Current Research and Management of Children With Type 2 Diabetes

Friday, August 12, 2005

Breakout Session

Speakers
Francine R Kaufman, MD
Paula Jameson, MSN, ARNP, CDE

Reported by Joelle Escoffery, PhD

This session addressed the similarities and difference between type 2 diabetes in adults and type 2 diabetes in the pediatric population. Although the relative progression of the disease and the underlying pathophysiology is similar between the 2 groups, the clinical presentation appears to differ. Type 2 diabetes in adults usually has a long and identifiable preclinical period, and screening efforts in high risk populations are relatively successful. Conversely, type 2 diabetes in youth appears to have a much quicker onset, as evidenced by the inability of screening to detect significant numbers of type 2 diabetes in youth. In youth, diagnosis of type 2 diabetes often coincides with puberty, and, unlike their adult counterparts, female adolescents are nearly twice as likely to develop type 2 diabetes as their male peers.

One of the greatest challenges in the area of pediatric endocrinology is to distinguish between type 1 and type 2 diabetes at the time of diagnosis. Although overweight and obesity are associated with an increased risk of type 2 diabetes, these conditions do not confer any benefit against autoimmune type 1 diabetes, as evidenced by the fact that as many as 20% of children with type 1 diabetes are obese. Similarly, 20% of children with type 1 diabetes may have a family history of type 2 diabetes. The presence of autoantibodies also does not provide a clear answer, as they are present in only 85% of children with type 1 diabetes and in 15% of children with type 2 diabetes. One factor that may assist the diagnosis of type 2 diabetes in youth is the presence of comorbid acanthosis nigricans or PCOS (both highly comorbid conditions associated with insulin resistance). Additionally, type 1 diabetes is more common among white children, whereas type 2 diabetes is more prevalent among minority children, including African Americans, Hispanics and Latinos, Asian Americans, and Pacific Islanders.

No clear guidelines exist for the treatment of youth with type 2 diabetes, so the guidelines for youth with type 1 have served as a starting point. In terms of the treatment paradigm, children who present in acute hyperglycemic crisis are frequently placed on insulin for stabilization and to overcome the insulin resistance. Children who are stable at time of diagnosis may be treated with diet and exercise alone initially, but they will eventually require pharmacologic therapy. Currently, insulin and metformin are approved for use in children, and safety and efficacy studies are underway with roziglitazone, sulfonylureas, and a variety of treatment combinations. Additionally, as children with type 2 diabetes face the same microvascular and macrovascular complications as their adult counterparts, many of them also require the use of agents to correct lipid and blood pressure abnormalities.

In terms of providing education to this population, there are a number of challenges facing the healthcare provider. The population is growing rapidly, and the prevalence can vary widely by geographic location and ethnicity. Type 2 diabetes in youth presents with a wide spectrum of clinical stages and is difficult to diagnose. Further, there is little research in the area to guide education, and many existing educational tools are not suitable for the pediatric population. The patient also faces a number of barriers, including the challenges of adolescence, language and literacy factors, transport and mobility difficulties, somnolence, lack of access to care and education, limited financial resources, multiple caregivers, varying perspectives on obesity, unhealthy family eating habits, and depression. However, adolescent learners have a lot of encouraging features, including great curiosity and a changing understanding of self that may be amenable to modification. This group needs to be educated on the basics of the disease, the importance of lifestlyle, blood glucose monitoring, and medication information (eg, purpose, proper administration, safety measures, and side effects). Coping skills are also important for this group, including issues related to body image, teasing, the importance of social support, and depression recognition and management. Education can be conducted in nontraditional setting, and linking learning to a fun activity (eg, bowling, dancing) has been a successful strategy.

As the obesity and diabetes epidemics continue to increase, strategies for diagnosing, treating, and educating the child with type 2 diabetes will become increasingly important.