%
5.8%
5.0%
3.8%
3.2%
18.2%
14.0%
12.1%
9.7%
7.1%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Most
deprived
Second most
deprived
Third least
deprived
Second least
deprived
Least
deprived
≤48 mmol/mol
>48 and ≤53 mmol/mol
>53 and <58 mmol/mol
≥58 and <69 mmol/mol
≥69 and ≤75 mmol/mol
>75 and ≤80 mmol/mol
>80 mmol/mol

Figure 32: Percentage of children and young people with Type 1 diabetes in England and Wales
achieving HbA1c targets by deprivation quintile, 2021/22

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NPDA National report 2021/22: Care processes and outcomes
3.3.6 HbA1c outcomes across PDUs in England and Wales

Figure 33 shows the median HbA1c value for all PDUs in England and Wales. Median HbA1c values
by PDU ranged from 54 mmol/mol to 69 mmol/mol.
50
52
54
56
58
60
62
64
66
68
70
Median PDU HbA1c in mmol/mol
National Median
Paediatric diabetes unit

Figure 33: Median HbA1c per PDU 2021/22

Figure 34 shows the percentage of children and young people with Type 1 diabetes achieving the
HbA1c target of <58 mmol/mol by PDU. The overall percentage achieving this target was 39.5%
(37.9% in 2020/21). The percentages achieving this target per PDU ranged from 19.2% to 72.7%.
0%
10%
20%
30%
40%
50%
60%
70%
80%
% of children and young people
Overall national %
Paediatric diabetes unit

Figure 34: Percentage of children and young people with HbA1c <58mmol/mol per PDU 2021/22

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NPDA National report 2021/22: Care processes and outcomes
3.4 HbA1c outcomes of children and young people
with Type 2 diabetes

HbA1c outcomes are jointly reported for England and Wales given the smaller numbers of children and
young people with Type 2 diabetes included within the audit. The mean and median HbA1c of children
and young people with Type 2 diabetes in England and Wales receiving care in a PDU in 2021/22 were
58.5 and 50 mmol/mol (Table 23), respectively: both lower than in 2020/21, with a narrower interquartile
range.

Table 23: HbA1c for all children and young people with Type 2 diabetes and one or more valid
HbA1c measurements in England and Wales, 2015/16 - 2021/22
Audit year
No. of children and
young people with
Type 2 diabetes
HbA1c in mmol/mol
Mean
Standard
deviation
Median
Interquartile
range
2021/22
929
58.5
23.1
50.0
27.5
2020/21
676
61.0
24.8
53.0
33.5
2019/20
731
58.6
23.6
51.0
28.0
2018/19
674
57.4
23.5
49.5
26.0
2017/18
650
61.3
25.3
53.0
28.5
2016/17
605
60.2
24.6
52.0
33.5
2015/16
539
59.7
25.4
51.0
30.5

Figure 35 shows variation in the percentages of children and young people with Type 2 diabetes
achieving HbA1c targets since 2017/18, with no strong trends across this period. There has been
improvement when compared directly to the previous 2020/21 audit year, however, with an increase
in those achieving the recommended target of lower or equal to 48 mmol/mol of 5.7%, and a
decrease of 2.3% in those recording HbA1c levels greater than 80mmol/mol.
46.6%
40.9%
44.3%
46.6%
40.5%
8.9%
9.9%
10.8%
11.9%
9.8%
6.7%
7.2%
6.7%
6.2%
7.7%
12.1%
11.4%
12.0%
11.3%
13.8%
4.1%
5.3%
5.5%
5.3%
5.4%
4.1%
5.3%
3.6%
2.5%
3.8%
17.5%
19.8%
17.1%
16.2%
18.9%
2021/22
2020/21
2019/20
2018/19
2017/18
% of children and young people with Type 2 diabetes
≤48 mmol/mol
>48 and ≤53 mmol/mol
>53 and <58 mmol/mol
≥58 and <69 mmol/mol
≥69 and ≤75 mmol/mol
>75 and ≤80 mmol/mol
>80 mmol/mol

Figure 35: Percentage of children and young people with Type 2 diabetes with an HbA1c result
within current and previous target ranges, 2017/18 - 2021/22

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NPDA National report 2021/22: Care processes and outcomes
3.4.1 HbA1c outcomes by sex

Figure 36 provides a breakdown of mean HbA1c amongst children and young people with Type 2
diabetes by sex in each audit year. It shows variation between the audit years, including a decrease
in mean HbA1c from the previous audit year (2020/21), and a tendency for girls to have higher
HbA1c.
2017/18
2018/19
2019/20
2020/21
2021/22
Boys
60.2
57.5
57.1
60.6
57.1
Girls
61.7
57.3
59.3
61.2
59.3
54
55
56
57
58
59
60
61
62
63
Mean HbA1c (mmol/mol)

Figure 36: Mean HbA1c for boys and girls with Type 2 diabetes, 2017/18 to 2021/22
3.4.2 HbA1c outcomes by duration of Type 2 diabetes

Figure 37 shows a trend of HbA1c increasing after the first year of diagnosis for children and young
people with Type 2 diabetes.
Less than 1
year
(n=404)
1-2 years
(n=325)
2-3 years
(n=89)
3-4 years
(n=49)
4-5 years
(n=38)
5-10 years
(n=22)
Children and young people with
Type 2 diabetes
50.8
62.5
64.8
68.6
72.3
65.6
45
50
55
60
65
70
75
Mean HbA1c (mmol/mol)

Figure 37: Mean HbA1c for children and young people with Type 2 diabetes, by duration of diabetes,
2021/22

51
NPDA National report 2021/22: Care processes and outcomes
3.4.3 HbA1c outcomes by deprivation quintile

Figure 38 shows variation in mean HbA1c by deprivation quintile across audit years. In the 2021/22
audit year, increased deprivation correlates with increases in mean HbA1c.
2015/16
2016/17
2017/18
2018/19
2019/20
2020/21
2021/22
Least deprived
55.5
54.1
59.4
50.5
49.1
52.4
53.5
Second least deprived
55.6
57.9
61.8
55.6
59.7
56.5
55.8
Third least deprived
56.2
60.3
57.7
59.1
56.6
62.4
58.1
Second most deprived
59.4
61.2
61.0
54.5
58.7
60.0
58.8
Most deprived
62.4
61.4
61.9
59.6
60.0
63.2
59.8
45
50
55
60
65
Mean HbA1c (mmol/mol)

Figure 38: Mean HbA1c for children and young people with Type 2 diabetes in England and Wales
by deprivation quintile, 2015/16 to 2021/22
3.4.4 HbA1c outcomes by ethnic category

Figure 39 shows that White children and young people with Type 2 diabetes had lower mean
HbA1c than those in other ethnic categories. Black children and young people with Type 2 diabetes
had higher mean HbA1c than those in other ethnic categories, although there was a substantial
decrease compared to the previous audit year (72.2 mmol/mol to 63.4 mmol/mol). These trends
largely mirror those seen with Type 1 diabetes.

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NPDA National report 2021/22: Care processes and outcomes
White
Asian
Black
Mixed
Other
2015/16
56.8
58.7
69.9
52.1
61.3
2016/17
55.6
61.3
71.9
64.0
62.9
2017/18
57.9
61.0
75.2
58.6
61.5
2018/19
54.1
58.0
66.9
60.2
56.7
2019/20
54.7
59.4
66.1
59.6
57.0
2020/21
57.1
61.6
72.2
61.7
61.2
2021/22
56.4
58.9
63.4
60.4
61.0
45
50
55
60
65
70
75
Mean HbA1c (mmol/mol)

Figure 39: Mean HbA1c for children and young people with Type 2 diabetes by ethnic category,
2015/16-2021/22
3.5 Small vessel (microvascular) disease

People with diabetes are at increased risk of microvascular disease including diabetic kidney
disease (nephropathy) and diabetic eye disease (retinopathy). This chapter explores the incidence
and demographics of early signs of microvascular disease in children with diabetes
3.5.1 Diabetic kidney disease

Annual albuminuria screening is recommended by NICE (2015) in all children with Type 1 diabetes
aged 12 and above, and for all those with Type 2 diabetes of any age. The presence of significant
albuminuria may be indicative of progressive diabetic kidney disease.

3.5.1.1 Albuminuria in young people with Type 1 diabetes

Nearly two-thirds (n = 12,580) of young people with Type 1 diabetes aged 12 years and above were
recorded as receiving an albuminuria screen during the audit period. Of those, 96.7% (n =12,162)
had a valid interpretation of their urinary albumin level. Increased risk of kidney disease is indicated
by the presence of either micro- or macro-albuminuria. Figure 40 shows that 11.5% of young people
in England and Wales with Type 1 diabetes were recorded as having micro- or macro-albuminuria.

53
NPDA National report 2021/22: Care processes and outcomes
88.5%
88.4%
91.2%
86.6%
88.5%
88.4%
92.6%
86.9%
82.7%
86.2%
90.8%
92.7%
88.9%
87.1%
89.1%
92.7%
86.9%
89.4%
80.8%
11.5%
11.6%
8.8%
13.4%
11.5%
11.6%
7.4%
13.1%
17.3%
13.8%
9.2%
7.3%
11.1%
12.9%
10.9%
7.3%
13.1%
10.6%
19.2%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
England and Wales
England
Wales
East Midlands
East of England
London and South East
North East and North Cumbria
North West
South Central
South West
West Midlands
Yorkshire and Humber
East of England (NHSE)
London (NHSE)
Midlands (NHSE)
North East and Yorkshire (NHSE)
North West (NHSE)
South East (NHSE)
South West (NHSE)
% of children and young people with Type 1 diabetes
Normo-albuminuria
Micro- or macro- albuminuria

Figure 40: Percentage of young people with Type 1 diabetes aged 12 years and older with
albuminuria by country, regional network and NHS England (NHSE) network

Table 24 shows that the percentage of young people with Type 1 diabetes aged 12 years and above
with albuminuria has remained stable since 2015/16.

Table 24: Percentage of young people with Type 1 diabetes aged 12 years and above with
albuminuria, 2015/16 to 2021/22
Audit Year
Total (n)
Normo-albuminuria (%)
Micro- or macro-
albuminuria (%)
2021/22
12,162
88.5
11.5
2020/21
9,785
89.7
10.3
2019/20
11,270
88.9
11.1
2018/19
11,075
90.2
9.8
2017/18
10,631
89.8
10.2
2016/17
9,938
90.0
10.0
2015/16
9,364
90.1
9.9

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NPDA National report 2021/22: Care processes and outcomes

Figure 41 shows slight variations in the presence of albuminuria by duration of diabetes between
the audit years, with small increases in most age groups except for those aged less than 1 year and
between 10-14 years.
Less than 1
year
1-2 years
3-4 years
5-9 years
10-14 years
15+ years
2016/17
10.6%
9.1%
8.7%
11.4%
9.2%
10.2%
2017/18
10.7%
8.9%
9.9%
10.3%
10.8%
13.5%
2018/19
10.8%
9.8%
10.2%
9.0%
9.9%
11.4%
2019/20
8.6%
10.3%
10.1%
11.9%
12.4%
11.3%
0%
3%
6%
9%
12%
15%
18%
% of young people with Type 1 diabetes

Figure 41: Percentage of young people with Type 1 diabetes aged 12 years and above with
albuminuria by duration of diabetes, 2016/17 - 2021/22

Figure 42 shows little difference in rates of albuminuria by age and sex, with boys having a
marginally higher rate at every age, with the exceptions of ages 12 and 18.

