Type 2 diabetes in the young: the evolving epidemic: the international diabetes federation consensus workshop

The effect of a communications campaign on middle school students' nutrition and physical activity: results of the HEALTHY study

The HEALTHY Study was a 3-year school-based intervention designed to change the behaviors of middle school students to reduce their risk for developing type 2 diabetes mellitus. This report examines the relation between exposure to communications campaign materials and behavior change among students in the HEALTHY intervention schools. Using data from campaign tracking logs and student interviews, the authors examined communications campaign implementation and exposure to the communications campaign as well as health behavior change. Campaign tracking documents revealed variability across schools in the quantity of communications materials disseminated. Student interviews confirmed that there was variability in the proportion of students who reported receiving information from the communication campaign elements. Correlations and regression analysis controlling for semester examined the association between campaign exposure and behavior change across schools. There was a significant association between the proportion of students exposed to the campaign and the proportion of students who made changes in health behavior commensurate with study goals. The results suggest that, in the context of a multifaceted school-based health promotion intervention, schools that achieve a higher rate of exposure to communication campaign materials among the students may stimulate greater health behavior change.

Progression of β-cell dysfunction in obese youth

The epidemic of childhood obesity has led to a remarkable increase in the prevalence of type 2 diabetes (T2D) among youth worldwide. The decreasing age at onset of T2D has alarming public health implications. In particular, the longer duration of the disease, as well as the faster onset and progression of T2D related complications, will present a considerable burden for young adults and a strain on public health. Therefore, it is important to understand the pathophysiology of early phases of disruption of glucose tolerance and identify those critical points in which diabetes may be prevented. β-Cell dysfunction has been shown to represent one of the key pathogenetic defects underlying the progression to diabetes in obese youth. In the present review, we describe longitudinal and cross-sectional studies of changes in insulin sensitivity and secretion across the spectrum of glucose tolerance in obese adolescents. Further, the role of ectopic fat accumulation is discussed in relation to its association with both β-cell dysfunction and insulin resistance.

Obesity and dental caries in children: a systematic review and meta-analysis

OBJECTIVES

Obesity and dental caries have become increasingly prevalent challenges to public health. Research results into the relationship between obesity and dental caries in children have been mixed and inconclusive. The aim of this review and meta-analysis was to provide evidence to quantify the relationship between obesity and dental caries in children using a systematic approach.

METHODS

A systematic search for papers between 1980 and 2010 addressing childhood obesity and dental caries was conducted and a random effects model meta-analysis applied.

RESULTS

Fourteen papers met the selection criteria. Overall, a significant relationship between childhood obesity and dental caries (effect size = 0.104, P = 0.049) was found. When analysed by dentition type (primary versus permanent), there was a nonsignificant association of obesity and dental caries in permanent and primary dentitions, yet on accounting only for standardized definitions for assessment of child obesity using body mass index, a strong significant relationship was evident in children with permanent dentitions. Moderating for study country of origin (newly 'industrialized' versus industrialized) showed a significant relationship between obesity and dental caries in children from industrialized but not newly industrialized countries. Cofactors such as age and socioeconomic class were significant moderators.

CONCLUSIONS

Future analysis should investigate these confounding variables, helping shape the future of obesity management programmes and oral health interventions, through determining common risk factors.

Efficacy of family-based weight control program for preschool children in primary care

OBJECTIVE

To test the efficacy of an innovative family-based intervention for overweight preschool-aged children and overweight parents conducted in the primary care setting.

METHODS

Children with BMI ≥ 85th percentile and an overweight parent were randomized to intervention or information control (IC). Trained staff delivered dietary and physical/sedentary activities education to parents over 6 months (10 group meetings and 8 calls). Parents in the intervention received also behavioral modification. An intention-to-treat analysis was performed by using mixed analysis of variance models to test changes in child percent over BMI (%OBMI) and z-BMI and to explore potential moderators of group differences in treatment response.

RESULTS

Ninety-six of 105 randomized families started the program: 46 children (31 girls/15 boys) in the intervention and 50 (33 girls/17 boys) in the IC, with 33 and 39 mothers and 13 and 11 fathers in intervention and IC, respectively. Baseline characteristics did not differ between groups. Children in the intervention group had greater %OBMI and z-BMI decreases at 3 and 6 months compared with those assigned to IC (P < .0021). A greater BMI reduction over time was also observed in parents in the intervention compared with parents assigned to IC (P < .0001). Child %OBMI and parent BMI changes were correlated (r = .31; P = .003). Children with greater baseline %OBMI were more likely to have a greater %OBMI decrease over time (P = .02).

CONCLUSIONS

Concurrently targeting preschool-aged overweight youth and their overweight parents for behavioral weight control in a primary care setting reduced child %OBMI and parent BMI, with parent and child weight changes correlating.

[Intensive insulin therapy in type 2 diabetes mellitus]

In the last couple of years, the intensive conservative insulin treatment (basal-bolus regime) became more and more popular even in patients with type 2 diabetes. Using this insulin treatment, continuous patient education, co-operation between the medical team (diabetologist, dietician and diabetes-nurses) and the patient as well as the availability of modern insulins, pens and glucometers are of great importance. Clearly, the basal-bolus treatment with human insulin has advantages over the conservative (conventional) treatment with twice daily premix insulins. Moreover, the basal-bolus treatment with insulin-analogues proved to be superior in some aspects as compared to human insulins. The intensive insulin treatment (basal-bolus regime with insulin-analogues) approaches the optimal insulin substitution and, with its use the adequate correction of each element of the glucose triad (fasting blood glucose, postprandial blood glucose, HbA1c) should be considered feasible even in patients with type 2 diabetes.

