Youth-Onset Type 2 Diabetes Consensus Report: Current Status, Challenges, and Priorities

The Characteristics Of Abdominal Fat Distribution In Japanese Adolescents With Type 2 Diabetes Mellitus

PURPOSE

The aim was to investigate the characteristics of abdominal fat distribution in Japanese adolescents with type 2 diabetes mellitus.

PATIENTS AND METHODS

Eighty-six Japanese adolescents with simple obesity or type 2 diabetes mellitus treated between 2002 and 2018 were included. The subjects were classified into the simple obesity group (SO group, n=38) and type 2 diabetes mellitus group (DM group, n=23) by matching average age and gender ratio. The metabolic parameters VFA, SFA, and V/S ratio were compared between the 2 groups. Multivariate logistic regression analysis was performed to identify clinical factors associated with type 2 diabetes mellitus. Linear regression analysis was performed between hemoglobin A1c (HbA1c) and visceral fat area (VFA), subcutaneous fat area (SFA), or VFA-to-SFA ratio (V/S ratio) among all enrolled subjects. Finally, correlation analyses were performed to determine the relationships between VFA, SFA, and V/S ratio and metabolic parameters of the DM group. For the metabolic parameters, serum lipids, alanine aminotransferase (ALT), and HbA1c were measured without fasting. The VFA and SFA at umbilical level were investigated using computed tomography.

RESULTS

VFA and V/S ratio in DM group were higher than those in SO group (p=0.04 and p<0.01, respectively). SFA in DM group was lower than that in SO group (p<0.01). VFA and SFA, and non-high density lipoprotein (HDL) cholesterol were identified as being independently associated with type 2 diabetes mellitus (odds ratio, 1.05, 0.98, and 1.04, respectively, p<0.05). HbA1c was correlated with VFA and V/S ratio (p<0.01). In DM group, VFA and SFA were positively correlated with systolic blood pressure (p<0.01), ALT (p<0.05), total cholesterol (p<0.05), and non-HDL cholesterol (p<0.01); however, V/S ratio was not correlated.

CONCLUSION

Abdominal fat distribution in Japanese adolescents with type 2 diabetes mellitus was different from those with simple obesity and might associate with glucose and lipid metabolism.

Incidence of Type 2 Diabetes in Kuwaiti Children and Adolescents: Results From the Childhood-Onset Diabetes Electronic Registry (CODeR)

Background: Type 2 Diabetes (T2D) in children and adolescents has become an important public health concern due to the increase in childhood obesity worldwide. The urgency to address T2D is evident as children and adolescents are at a higher risk of complications due to prolonged disease duration. We aimed to estimate the incidence rate (IR) of T2D in Kuwaiti children and adolescents aged 14 years and younger between 2011 and 2013 and to describe their clinical characteristics at the time of diagnosis. Material and Methods: All newly diagnosed patients were registered through the Childhood-Onset Diabetes electronic Registry implemented in Kuwait. Cases who met the 2018 ISPAD guidelines for diagnosis of T2D were included. Results: A total of 32 patients were included, equally distributed gender-wise, with a mean age 12.2 years (±1.7 SD), lower for females than males (11.5 vs. 12.2, p < 0.025). Data ascertainment was 94.1% (95%CI; 91.6-96.6%). Overall IR was 2.56 (95% CI; 1.78-3.56) per 100,000 Kuwaiti children and adolescents per year. Most of the patients (n = 30; 93.8%) presented with T2D between the ages 10-14 years, with age-specific IR of 8.0 (95%CI; 5.5-11.3). No statistically significant difference between males and females with regards to BMI z scores or HbA1C at diagnosis. Conclusion: The true incidence of T2D in Kuwaiti children and adolescents is expected to be considerably higher as we have reported only symptomatic cases. Future research should focus on screening children and adolescents at risk to enable accurate estimates. More efforts are needed to better understand the clinical course of T2D early in life to improve management, prevent complications and improve quality of life.

Variation in incidence of type 2 diabetes mellitus: time series of Mexican adolescents

PURPOSE

To study temporal changes in the cumulative incidence (CI) of type 2 diabetes mellitus during early and late adolescence from 2003 to 2013.

METHODS

This was an ecologic, analytical study of trends over time. Data were weekly reports of new cases (General Directorate of Epidemiology). Specific CI was calculated and standardized by age using the direct method (WHO). Autoregressive Integrated Moving Average models offering a better fit to the observed series were calculated and controlled by intentional screening. Structural break point analysis was performed.

RESULTS

The CI was lower in younger adolescents than in older adolescents. In early adolescence, the incidence was similar in both sexes and stable over time [Autoregressive Integrated Moving Average female: (2,0,2)(0,0,0), male: (1,0,1)(0,0,0); P < .001], whereas in late adolescence, the female incidence was higher than the male incidence and showed a linear increase [female: (1,1,2)(1,0,0), male: (1,0,1)(0,0,0); P < .001)]. The female series showed two structural break points, in 2010 and 2012. The male early adolescent series showed one break point in 2011.

CONCLUSIONS

Although there was an increase in the CI of type 2 diabetes mellitus during the study period, only the female late adolescence series showed an epidemiologically significant linear trend. There was also a brief, limited rise between 2010 and 2012 that affected all adolescents. This suggests that the disease may be triggered by specific events.

Effects of a Community-Based Diabetes Prevention Program for Latino Youth with Obesity: A Randomized Controlled Trial

OBJECTIVE

This study examined the short- and long-term effects of a community-based lifestyle intervention among Latino youth with obesity.

METHODS

Latino adolescents (14-16 years old) were randomized to a 3-month lifestyle intervention (n = 67) or comparison control (n = 69) and followed for 12 months. The intervention included weekly nutrition and health classes delivered to groups of families and exercise sessions (3 days/week) delivered to groups of adolescents. Comparison youth received laboratory results and general health information. Primary outcomes included insulin sensitivity and weight-specific quality of life (QoL) with secondary outcomes of BMI percentile (BMI%), waist circumference, and percent body fat.

RESULTS

At 3 months, youth in the intervention group exhibited significant increases in insulin sensitivity (P < 0.05) and weight-specific QoL (P < 0.001), as well as reductions in BMI%, waist circumference, and percent body fat compared with controls. Increases in weight-specific QoL and reductions in BMI% and percent body fat remained significant at 12 months (P < 0.001), while changes in insulin sensitivity did not. In a subsample of youth with prediabetes at baseline, insulin sensitivity (P = 0.01), weight-specific QoL (P < 0.001), and BMI% (P < 0.001) significantly improved at 3 months.

CONCLUSIONS

Lifestyle intervention can improve cardiometabolic and psychosocial health in a vulnerable population of Latino adolescents at high risk for developing type 2 diabetes.

Eligibility for clinical trials is limited for youth with type 2 diabetes: Insights from the Pediatric Diabetes Consortium T2D Clinic Registry

BACKGROUND/OBJECTIVE

Restrictive eligibility criteria have hampered enrollment into trials for new drugs for youth with type 2 diabetes (T2D). We utilized Pediatric Diabetes Consortium (PDC) T2D Registry enrollment data to estimate the percentage of patients who would be excluded from current T2D trials based on out-of-range HbA1c levels. We also examined whether well-controlled patients could be included because baseline HbA1c would rise during a 6 to 12-month study if assigned to control group.

METHODS

Clinical characteristics and HbA1c levels were collected from 956 T2D patients aged 10 to <18 years upon Registry enrollment. HbA1c levels were also analyzed in 6-month intervals during the first 30 months of T2D duration.

RESULTS

There was an approximately 2:1 ratio of females to males; the majority were obese and from economically disadvantaged minority families. On enrollment in the Registry, 53% of patients would be excluded from current trials because HbA1c levels were either <6.5% (<48 mmol/mol) (37%) or >10.5% (>91 mmol/mol) (16%). Furthermore, in patients with HbA1c levels <6.5% (<48 mmol/mol) and T2D duration between 6 and 30 months, mean HbA1c levels increased by 0.6% (6 mmol/mol) and 0.9% (10 mmol/mol) over the subsequent 6 and 12 months, respectively.