55
NPDA National report 2021/22: Care processes and outcomes
12
13
14
15
16
17
18
Boys
10.9%
10.9%
12.4%
11.9%
13.5%
11.3%
11.2%
Girls
12.3%
10.1%
11.4%
11.2%
11.4%
10.4%
12.3%
0%
3%
6%
9%
12%
15%
% of young people with Type 1 diabetes
Age and sex

Figure 42: Percentage of young people with Type 1 diabetes aged 12 years and above with
albuminuria by age and sex, 2016/17 - 2021/22

Figure 43 shows that prevalence of albuminuria decreased in nearly all deprivation quintiles in
2021/22, but no clear relationship between prevalence of albuminuria and deprivation.
Most deprived
Second most
deprived
Third least
deprived
Second least
deprived
Least deprived
2016/17
12.0%
11.1%
8.6%
10.0%
8.4%
2017/18
11.2%
11.0%
10.4%
9.5%
9.1%
2018/19
9.8%
10.0%
9.4%
10.4%
9.4%
2019/20
10.3%
10.9%
10.3%
12.2%
11.9%
2020/21
10.2%
10.5%
10.5%
9.9%
10.3%
2021/22
11.5%
12.9%
11.6%
10.4%
11.0%
0%
3%
6%
9%
12%
15%
% of young people with
Type 1 diabetes
Deprivation quintile

Figure 43: Percentage of young people with Type 1 diabetes aged 12 years and above with
albuminuria by deprivation quintile, 2016/17 - 2021/22

56
NPDA National report 2021/22: Care processes and outcomes

Figure 44 shows that young people with Type 1 diabetes and higher HbA1c tend to be more at risk
of albuminuria. It also shows that albuminuria can be present even amongst those meeting the
lower HbA1c targets.
10.4%
11.8%
10.2%
12.3%
12.3%
13.4%
26.4%
30.3%
10.2%
11.5%
6.5%
5.6%
23.9%
15.1%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Micro/macro albuminuria
Normoalbuminuria
≤48 mmol/mol
>48 and ≤53 mmol/mol
>53 and <58 mmol/mol
≥58 and <69 mmol/mol
≥69 and ≤75 mmol/mol
>75 and ≤80 mmol/mol
>80 mmol/mol

Figure 44: Percentage of young people with Type 1 diabetes achieving HbA1c targets by presence
of albuminuria, 2021/22

3.5.1.2 Albuminuria in children and young people with Type 2 diabetes

Figure 45 shows that albuminuria was present in 20.6% of children and young people with Type 2
diabetes with a valid PDU interpretation of their urinary albumin level (n=480) in 2021/22. The
percentage of children and young people with Type 2 diabetes with albuminuria is almost twice
that recorded for young people with Type 1 diabetes (11.5%) – indicating that children and young
people with Type 2 diabetes are at greater risk of kidney disease.
14.6%
21.0%
22.1%
20.6%
25.7%
23.4%
20.6%
0%
5%
10%
15%
20%
25%
30%
2015/16
2016/17
2017/18
2018/19
2019/20
2020/21
2021/22
% of children and young people with
albuminuria
Audit year

Figure 45: Percentage of children and young people with Type 2 diabetes with albuminuria in
England and Wales, 2015/16 - 2021/22

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NPDA National report 2021/22: Care processes and outcomes
3.5.2 Eye Disease

3.5.2.1 Retinopathy in young people with Type 1 diabetes

There were 10,866 young people with Type 1 diabetes aged 12 years and above recorded as receiving
an eye screen during the audit period. Of those, 96.3% (n = 10,468) had a valid eye screen result
recorded. Table 25 shows that 11.4% of young people with Type 1 diabetes aged 12 and above had an
abnormal eye screen result recorded within the audit period. This percentage is lower than the
rates seen immediately prior to the pandemic, despite young people with known retinopathy
being prioritized for screening in many areas since 2020/21, which could skew the results.

The NPDA only records an eye screen as being normal or abnormal. Most abnormal screens in this
age group are likely to represent background retinopathy.

Table 25: Percentage of young people with Type 1 diabetes aged 12 years and above with a normal/
abnormal eye screening result, 2015/16 to 2021/22
Audit Year
Total (n)
Normal %
Abnormal %
2021/22
10,866
88.6
11.4
2020/21
4,247
83.1
16.9
2019/20
10,852
88.0
12.0
2018/19
11,431
86.9
13.1
2017/18
11,134
87.2
12.8
2016/17
9,938
85.2
14.8
2015/16
9,788
84.7
15.3

Figure 46 provides a breakdown of screening results in 2021/22 of all those who also had a recorded
retinopathy screening result in 2020/21. It shows that of those with a normal result in 2020/21, a
tenth (9.3%) were found to have retinopathy in 2021/22, whilst almost half (47.2%) of those with
retinopathy in 2020/21 had a normal result in 2021/22. If the young people without retinopathy in
2020/21 who were screened for retinopathy in 2021/22 are representative, these results suggest that
moving to a biennial screening frequency could lead to similar percentages of young people
missing a timely retinopathy diagnosis if biennial screening intervals are maintained.

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NPDA National report 2021/22: Care processes and outcomes
90.7%
47.2%
9.3%
52.8%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Normal results in 2020/21 (n=1828)
Abnormal results in 2020/21 (n=337)
% of young people with
Type 1 diabetes
Normal results in 2021/22
Abnormal result in 2021/22

Figure 46: Retinopathy screening outcomes of young people aged 12 years and above with Type 1
diabetes in 2021/22 by result of screening 2020/21

3.5.2.2 Retinopathy in young people with Type 2 diabetes

Figure 47 shows that 8.4% of young people with Type 2 diabetes aged 12 years and above with a
valid eye screening result (n=383) had an abnormal result, a marked increase on previous audit
years. The rate of retinopathy found amongst young people with Type 1 diabetes was 11.4% by
comparison.
6.2%
4.8%
5.6%
6.7%
6.1%
3.5%
8.4%
0%
1%
2%
3%
4%
5%
6%
7%
8%
9%
2015/16
2016/17
2017/18
2018/19
2019/20
2020/21
2021/22
% of children and young people with Type
2 diabetes
Audit year

Figure 47: Eye screening results for young people aged 12 years and above with Type 2 diabetes
2015/16 to 2021/22

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NPDA National report 2021/22: Care processes and outcomes
3.6 Large vessel disease – Cardiovascular Disease
(CVD) risk factors

People with diabetes are at an increased risk of cardiovascular disease secondary to macrovascular
risk factors including high blood pressure, abnormal lipid levels and high body mass index. This
chapter examines the prevalence of these risk factors, and patient characteristics associated with
higher risk for them.
3.6.1 Blood pressure and cholesterol

High blood pressure and/or raised blood cholesterol increases lifetime risk of cardiovascular disease,
including stroke and heart disease. In adults with Type 1 diabetes, maintaining normal blood
pressure and cholesterol within target (less than 5 mmol/L) reduces this risk. Although screening
of total cholesterol levels is no longer a mandatory requirement for children and young people
with Type 1 diabetes following NICE guidance NG18 (2015), results are still presented where data
have been submitted. Diastolic and systolic blood pressure measurements were converted to age-
and sex-adjusted centiles using survey data between 1995 and 1998 from the general population
aged between 4 and 24 years old (Jackson et al., 2007).

3.6.1.1 Blood pressure and cholesterol in young people with Type 1 diabetes

Table 26 and Table 27 shows the percentages of young people aged 12 and above with Type 1
diabetes with a recorded blood pressure in the audit period (n=16,377) classified as having ‘high
normal’ (91st -98th centile) or ‘high’ blood pressure (>98th centile), by country, regional network
and NHS England region. Three-tenths of young people (30%) with Type 1 diabetes had high blood
pressure (hypertension); this represents a slight decrease compared to the figure reported in the
2020/21 audit (31%).

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NPDA National report 2021/22: Care processes and outcomes

Table 26: Percentage of young people with Type 1 diabetes aged 12 years and above falling within
blood pressure ranges by country and regional network, 2021/22
‘High normal’ blood pressure
(91st–98th centile)
High blood pressure
(>98th centile)
Country/region
Diastolic
(%)
Systolic
(%)
Diastolic
and/or
systolic
Diastolic
(%)
Systolic
(%)
Diastolic
and/or
systolic
England and Wales
30.1
8.7
30.9
28.7
3.9
30.0
England
29.9
8.5
30.7
28.5
3.9
29.7
Wales
33.8
12.0
34.2
34.0
5.2
35.0
East Midlands
28.8
9.3
30.1
30.6
3.5
31.5
East of England
30.0
8.1
29.9
29.3
6.1
31.5
London and South East
31.7
7.5
32.6
27.3
2.5
28.1
North East and North Cumbria
30.7
7.2
31.2
24.9
2.8
25.7
North West
29.2
8.5
30.1
29.6
4.2
30.9
South Central
26.2
6.6
27.3
25.6
2.9
26.5
South West
28.3
11.5
28.8
33.3
5.8
35.3
West Midlands
30.9
9.4
31.6
28.4
4.3
30.1
Yorkshire and Humber
30.2
9.8
31.6
27.9
3.8
28.9

Table 27: Percentage of young people with Type 1 diabetes aged 12 years and above falling within
blood pressure ranges by NHS England region, 2021/22
‘High normal’ blood pressure
(91st–98th centile)
High’ blood pressure
(>98th centile)
NHS England region
Diastolic
(%)
Systolic
(%)
Diastolic
and/or
systolic
Diastolic
(%)
Systolic
(%)
Diastolic
and/or
systolic
East of England
29.8
8.0
29.7
29.4
6.1
31.5
London
31.3
6.7
32.2
25.8
2.0
26.5
Midlands
30.1
9.3
31.0
29.3
3.9
30.6
North East and Yorkshire
30.4
8.9
31.5
26.8
3.5
27.8
North West
29.2
8.5
30.1
29.6
4.2
30.9
South East
30.2
7.6
31.1
28.0
2.9
28.8
South West
27.0
11.3
27.7
32.0
5.7
34.0

Table 28 shows the percentages of young people aged 12 and above with Type 1 diabetes with a
recorded cholesterol screen (n=11,522) exceeding the target for total blood cholesterol, by country
and region. It shows that 19% exceeded the higher (≥5 mmol/L) level for total blood cholesterol.
This figure is 0.8% lower than the one reported in the 2021/22 audit (19.8%). Table 29 displays
equivalent data for each NHS England region.

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NPDA National report 2021/22: Care processes and outcomes
Table 28: Percentage of young people with Type 1 diabetes aged 12 years and above exceeding
cholesterol targets by country and regional network, 2021/22
Country/region
4 mmol/l or more (%)
5 mmol/l or more (%)
England and Wales
61.0
19.0
England
61.1
18.8
Wales
59.6
21.1
East Midlands
58.7
15.5
East of England
61.6
17.5
London and South East
62.5
19.8
North East and North Cumbria
61.2
20.9
North West
63.3
20.6
South Central
61.1
18.6
South West
63.9
20.8
West Midlands
58.0
18.2
Yorkshire and Humber
57.9
16.7
Table 29: Percentage of young people with Type 1 diabetes aged 12 years and above exceeding
cholesterol targets by NHS England region, 2021/22
NHS England region
4 mmol/l or more (%)
5 mmol/l or more (%)
East of England
61.4
17.7
London
63.6
20.7
Midlands
58.2
17.2
North East and Yorkshire
58.9
18.0
North West
63.3
20.6
South East
60.5
18.1
South West
63.9
20.5
Figure 48 shows the percentages of young people aged 12 years and older with Type 1 diabetes
with ‘high’ blood pressure (>98th centile) and the percentage above the target for total blood
cholesterol (≥5 mmol/L) reported to the audit since 2013/14.

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NPDA National report 2021/22: Care processes and outcomes
0%
5%
10%
15%
20%
25%
30%
35%
2013/14
2014/15
2015/16
2016/17
2017/18
2018/19
2019/20
2020/21
2021/22
% of young people with Type 1 diabetes
Audit year
Cholesterol level (≥5 mmol/L)
High blood pressure (>98th centile)

Figure 48: Percentage of young people aged 12 years and older with Type 1 diabetes with high blood
pressure and total blood cholesterol above targets in England and Wales, 2013/14 to 2021/22

3.6.1.2 Blood Pressure and cholesterol in patients with Type 2 diabetes

Table 30 shows the percentage of children and young people with Type 2 diabetes with a recorded
blood pressure in the audit period (n=805) classified as ‘high normal’ (91st - 98th centile) or ‘high’
blood pressure (>98th centile). Nearly half (46.7%) of children and young people with Type 2 diabetes
had high blood pressure.