Type 2 diabetes in young Indigenous Australians in rural and remote areas: diagnosis, screening, management and prevention

The burden of type 2 diabetes mellitus (T2DM) among Indigenous children and adolescents is much greater than in non-Indigenous young people and appears to be rising, although data on epidemiology and complications are limited. Young Indigenous people living in remote areas appear to be at excess risk of T2DM. Most young Indigenous people with T2DM are asymptomatic at diagnosis and typically have a family history of T2DM, are overweight or obese and may have signs of hyperinsulinism such as acanthosis nigricans. Onset is usually during early adolescence. Barriers to addressing T2DM in young Indigenous people living in rural and remote settings relate to health service access, demographics, socioeconomic factors, cultural factors, and limited resources at individual and health service levels. We recommend screening for T2DM for any Aboriginal or Torres Strait Islander person aged > 10 years (or past the onset of puberty) who is overweight or obese, has a positive family history of diabetes, has signs of insulin resistance, has dyslipidaemia, has received psychotropic therapy, or has been exposed to diabetes in utero. Individualised management plans should include identification of risk factors, complications, behavioural factors and treatment targets, and should take into account psychosocial factors which may influence health care interaction, treatment success and clinical outcomes. Preventive strategies, including lifestyle modification, need to play a dominant role in tackling T2DM in young Indigenous people.

Human islet amyloid polypeptide at the air-aqueous interface: a Langmuir monolayer approach

Human islet amyloid polypeptide (hIAPP) is the source of the major component of the amyloid deposits found in the islets of Langerhans of around 95 per cent type 2 diabetic patients. The formation of aggregates and mature fibrils is thought to be responsible for the dysfunction and death of the insulin-producing pancreatic β-cells. Investigation on the conformation, orientation and self-assembly of the hIAPP at time zero could be beneficial for our understanding of its stability and aggregation process. To obtain these insights, the hIAPP at time zero was studied at the air-aqueous interface using the Langmuir monolayer technique. The properties of the hIAPP Langmuir monolayer at the air-aqueous interface on a NaCl subphase with pH 2.0, 5.6 and 9.0 were examined by surface pressure- and potential-area isotherms, UV-Vis absorption, fluorescence spectroscopy and Brewster angle microscopy. The conformational and orientational changes of the hIAPP Langmuir monolayer under different surface pressures were characterized by p-polarized infrared-reflection absorption spectroscopy, and the results did not show any prominent changes of conformation or orientation. The predominant secondary structure of the hIAPP at the air-aqueous interface was α-helix conformation, with a parallel orientation to the interface during compression. These results showed that the hIAPP Langmuir monolayer at the air-aqueous interface was stable, and no aggregate or domain of the hIAPP at the air-aqueous interface was observed during the time of experiments.

Oral disposition index in obese youth from normal to prediabetes to diabetes: relationship to clamp disposition index

OBJECTIVE

We sought to assess the glucose disposition index using an oral glucose tolerance test (OGTT; oDI) compared with the glucose disposition index measured from the combination of the euglycemic-hyperinsulinemic and hyperglycemic clamps (cDI) in obese pediatric subjects spanning the range of glucose tolerance.

STUDY DESIGN

Overweight/obese adolescents (n = 185) with varying glucose tolerance (87 normal, 54 impaired, 31 with type 2 diabetes, and 13 with type 1 diabetes) completed an OGTT and both a hyperinsulinemic-euglycemic and a hyperglycemic clamp study. Indices of insulin sensitivity and β-cell function were calculated, and 4 different oDI estimates were calculated as the products of insulin and C-peptide-based sensitivity and secretion indices.

RESULTS

Mirroring the differences across groups by cDI, the oDI estimates were greatest in normal glucose tolerance adolescents and lowest in type 2 diabetes mellitus and obese with type 1 diabetes mellitus adolescents. The insulin-based oDI estimates correlated with cDI overall (r ≥ 0.74, P < .001) and within each glucose tolerance group (r ≥ 0.40, P < .001). Also, oDI and cDI predicted 2-hour OGTT glucose similarly.

CONCLUSIONS

The oDI is a simple surrogate estimate of β-cell function relative to insulin sensitivity that can be applied to obese adolescents with varying glucose tolerance in large-scale epidemiological studies where the applicability of clamp studies is limited due to feasibility, cost, and labor intensiveness.

Adolescent perspectives on wearing accelerometers to measure physical activity in population-based trials

BACKGROUND

Accelerometers are increasingly used in health research to measure physical activity, but few published studies document participants' views and experiences of wearing accelerometers, preferring to focus on measurement decisions and outcomes, and fewer still have reported the views and experiences of adolescent participants.

PURPOSE

The purpose of this study is to examine the use of accelerometers with young people including recruitment, retention and adherence to protocol.

METHODS

The AHEAD (Activity and Healthy Eating in Adolescence) feasibility study, involving over 1000 students aged 12/13 years, took place in south-west England between 2007 and 2009. Piloting work was followed by an exploratory trial, incorporating a process evaluation, in six schools. Students were asked to wear accelerometers for 7 days at baseline and follow-up.

RESULTS

Eighty-nine percent of students provided some accelerometer data at baseline and 87% at follow-up. However, adherence (recording ≥ 600 minutes per day for ≥ 3 days) fell from 75% at baseline to 56% at follow-up. Factors affecting adherence included the following: the use and type of incentives, appearance, discomfort and unforeseen changes to the school timetable.

CONCLUSIONS

If worn properly, accelerometers can provide an important objective measure of physical activity in population-based studies promoting physical activity. But to achieve generalizable results, it is important to maximize recruitment, retention and adherence to protocol across the study population. For adolescents, adherence may be improved by the following: a 'two-part' reward (part one for returns, part two for adherence), personal activity graphs, and less obtrusive belts and monitors.

Increasing rates of diabetes amongst status Aboriginal youth in Alberta, Canada

OBJECTIVES

To track and compare trends in diabetes rates from 1995 to 2007 for Status Aboriginal and general population youth.

STUDY DESIGN

Longitudinal observational research study (quantitative) using provincial administrative data.

METHODS

De-identified data was obtained from Alberta Health and Wellness administrative databases for Status Aboriginal (First Nations and Inuit people with Treaty status) and general population youth (<20 years). Diabetes cases were identified using the National Diabetes Surveillance System algorithm. Crude annual diabetes prevalence and incidence rates were calculated. The likelihood of being a prevalent case and incident case of diabetes for the 2 populations was compared for the year 2007. Average Annual Percent Changes (AAPC) in prevalence and incidence from 1995 to 2007 were determined and compared between the 2 groups to examine trends over time.