CONCLUSIONS

Eligibility criteria for current clinical trials still exclude a large proportion of pediatric T2D patients because of HbA1c levels. Including patients with HbA1c <6.5% (<48 mmol/mol) would enhance recruitment and allow comparisons of the investigational treatment with placebo-assigned subjects in whom HbA1c levels would on average increase during the 6 to 12 months of the trial.

Treatment adherence and BMI reduction are key predictors of HbA1c 1 year after diagnosis of childhood type 2 diabetes in the United Kingdom

BACKGROUND/OBJECTIVE

Type 2 Diabetes (T2DM) is increasing in childhood especially among females and South-Asians. Our objective was to report outcomes from a national cohort of children and adolescents with T2DM 1 year following diagnosis.

METHODS

Clinician reported, 1-year follow-up of a cohort of children (<17 years) diagnosed with T2DM reported through the British Paediatric Surveillance Unit (BPSU) (April 2015-April 2016).

RESULTS

One hundred (94%) of 106 baseline cases were available for review. Of these, five were lost to follow up and one had a revised diagnosis. Mean age at follow up was 15.3 years. Median BMI standard deviation scores (SDS) was 2.81 with a decrease of 0.13 SDS over a year. HbA1c <48 mmol/mol (UK target) was achieved in 38.8%. logHbA1c was predicted by clinician reported compliance and attendance concerns (β = 0.12, P = <0.0001) and change in body mass index (BMI) SDS at 1-year (β = 0.13, P=0.007). In over 50%, clinicians reported issues with compliance and attendance. Mean clinic attendance was 75%. Metformin was the most frequently used treatment at baseline (77%) and follow-up (87%). Microalbuminuria prevalence at 1-year was 16.4% compared to 4.2% at baseline and was associated with a higher HbA1c compared to those without microalbuminuria (60 vs 49 mmol/mol, P = 0.03).

CONCLUSIONS

Adherence to treatment and a reduction in BMI appear key to better outcomes a year after T2DM diagnosis. Retention and clinic attendance are concerning. The prevalence of microalbuminuria has increased 4-fold in the year following diagnosis and was associated with higher HbA1c.

Design of a randomized controlled trial to decrease depression and improve insulin sensitivity in adolescents: Mood and INsulin sensitivity to prevent Diabetes (MIND)

BACKGROUND

Depressive symptoms often manifest in adolescence and predict worsening insulin sensitivity, a key precursor in the path to β-cell failure and type 2 diabetes (T2D).

OBJECTIVE

To assess the efficacy of a six-week cognitive-behavioral group versus six-week health education group for improving insulin sensitivity and preserving β-cell function in adolescent girls at-risk for T2D with depressive symptoms and evaluate mechanisms underlying the association between depression and insulin dynamics.

DESIGN

Randomized controlled trial of N = 150 12-17-year-old girls with overweight/obesity (body mass index [BMI; kg/m2] ≥85th percentile), elevated depressive symptoms (Center for Epidemiologic Studies-Depression Scale [CES-D] total score > 20), and diabetes family history.

METHODS

Girls at-risk for T2D with elevated depressive symptoms are recruited from the Denver-metropolitan area and randomized to participate in one of two six-week interventions. The cognitive-behavioral group is a depression prevention program involving psycho-education, restructuring negative thoughts, and behavioral activation. The health education group is a didactic control that provides knowledge about healthy living. Participants are assessed at baseline, immediate post-intervention, and one-year follow-up. Primary outcomes are insulin sensitivity and β-cell function from oral glucose tolerance tests. Secondary outcomes are disinhibited eating, physical activity, sleep, and cortisol.

SUMMARY

Results from this adequately powered randomized controlled trial will determine whether decreasing depressive symptoms with a behavioral health program preventatively alters insulin sensitivity and β-cell function trajectories in adolescents at-risk for T2D. Results from the MIND Project will add to knowledge of the contribution of depressive symptoms to T2D risk.

Adolescent type 2 diabetes: Comparing the Pediatric Diabetes Consortium and Germany/Austria/Luxemburg Pediatric Diabetes Prospective registries

OBJECTIVE

To examine and compare the clinical characteristics and treatment of youth with type 2 diabetes (T2D) in two registries: one in Europe and one in the United States.

METHODS

Youth with onset of T2D at 10 to 18 years of age with current age <20 years and an office visit after diabetes duration >1 year were identified in the European (Prospective Diabetes Follow-up, DPV) and the United States (Pediatric Diabetes Consortium, PDC) databases. Demographic, physical and clinical characteristics and treatment at diagnosis as well as physical characteristics, treatment, laboratory data, and diabetes adverse events at most recent visit were analyzed from both registries.

RESULTS

At diagnosis, the majority were female and obese; 70% of DPV vs 34% of PDC youth were diagnosed by targeted diabetes testing. PDC youth were younger, 12 vs 13 years (P < 0.001), had a greater body mass index-SDS, 3.07 vs 2.74 (P < 0.001), a higher hemoglobin A1c (HbA1c), 9.9% vs 7.1% (P < 0.001), were more likely to present in DKA, 7.5% vs 1.3% (P < 0.001) and more likely to be treated with insulin, 62% vs 32% (P < 0.001); insulin treatment difference was not significant when adjusted for HbA1c. At follow-up, DPV youth had shorter diabetes duration, 2.1 vs 3.2 years (P < 0.001), lower HbA1c, 6.5% vs 7.8% (P < 0.001), were less likely to be treated with insulin, 36% vs 56%, (P < 0.001), and were more likely to have dyslipidemia and hypertension than PDC youth. PDC youth had a higher rate of microalbuminuria.

CONCLUSIONS

Both DPV and PDC youth have multiple risks for diabetes complications. Understanding reasons for persistently higher HbA1c in PDC youth requires further study.

Percentile curves for cardiometabolic disease markers in Canadian children and youth: a cross-sectional study

Background

The objective of this study to develop percentile curves for cardiometabolic disease markers in a population-based sample of Canadian children and youth.

Methods

The analysis used data from 6116 children and adolescents between 6 and 19 years of age who participated in the Canadian Health Measures Survey cycles 1 (2007/2009), 2 (2009/2011), and 3 (2012/2013). Total cholesterol, HDL cholesterol, and hemoglobin A1c levels as well as fasting levels of triglycerides, insulin, and homeostasis model assessment insulin resistance were measured using standardized procedures. Age- and sex-specific centiles for all markers were calculated using Cole and Green’s LMS method.

Results

With the exception of hemoglobin A1c, all markers showed age- and sex-related differences during childhood and adolescence.

Conclusions

We have developed centile curves for cardiometabolic disease markers in Canadian children and adolescents and demonstrated age and sex differences that should be considered when evaluating these markers in this age group.

Changes in diabetes medication regimens and glycemic control in adolescents and young adults with youth-onset type 2 diabetes: The SEARCH for diabetes in youth study

OBJECTIVE

The aim of this study was to describe recent medication patterns and changes in medication patterns and glycemic control in adolescents and young adults with incident type 2 diabetes (T2D).

METHODS

Using data from the SEARCH for Diabetes in Youth Study, we conducted a cross-sectional analysis of treatments for adolescents and young adults with incident T2D in 2 periods (2002-2005 vs 2008/2012), and a longitudinal analysis of medications and glycemic control for a subset with baseline and follow-up visits. Comparisons were performed using χ2 , Fisher's exact, or ANOVA.

