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

Prevalence of components of the metabolic syndrome in schoolchildren with newly diagnosed type 2 diabetes mellitus

OBJECTIVE

To examine the prevalence of components of the metabolic syndrome (MS) other than hyperglycemia at diagnosis in schoolchildren with type 2 diabetes mellitus (T2DM).

DESIGN

The study involved 112 Japanese schoolchildren, 45 males and 67 females aged 12.9 +/- 1.5 yr, who were diagnosed as having T2DM. The body weight, blood pressure and fasting serum triglyceride (TG), and high-density lipoprotein cholesterol cholesterol (HDL-C) levels were also measured at diagnosis. The criteria adopted for the diagnosis of MS were as follows; i.e., TG > or =150 mg/dL, HDL-C <40 mg/dL, systolic blood pressure > or =130 mmHg, and/or diastolic blood pressure > or =85 mmHg. Obesity was defined as percent overweight > or =20.0%.

RESULTS

As much as 83.0% of the patients had obesity. The prevalence of increased TG was 33.0% and that of decreased HDL-C was 21.4% among the patients. Elevated blood pressure was identified in 11.6% of the patients. Of the total, 15.2% of the patients had no other components of MS besides hyperglycemia; 49.1% had only one other component, which was obesity in the majority; 17.0% had two other components of MS besides hyperglycemia, which were obesity and elevated TG in the majority; 18.8% of the patients had three or more components of MS besides hyperglycemia.

CONCLUSIONS

We found a high prevalence of other components of MS besides hyperglycemia in the patients even at the time of diagnosis. Early detection of other components of MS would appear to be of importance for preventing the development of cardiovascular disease in children with T2DM.

Glycemic status and brain injury in older individuals: the age gene/environment susceptibility-Reykjavik study

OBJECTIVE

To examine the association of glycemic status to magnetic resonance imaging indicators of brain pathological changes.

RESEARCH DESIGN AND METHODS

This was a cross-sectional, population-based study of 4,415 men and women without dementia (mean age 76 years) participating in the Age Gene/Environment Susceptibility-Reykjavik Study. Glycemic status groups included the following: type 2 diabetes (self-report of diabetes, use of diabetes medications, or fasting blood glucose > or =7.0 mmol/l [11.1%]); impaired fasting glucose (IFG) (fasting blood glucose 5.6-6.9 mmol/l [36.2%]); and normoglycemic (52.7%). Outcomes were total brain volume, white and gray matter volume, white matter lesion (WML) volume, and presence of cerebral infarcts.

RESULTS

After adjustment for demographic and cardiovascular risk factors, participants with type 2 diabetes had significantly lower total brain volume (72.2 vs. 71.5%; P < 0.001) and lower gray and white matter volumes (45.1 vs. 44.9%, P < 0.01 and 25.7 vs. 25.3%, P < 0.001, respectively) and were more likely to have single (odds ratio 1.45 [95% CI 1.14-1.85]) or multiple (2.27 [1.60-3.23]) cerebral infarcts compared with normoglycemic participants. Longer duration of type 2 diabetes was associated with lower total brain volume and gray and white matter volume, higher WML volume (all P(trend) < 0.05), and a greater likelihood of single and multiple cerebral infarcts (all P(trend) < 0.01).

CONCLUSIONS

Type 2 diabetic participants have more pronounced brain atrophy and are more likely to have cerebral infarcts. Duration of type 2 diabetes is associated with brain changes, suggesting that type 2 diabetes has a cumulative effect on the brain.

Oral glucose tolerance test in Italian overweight/obese children and adolescents results in a very high prevalence of impaired fasting glycaemia, but not of diabetes

BACKGROUND

Very few studies on glucose abnormalities in European overweight/obese children and adolescents are available, and scientific evidence on the value of standard oral glucose tolerance test (OGTT) in childhood is lacking. We therefore aimed to establish prevalence and features of impaired fasting glucose (IFG), impaired glucose tolerance (IGT) and type 2 diabetes (T2D) in a large cohort of Italian overweight/obese children and adolescents and to assess the validity of standard OGTT in the paediatric population.

METHODS

This is a 1-year observational study conducted on 736 (535 overweight/obese and 201 normal weight) consecutive paediatric patients attending the outpatient clinic of Paediatric Endocrine Unit. Clinical and biochemical parameters were collected for all participants. All overweight/obese subjects underwent OGTT.