RESULTS

While the prevalence of diabetes was higher in the general population in 1995, by 2007 there were no between group differences, reflected in the significantly higher AAPC of 6.98 for Status Aboriginal youth. Status Aboriginal males had a lower diabetes risk in 1995 compared with females, and experienced a greater increase in prevalence over the 13 years (AAPC 9.18) so that by 2007 their rates were equivalent to those of the females. Differences in diabetes incidence trends were only observed among male youth, where increases in incidence were greater for Status Aboriginal (AAPC 11.65) compared to general population males (AAPC 4.62) (p = 0.03).

CONCLUSION

Youth-onset diabetes is an increasing problem in Alberta, especially among young Status Aboriginal males.

[Are there any clinical and metabolic differences between immigrant and Spanish-born diabetic patients?]

AIM

To determine the clinical features and the metabolic control in immigrant diabetic patients in two Primary Care centres in La Rioja, Spain.

DESIGN

Descriptive study.

SETTING

Two urban Primary Care centres which cover a population of 11,700 and 23,000 patients in Logroño.

PRIMARY OUTCOMES

Socio-demographic variables (age, sex, origin country of origin, age at onset of diabetes), clinical variables (blood pressure, waist circumference (WC), high, weight, BMI) and analytical variables (fasting blood glucose, HbA1c, lipid profile). The immunology of DM and baseline C-peptide were studied in patients younger than 40 years old.

PARTICIPANTS

A total of 70 diabetic immigrants, aged between 18 and 70 years old and registered until December 31(st) 2009, and 70 Spanish-born diabetic patients were selected by consecutive sampling.

RESULTS

The final sample consisted of 140 patients (70 immigrants, 70 Spanish). Mean age of Spanish-born diabetics, 55.5 years, of immigrants 45.7 years (P=.002).Age at diagnosis 38.4 years in immigrants and 48.1 years in autochthonous (P=.004).WC in immigrants 104.1cm, in Spanish-born, 105.3 cm (P=.56).BMI in immigrants 29, in Spanish-born 32.1 (P=.06).Mean glycated haemoglobin (HbA1c) in immigrants 8.4%, in Spanish-born 7.5% (P=.002). Blood pressure and lipid values were lower in Hindustani and North African patients than in Spanish-born and other immigrant groups.

CONCLUSIONS

Immigrant diabetic patients are younger at diagnosis, have an unchanged baseline C-peptide secretion, higher HbA1c levels, higher WC with lower BMI compared to Spanish-born patients.

Duration of diabetes and risk of ischemic stroke: the Northern Manhattan Study

BACKGROUND AND PURPOSE

Diabetes increases stroke risk, but whether diabetes status immediately before stroke improves prediction and whether duration is important are less clear. We hypothesized that diabetes duration independently predicts ischemic stroke.

METHODS

Among 3298 stroke-free participants in the Northern Manhattan Study, baseline diabetes and age at diagnosis were determined. Incident diabetes was assessed annually (median, 9 years). Cox proportional hazard models were used to estimate hazard ratios (HR) and 95% CI for incident ischemic stroke using baseline diabetes, diabetes as a time-dependent covariate, and duration of diabetes as a time-varying covariate; models were adjusted for demographic and cardiovascular risk factors.

RESULTS

Mean age was 69 ± 10 years (52% Hispanic, 21% white, and 24% black); 22% had diabetes at baseline and 10% had development of diabetes. There were 244 ischemic strokes, and both baseline diabetes (HR, 2.5; 95% CI, 1.9-3.3) and diabetes considered as a time-dependent covariate (HR, 2.4; 95% CI, 1.8-3.2) were similarly associated with stroke risk. Duration of diabetes was associated with ischemic stroke (adjusted HR, 1.03 per year with diabetes; 95% CI, 1.02-1.04). Compared to nondiabetic participants, those with diabetes for 0 to 5 years (adjusted HR, 1.7; 95% CI, 1.1-2.7), 5 to 10 years (adjusted HR, 1.8; 95% CI, 1.1-3.0), and ≥ 10 years (adjusted HR, 3.2; 95% CI, 2.4-4.5) were at increased risk.

CONCLUSIONS

Duration of diabetes is independently associated with ischemic stroke risk adjusting for risk factors. The risk increases 3% each year, and triples with diabetes ≥ 10 years.

Type 2 diabetes in pediatrics and adults: thoughts from a clinical pharmacology perspective

Type 2 diabetes results when insulin secretion is unable to keep the plasma glucose levels as per acceptable range. This leads to chronic hyperglycemia and its associated microvascular complications such as renal impairment (diabetic nephropathy), retinal abnormalities (diabetic retinopathy), and autonomic, sensory, and motor neuropathies (diabetic neuropathy) and macrovascular disease. Historically, type 2 diabetes is well known as an adult-onset disease; however, lately, the incidence of the disease is reported to be increasing in children. Despite the wealth of information concerning type 2 diabetes in adults, data unique to the pediatric age group regarding the pathophysiology and therapy for type 2 diabetes are limited. For treatment in pediatric type 2 diabetes, metformin and insulin are the only antidiabetic agents approved currently. There are data of use of other oral antidiabetic drugs including glimepiride, rosiglitazone, and glyburide (in combination with metformin) in pediatric patients; however, formal clinical trials to establish the safety and efficacy have not been conducted. This review will compare the clinical pharmacology aspects of the oral type 2 diabetic drugs in pediatric and adult populations in order to determine any differences between the two patient groups.

Adherence to oral antidiabetic medications in the pediatric population with type 2 diabetes: a retrospective database analysis

BACKGROUND

Little has been done in assessing adherence to oral antidiabetic (OAD) medications in the pediatric population presenting with type 2 diabetes. This study provided information on adherence rates in the Texas Medicaid pediatric population with type 2 diabetes, which is rare in the literature. The knowledge of adherence rates in the pediatric population with type 2 diabetes might help improve the care given to pediatric patients with type 2 diabetes.