RESULTS

Of 646 individuals in the cross-sectional analysis, a majority in each period received metformin (64.9% vs 70.4%) and/or insulin (38.1% vs 38.4%), while fewer used sulfonylureas (5.6% vs 3.6%) with non-significant changes over time. There was a significant reduction in thiazolidinedione use (5.0% vs 2.0%, P < .05). In the longitudinal analysis, 322 participants were followed for 7 years, on average. Baseline metformin users had a lower A1C (6.4% [46.7 mmol/mol]) compared to insulin (8.4% [68.2 mmol/mol], P < .001) or insulin plus any oral diabetes medication (ODM) users (7.7% [60.4 mmol/mol], P < .001). Among baseline metformin users (n = 138), 29.7% reported metformin at follow-up, with the remainder adding (19.6%) or switching to insulin (8.0%), ODM (15.9%), or lifestyle only (26.8%). Of those receiving insulin (±ODM) (n = 129), 76% reported insulin use at follow-up. Overall, 35% were at A1C goal (<7.0%, 53 mmol/mol) at follow-up.

CONCLUSIONS

Youth-onset T2D is still largely being treated with metformin and/or insulin. The majority treated were not at American Diabetes Association (ADA)-recommended goal 7 years after diagnosis.

The impact of extremes of maternal age on maternal and neonatal pregnancy outcomes in women with pregestational diabetes mellitus

Background:. Diabetes mellitus (DM) during pregnancy increases the risk for many complications such as preeclampsia and cesarean section. Teen (age <20) and advanced maternal age (AMA, age ≥35) pregnancies are both at increased risk for maternal and neonatal morbidity and mortality. Understanding the risks and complications unique to teen and AMA women with pregestational DM is imperative to providing care and improving outcomes.Objective:. This study sought to determine how maternal and neonatal outcomes are affected by pregestational DM in teen and AMA pregnancies.Study design:. This is a retrospective cohort study of 1.58 million pregnancies in California from 2005 through 2008s, of which 10,034 diabetic women with nonanomalous, singleton pregnancies were identified. Women with gestational DM were excluded. Maternal outcomes examined include preeclampsia, placental abruption, chorioamnionitis, preterm delivery, and cesarean section. Neonatal outcomes include size for gestational age, birth weight >4000 g, shoulder dystocia, brachial plexus injury, jaundice, and intrauterine fetal demise (IUFD). Multivariate regression analyses and chi-squared test were used for statistical comparisons and a p-value of less than .05 was used to indicate statistical significance.Results:. Compared to women of age 20-34 years with pregestational DM as the reference group, women <20 years old with DM had higher rates of preeclampsia (aOR 1.72; 95% CI 1.29-2.29; p-value < .001) and lower rates of cesarean delivery (aOR 0.63; 95% CI 0.47-0.85; p < .001). Neonates of teen mothers were more likely to be large for gestational age (LGA; > 90%ile; aOR 1.60; 95% CI 1.14-2.23; p = .006), whereas neonates in the maternal age category of 35-39 years had lower rates of LGA >90%ile (aOR 0.81; 95% CI 0.70-0.92; p = .001). Odds of IUFD were greatest in women age 35-39 years old (aOR 1.73; 95% CI 1.05-2.85; p = .031). Analysis examining women >40 years old showed no statistically significant difference in outcomes.Conclusion: Pregnancy outcomes in women with pregestational diabetes differ depending on maternal age category. Teens are at higher risk for preeclampsia and LGA neonates, but at lower risk for cesarean. Women aged 35-39 years are at higher risk for cesarean delivery, are less likely to have LGA neonates, and more likely to experience IUFD. Understanding the etiologies behind these differences may lead to improvements in these clinical outcomes.

Long term (>1 year) postpartum glucose tolerance status among Indian women with history of Gestational Diabetes Mellitus (GDM) diagnosed by IADPSG criteria

AIM

To determine prevalence of long term dysglycemia and its risk factors among women with history of GDM diagnosed using IADPSG criteria at a tertiary care hospital in North India.

METHODS

Women with GDM diagnosed between 2012 and 2016 were invited. Socio-demographic, anthropometric, medical data were collected and 75 gm OGTT with serum insulin estimation, HbA1c and fasting lipid profile were done at the hospital visit.

RESULTS

Women (N = 267) were tested at 32.5 (±4.6) years of age and at a median (q_25-q₇₅) of 20 (12-44) months following the index delivery. Dysglycemia was found in 57.7% by ADA criteria [Diabetes in 10.5% and prediabetes in 47.2%]. Risk factors for cardiovascular disease were significantly more prevalent among these women. On multivariable analysis, HOMA-IR correlated positively, while insulinogenic index correlated negatively with postpartum dysglycemia.

CONCLUSION

This is possibly the first long term (>1 year) glucose tolerance outcome study in South Asian women with history of GDM diagnosed by IADPSG criteria, which demonstrates significantly elevated risk of postpartum dysglycemia. While the IADPSG criteria identify women with a lower future conversion to diabetes compared with previous criteria, prediabetes conversion remains high, thereby offering an opportunity to intervene early and prevent progression to future diabetes.

Risk of hypoglycemia in youth with type 2 diabetes on insulin

BACKGROUND

The objective of this study was to ascertain the risk of hypoglycemia among youth with type 2 diabetes (T2D) on insulin therapy.

METHODS

Twenty-two youth with T2D on insulin therapy (M=12, F=10, age=14.4±4.0 years) were enrolled from a single pediatric endocrine practice. They were followed-up for 3 months with weekly phone calls and monthly in-person visits to review blood glucose logs and document any signs or symptoms of hypoglycemia (defined as finger stick glucose of ≤70 mg/dL). Episodes of hypoglycemia were categorized into five categories: severe, documented symptomatic, asymptomatic, probable symptomatic and relative hypoglycemia. In addition to examining the risk of hypoglycemia, the degree to which hypoglycemia was associated with patient demographics (e.g. age, gender and body mass index [BMI]) or clinical factors (i.e. duration of diabetes, duration of insulin treatment, glycemic control or insulin dose and regimen) was determined.

RESULTS

Nine hypoglycemic events occurred during the study period in five patients with an incidence rate of nine events per 5.3 patient-years. Of the hypoglycemic events, five were symptomatic and four were asymptomatic. No severe hypoglycemic events occurred. Hypoglycemia was not associated with age, ethnicity, duration of insulin treatment, insulin dose or initial hemoglobin (HbA1c). However, a significant difference in BMI was noted, with T2D youth who experienced hypoglycemia having a lower BMI than those who did not experience hypoglycemia.

CONCLUSIONS

The results of this study suggest that the risk of hypoglycemia in youth with T2D on insulin therapy is low.

Advances in the Genetics of Youth-Onset Type 2 Diabetes

PURPOSE OF REVIEW

To provide an update on knowledge the role of genetics in youth-onset type 2 diabetes (T2D).

RECENT FINDINGS

The prevalence in youth of T2D, once thought to be exclusively a disease of adults, has increased by over 35% since 2001. Youth with T2D tend to have higher rates of complications, more aggressive disease, with more rapid loss of beta-cell function and a less favorable response to treatment than adults. Obesity is the most important risk factor for T2D, and the rise in childhood overweight and obesity appears responsible for the dramatic increase in T2D in youth. However, some obese children do not develop T2D, consistent with genetic differences in susceptibility to the disease in the setting of obesity and insulin resistance, currently far less well characterized in youth than in adults. Recent studies have begun to show associations of several established adult T2D genetic risk variants with youth-onset T2D and related glycemic quantitative traits, including the strongest known cross-population T2D genetic contributor TCF7L2. Maturity-onset diabetes of the young (MODY), a diabetes subtype distinct from type 1 diabetes (T1D) and T2D, is now known to result from a highly penetrant gene mutation in one of several genes. MODY has been shown to account for or contribute to at least 4.5% of clinically diagnosed T2D, even among those who are overweight or obese, impacting treatment decisions. The recently formed ProDiGY (Progress in Diabetes Genetics in Youth) Consortium is using genome-wide association studies and whole exome sequencing to understand the genetic architecture of T2D in youth, including how it differs from that of adults. The limited amount of research conducted to date on the genetics of youth-onset T2D, which tends to be a more aggressive disease than adult T2D, suggests some overlap with genes involved in adult T2D and a sizeable influence of highly penetrant monogenic diabetes variants. The ProDiGY Consortium is expected to provide a more comprehensive understanding of youth T2D genetics.

