As the incidence of type 2 diabetes (T2D) continues to rise in youth and adolescents in the United States, the American Diabetes Association (ADA) published a position statement outlining the recognition, management, and prevention of T2D in the pediatric population. The statement, developed by a group of 6 endocrinology and psychology professionals, will be published in the December 2018 print issue of Diabetes Care.
The position statement addresses pathophysiology, risk screening and diagnosis, lifestyle management, and other aspects of comprehensive care for youth-onset T2D based on more than 260 relevant pieces of literature.
- The pathophysiology of T2D in youth and adults encompasses the relationship between disordered insulin sensitivity and β-cell function. In most youth, diminished insulin sensitivity due to puberty and/or obesity results in strong pancreatic β-cell compensatory insulin secretion. However, young patients with obesity who develop T2D show “severe peripheral and hepatic insulin resistance, with [approximately] 50% lower peripheral insulin sensitivity than peers with obesity without diabetes.” Research also indicates that β-cell failure and reduced insulin sensitivity, like in adults, leads to prediabetes and T2D in high-risk youth. In fact, the effects of worsening β-cell function and insulin sensitivity appear to be more pronounced in youth compared with adults with similar levels of glycemic irregularity.
- Almost all youth with T2D in North America are overweight or obese. Risk-based screening for prediabetes or T2D in young patients who are overweight or obese is recommended after the onset of puberty or after age 10. If tests are normal, testing should be repeated at 3-year intervals or more frequently with increasing body mass index (BMI).
- Nonmodifiable risk factors for T2D in a pediatric population include a strong family history of T2D (first- or second-degree relative), being the offspring of a mother whose pregnancy was complicated by gestational diabetes, minority race/ethnicity (Native American, African American, Latino, Asian American, Pacific Islander), and physiologic insulin resistance from puberty.
- In pediatric patients for whom a diagnosis of T2D is being considered, it is recommended clinicians perform tests to confirm the exact type of diabetes. A panel of pancreatic autoantibodies should be tested to exclude the possibility of type 1 diabetes (T1D) and evaluation of genetics and clinical presentation can be performed to rule out monogenic diabetes.
- A reasonable glycemic target for patients with youth-onset diabetes is <7%. This goal can be individualized and lowered for patients if hypoglycemia and other adverse effects of diabetes treatment can be avoided. Rates of hypoglycemia are generally low in youth-onset T2D; youth taking insulin to treat T2D should have individualized glycated hemoglobin (HbA1c) targets. HbA1c should be monitored every 3 months in all cases of youth-onset T2D.
- Because patients with youth-onset T2D are more likely to be of minority ethnic/racial background and educational materials developed for adults with T2D or youth with T1D may not address the issues unique to them and their families, programs specific to youth with T2D are necessary.
- All youth and adolescents with T2D and their families should receive comprehensive, culturally-relevant self-management support. Lifestyle programs intended to integrate weight loss and diabetes management should be provided for patients who are overweight or obese, with the goal of achieving a 7% to 10% reduction in excess weight. Considering the necessity of long-term weight and lifestyle management in young patients, these interventions should be based on a chronic care model.
- Pharmacologic therapy should be initiated at diagnosis of T2D, taking into consideration medication adherence and treatment effects on weight in patients with overweight/obesity and T2D. Clinicians should also assess for psychosocial factors when making treatment decisions — including food insecurity, housing stability, and financial barriers — and refer patients to behavioral/mental health specialty care when necessary.
- Metabolic surgery may be considered in adolescents with T2D who are obese (BMI >35 kg/m2). Long-term effects of metabolic surgery in adolescents with obesity remain to be determined, although positive outcomes, including remission of T2D, have been recorded in literature.
- Prevention and management of diabetes complications is important for youth-onset T2D, as the risk for microvascular complications is high. Blood pressure and symptoms of obstructive sleep apnea should be monitored at every visit. Screening for neuropathy, retinopathy, nonalcoholic fatty liver disease, and dyslipidemia tests should be performed annually. In adolescent girls with T2D, evaluation for polycystic ovary syndrome should be performed as indicated.
- The important transition from pediatric to adult care for young adults with T2D should begin well before patients are transferred to an adult-oriented diabetes specialist. The gradual, collaborative process should begin ≥1 year before the full transition.
The panel of researchers who contributed to the ADA statement piece suggested that future research investigate the mechanisms underlying the differences between youth and adults in T2D progression. In particular, research should assess why β-cell function deteriorates at a faster rate in young patients and the poor response to glucose-lowering medications observed in youth and adolescents.
“The present guidelines are based on current data, experience, opinion, and gained ‘wisdom.’ However, we anticipate that future guidelines will change as more scientific data emerge to support evidence-based recommendations,” concluded the researchers.
Arslanian S, Bacha F, Grey M, Marcus MD, White NH, Zeitler P. Evaluation and management of youth-onset type 2 diabetes: a position statement by the American Diabetes Association [published online November 13, 2018]. Diabetes Care. doi:10.2337/dci18-0052