RESULTS

We observed a high prevalence of IFG (7.66%), more than twice that observed in other European children, but a low prevalence of IGT (3.18%) and T2D (0.18%). IFG was useless to predict IGT, having very low predictive value (7.3%) and sensitivity (17.6%). Compared to normal weight children, overweight/obese subjects showed significant differences in most metabolic and clinical parameters. In the overweight/obese group, having hyperglycaemia was associated to significantly higher blood pressure, homeostasis model assessment for insulin resistance, insulin and triglycerides.

CONCLUSIONS

In our children, the prevalence of IFG is higher than that reported in other European cohorts, whereas T2D is rare. IFG appears not useful to detect IGT in childhood. Paediatric diagnostic cut-points, glucose load and timing of sampling need to be further validated to define glucose abnormalities in obese children that, compared with normal weight subjects, already are characterised by a different metabolic phenotype.

Soya protein does not affect glycaemic control in adults with type 2 diabetes

Evidence from observational, animal and human studies supports a role for soya protein and its isoflavones in the improvement of glycaemic control in type 2 diabetes. The objective of the present study was to determine the effect of isoflavone-rich soya protein on markers of glycaemic control in adults with type 2 diabetes. Using a randomised, crossover, double-blind, placebo-controlled design, adults with diet-controlled type 2 diabetes (n 29) consumed soya protein isolate (SPI) and milk protein isolate (MPI) for 57 d each separated by a 4-week washout. Blood was collected on days 1 and 57 of each treatment period for analysis of fasting HbA1C, and fasting and postprandial glucose, insulin and calculated indices of insulin sensitivity and resistance. Urine samples of 24 h were collected at the end of each treatment period for analysis of isoflavones. Urinary isoflavone excretion was significantly greater following consumption of SPI compared with MPI, and 20.7 % of the subjects (n 6) were classified as equol excretors. SPI consumption did not significantly affect fasting or postprandial glucose or insulin, fasting HbA1C, or indices of insulin sensitivity and resistance. These data do not support a role for soya protein in the improvement of glycaemic control in adults with diet-controlled type 2 diabetes and contribute to a limited literature of human studies on the effects of soya protein on the management of type 2 diabetes.

Distribution of fasting plasma glucose and prevalence of impaired fasting glucose, impaired glucose tolerance and type 2 diabetes in the Mexican paediatric population

Published data on the distribution of fasting plasma glucose (FPG) in children are scarce. We therefore set out to examine the distribution of FPG and determine the prevalence of impaired fasting glucose (IFG), impaired glucose tolerance (IGT) and type 2 diabetes (T2-DM) in Mexican children aged 6-18 years in a community-based cross-sectional study. A total of 1534 apparently healthy children were randomly enrolled and underwent an oral glucose tolerance test. IFG was defined by an FPG value between >or=100 and <126 mg/dL, IGT by glucose concentration 2-h post-load between >or=140 and <200 mg/dL, and T2-DM by glucose concentration 2-h post-load >or=200 mg/dL. The FPG level at the 75(th) percentile of distribution was 98.0, 100.0 and 99.0 mg/dL for children aged 6-9, 10-14 and 15-18 years, respectively; the 95(th) percentile of FPG was greater than 100 mg/dL for all the age strata. In the population overall, the prevalences of IFG, IGT, and T2-DM were 18.3%, 5.2% and 0.6%, respectively. Among obese children and adolescents, the prevalences of IFG, IGT, IFG + IGT and T2-DM were 19.1%, 5.7%, 2.5% and 1.3%. Our study shows a high prevalence of prediabetes and is the first that reports the distribution of FPG in Mexican children and adolescents.

Diabetes mellitus in young immigrants from hindustan. A descriptive study

AIM

To analyze the physiological and clinical characteristics of diabetes mellitus (DM) in young immigrants from Hindustan.

MATERIAL AND METHODS

We performed a descriptive analysis of clinical and laboratory variables related to DM in diabetic Hindustanis aged between 15 and 40 years old. Body mass index (BMI) and waist perimeter (WP) were calculated. The immunology of DM and baseline C-peptide were studied and insulin resistance (IR) was determined by Homeostasis Model Assessment: Insulin Resistance (HOMA-IR).

