Best Practices in Youths and Adolescents with Obesity and Type 2 Diabetes Mellitus

At the Endocrine Society’s annual meeting, ENDO 2021, held virtually from March 20 to 23, Seema Kumar from the Mayo Clinic presented a review covering the evaluation and assessment of pediatric obesity and type 2 diabetes mellitus (T2DM). Topics addressed included an overview of lifestyle interventions, the American Diabetes Association (ADA) guidelines for goal-directed disease management, and the safety and efficacy of bariatric surgery for this patient population.

Kumar, together with Sachi Singhal, wrote a review aligned with this topic that was published in Children, “Current Perspectives on Management of Type 2 Diabetes in Youth.” In the review, the authors describe the rising prevalence of T2DM among youth (defined as less than 20 years of age) and how it parallels the worldwide increase in childhood obesity. T2DM is more progressive in this population compared to adults, and disease-related complications develop more rapidly and show lower response rates to pharmacotherapy.

The study authors recommended the use of the ADA criteria for diagnosing T2DM in youth: glycated hemoglobin A_1c (HbA_1c) of at least 6.5%, or 2-h glucose concentration during an oral glucose tolerance test of at least 200 mg/dL, or fasting plasma glucose (FPG) at least 126 mg/dL. If the patient is asymptomatic, the test should be repeated for confirmation.

In a patient with symptoms of hyperglycemia, random glucose of at least 200 mg/dL is considered diagnostic of diabetes. Being overweight or obese does not rule out type 1 diabetes, and given that T2DM is extremely rare in prepubescent children, testing for monogenic diabetes should be considered in some cases.

The first line of treatment recommended for pediatric T2DM is metformin and lifestyle modifications, as long as there is no significant hyperglycemia. An HbA_1c of less than 7% or FPG less than 130 mg/dL is an appropriate goal for most youth with T2DM, although it may be appropriate to set more stringent goals for select individuals.

Pancreatic autoimmunity assessment is also recommended because antibody-positive youths progress more rapidly to insulin requirement and are at higher risk for autoimmune disorders. Pharmacotherapeutic options are limited for youths with T2DM, but a number of pediatric clinical trials are underway for medications that have already been approved for adults with T2DM. The GLP-1 agonist liraglutide was recently approved for T2DM in adolescents are at least 10 years old.

Metabolic surgery can be considered in select adolescents with severe obesity (BMI ≥35 kg/m2) who also have poor glycemic control and/or serious comorbidities despite pharmacological and lifestyle interventions. Bariatric surgery is associated with excellent rates of T2DM remission in this population.

Furthermore, despite there being no differences in percent weight change, a separate study found that remission rates were higher with this surgery among adolescents than in adults (86% vs 53%, respectively; risk ratio 1.27; 95% CI, 1.03-1.57).

Study investigators concluded, “The prevalence of T2DM in children and adolescents is increasing due to the epidemic of childhood obesity. T2DM disproportionately affects children from ethnic minorities. Youth with T2DM often have additional cardiovascular risk factors.”

The disease in youths is not as responsive to available therapies, but new treatments are being tested in ongoing clinical trials. When lifestyle changes, medication, and other interventions have failed to make a difference in adolescents with severe obesity and serious comorbidities, bariatric surgery should be considered.

References

1. Kumar S. Obesity in youth and adolescent: treatment of a growing problem- best medical practices in obesity and type 2 diabetes mellitus in kids. Presented at: ENDO 2021; March 20-23, 2021; Session S30.

2. Singhal S, Kumar S. Current perspectives on management of type 2 diabetes in youth. Children. 2021; 8(1):37. doi:10.3390/children8010037