OBJECTIVE

To describe OAD medication use, and assess trends in medication adherence and persistence among Texas pediatric Medicaid patients.

METHODS

Texas Medicaid prescription claims data of patients between 10 and 18 years of age, with at least 2 prescriptions of the same OAD medication from January 1, 2006 to December 31, 2009, were analyzed. Adherence was assessed using the medication possession ratio (MPR) as a proxy.

RESULTS

A total of 3109 patients met the study's inclusion criteria. The mean (SD) age of the 3109 eligible patients was 14.2 (2.3) years; 60% were Hispanics, 14% were blacks, 13% were whites, and another 13% were other minority races; 67% of the population were females; and 91% were on metformin of the 6 OAD medications included in the study The overall mean (SD) MPR for patients was 44.69% (27.06%). Adherence differed by gender (P < 0.0001), race (P < 0.0001), and age category (P < 0.0001). Males had higher mean (SD) MPR (47.47% [27.42%]) compared with females (43.29% [26.78%]). Mean MPR for whites (50.04% [29.65%]) was significantly higher compared with blacks (44.24% [26.16%]) and Hispanics (42.50% [26.10%]). Patients ≤12 years of age had significantly higher mean MPR (48.82% [27.37%]) compared with those in older age categories. Logistic regression analysis suggested that age was significantly related (odds ratio [OR] = 0.91; 95% CI, 0.87-0.95) to being adherent (MPR ≥80%). Males were 25% (OR = 1.25; 95% CI, 1.02-1.53; P = 0.034) more likely to be adherent (MPR ≥80%) compared with females, and whites were twice as likely to be adherent (MPR ≥80%) compared with Hispanics (OR = 2.02; 95% CI, 1.54-2.66; P = 0.0012). Overall, mean (SD) days to nonpersistence was 108 (86) days. Persistence was significantly and negatively associated with age (P < 0.0001). White race was significantly related to longer persistence.

CONCLUSION

Adherence and persistence to OAD medications in the selected Texas Medicaid pediatric population between 10 and 18 years was generally suboptimal, especially in adolescents.

Type 2 diabetes in childhood: clinical characteristics and role of β-cell autoimmunity

The global obesity epidemic has led to dramatic increases in the incidence and prevalence of type 2 diabetes mellitus (T2DM) among youth worldwide. In today's clinical practice it has become increasingly difficult to distinguish type 1 diabetes mellitus (T1DM) from T2DM as many children with T1DM are overweight at diagnosis. Numerous recent publications note a significant proportion of physician-diagnosed T2DM youth with evidence of pancreatic autoimmunity, exemplifying the challenges in distinguishing between T1DM and T2DM. The clinical implications of the phenomenon of antibody positivity in phenotypic T2DM youth, also referred to as "type 1.5 diabetes" (T1.5 DM), "double diabetes," "latent autoimmune diabetes in youth" (LADY), and "hybrid diabetes," are unclear at present. Current and future work should determine if the presence of autoantibodies in phenotypic T2DM youth/children affects clinical course; this will facilitate the development of optimal treatment strategies.

Ocular telehealth screenings in an urban community

The current U.S. economic recession has resulted in a loss of income, housing, and healthcare coverage. Our major goal in this socioeconomic setting was to provide ophthalmic remote health screenings for urban soup kitchen and homeless populations in order to identify and refer undetected vision-threatening disease (VTD). We assessed visual acuity, blood pressure, pulse/oxygen saturation, body mass index, and intraocular pressure for 341 participants at soup kitchens as part of the homeless outreach program in Newark, NJ. History of diabetes, hypertension, and smoking, last ocular examination, and ocular history were noted. Imaging was performed with an 8.2 megapixel non-mydriatic retinal camera with high-speed Internet ready for off-site second opinion image evaluation. Positive VTD findings were identified in 105 participants (31%) (mean age, 53.6 years), of whom 78% were African American, 73% males, and 62% smokers. We detected glaucoma in 34 participants (32%), significant cataract in 22 (21%), diabetic retinopathy in 5 (5%), optic atrophy in 1 (1%), age-related macular degeneration in 1 (1%), and other retinal findings in 43 (41%). The incidence of VTDs was higher among this cohort than among study groups in previous screenings (31% vs. 12%). This finding shows an increase in ocular morbidity in a younger, at-risk population with elevated rates of hypertension, diabetes, and smoking. Functional visual impairment was 2.5 times higher than the national average (16% vs. 6.4%). Comprehensive, community-based screenings can provide more sensitive detection of VTDs in high-risk groups with low access to ophthalmic care and can be an integral part of recession solutions for improving healthcare.

Preventive pharmacotherapy in type 2 diabetes mellitus

Over the last few decades certain demographic changes have been observed worldwide, which have led to an increase in the prevalence of chronic non-communicable diseases. Type 2 diabetes mellitus and associated cardiovascular disease are major contributors to this disease burden leading to rising morbidity and mortality. It is worrisome to see that type 2 diabetes with its micro- and macrovascular complications is occurring in younger populations where it was hitherto unseen. Prevention appears to be an important strategy to reduce the burden of disease. Along with inculcating healthy lifestyle habits across populations, it may be suitable to use preventive pharmacotherapy in those with pre-diabetes and / or other risk factors like obesity, hypertension, and on the like. Metformin, alpha glucosidase inhibitors like acarbose, miglitol, and voglibose, and pioglitazone have all been used with success. The issues of compliance and adverse effects during long-term use have tempered the use of these drugs. The best approach would be to motivate the patient for effective lifestyle changes, and pharmacological management if the lifestyle changes are not successful in achieving their goals.