RESULTS

The final sample consisted of 30 patients. The prevalence of DM was 0.84%. All patients had DM2 and 50% had high IR. Baseline C-peptide secretion was preserved in all patients. The cut-off points that best predicted IR in this ethnic group were a BMI higher than 25 and a WC of more than 95 cm.

CONCLUSIONS

Most young Hindustani immigrants with diabetes have DM2 with preserved baseline insulin secretion and IR. Lower degrees of obesity than in the Spanish population were associated with IR.

Physical activity may facilitate diabetes prevention in adolescents

OBJECTIVE

The aim of this study was to examine the association of physical activity with glucose tolerance and resting energy expenditure (REE) among adolescents.

RESEARCH DESIGN AND METHODS

Subjects were 32 male and female adolescents aged 12-18 years. Intravenous glucose tolerance (K(g)) and REE were assessed under inpatient conditions after an overnight fast. K(g) was determined as the inverse slope of time versus (ln) glucose over minutes 8-19 of an intravenous glucose tolerance test. Physical activity was assessed over 8 days using accelerometry (counts per minute).

RESULTS

In multiple linear regression analysis, K(g) was positively associated with total physical activity (TPA), moderate physical activity (MPA), and 5-min bouts of MPA. Similarly, REE was positively associated with TPA, MPA, and 5-min bouts of MPA.

CONCLUSIONS

In this population, physical activity was positively related to both glucose tolerance and REE. These results suggest that moderate activity may be beneficial in the prevention of diabetes in adolescent populations both through promoting efficient glucose disposal and through increasing energy expenditure.

Insulin resistance and obesity in childhood

Childhood obesity is a significant health problem that has reached epidemic proportions around the world and is associated with several metabolic and cardiovascular complications. Insulin resistance is a common feature of childhood obesity and is considered to be an important link between adiposity and the associated risk of type 2 diabetes and cardiovascular disease. Insulin resistance is also a key component of the metabolic syndrome, and its prevalence in the paediatric population is increasing, particularly among obese children and adolescents. Several factors are implicated in the pathogenesis of obesity-related insulin resistance, such as increased free fatty acids and many hormones and cytokines released by adipose tissue. Valid and reliable methods are essential to assess the presence and the extent of insulin resistance, the associated risk factors and the effect of pharmacological and lifestyle interventions. The two most common tests to assess insulin resistance are the hyperinsulinemic euglycemic clamp and the frequently sampled i.v. glucose tolerance test utilizing the minimal model. However, both these tests are not easily accomplished, are time consuming, expensive and invasive. Simpler methods to assess insulin resistance based on surrogate markers derived from an oral glucose tolerance test or from fasting insulin and glucose levels have been validated in children and adolescents and widely used. Given the strong association between obesity, insulin resistance and the development of metabolic syndrome and cardiovascular disease, prevention and treatment of childhood obesity appear to be essential to prevent the development of insulin resistance and the associated complications.

Reproducibility of the oral glucose tolerance test in overweight children

OBJECTIVE

We examined the reproducibility of the oral glucose tolerance test (OGTT) in overweight children and evaluated distinguishing characteristics between those with concordant vs. discordant results.

DESIGN

Sixty overweight youth (8-17 yr old) completed two OGTTs (interval between tests 1-25 d). Insulin sensitivity was assessed by the surrogate measures of fasting glucose to insulin ratio, whole-body insulin sensitivity index, and homeostasis model assessment of insulin resistance, and insulin secretion by the insulinogenic index with calculation of the glucose disposition index (GDI).

RESULTS

Of the 10 subjects with impaired glucose tolerance (IGT) during the first OGTT only three (30%) had IGT during the second OGTT. The percent positive agreement between the first and second OGTT was low for both impaired fasting glucose and IGT (22.2 and 27.3%, respectively). Fasting blood glucose had higher reproducibility, compared with the 2-h glucose. Youth with discordant OGTTs, compared with those with concordant results, were more insulin resistant (glucose/insulin 2.7+/-1.4 vs. 4.1+/-1.8, P=0.006, whole-body insulin sensitivity index of 1.3+/-0.6 vs. 2.2+/-1.1, P=0.003, and homeostasis model assessment of insulin resistance 10.6+/-8.1 vs. 5.7+/-2.8, P=0.001), had a lower GDI (0.45+/-0.58 vs. 1.02+/-1.0, P=0.03), and had higher low-density lipoprotein cholesterol (117.7+/-36.6 vs. 89.9+/-20.1, P=0.0005) without differences in physical characteristics.

