Experts note alarming rise of type 2 diabetes in youth
Experts note alarming rise of type 2 diabetes in youth
ADA calls it an emerging epidemic
Type 2 diabetes was formerly a disease of aging found in overweight, sedentary adults. However, an increasingly overweight television-viewing, fast-food-eating American public has created an alarming rise in type 2 diabetes in prepubescent children and prompted an expert panel of the American Diabetes Association (ADA) in Alexandria, VA, to issue a consensus statement on the detection and treatment of type 2 diabetes in children. The statement was published recently in both Diabetes Care1 and Pediatrics.
"Type 2 diabetes in children is an emerging epidemic," says Arlan Rosenbloom, MD, chair of the consensus panel and distinguished professor emeritus of pediatrics at the University of Florida in Gainesville. "This document is an up-to-date resource for health care professionals to help them diagnose, treat, and ultimately lower the risk of complications of this disease in children and adolescents."
The panel concluded that type 2 diabetes commonly occurs in children with the following risk factors:
• overweight, often with a body mass index (BMI) greater than the 85th percentile for age and sex;
• older than 10 years of age;
• members of certain ethnic groups, including Native Americans, African Americans, Hispanic Americans, Asians/Pacific Islanders;
• family history of diabetes.
"Certainly an increase in obesity and sedentary lifestyles in young people is contributing to this epidemic," says Rosenbloom. "It’s also possible that there are issues of fetal nutrition at work. We are seeing type 2 diabetes in children who were underweight at birth and also in children who were overweight babies — typical of those born to mothers with gestational diabetes."
In fact, Rosenbloom says some experts theorize that a vicious cycle is contributing to this escalation in type 2 diabetes in younger people. "It’s possible that an increase in obesity in adults results in more cases of gestational diabetes. Gestational diabetes increases the risk of the mother delivering an overweight baby. That overweight baby has an increased risk of developing type 2 diabetes later in life."
Despite the risks associated with undiagnosed and untreated diabetes, the panel cautions that only asymptomatic children at substantial risk should be tested for type 2 diabetes. In general, the panel recommends that children who have a BMI greater than the 85th percentile for their age and sex and two or more of the other risk factors for type 2 diabetes should be tested every two years starting at age 10. Younger children should be tested only after the onset of signs of insulin resistance or conditions associated with insulin resistance, such as hypertension. The fasting plasma glucose (FPG) or two-hour post-prandial glucose should be used to screen children for type 2 diabetes, according to the panel, which added that the FPG is the preferred test due to its convenience and lower cost.
Diet alone rarely enough
Diagnosing type 2 diabetes in children is only the first challenge. The more important challenge is properly managing the disease. "Young people are not good at compliance," notes Rosenbloom. "Fewer than 10% of children being treated for type 2 diabetes are able to be controlled with diet and exercise alone in practical terms."
The panel found that of children currently being treated for type 2 diabetes:
• 50% are being treated with oral hyperglycemic agents;
• 40% are being treated with insulin;
• 10% are being treated with diet and exercise alone.
The panel recommends that treatment of type 2 diabetes be based on the child’s clinical presentation at the time of diagnosis. Clinical features that suggest initial treatment with insulin may be necessary include dehydration and the presence of ketosis.
Children who are less ill may be treated appropriately with diet, exercise, and oral agents, recommends the panel. At this time, however, insulin is the only drug approved by the U.S. Food and Drug Administration in Rockville, MD, Rosenbloom adds.
"We have some concerns because there is no experience using these oral agents in children," notes Rosenbloom. "For example, troglitazine has been associated with fatal liver failure, so it’s not recommended for use in children. If treatment goals can’t be met with nutrition and exercise and drug therapy is indicated, the oral agent most highly recommended is metformin."
The panel notes that metformin has several advantages that make it a good choice for treating type 2 diabetes in children:
• It helps stabilize or decrease weight.
• It decreases LDL cholesterol and triglyceride levels.
• It may normalize ovulation abnormalities.
"Of course, normalizing ovulation is a desirable outcome, but it also increases the possibility of an unplanned pregnancy," says Rosenbloom. "Pregnancy counseling should be included in the treatment plan for adolescent girls with type 2 diabetes."
The full text of the consensus statement can be found on the ADA Web site at www.diabetes. org/ada/Consensus/pg381.htm.
Reference
1. American Diabetes Association Consensus Panel. Type 2 diabetes in children and adolescents. Diabetes Care 2000; 22:381-399.
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