TYPE 2 DIABETES IN

YOUNG

Alaa Abdelsalam Dawood, MD,PhD

Ass. Prof of Diabetes and

Endocrinology

Menofyia university

Agenda

Prevalence of type 2 DM in young

Is it important to differentiate between Type 1 and

Type 2 in Children ?

Diagnosis of type 2 DM

Prevention: Primary and secondary

The incidence of type 2 diabetes in children and adolescents has reached

epidemic proportions in the United States. Recent reports indicate that as many

as 45% of pediatric patients diagnosed with diabetes in the United States have

type 2 diabetes. Furthermore, the prevalence of type 2 diabetes may be

underestimated due to misclassification of the disease. Prior to the late 1990s,

only 1% to 2% of children diagnosed with diabetes mellitus in the United States

had type 2 diabetes. Since then, owing to a combination of greater awareness,

increased screening, and higher incidence, the prevalence of type 2 diabetes

among US children has not only increased, but is expected to continue to grow

and to exceed that of type 1 diabetes.

2008

A large prospective study (TODAY study) provides

data on the youth-onset T2DM:

Glycemic control among adolescents with T2DM is often

poor.

Studies in several populations report that less than half

of the adolescents with type 2 diabetes regularly

attend follow-up visits.

One study reported mean glycated hemoglobin

concentrations of 12 percent, even among patients

involved in active follow-up

Is it important to differentiate between Type 1 and

Type 2 in Children ?

At the time of diagnosis, determining whether a

patient has type 1 or type 2 diabetes is of utmost

importance because insulin is life saving in type 1

Mortality rates and standardized mortality ratios in

type 2 diabetes are likely higher than those in type

1 diabetes

When in doubt ?

Clinical Presentation Type 1 Diabetes Type 2 Diabetes

Onset Abrupt Insidious

Family history of type 2

diabetesUncommon Common

ObesityNot typically present;

may be thinTypically present

Polyuria or Polydipsia Symptomatic Mild or absent

Ketonuria Usually present Present in up to 33%

Ketoacidosis at diagnosis Present in 30% to 40% Present in 5% to 25%

Hypertension, Hyperlipidemia Not typically present Typically present

Sleep apnea, Acanthosis

nigricansNot typically present Often present

Polycystic ovary syndrome Not present May be present (females)

C-peptide levels Low* Normal or elevated†

Beta-cell autoimmune

markers (autoantibodies to

islet cells, GAD, insulin)

Often but not always

present (> 70%)Absent or low (< 35%)

Work up

A random plasma glucose of 200 mg/dL or more in

symptomatic child.

OGT testing

Fasting plasma glucose value of 126 mg/dL or greater

2-hour plasma glucose value of 200 mg/dL or greater

Work up

Fundus Exam at diagnosis

Microalbuminuria

Test for Neuropathy

Lipid

Primary Prevention

Diet control: It is important to maintain healthy components of

traditional diets (i.e., micronutrient rich food such as fruits,

vegetables and whole grain cereals) and guard against

heavily marketed energy dense fatty and salty foods (e.g.

prepackaged snacks, ice-creams and chocolates).

Primary Prevention

Exercises

Children should be encouraged to be active not only for weight control

but for general well being.

WHO recommends at least 30 minutes of cumulative moderate exercise

(equivalent to walking briskly) for all ages; plus for children, an

additional 20 minutes of vigorous exercise (equivalent to running), three

times a week. These recommendations are basically for prevention of

CHD.

Prevention of obesity may require more physical exertion. In general,

moderate to vigorous activities for a period of at least one hour a day

may be a more practical recommendation for children.

Also, sedentary habits like television watching, computers should be

restricted to 1-2 hours daily.

Preventing obesity in women of childbearing age is another primary

prevention goal, because exposure to the environment of a diabetic

pregnancy places the fetus at increased risk of future onset of diabetes.

Screening Children for Type 2 Diabetes and Prediabetes

All Children with ≥2 risk factors: Family History

Race/Ethnicity; Native, African American, Latino, Pacific Slander

Maternal History of Gestational DM during child’s gestation

Signs of insulin resistance as :

Acanthosis nigricans

Hypertension

PCO

Small birth weight

Begin testing at age of 10 y or Pubertal and repeat testing each 3years.