The Distribution of Different Types of Diabetes in Childhood: A Single Center Experience

OBJECTIVE

Type 1 diabetes (T1D) is the most common cause of diabetes in childhood but type 2 diabetes (T2D) and maturity onset diabetes of the young (MODY) are emerging as noteworthy causes of diabetes at young ages. The aim is to determine the distribution, trends and clinical features of the different types of diabetes in childhood in one tertiary center.

METHODS

The records of children and adolescents aged 0-18 years who were diagnosed as “diabetes/persistent hyperglycemia” between January 1999 and December 2016, were reviewed. Clinical and laboratory characteristics of the patients at diagnosis and type of diabetes were recorded.

RESULTS

The mean ± standard deviation age of 835 patients (48.7% females) at diagnosis was 8.8±4.4 years. Eighty-four percent of the patients were diagnosed as T1D, 5.7% as T2D, 5.3% as clinical MODY and 5% as being cases of other types of diabetes. The frequency of diabetic ketoacidosis (DKA) and severe DKA in T1D were 48.4% and 11.6%, respectively. Fourteen patients (29.2%) with T2D presented with ketosis and two of them (4.2%) had DKA at diagnosis. Antibody positivity was 83.1% in T1D and 14.8% in T2D. A statistically significant increase in the frequency of T2D has clearly been demonstrated in recent years with a frequency of 1.9%, 2.4% and 7.9% in 1999-2004, 2005-2010 and 2011-2016, respectively (p<0.001). In MODY, genetic analysis was performed in 26 (59%) patients and HNF1A and GCK gene mutations were detected in 3 (11.5%) and 14 (53.8%) patients, respectively.

CONCLUSION

Although the most frequent cause of DM is T1D in childhood, a trend towards increase in the frequency of T2D in recent years is notable in our population.

A tailored intervention to promote uptake of retinal screening among young adults with type 2 diabetes - an intervention mapping approach

BACKGROUND

Young adults (18-39 years) with type 2 diabetes are at risk of early development and rapid progression of diabetic retinopathy, a leading cause of vision loss and blindness in working-age adults. Retinal screening is key to the early detection of diabetic retinopathy, with risk of vision loss significantly reduced by timely treatment thereafter. Despite this, retinal screening rates are low among this at-risk group. The objective of this study was to develop a theoretically-grounded, evidence-based retinal screening promotion leaflet, tailored to young adults with type 2 diabetes.

METHODS

Utilising the six steps of Intervention Mapping, our multidisciplinary planning team conducted a mixed-methods needs assessment (Step 1); identified modifiable behavioural determinants of screening behaviour and constructed a matrix of change objectives (Step 2); designed, reviewed and debriefed leaflet content with stakeholders (Steps 3 and 4); and developed program implementation and evaluation plans (Steps 5 and 6).

RESULTS

Step 1 included in-depth qualitative interviews (N = 10) and an online survey that recruited a nationally-representative sample (N = 227), both informed by literature review. The needs assessment highlighted the crucial roles of knowledge (about diabetic retinopathy and screening), perception of personal risk, awareness of the approval of significant others and engagement with healthcare team, on retinal screening intentions and uptake. In Step 2, we selected five modifiable behavioural determinants to be targeted: knowledge, attitudes, normative beliefs, intention, and behavioural skills. In Steps 3 and 4, the "Who is looking after your eyes?" leaflet was developed, containing persuasive messages targeting each determinant and utilising engaging, cohort-appropriate imagery. In Steps 5 and 6, we planned Statewide implementation and designed a randomised controlled trial to evaluate the leaflet.

CONCLUSIONS

This research provides an example of a systematic, evidence-based approach to the development of a simple health intervention designed to promote uptake of screening in accordance with national guidelines. The methods and findings illustrate how Intervention Mapping can be employed to develop tailored retinal screening promotion materials for specific priority populations. This paper has implications for future program planners and is intended to assist those wishing to use Intervention Mapping to create similar theoretically-driven, tailored resources.

Infant-juvenile type 2 diabetes

In recent years, we have witnessed an increase in the number of cases of type 2 diabetes mellitus (DM2) in children and adolescents, which has paralleled the increase in the worldwide prevalence of obesity. Although screening the general population does not appear to be cost-effective, special attention should be paid to children with excess weight, obesity or other factors that predispose them to a state of insulin resistance. When faced with the diagnosis of childhood DM2, the presence of comorbidities (such as hypertension, dyslipidemia and microalbuminuria) should be assessed, and appropriate treatment and follow-up should be administered to prevent the onset of complications, given that the DM2 in this population group will last longer than that started in adulthood.

Cardiovascular risk factors in adolescents with prediabetes

AIMS

Adolescents with Type 2 diabetes are more likely to have cardiovascular disease (CVD) risk factors but there are few data available among adolescents with prediabetes. We characterized CVD risk factors among adolescents with prediabetes in the USA and compared levels of those risk factors with adolescents with normal glucose.

METHODS

The 2005-2014 National Health and Nutrition Examination Survey, a nationally representative cross-sectional survey, included 2843 adolescents aged 12-19 years after excluding those with diabetes. Prediabetes was based on an HbA1c , a fasting plasma glucose or a 2-h plasma glucose. We determined cardiometabolic risk factors in adolescents using age-appropriate cut-off points. We calculated odds ratios (OR) and 95% confidence intervals (CI) of these outcomes associated with having prediabetes compared with normal glucose levels.

RESULTS

The weighted prevalence of prediabetes was 17.4%. After adjustment, prediabetes (vs. normal glucose) was associated with obesity (OR 1.86, 95% CI 1.35-2.55), low HDL-cholesterol (OR 1.62, 95% CI 1.08-2.44), high triglycerides (OR 1.61, 95% CI 1.12-2.30) and elevated liver transaminase (OR 2.09, 95% CI 1.19-3.67), but not with hypertension (OR 1.77, 95% CI 0.88-3.54), elevated total cholesterol (OR 1.30, 95% CI 0.82-2.06), elevated LDL-cholesterol (OR 1.59, 95% CI 0.88-2.88) or albuminuria (OR 1.24, 95% CI 0.76-2.02).

CONCLUSIONS

US adolescents with prediabetes are more likely to have obesity, low HDL-cholesterol, high triglycerides and elevated liver transaminase than adolescents with normal glucose. Addressing prediabetes in youth is important for the prevention of Type 2 diabetes and long-term comorbidity.

Determinants of Readiness for Adopting Healthy Lifestyle Behaviors Among Indigenous Adolescents with Type 2 Diabetes in Manitoba, Canada: A Cross-Sectional Study

OBJECTIVE

The aim of this study was to determine whether the readiness for adopting healthy lifestyle behaviors was associated with mental health and comorbid conditions in youth with T2D.

METHODS

A cross-sectional comparison of various measures of mental health (distress, stress, resilience) and comorbid conditions (glycated hemoglobin, adiposity, hypertension) was conducted within a cohort of indigenous youth with T2D living in Canada, stratified according to their readiness to adopt healthy lifestyle behaviors based on Prochaska's transtheoretical model.

RESULTS

Within the entire cohort (n = 162), only 14% were considered ready to adopt all healthy lifestyle behaviors. The readiness to adopt all lifestyle behaviors was associated with higher positive mental health (47 vs. 39 units; P < 0.05) and sense of mastery (40 vs. 37 units; P < 0.05), lower perceived stress (27 vs. 29 units; P < 0.05) and distress (8 vs. 10 units; P < 0.05), and better glycemic control (HbA1c: 8.4 ± 2.6% vs. 9.7 ± 2.8%; P < 0.05) compared with youth who were not ready to adopt all lifestyle behaviors.