Diabetes in pregnancy among indigenous women in Australia, Canada, New Zealand, and the United States: a method for systematic review of studies with different designs

BACKGROUND

Diabetes in pregnancy, which includes gestational diabetes mellitus (GDM) and type 2 diabetes mellitus (T2DM), is associated with poor outcomes for both mother and infant during pregnancy, at birth and in the longer term. Recent international guidelines recommend changes to the current GDM screening criteria. While some controversy remains, there appears to be consensus that women at high risk of T2DM, including indigenous women, should be offered screening for GDM early in pregnancy, rather than waiting until 24-28 weeks as is current practice. A range of criteria should be considered before changing screening practice in a population sub-group, including: prevalence, current practice, acceptability and whether adequate treatment pathways and follow-up systems are available. There are also specific issues related to screening in pregnancy and indigenous populations. The evidence that these criteria are met for indigenous populations is yet to be reported. A range of study designs can be considered to generate relevant evidence for these issues, including epidemiological, observational, qualitative, and intervention studies, which are not usually included within a single systematic review. The aim of this paper is to describe the methods we used to systematically review studies of different designs and present the evidence in a pragmatic format for policy discussion.

METHODS/DESIGN

The inclusion criteria will be broad to ensure inclusion of the critical perspectives of indigenous women. Abstracts of the search results will be reviewed by two persons; the full texts of all potentially eligible papers will be reviewed by one person, and 10% will be checked by a second person for validation. Data extraction will be standardised, using existing tools to identify risks for bias in intervention, measurement, qualitative studies and reviews; and adapting criteria for appraising risk for bias in descriptive studies. External validity (generalisability) will also be appraised. The main findings will be synthesised according to the criteria for population-based screening and summarised in an adapted "GRADE" tool.

DISCUSSION

This will be the first systematic review of all the published literature on diabetes in pregnancy among indigenous women. The method provides a pragmatic approach for synthesizing relevant evidence from a range of study designs to inform the current policy discussion.

Clinical profile of diabetes in the young seen between 1992 and 2009 at a specialist diabetes centre in south India

AIM

To describe the trends and clinical profile of young diabetic patients (YD) attending a tertiary diabetes centre in south India.

METHODS

We reviewed medical records of 2630 YD patients (age at onset ≤25 years) registered between 1992 and 2009. Patients were classified as type 1 diabetes (T1DM), type 2 diabetes (T2DM) gestational diabetes mellitus (GDM) and other types. Retinopathy was assessed initially by direct and indirect ophthalmoscopy and later by retinal photography, nephropathy if urine protein excretion was >500 mg/day, neuropathy if vibration perception threshold on biothesiometry was ≥20 V.

RESULTS

The percentage of YD patients rose from 0.55% in 1992 to 2.5% in 2009 (trend chi square, 15.1, p<0.001). Of the 2630 YD subjects registered, 1135 (43.2%) had T1DM, 1262 (48.0%) had T2DM, 118 (4.5%) had GDM and 115 (4.4%) other types. T1DM patients were younger, had lower body mass index, waist circumference, systolic and diastolic blood pressures, and less family history of diabetes compared to T2DM (p<0.001 for each). Retinopathy was seen in 71.9% and 77.3% nephropathy in 22.1% and 12.1% and neuropathy in 34.5% and 21.4% of T2DM and T1DM respectively in those with ≥15 years duration of diabetes.

CONCLUSIONS

The percentage of YD in south India is increasing, predominantly due to early onset T2DM.

Genome-wide association studies and type 2 diabetes

In recent years, the search for genetic determinants of type 2 diabetes (T2D) has changed dramatically. Although linkage and small-scale candidate gene studies were highly successful in the identification of genes, which, when mutated, caused monogenic forms of T2D, they were largely unsuccessful when applied to the more common forms of the disease. To date, these approaches have only identified two loci (PPARG, KCNJ11) robustly implicated in T2D susceptibility. The ability to perform large-scale association analysis, including genome-wide association studies (GWAS) in many thousands of samples from different populations, and subsequently, the shift to form large international collaborations to perform meta-analyses across many studies has taken the number of independent loci showing genome-wide significant associations with T2D to 44. This number includes six loci identified initially through the analysis of quantitative glycaemic phenotypes, illustrating the usefulness of this approach both to identify new disease genes and gain insight into the mechanisms leading to disease. Combined, these loci still only account for ∼10% of the observed familial clustering in Europeans, leaving much of the variance unexplained. In this review, we will describe what GWAS have taught us about the genetic basis of T2D and discuss possible next steps to uncover the remaining heritability.

Effects of resistance training and aerobic exercise on insulin sensitivity in overweight korean adolescents: a controlled randomized trial

BACKGROUND

Data on the impact of resistance training on insulin resistance in overweight or obese children are inconclusive.

METHODS

Thirty overweight South Korean adolescents (mean age of 13.10 years) were divided by sex, and then randomly assigned to one of three treatment groups, which were the diet only (DO), diet with aerobic exercise (AE), or diet with resistance training (RT) group. Physiologic and metabolic parameters were assessed at baseline and after 12 weeks of exercise training and diet modification.

RESULTS

Both exercise groups (aerobic and resistance) showed significant improvements in their insulin area under the curve and insulin sensitivity index values when compared to their baseline values while the DO group showed no significant changes in these variables. Age-, sex-, and body mass index (BMI)-adjusted intergroup comparison analyses showed a marked reduction in BMI and a significant reduction in muscle mass in the AE group when compared to the RT group and the DO group, respectively.

CONCLUSION

A 12-week exercise training program of either resistance or aerobic activity improved insulin sensitivity in overweight adolescents, although it failed to show superiority over a DO program. Aerobic exercise decreased both body weight and BMI, and it was noted that this group also had a significant reduction in muscle mass when compared to the DO group.

