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what’s new in type 2? what’s new in type 2?
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
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
Obesity
Visceral Adiposity
Adipocytokines Androgens
Puberty
Insulin ResistanceInflammation
Cardiovascular Disease
DyslipidemiaHypertension
Prevalence of obesity is increasing
Prevalence of obesity is increasing
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
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
Factors contributing to the obesity epidemic
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
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 syndromeThe metabolic syndrome
Insulin resistanceHypertensionDyslipidemia
Insulin resistanceHypertensionDyslipidemia
Ford et al, Diabetes Care 31:587,2008
Ford et al, Diabetes Care 31:587,2008
Metabolic syndrome prevalence by IDF definition 4.5% US teens National health and nutrition examination survey 1999-2004 of 2014 teens age 12-17
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 diabetesType 1 diabetes
beta cell destruction leading to absolute insulin deficiency
Autoimmuneidiopathic
beta cell destruction leading to absolute insulin deficiency
Autoimmuneidiopathic
Type 2 diabetes mellitus:Type 2 diabetes mellitus:
Both insulin resistance and relative insulin insufficiency:
Secretory defect with insulin resistanceInsulin resistance and insufficient
compensatory increase in insulin production
Both insulin resistance and relative insulin insufficiency:
Secretory defect with insulin resistanceInsulin resistance and insufficient
compensatory increase in insulin production
Other specific types of diabetes
Other specific types of diabetes
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
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 intoleranceDefinition 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
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
Prevalence of diabetes in children under 18 years
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
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
Risk factors for type 2 diabetes
Risk factors for type 2 diabetes
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
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 diabetesScreening for type 2 diabetes
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)
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
Screening obese children for diabetes
Fasting blood sugar consider fasting lipidsconsider 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)
Fasting blood sugar consider fasting lipidsconsider 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)
Impaired glucose tolerance in children with marked obesity 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)
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)
Teen diabetes and the pediatrician
Teen diabetes and the pediatrician
Coordinate care with an endocrinologistAddress adolescent health issues
Acute infections (including STDs) Contraceptive needs Smoking cessation Depression Family support issues
Coordinate care with an endocrinologistAddress adolescent health issues
Acute infections (including STDs) Contraceptive needs Smoking cessation Depression Family support issues
Diabetes Specialty visitsDiabetes Specialty visits
At least every 3 months for education, review of blood sugars, med adjustment
Monitor growth, blood pressure (<130/80) Glucose control goals (individualize):
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
At least every 3 months for education, review of blood sugars, med adjustment
Monitor growth, blood pressure (<130/80) Glucose control goals (individualize):
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 diabetesTreatment goals for diabetes
Hemoglobin A1c <7%Preprandial blood glucose 90-130 mg/dlPostprandial blood glucose < 180 mg/dlBlood pressure < 130/80LDL cholesterol < 100 mg/dlTriglycerides < 150 mg/dlHDL cholesterol > 40 mg/dl
Hemoglobin A1c <7%Preprandial blood glucose 90-130 mg/dlPostprandial blood glucose < 180 mg/dlBlood pressure < 130/80LDL cholesterol < 100 mg/dlTriglycerides < 150 mg/dlHDL cholesterol > 40 mg/dl
Management of hyperlipidemia
Management of hyperlipidemia
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)
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
Barriers to good diabetes control
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
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
Encouraging optimum diabetes control
Give credit for honesty and effortDiabetes visit should build self esteemSupport parental involvementSet realistic goals with teen and familyKeep it interesting (new technologies)Encourage regular visits and contactGroup programs for teens (camps)
Give credit for honesty and effortDiabetes visit should build self esteemSupport parental involvementSet realistic goals with teen and familyKeep it interesting (new technologies)Encourage regular visits and contactGroup programs for teens (camps)
Presentation of type 2 diabetes
Presentation of type 2 diabetes
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
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:
Is it type 1 or type 2? More likely type 2 if overweight and:PubertalMilder symptomsAcanthosis nigricansFamily history of type 2High risk ethnic group
PubertalMilder symptomsAcanthosis nigricansFamily history of type 2High risk ethnic group
Features of type 2 diabetesFeatures of type 2 diabetes
Insulin /C peptide over upper limit of normal for assay
Negative pancreatic antibody panelInitial insulin requirements 1.3-1.5
units/kg/day falling to little or no insulin requirement over 1-2 months
Ketosis seldom occurs spontaneously
Insulin /C peptide over upper limit of normal for assay
Negative pancreatic antibody panelInitial insulin requirements 1.3-1.5
units/kg/day falling to little or no insulin requirement over 1-2 months
Ketosis seldom occurs spontaneously
14 year old male with ? diabetes
14 year old male with ? diabetes
2 weeks ago, vomiting, diarrhea,fatigueGlucosuria, random blood sugar in 180sRepeat BG=286 mg/dl occasional
nocturia, no thirst, 6 lb weight lossBW 7 lb, MGM, MGGM type 2 diabetesMaternal aunt low thyroidBMI 35, 99%ile, 101kg ht 170 cmSMR 3, acanthosis, psoriasis
2 weeks ago, vomiting, diarrhea,fatigueGlucosuria, random blood sugar in 180sRepeat BG=286 mg/dl occasional
nocturia, no thirst, 6 lb weight lossBW 7 lb, MGM, MGGM type 2 diabetesMaternal aunt low thyroidBMI 35, 99%ile, 101kg ht 170 cmSMR 3, acanthosis, psoriasis
Idiopathic diabetesIdiopathic diabetes
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
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 activityHealthy eating and activity
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
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
Management of type 2 diabetes in teens
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
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
Use of metformin in type 2 diabetes
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
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 metforminAdvantages of metformin
Mild weight loss (teens love this)Decreased insulin requirement/
decreased insulin resistanceNot associated with hypoglycemiaBeneficial effects on cardiovascular
disease shown in adults
Mild weight loss (teens love this)Decreased insulin requirement/
decreased insulin resistanceNot associated with hypoglycemiaBeneficial effects on cardiovascular
disease shown in adults
When to begin insulin rather than oral agent in type 2:
When to begin insulin rather than oral agent in type 2:
Ketones presentMarked hyperglycemia with dehydrationContraindications to metformin
(significantly abnormal LFTs, elevated BUN/ creatinine, pregnancy)
Ketones presentMarked hyperglycemia with dehydrationContraindications to metformin
(significantly abnormal LFTs, elevated BUN/ creatinine, pregnancy)
When metformin is not enough:
When metformin is not enough:
Add insulin (NPH, glargine,detemir, or short acting insulin with meals or combinations)
Add a second oral agentTake a look at lifestyle again (food and
beverage choices, activity) Enlist more adult support
Add insulin (NPH, glargine,detemir, or short acting insulin with meals or combinations)
Add a second oral agentTake a look at lifestyle again (food and
beverage choices, activity) Enlist more adult support
Prevention of type 2 diabetesPrevention of type 2 diabetes
Lifestyle modification (exercise, healthy eating)
Treatment of prediabetic conditions with metformin or other insulin sensitizing agents? Glucose intolerance Extreme obesity with insulin resistance Polycystic ovary syndrome
Lifestyle modification (exercise, healthy eating)
Treatment of prediabetic conditions with metformin or other insulin sensitizing agents? Glucose intolerance Extreme obesity with insulin resistance Polycystic ovary syndrome