CONCLUSIONS

The readiness for adopting healthy lifestyle behaviors is low among adolescents with T2D. Being ready to adopt healthy lifestyle behaviors is associated with better mental health and glycemic control.

Comparison of Surgical and Medical Therapy for Type 2 Diabetes in Severely Obese Adolescents

IMPORTANCE

Because of the substantial increase in the occurrence of type 2 diabetes in the pediatric population and the medical complications of this condition, therapies are urgently needed that will achieve better glycemic control than standard medical management.

OBJECTIVE

To compare glycemic control in cohorts of severely obese adolescents with type 2 diabetes undergoing medical and surgical interventions.

DESIGN, SETTING, AND PARTICIPANTS

A secondary analysis of data collected by the Teen-Longitudinal Assessment of Bariatric Surgery (Teen-LABS) and Treatment Options of Type 2 Diabetes in Adolescents and Youth (TODAY) consortia was performed. Teen-LABS enrolled 242 adolescents (≤19 years of age) from March 1, 2007, through December 31, 2011. TODAY randomized 699 participants (aged 10-17 years) from July 24, 2004, through February 25, 2009. Data analysis was performed from July 6, 2015, to June 24, 2017. Anthropometric, clinical, and laboratory data from adolescents with severe obesity and type 2 diabetes who underwent treatment with metabolic or bariatric surgery in the Teen-LABS study or medical therapy in the TODAY study were compared.

INTERVENTIONS

Teen-LABS participants underwent a primary bariatric surgical procedure; TODAY participants were randomized to receive metformin therapy alone or in combination with rosiglitazone or an intensive lifestyle intervention; insulin therapy was given in cases of progression of disease.

MAIN OUTCOMES AND MEASURES

Glycemic control, body mass index, prevalence of elevated blood pressure, dyslipidemia, abnormal kidney function, and clinical adverse events were measured.

RESULTS

Data from 30 participants from Teen-LABS (mean [SD] age at baseline, 16.9 [1.3] years; 21 [70%] female; 18 [66%] white) and 63 from TODAY (mean [SD] age at baseline, 15.3 [1.3] years; 28 [44%] female; 45 [71%] white) were analyzed. During 2 years, mean hemoglobin A1c concentration decreased from 6.8% (95% CI, 6.4%-7.3%) to 5.5% (95% CI, 4.7% -6.3%) in Teen-LABS and increased from 6.4% (95% CI, 6.1%-6.7%) to 7.8% (95% CI, 7.2%-8.3%) in TODAY. Compared with baseline, the body mass index decreased by 29% (95% CI, 24%-34%) in Teen-LABS and increased by 3.7% (95% CI, 0.8%-6.7%) in TODAY. Twenty-three percent of Teen-LABS participants required a subsequent operation during the 2-year follow-up.

CONCLUSIONS AND RELEVANCE

Compared with medical therapy, surgical treatment of severely obese adolescents with type 2 diabetes was associated with better glycemic control, reduced weight, and improvement of other comorbidities. These data support the need for a well-designed, prospective controlled study to define the role of surgery for adolescents with type 2 diabetes, including health and surgical outcomes.

Barriers and strategies for oral medication adherence among children and adolescents with Type 2 diabetes

AIMS

Examine barriers for taking glucose-lowering oral medications, associated baseline characteristics, strategies used, and the adherence impact in the Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY) study.

METHODS

We studied youth prescribed oral diabetes medications over two years (N = 611, 583, and 525 at 6, 12, and 24 months). Clinicians documented barriers (e.g. forgetting, routines, other concerns) in the subsample that reported missed doses (N = 423 [69.2%], 422 [72.4%], and 414 [78.9%] at 6, 12, and 24 months, respectively). Adherence strategies were also assessed (e.g. family, schedule, reminder device) using standard questions. Logistic regression was used to analyze associations with medication adherence.

RESULTS

Those missing doses were not different from the total sample (61.5% female, 13.9 ± 2.0 years, >80% racial/ethnic minorities). No baseline demographic or clinical predictors of barriers to medication adherence were identified. Among those for whom barriers were assessed, "forgetting" with no reason named (39.3%) and disruptions to mealtime, sleep, and schedule (21.9%) accounted for the largest proportion of responses. Family support was the primary adherence strategy identified by most youth (≥50%), followed by pairing the medication regimen with daily routines (>40%); the latter strategy was associated with significantly higher adherence rates (p = 0.009).

CONCLUSIONS

Family supported medication adherence was common in this mid-adolescent cohort, but self-management strategies were also in evidence. Findings are similar to those reported among youth with other serious chronic diseases. Prospective studies of multi-component family support and self-management interventions for improving medication adherence are warranted.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00081328.

Transfer from paediatric to adult care for young adults with Type 2 diabetes: the SEARCH for Diabetes in Youth Study

AIM

To describe factors associated with transfer from paediatric to adult care and poor glycaemic control among young adults with Type 2 diabetes, using the SEARCH for Diabetes in Youth study.

METHODS

Young adults with Type 2 diabetes were included if they had a baseline SEARCH visit while in paediatric care at < 18 years and ≥ 1 follow-up SEARCH visit thereafter at 18-25 years. At each visit, HbA1c , BMI, self-reported demographic and healthcare provider data were collected. Associations of demographic factors with transfer of care and poor glycaemic control (HbA1c ≥ 75 mmol/mol; 9.0%) were explored with multivariable logistic regression.

RESULTS

182 young adults with Type 2 diabetes (36% male, 75% minority, 87% with obesity) were included. Most (n = 102, 56%) reported transfer to adult care at follow-up; a substantial proportion (n = 28, 15%) reported no care and 29% did not transfer. Duration of diabetes [odds ratio (OR) 1.4, 95% confidence interval (95% CI) 1.1, 1.8] and age at diagnosis (OR 1.8, 95% CI 1.4, 2.4) predicted leaving paediatric care. Transfer to adult or no care was associated with a higher likelihood of poor glycaemic control at follow-up (adult: OR 4.5, 95% CI 1.8, 11.2; none: OR 4.6, 95% CI 1.4, 14.6), independent of sex, age, race/ethnicity or baseline HbA1c level.

CONCLUSIONS

Young adults with Type 2 diabetes exhibit worsening glycaemic control and loss to follow-up during the transfer from paediatric to adult care. Our study highlights the need for development of tailored clinical programmes and healthcare system policies to support the growing population of young adults with youth-onset Type 2 diabetes.

Targeting postprandial glycaemia in children with diabetes: Opportunities and challenges

Postprandial glycaemia makes a substantial contribution to overall glycaemic control in diabetes, particularly in patients whose preprandial glycaemia is relatively well controlled and glycated haemoglobin (HbA1c) only modestly elevated. Our review addresses the determinants of postprandial glycaemia and how it may be targeted therapeutically in children with diabetes. Postprandial glycaemia is influenced by preprandial glycaemia, macronutrients and their absorption, insulin delivery and sensitivity, the action of the enteroendocrine system, and the rate of gastric emptying. Contemporary continuous glucose monitoring systems reveal patterns of post prandial glycaemia and allow management to be guided more precisely. Delays in blood glucose determination, insulin delivery and its absorption remain challenges in the rapidly evolving closed loop continuous subcutaneous insulin and glucagon delivery systems developed for children with type 1 diabetes. Augmentation of the incretin system through nutritional preloads or incretin mimetics targets postprandial glycaemia by slowing gastric emptying as well as insulinotropic and glucagonostatic effects. These treatments are of particular relevance to children with type 2 diabetes. Following the development of targeted therapies in adults, postprandial blood glucose control will now be increasingly targeted in the treatment of diabetes in children.