Ancestry-informative markers on chromosomes 2, 8 and 15 are associated with insulin-related traits in a racially diverse sample of children

Type 2 diabetes represents an increasing health burden. Its prevalence is rising among younger age groups and differs among racial/ethnic groups. Little is known about its genetic basis, including whether there is a genetic basis for racial/ethnic disparities. We examined a multi-ethnic sample of 253 healthy children to evaluate associations between insulin-related phenotypes and 142 ancestry-informative markers (AIMs), while adjusting for sex, age, Tanner stage, genetic admixture, total body fat, height and socio-economic status. We also evaluated the effect of measurement errors in the estimation of the individual ancestry proportions on the regression results. We found that European genetic admixture is positively associated with insulin sensitivity (S I ), and negatively associated with the acute insulin response to glucose, fasting insulin levels and the homeostasis model assessment of insulin resistance. Our analysis revealed associations between individual AIMs on chromosomes 2, 8 and 15 and these phenotypes. Most notably, marker rs3287 at chromosome 2p21 was found to be associated with S I ( p = 5.8 × 10(-5)). This marker may be in admixture linkage disequilibrium with nearby loci ( THADA and BCL11A ) that previously have been reported to be associated with diabetes and diabetes-related phenotypes in several genome-wide association and linkage studies. Our results provide further evidence that variation in the 2p21 region containing THADA and BCL11A is associated with type 2 diabetes. Importantly, we have implicated this region in the early development of diabetes-related phenotypes, and in the genetic aetiology of population differences in these phenotypes.

Coping skills training in a telephone health coaching program for youth at risk for type 2 diabetes

INTRODUCTION

The purpose of this article is to describe components of a health coaching intervention based on coping skills training delivered via telephone. This intervention was provided to urban adolescents at risk for type 2 diabetes mellitus (T2DM), reinforcing a school-based curriculum designed to promote a healthy lifestyle and prevent T2DM.

METHOD

Health coaching via telephone was provided to at-risk urban youth enrolled in a study of an intervention to reduce risk for T2DM. Vignettes are used to describe the use of several coping skills in this high-risk youth population.

RESULTS

A variety of vignettes illustrate how telephone health coaching reinforced lifestyle changes in students by incorporating coping skills training.

DISCUSSION

Given the benefits and the challenges of the telephone health coaching intervention, several suggestions for others who plan to use a similar method are described.

Microvascular disease in children and adolescents with type 1 diabetes and obesity

The incidence of type 1 diabetes (T1D) is increasing worldwide and is associated with a significant burden, mainly related to the development of vascular complications. Over the last decades, concomitant with the epidemic of childhood obesity, there has been an increasing number of cases of type 2 diabetes (T2D) among children and adolescents. Microvascular complications of diabetes, which include nephropathy, retinopathy and neuropathy, are characterized by damage to the microvasculature of the kidney, retina and neurons. Although clinically evident microvascular complications are rarely seen among children and adolescents with diabetes, there is clear evidence that their pathogenesis and early signs develop during childhood and accelerate during puberty. Diabetic vascular complications are often asymptomatic during their early stages, and once symptoms develop, there is little to be done to cure them. Therefore, screening needs to be started early during adolescence and, in the case of T2D, already at diagnosis. Identification of risk factors and subclinical signs of complications is essential for the early implementation of preventive and therapeutic strategies, which could change the course of vascular complications and improve the prognosis of children, adolescents and young adults with diabetes.

Cardiovascular and metabolic risk profiles in young and old patients with type 2 diabetes

BACKGROUND

Young patients (aged < 40 years) with type 2 diabetes (T2D) have a high lifetime risk of developing cardiovascular disease (CVD). However, little is known about the CVD risk profile of this cohort in the UK primary care setting.

AIM

To determine CVD risk profile of young patients with T2D without CVD compared to older (aged >40 years) subjects.

DESIGN

A cross-sectional study using The Health Improvement Network (THIN) database, which contains anonymized patient information from more than 300 general practices throughout England and Wales.

METHODS

T2D subjects above the age of 18 years without previous CVD and not on lipid or blood pressure lowering therapy were randomly selected. Data on glycaemic control and CVD risk factors [weight, body mass index (BMI), lipid profile] were collected.

RESULTS

A total of 49,919 patients with T2D were identified, of whom 2756 (0.5%) and 47,163 (99.5%) were aged below and above 40 years, respectively. Despite being at least 30 years younger (mean age: early vs. later onset; 33.8 vs. 66.9 years, P < 0.001), the proportions of adverse CVD risk profiles for young patients were similar to the older cohort with T2D. For young vs. old patients: the prevalence of BMI >25: 84.4% vs. 85.3%, P = 0.77; total cholesterol >4 mmol/l: 53.4% vs. 53.8%, P = 0.76; systolic hypertension: 58.2 vs. 58.4%, P = 0.36 and diastolic hypertension: 28.1 vs. 28.5%, P = 0.73). Glycaemic controls were similarly suboptimal between the two groups (mean HbA1c: young vs. old; 7.6% vs. 7.5%, P = 0.49). The prevalence of risk factor clustering were also similar between young vs. old patients with T2D.

DISCUSSION

Young T2D subjects possess risk factors that confer high lifetime risk for macrovascular complications, and therefore merits aggressive cardioprotective treatment.

Impact of diabetes and hypertension on left ventricular longitudinal systolic function

BACKGROUND

The assessment of the longitudinal component of left ventricular (LV) function is of major clinical importance for the early detection of LV contractile impairment. The aim of this study was to compare the impact of isolated type-2 diabetes, isolated hypertension, and co-existence of both on LV longitudinal systolic performance, with particular focus on their potential interaction effect.

METHODS

The study population included 163 consecutive patients: 84 patients with hypertension, 36 with diabetes, and 43 who have both hypertension and diabetes; 70 healthy controls were also recruited. Systolic mitral annulus velocity (S(m)) by Tissue Doppler and left atrioventricular plane displacement (AVPD) by M-mode were measured in all subjects.

RESULTS

AVPD was similarly reduced in hypertensives (13.2±2.2mm) and diabetics (13.5±2.3mm) when compared with the controls (15.1±2.4mm), and further depressed in diabetic hypertensives (11.5±3.0mm). Similar results were found for S(m). General linear model analysis revealed no significant interaction terms between diabetes and hypertension.

CONCLUSIONS

Normotensive diabetics and nondiabetic hypertensives show comparable depression in LV longitudinal systolic indices when compared with age- and gender-matched healthy controls; the co-existence of diabetes and hypertension leads to further impairment in LV longitudinal systolic function in an additive manner.