Table 30: Percentage of children and young people with Type 2 diabetes with “high” or “high-
normal” blood pressure, 2016/17 - 2021/22
‘High normal’ blood pressure
(91st–98th centile)
High blood pressure
(>98th centile)
Audit Year
Diastolic
(%)
Systolic
(%)
Diastolic
and/or
systolic
Diastolic
(%)
Systolic
(%)
Diastolic
and/or
systolic
2021/22
24.2
16.3
25.7
44.5
12.0
46.7
2020/21
21.4
14.6
22.0
46.8
13.5
49.3
2019/20
28.3
16.1
26.8
42.8
10.4
44.3
2018/19
25.4
17.6
39.6
42.5
10.1
44.6
2017/18
22.2
xx-xxxx-xxxx
34.1
42.7
13.1
44.9
2016/17
24.5
15.8
36.2
42.2
13.6
45.6

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NPDA National report 2021/22: Care processes and outcomes

Table 31 shows the percentage of children and young people with Type 2 diabetes with a recorded
cholesterol screen (n=564) above the target for total blood cholesterol. It shows that 28.5% met or
exceeded the higher target for total blood cholesterol (≥5 mmol/L) in 2021/22, a similar percentage
with respect to 2020/21 (28%).

Table 31: Percentage of children and young people with Type 2 diabetes, with recorded cholesterol
screen above the target for total blood cholesterol 2016/17-2021/22
Audit Year
4 mmol/l or more
5 mmol/l or more
2021/22
66.3
28.5
2020/21
71.4
28.0
2019/20
69.1
28.8
2018/19
69.1
28.3
2017/18
74.9
33.8
2016/17
75.9
36.2

3.6.2 Body Mass Index

Higher Body Mass Index (BMI, weight/height2) is associated with increased cardiovascular risk. BMI
has been standardised using appropriate UK 1990 centile charts to allow direct comparisons across
different ages and between sexes. The following categories of BMI are shown based on the UK 1990
standards (Pan & Cole, 2012):
•
Underweight: below the 2nd centile
•
Healthy weight: between the 2nd and 85th centile
•
Overweight: between the 85th and 95th centile
•
Obese: above the 95th centile

Comparisons can be made with the National Child Measurement Programme in England (NCMP,
2022) and the Child Measurement Programme in Wales (CMP, 2022). These programmes measure
the height and weight of all children in Reception class (aged 4 to 5 years old) in both countries
and Year 6 (aged 10 to 11 years old) in England.

3.6.2.1 Body Mass Index and Type 1 diabetes

Figure 49 shows the prevalence of obesity and overweight in children with Type 1 diabetes
compared against the prevalence within the wider population in England and Wales.

For 2021/22, in England 36.5% of children aged 4 to 5 years old with Type 1 diabetes were overweight
or obese (a decrease from 40.4% in 2020/21) – higher than the 22.3% in the National Child
Measurement Programme (NCMP) for England 2021/22. In Wales, 45.7% of children with Type 1
diabetes aged 4 to 5 years were overweight or obese (a decrease from 57.2% in 2020/21) – markedly
higher than the 26.9% recorded in the Child Measurement Programme (CMP) for Wales in 2018/19
(the latest data available). However, given the small numbers of children with Type 1 diabetes at
these ages in Wales, this fluctuation could be artefactual.

The prevalence of overweight and obesity in children aged 10 to 11 years old with Type 1 diabetes in
England 2021/22 was 43.2% (a small increase from 42.1% in 2020/21) compared to 37.8% amongst
the wider cohort within the National Child Measurement Programme for England 2021/22.

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NPDA National report 2021/22: Care processes and outcomes
36.5%
22.3%
43.2%
37.8%
45.7%
26.9%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Children with
Type 1 diabetes
Children in
the NCMP*
Children with
Type 1 diabetes
Children in
the NCMP*
Children with
Type 1
diabetes
Children in
the CMP**
Aged 4-5
Aged 10-11
Aged 4-5
England
Wales
% of children aged 4 to 5 or aged 10 to 11
Prevalence of overweight and obese children by country

* National Child Measurement Programme (England)

** Child Measurement Programme (Wales)

Figure 49: Percentage of children with Type 1 diabetes with obesity and overweight, aged 4 to 5
and aged 10 to 11 years old, compared to the wider population by country, 2021/22

Figure 50 shows the percentage of children and young people with Type 1 diabetes included in the
audit within each BMI category for 2020/21 and 2021/22. Proportions of children and young people
in each weight category remained relatively stable across the two audit years.

When comparing the two age groups in 2021/22, there was almost double the proportion of young
people who were underweight (1.3%) compared to children aged 0-11 years old (0.7%). There was
also a higher proportion of young people who were obese (by approximately 3%) than children
aged 0-11 years old in both audit years.

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NPDA National report 2021/22: Care processes and outcomes
1.4%
54.6%
18.2%
25.8%
1.0%
57.5%
18.3%
23.1%
1.3%
55.0%
17.8%
26.0%
0.7%
58.9%
17.8%
22.6%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Underweight
Healthy weight
Overweight
Obese
Underweight
Healthy weight
Overweight
Obese
12+ years old
0 to 11 years old
Percentage of children with Type 1 diabetes in each BMI category
2021/22
2020/21

Figure 50: Percentage of children and young people with Type 1 diabetes within BMI categories by
age group, 2020/21 - 2021/22

Figure 51 shows the distribution of BMI of children and young people with Type 1 diabetes for
2020/21 and 2021/22 compared to the 1990 reference population. It shows that overall, children and
young people with Type 1 diabetes had a higher BMI than the general population, and a shift
towards lower BMIs in 2021/22 compared to 2020/21.

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NPDA National report 2021/22: Care processes and outcomes
1st
5th10th
25th
50th
75th 85th
95th
99th
Centiles
UK1990 reference
2020/21
2021/22

Figure 51: Distribution of body mass index of children and young people with Type 1 diabetes in
2020/21 and 2021/22 compared to the 1990 reference population

Figure 52 shows that the percentage of boys and girls with overweight or obesity increases with
deprivation, and that girls aged under 12 were less likely to be overweight or obese compared to
boys, whereas this trend was reversed in girls and boys aged 12 and above.
0%
10%
20%
30%
40%
50%
60%
Most deprived
Second most
deprived
Third least
deprived
Second least
deprived
Least deprived
Most deprived
Second most
deprived
Third least
deprived
Second least
deprived
Least deprived
% of children and young people with
Type 1 diabetes
Boys (Overweight or Obese)
Girls (Overweight or Obese)

Figure 52: Percentage of children and young people with Type 1 diabetes within the overweight or
obese BMI category, by deprivation quintile, age group and sex, 2021/22
UK1990 reference
2020/21
2021/22

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NPDA National report 2021/22: Care processes and outcomes

Figure 53 shows that higher percentages of children and young people with Type 1 diabetes at a
healthy weight are meeting lower HbA1c targets compared to children and young people with
overweight or obesity. Obese and underweight children and young people are more likely to have
an HbA1c exceeding 80mmol/mol than those who are overweight or at a healthy weight.
12.5%
13.8%
11.6%
9.1%
14.7%
14.1%
13.3%
10.7%
13.6%
15.3%
13.4%
12.8%
30.0%
30.8%
33.7%
34.3%
8.4%
9.8%
11.2%
13.7%
2.9%
4.4%
4.9%
6.4%
17.9%
11.7%
11.9%
13.1%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Underweight
Healthy weight
Overweight
Obese
≤48 mmol/mol
>48 and ≤53 mmol/mol
>53 and <58 mmol/mol
≥58 and <69 mmol/mol
≥69 and ≤75 mmol/mol
>75 and ≤80 mmol/mol
>80 mmol/mol

Figure 53: Percentage of children and young people with Type 1 diabetes achieving HbA1c targets
by BMI category, 2021/22

3.6.2.2 Body Mass Index and Type 2 diabetes

Table 32 shows the percentage of children and young people with Type 2 diabetes in each BMI
category for England and Wales from 2016/17 to 2021/22. It shows that in each audit year, most
children and young people with Type 2 diabetes were obese.

Table 32: Body mass index categories for children and young people with Type 2 diabetes, 2016/17
to 2021/22
Audit Year
Total (n)
Underweight
(%)
Healthy weight
(%)
Overweight
(%)
Obese
(%)
2021/22
972
7.2*
7.3
85.5
2020/21
648
8.1*
7.4
84.6
2019/20
796
7.2*
8.7
84.2
2018/19
737
7.6*
7.7
84.7
2017/18
677
0.0
5.9
9.5
84.6
2016/17
658
6.5*
8.1
85.4

* Results merged to mask small numbers

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NPDA National report 2021/22: Care processes and outcomes

Figure 54 shows similar percentages of children and young people with Type 2 diabetes within
each weight category when broken down by sex.
Healthy Weight
Overweight
Obese
Boys
5.9%
6.1%
87.5%
Girls
7.5%
8.0%
84.3%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
% of children and young people with
Type 2 diabetes

Figure 54: Percentage of children and young people with Type 2 diabetes who were in healthy
weight, overweight or obese categories by sex, 2021/22
3.7 Psychological assessment

Psychological assessment and access to psychology services should be available to all children and
young people and their families with diabetes as children and young people with diabetes have a
greater risk of emotional and behavioural difficulties. All children and young people with diabetes
and their family members or carers (as appropriate) should be offered emotional support after
diagnosis, which should be tailored to their emotional, social, cultural and age-dependent needs.
3.7.1 Psychological outcomes of children and young people
with Type 1 diabetes

There were 23,656 (75.5%) children and young people with Type 1 diabetes recorded as having a
psychological screening assessment within the audit period, 91.4% (n=21,616) of whom had a known
outcome of the assessment recorded. Of these, 39% (n=8,425) were assessed as requiring additional
psychological or CAMHS support outside of multidisciplinary team (MDT) clinics (hereafter
‘additional psychological support’). Table 33 shows a decrease in the number of children and young
people recorded as requiring additional support compared to 2020/21.

Table 33: Outcome of assessment of the need for psychological support and/or child and adolescent
mental health services (CAMHS) support, for children and young people with Type 1 diabetes,
2017/18 – 2021/22
Audit year
No. of children and young people with a
known outcome of psychological assessment
Required additional
support (n)
Required additional
support (%)
2021/22
21,616
8,425
39.0
2020/21
19,434
9,031
46.5
2019/20
21,137
9,283
43.9
2018/19
20,852
8,153
39.1
2017/18
20,114
5,672
28.2

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NPDA National report 2021/22: Care processes and outcomes

Figure 55 shows that the percentages of younger boys and girls assessed as requiring additional
psychological support were similar up to age 11. Rates diverged thereafter as more adolescent girls
were recorded as requiring additional support compared to adolescent boys.
0-1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19-22
Boys
41%
42%
36%
33%
32%
34%
36%
36%
37%
38%
41%
37%
36%
39%
37%
35%
30%
24%
25%
Girls
39%
44%
32%
33%
33%
38%
40%
36%
39%
40%
43%
48%
48%
46%
45%
44%
40%
33%
29%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
% of children and young people requiring additional
psychological support
Age and sex

Figure 55: Percentage of children and young people with Type 1 diabetes who were assessed as
requiring additional psychological support by age and sex, 2021/22

Figure 56 shows that children and young people with Type 1 diabetes who required additional
psychological support were more likely to have an HbA1c in the higher ranges compared to those
who did not require additional psychological support.
11.3%
12.8%
11.1%
14.3%
13.0%
15.4%
31.2%
33.2%
11.5%
10.3%
5.5%
4.4%
16.3%
9.6%
0%
20%
40%
60%
80%
100%
Required additional
psychological support
Did not require additional
psychological sypport
≤48 mmol/mol
>48 and ≤53 mmol/mol
>53 and <58
≥58 and <69 mmol/mol
≥69 and ≤75 mmol/mol
>75 and ≤80 mmol/mol
>80 mmol/mol

Figure 56: Percentage of children and young people with Type 1 diabetes achieving HbA1c targets
by outcome of psychological assessment, 2021/22

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NPDA National report 2021/22: Care processes and outcomes
3.7.2 Psychological outcomes of children and young people
with Type 2 diabetes

There were 709 (62%) children and young people with Type 2 diabetes recorded as receiving a
psychological assessment within the audit period, 636 (90%) of whom had a known outcome of the
assessment recorded.

Of the children and young people with Type 2 diabetes with a known result, close to half (48.3%)
were assessed as requiring additional psychological or CAMHS support outside of MDT clinics
(Table 34).