Renal Hyperfiltration in Adolescents with Type 2 Diabetes: Physiology, Sex Differences, and Implications for Diabetic Kidney Disease

PURPOSE OF REVIEW

Compared to adult-onset type 2 diabetes (T2D), youth with T2D have a more aggressive phenotype with greater insulin resistance (IR), more rapid β cell decline, and higher prevalence of diabetic kidney disease (DKD).

RECENT FINDINGS

Hyperfiltration is common in youth with T2D and predicts progressive DKD. Hyperfiltration is a consequence of early changes in intrarenal hemodynamic function, including increased renal plasma flow (RPF) and glomerular pressure. Girls with T2D are disproportionally affected by DKD, with a 3-fold greater risk of developing hyperfiltration over 5 years compared to boys. Despite the high prevalence and gravity of DKD in youth-onset T2D, widely effective therapeutic options are lacking. In this review, we focus on pathophysiology underlying early DKD in T2D and sex differences and summarize promising novel medical therapies and bariatric surgery.

Global aetiology and epidemiology of type 2 diabetes mellitus and its complications

Globally, the number of people with diabetes mellitus has quadrupled in the past three decades, and diabetes mellitus is the ninth major cause of death. About 1 in 11 adults worldwide now have diabetes mellitus, 90% of whom have type 2 diabetes mellitus (T2DM). Asia is a major area of the rapidly emerging T2DM global epidemic, with China and India the top two epicentres. Although genetic predisposition partly determines individual susceptibility to T2DM, an unhealthy diet and a sedentary lifestyle are important drivers of the current global epidemic; early developmental factors (such as intrauterine exposures) also have a role in susceptibility to T2DM later in life. Many cases of T2DM could be prevented with lifestyle changes, including maintaining a healthy body weight, consuming a healthy diet, staying physically active, not smoking and drinking alcohol in moderation. Most patients with T2DM have at least one complication, and cardiovascular complications are the leading cause of morbidity and mortality in these patients. This Review provides an updated view of the global epidemiology of T2DM, as well as dietary, lifestyle and other risk factors for T2DM and its complications.

A 26-week, randomized trial of insulin detemir versus NPH insulin in children and adolescents with type 2 diabetes (iDEAt2)

There are limited studies evaluating the safety and efficacy of treatments in young people with type 2 diabetes (T2D). This study compared the efficacy and safety of insulin detemir versus neutral protamine Hagedorn (NPH) insulin, both in combination with metformin and lifestyle intervention, in children and adolescents with T2D. This randomized, open-label, phase 3 trial recruited patients (n = 42) aged 10-17 years diagnosed with T2D already receiving metformin ± other oral antidiabetic drugs ± basal insulin. Patients were randomized (1:1) to receive either insulin detemir or NPH insulin, both with the maximum tolerated dose of metformin, and lifestyle intervention, over 26 weeks. Enrollment terminated prematurely after 17 months due to a very slow recruitment rate (12% of the target met). After 26 weeks, the observed mean HbA_1c value had decreased by 0.61% points in the insulin detemir group vs. 0.84% points in the NPH insulin group. The rate of symptomatic blood glucose-confirmed hypoglycemic episodes was 0.4 episodes/patient-year of exposure (PYE) for insulin detemir vs. 1.1 episodes/PYE for NPH insulin.

CONCLUSION

No safety issues were revealed with either basal insulin. Due to the low number of patients recruited, no efficacy conclusions could be drawn. ClinicalTrials.gov identifier: NCT02131272. What is known: • There is a growing worldwide epidemic of type 2 diabetes in children and adolescents. • There is a lack of research and limited treatment options currently available in this population. What is new: • No safety issues with insulin detemir or neutral protamine Hagedorn insulin in children and adolescents with type 2 diabetes were observed. • Improving clinical trial recruitment, along with providing early, efficacious, and safe treatment options, in this population is critical.

Type 2 diabetes in adolescents and young adults

The prevalence of type 2 diabetes in adolescents and young adults is dramatically increasing. Similar to older-onset type 2 diabetes, the major predisposing risk factors are obesity, family history, and sedentary lifestyle. Onset of diabetes at a younger age (defined here as up to age 40 years) is associated with longer disease exposure and increased risk for chronic complications. Young-onset type 2 diabetes also affects more individuals of working age, accentuating the adverse societal effects of the disease. Furthermore, evidence is accumulating that young-onset type 2 diabetes has a more aggressive disease phenotype, leading to premature development of complications, with adverse effects on quality of life and unfavourable effects on long-term outcomes, raising the possibility of a future public health catastrophe. In this Review, we describe the epidemiology and existing knowledge regarding pathophysiology, risk factors, complications, and management of type 2 diabetes in adolescents and young adults.

12. Children and Adolescents: Standards of Medical Care in Diabetes-2018

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Characteristics of Obstructive Sleep Apnea Across the Spectrum of Glucose Tolerance in Obese Adolescents

BACKGROUND

It is not known if dysglycemia and sleep-disordered breathing are linked in adolescents, as in adults.

OBJECTIVE

To perform a pilot study evaluating measures of sleep-disordered breathing across the spectrum of glucose tolerance in obese adolescents. We hypothesized that dysglycemia would be associated with sleep-disordered breathing.

PARTICIPANTS/METHODS

This was a prospective, cross-sectional clinical pilot study that included 57 adolescents [body mass index (BMI) 38.9 ± 8.4 kg/m²] aged 12-18 years (14.5 ± 1.6) with normal glucose tolerance (NGT), or dysglycemia [impaired glucose tolerance (IGT) or type 2 diabetes (T2D)].

MEASURES

Anthropometrics, overnight polysomnogram, and oral glucose tolerance tests were performed. Participant characteristics and outcome measures were compared by glucose tolerance status. Correlational analyses were conducted to assess the associations between variables of interest.

RESULTS

Participants with dysglycemia (n = 21) were not different from those with NGT (n = 36) for BMI, waist circumference, body fat, or sleep characteristics. Nocturnal oxygen desaturation was associated with higher BMI (r = -0.334, p = 0.012). The apnea-hypopnea index (AHI) was not associated with physical and metabolic parameters. Although participants with dysglycemia tended to have higher AHIs (median 3.2, 2.2, and 1.6 events/h for T2D, IGT, and NGT, respectively), there was not a linear relationship between measures of glycemia and AHI.

CONCLUSION

Further study with a larger proportion of youth with prediabetes and T2D is necessary to determine whether evaluation for sleep-disordered breathing is uniformly warranted.

Enhancing pediatric clinical trial feasibility through the use of Bayesian statistics

BackgroundPediatric clinical trials commonly experience recruitment challenges including limited number of patients and investigators, inclusion/exclusion criteria that further reduce the patient pool, and a competitive research landscape created by pediatric regulatory commitments. To overcome these challenges, innovative approaches are needed.MethodsThis article explores the use of Bayesian statistics to improve pediatric trial feasibility, using pediatric Type-2 diabetes as an example. Data for six therapies approved for adults were used to perform simulations to determine the impact on pediatric trial size.ResultsWhen the number of adult patients contributing to the simulation was assumed to be the same as the number of patients to be enrolled in the pediatric trial, the pediatric trial size was reduced by 75-78% when compared with a frequentist statistical approach, but was associated with a 34-45% false-positive rate. In subsequent simulations, greater control was exerted over the false-positive rate by decreasing the contribution of the adult data. A 30-33% reduction in trial size was achieved when false-positives were held to less than 10%.ConclusionReducing the trial size through the use of Bayesian statistics would facilitate completion of pediatric trials, enabling drugs to be labeled appropriately for children.

