ADA Releases Type 2 Diabetes Guidelines for Youth
 
There are fundamental differences in the pathogenesis and course of type 2 diabetes between young people and adults that necessitate a different approach in youth with the disease, with an emphasis on the patient's social context and long-term management, say experts in a new position statement.
 
Writing on behalf of the American Diabetes Association (ADA), the authors developed guidelines on the pathogenesis, risk assessment, diagnostic criteria, and management of type 2 diabetes in young individuals, as well as associated comorbidities and complications and the transition to adult care.
 
They stress the need for risk-based screening in overweight and obese children and the development of culturally and contextually sensitive education and lifestyle management programs, particularly given the demographic profile of young patients with type 2 diabetes.
 
The statement, published online November 13 in Diabetes Care, was issued as the incidence of type 2 diabetes in the United States is estimated to have increased by 4.8% in people aged under 20 years in the decade between 2002 and 2012.
 
Type 2 diabetes also "appears to be more aggressive in youth than in adults, with a faster rate of deterioration of beta-cell function and poorer response to glucose-lowering medication," lead author Silva Arslanian, MD, from the University of Pittsburgh, Pennsylvania, said in an ADA news release.
 
"Furthermore, there is a higher risk for complications in people with earlier-onset type 2 diabetes, which is possibly related to prolonged lifetime exposure to hyperglycemia and other atherogenic risk factors, including insulin resistance, dyslipidemia, hypertension, and chronic inflammation."
 
Arslanian therefore urges clinicians to "continue to make strides in recognizing the specific needs of youth and adolescents who are at risk or diagnosed with type 2 diabetes."
 
Youth-Onset Type 2 Diabetes Is Different
William T. Cefalu, MD, chief scientific, medical, and mission officer at the ADA, who was not involved in developing the statement, echoed those comments.
 
"Over the last 20 years, there has been a tremendous increase in knowledge of youth-onset type 2 diabetes and the important differences that exist from diabetes presenting at an older age," he explained.
"It is critical that we have a continually evolving understanding of how this disease impacts youth and that we implement effective strategies to best manage type 2 diabetes when diagnosed at a young age."
 
To develop the statement, six pediatric endocrinology and psychology experts gathered to review more than 260 articles, expert consensus documents, and scientific research articles from the field.
They say that children and adolescents over 10 years of age, or who have already started puberty, should be considered for risk-based screening if they are overweight or obese, defined as a body mass index (BMI) ≥ 85th percentile and ≥ 95th percentile, respectively.
 
Other risk factors to take into consideration include a maternal history of diabetes or of gestational diabetes during the child's gestation; a close family history of type 2 diabetes; being from an African American, Latino, or other non-Caucasian backgrounds; and having signs of insulin resistance.
 
The authors point out that, although the laboratory-based diagnostic criteria for prediabetes and diabetes are the same in young people as in adults, "these criteria have been extrapolated from adults" and so "the exact relevance of these definitions for pediatric populations remains unclear."
 
They also note that "there are fundamental differences in insulin sensitivity and beta-cell function between youth and adults with prediabetes and type 2 diabetes, which could possibly explain why some youth develop type 2 diabetes decades earlier than adults."
 
Spelling out the laboratory criteria for diagnosing prediabetes and diabetes in terms of the HbA1c, fasting plasma glucose, and oral glucose tolerance tests, they say that the type of diabetes should be confirmed using a panel of pancreatic autoantibodies to exclude autoimmune type 1 diabetes.
 
Comprehensive, Culturally Sensitive Diabetes Management for Youth
Alongside setting glycemic targets, the authors stress that "all youth with type 2 diabetes and their families should receive comprehensive diabetes self-management education/support that is specific to youth with type 2 diabetes and is culturally competent," taking into account their ethnic background.
 
They also say that healthcare providers should consider factors such as potential food insecurity, housing stability, and financial barriers, and assess diabetes distress and mental/behavioral health in young patients.
Medication adherence and treatment effects on weight should also be considered when choosing glucose-lowering or other medications in overweight/obese patients, and all young women of childbearing age should have preconception counseling incorporated into their clinic visits.
 
The authors also emphasize that lifestyle management in young patients should take a chronic care approach and focus on education, weight management, exercise, nutritional, and psychological factors.
 
And they present an algorithm for the management of new-onset diabetes in overweight youth, which is based on the presence of relevant risk factors and sets out appropriate pharmacologic treatment.
 
There is also a section on metabolic surgery, which says that it "may be considered" in adolescents with type 2 diabetes who have a BMI > 35 kg/m2and uncontrolled glycemia and/or serious comorbidities but have failed lifestyle and pharmacologic interventions.
 
However, the authors underline that it "should be performed only by an experienced surgeon working as part of a well-organized and engaged multidisciplinary team including a surgeon, endocrinologist, nutritionist, behavioral health specialist, and nurse."
 
Manage Transition to Adult Care Carefully
After setting out a range of recommendations aimed at preventing and managing diabetes complications, the guidelines end with a discussion of the transition from pediatric to adult care.
 
Here, the authors say that it is "a challenge that has only recently received attention in the literature" but the importance of which is now being recognized.
 
Owing to the potential impact of a change in healthcare provider, they state that young people with type 2 diabetes should be transferred to adult care only "when deemed appropriate by the patient and provider."
Summarizing, they write that the guidelines presented in the statement "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."
 
Diabetes Care. Published online November 13, 2018. 
 
 
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CONCLUSIONS
Even though our knowledge of youth- onset type 2 diabetes has increased tremendously over the last two decades, robust and evidence-based data are still limited regarding diagnostic and therapeutic approaches and prevention of complications. The current-day information indicates that there are fundamental differences in insulin sensitivity and b-cell function between youth and adults with prediabetes and type 2 diabetes, which could possibly explain why some youth develop type 2 diabetes decades earlier than adults.
 
Youth are more insulin resistant and have b-cells that are hyperresponsive to stimulation compared with adults. Puberty-related physio- logic insulin resistance, particularly in obese youth, may play a role in this heightened insulin resistance. It remains an enigma, though, why some individuals with youth-onset type 2 diabetes dem- onstrate durable control and others do not.
 
Furthermore, type 2 diabetes appears to be more aggressive in youth than adults, with a faster rate of de- terioration of b-cell function and poorer response to glucose-lowering medications. Future research should probe the mechanisms responsi- ble for this youth–adult contrast in the various aspects of type 2 diabetes. Lastly, complications in youth with type 2 diabetes appear early, resulting in higher rates of morbidity and mortality com- pared with type 1 diabetes. Preexisting obesity and its comorbidities might play a key role in amplifying the complications of youth-onset type 2 diabetes. Intervention/prevention strategies for type 2 diabetes should not be limited to youth with dysglycemia only, but youth with obesity at large.
 
In closing, 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.
 
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