Table 34: Outcome of assessment of the need for psychological support and/or child and adolescent
mental health services (CAMHS) support, for children and young people with Type 2 diabetes,
2017/18 – 2021/22
Audit Year
No. of children and young people with a
known outcome of psychological assessment
Required additional
support
(n)
Required additional
support
(%)
2021/22
636
307
48.3
2020/21
506
301
59.5
2019/20
534
286
53.6
2018/19
457
208
45.5
2017/18
417
126
30.2
3.8 Hospital Admissions

Diabetes-related hospital admission rates in this section have been calculated from data submitted
by PDUs. Previous hospital admission reports from the NPDA have utilised linked admission data
taken from Hospital Episode Statistics (HES) in England, and the Patient Episode Database for
Wales (PEDW) (RCPCH, 2014, 2017, 2023), hence rates are not directly comparable. NPDA reported
admissions data submitted by PDUs for the first time in the 2016/17 core report to encourage
submission of higher quality admissions data, which permits regional network and unit level
comparisons.

Results in this section are presented for children and young people with Type 1 diabetes only due
to small numbers with other types of diabetes. In 2021/22, 167 out of 171 PDUs submitted admission
data for children and young people with Type 1 diabetes. There were 6,564 diabetes-related
admissions within the 2021/22 audit year reported for 5,268 children and young people with Type 1
diabetes.
3.8.1 Type 1 diabetes-related admissions

Table 35 shows the percentages of children and young people with Type 1 diabetes being managed
within PDUs who submitted admissions data, who were admitted at least once with a diabetes-
related admission, not associated with diagnosis, within the audit year by country and regional
network. Table 36 displays this information by NHS England region.

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NPDA National report 2021/22: Care processes and outcomes

Table 35: Percentage of children and young people with Type 1 diabetes admitted at least once for
a diabetes-related reason that was not associated with diagnosis by country and regional network,
2021/22
Country/region
No. of
children
and young
people with
T1 diabetes*
Diabetic
Ketoacidosis
(%)
Hypogly­
caemia
(%)
Ketosis
without
Acidosis
(%)
Stabilisation
(%)
Other
(incl.
surgery)
(%)
England
and Wales
30,595
2.4%
0.9%
0.9%
1.9%
3.8%
England
29,084
2.4%
0.9%
0.9%
1.9%
3.8%
Wales
1,511
3.1%
1.3%
0.9%
2.0%
3.1%
East Midlands
2,208
1.8%
0.3%
0.1%
2.8%
1.9%
East of England
3,386
2.5%
1.2%
0.5%
1.7%
5.1%
London and
South East
6,897
2.3%
0.7%
0.5%
1.8%
2.9%
North East and
North Cumbria
1,774
1.6%
0.5%
0.6%
0.9%
2.1%
North West
3,851
2.4%
0.8%
1.2%
1.1%
4.1%
South Central
2,945
2.1%
1.5%
1.4%
2.3%
6.4%
South West
2,201
1.9%
1.0%
1.7%
2.2%
4.5%
West Midlands
2,806
2.9%
1.0%
0.7%
2.9%
4.1%
Yorkshire and
Humber
3,016
3.1%
0.8%
1.5%
1.7%
3.5%

* Totals shown include only children and young people with Type 1 diabetes being managed by PDUs submitting admissions data.

Table 36: Percentage of children and young people with Type 1 diabetes admitted at least once for
a diabetes-related reason that was not associated with diagnosis by NHS England region 2021/22
NHS England
region
No. of
children
and young
people with
T1 diabetes*
Diabetic
Ketoacidosis
(%)
Hypogly­
caemia
(%)
Ketosis
without
Acidosis
(%)
Stabilisation
(%)
Other
(incl.
surgery)
(%)
East of England
3,544
2.5%
1.4%
0.5%
1.8%
5.1%
London
4,518
1.9%
0.7%
0.5%
1.5%
2.6%
Midlands
5,014
2.4%
0.7%
0.5%
2.9%
3.1%
North East and
Yorkshire
4,790
2.6%
0.7%
1.1%
1.4%
3.0%
North West
3,851
2.4%
0.8%
1.2%
1.1%
4.1%
South East
4,658
2.6%
1.0%
1.0%
2.0%
4.9%
South West
2,709
1.9%
1.1%
1.4%
2.4%
4.8%

* Totals shown include only children and young people with Type 1 diabetes being managed by PDUs submitting admissions data.

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NPDA National report 2021/22: Care processes and outcomes
3.8.2 DKA at diagnosis

Figure 57 shows that for England and Wales combined, 25.7% of the newly diagnosed patients
being managed by PDUs submitting admissions data in 2021/22 (n = 3,795), had DKA at diagnosis
of Type 1 diabetes. This finding is lower than the most recent rate reported in the previous NPDA
Hospital admissions reports (RCPCH, 2017, 2023), and is stable when compared to the percentage
reported for 2020/21 (25.8%). This is significantly lower than the incidence rates reported in the
most recent NPDA Hospital Admissions report (2023) combining NPDA and HES and PEDW data,
but is similar to the percentage reported in the 2020/21 NPDA.
25.7%
25.9%
20.9%
26.6%
26.7%
28.2%
24.6%
23.0%
27.8%
26.3%
18.5%
28.8%
27.2%
30.4%
22.2%
27.2%
23.0%
26.4%
25.7%
25.8%
25.6%
29.9%
25.0%
21.8%
31.2%
17.4%
21.1%
29.2%
27.7%
17.0%
32.1%
0%
5%
10%
15%
20%
25%
30%
England and Wales
England
Wales
East Midlands
East of England
London and South East
North East and North
Cumbria
North West
South Central
South West
West Midlands
Yorkshire and Humber
NHS England region
East of England
London
Midlands
North East and Yorkshire
North West
South East
South West
% of children and young people with Type 1 diabetes

Figure 57: Percentage of children and young people with Type 1 diabetes who had DKA at diagnosis
in 2021/22 by country, regional network and NHS England region
4. Treatment regimen and
diabetes monitoring

The NPDA collects treatment regimen data and data on usage of glucose monitoring technology amongst
children and young people with diabetes. Where a treatment regimen and/or glucose monitoring
technology changes throughout the audit year, the latest regimen recorded is used for the analysis.
2021/22
2020/2

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NPDA National report 2021/22: Care processes and outcomes
4.1 Treatment regimens
4.1.1 Treatment regimens of children and young people with
Type 1 diabetes

There were 30,052 children and young people with Type 1 diabetes with a valid treatment regimen
recorded within the audit period. Table 37 provides a breakdown of the treatment regimens
recorded by nation and region for children and young people with Type 1 diabetes.

Table 38 provides this breakdown by NHS England region.

Table 37: Percentage of children and young people with Type 1 diabetes, on each treatment
regimen, by country and region, 2021/22
Country/region
No. of children
and young
people with
T1 diabetes
One – three
injections/day
Four or more
injections/day
Insulin pump
England and Wales
30,052
2.5%
57.2%
40.3%
England
28,585
2.6%
57.2%
40.2%
Wales
1,467
0.5%
56.9%
42.6%
East Midlands
2,033
1.7%
50.5%
47.9%
East of England
3,273
1.6%
65.4%
33.0%
London and South East
6,656
3.2%
53.8%
43.0%
North East and North Cumbria
1,752
1.5%
51.3%
47.2%
North West
3,616
4.0%
56.4%
39.6%
South Central
2,802
6.4%
54.8%
38.8%
South West
2,393
1.1%
66.4%
32.6%
West Midlands
3,140
1.4%
58.1%
40.5%
Yorkshire and Humber
2,920
0.6%
58.7%
40.7%

Table 38: Percentage of children and young people with Type 1 diabetes, on each treatment
regimen, by NHS England region, 2021/22
NHS England region
No. of children
and young
people with
T1 diabetes
One – three
injections/day
Four or more
injections/day
Insulin pump
East of England
3,431
1.5%
66.0%
32.6%
London
4,367
3.5%
52.5%
43.9%
Midlands
5,173
1.5%
55.1%
43.4%
North East and Yorkshire
4,672
0.9%
55.9%
43.1%
North West
3,616
4.0%
56.4%
39.6%
South East
4,441
5.0%
53.5%
41.4%
South West
2,885
1.5%
66.2%
32.3%

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NPDA National report 2021/22: Care processes and outcomes

In England and Wales, 1.2% of children and young people with Type 1 diabetes using insulin
injections were also using other blood glucose lowering medication (BGLM), whereas 0.4% of
children and young people using insulin pump therapy were using other BGLM.

Figure 58 shows the breakdown of insulin regimens amongst those with a recorded sex and age
(n=30,017). Younger children (< 4 years) were more likely to be using insulin pump therapy than
older children, in keeping with the trend seen in other European and transatlantic cohorts (Sherr
et al., 2016), and pump usage was more prevalent in girls.
49%48%
51%
45%44%42%44%42% 42% 42% 43% 42% 39% 39% 38% 35% 38%
35%
45%
38%
43%
51% 52% 49% 55% 56% 58% 56% 58% 58% 58% 57% 58% 61% 61% 62% 65% 62% 65%
55%
62% 57%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0-1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19+
Boys Girls
Age
Sex
Insulin pump
Injections

Figure 58: Percentage of children and young people with Type 1 diabetes recorded as using insulin
injections or insulin pump therapy by age and sex, 2021/22

Since 2014/15, there has been an increase in insulin pump usage for all age groups with a
corresponding reduction in use of insulin injections (Figure 59).

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NPDA National report 2021/22: Care processes and outcomes
0%
10%
20%
30%
40%
50%
60%
70%
80%
2014/15
2015/16
2016/17
2017/18
2018/19
2019/20 2020/21
2021/22
% of children and young people with Type 1
diabetes
Audit year
Insulin injections
0–4 years
Insulin injections
5–9 years
Insulin injections
10–14 years
Insulin injections
15–19 years
Insulin pump therapy
0–4 years
Insulin pump therapy 5–
9 years
Insulin pump therapy
10–14 years
Insulin pump therapy
15–19 years

Figure 59: Percentage of children and young people with Type 1 diabetes using daily insulin
injections or pump therapy by age group, 2014/15 to 2021/22

Insulin pump usage increased with duration of diabetes (Figure 60) with 81.8% of those in their first
year of diagnosis of Type 1 diabetes using insulin injections, compared to less than half (47.4%) of
those after 5 to 9 years post diagnosis. The percentage of those using insulin pumps in the first year
of Type 1 diabetes increased, from 13.9% in 2020/21 to 18.2% in 2021/22.
81.8%
62.3%
54.9%
47.4%
46.3%
47.9%
18.2%
37.7%
45.1%
52.6%
53.7%
52.1%
0%
20%
40%
60%
80%
100%
Less than 1
year
1-2 years
3-4 years
5-9 years
10-14 years
15+ years
% of children and young people
with Type 1 diabetes
Duration of diabetes
Insulin injections
Insulin pump

Figure 60: Percentage of children and young people with Type 1 diabetes using insulin injections
or insulin pump therapy by duration of diabetes, 2021/22.
5–9 years

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NPDA National report 2021/22: Care processes and outcomes

Figure 61 shows that White children and young people were more likely to be using a pump compared
to those within Asian and Black ethnic groups. Insulin pump therapy usage was also more prevalent in
those living in the least deprived compared to the most deprived areas of the country. Increases in
insulin pump therapy usage was seen across every ethnicity and deprivation quintile, compared to the
previous two audit years.
White
Mixed
Other
Asian
Black
Most
Second
most
Third
least
Second
least
Least
Ethnicity
Deprivation
2019/20
39.8%
35.0%
34.9%
29.7%
26.7%
31.7%
35.8%
37.5%
42.4%
44.3%
2020/21
40.2%
37.8%
34.6%
31.1%
27.4%
32.5%
36.3%
38.4%
42.4%
44.0%
2021/22
42.2%
38.0%
37.7%
33.0%
29.0%
34.1%
38.8%
41.1%
44.1%
45.1%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
% children and young people with
Type 1 diabetes using insulin pump therapy

Figure 61: Percentage of children and young people with Type 1 diabetes using insulin pump
therapy by ethnic group and deprivation, 2021/22

Figure 62 shows that despite increases in insulin pump usage compared to insulin injections in all
quintiles of deprivation, the gap between the most and least deprived areas has widened with
time. In 2014/15, the percentages on insulin pump therapy for the most and least deprived areas
were 18.4% versus 26.3% (a difference of 7.9 percentage points), whereas in 2021/22 the gap had
widened to 34.1% versus 45.1%, respectively (a difference of 11.0 percentage points). However, this
gap has consistently narrowed in recent years from 2019/20 and 2020/21, when there were 12.6%
and 11.5% differences, respectively.

