title: Higher incidence of childhood-onset type 1 diabetes mellitus in remote areas: a UK regional small-area analysis.
abstract: OBJECTIVE
  We investigated the association between the incidence of type 1 diabetes mellitus and remoteness (a proxy measure for exposure to infections) using recently developed techniques for statistical analysis of small-area data.
  
  
  METHODS
  New cases in children aged 0 to 14 years in Northern Ireland were prospectively registered from 1989 to 2003. Ecological analysis was conducted using small geographical units (582 electoral wards) and area characteristics including remoteness, deprivation and child population density. Analysis was conducted using Poisson regression models and Bayesian hierarchical models to allow for spatially correlated risks that were potentially caused by unmeasured explanatory variables.
  
  
  RESULTS
  In Northern Ireland between 1989 and 2003, there were 1,433 new cases of type 1 diabetes, giving a directly standardised incidence rate of 24.7 per 100,000 person-years. Areas in the most remote fifth of all areas had a significantly (p=0.0006) higher incidence of type 1 diabetes mellitus (incidence rate ratio=1.27 [95% CI 1.07, 1.50]) than those in the most accessible fifth of all areas. There was also a higher incidence rate in areas that were less deprived (p<0.0001) and less densely populated (p=0.002). After adjustment for deprivation and additional adjustment for child population density the association between diabetes and remoteness remained significant (p=0.01 and p=0.03, respectively).
  
  
  CONCLUSIONS
  In Northern Ireland, there is evidence that remote areas experience higher rates of type 1 diabetes mellitus. This could reflect a reduced or delayed exposure to infections, particularly early in life, in these areas.
authors.affiliation: School of Medicine and Dentistry, The Queen's University of Belfast, Belfast, UK. c.cardwell@qub.ac.uk
authors.forename: C R
authors.initials: CR
authors.lastname: Cardwell
authors.forename: D J
authors.initials: DJ
authors.lastname: Carson
authors.forename: C C
authors.initials: CC
authors.lastname: Patterson
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D003922:Diabetes Mellitus, Type 1 / Q000453:epidemiology*; D006801:Humans; D015994:Incidence; D007223:Infant; D007231:Infant, Newborn; D009660:Northern Ireland / Q000453:epidemiology; D011156:Population Density; D017062:Small-Area Analysis; D012959:Socioeconomic Factors