[Risk-stratified screening for diabetes in adolescents: results of the first investigation in Hungary]

The prevalence of type 2 diabetes mellitus in children and adolescents is increasing throughout the world. Early detection of blood glucose abnormalities is essential to improve long term prognosis of type 2 diabetes, as intervention strategies could be the most effective in youngsters.

AIM

To assess the prevalence of blood glucose abnormalities in asymptomatic adolescents having increased risk of diabetes, a screening program of the Hungarian Diabetes Association has been carried out in pediatric primary care setting.

METHODS

660 adolescents aged 12-18 years recruited from general pediatric practices were involved in the study. Risk assessment was performed by a questionnaire compiled according to the ADA recommendation for testing type 2 diabetes in childhood. Fasting plasma glucose and OGTT were performed in adolescents having increased risk for type 2 diabetes (overweight plus two additional clinical risk factors) and results were assessed according to WHO criteria.

RESULTS

285 adolescents of 660 were selected with increased risk for type 2 diabetes established by questionnaire (age: 15.2±1.8 years, BMI: 30.2±4.2 kg/m 2 , 141 males). Among subjects with increased risk, 16 (5.6%) had any type of blood glucose abnormalities: 4 (1.40%) IFG, 5 (1.75%) IFG+IGT, 6 (2.11%) IGT and 1 (0.35%) type 2 diabetes. Assessing the effect of clinical variables, increased BMI proved to be the strongest predictor of the diabetes risk [OR (95% CI): 1.216 (1.174-1.258), p<0.0001].

CONCLUSIONS

Screening procedure among asymptomatic adolescents with high risk of type 2 diabetes in the general pediatric practice is a simple and effective method for early detection of blood glucose abnormalities. Screening for type 2 diabetes in adolescents at risk should be encouraged in Hungary, and should be performed in pediatric primary care setting.

Implications of type 2 diabetes on adolescent reproductive health risk: an expert model

PURPOSE

The purpose of this article was to summarize scientific knowledge from an expert panel on reproductive health among adolescents with type 2 diabetes (T2D).

METHODS

Using a mental model approach, a panel of experts--representing perspectives on diabetes, adolescents, preconception counseling, and reproductive health--was convened to discuss reproductive health issues for female adolescents with T2D.

RESULTS

Several critical issues emerged. Compared with adolescents with type 1 diabetes, (1) adolescents with T2D may perceive their disease as less severe and have less experience managing it, putting them at risk for complications; (2) T2D is more prevalent among African Americans, who may be less trusting of the medical establishment; (3) T2D is associated with obesity, and it is often difficult to change one's lifestyle within family environments practicing sedentary and dietary behaviors leading to obesity; (4) teens with T2D could be more fertile, because obesity is related to earlier puberty; (5) although obese teens with T2D have a higher risk of polycystic ovary syndrome, which is associated with infertility, treatment with metformin can increase fertility; and (6) women with type 2 diabetes are routinely transferred to insulin before or during pregnancy to allow more intensive management.

CONCLUSIONS

Findings from the expert panel provide compelling reasons to provide early, developmentally appropriate, culturally sensitive preconception counseling for teens with T2D.

Medical consequences of childhood obesity: a Hong Kong perspective

Childhood obesity is a global epidemic and is associated with medical consequences. These consequences of childhood obesity include its association with cardiovascular risk factors, notably impaired glucose tolerance, hypertension, atherogenic dyslipidemia, micro inflammation, and comorbidities including nonalcoholic fatty liver disease (NAFLD), sleep apnoea, and early atherosclerosis. This article aims to demonstrate and review the local clinical evidences in Hong Kong Chinese children and adolescents in exploring the epidemiology and medical consequences associated with obesity in the youth population and highlighting the research direction in searching the etiology of these associations.

Multidisciplinary management of type 2 diabetes in children and adolescents

Although once considered a disease of adults, the prevalence of type 2 diabetes in youth is increasing at a significant rate. Similar to adults, youth with type 2 diabetes are at increased risk for developing hypertension, lipid abnormalities, renal disease, and other diabetes-related complications. However, children and adolescents with type 2 diabetes also face many unique management challenges that are different from adults with type 2 diabetes or children with type 1 diabetes. To deliver safe, effective, high-quality, cost-effective health care to adolescents with type 2 diabetes, reorganization and redesign of health care systems are needed. Multidisciplinary health care teams, which allow individuals with specialized training to maximally utilize their skills within an organized diabetes treatment team, may increase efficiency and effectiveness and may improve outcomes in children with type 2 diabetes. This review article provides a brief review of type 2 diabetes in children and adolescents, provides an overview of multidisciplinary health care teams, and discusses the role of multidisciplinary health care management in youth with type 2 diabetes.

Type 2 diabetes in the pediatric population: Are we meeting ADA clinical guidelines in Ohio?

Several studies have demonstrated the importance of achieving the American Diabetes Association (ADA) clinical guidelines in adults. However, research is limited on adherence to these guidelines in the pediatric population. This retrospective chart review examined 56 charts from 6 physician offices and 1 multispecialty health care system in Ohio. Variables of interest included recommendations from the 2007 ADA Standards of Medical Care in Diabetes. HgA1c was measured every 3 months in 44.6% of patients, while 55% achieved A1c goal. Blood pressure was monitored in all patients, with 57% meeting goal. Lipids and urine microalbumin were tested annually in 51.7% and 26.7% of patients, respectively. Dilated eye and foot exams were performed on 53.5% and 37.5% of patients, respectively. Adherence to ADA clinical guidelines for pediatric patients with type 2 diabetes is suboptimal. The authors recommend that specific evidence-based guidelines be evaluated for children with type 2 diabetes.

The prevalence of impaired fasting glucose and type 2 diabetes in a population-based sample of overweight/obese children in the Middle East

BACKGROUND

Type 2 diabetes mellitus (T2DM) and impaired fasting glucose (IFG) are increasing in young population who are facing an escalating trend of overweight. The aim of this study was to determine the prevalence of IFG and T2DM for the first time in a population-based sample of Iranian obese children.

