Type 2 Diabetes in Children and
Adolescents
Prevention
 Obesity is a major modifiable risk factor.
 Family-based healthy behaviour interventions
(changes in diet and physical activity patterns) have
been shown to result in significant weight reduction
in children and adolescents.
Source: Canadian Diabetes Association(2018)
Prevention
 The role of pharmacotherapy in the treatment of
childhood obesity is controversial as there are few
controlled trials and no long-term safety or
efficacy data.
 Bariatric surgery in adolescents should be limited to
exceptional cases (BMI s35 kg/m2 with severe
comorbidities or s40 kg/m2 with less severe
comorbidities) and be performed only by
experienced teams.
Source: Canadian Diabetes Association(2018)
ADA Recommendations
 If tests are normal, repeat testing at a minimum of 3-year
intervals E, or more frequently if BMI is increasing. C
 Fasting plasma glucose, 2-h plasma glucose during a 75-g
oral glucose tolerance test, and A1C can be used to test for
prediabetes or diabetes in children and adolescents. B
Source: American Diabetes Association Standards of Medical Care in Diabetes(2021)
ADA Recommendations
 Children and adolescents with overweight/obesity in whom
the diagnosis of type 2 diabetes is being considered should
have a panel of pancreatic autoantibodies tested to
exclude the possibility of autoimmune type 1 diabetes. B
Source: American Diabetes Association Standards of Medical Care in Diabetes(2021)
CDA Recommendations
 A fasting plasma glucose (FPG) is the
recommended routine screening tool for children
and adolescents.
 The use of the A1C for diagnosis of type 2
diabetes in children and adolescents is not
recommended (because it diverges to some
extent from FPG values and OGTT values).
Source: Canadian Diabetes Association(2018)
CDA Recommendations
An oral glucose tolerance test (1.75 g/kg;
maximum 75g) may be used as a screening tool in:
 very obese children (BMI ẕ99th percentile for age
and gender) or
 those with multiple risk factors who meet the
criteria in recommendation
Source: Canadian Diabetes Association(2018)
CDA Recommendations
Screening for type 2 diabetes should be performed every 2
years using an FPG test in children with any of the following:
1. s 3 risk factors in non-pubertal or s 2 risk factors in
pubertal children
a. Obesity (BMI ẕ95th percentile for age and gender)
b. Member of high-risk ethnic group (e.g. Aboriginal, African,
Asian, Hispanic or So Asian descent
c. Family history of type 2 diabetes and/or exposure
to hyperglycemia in utero
Source: Canadian Diabetes Association(2018)
CDA Recommendations
d. Signs or symptoms of insulin resistance (including
acanthosis nigricans, hypertension, dyslipidemia, NAFLD [ALT
> 3x upper limit of normal or fatty liver, fatty liver on
ultrasound], PCOS)
2. Impaired fasting glucose or impaired glucose tolerance
3. Use of atypical antipsychotic medications
Source: Canadian Diabetes Association(2018)
CDA Recommendations
 Commencing at the time of diagnosis of type 2
diabetes, all children should receive ongoing
intensive counselling, including lifestyle
modification, from an interdisciplinary pediatric
healthcare team.
Source: Canadian Diabetes Association(2018)
Required Readings
American Diabetes Association (2021) - Diabetes in
Children and Adolescents
National Clinical Guidelines (2018) - The diagnosis and
management of diabetes mellitus in children and
adolescents
Diabetes Canada Clinical Guidelines (2018)
Recommended Readings
 ISPAD (2018) - Chapter 3: Type 2 Diabetes mellitus in youth
Treatment Goals and Challenges in the
Management of Youth with Type 2
Diabetes
Treatment Goals of Type 2 Diabetes
 Diabetes care goals must be directed toward
reducing insulin resistance and preventing
complications.
 The importance of good metabolic control in
reducing the risk of microvascular disease in
adults with type 2 diabetes is well
documented.
Sources: Canadian Diabetes Association(2018)
International Society for Pediatric and Adolescents Diabetes (2018)
Treatment Goals of Type 2 Diabetes
Goals of therapy should include:
 Achieve and maintain a near-normal A1C level c
7.0% for most children and adolescents.
 Maintain FPG levels as close to normal as possible
(3.8 to 8.3 mmol/L for youth aged 10 to 17).
 Attain and maintain a healthy weight.
 Maintain normal physical growth.
 Eliminate symptoms associated with high BG
levels.
Source: Canadian Diabetes Association(2018)
International Society for Pediatric and Adolescents Diabetes (2018)
Treatment Goals of Type 2 Diabetes
 Effectively treat comorbid conditions, such as
hypertension and dyslipidemia.
 Maintain psychological and emotional wellbeing.
 Prevent complications.
Source: Canadian Diabetes Association(2018)
International Society for Pediatric and Adolescents Diabetes (2018)
ADA Recommendations
 A reasonable A1C target for most children and adolescents
with type 2 diabetes treated with oral agents alone is <7%.
 More stringent A1C targets (such as <6.5%) may be
appropriate for selected individual patients if this can be
achieved without significant hypoglycemia or other
adverse effects of treatment.
