View
13
Download
0
Category
Preview:
Citation preview
TYPE 2 DIABETES IN
YOUNG
Alaa Abdelsalam Dawood, MD,PhD
Ass. Prof of Diabetes and
Endocrinology
Menofyia university
Agenda
Prevalence of type 2 DM in young
Is it important to differentiate between Type 1 and
Type 2 in Children ?
Diagnosis of type 2 DM
Prevention: Primary and secondary
The incidence of type 2 diabetes in children and adolescents has reached
epidemic proportions in the United States. Recent reports indicate that as many
as 45% of pediatric patients diagnosed with diabetes in the United States have
type 2 diabetes. Furthermore, the prevalence of type 2 diabetes may be
underestimated due to misclassification of the disease. Prior to the late 1990s,
only 1% to 2% of children diagnosed with diabetes mellitus in the United States
had type 2 diabetes. Since then, owing to a combination of greater awareness,
increased screening, and higher incidence, the prevalence of type 2 diabetes
among US children has not only increased, but is expected to continue to grow
and to exceed that of type 1 diabetes.
2008
A large prospective study (TODAY study) provides
data on the youth-onset T2DM:
Glycemic control among adolescents with T2DM is often
poor.
Studies in several populations report that less than half
of the adolescents with type 2 diabetes regularly
attend follow-up visits.
One study reported mean glycated hemoglobin
concentrations of 12 percent, even among patients
involved in active follow-up
At the time of diagnosis, determining whether a
patient has type 1 or type 2 diabetes is of utmost
importance because insulin is life saving in type 1
Mortality rates and standardized mortality ratios in
type 2 diabetes are likely higher than those in type
1 diabetes
When in doubt ?
Clinical Presentation Type 1 Diabetes Type 2 Diabetes
Onset Abrupt Insidious
Family history of type 2
diabetesUncommon Common
ObesityNot typically present;
may be thinTypically present
Polyuria or Polydipsia Symptomatic Mild or absent
Ketonuria Usually present Present in up to 33%
Ketoacidosis at diagnosis Present in 30% to 40% Present in 5% to 25%
Hypertension, Hyperlipidemia Not typically present Typically present
Sleep apnea, Acanthosis
nigricansNot typically present Often present
Polycystic ovary syndrome Not present May be present (females)
C-peptide levels Low* Normal or elevated†
Beta-cell autoimmune
markers (autoantibodies to
islet cells, GAD, insulin)
Often but not always
present (> 70%)Absent or low (< 35%)
Work up
A random plasma glucose of 200 mg/dL or more in
symptomatic child.
OGT testing
Fasting plasma glucose value of 126 mg/dL or greater
2-hour plasma glucose value of 200 mg/dL or greater
Primary Prevention
Diet control: It is important to maintain healthy components of
traditional diets (i.e., micronutrient rich food such as fruits,
vegetables and whole grain cereals) and guard against
heavily marketed energy dense fatty and salty foods (e.g.
prepackaged snacks, ice-creams and chocolates).
Primary Prevention
Exercises
Children should be encouraged to be active not only for weight control
but for general well being.
WHO recommends at least 30 minutes of cumulative moderate exercise
(equivalent to walking briskly) for all ages; plus for children, an
additional 20 minutes of vigorous exercise (equivalent to running), three
times a week. These recommendations are basically for prevention of
CHD.
Prevention of obesity may require more physical exertion. In general,
moderate to vigorous activities for a period of at least one hour a day
may be a more practical recommendation for children.
Also, sedentary habits like television watching, computers should be
restricted to 1-2 hours daily.
Preventing obesity in women of childbearing age is another primary
prevention goal, because exposure to the environment of a diabetic
pregnancy places the fetus at increased risk of future onset of diabetes.