CONCLUSIONS

Our results show poor reproducibility of the OGTT in obese youth, in particular for the 2-h plasma glucose. Obese youth who have discordant OGTT results are more insulin resistant with higher risk of developing type 2 diabetes mellitus, as evidenced by a lower GDI. The implications of this remain to be determined in clinical and research settings.

Associations of overweight with insulin resistance, beta-cell function and inflammatory markers in Chinese adolescents

BACKGROUND

Obesity is a growing global health problem. Obesity-associated inflammatory and metabolic consequences may vary in different ethnic populations, and data in Chinese adolescents are sparse. In this study, we analysed the clinical and biochemical factors associated with overweight and obesity in Chinese adolescents.

METHODS

This is a cross-sectional cohort study with 2102 Chinese adolescents randomly selected from 14 secondary schools in Hong Kong. Clinical and biochemical parameters including inflammatory markers, among different groups stratified by degrees of obesity, were compared by multivariate logistic regression analysis.

RESULTS

The median age was 16 yr (interquartile range: 14-17 yr) (45.6% boys and 54.4% girls). Among the boys, 16.5% were overweight and 6.8% were obese. The respective percentages in girls were 8.2 and 5.8%. Compared with the group with normal weight in both boys and girls, high systolic blood pressure (SBP), increased insulin resistance (by homoeostasis model assessment, HOMA-IR), elevated high-sensitivity C-reactive protein (hsCRP) level and low high-density lipoprotein cholesterol (HDL-C) level were independently associated with overweight/obesity. In boys, the respective odds ratio (95% CI) was 1.03 (1.01-1.05) for SBP, 21.0 (12.0-36.8) for HOMA-IR, 3.65 (2.10-6.35) for hsCRP and 0.24 (0.11-0.51) for HDL-C. In girls, the respective figures were 1.02 (1.00-1.04), 9.82 (5.65-17.1), 6.28 (3.12-12.6) and 0.18 (0.08-0.41). In girls, low-density lipoprotein cholesterol was also independently associated with overweight/obesity [1.56 (1.09-2.24)].

CONCLUSIONS

In Chinese adolescents, overweight/obesity is independently associated with SBP, insulin resistance, hsCRP and low HDL-C. Early intervention in overweight and obese adolescents may potentially retard the development of these cardiovascular risk factors.

Cardiorespiratory fitness and physical activity in youth with type 2 diabetes

OBJECTIVE

The increased incidence of type 2 diabetes (T2D) among youth is hypothesized to be due, in part, to low levels of fitness and activity. Therefore, the purpose of this investigation was to examine whether cardiorespiratory fitness and physical activity are reduced in youth with T2D compared with overweight controls.

PARTICIPANTS

Thirteen adolescent boys with previously diagnosed T2D (mean duration 2.4 +/- 1.8 yr) were matched for age and body mass index to 13 overweight, non-diabetic controls.

METHODS

Cardiorespiratory fitness was assessed during a progressive exercise test to volitional fatigue and physical activity was estimated from a 7-d physical activity recall.

RESULTS

Youth with T2D reported performing approximately 60% less moderate to vigorous physical activity compared with their non-diabetic counterparts (0.6 +/- 0.2 vs. 1.4 +/- 0.3 h/d, p = 0.04). Furthermore, diabetic youth exhibited significantly lower cardiorespiratory fitness levels compared with controls (28.7 +/- 1.6 vs. 34.6 +/- 2.2 mL/kg/min, p < 0.05).

CONCLUSIONS

These findings support the hypothesis that cardiorespiratory fitness and physical activity are reduced in youth with T2D. Whether reduced fitness and activity contributed to the pathophysiology of the disorder cannot be determined from the cross-sectional analysis. Longitudinal studies are warranted to examine whether improvements in fitness and increased physical activity can prevent the development of T2D in high-risk youth.