Incorporation of suboptimal health status as a potential risk assessment for type II diabetes mellitus: a case-control study in a Ghanaian population

Due to a paradigm shift in lifestyles, there is growing concern that type 2 diabetes mellitus (T2DM) will reach epidemic proportions in Ghana. However, specific characteristics of the disease are under explored in this region. More challenging are those yet to be diagnosed or who complain of poor health in the absence of a diagnosed disease-suboptimal health status (SHS). We conducted a study to examine various factors that characterise SHS and T2DM. Using a cross-sectional design, we recruited 264 people as controls and 241 T2DM patients from January to June 2016. The controls were categorised into high and low SHS based on how they rated on an SHS questionnaire-25 (SHSQ-25). Anthropometric and biochemical parameters: body mass index (BMI); blood pressure (BP); fasting plasma glucose (FPG); glycated haemoglobin (HbA1c); serum lipids [(total cholesterol, triglycerides (TG), high- and low-density lipoprotein-cholesterol (HDL-c and LDL-c)] were measured. The male to female ratio for T2DM and controls were 99:142 and 98:166, respectively, whilst the mean ages were 55.89 and 51.52 years. Compared to controls, T2DM patients had higher FPG (8.96 ± 4.18 vs. 6.08 ± 1.79; p < 0.0001) and HbA1c (8.23 ± 2.09 vs. 5.45 ± 1.00; p < 0.0001). Primarily sedentary [adjusted odds ratio (aOR) = 2.97 (1.38-6.39); p = 0.034)], systolic blood pressure (SBP) (p = 0.001) and diastolic blood pressure (DBP) (p = 0.001) significantly correlated with high SHS. After adjusting for age and gender, central adiposity [aOR = 1.74 (1.06-2.83); p = 0.027)], underweight [aOR = 5.82 (1.23-27.52); p = 0.018)], high SBP [aOR = 1.86 (1.14-3.05); p = 0.012)], high DBP [aOR = 2.39 (1.40-4.07); p = 0.001)] and high TG [aOR = 2.17 (1.09-4.33); p = 0.029)] were found to be independent risk factors associated with high SHS. The management of T2DM in Ghana is suboptimal and undiagnosed risk factors remain prevalent. The SHSQ-25 can be translated and applied as a practical tool to screen at-risk individuals and hence prove useful for the purpose of predictive, preventive and personalised medicine.

Prevention of Type 2 Diabetes in U.S. Hispanic Youth: A Systematic Review of Lifestyle Interventions

CONTEXT

Prevalence of type 2 diabetes mellitus (T2DM) in youth has increased rapidly in recent decades along with rises in childhood obesity. Disparities in risk and prevalence of T2DM are evident in Hispanic youth when compared with non-Hispanic whites. Targeted diabetes prevention programs have been recommended to reduce risk prior to adulthood in this population. This systematic review explores the effectiveness of lifestyle-based diabetes prevention interventions for Hispanic youth.

EVIDENCE ACQUISITION

PubMed, PsycINFO, Web of Science, and CENTRAL were searched from database inception to March 1, 2017, for studies that evaluated lifestyle-focused prevention trials targeting U.S. Hispanic youth under age 18 years. Fifteen publications met criteria for inclusion.

EVIDENCE SYNTHESIS

Of the 15 studies, 11 were RCTs; four were uncontrolled. Interventions were heterogeneous in intensity, content, and setting. Duration of most trials was 12-16 weeks. Mean age of participants ranged from 9.8 to 15.8 years, sample sizes were generally small, and the majority of participants were overweight (BMI ≥85th percentile). Three studies reported statistically significant reductions in mean BMI, four in BMI z-score, and six in fasting glucose/insulin. Study quality was moderate to high. Effect sizes were generally small to medium.

CONCLUSIONS

Evidence for the impact of lifestyle-based diabetes prevention interventions targeting U.S. Hispanic youth remains limited. Few interventions demonstrated success in reducing BMI and glucose regulation and follow-up times were brief. More studies are needed that recruit larger samples sizes, extend follow-up times, explore innovative delivery modalities, and examine effectiveness across sex and age.

Ophthalmic manifestations of endocrine disorders-endocrinology and the eye

Disorders of the endocrine system usually manifest in a multi-organ fashion. More specifically, many endocrinopathies become apparent in the eye first through a variety of distinct pathophysiologic disturbances. The eye provides physicians with valuable clues for the recognition and management of numerous systemic diseases, including many disorders of the endocrine pathway. Recognizing ophthalmic manifestations of endocrine disorders is critical not only for rapid diagnosis and treatment, but also to prevent significant morbidity and mortality. In this review, we discuss relevant ophthalmic findings associated with key disorders of the pancreas, thyroid gland, and hypothalamic-pituitary axis, as well as with multiple hereditary endocrine syndromes. We have chosen to focus on diabetes mellitus (DM), Graves' ophthalmopathy, pituitary tumors, and some less common disorders that underscore the unique relationship between the eye and the endocrine system.

Role of a registered dietitian in pediatric type 1 and type 2 diabetes

Type 1 and type 2 diabetes are complex, chronic diseases that are best managed by a multidisciplinary care team. Type 1 diabetes is most commonly diagnosed in the pediatric population, although the prevalence of type 2 diabetes in youth is increasing rapidly. A registered dietitian (RD) is a critical member of the diabetes team who provides focused nutrition education from diagnosis and throughout routine follow-up care. Specifically in the pediatric population, the RD also assesses growth and development, as well as eating behaviors, food choices and meal patterns. Based on a review of research, ongoing support from an RD improves glycemic control and delays onset of diabetes complications. In addition, dietitian-led nutrition education helps better manage lipid levels and aids in weight management. A sample model describing RD involvement in a pediatric diabetes care team is discussed in further detail.

Use of Continuous Glucose Monitoring in Youth-Onset Type 2 Diabetes

PURPOSE OF REVIEW

Continuous glucose monitoring (CGM) technology has long been accepted as a tool for managing glycemia in type 1 diabetes (T1D) and is receiving increased attention as a tool for monitoring glucose patterns in patients with other forms of diabetes, in particular type 2 diabetes (T2D). Recent studies in adults with T2D have shown benefits of CGM in the investigation of glycemic variability, as well as utility as a tool for improving glycemic control. The literature on CGM use in youth-onset T2D, however, is sparse. This paper reviews the various roles for CGM in T2D, with a focus on published reports of CGM use in youth-onset T2D. The gaps in knowledge are highlighted, along with a discussion regarding need for future studies of potential applications for CGM in this younger population.

RECENT FINDINGS

CGM systems provide insight into glycemic abnormalities in obese youth with and at risk for T2D. This technology has enabled examination of the relationship between free-living glycemic profiles and traditional diabetes screening tests, as well as markers of cardiometabolic risk in this high-risk population. Investigators are incorporating CGM technology into the study of T2D in youth, but interventional studies of CGM as a tool for glycemic control in youth-onset T2D are limited. Youth with T2D face a more aggressive disease than adults with T2D, and further studies utilizing advances in glucose monitoring technology to improve outcomes in this population are needed.

Pharmacotherapy options for pediatric diabetes

PURPOSE OF REVIEW

Type 1 diabetes (T1D) and type 2 diabetes (T2D) are frequent conditions during childhood and adolescence. The present review offers an update on current available treatment strategies for T1D and T2D approved for use in children and adolescents.

RECENT FINDINGS

Insulin remains the main and essential therapeutic strategy in youth with T1D. A second generation of insulin analogues is being evaluated and could help in improving glycemic control. Over the last decades advances in technology have allowed the implementation of insulin pump therapy and continuous glucose monitoring, and are now leading the way towards the development of an artificial pancreas or closed loop system.Treatment of T2D is based on lifestyle interventions and metformin as the first-line drug to be used. Little evidence is available for other oral hypoglycemic drugs, currently used in adults.

SUMMARY

Although much progress has been made in the field of diabetes management, there are still several unmet goals. One of the main issues is to develop a system allowing more physiological insulin coverage. For both T1D and T2D, there is a strong need of new drugs to be used alone or in combination, mainly in patients struggling to achieve good glycemic control.

