November 2018

ADA Issues New Guidelines for Youth with T2D

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Youth-onset type 2 diabetes (T2D), defined as T2D that develops before 20 years of age, is a growing medical challenge in the United States. A national study reported a 4.8% increase in newly diagnosed cases of T2D in this age group from 2002 to 2012.

Existing evidence demonstrates that youth-onset T2D is different from T2D in adults. Because youth-onset T2D is more aggressive, in some cases, thus causing complications earlier in life, the American Diabetes Association recently released “Evaluation and Management of Youth-Onset Type 2 Diabetes: A Position Statement by the American Diabetes Association.” The guidelines are already online and will be published in the December 2018 issue of Diabetes Care (http://care.diabetesjournals.org/).

The position statement, written by a team of pediatric experts, is based on expert consensus, scientific research, and a review of more than 260 items from the medical literature. The statement’s objective is to provide an improved, up-to-date understanding of T2D in youth. It outlines pathophysiology, diagnosis, and risk factors; components of lifestyle management and pharmacotherapeutic approaches to glycemic management; associated comorbidities and complications; and making the transition from pediatric to adult care.

The guidelines discuss pathogenesis, risk assessment, diagnostic criteria, and the importance of confirming the type of diabetes in a youthful patient. Highlighted are the modifiable and nonmodifiable risk factors for T2D in youth, including puberty-related physiologic insulin resistance in obese youth.

The authors emphasize that there are fundamental differences in insulin sensitivity and ß-cell function between youth and adults with prediabetes and T2D, which could offer an explanation as to why some youth develop T2D decades earlier than adults. Recommendations include risk-based screening of youth who are overweight or obese based on their BMI* or who have additional risk factors for diabetes.

Lifestyle management of T2D in youth is addressed, including recommendations on patient education, weight management, exercise, nutrition, and psychosocial factors. Guidelines suggest that youth with T2D, and their families, receive comprehensive diabetes self-management education and support that is specific to youth and culturally appropriate, and that providers use standardized, validated tools to assess diabetes distress and mental/behavioral health in youth with T2D, referring them to specialty care when necessary.

Pharmacotherapeutic approaches to glycemic management of T2D in youth are included, with an algorithm illustrating the specific management of new-onset diabetes in overweight youth. The position statement further indicates that metabolic surgery can be considered for the treatment of adolescents with T2D who have a BMI >35, uncontrolled glycemia, and/or serious comorbidities that persist despite lifestyle and pharmacologic intervention.

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Additionally, the statement details potential diabetes-related complications and guidelines on screening, prevention, and management for each. A key recommendation for LER readers is in the “Neuropathy” section:

Youth with type 2 diabetes should be screened for the presence of neuropathy by foot examination at diagnosis and annually. The examination should include inspection, assessment of foot pulses, pinprick and 10-g monofilament sensation tests, testing of vibration sensation using a 128-Hz tuning fork, and ankle reflexes.

Transitioning patients properly from pediatric to adult care providers is addressed as well, as the authors indicate this is essential in providing appropriate care of youth with T2D.

“Research has indicated type 2 diabetes appears to be more aggressive in youth than in adults, with a faster rate of deterioration of ß-cell function and poorer response to glucose-lowering medications,” said lead author Silva Arslanian, MD, Scientific Director and Principal Investigator of the Center for Pediatric Research in Obesity and Metabolism, UPMC Children’s Hospital of Pittsburgh, and the Richard L. Day Endowed Professor of Pediatrics at the University of Pittsburgh School of Medicine. “Furthermore, there is a higher risk for complications in people with earlier-onset type 2 diabetes, which is possibly related to prolonged lifetime exposure to hyperglycemia and other atherogenic risk factors, including insulin resistance, dyslipidemia, hypertension, and chronic inflammation. Thus, we must continue to make strides in recognizing the specific needs of youth and adolescents who are at risk of or who have a diagnosis of type 2 diabetes.”

* Calculated as the patient’s weight in kilograms divided by his/her height in meters squared.

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