what’s new in type 2?
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We are in a diabesity epidemic!
 Prevalence of type 2 diabetes and metabolic
syndrome is increasing in children and their
parents
 Risk of complications of type 2 are higher in
type 2 with onset 18-45 than in older adults
 Most children with diabetes are cared for by
their primary doctors
JCEM 88:1417,2003, Goran
Obesity
Visceral Adiposity
Androgens
Adipocytokines
Puberty
Inflammation
Insulin Resistance
Hypertension
Dyslipidemia
Cardiovascular Disease
Prevalence of obesity is
increasing
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Prevalence of overweight in US children
doubled from 1980-1994
Overweight 50% higher in poor US teens
17%US children and teens overweight (BMI
>95%ile) 2004 NHANES
4% US children BMI>99%ile
1:17,741 pedi endos to obese kids in US
Waist circumference increased 3.7 cm in
teens 1994-2004 NHANES
Factors contributing to the
obesity epidemic
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Increase in intake of regular soda (high
fructose corn syrup), fast foods, increase in
portion size of fast foods, Increase in high
carb snacks
 Decrease in physical activity
 Increase in physical inactivity (TV, video,
computer time)
 each hour TV time=+167 kcal/day,
Wiecha,Arch Ped Adol Med 160:436,2006
The metabolic syndrome
Insulin resistance
 Hypertension
 Dyslipidemia
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Ford et al, Diabetes Care
31:587,2008
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Metabolic syndrome prevalence by IDF
definition 4.5% US teens National
health and nutrition examination survey
1999-2004 of 2014 teens age 12-17
Type 1 diabetes
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beta cell destruction leading to absolute
insulin deficiency
 Autoimmune
 idiopathic
Type 2 diabetes mellitus:
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Both insulin resistance and relative
insulin insufficiency:
 Secretory
defect with insulin resistance
 Insulin resistance and insufficient
compensatory increase in insulin production
Other specific types of
diabetes
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Genetic defects in beta cell function (MODY,
mitochondrial DM)
Genetic defects in insulin action (type A)
Diseases of exocrine pancreas (CF etc)
Endocrinopathies (Cushing’s etc)
Drug induced (steroids etc)
Immune mediated ( insulin receptor
antibodies )
Genetic syndromes associated with DM
Gestational diabetes
Definition of impaired fasting
glucose/ glucose intolerance
Fasting plasma glucose 100-125 mg/dl
(5.6-6.9 mmol/l)
 2 h plasma glucose 140 mg/dl-199
mg/dl (7.8-11 mmol/l) on OGTT
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Prevalence of diabetes in
children under 18 years
Overall 1/300 (all types) (incidence
15/100,000)
 Type 2 diabetes 4-30% depending on
ethnic mix of population
 Prevalence of Type 2 diabetes is rapidly
increasing with increase of obesity and
inactive lifestyle
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Risk factors for type 2
diabetes
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Obesity with signs of insulin resistance
(acanthosis nigricans, polycystic ovary
syndrome) usually post pubertal
 Ethnic heritage (African American, Native
American, Asian, Latino, pacific islander)
 Family history of type 2
 history of SGA or LGA
Screening for type 2 diabetes
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BMI of 85%ile or weight > 120% above
ideal body weight, age 10 or above or
pubertal and:
 Family
history of type 2 diabetes
 At risk ethnic group
 Signs or conditions associated with insulin
resistance (acanthosis nigricans,
hypertension, hyperlipidemia, PCOS)
Screening obese children for
diabetes
Fasting blood sugar
 consider fasting lipids
 consider insulin level : fasting
glucose/insulin > 4.5 normal (insulin not
always accurate in commercial labs)
 Glucose 2 hour post 75 gm (1.75
gm/kg) glucose load (not yet the official
recommendation of the AAP, ADA)
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Impaired glucose tolerance in
children with marked obesity
Impaired glucose tolerance in 25% of
very obese children ages 4-10 years
 Impaired glucose tolerance in 21% very
obese adolescents, 4% silent diabetes
 Fasting blood glucose screening would
miss many individuals with impaired
glucose tolerance (N Eng J Med
2002;346:802)
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Teen diabetes and the
pediatrician
Coordinate care with an endocrinologist
 Address adolescent health issues
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 Acute
infections (including STDs)
 Contraceptive needs
 Smoking cessation
 Depression
 Family support issues
Diabetes Specialty visits
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At least every 3 months for education, review
of blood sugars, med adjustment
 Monitor growth, blood pressure (<130/80)
 Glucose control goals (individualize):
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Hemoglobin A1c<7% (ideal) (lower in type 2):
Preprandial plasma glucose 90-130 mg/dl
Post prandial <180 mg/dl
Yearly microalbumin, lipids, retinopathy screen
Treatment goals for diabetes
Hemoglobin A1c <7%
