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Diabetes Spectrum
Volume 13 Number 2, 2000, Page 95
From Research to Practice / Diabetes and Adolescents

Type 2 Diabetes Mellitus in Teens

the 1 last update 14 Jul 2020 Stephen W. Ponder, MD, CDE, Susan Sullivan, RN, CDE,
and Grete McBath, RD, LD, CDE


.

In Brief

Included in this comprehensive discussion of type 2 diabetes in teens is a brief review of definitions of type 1 and forms of non-type 1 diabetes, the epidemiology of type 2 diabetes in teens, and the scope of related problems. Management considerations including pharmaceutical interventions for teens with type 2 diabetes are described.

The end of the 20th century witnessed a dramatic rise in the incidence of type 2 diabetes in children. Although considered uncommon a few decades ago, type 2 diabetes in adolescents now represents one of the most rapidly growing forms of diabetes in the United States and perhaps worldwide.

Not surprisingly, the incidence of type 2 diabetes in adolescents has paralleled the epidemic of childhood obesity now occurring in Westernized societies.1 It is believed that the genetic and lifestyle factors that increase the risk of developing type 2 diabetes in adolescents and adults are similar. This article provides an overview of this problem, plus provides direction for clinicians caring for these children.

DEFINITIONS
In 1997, the American Diabetes Association (ADA) Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus categorized four major forms of diabetes and revised the metabolic parameters for diagnosis.2 Type 1, type 2, gestational diabetes mellitus (GDM), and a category labeled "other specific types" constitutes the current etiological classification scheme. It is reasonable to speculate that, as more is learned from studies of the molecular genetics of type 1, type 2, and GDM, better defined clinical subtypes will emerge. Although the ADA diagnostic criteria were developed primarily from data obtained from adults, they are to be applied equally to children and adolescents.

The categories of type 1 and type 2 diabetes are clinically defined. While this allows flexibility in assigning type to a given patient based on clinical presentation, it sometimes requires revision as the clinical course may alter the assignment (and perhaps the choice of therapeutic options) over time. For example, some overweight adolescents initially presenting with classic signs and symptoms of type 1 diabetes may actually have type 2 diabetes. Medical management with oral agents after an initial period of stabilization with insulin is often possible. If type 2 diabetes is suspected, clinicians are cautioned to not make hasty statements regarding the long-term need for insulin therapy.

For now, the designation of type 1 diabetes suggests a chronic, immune-mediated destruction of functional -cell mass with characteristic laboratory measures in serum of -cell autoimmunity (anti-glutamic acid decarboxylase [GAD], anti-insulin, and antibodies to tyrosine phosphatases IA-2 and IA-2 ) found in the majority of cases. In type 1 diabetes, insulin therapy is always indicated and is the only appropriate pharmacological option. Oral agents are contraindicated, although the presence of residual insulin secretory capacity at time of diagnosis (i.e., the honeymoon phase) may lead inexperienced practitioners to attempt therapy with them with potentially disastrous consequences.

Nonimmune forms of diabetes in children and adolescents include "idiopathic" type 1 diabetes, type 2 diabetes with insulin resistance, atypical diabetes mellitus, maturity onset diabetes of youth (MODY), genetic defects in insulin action, and secondary diabetes (e.g., cystic fibrosis).

Idiopathic Type 1 Diabetes
This form is clinically indistinguishable from type 1 diabetes due to autoimmune-mediated -cell destruction. In fact, it can only be diagnosed by the failure to demonstrate evidence of serum markers of -cell-directed autoimmunity (e.g., anti-GAD antibodies). The cause(s) are unknown. The management is the same as with any patient with type 1 diabetes.

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The insulin resistance syndrome is the metabolic state characterized by fasting and/or postprandial hyperinsulinemia plus one or more of the following: hypertension (initially systolic >diastolic), dyslipidemia (hypertriglyceridemia, decreased high-density lipoprotein (HDL) cholesterol fraction), obesity (abnormal weight for height or body mass index [BMI] > 25, menstrual disturbances, and hirsutism secondary to ovarian hyperandrogenism. The expression of this syndrome may be seen as early as 2 years of age with the appropriate genetic background and environmental milieu.

reverses diabetes type 2 with keto (β˜‘ vision) | reverses diabetes type 2 medshow to reverses diabetes type 2 for The hallmark of type 2 diabetes in adolescents, as in most adults, is insulin resistance. The development of overt glucose intolerance ultimately arises on this "foundation" of insulin resistance. For years, reduced hepatic and skeletal muscle insulin sensitivity is compensated for by increased pancreatic insulin secretion, resulting in normal glucose tolerance. In a typical adolescent with type 2 diabetes, steady increases in insulin resistance accompany the normal progression through puberty secondary to increased growth hormone secretion. This contributes to the development of postprandial hyperglycemia. Many children of predominantly non-European origin (e.g., African Americans, Hispanics, American Indians) are prone to insulin resistance which creates an even greater insulin secretory requirement. Abnormal sustained elevations in plasma glucose contribute to an erosion of insulin secretory capacity due to the phenomenon of glucose toxicity. Ultimately, fasting, as well as postprandial, hyperglycemia occurs.