77
NPDA National report 2021/22: Care processes and outcomes
0%
10%
20%
30%
40%
50%
60%
70%
80%
2014/15
2015/16
2016/17
2017/18
2018/19
2019/20
2020/21
2021/22
% of children and young people with
Type 1 diabetes
Audit year
Most deprived - Insulin injections
Most deprived - Insulin pump therapy
Least deprived - Insulin injections
Least deprived - Insulin pump therapy

Figure 62: Percentage of children and young people with Type 1 diabetes using insulin injections
or insulin pump therapy by “least” and “most” deprived quintile, 2014/15 to 2021/22

Figure 63 shows a general trend for children and young people with Type 1 diabetes using insulin
pump therapy achieving lower HbA1c targets compared to those on insulin injections. These data
do not account for the influence of deprivation, age, duration of diabetes or other factors which
may influence the choice of insulin regimen, which have also been shown to impact upon target
achievement.
12.0%
12.2%
10.8%
16.4%
11.8%
17.6%
30.5%
34.6%
11.9%
9.7%
6.0%
3.6%
17.1%
6.0%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Injections
Insulin pump
≤48 mmol/mol
>48 and ≤53 mmol/mol
>53 and <58 mmol/mol
≥58 and <69 mmol/mol
≥69 and ≤75 mmol/mol
>75 and ≤80 mmol/mol
>80 mmol/mol

Figure 63: Percentage of children and young people with Type 1 diabetes achieving HbA1c targets
by treatment regimen, 2021/22
4.1.2 Treatment regimens of children and young people with
Type 2 diabetes

Table 39 shows the breakdown of diabetes treatment regimen for children and young people with
Type 2 diabetes. Data was either missing or reported as ‘unknown’ for 33.4% of children and young
people with Type 2 diabetes.
7.9% difference
11.0% difference

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NPDA National report 2021/22: Care processes and outcomes

The majority of those with Type 2 diabetes were either managing their diabetes with diet alone
(11.4%) or in combination with another blood glucose lowering agent (48.1%). However, given that
there was a cohort on insulin alone, and missing data, caution should be taken when interpreting
these results.

Table 39: Percentage of children and young people with Type 2 diabetes using each treatment
regimen, England and Wales, 2020/21 to 2021/22
Treatment regimen
2020/21
2021/22
No. of children and young people with Type 2 diabetes
with a recorded treatment regimen (n)
648
855
Dietary management
Only (%)
11.4
11.9
And other BGLM† (%)
48.1
49.4
1 to 3 insulin injections
Only (%)
2.6
4.1
And other BGLM† (%)
11.6
11.2
4 or more insulin
injections
Only (%)
12.5
11.1
And other BGLM† (%)
11.6
10.6
Insulin pump
Only (%)
2.2*
1.6*
And other BGLM† (%)

*Results merged to mask small numbers

† And other blood glucose lowering medication
4.2 Glucose monitoring devices

NICE guidance applicable at the time of the 2020/21 audit (NG18) stated that ongoing real time
continuous glucose monitoring (rtCGM) monitoring with alarms should be offered to children and
young people with Type 1 diabetes who:
•
had frequent severe hypoglycaemia or
•
had impaired hypoglycaemia awareness that is associated with adverse consequences (for
example, seizures or anxiety) or
•
couldn’t recognise or communicate about symptoms of hypoglycaemia (for example,
because of cognitive or neurological disabilities).

However, new guidance published in 2022 (NG18- 2022) now recommends that it should be offered
to all children and young people with Type 1 diabetes, as long as it is provided alongside education
to support children and young people and their families and carers to use it.
4.2.1 Usage of glucose monitoring devices among children
and young people with Type 1 diabetes

There were 27,578 children and young people with Type 1 diabetes with a valid indication of glucose
monitoring usage (indicating use of a specific technology or none) reported within the audit
period. Figure 64 presents this number broken down by country, regional network and NHS
England region.

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NPDA National report 2021/22: Care processes and outcomes

Flash glucose monitors were the most commonly used glucose monitoring device in England
(42.1%), followed by rtCGMs (29.5%). The reverse was found in Wales, where rtCGMs were the most
commonly used glucose monitoring devices (40.8%). Additionally, close to 2% of children and
young people with Type 1 diabetes in both countries used modified Flash glucose monitors
(mFlash), whereas nearly three in ten did not use Flash/mFlash or rtCGM. There has been an
increase in those using rtCGMs overall since the previous audit year of 2020/21 (an increase from
27.9% to 30%). These results should be interpreted with some caution given that 12% (n = 3,771) of
children and young people with Type 1 diabetes had an unknown or missing entry for this data
item. Percentages of missing data also varied by region.

In this section, those using rtCGM as part of a closed-loop system are included in the rtCGM
numerators. Usage of closed-loop systems as a treatment regimen is presented in Figure 74 and
Figure 75.
41.5%
42.1%
28.5%
58.3%
34.7%
41.8%
39.4%
43.4%
33.3%
49.0%
37.4%
47.6%
34.5%
38.0%
46.1%
44.6%
43.4%
38.4%
50.8%
2.2%
2.2%
1.7%
0.5%
2.4%
2.3%
4.6%
3.5%
3.1%
0.2%
2.3%
0.6%
2.3%
2.7%
1.5%
2.0%
3.5%
2.5%
0.8%
30.0%
29.5%
40.8%
23.8%
28.1%
29.0%
25.3%
29.1%
39.5%
19.4%
34.3%
31.4%
28.3%
31.2%
29.9%
29.2%
29.1%
34.0%
20.7%
0.4%
0.4%
0.3%
0.2%
2.3%
0.5%
1.4%
0.2%
26.0%
25.9%
29.1%
17.4%
34.7%
26.5%
30.6%
23.8%
24.0%
31.4%
23.7%
20.4%
34.8%
27.6%
21.1%
24.1%
23.8%
25.2%
27.7%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
England and Wales
England
Wales
East Midlands*
East of England*
London and South East
North East and North…
North West
South Central*
South West
West Midlands
Yorkshire and Humber*
NHS England Regions
East of England*
London
Midlands
North East and Yorkshire*
North West
South East*
South West
% of children and young people with Type 1 diabetes with stated glucose monitoring device
usage
Flash
mFlash
rtCGM
Other
Not using Flash/mFlash or rtCGM

* “Other” category hidden to mask small numbers

Figure 64: Percentage breakdowns of stated glucose monitoring device usage by country, region
and NHS England region

Figure 65 shows that younger children with Type 1 diabetes were more likely to be using rtCGM,
and less likely to use Flash or mFlash devices, than those who were older.

80
NPDA National report 2021/22: Care processes and outcomes
65%
70%
38%
40%
27%
29%
20%
22%
15%
13%
40%
40%
47%
48%
47%
47%
20%
17%
22%
20%
26%
23%
34%
32%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Boys
Girls
Boys
Girls
Boys
Girls
Boys Girls
0 – 4 years
5 – 9 years
10 – 14 years
15 – 19 years
% of children and young people with Type 1 diabetes
by stated glucose monitoring device usage
rtCGM
Flash/mFlash
Not using Flash/mFlash or rtCGM

Figure 65: Percentages of children and young people with Type 1 diabetes by glucose monitoring
device usage, by age and sex, 2021/22. Due to rounding some data points are over 100%.

Figure 66 shows that rtCGM was more likely to be used in the second year following diagnosis of
Type 1 diabetes.
65%
70%
38%
40%
27%
29%
20%
22%
15%
13%
40%
40%
47%
48%
47%
47%
20%
17%
22%
20%
26%
23%
34%
32%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Boys
Girls
Boys
Girls
Boys
Girls
Boys
Girls
0 – 4 years
5 – 9 years
10 – 14 years
15 – 19 years
% of children and young people with Type 1
diabetes by stated glucose monitoring device
usage
rtCGM
Flash/mFlash
Not using Flash/mFlash or rtCGM

Figure 66: Percentage of children and young people with Type 1 diabetes with glucose monitoring
device usage, by duration of diabetes. Due to rounding some data points are over 100%.

Figure 67 shows how use of glucose monitoring devices differs by ethnic group and deprivation
quintile.

Asian and Black children and young people with Type 1 diabetes had the lowest usage of rtCGMs,
and the highest proportions stating no usage of other glucose monitoring devices. White children
and those of mixed ethnicity had the highest usage of rtCGMs, while those with a stated ethnicity
of “Other” had the highest usage of Flash or modified Flash devices.

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NPDA National report 2021/22: Care processes and outcomes

Figure 67 also shows a strong association between deprivation and rtCGM use, with children and
young people with Type 1 diabetes living in more deprived areas being less likely to use rtCGMs
than those living in less deprived areas. There has been a greater increase seen in usage of rtCGMs
for those living in less deprived areas than those in more deprived areas, compared to the previous
audit year of 2020/21.
32%
31%
27%
25%
22%
24%
26%
31%
33%
38%
42%
44%
48%
45%
42%
45%
44%
44%
44%
42%
26%
25%
25%
29%
36%
31%
30%
25%
23%
20%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Mixed
White
Other
Asian
Black
Most
Second
most
Third
least
Second
least
Least
Ethnicity
Deprivation
% of children and young people with Type 1 diabetes by stated
glucose monitoring device usage
rtCGM
Flash/mFlash
Not using Flash/mFlash or rtCGM
2020/21 rtCGM use

Figure 67: Percentage of children and young people with Type 1 diabetes with stated glucose
monitoring device usage, by ethnic group and deprivation quintile 2021/22

Figure 68 shows the usage of rtCGMs within each ethnic group by deprivation quintile. It shows
that rtCGM use was more prevalent among those living in the least and second least deprived
quintile within most ethnic groups, and that Black children and young people typically had lower
use than other ethnic groups irrespective of deprivation status.

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NPDA National report 2021/22: Care processes and outcomes
White
Asian
Black
Mixed
Other
Most deprived
23.9%
23.2%
23.9%
28.8%
23.0%
Second most deprived
26.9%
20.3%
22.5%
28.1%
15.9%
Third least deprived
31.5%
30.3%
15.1%
35.7%
30.7%
Second least deprived
32.8%
30.7%
20.0%
35.6%
35.1%
Least deprived
38.0%
35.5%
27.3%
31.5%
45.1%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
% of children and young people
with Type 1 diabetes
using an rtCGM

Figure 68: Percentage of children and young people with Type 1 diabetes using an rtCGM by ethnic
group and deprivation quintile, 2021/22

Figure 69 shows the usage of Flash glucose monitors (including modified Flash monitors) by
children and young people with Type 1 diabetes, within each ethnic group by deprivation quintile.
It shows stable usage of Flash monitors across ethnicities and deprivation quintiles,
White
Asian
Black
Mixed
Other
Most deprived
45.0%
45.9%
39.9%
43.2%
47.2%
Second most deprived
44.4%
46.0%
41.7%
39.4%
58.0%
Third least deprived
44.1%
42.1%
46.0%
41.7%
44.7%
Second least deprived
44.0%
44.3%
48.0%
44.3%
44.6%
Least deprived
41.4%
46.1%
40.9%
43.1%
37.8%
0%
10%
20%
30%
40%
50%
60%
70%
% of children and young people
with Type 1 diabetes
using Flash or mFlash
glucose monitors

Figure 69: Percentage of children and young people with Type 1 diabetes using Flash monitors by
ethnic group and deprivation quintile, 2021/22

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Figure 70 shows that despite increases in rtCGM usage in all quintiles of deprivation, the gap
between the most and least deprived areas has widened with time. This gap reached 13.8% in
2021/22, an increase from 6.7% in 2017/18.
2017/18
2018/19
2019/20
2020/21
2021/22
Most deprived - CGM
6.1%
8.2%
14.0%
23.8%
23.9%
Least deprived - CGM
12.8%
16.1%
25.2%
34.7%
37.7%
0%
5%
10%
15%
20%
25%
30%
35%
40%
Percentge of children and young
people with Type 1 diabetes
Audit year

Figure 70: Percentage of children and young people with Type 1 diabetes using a real-time
continuous glucose monitor (CGM) by “least” and “most” deprived quintile, 2017/18 to 2021/22

Figure 71 shows that children and young people with Type 1 diabetes using rtCGM were more likely
to achieve lower HbA1c targets compared to those who were not using rtCGM.