Source: American Diabetes Association Standards of Medical Care in Diabetes(2021)
ADA Recommendations
 Appropriate patients might include those with short
duration of diabetes and lesser degrees of β-cell
dysfunction and patients treated with lifestyle or
metformin only who achieve significant weight
improvement. E
 A1C targets for patients on insulin should be individualized,
taking into account the relatively low rates of hypoglycemia
in youth-onset type 2 diabetes. E
Source: American Diabetes Association Standards of Medical Care in Diabetes(2021)
CDA Recommendation
The target A1C for most children with type 2
diabetes should be ≤ 7.0%.
Source: Canadian Diabetes Association(2018)
Treatment Considerations
 Teens are different from adults
 Subject to peer pressure
 Often rebel against authority
 Tend to engage in risk-taking behavior
Source: Canadian Diabetes Association(2018)
International Society for Pediatric and Adolescents Diabetes (2018)
Treatment Considerations
 Interprofessional pediatric diabetes health-care team:
o Pediatric endocrinologist OR pediatrician with
diabetes expertise
o Diabetes educator
o Mental health professional
 Treatment programs for adolescents with type 2
diabetes should address the health behaviors of the
entire family, emphasizing healthy eating and physical
activity.
Source: Canadian Diabetes Association(2018)
International Society for Pediatric and Adolescents Diabetes (2018)
Treatment Considerations
The principles of treatment include:
 self-management education (SME)
 nutrition therapy
 exercise plan
 pharmacological therapy
 monitoring and psychosocial support
Source: Canadian Diabetes Association(2018)
International Society for Pediatric and Adolescents Diabetes (2018)
Treatment Considerations
The CDA clinical practice guidelines emphasize that to be
effective, treatment programs for adolescents with type 2
diabetes need to address the lifestyle and health habits
and psychosocial functioning of the whole family.
Source: Canadian Diabetes Association(2018)
International Society for Pediatric and Adolescents Diabetes (2018)
Physical Activity
 Children with T2D should strive to achieve the
same activity level recommended for children
in general:
o 60 minutes/day of moderate-to-vigorous
physical activity.
o Limit sedentary screen time to c2 hours per
day.
Source: Canadian Diabetes Association(2018)
International Society for Pediatric and Adolescents Diabetes (2018)
Mental Health
 Psychological issues (depression, binge eating,
smoking cessation) need to be addressed and
interventions offered as required.
 19.4% have neuropsychiatric disorder at
presentation of type 2 diabetes.
Source: Canadian Diabetes Association(2018)
International Society for Pediatric and Adolescents Diabetes (2018)
ADA Recommendation
• Youth with diabetes, like all children, should be encouraged to
participate in at least 30–60 min of moderate to vigorous physical
activity at least 5 days per week (and strength training on at least 3
days/week) B and to decrease sedentary behavior. C
Source: American Diabetes Association Standards of Medical Care in Diabetes(2021)
ADA Recommendation
Youth with overweight/obesity and type 2 diabetes
and their families should be provided with
developmentally and culturally appropriate
comprehensive lifestyle programs that are integrated
with diabetes management to achieve 7–10%
decrease in excess weight. C
Source: American Diabetes Association Standards of Medical Care in Diabetes(2021)
CDA Recommendation
All children should receive guidance:
 promoting healthy eating, limiting sugar sweetened
beverage intake [Grade C, Level 3].
 limiting screen time, improving sleep quantity and
quality, decreasing sedentary behaviors and increasing
both light and vigorous physical activity [Grade C, Level
3] to prevent type 2 diabetes.
Source: Canadian Diabetes Association(2018)
Recommended Reading
ISPAD - Chapter 14: Exercise in children and adolescents with diabetes
Peter Adolfsson, Michael C Riddell, Craig E Taplin, Elizabeth A Davis, Paul
A Fournier, Francesca Annan, Andrea E Scaramuzza, Dhruvi Hasnani and
Sabine E. Hofer.
Pharmacotherapy
 Limited data about the safety or efficacy of
non-insulin antihyperglycemic agents in
children.
 None of the non-insulin antihyperglycemic
agents have been approved by Health Canada
for use in children.
Source: Canadian Diabetes Association (2018)
International Society for Pediatric and Adolescents Diabetes (2018)
Pharmacotherapy
 Metformin has been shown to be safe in adolescents
for up to 16 weeks, reducing A1C by 1.0% - 2.0% and
lowering FPG with similar side effects as seen in
adults.
 Glimepiride has also been shown to be safe and
effective in adolescents for up to 24 weeks, reducing
A1C by 0.54% but weight gain of 1.3 kg.
 Therefore, metformin preferred over glimepiride.
Source: Canadian Diabetes Association(2018)
Pharmacotherapy
 Metformin should be initiated in conjunction
with healthy behavior interventions.
 If glycemic targets are not achieved within 3-6 months
from diagnosis, then initiate basal insulin.
 If targets still not achieved on combination
metformin and basal insulin, then add prandial
insulin.