In contrast to many adults who develop type 2 diabetes in middle life or later, adolescents are more likely to demonstrate early recovery of -cell function following resolution of the glucose toxic state. This has significant implications for long-term pharmacological management. The explanation for this finding may be that, in some cases, adults with type 2 diabetes may have gone undiagnosed for years, accruing irreversible -cell damage from years of insulin resistance preceding the development of overt glucose intolerance.

The prevalence of insulin resistance is high in the Hispanic community of South Texas. However, well before glucose intolerance occurs, many adolescents have already experienced years of co-morbidity due to underrecognized insulin resistance-related problems (e.g., hypertension, dyslipidemia). As a late event in the progression of the insulin resistance syndrome, type 2 diabetes truly represents the "tip of the iceberg" in regards to a much more insidious process.

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A form of diabetes that disproportionately affects African Americans and Asian Indians has been described as atypical diabetes mellitus.3-6 Onset of diabetes is explosive, often including diabetic ketoacidosis (DKA) as a presenting feature. Following initial stabilization, patients may be managed similar to children with type 2 diabetes.

In these cases, family history is strong for diabetes. However, obesity does not appear to be a regular feature of this condition, and insulin sensitivity is normal. A defect in first phase insulin release is associated with atypical diabetes mellitus, and the typical immunological profile found in patients with type 1 diabetes is absent.

Maturity Onset Diabetes of Youth
In 1974, the acronym MODY was created by Tattersall and Fajans to describe a mild form of diabetes that had largely gone forgotten after the discovery of insulin but was "rediscovered" following the development of oral hypoglycemic agents in the 1950s.7 After a quarter century of further investigation, we know that MODY encompasses an expanding group of specific genetic defects of -cell function. Depending on location, the relative incidence of all forms of MODY ranges between 2 and 5% compared to all other forms of type 2 diabetes.8 As a group of disorders, MODY is clinically and genetically heterogeneous.9 Clinicians unfamiliar with the term often misapply it to any child or adolescent with a noninsulin-requiring form of diabetes.

There are mutations defined in five proteins involved with the control of insulin secretion or sensitivity that characterize the known MODY subtypes. MODY 1Β­3 have fairly well-defined clinical presentations. MODY 4 is rare and has the 1 last update 14 Jul 2020 an average age of onset in middle life. MODY 5 has only been described in two Japanese families. A new MODY subtype has been recently described.10 There are mutations defined in five proteins involved with the control of insulin secretion or sensitivity that characterize the known MODY subtypes. MODY 1Β­3 have fairly well-defined clinical presentations. MODY 4 is rare and has an average age of onset in middle life. MODY 5 has only been described in two Japanese families. A new MODY subtype has been recently described.10

The presenting feature of MODY is mild, occasional fasting hyperglycemia in a lean child with a prominent family history of glucose intolerance in multiple (at least three) generations. In most cases, MODY evolves slowly into overt diabetes. Clinical presentations vary according to the nature of the genetic lesion. MODY, when clinically diagnosed, can now be defined through genetic testing, but only in research laboratories. Several recent reviews have summarized the current understanding of MODY.9,11-14

Other Genetic Defects in Insulin Action
A partial list of the genetic defects in insulin action include a number of well described conditions including Type A insulin resistance, Leprechaunism, Rabson-Mendenhall syndrome, and the Lipoatrophic syndromes. The clinical course of mutations in the insulin gene has been described in several kindreds. In the cases examined so far, affected children are generally asymptomatic, and glucose intolerance or mild diabetes does not occur until adulthood. Although these conditions are often diagnosed in youth, they will not be discussed further due their extremely low prevalence.

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Secondary diabetes in adolescence as a result of cystic fibrosis (CF) deserves special mention. As therapies for CF extend the longevity of children with this disease, the rate of glucose intolerance and overt diabetes has increased.

Therapy for 1 last update 14 Jul 2020 for CF diabetes requires special attention to patients''s care plans. Therapy for CF diabetes requires special attention to patients''s care plans.

