Type 2 Diabetes in Children and Adolescents. Arlan L. Rosenbloom

Available Hypoglycemic Agents

       Treatment Recommendation

       Treatment of Comorbidities

       8 Patients

      Acknowledgments

      We acknowledge the helpful reviews provided by Nathaniel Clark, MD, MS, RD; Kenneth L. Jones, MD; Francine R. Kaufman, MD; and Georgeanna Klingensmith, MD; and the support and inspiration of the diabetes team of the University of Florida Pediatric Endocrine Division.

      C H A P T E R 1

      Introduction

      There has been wide recognition in the past decade of the increasing frequency of type 2 diabetes in youth, largely but not exclusively in North America and especially but also not exclusively among Native American, African American, and Hispanic American youth (1–3). An epidemic can be defined simply as an increase in prevalence (i.e., the number of cases in the population) resulting from increased incidence (i.e., the number of cases diagnosed per year). The epidemiologist always asks whether there has been a true increase in incidence or simply an increase in recognition or reporting. Pediatric diabetologists, however, do not doubt that we are witnessing an epidemic of type 2 diabetes in people under 21 years of age (2,4,5).

      Although we lack general North American population–based data, such information from the Pima Indian population and from Japan confirm phenomenal increases over the past 20–25 years, and clinic-based data are uniformly alarming (6–8). In some settings, particularly those with a large minority population, newly diagnosed type 2 diabetes is being seen as much or more often than newly diagnosed type 1 diabetes in the 10- to 20-year-old age-group (9).

      This is not a newly recognized disease in this population; insulin resistance and occasional type 2 diabetes have been known as complications of childhood obesity for at least 30 years. Harvey Knowles wrote in 1971 (10),

      “A second type of diabetes in young persons closely resembles that of the stable middle-aged onset type. Herein the patients, as a rule, have no symptoms, are overweight, can secrete insulin, and respond to sulfonylurea therapy. Often the diagnosis is made serendipitously. In the Juvenile Diabetic Clinic at the Cincinnati General Hospital, 11 of these patients have been followed along with 300 patients with the unstable insulin deficient type of diabetes. The age of these 11 patients at diagnosis ranged from 11 to 17 years. The prevalence of this type of diabetes very likely is higher than presently appreciated, because of lack of symptoms or signs leading to suspicion of diabetes.”

      The concern is not simply that type 2 diabetes threatens to become as frequent as type 1 diabetes in the pediatric population. It is the recognition that type 2 diabetes is a manifestation of the insulin resistance syndrome, which bestows additional cardiovascular risk (11), that youth-onset type 2 diabetes may be associated with greater risk of microvascular disease than even type 1 diabetes (12), that the context and treatment paradigm is more problematic than that for type 1 diabetes, and that the public health implications are consequently more devastating. Compared with patients with type 1 diabetes, young patients with type 2 diabetes are more likely to have single parents with less than a high school education and fewer economic and community resources and, because they are adolescents, are more likely to be influenced by their peers than by their parents or other adults (2,13). For these and other reasons, patients with type 2 diabetes are less likely to be compliant with treatment, and treatment is even more sharply focused on behavior than is treatment for type 1 diabetes. These factors combine to make the risk of early complications even greater in type 2 diabetes than in type 1 diabetes.

      This book is part of the continuing response of the American Diabetes Association (ADA) to this serious, emerging public health problem. In late 1998, ADA organized a consensus panel to address the following questions about type 2 diabetes in children and adolescents:

      

What is the classification of diabetes in children and adolescents?

      

What is the epidemiology?

      

What is the pathophysiology?

      

Who should be tested?

      

How should children and adolescents with type 2 diabetes be treated?

      

Can type 2 diabetes in children and adolescents be prevented?

      The resulting consensus statement was accepted by a committee of the American Academy of Pediatrics and published simultaneously in Diabetes Care (14) and Pediatrics (15). Although these questions were addressed by experts with extensive clinical and research experience with type 2 diabetes in children, little of the consensus report was evidence based or data based. There has been substantial funding since then to better understand the pathogenesis, scope, prevention, and treatment of this condition.

      Our intention with this book is to put the available information into a readily accessible format for the physician or diabetes educator dealing with this challenging individual and community problem. The book follows the basic structure set forth in the ADA consensus statement. We have chosen to use an outline rather than formal narrative style, which we hope will enhance the accessibility and identification of needed information.

      REFERENCES

      1. Fagot-Campagna A, Pettitt DJ, Engelgau MM, Burrows MT, Geiss LS, Valdez R, et al.: Type 2 diabetes among North American children and adolescents: an epidemiological review and a public health perspective. J Pediatr 136:664–672, 2000

      2. Rosenbloom AL: Increasing incidence of type 2 diabetes mellitus in children and adolescents: treatment considerations. Pediatr Drugs 4:209–221, 2002

      3. Kadiki OA, Reddy MR, Marzouk AA: Incidence of insulin-dependent diabetes (IDDM) and non-insulin-dependent diabetes (NIDDM) (0–34 years at onset) in Benghazi, Libya. Diabetes Res Clin Pract 32:165–173, 1996

      4. Dabelea-D, Pettitt DJ, Jones KL, Arslanian SA: Type 2 diabetes mellitus in minority children and adolescents. Endocrinol Metab Clin North Am 28:709–729, 1999

      5. Kaufman FR: Type 2 diabetes mellitus in children and youth: a new epidemic. J Pediatr Endocrinol Metab 15 (Suppl. 2):737–744, 2002

      6. Dabelea D, Hanson RL, Bennett PH, Roumain J, Knowler WC, Pettitt DJ: Increasing prevalence of type 2 diabetes in American Indian children. Diabetologia 41:904–910, 1998

      7. Kitagawa T, Owada M, Urakami T, Yamauchi K: Increased incidence of non-insulin dependent diabetes mellitus among Japanese schoolchildren correlates with an increased intake of animal protein and fat. Clin Pediatr 37:111–115, 1998

      8. Pinhas-Hamiel O, Dolan LM, Daniels SR, Standiford D, Khoury PR, Zeitler P: Increased incidence of non-insulin-dependent diabetes mellitus among adolescents. J Pediatr 128:608–615, 1996

      9. Neufeld ND, Raffal LF, Landon C, Chen Y-DI, Vadheim CM: Early presentation of type 2 diabetes in Mexican-American youth. Diabetes Care 21:80–86, 1998

      10. Knowles HC: Diabetes mellitus in childhood and adolescence. Med Clin North Am 55:975–987, 1971

      11. Hu FB, Stampfer MJ,