METHODS

This cross-sectional, population-based study was conducted in Isfahan, the second large city of Iran. Overall, 672 overweight and obese school students, selected from 7554 students, aged 6-19 yr, were screened for IFG and T2DM. Fasting plasma glucose (FPG) and lipid profile were measured in all participants. Oral glucose tolerance test and insulin level were measured in those children with IFG. Insulin resistance was defined as homeostasis model assessment for insulin resistance (HOMA-IR) > 3.10.

RESULTS

Among the7554 students (48.7% boys and 51.3% girls) studied, 9.34% (n = 706) were overweight and 5.3% (n = 403) were obese. A number of 672 overweight and obese students including 302 (44.9%) boys and 370 (55.1%) girls, with a mean age of 12.8 +/- 3.10 yr underwent biochemical work up. Overall, the prevalence of IFG was 4.61% (n = 31), the corresponding figure was 2% (n = 4) in the 6-10 yr age group, and 5% (n = 27) in those aged 10.1-19 yr. The prevalence of T2DM was 0.1% (n = 1; age, 18.00 yr). Impaired glucose tolerance and insulin resistance were detected in three and six participants with IFG, who consisted 0.4 and 0.8% of total obese and overweight students, respectively.

CONCLUSIONS

Although the prevalence of T2DM is low in Iranian obese children, IFG is not uncommon. Preventive measures and screening of FPG should be considered for these children.

Pediatric endocrinologists' management of children with type 2 diabetes

OBJECTIVE To understand physician behaviors and attitudes in managing children with type 2 diabetes. RESEARCH DESIGN AND METHODS A survey was mailed to a nationwide sample of pediatric endocrinologists (PEs). RESULTS A total of 40% of PEs surveyed responded (211 of 527). Concordance with current monitoring guidelines varied widely, ranging from 36% (foot care) to 93% (blood pressure monitoring). Given clinical vignettes addressing hyperlipidemia, hypertension, and microalbuminuria, only 34% of PEs were fully concordant with current treatment guidelines. Reported barriers included concerns about patient adherence, insufficient scientific evidence about treatment, and lack of familiarity with current recommendations. Providers aged < or =45 years or in clinical practice <10 years reported significantly more aggressive management behaviors and had higher concordance with guidelines. CONCLUSIONS Screening and management of pediatric type 2 diabetes varied widely among PEs, suggesting opportunities for quality improvement. More aggressive management of type 2 diabetes among younger providers may be related to recent training when type 2 diabetes was more common.

Effects of exercise on insulin sensitivity, inflammatory cytokines, and serum tartrate-resistant acid phosphatase 5a in obese Chinese male adolescents

The benefits of exercise on glucose metabolism, inflammation, and serum tartrate-resistant acid phosphatase 5a (TRACP 5a) protein levels in Chinese male adolescents have not been extensively analyzed. Therefore, we examined the effects of a 12-week exercise program on weight, adiposity, insulin sensitivity (IS), and inflammatory marker expression, including the novel macrophage marker TRACP 5a, in obese Chinese male adolescents. A total of 106 male adolescents were recruited from the Army Academy in Taiwan and classified as lean (body mass index [BMI], 20.9 +/- 0.2 kg/m(2)) or obese (BMI, 27.7 +/- 0.2 kg/m(2)). Body composition, IS, and inflammatory markers were measured in both groups at baseline and in the obese group after completion of a 12-week exercise program. Body weight, BMI, waist circumference, body fat mass and percentage, homeostasis model assessment for insulin resistance, fasting plasma glucose, fasting serum insulin, 2-hour postchallenge plasma glucose concentration, interleukin-6, C-reactive protein, and serum TRACP 5a were significantly higher in the obese group as compared with the lean group. In addition, serum TRACP 5a was positively correlated with body mass and fat indices. After completion of the exercise program, significant reductions in all anthropometric, metabolic, and inflammatory indicators, with the exception of serum TRACP 5a were observed. Although the obese participants remained obese, exercise training significantly improved IS and reduced interleukin-6 and C-reactive protein. Tartrate-resistant acid phosphatase 5a remained unaffected by exercise training, consistent with our hypothesis that it is associated with increased adipose tissue in obese individuals.

Aerobic exercise in obese diabetic patients with chronic kidney disease: a randomized and controlled pilot study

Background

Patients with obesity, diabetes, and chronic kidney disease (CKD) are generally physically inactive, have a high mortality rate, and may benefit from an exercise program.

Methods

We performed a 24-week randomized controlled feasibility study comparing aerobic exercise plus optimal medical management to medical management alone in patients with type 2 diabetes, obesity (body mass index [BMI] > 30 kg/m²), and stage 2-4 CKD (estimated glomerular filtration rate [eGFR] 15-90 mL/min/1.73 m² with persistent proteinuria). Subjects randomized to exercise underwent thrice weekly aerobic training for 6 followed by 18 weeks of supervised home exercise. The primary outcome variable was change in proteinuria.

Results

Seven subjects randomized to exercise and 4 control subjects completed the study. Exercise training resulted in an increase in exercise duration during treadmill testing, which was accompanied by slight but insignificant decreases in resting systolic blood pressure and 24-hour proteinuria. Exercise did not alter GFR, hemoglobin, glycated hemoglobin, serum lipids, or C-reactive protein (CRP). Caloric intake and body weight and composition also did not change with exercise training.

Conclusion

Exercise training in obese diabetic patients with CKD is feasible and may have clinical benefits. A large-scale randomized controlled trial to determine the effects of exercise on renal functions, cardiovascular fitness, inflammation, and oxidative stress in diabetic patients with CKD is planned.

Clinical management of type 2 diabetes in indigenous youth

Youth-onset type 2 diabetes is a serious public health problem for Indigenous people throughout the world. This article reviews the epidemiology, disease burden, treatment, and challenges in achieving successful clinical management of this disorder in Indigenous youth. Screening criteria and the complications and comorbidities of type 2 diabetes are also reviewed.