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Diagnoses of type 2 diabetes among US youth increased three-fold between 2001 and 2009. These children will enter their 20s with adult complications. Here, how to help stem the tide.
The twin epidemics of obesity and diabetes among US children and adolescents have been smoldering for years and threaten to foster the ill health of their adult generations. A study published recently in the Journal of the American Medical Association has added fuel to the fire with its finding of a significant jump in the last decade in diagnoses of both type 1 and type 2 diabetes (T1DM, T2DM) among US youth.1 The study, part of the SEARCH for Diabetes in Youth study, is the first to report on changes in prevalence of T2DM by race/ethnicity in US youth under age 20.
Key results include:
-- From 2001 to 2009, diagnoses of T1DM increased by 21.1%, while diagnoses of T2DM increased by 30.5% among US youth.
-- In 2009, the prevalence of T2DM was highest among American Indians, followed by black, Hispanic, and Asian Pacific Islander youth, while white youth had the lowest prevalence.
-- Significant increases in T2DM occurred in both sexes, all age groups, and in white, Hispanic, and black youth.
The increased prevalence of childhood-onset T2DM means that these children enter adulthood with an established disease burden.2 The disease in youth may also be more aggressive than in adults. Microvascular and macrovascular complications appear early in the course of the disease,3 increasing the risk of long-term complications in adulthood, especially atherosclerosis and cardiovascular disease.4 For these reasons, aggressive, targeted screening and multifaceted management are warranted.3,4
Screening and Diagnosis of T2DM in Youth
Age-specific issues can make it tricky to diagnose T2DM in children and teenagers. In the past, most children with T1DM were generally thin. That standard no longer applies across the board. Though obesity is usually present in children with T2DM, some children with T1DM are now also overweight, which complicates the differential diagnosis between T1DM and T2DM.5
In 2013, updated guidelines from the American Diabetes Association (ADA)6 dedicated a separate section to T2DM in youth, which drew heavily on a similar statement from 20006,7:
-- Targeted screening: Begin at age 10, or onset of puberty in overweight (≥ 120% of ideal weight) and obese children with 2 or more risk factors (T2DM in ï¬rst- or second-degree relatives, member of a high risk ethnic group, or history of in utero exposure to obesity or hyperglycemia)
-- Screening tests: Fasting plasma glucose is preferred, using the same diagnostic criteria as in adults; oral glucose tolerance test and HbA1c can also be used
-- Age: Observed peak age at diagnosis is 13.5 yrs, or mid-puberty, likely related to growth hormone secretion and associated hyperinsulinemia
-- Additional risk factors: acanthosis nigricans, dyslipidemia, hypertension, nonalcoholic fatty liver disease, antipsychotic medication use, or polycystic ovarian syndrome (PCOS)
-- Clinical symptoms: Most present with glucosuria without ketonuria
-- Related symptoms: Absent or mild polyuria or polydipsia, mild or no weight loss, fatigue, blurred vision, vaginitis
-- Metabolic decompensation: Ketosis, diabetic ketoacidosis (in up to 25% at presentation), hyperglycemic hyperosmolar nonketotic state
-- Comorbidities: Check blood pressure, fasting lipid profiles, microalbuminuria, and dilated eye exams at diagnosis
-- Unclear clinical presentation: C-peptide and fasting insulin (elevated in T2DM but not in T1DM) or autoantibodies (elevated in T1DM but not in T2DM) may be helpful
Pharmacotherapy for youth with T2DM is limited. Only metformin and insulin are FDA-approved for use in this population and few randomized controlled trials of other oral agents have been conducted in youth.5
As in diagnosis, age-specific concerns affect the management of T2DM in youth. Key recommendations from the ADA include:
-- Acute presentation: Insulin until metabolic control is achieved, with some children able to be weaned off insulin over several weeks
-- Nonacute presentation:
- Lifestyle modification: First line, with nutrition counseling and at least 60 minutes of physical activity per day
- Pharmacotherapy: Metformin should be tried first; it can normalize ovulation in girls with PCOS, however, increasing the risk for unplanned pregnancy-pregnancy counseling should be part of management; consider adjunctive therapy if adequate glycemic control is not achieved after 3 to 6 months; adolescents with irregular eating habits may benefit from meglinitide; ACE inhibitors are first-line in youth with microalbuminuria; statins are contraindicated in pregnancy-again, contraceptive and pregnancy counseling are advisable
- Prevention: Weight control, increase physical activity in high risk children
In 2013, the American Academy of Pediatrics (AAP) issued guidelines for the treatment of T2DM in
children and adolescents. Though similar to the ADA recommendations, key differences from the AAP guidelines include8:
-- At diagnosis: Start pharmacotherapy along with diet and exercise modification; metformin is first-line
-- Insulin: Start in youth who are ketotic or in diabetic ketoacidosis, and in whom the differential between T1DM and T2DM is unclear
-- Activity: Moderate-to-vigorous physical activity at least 60 minutes per day; limit “screen” time (TV, computer) to less than 2 hours per day
-- Adjunctive medication: Recommendations are similar to adults, though research is limited on their use in youth
-- The prevalence of T2DM among US youth may have risen as much as 30% over the last decade
-- Targeted screening of at-risk youth should begin at age 10, using the same criteria recommended by the ADA for adults
-- Lifestyle modification is a cornerstone of treatment for youth with T2DM
-- Metformin is first-line pharmacotherapy for non-acute presentations of T2DM
-- Youth with T2DM may have more aggressive disease, putting them at higher risk for short- and long-term complications of T2DM and necessitating aggressive screening and treatment regimens.