Type 2 diabetes in adolescents: a severe phenotype posing major clinical challenges and public health burden

Type 2 diabetes in adolescence manifests as a severe progressive form of diabetes that frequently presents with complications, responds poorly to treatment, and results in rapid progression of microvascular and macrovascular complications. Although overall still a rare disease, adolescent type 2 diabetes now poses major challenges to paediatric and adult diabetes services in many countries. Therapeutic options are heavily curtailed by a dearth of knowledge about the condition, with low numbers of participants and poor trial recruitment impeding research. Together with lifestyle modification, metformin remains the first-line therapy for adolescents with type 2 diabetes, although the majority rapidly progress to treatment failure and insulin therapy. Early bariatric surgery is controversial but has great potential to transform outcomes. Health systems must respond by both concentrating patients in specialist clinical services integrated with translational research programmes, but also by joining up with local health and social care services to improve engagement and uptake of services.

Prenatal, Obstetric and Perinatal Factors Associated With the Development of Childhood-Onset Type 2 Diabetes

OBJECTIVE

To explore associations among prenatal, obstetric and perinatal factors and the development of childhood-onset type 2 diabetes.

METHODS

This retrospective, case-control study utilized administrative data housed at the Manitoba Centre for Health Policy. De-identified health records were examined from a sample of 270 children (aged 10 to 17 years at time of diagnosis) with type 2 diabetes and 1341 children without type 2 diabetes matched for age, sex and geographic location. Patients and control subjects were linked to their de-identified biological mothers' health records. Prenatal, obstetric and perinatal factors were investigated. Univariate and multivariable conditional regression analyses were conducted to identify key factors associated with the development of type 2 diabetes in children.

RESULTS

The mean age at diagnosis was 13.1 years, and 61% of patients were girls. The majority (71.1%) of children with type 2 diabetes resided in rural areas. Exposure to maternal pregestational diabetes increased the odds of childhood-onset type 2 diabetes nearly 6-fold, and exposure to gestational diabetes carried a 4-fold increased risk. Breastfeeding was found to be protective, decreasing the risk of childhood-onset type 2 diabetes (odds ratio = 0.52, 95% confidence interval = 0.36-0.74). Low maternal income was significantly associated with development of childhood-onset type 2 diabetes (odds ratio = 6.67, 95% confidence interval = 3.01-14.79).

CONCLUSIONS

Health and social policies and programs are needed to provide financial, educational and clinical resources that target women whose pregnancies are affected by poverty, type 2 diabetes or gestational diabetes. Breastfeeding should be encouraged to aid in the prevention of childhood-onset type 2 diabetes.

Pilot randomized controlled trial of a mindfulness-based group intervention in adolescent girls at risk for type 2 diabetes with depressive symptoms

OBJECTIVE

(1) Evaluate feasibility and acceptability of a mindfulness-based group in adolescent girls at-risk for type 2 diabetes (T2D) with depressive symptoms, and (2) compare efficacy of a mindfulness-based versus cognitive-behavioral group for decreasing depressive symptoms and improving insulin resistance.

DESIGN AND SETTING

Parallel-group, randomized controlled pilot trial conducted at a university.

PARTICIPANTS

Thirty-three girls 12-17y with overweight/obesity, family history of diabetes, and elevated depressive symptoms were randomized to a six-week mindfulness-based (n=17) or cognitive-behavioral program (n=16).

INTERVENTIONS

Both interventions included six, one-hour weekly group sessions. The mindfulness-based program included guided mindfulness awareness practices. The cognitive-behavioral program involved cognitive restructuring and behavioral activation.

MAIN OUTCOME MEASURES

Adolescents were evaluated at baseline, post-intervention, and six-months. Feasibility/acceptability were measured by attendance and program ratings. Depressive symptoms were assessed by validated survey. Insulin resistance was determined from fasting insulin and glucose, and dual energy x-ray absorptiometry was used to assess body composition.

RESULTS

Most adolescents attended ≥80% sessions (mindfulness: 92% versus cognitive-behavioral: 87%, p=1.00). Acceptability ratings were strong. At post-treatment and six-months, adolescents in the mindfulness condition had greater decreases in depressive symptoms than adolescents in the cognitive-behavioral condition (ps<.05). Compared to the cognitive-behavioral condition, adolescents in the mindfulness-based intervention also had greater decreases in insulin resistance and fasting insulin at post-treatment, adjusting for fat mass and other covariates (ps<.05).

CONCLUSIONS

A mindfulness-based intervention shows feasibility and acceptability in girls at-risk for T2D with depressive symptoms. Compared to a cognitive-behavioral program, after the intervention, adolescents who received mindfulness showed greater reductions in depressive symptoms and better insulin resistance. ClinicalTrials.gov identifier: NCT02218138 clinicaltrials.gov.

A case of base rate bias, or are adolescents at a higher risk of developing complications after catheterizable urinary channel surgery?

OBJECTIVE

Adolescents are considered to be at high risk of developing complications after lower genitourinary tract reconstruction. This perception may be due to base rate bias, where clinicians favor specific information (adolescents with complications), while ignoring more general information (number of total adolescents being followed). The goal of this study was to assess whether age was a true risk factor for subfascial and stomal revisions after continent catheterizable urinary (CCU) channel procedures.

MATERIALS AND METHODS

Consecutive patients aged <21 years and who underwent appendicovesicostomy and Monti surgery at the present institution were retrospectively reviewed; demographic and surgical data were collected. Time to subfascial or stomal revision was stratified by age at initial surgery (child: <8, preteen: 8-12, adolescent: 13-17, adult: ≥18 years old) and analyzed with Cox proportional-hazards regression. Secondary analyses included: different age categories at initial surgery (<8, 8-11, 12-15, 16-19, ≥20 years), analyzing age as a continuous and a time-varying covariate.

RESULTS

Of the 510 patients with CCU channels (median age at surgery: 7.9 years), 63 (12.4%) had subfascial and 53 (10.4%) had stomal revision (median follow-up: 6.8 years). Median age at subfascial and stomal revision was 11.3 and 10.3 years, respectively. Preteens contributed 33.0% and adolescents contributed 29.3% of the total follow-up time (3263.9 person-years). Over 80% of revisions occurred within 5 years of surgery, regardless of age at initial surgery (P ≥ 0.57) (Summary table). On multivariate analysis, age at initial surgery was not associated with undergoing subfascial (P ≥ 0.62) or stomal revisions (P ≥ 0.69). Montis were 2.1 times more likely than appendicovesicostomies to undergo a subfascial revision (P = 0.03). No other variables were associated with the risk of subfascial or stomal revision (P ≥ 0.11). Secondary analyses provided similar results.

DISCUSSION

Since the median age at surgery was 8 years old and most complications occurred within the first 5 years of follow-up, it is not surprising that most revisions occurred in 8-13 year olds. Pediatric urologists appear to base their impression of adolescents being "high risk" on specific information (adolescents having complications), while subconsciously ignoring more general information (adolescents represent a large proportion of patients in follow-up). This study had several limitations: channel complications treated non-surgically (e.g. prolonged catheterization) were not included. The findings may not be generalizable to other genitourinary reconstructive procedures or clinical settings.

CONCLUSIONS

While complications were twice as high in Monti channels than appendicovesicostomies, no single age group was at increased risk. The impression that adolescents are a high-risk group appears to represent a base rate bias.

Collaboration Is Key for Successful Treatment of Youth-Onset Type 2 Diabetes

Type 2 diabetes (T2D) is increasing in U.S. adolescents, particularly those of ethnic and racial minority groups. Risk factors for youth-onset T2D include obesity, family history of T2D, poor diet, lack of exercise, and poverty. The onset of diabetes-related complications is accelerated in adolescents with T2D compared to adults, and knowledge regarding the optimal way to prevent and slow complications is lacking. Existing treatment options are limited, and research into novel pharmacologic treatments is hindered by lack of sufficient patient population for clinical trials. Health care providers and investigators should collaborate both with each other, and with patients and their communities to build networks that will allow comprehensive evaluation of this disease in order to offer optimal, comprehensive care for these adolescents.