Since minority youth are disproportionately affected, socioeconomic factors may limit access to the same diabetes education and care that children with type 1 diabetes receive. The obstacles to optimal diabetes education and care in this special population include cultural and language barriers, lack of adequate health insurance coverage, and geographic barriers to qualified diabetes care providers.39

One particularly challenging problem in South Texas is a pervasive fatalism in the Mexican-American community, which results in a reduced adherence to treatment recommendations. Ultimately, this belief may lead to increased morbidity and mortality, which then becomes a self-fulfilling prophecy.

As with anyone with diabetes, teens with type 2 diabetes should regularly monitor blood glucose at home to assess the quality of their control. It is well known that many adolescents are poorly adherent with this self-care behavior, regardless of the nature of their diabetes. Clinicians should spend quality "face time" with teens to explain and emphasize the value of blood glucose self-monitoring.

Reviewing the monitoring data in the presence of teenage patients is a powerful illustration of its value and validates the effort the teens have made in obtaining the information. A cursory or cavalier review of the blood glucose log is a strong disincentive for teens to continuing this self-care behavior. Ongoing diabetes education provided by a certified diabetes educator can guide teens through the proper use of these data and is the best approach to promote adherence with this aspect of the self care regimen.

Since ketosis is a possible consequence for some teens with type 2 diabetes, it is imperative that proper education for sick-day care and ketosis management be provided, as it is for children with type 1 diabetes.

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Although target weight can be useful, it should never be used as a goal for children. Instead, an overall plan to reduce intake and increase physical activity should be implemented.42 An experienced pediatric dietitian should provide MNT.

Strategies for weight management
Nutritional education is a cornerstone of therapy for children with type 2 diabetes. Often, these children come from a home environment with a poor understanding of healthy eating habits. Commonly reported behaviors include skipping meals, heavy snacking, and excessive television/video game/computer involvement. Like many adults, adolescents engage in nonappetite-based eating (i.e., emotional eating, television-cued eating, boredom) and on and off ("yo-yo") dieting.

Adolescents and their families must be encouraged to consistently make better food choices. This begins by teaching parents what foods to bring home and how to plan meals and snacks. Although most experts believe children are able to self-regulate eating, one must consider that adolescents with type 2 diabetes may have lost this ability and may lack parental involvement to support effective behavior change. Behavior modification should start by helping children recognize eating cues and satiety factors. Parents can help by learning appropriate serving sizes for children.

Changing food habits is one of the most challenging aspects of care and demands regular follow-up with an experienced pediatric dietitian. Infrequent visits are associated with a high probability of continued weight gain.

Probably the most overlooked aspect of weight management is determining when a child, teen, and family is ready to change. There are many types of readiness-to-change questionnaires. The most basic tool is to just ask. Readiness and motivation can change at any point for the better or worse. Level of commitment should be addressed at each visit.

Discussing the insulin resistance syndrome with an obese adolescent can be challenging and at times frustrating. A thorough explanation of this condition, with all its attendant risks, is needed if a child and family are to be expected to make the lifestyle changes. In the absence of overt diabetes, clinicians will have to identify other factors to motivate adolescents toward change. Based on individual assessment, this may include an appeal to improve athletic performance or academic scores (especially if OSA is present), or even for cosmetic reasons.

If a child does not have diabetes but has significant risk factors and is unwilling to make change despite all efforts to explain the risks, then it is unwise to compel the child to embark on a weight management program. In these cases, encourage routine follow-up to assess for glucose intolerance and suggest that the child or family return when they are willing to change.

Most successful weight management programs focus on behavior change and de-emphasize weight loss as an outcome. One should avoid using the term "diet" when discussing changes in food choices. Such a term implies a temporary solution and not a life-long change.43

Clinicians should start slowly, trying to focus on two or three behavior change goals to work on for each visit. If clinicians advocate a comprehensive change in an adolescent''s Hospital in Corpus Christi, Tex.


Note of disclosure: Dr. Ponder is a co-investigator in two pharmacological studies funded by Bristol Myers Squib Corporation. The studies involve a drug that is being evaluated as a treatment for type 2 diabetes mellitus in pediatric patients.


Guest Editor

Jane K. Kadohiro, DrPH, APRN, CDE, is an assistant professor of nursing at the University of Hawaii at Manoa School of Nursing in Honolulu, where her research is in diabetes among adolescents. Dr. Kadohiro served in several capacities for the Hawaii State Department of Health, from public health nurse to chief of the chronic disease and preventive health services branches, before beginning her faculty position in 1991.

In Hawaii, Dr. Kadohiro has been a founding member, past president, or director, and continues to be an active volunteer for the American Diabetes Association (ADA), the Hawaii State Diabetes Control Program, and the Hawaii Association of Diabetes Educators. For the past 18 years, she has been the director for He Ola Ke Keiki, Hawaii''s continuing education committee.


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