Figure 71: Percentage of children and young people with Type 1 diabetes achieving HbA1c targets
by rtCGM usage, 2021/22
15%
11%
17%
11%
18%
13%
33%
32%
8%
12%
3%
6%
5%
16%
0%
20%
40%
60%
80%
100%
Using rtCGM
Not using rtCGM
≤48 mmol/mol
>48 and ≤53 mmol/mol
>53 and <58 mmol/mol
≥58 and <69 mmol/mol
≥69 and ≤75 mmol/mol
>75 and ≤80 mmol/mol
>80 mmol/mol
6.7% difference
13.8% difference

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Figure 72 shows that there was little difference in the proportions of children and young people
with Type 1 diabetes achieving HbA1c targets who were or were not using Flash or mFlash monitors.
11%
13%
12%
14%
13%
15%
33%
32%
12%
10%
6%
5%
14%
12%
0%
20%
40%
60%
80%
100%
Using Flash or mFlash
Not using Flash or mFlash
≤48 mmol/mol
>48 and ≤53 mmol/mol
>53 and <58 mmol/mol
≥58 and <69 mmol/mol
≥69 and ≤75 mmol/mol
>75 and ≤80 mmol/mol
>80 mmol/mol

Figure 72: Percentage of children and young people with Type 1 diabetes achieving HbA1c targets
by Flash/mFlash monitors usage, 2021/22

Figure 73 shows that rtCGM was more prevalent amongst pump users than those using insulin
injections. Conversely, Flash or mFlash monitors were more likely to be used by those on insulin
injections than amongst pump users. Children and young people with Type 1 diabetes using insulin
injections were also more likely to not be using any glucose monitoring device.

Figure 73: Percentage of children and young people with Type 1 diabetes using insulin injections
or insulin pump therapy by glucose monitoring device usage, 2021/22

Figure 74 shows that the usage of rtCGMs has increased in each audit year since 2018/19. For the
2021/22 audit, data on closed-loop systems was collected for the first time and can be seen to
account for nearly one-tenth of children and young people with Type 1 diabetes with stated
treatment regimens and technology usage.
16.2%
50.8%
49.5%
35.3%
34.3%
13.8%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Insulin
injections
Insulin pump
therapy
rtCGM
Flash or mFlash
Not using Flash/mFlash or rtCGM

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Figure 74: Percentages of children and young people with Type 1 diabetes using insulin injections
only, insulin injections and Flash/mFlash, insulin injections and rtCGM, insulin pump only, insulin
pump and Flash/mFlash, insulin pump and rtCGM, by country, 2018/19 to 2021/22

Figure 75 shows the proportions of children and young people with Type 1 diabetes using different
combinations of treatment regimens and glucose monitoring devices achieving HbA1c targets.

Those using closed-loop systems were the most likely to achieve the lowest HbA1c targets, followed
by those using rtCGMs in combination with injections or pump therapy. Those using insulin pumps
or injections without glucose monitoring devices, or with insulin pumps in combination with Flash
monitors, were the least likely to achieve lower HbA1c targets.
58%
55%
51%
20%
58%
55%
51%
20%
57%
53%
47%
22%
29%
30%
22%
3%
6%
9%
10%
3%
6%
10%
9%
8%
8%
12%
13%
30%
26%
21%
5%
30%
26%
21%
5%
25%
21%
19%
7%
14%
14%
8%
9%
14%
19%
13%
9%
14%
18%
13%
11%
18%
22%
16%
9%
8%
12%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
18/19
19/20
20/21
21/22
18/19
19/20
20/21
21/22
18/19
19/20
20/21
21/22
England and Wales
England
Wales
Injections only
Injections & Flash/mFlash
Injections & rtCGM
Pump only
Pump & Flash/mFlash
Pump & rtCGM
Closed-loop system

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Figure 75: Percentage of children and young people with Type 1 diabetes achieving HbA1c targets
by treatment regimen in combination with glucose monitoring devices (where applicable), 2021/22
4.3 Assessing the probability of achieving HbA1c
targets using multivariate analyses including
treatment regimen, use of technology,
demographic and socio-economic factors
4.3.1 Introduction

This report has demonstrated that several patient characteristics are associated with greater use of
technologies and achievement of lower HbA1c values. However, so far the analyses in this report
have been univariate or bivariate, meaning that only one or two variables are associated at a time.
Using only these types of analyses makes it difficult to ascertain whether the lower observed HbA1c
is due to the use of technology or other confounding variables.

With this in mind, we constructed multivariate binomial logistic regression and linear regression
models to estimate the effect of technology on HbA1c levels while accounting for the influence of
other characteristics. Essentially, we asked the question: “What is the average difference in HbA1c
between children who share the same demographic and socio-economic characteristic but use
different technologies?” Specifically, we used these models to look at the probabilities of achieving
HbA1c targets of ≤48 mmol/mol or <58 mmol/mol, along with exploring the overall relationship
between HbA1c and use of technology.

Some of the results of these analyses are highlighted in the next sections in bullet-point format,
and the full results can be seen in Table 40, along with the demographic and socio-economic
characteristics which the models controlled for.
8%
8%
11%
12%
14%
14%
19%
12%
14%
9%
11%
17%
14%
21%
14%
17%
11%
12%
19%
15%
20%
37%
37%
29%
31%
35%
32%
29%
14%
11%
13%
12%
8%
10%
6%
5%
5%
6%
6%
3%
5%
2%
11%
8%
22%
16%
4%
10%
3%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Pump only
(n=1,390)
Pump & Flash/mFlash
(n=3,717)
Injections only
(n=4,985)
Injections & Flash/mFlash
(n=7,593)
Pump & rtCGM
(n=3,541)
Injections & rtCGM
(n=2,463)
Closed-loop system
(n=2,223)
≤48 mmol/mol
>48 and ≤53 mmol/mol
>53 and <58 mmol/mol
≥58 and <69 mmol/mol
≥69 and ≤75 mmol/mol
>75 and ≤80 mmol/mol
>80 mmol/mol

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It is important to note that these analyses were conducted using patient-level data collected as
part of the NPDA 2021/22 core audit. NPDA data is descriptive rather than experimental, which
means that we are unable to fully control for all confounding factors. As a result, there are likely
other factors which are not accounted for in the models which contribute to the differences in
outcomes. Indeed, the regression analyses showed that only 6-13% of the variation in outcomes
presented is explained by the patient factors included within the models.
4.3.2 What the models tell us about the impact of
technology on achieving an HbA1c ≤48 mmol/mol
•
Children and young people using closed-loop systems had the highest increase in
probability of achieving this target (by 11.9 percentage points). This equates to an extra 11.9
children and young people achieving the target for every 100 that switch from using
insulin injections alone.
•
Using insulin pumps in tandem with rtCGMs increased the probability of achieving this
target by 6.6 percentage points. This equates to an extra 6.6 children and young people
achieving the target for every 100 that switch from using insulin injections alone.
•
Using insulin injections with rtCGM increased the probability of achieving this target by 3.4
percentage points. This equates to an extra 3.4 children and young people achieving the
target for every 100 that switch from using insulin injections alone.
4.3.3 What the models tell us about the impact of
technology on achieving an HbA1c <58 mmol/mol
•
Children and young people using closed-loop systems had an increase in probability of
achieving an HbA1c below 58 mmol/mol by 31.3 percentage points. This equates to an extra
31.3 children and young people achieving the target for every 100 that switch from using
insulin injections alone.
•
Those using insulin pumps in combination with rtCGMs had an increase in probability of
achieving this target by 20.2 percentage points. This equates to an extra 20.2 children and
young people achieving the target for every 100 that switch from using insulin injections
alone.
•
Using insulin pumps in addition to Flash/mFlash devices, or insulin pumps on their own,
increased the probability of achieving an HbA1c below 58 mmol/mol by 10.9 and 7.9
percentage points respectively. This equates to an extra 10.9 and 7.9 children and young
people respectively achieving the target for every 100 that switch from using insulin
injections alone.
•
Using insulin injections with rtCGMs increased the probability of achieving this target by
9.8 percentage points. This equates to an extra 9.8 children and young people achieving
the target for every 100 that switch from using insulin injections alone.

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NPDA National report 2021/22: Care processes and outcomes
4.3.4 What the models tell us about the overall relationship
between HbA1c and usage of different technologies
•
Usage of closed-loop systems was associated with the largest average reduction in HbA1c
(-11.0 mmol/mol, 95% CI -10.4 to -11.7), compared to using insulin injections alone.
•
Usage of insulin pumps in conjunction with a glucose monitoring device (rtCGM or Flash/
mFlash) outside of a closed-loop system gave the next largest average reductions (-8.4,
95% CI -9.0 to -7.8, and -6.5 mmol/mol, 95% CI -7.1 to -5.8), respectively, compared to using
insulin injections alone.
•
Those living in the least deprived areas had an average reduction in HbA1c of -6.1 mmol/
mol (95% CI -6.7 to -5.6) compared to those living in the most deprived areas.
•
Usage of an insulin pump combined with a glucose monitoring device, factors that are
modifiable by clinical teams and policy makers, had higher impact on HbA1c outcomes
than the level of deprivation in a patient’s area of residence.

Table 40: Results of regression analysis of mean HbA1c by taking into account treatment regimen
and measurable socio-demographic co-factors
Variable
Marginal
effects (%)
P value
Marginal
effects (%)
P value
Coefficient
P value
Treatment regimen and technology combination (cf. insulin injections only)
Injections & Flash/
mFlash
0.3
(-0.7 to 1.3)
0.509
2.1
(0.5 to 3.7)
0.010
-1.5
(2.1 to -0.8)
0.000
Injections & rtCGM
3.4
(1.9 to 4.9)
0.000
9.8
(7.6 to 12.1)
0.000
-4.2
(-4.9 to -3.4)
0.000
Insulin pump only
0.8
(-1.2 to 2.8)
0.439
7.9
(4.9 to 10.8)
0.000
-5.3
(-6.2 to -4.3)
0.000
Insulin pump & Flash/
mFlash
-0.1
(-1.4 to 1.2)
0.890
10.9
(8.9 to 12.9)
0.000
-6.5
(-7.1 to -5.8)
0.000
Insulin pump & rtCGM
6.6
(5.1 to 8.1)
0.000
20.2
(18.0 to 22.3)
0.000
-8.4
(-9.0 to -7.8)
0.000
Closed-loop system
11.9
(9.9 to 13.8)
0.000
31.3
(29.0 to 33.7)
0.000
-11.0
(-10.4 to -11.7)
0.000
Sex/Age/Duration of diabetes
Male (cf to female)
2.8
(2.0 to 3.6)
0.000
3.7
(2.5 to 4.8)
0.000
-1.4
(-1.8 to -1.0)
0.000
Age (in whole years)
0.8
(0.7 to 1.1)
0.000
0.5
(0.3 to 0.7)
0.000
0.3
(0.2 to 0.4)
0.000
Duration (in whole
years)
-1.9
(-2.0 to -1.7)
0.000
-2.3
(-2.5 to -2.2)
0.000
0.7
(-1.7 to -1.0)
0.000

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Variable
HbA1c ≤48 mmol/mol
HbA1c <58 mmol/mol
Linear regression
(HbA1c mmol/mol)
Marginal
effects (%)
P value
Marginal
effects (%)
P value
Coefficient
P value
Ethnic group (cf. White)
Asian
0.4
(-1.2 to 2.1)
0.610
-2.4
(-4.8 to 0.0)
0.046
-0.2
(-0.9 to 0.6)
0.659
Black
-1.8
(-3.7 to 0.2)
0.082
-7.5
(-10.5 to -4.5)
0.000
4.4
(3.2 to 5.6)
0.000
Mixed
-0.5
(-2.7 to 1.7)
0.656
-3.9
(-7.0 to -0.6)
0.018
2.4
(1.3 to 3.6)
0.000
Other
-0.1
(-2.7 to 2.4)
0.920
3.0
(-0.8 to 6.8)
0.124
-1.4
(-2.6 to -0.3)
0.011
Not stated or unknown
1.7
(-0.4 to 3.7)
0.105
5.4
(2.3 to 8.5)
0.001
-1.4
(-2.3 to 0.4)
0.007
Deprivation (cf. most deprived)
Second most deprived
1.1
(0.0 to 2.2)
0.051
5.1
(3.3 to 6.8)
0.000
-2.1
(-2.7 to -1.5)
0.000
Third least deprived
3.2
(2.1 to 4.4)
0.000
8.9
(7.1 to 10.7)
0.000
-3.4
(-4.0 to -2.8)
0.000
Second least deprived
3.6
(2.4 to 4.8)
0.000
10.9
(9.1 to 12.7)
0.000
-4.6
(-5.2 to -4.0)
0.000
Least deprived
5.0
(3.7 to 6.2)
0.000
14.7
(12.9 to 16.6)
0.000
-6.1
(-6.7 to -5.6)
0.000
Constant
12.0
(11.6 to 12.4)
0.000
39.4
(38.9 to 40.0)
0.000
64.6
(63.8 to 65.5)
0.000
Pseudo R-squared (HbA1c ≤48 mmol/mol): 6.1%
Pseudo R-squared (HbA1c <58 mmol/mol): 5.8%
Adjusted R-squared (Linear regression): 12.6%
N = 25,866 and includes all children and young people with Type 1 diabetes reported to the 2021/22 NPDA with a valid record for
treatment regimen of insulin pump therapy or multiple daily injections; rtCGM usage; Flash or mFlash usage; closed-loop system
usage; gender; age; duration; ethnicity; and deprivation.
Results with a P value greater than 0.05 are shaded grey.
Confidence intervals were calculated using standard errors that are robust to heteroskedasticity.