 Preprandial blood glucose 90-130 mg/dl
 Postprandial blood glucose < 180 mg/dl
 Blood pressure < 130/80
 LDL cholesterol < 100 mg/dl
 Triglycerides < 150 mg/dl
 HDL cholesterol > 40 mg/dl
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Management of
hyperlipidemia
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Dietary counseling, repeat lipids in 3 months
 LDL 130-159 mg/dl consider medication
(family history, blood pressure, smoking)
 LDL> 160 mg/dl : begin statin at low dose,
monitor LFTs, watch for persistent muscle
pains, use with extreme caution in sexually
active females (Diabetes Care
26:2194,2003)
Barriers to good diabetes
control
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Expense of blood glucose monitoring,
medications
Cultural bias against insulin or medical
intervention: fatalistic attitude toward illness
Insufficient parental supervision of
medications and monitoring
Normal adolescent development (denial)
Depression
Increasing obesity
Encouraging optimum
diabetes control
Give credit for honesty and effort
 Diabetes visit should build self esteem
 Support parental involvement
 Set realistic goals with teen and family
 Keep it interesting (new technologies)
 Encourage regular visits and contact
 Group programs for teens (camps)
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Presentation of type 2
diabetes
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most teens with type 2 diabetes are
identified by screening
Polyuria/ polydipsia/ nocturia common
symptoms but not always complaints
Girls may present with recurrent yeast
infections
5-25% present in DKA or hyperosmolar
dehydration
up to 33% have ketones at presentation
Is it type 1 or type 2? More
likely type 2 if overweight and:
Pubertal
Milder symptoms
Acanthosis nigricans
Family history of type 2
High risk ethnic group
Features of type 2 diabetes
Insulin /C peptide over upper limit of
normal for assay
 Negative pancreatic antibody panel
 Initial insulin requirements 1.3-1.5
units/kg/day falling to little or no insulin
requirement over 1-2 months
 Ketosis seldom occurs spontaneously
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14 year old male with ?
diabetes
2 weeks ago, vomiting, diarrhea,fatigue
 Glucosuria, random blood sugar in 180s
 Repeat BG=286 mg/dl occasional
nocturia, no thirst, 6 lb weight loss
 BW 7 lb, MGM, MGGM type 2 diabetes
 Maternal aunt low thyroid
 BMI 35, 99%ile, 101kg ht 170 cm
 SMR 3, acanthosis, psoriasis
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Idiopathic diabetes
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African American / Asian teens with negative
antibodies
Insulinopenia: ketosis prone (episodic
ketosis)
Family history positive for early onset of
diabetes in multiple generations
Absolute requirement for insulin replacement
may come and go between episodes of
ketosis
Control is usually poor without insulin
Healthy eating and activity
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Avoid regular soda/ large amounts of fruit
juice
Encourage whole fruits, vegetables, low fat
milk, (? low glycemic index choices,
increased fiber)
Have healthy foods for all at home
Limit inactivity (TV off), encourage activity (30
minutes per day, 5+ days /week)
?discuss cigarette smoking
Management of type 2
diabetes in teens
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If presenting in DKA or severe hyper osmolar
state, start with insulin (be aware of cultural
biases against insulin)
Teach blood sugar monitoring from the
beginning (pre and some post meal)
Teach healthy eating and exercise
Begin metformin at low dose increasing over
several weeks if no contraindications
Address lipid issues
Use of metformin in type 2
diabetes
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Start low (500 mg with meal, go slow)
Increase slowly to max 1000 mg bid, 850 mg
tid with meals (or Glucophage XR)
GI side effects common (nausea, diarrhea,
abdominal discomfort) in first two weeks
Avoid dehydration (stop if vomiting)
Home BG monitoring premeal and some 2 h
post meal
Yearly CBC, BUN, creat, ALT,AST
? multivitamin
Advantages of metformin
Mild weight loss (teens love this)
 Decreased insulin requirement/
decreased insulin resistance
 Not associated with hypoglycemia
 Beneficial effects on cardiovascular
disease shown in adults
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When to begin insulin rather
than oral agent in type 2:
Ketones present
 Marked hyperglycemia with dehydration
 Contraindications to metformin
(significantly abnormal LFTs, elevated
BUN/ creatinine, pregnancy)
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When metformin is not
enough:
Add insulin (NPH, glargine,detemir, or
short acting
insulin with meals or combinations)
 Add a second oral agent
 Take a look at lifestyle again (food and
beverage choices, activity)
 Enlist more adult support
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Prevention of type 2 diabetes
Lifestyle modification (exercise, healthy
eating)
 Treatment of prediabetic conditions with
metformin or other insulin sensitizing
agents?
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 Glucose
intolerance
 Extreme obesity with insulin resistance
 Polycystic ovary syndrome