Type 2 diabetes mellitus in children and adolescents: where do we stand with drug treatment and behavioral management?

Type 2 diabetes, once considered a disease of adults, is a growing problem in the pediatric population. The emergence of type 2 diabetes in this age group has paralleled the epidemic of childhood obesity. Lifestyle modifications represent first-line therapy for children and adolescents with type 2 diabetes. However, many children and adolescents go on to require treatment with oral medications or insulin for optimal control. A paucity of data exist regarding the optimal treatment regimen for children and adolescents with type 2 diabetes. Further research regarding the treatment of type 2 diabetes in youth is required.

Point-of-care testing as a tool for screening for diabetes and pre-diabetes

AIM

To determine the utility of finger-prick point-of-care testing (POCT) of blood glucose for the detection of dysglycaemia.

METHODS

A fasting POCT and an oral glucose tolerance test (OGTT) with laboratory assays were performed as part of the baseline screening for 5309 participants enrolled in the Te Wai o Rona Diabetes Prevention Strategy. Participants were aged 46 +/- 19 years with no self-reported diabetes. Dysglycaemia, including diabetes, was defined using World Health Organization criteria. Agreement between the two fasting plasma glucose measurements and their screening properties (with sensitivity and specificity for cut points) were compared using receiver operator characteristic analysis.

RESULTS

A total of 3225 participants had both capillary and venous fasting blood sampled within 30 min and then underwent OGTT. New diabetes was found in 161 participants (5.0%) and pre-diabetes in 414 [impaired glucose tolerance 299 (9.3%), impaired fasting glucose 115 (3.6%)]. The mean difference in capillary and venous measures was 0.02 mmol/l (95% confidence interval -0.04 to +0.01; limits of agreement -1.37 to 1.33 mmol/l). Capillary POCT was a poorer predictor of dysglycaemia and impaired glucose tolerance and new diabetes (area under curve 0.76 and 0.71) than venous laboratory analysis (area under curve 0.87 and 0.81 respectively). Optimal screening criteria were best at a venous glucose of 5.4 mmol/l; 77% sensitivity/specificity.

CONCLUSIONS

POCT significantly underestimated the true blood glucose at diagnostic levels for diabetes. POCT cannot be recommended as a means of screening for or diagnosing diabetes or pre-diabetes.

Diabetes mellitus among young adults in Sri Lanka--role of GAD antibodies in classification and treatment: the Sri Lanka Young Diabetes study

AIMS/HYPOTHESIS

Diabetes mellitus is increasing among young adult South Asians. The aim of this study was to determine the prevalence and phenotypic characteristics of diabetes subtypes based on GAD65 autoantibody (GADA) status in those with young adult-onset diabetes in Sri Lanka.

METHODS

Clinical, metabolic and GADA data were available for 992 consecutively recruited individuals with diabetes aged < or =45 years (age at diagnosis 16-40 years). Participants were classified according to the following definitions: type 1 diabetes, insulin-dependent <6 months from diagnosis; latent autoimmune diabetes in adults (LADA), GADA-positive, age > or =30 years and insulin-independent > or =6 months from diagnosis; type 2 diabetes, GADA-negative and insulin-independent > or =6 months from diagnosis.

RESULTS

The median (interquartile range) age at diagnosis and diabetes duration were 33.0 (29.0-36.1) and 4.0 (1.1-7.1) years, respectively; 42.1% were male. GADA positivity was seen in 5.4% of participants (n = 54) and GADA levels negatively correlated with age at diagnosis (p < 0.0001), BMI (p < 0.0001) and time to insulin requirement (p = 0.006). Type 1 diabetes, type 2 diabetes and LADA were present in 7.0%, 89.7% and 2.6%, respectively. The remaining 0.7% of the participants were GADA-positive, insulin independent > or =6 months from diagnosis and were diagnosed at age <30 years. The metabolic syndrome and homeostasis model assessment of beta cell function (HOMA %B) were lowest in GADA-positive type 1 diabetes and increased progressively in latent autoimmune diabetes, GADA-negative type 1 diabetes and type 2 diabetes. Among those requiring insulin, 69.2% had fasting C-peptide levels in the lowest quartile, whereas only 19.5% were GADA-positive (p < 0.0001).