Secondary prevention

Measures that are employed to delay or prevent the

occurrence of complications of diabetes:

Excellent glycemic control,

blood pressure control,

Dyslipidemia control

Screening for complications of diabetes

Psychological and social support

Life Style Management

Diet

low in sodium is recommended to reduce blood pressure.

Diets that promote the consumption of fruits, vegetables, and low-fat dairy products

Physical activity

Increasing physical activity is associated with a reduction in the risk of stroke. The goal is to engage in at least 30 minutes of moderate intensity activity on a daily basis.

Pharmacological treatment

Pharmacologic therapy is indicated when the

disease is not well controlled with diet and exercise:

Metformin should be the first oral agent used in

children and teenagers with an A1c level of less than

9%.

If metformin is unsuccessful as monotherapy, the

addition of insulin, a sulfonylurea, or another

hypoglycemic agent may be appropriate.

Pharmacological treatment

Insulin Therapy when:

When the distinction between type 1 or 2

Type 2 with ketosis

A1c % ≥ 9 , ADA

What is the target of HbA1c in type 2 diabetes in children ?

(Diabetes Care. 2015)

Before meals 90-130 mg/dl

Bedtime 90-150 mg/dl

HbA1c < 7.5%

Co-Morbidities : Hypertension

Management of Dyslipidemia in Children (1)

All type 2 diabetes in children should have basal

screening lipid profile

If the initial screening is normal……each 2y

Life Style Modification

Diet

Physical exercise

Control of Hyperglycemia

Control of Hypertension

± Omega 3

Management of Dyslipidemia in Children (2)

Target Management EAS 2013

Co-Morbidities : Diabetic Retinopathy

Co-Morbidities : Diabetic Nephropathy

Co-Morbidities: Obesity related Conditions

Co-Morbidities: Depression

Diabetic Nephropathy

In a comparative study among Japanese youths with type 1 and type 2 diabetes, the incidence of nephropathy among patients with type 2 diabetes was earlier and higher than it was in those with type 1 diabetes

The SEARCH for Diabetes in Youth Study found that American youth with type 2 diabetes are at a 4 fold increased risk of renal failure compared to pediatric patients with type 1 diabetes

Conclusion

Distinction between type 1 and type 2 in children is

mandatory

Of all microvascular complications, diabetic

nephropathy is more in type 2 diabetes in children

Life style modification is essential line of treatment

Metformin and insulin are the only FDA allowed in

children

Screening and Prevention are the gold standard

Thank You.

experts estimate that type 2 diabetes has grown

from less than 5 percent in 1994 to about 20

percent of all newly diagnosed cases of the disease

among youth in more recent years

Dyslipidemia

Treatment c Initial therapy may consist of optimization of glucose control and MNT using a Step 2 American Heart Association (AHA) diet aimed at a decrease in the amount of saturated fat in the diet. B c After the age of 10 years, the addition of a statin in patients who, after MNT and lifestyle changes, have LDL cholesterol .160 mg/dL (4.1 mmol/L) or LDL cholesterol .130 mg/dL (3.4 mmol/L) and one or more cardiovascular disease (CVD) risk factors is reasonable. E c The goal of therapy is an LDL cholesterol value ,100 mg/dL (2.6 mmol/L). E

Hypertension

Initial treatment of high-normal blood pressure (SBP or DBP consistently $90th percentile for age, sex, and height) includes dietary intervention and exercise, aimed at weight control and increased physical activity, if appropriate. If target blood pressure is not reached with 3–6 months of lifestyle intervention, pharmacological treatment should be considered. E c Pharmacological treatment of hypertension (SBP or DBP consistently $95th percentile for age, sex, and height) should be considered as soon as hypertension is confirmed. E c ACE inhibitors or angiotensinreceptor blockers (ARBs) should be considered for the initial pharmacological treatment of hypertension, following appropriate reproductive counseling due to its potential teratogenic effects. E c The goal of treatment is blood pressure consistently ,90th percentile for age, sex, and height. E