Source: Canadian Diabetes Association(2018)
Recommended Reading
• TODAY Study Group (2012). Treatment Options for Type 2
• Diabetes in Adolescents and Youth (TODAY),
• New England Journal of Medicine; 14;366(24):2247-56.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2752327/
TODAY Study
 Treatment Options for Type 2 Diabetes in
Adolescents and Youth (TODAY)
 699 patients 10 to 17 years of age (mean duration of
diagnosed type 2 diabetes, 7.8 months), were randomly
assigned to:
 continued treatment with metformin alone or
 metformin combined with rosiglitazone (4 mg twice a day) or
 metformin and a lifestyle-intervention program
focusing on weight loss through eating and activity
behaviors
Source: Canadian Diabetes Association(2018)
TODAY Study
The primary outcome
 Glycemic control, defined as a glycated hemoglobin
level of at least 8% for 6 months or
 sustained metabolic decompensation requiring insulin
Source: Canadian Diabetes Association(2018)
TODAY Study
Results
 319 (45.6%) reached the primary outcome over an
average follow-up of 3.86 years.
 Rates of failure were 51.7%, 38.6%, and 46.6% for
metformin alone, metformin plus rosiglitazone, and
metformin plus lifestyle intervention, respectively.
Source: Canadian Diabetes Association(2018)
TODAY Study
Results
 Metformin plus rosiglitazone was superior to
metformin alone (P=0.006); metformin plus lifestyle
intervention was intermediate but not significantly
different from metformin alone or metformin plus
rosiglitazone.
Source: Canadian Diabetes Association(2018)
TODAY study: Treatment Options for Type 2 Diabetes in Adolescents and Youth
~50% of patients on metformin will require additional glycemic therapy
Failurerates:
Metformin alone, 51.7%
Metformin + lifestyle, 46.6%
Metformin + rosiglitazone, 38.6%
Proportion Free of GlycemicFailure
1.00
0.75
0.50
0.25
0.00
0
12
24
36
Months since Randomization
Source: Canadian Diabetes Association (2018)
TODAY Study Group. N Engl J Med 2012;366:2247-56.
48
60
TODAY Study
Conclusion
 Monotherapy with metformin was associated with
durable glycemic control in approximately half of
children and adolescents with type 2 diabetes. The
addition of rosiglitazone, but not an intensive lifestyle
intervention, was superior to metformin alone.
Source: Canadian Diabetes Association(2018)
Management of new-onset diabetes in overweight youth
Source: American Diabetes Association Standards of Medical Care in Diabetes(2021)
ADA Recommendation
 Initiate pharmacologic therapy, in addition to behavioral counseling
for healthful nutrition and physical activity changes, at diagnosis of
type 2 diabetes. A
 In incidentally diagnosed or metabolically stable patients (A1C <8.5%
[69 mmol/mol] and asymptomatic), metformin is the initial
pharmacologic treatment of choice if renal function is normal. A
 If glycemic targets are no longer met with metformin (with or without
basal insulin), liraglutide should be considered in children 10 years of age
or older if they have no past medical history or family history of medullary
thyroid carcinoma or multiple endocrine neoplasia type 2. A
Source: American Diabetes Association Standards of Medical Care in Diabetes(2021)
ADA Recommendation
 Youth with marked hyperglycemia (blood glucose s250
mg/dL [13.9 mmol/L], A1C s8.5% [69 mmol/mol])
without acidosis at diagnosis who are symptomatic
with polyuria, polydipsia, nocturia, and/or weight loss
should be treated initially with basal insulin while
metformin is initiated and titrated. B
Source: American Diabetes Association Standards of Medical Care in Diabetes(2021)
ADA Recommendation
 In patients with ketosis/ketoacidosis, treatment with
subcutaneous or intravenous insulin should be initiated to
rapidly correct the hyperglycemia and the metabolic
derangement. Once acidosis is resolved, metformin should
be initiated while subcutaneous insulin therapy is
continued. A
Source: American Diabetes Association Standards of Medical Care in Diabetes(2021)
ADA Recommendation
 In individuals presenting with severe
hyperglycemia (blood glucose s600 mg/dL
[33.3 mmol/L]), consider assessment for
hyperglycemic hyperosmolar nonketotic
syndrome. A
Source: American Diabetes Association Standards of Medical Care in Diabetes(2021)
ADA Recommendation
 Patients treated with basal insulin who
do not meet glycemic target should be
moved to multiple daily injections
(MDI) with basal and premeal bolus
insulins. E
Source: American Diabetes Association Standards of Medical Care in Diabetes(2021)
ADA Recommendation
 In patients initially treated with insulin and
metformin who are meeting glucose targets
based on home blood glucose monitoring, insulin
can be tapered over 2–6 weeks by decreasing
the insulin dose 10–30% every few days. B
Source: American Diabetes Association Standards of Medical Care in Diabetes(2021)
ADA Recommendation

Use of medications not approved by the U.S. Food and Drug
Administration for youth with type 2 diabetes is not
recommended outside of research trials. B
Source: American Diabetes Association Standards of Medical Care in Diabetes(2021)