CONCLUSIONS/INTERPRETATION

The prevalence of GADA-positive autoimmune diabetes is low among individuals with young adult-onset diabetes in Sri Lanka. Young-onset diabetic phenotypes appear as a continuum from autoimmune type 1 diabetes to type 2 diabetes.

Diabetic nephropathy in children and adolescents

Type 1 diabetes mellitus (T1DM) commonly occurs in childhood or adolescence, although the rising prevalence of type 2 diabetes mellitus (T2DM) in these age groups is now being seen worldwide. Diabetic nephropathy (DN) develops in 15-20% of subjects with T1DM and in similar or higher percentage of T2DM patients, causing increased morbidity and premature mortality. Although overt DN or kidney failure caused by either type of diabetes are very uncommon during childhood or adolescence, diabetic kidney disease in susceptible patients almost certainly begins soon after disease onset and may accelerate during adolescence, leading to microalbuminuria or incipient DN. Therefore, all diabetics warrant ongoing assessment of kidney function and screening for the earliest manifestations of renal injury. Pediatric health care professionals ought to understand about risk factors, strategy for prevention, method for screening, and treatment of early DN. This review considers each form of diabetes separately, including natural history, risk factors for development, screening for early manifestations, and strategy recommended for prevention and treatment of DN in children and adolescents.

Geographic distribution of childhood diabetes and obesity relative to the supply of pediatric endocrinologists in the United States

OBJECTIVE

To determine the geographic distribution of childhood diabetes and obesity relative to the supply of US pediatric endocrinologists.

STUDY DESIGN

Estimation of observed and "index" ratios of children with diabetes (by region and division) and obesity (body mass index >/=95th % for age and sex) (by region and state) to board-certified pediatric endocrinologists.

RESULTS

At the national level, the ratio of children with diabetes to pediatric endocrinologists is 290:1, and the ratio of obese children to pediatric endocrinologists is 17,741:1. Ratios of children with diabetes to pediatric endocrinologists in the Midwest (370:1), South (335:1), and West (367:1) are twice as high as in the Northeast (144:1). Across states, there is up to a 19-fold difference in the observed ratios of obese children to pediatric endocrinologists. Under conditions of equitably distributed endocrinologist supply, variation across states would be mitigated considerably.

CONCLUSIONS

The distribution of children with diabetes and obesity does not parallel the distribution of pediatric endocrinologists in the United States, due largely to geographic disparities in endocrinologist supply. Given the large burden of obese children to endocrinologists, multidisciplinary models of care delivery are essential for the US health care system to address the needs of children with diabetes and obesity.

Screening for overweight and diabetes in rural Hispanic and Caucasian fifth-grade children

Fifth-grade children were screened for overweight and diabetes and comparisons between Hispanic and Caucasian children in this rural setting are presented. Hispanic children had a significantly higher mean Body Mass Index percentile and waist circumference than Caucasians but blood glucose differences were not significant. Twenty-six percent of all children had slightly elevated glucose levels (100-125 mg per dL) and 2% had elevated levels (equal to or greater than 126 mg per dL) but none of the children were found to have diabetes. There were significant positive correlations between random blood glucose, Body Mass Index percentile and waist circumference. Researchers concluded that a two-step screening process is appropriate.

Epidemiology of paediatric metabolic syndrome and type 2 diabetes mellitus

The epidemic in childhood obesity is a driving force behind the increase in paediatric metabolic syndrome, a collection of abnormalities that is associated in adults with increased risk for cardiovascular disease and type 2 diabetes mellitus. Although there is no clear consensus about the paediatric definition for metabolic syndrome, the prevalence of this syndrome is clearly rising. Children with metabolic syndrome are at increased risk for metabolic syndrome in adulthood. A late consequence of metabolic syndrome is type 2 diabetes, which increasingly affects adolescents. The rise in metabolic syndrome and type 2 diabetes in children is almost sure to lead to an increase in associated complications in young adulthood, including early cardiovascular disease. This epidemic will bear fruit in forthcoming decades, putting further stress on the healthcare system and probably leading to increased morbidity and a shorter lifespan for future generations.

Exercise alone reduces insulin resistance in obese children independently of changes in body composition

CONTEXT

The number of obese children with insulin resistance and type 2 diabetes is increasing, but the best management strategy is not clear.