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5. Thyroid and coeliac disease
5.1 Thyroid and coeliac disease amongst children
and young people with Type 1 diabetes

Children and young people with Type 1 diabetes are at an increased risk of other autoimmune
conditions including thyroid and coeliac disease.

Table 41 shows that the prevalence of thyroid disease in 2021/22 for children and young people with
Type 1 diabetes was 2.7%, unchanged from 2020/21. 5.5% of children and young people with Type 1
diabetes had coeliac disease, compared to 5.2% in 2020/21. This figure is also higher than the
prevalence rate of 3.5% reported in an international collaborative study across three continents
(Craig et al., 2017).

Table 42 shows the prevalence rates for thyroid and coeliac disease by NHS England region.

Table 41: Percentage of children and young people with Type 1 diabetes with thyroid or coeliac
disease by country and regional network in England and Wales, 2021/22
Country/region
No. of children and young
people with Type 1 diabetes
Coeliac disease
Thyroid disease
England and Wales
31,349
5.5%
2.7%
England
29,838
5.5%
2.6%
Wales
1,511
6.0%
3.2%
East Midlands
2,208
5.7%
2.9%
East of England
3,386
5.3%
2.8%
London and South East
6,897
4.8%
2.7%
North East and North Cumbria
1,774
4.6%
3.8%
North West
3,851
6.2%
2.2%
South Central
2,945
6.9%
2.0%
South West
2,438
4.3%
2.8%
West Midlands
3,323
5.7%
2.6%
Yorkshire and Humber
3,016
5.8%
2.4%

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Table 42: Percentage of children and young people with Type 1 diabetes with thyroid or coeliac
disease by NHS England region, 2021/22
NHS England region
No. of children and young
people with Type 1 diabetes
Coeliac disease
Thyroid disease
East of England
3,544
5.3%
2.9%
London
4,518
4.6%
2.3%
Midlands
5,531
5.7%
2.8%
North East and Yorkshire
4,790
5.3%
2.9%
North West
3,851
6.2%
2.2%
South East
4,658
6.4%
2.6%
South West
2,946
4.2%
2.6%

Figure 76 shows year-on-year variation in prevalence of thyroid and coeliac disease amongst those
with Type 1 diabetes.
2014/15
2015/16
2016/17
2017/18
2018/19
2019/20
2020/21
2021/22
Thyroid
3.2%
3.5%
2.6%
3.0%
3.3%
3.1%
2.7%
2.7%
Coeliac
4.7%
4.0%
4.4%
5.6%
6.5%
5.8%
5.2%
5.5%
0%
1%
2%
3%
4%
5%
6%
7%
8%
% of children and young people with Type 1
diabetes

Figure 76: Percentage of children and young people with Type 1 diabetes with thyroid or coeliac
disease in England and Wales, 2014/15 to 2021/22.

Figure 77 shows that there was a higher prevalence of both autoimmune conditions amongst
girls compared to boys.

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NPDA National report 2021/22: Care processes and outcomes

4.6%
5.3%
4.7%
4.1%
4.3%
6.6%
7.8%
7.0%
6.5%
6.8%
0%
2%
4%
6%
8%
10%
2017/18
2018/19
2019/20
2020/21
2021/22
Coeliac disease
Boys
Girls
1.9%
2.2%
2.0%
1.8%
1.7%
4.2%
4.5%
4.3%
3.7%
3.7%
0%
2%
4%
6%
8%
10%
2017/18
2018/19
2019/20
2020/21
2021/22
Thyroid disease
Boys
Girls

Figure 77: Percentage of children and young people with Type 1 diabetes and comorbid coeliac or
thyroid disease by sex, 2017/18 to 2021/22

Coeliac disease prevalence was higher amongst children and young people with Type 1 diabetes
living in the least deprived areas compared to the most deprived areas but there was no clear
association between prevalence of thyroid disease and areas of deprivation (Figure 78).
Most
deprived
Second most
deprived
Third least
deprived
Second least
deprived
Least
deprived
Thyroid
2.7%
2.9%
2.5%
2.8%
2.4%
Coeliac
5.1%
5.2%
5.5%
5.8%
5.9%
0%
1%
2%
3%
4%
5%
6%
7%
8%
% of children and young people
with Type 1 diabetes
Deprivation Quintile

Figure 78: Percentage of children and young people with Type 1 diabetes and coeliac or thyroid
disease by deprivation quintile, 2021/22

Figure 79 shows that the prevalence of both autoimmune conditions was highest amongst Asian
children and young people with Type 1 diabetes. Those of Black ethnicity had the lowest rates of
both coeliac and thyroid disease out of all ethnic groups.

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NPDA National report 2021/22: Care processes and outcomes
White
Asian
Black
Mixed
Other
Thyroid
2.7%
4.3%
1.3%
1.5%
2.3%
Coeliac
5.7%
6.1%
3.0%
3.9%
4.6%
2.7%
4.3%
1.3%
1.5%
2.3%
5.7%
6.1%
3.0%
3.9%
4.6%
0%
1%
2%
3%
4%
5%
6%
7%
% of children and young people with
Type 1 diabetes

Figure 79: Percentage of children and young with Type 1 diabetes and coeliac or thyroid disease by
ethnic group, 2021/22

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6. List of Tables
Table 1: Number of children and young people
with diabetes by age-group and type of diabetes,
2021/22
5
Table 2: Number of children and young people
with Type 1 diabetes by country, region and age
group, 2021/22
7
Table 3: Number of children and young people
with Type 1 diabetes by NHS England region and
age group, 2021/22
7
Table 4: Ethnic groups of children and young
people with Type 1 diabetes in England and Wales,
2021/22
8
Table 5: Percentage and number of children and
young people with Type 1 diabetes by deprivation
quintile, 2021/22
8
Table 6: Number of children and young people
with Type 2 diabetes by country, region and NHS
England region, 2021/22
16
Table 7: Children and young people with Type 2
diabetes in England and Wales by ethnic group,
2021/22
17
Table 8: Numbers and percentages of children and
young people with Type 2 diabetes by deprivation
quintile, 2021/22
18
Table 9: Percentage of children and young people
with Type 1 diabetes who completed a full year of
care recorded as receiving health checks, 2015/16 to
2021/22
19
Table 10: Percentage of children and young people
of all ages with Type 1 diabetes who completed a
full year of care recorded as having received health
checks by country, region and NHS England region,
2021/22
23
Table 11: Percentage of young people aged 12 and
above with Type 1 diabetes who completed a full
year of care recorded as having received health
checks by country and region, 2021/22
24
Table 12: Percentage of children and young
people with Type 1 diabetes who completed a
full year of care by number of HbA1c
measurements recorded 2021/22, by country,
region and NHS England region
29
Table 13: Percentage of children and young
people with Type 1 diabetes who completed a full
year of care who were offered and/or attended an
additional dietetic appointment by country and
region, 2021/22
30
Table 14: Percentage of children and young people
with Type 1 diabetes who completed a full year of
care recorded as receiving health checks by region
and country, 2021/22
31
Table 15: Percentage of children and young people
with Type 2 diabetes who completed a full year of
care recorded as receiving recommended health
checks, 2015/16 to 2021/22
36
Table 16: Percentage of children and young
people with Type 2 diabetes who completed
a full year of care recorded as being offered
and attending an additional dietetic
appointment, 2017/18 to 2021/22
37
Table 17: Percentage of young people with Type 2
diabetes who completed a full year of care recorded
as receiving health checks by region and country,
2017/18 to 2021/22
37
Table 18: HbA1c for all children and young people
with Type 1 diabetes with one or more valid HbA1c
measurement by country and regional network
2021/22
40
Table 19: HbA1c for all children and young people
with Type 1 diabetes with one or more valid HbA1c
measurement by NHS England region 2021/22
40
Table 20: Percentage of children and young people
with Type 1 diabetes achieving HbA1c targets by
country and regional network, 2021/22
42
Table 21: Percentage of children and young people
with Type 1 diabetes achieving HbA1c targets by
NHS England region, 2021/22
42
Table 22: Mean HbA1c for children and young
people with Type 1 diabetes by ethnic category and
deprivation quintile, 2021/22
45
Table 23: HbA1c for all children and young people
with Type 2 diabetes and one or more valid
HbA1c measurements in England and Wales,
2015/16 - 2021/22
49

95
NPDA National report 2021/22: Care processes and outcomes
Table 24: Percentage of young people with Type 1
diabetes aged 12 years and above with albuminuria,
2015/16 to 2021/22
53
Table 25: Percentage of young people with
Type 1 diabetes aged 12 years and above with
a normal/abnormal eye screening result,
2015/16 to 2021/22
57
Table 26: Percentage of young people with Type
1 diabetes aged 12 years and above falling within
blood pressure targets by country and regional
network, 2021/22
60
Table 27: Percentage of young people with Type
1 diabetes aged 12 years and above falling within
blood pressure targets by NHS England region,
2021/22
60
Table 28: Percentage of young people with Type
1 diabetes aged 12 years and above falling within
cholesterol targets by country and regional
network, 2021/22
61
Table 29: Percentage of young people with
Type 1 diabetes aged 12 years and above falling
within cholesterol targets by NHS England
region, 2021/22
61
Table 30: Percentage of children and young people
with Type 2 diabetes with “high” or “high-normal”
blood pressure, 2016/17 - 2021/22
Table 31: Percentage of children and young people
with Type 2 diabetes, with recorded cholesterol
screen above the target for total blood cholesterol
2016/17-2021/22
62
Table 32: Body mass index categories for children
and young people with Type 2 diabetes, 2016/17 to
2021/22
67
Table 33: Outcome of assessment of the need for
psychological support and/or child and adolescent
mental health services (CAMHS) support, for
children and young people with Type 1 diabetes,
2017/18 – 2021/22
68
Table 34: Outcome of assessment of the need for
psychological support and/or child and adolescent
mental health services (CAMHS) support, for
children and young people with Type 2 diabetes,
2017/18 – 2021/22
70
Table 35: Percentage of children and young people
with Type 1 diabetes admitted at least once for a
diabetes-related reason that was not associated
with diagnosis by country and regional network,
2021/22
71
Table 36: Percentage of children and young people
with Type 1 diabetes admitted at least once for a
diabetes-related reason that was not associated
with diagnosis by NHS England region 2021/22
71
Table 37: Percentage of children and young people
with Type 1 diabetes, on each treatment regimen,
by country and region, 2021/22
73
Table 38: Percentage of children and young people
with Type 1 diabetes, on each treatment regimen,
by NHS England region, 2021/22
73
Table 39: Percentage of children and young people
with Type 2 diabetes using each
treatment regimen, England and Wales,
2020/21 to 2021/22
78
Table 40: Results of regression analysis of mean
HbA1c by taking into account treatment regimen
and measurable socio-demographic co-factors 88
Table 41: Percentage of children and young people
with Type 1 diabetes with thyroid or coeliac disease
by country and regional network in England and
Wales, 2021/22
90
Table 42: Percentage of children and young people
with Type 1 diabetes with thyroid or coeliac disease
by NHS England region, 2021/22
91