Screening Children for Type 2 Diabetes and Prediabetes
All Children with ≥2 risk factors: Family History
Race/Ethnicity; Native, African American, Latino, Pacific Slander
Maternal History of Gestational DM during child’s gestation
Signs of insulin resistance as :
Acanthosis nigricans
Hypertension
PCO
Small birth weight
Begin testing at age of 10 y or Pubertal and repeat testing each 3years.
Secondary prevention
Measures that are employed to delay or prevent the
occurrence of complications of diabetes:
Excellent glycemic control,
blood pressure control,
Dyslipidemia control
Screening for complications of diabetes
Psychological and social support
Life Style Management
Diet
low in sodium is recommended to reduce blood pressure.
Diets that promote the consumption of fruits, vegetables, and low-fat dairy products
Physical activity
Increasing physical activity is associated with a reduction in the risk of stroke. The goal is to engage in at least 30 minutes of moderate intensity activity on a daily basis.
Pharmacological treatment
Pharmacologic therapy is indicated when the
disease is not well controlled with diet and exercise:
Metformin should be the first oral agent used in
children and teenagers with an A1c level of less than
9%.
If metformin is unsuccessful as monotherapy, the
addition of insulin, a sulfonylurea, or another
hypoglycemic agent may be appropriate.
Pharmacological treatment
Insulin Therapy when:
When the distinction between type 1 or 2
Type 2 with ketosis
A1c % ≥ 9 , ADA
What is the target of HbA1c in type 2 diabetes in children ?
(Diabetes Care. 2015)
Before meals 90-130 mg/dl
Bedtime 90-150 mg/dl
HbA1c < 7.5%
Management of Dyslipidemia in Children (1)
All type 2 diabetes in children should have basal
screening lipid profile
If the initial screening is normal……each 2y
Life Style Modification
Diet
Physical exercise
Control of Hyperglycemia
Control of Hypertension
± Omega 3
Diabetic Nephropathy
In a comparative study among Japanese youths with type 1 and type 2 diabetes, the incidence of nephropathy among patients with type 2 diabetes was earlier and higher than it was in those with type 1 diabetes
The SEARCH for Diabetes in Youth Study found that American youth with type 2 diabetes are at a 4 fold increased risk of renal failure compared to pediatric patients with type 1 diabetes
Conclusion
Distinction between type 1 and type 2 in children is
mandatory
Of all microvascular complications, diabetic
nephropathy is more in type 2 diabetes in children
Life style modification is essential line of treatment
Metformin and insulin are the only FDA allowed in
children
Screening and Prevention are the gold standard
experts estimate that type 2 diabetes has grown
from less than 5 percent in 1994 to about 20
percent of all newly diagnosed cases of the disease
among youth in more recent years
Dyslipidemia
Treatment c Initial therapy may consist of optimization of glucose control and MNT using a Step 2 American Heart Association (AHA) diet aimed at a decrease in the amount of saturated fat in the diet. B c After the age of 10 years, the addition of a statin in patients who, after MNT and lifestyle changes, have LDL cholesterol .160 mg/dL (4.1 mmol/L) or LDL cholesterol .130 mg/dL (3.4 mmol/L) and one or more cardiovascular disease (CVD) risk factors is reasonable. E c The goal of therapy is an LDL cholesterol value ,100 mg/dL (2.6 mmol/L). E
Hypertension
Initial treatment of high-normal blood pressure (SBP or DBP consistently $90th percentile for age, sex, and height) includes dietary intervention and exercise, aimed at weight control and increased physical activity, if appropriate. If target blood pressure is not reached with 3–6 months of lifestyle intervention, pharmacological treatment should be considered. E c Pharmacological treatment of hypertension (SBP or DBP consistently $95th percentile for age, sex, and height) should be considered as soon as hypertension is confirmed. E c ACE inhibitors or angiotensinreceptor blockers (ARBs) should be considered for the initial pharmacological treatment of hypertension, following appropriate reproductive counseling due to its potential teratogenic effects. E c The goal of treatment is blood pressure consistently ,90th percentile for age, sex, and height. E
Recommended