96
NPDA National report 2021/22: Care processes and outcomes
7. List of Figures
Figure 1: Total number of children and young
people with Type 1 diabetes broken down
by age and sex 2020/21 - 2021/22
6
Figure 2: Prevalence of Type 1 diabetes per
100,000 general population among children
aged 0-15 years by age and sex, 2013/14 to 2021/22 9
Figure 3: Prevalence of Type 1 diabetes per
100,000 general population by age group
and sex, 2013/14 to 2021/22
10
Figure 4: Incidence of Type 1 diabetes per
100,00 general population among children
aged 0-15 years by sex, 2013/14 to 2021/22
11
Figure 5: Number of new cases of Type 1 diabetes
amongst children and young people receiving
care from a PDU by month, 2013/14-2021/22
12
Figure 6: Newly diagnosed children and young
people with Type 1 diabetes by age group
and sex, 2021/22
13
Figure 7: Incidence of Type 1 diabetes per 100,000
general population by age group and sex,
2013/14 to 2021/22
13
Figure 8: Numbers of new cases of Type 1 diabetes
presenting in 2020/21 and 2021/22 by age at the
beginning of the audit year
14
Figure 9: Incidence of Type 1 diabetes amongst
children and young people aged 0-15 years per
100,000 by NHS network.
14
Figure 10: Numbers of children and young people
with Type 2 diabetes included in the NPDA,
2011/12- 2021/22
15
Figure 11: Numbers of children and young people
with Type 2 diabetes by age and sex, 2021/22
and changes in numbers between
2020/21 and 2021/22.
16
Figure 12: Percentage of children and young
people who completed a full year of care
recorded as receiving individual health checks,
2004/05 to 2021/22
20
Figure 13: Percentage of young people aged 12 or
above who completed a full year of care recorded
as receiving all seven/six key health checks,
2004/05 to 2021/22
21
Figure 14: Percentage of children and young
people aged 12 and above in 2020/21 receiving
retinopathy screening in 2021/22, by screening
result in 2020/21
22
Figure 15: Percentage of children and young
people with Type 1 diabetes receiving each key
health check by PDU, 2021/22
25
Figure 16: Percentage of young people aged
12 years and above with Type 1 diabetes who
completed a full year of care recorded as receiving
all six health checks by unit, 2021/22
26
Figure 17: Funnel plot of key health check
completion rates for young people aged
12 years and above with Type 1 diabetes who
completed a full year of care 2021/22, by PDU
27
Figure 18: Percentage of children and young
people with Type 1 diabetes who completed a full
year of care by number of HbA1c measurements
recorded per child or young person,
2016/17 to 2021/22
28
Figure 19: Percentage of offered dietetic
appointments attended by age group and
duration of diabetes, 2021/22
30
Figure 20: Completion rates for psychological
assessment, flu vaccine recommendation, “Sick day
rules” advice and blood ketone testing, for children
and young people with Type 1 diabetes who
completed a full year of care, 2017/18 to 2021/22
32
Figure 21: Percentage of newly diagnosed children
and young people with Type 1 diabetes who
received screening for thyroid and coeliac disease
within 90 days of diagnosis, 2015/16 to 2021/22
33
Figure 22: Percentage of newly diagnosed children
and young people with Type 1 diabetes who
received level 3 carbohydrate counting education
within 14 days of diagnosis, 2017/18 to 2021/22
34

97
NPDA National report 2021/22: Care processes and outcomes
Figure 23: Percentage of children and young
people with Type 2 diabetes who completed a
full year of care recorded as receiving key health
checks, 2015/16 to 2021/22
35
Figure 24: Number of HbA1c measurements
recorded for children and young people with
Type 2 diabetes receiving a full year of care,
2016/17 – 2021/22
36
Figure 25: Median HbA1c for children and young
people with all types of diabetes in England and
Wales 2009/10 to 2021/22, with associated
NHS policy and/or paediatric diabetes
delivery structural changes
39
Figure 26: Percentage of children and young
people with Type 1 diabetes with an HbA1c result
within current and previous target ranges,
2010/11 - 2021/22
41
Figure 27: Mean HbA1c for boys and girls
with Type 1 diabetes, 2003/04 to 2021/22
43
Figure 28: Mean HbA1c for children and young
people with Type 1 diabetes in England and Wales
by duration of diabetes and age group, 2021/22 44
Figure 29: Mean HbA1c for children and young
people with Type 1 diabetes in England and
Wales by ethnic group, 2003/04 to 2021/22
45
Figure 30: Percentage of children and young
people with Type 1 diabetes in England and
Wales achieving HbA1c targets by ethnic
group, 2021/22
46
Figure 31: Mean HbA1c for children and young
people with Type 1 diabetes by deprivation
quintile, 2013/14 to 2021/22
47
Figure 32: Percentage of children and young
people with Type 1 diabetes in England and Wales
achieving HbA1c targets by deprivation quintile,
2021/22
47
Figure 33: Median HbA1c per PDU 2021/22
48
Figure 34: Percentage of children and
young people with HbA1c <58mmol/mol
per PDU 2021/22
48
Figure 35: Percentage of children and young
people with Type 2 diabetes with an HbA1c result
within current and previous target ranges,
2017/18 - 2021/22
49
Figure 36: Mean HbA1c for boys and girls
with Type 2 diabetes, 2017/18 to 2021/22
50
Figure 37: Mean HbA1c for children and young
people with Type 2 diabetes, by duration of
diabetes, 2021/22
50
Figure 38: Mean HbA1c for children and young
people with Type 2 diabetes in England and
Wales by deprivation quintile, 2015/16 to 2021/22 51
Figure 39: Mean HbA1c for children and young
people with Type 2 diabetes by ethnic category,
2015/16-2021/22
52
Figure 40: Percentage of young people with Type 1
diabetes aged 12 years and older with albuminuria
by country, regional network and NHS England
(NHSE) network
53
Figure 41: Percentage of young people with Type 1
diabetes aged 12 years and above with albuminuria
by duration of diabetes, 2016/17 - 2021/22
54
Figure 42: Percentage of young people with Type 1
diabetes aged 12 years and above with albuminuria
by age and sex, 2016/17 - 2021/22
55
Figure 43: Percentage of young people with Type 1
diabetes aged 12 years and above with albuminuria
by deprivation quintile, 2016/17 - 2021/22
55
Figure 44: Percentage of young people with Type
1 diabetes achieving HbA1c targets by presence of
albuminuria, 2021/22
56
Figure 45: Percentage of children and young
people with Type 2 diabetes with albuminuria in
England and Wales, 2015/16 - 2021/22
56
Figure 46: Retinopathy screening outcomes of
young people aged 12 years and above with
Type 1 diabetes in 2021/22 by result of
screening 2020/21
58
Figure 47: Eye screening results for young people
aged 12 years and above with Type 2 diabetes
2015/16 to 2021/22
58
Figure 48: Percentage of young people aged 12
years and older with Type 1 diabetes with high
blood pressure and total blood cholesterol
above targets in England and Wales, 2013/14
to 2021/22
62

98
NPDA National report 2021/22: Care processes and outcomes
Figure 49: Percentage of children with Type 1
diabetes with obesity and overweight, aged 4 to 5
and aged 10 to 11 years old, compared to the
wider population by country, 2021/22
64
Figure 50: Percentage of children and young
people with Type 1 diabetes within BMI categories
by age group, 2020/21 - 2021/22
65
Figure 51: Distribution of body mass index of
children and young people with Type 1 diabetes in
2020/21 and 2021/22 compared to the 1990 reference
population
66
Figure 52: Percentage of children and young
people with Type 1 diabetes within the overweight
or obese BMI category, by deprivation quintile,
age group and sex, 2021/22
66
Figure 53: Percentage of children and young
people with Type 1 diabetes achieving HbA1c
targets by BMI category, 2021/22
67
Figure 54: Percentage of children and young
people with Type 2 diabetes who were in
healthy weight, overweight or obese
categories by sex, 2021/22
68
Figure 55: Percentage of children and young
people with Type 1 diabetes who were assessed as
requiring additional psychological support
by age and sex, 2021/22
69
Figure 56: Percentage of children and young people
with Type 1 diabetes achieving HbA1c targets by
outcome of psychological assessment, 2021/22
69
Figure 57: Percentage of children and young
people with Type 1 diabetes who had DKA at
diagnosis in 2021/22 by country, regional network
and NHS England region
72
Figure 58: Percentage of children and young
people with Type 1 diabetes recorded as using
insulin injections or insulin pump therapy by age
and sex, 2021/22
74
Figure 59: Percentage of children and young
people either on daily insulin injections or pump
therapy by age group, 2014/15 to 2021/22
75
Figure 60: Percentage of children and young
people either on daily insulin injections or pump
therapy by duration of diabetes for England and
Wales, 2021/22
75
Figure 61: Percentage of children and young people
with Type 1 diabetes using insulin pump therapy
by ethnic group and deprivation, 2021/22
76
Figure 62: Percentage of children and young
people with Type 1 diabetes using insulin injections
or insulin pump therapy by “least” and “most”
deprived quintile, 2014/15 to 2021/22
77
Figure 63: Percentage of children and young
people with Type 1 diabetes achieving HbA1c
targets by treatment regimen, 2021/22
77
Figure 64: Percentage breakdowns of stated
glucose monitoring device usage by country,
region and NHS England region
79
Figure 65: Percentages of children and young
people with Type 1 diabetes by glucose monitoring
device usage, by age and sex, 2021/22
80
Figure 66: Percentage of children and young
people with Type 1 diabetes with glucose monitoring
device usage, by duration of diabetes.
80
Figure 67: Percentage of children and young
people with Type 1 diabetes with stated glucose
monitoring device usage, by ethnic group and
deprivation quintile 2021/22
81
Figure 68: Percentage of children and young
people with Type 1 diabetes using an rtCGM by
ethnic group and deprivation quintile, 2021/22
82
Figure 69: Percentage of children and young
people with Type 1 diabetes using Flash monitors by
ethnic group and deprivation quintile, 2021/22
82
Figure 70: Percentage of children and young
people with Type 1 diabetes using a real-time
continuous glucose monitor (CGM) by “least” and
“most” deprived quintile, 2017/18 to 2021/22
83
Figure 71: Percentage of children and young
people with Type 1 diabetes achieving HbA1c targets
by rtCGM usage, 2021/22
83
Figure 72: Percentage of children and young
people with Type 1 diabetes achieving HbA1c targets
by Flash/mFlash monitors usage, 2021/22
84
Figure 73: Percentage of children and young
people with Type 1 diabetes using insulin injections
or insulin pump therapy by glucose monitoring
device usage, 2021/22
84

99
NPDA National report 2021/22: Care processes and outcomes
Figure 74: Percentages of children and young
people with Type 1 diabetes using insulin injections
only, insulin injections and Flash/mFlash, insulin
injections and rtCGM, insulin pump only, insulin
pump and Flash/mFlash, insulin pump and
rtCGM, by country, 2018/19 to 2021/22
85
Figure 75: Percentage of children and young
people with Type 1 diabetes achieving HbA1c
targets by treatment regimen in combination with
glucose monitoring devices (where applicable),
2021/22
86
Figure 76: Percentage of children and young people
with Type 1 diabetes with thyroid or coeliac disease
in England and Wales, 2014/15 to 2021/22.
91
Figure 77: Percentage of children and young
people with Type 1 diabetes and comorbid coeliac
or thyroid disease by sex, 2017/18 to 2021/22
92
Figure 78: Percentage of children and young
people with Type 1 diabetes and coeliac or thyroid
disease by deprivation quintile, 2021/22
92
Figure 79: Percentage of children and young with
Type 1 diabetes and coeliac or thyroid disease by
ethnic group, 2021/22
93

100
NPDA National report 2021/22: Care processes and outcomes
8.
References
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teams/child-measurement-programme/cmp-2020-
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Jackson LV, Thalange NK & Cole TJ (2007) Blood
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Nathan DM, Cleary PA, Backlund JY et al. (2005)
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NCMP (2022) National Child Measurement
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NHS England (2020) National Tariff Payment
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NICE (2004) Diagnosis and management of type
1 diabetes in children, young people, and adults
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NICE (2015) Diabetes (type 1 and type 2) in children
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NICE (2015) Diabetic foot problems: prevention and
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329:977–986.

Appendix 1: Full audit analysis
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Scotland (SC038299).
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and Child Health
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London, WC1X 8SH
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Improvement Partnership (HQIP)
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Paediatrics and Child Health
RCPCH
Published by RCPCH April 2022
Published by RCPCH August 2023