OBJECTIVE

The objective of this study was to assess the effect of a structured 8-wk exercise training program on insulin resistance and changes in body composition in obese children.

DESIGN

The study was 8 wk of structured supervised exercise intervention with outcome measures before and after the exercise period.

SUBJECTS

Fourteen obese children (12.70 +/- 2.32 yr; eight male, six female) with high fasting insulin levels were enrolled into the study.

INTERVENTION

INTERVENTION consisted of 8 wk of supervised circuit-based exercise training, composed of three fully supervised 1-h sessions per week.

OUTCOME MEASURES

Outcome measures were assessed pretraining program and posttraining program and included insulin sensitivity (euglycemic-hyperinsulinemic clamp studies), fasting insulin and glucose levels, body composition using dual energy x-ray absorptiometry scan, lipid profile, and liver function tests.

RESULTS

Insulin sensitivity improved significantly after 8 wk of training (M(lbm) 8.20 +/- 3.44 to 10.03 +/- 4.33 mg/kg.min, P < 0.05). Submaximal exercise heart rate responses were significantly lower following the training (P < 0.05), indicating an improvement in cardiorespiratory fitness. Dual energy x-ray absorptiometry scans revealed no differences in lean body mass or abdominal fat mass.

CONCLUSION

An 8-wk exercise training program increases insulin sensitivity in obese children, and this improvement occurred in the presence of increased cardiorespiratory fitness but is independent of measurable changes in body composition.

Behavioral Medicine Review: Weight Control in a Land of Milk and Honey

Obesity and its cardiometabolic comorbidities are on a skyrocketing trajectory with ominous public health implications. Focusing on primary care as a microcosm of the broader obesity crisis, this review discusses considerations for the prevention and management of obesity and its associated risks.

Paediatric diabetes: achieving practical, effective insulin therapy in type 1 and type 2 diabetes

Both type 1 and type 2 diabetes can occur in children and adolescents. Type 1 diabetes is the most common chronic disease in children in the developed countries and the number of adolescents with type 2 diabetes is rising as a consequence of the obesity epidemic. As they grow, children and adolescents with diabetes have special and changing needs; these must be recognized and addressed as there are major physiological, medical, psychological, social and emotional differences in adults with diabetes. Glycaemic control is important to prevent or delay long-term complications also in the paediatric age group. This goal is often achieved using insulin. However, practical issues associated with insulin use in paediatric patients include attainment of target glycaemic levels without increased risk of hypoglycaemia, hormone-driven fluctuations in insulin requirements, and the psychological and social impacts of weight gain and puberty. This article reviews the advances that are helping to overcome these issues and enable paediatric patients to achieve their treatment goals.

CONCLUSION

Advanced insulin formulations, particularly insulin analogues, tailored insulin regimens and delivery systems combined with age-appropriate education, patient/carer involvement and ongoing support from the wider diabetes team will assist in the effective management of diabetes among children and adolescents.

Behavioral Medicine Review: Strategic Management of Diabetes Risk

There is widespread public health concern about the upsurge in diabetes and its cardiometabolic comorbidities. Unfortunately, too many patients still do not receive best practices care. This review discusses some key contributing dynamics as well as considerations for progress toward the more comprehensive, strategic management of diabetes and its associated risks.

Screening and diagnosis of prediabetes: where are we headed?

It is currently estimated that more than 300 million people have impaired glucose tolerance (IGT), putting them at increased risk for type 2 diabetes mellitus (T2DM) and its adverse consequences. In addition, many others are at risk on the basis of a family history of T2DM, obesity, dyslipidaemia and hypertension. Screening for risk should include both blood glucose testing in high-risk populations and prescreening (e.g. by questionnaire, waist circumference measurement) to identify high-risk individuals in overall low-risk populations; these individuals should then undergo glucose testing. Fasting plasma glucose measurement cannot diagnose IGT; the preferred definite test for diagnosis is oral glucose tolerance testing.

Vascular inflammatory markers in early-onset obese and type 2 diabetes subjects before and after three months' aerobic exercise training

Early-onset type 2 diabetes (T2DM) may lead to very early vascular complications. Cardiovascular mortality is two to five times higher in adults with diabetes than in people without diabetes. The cardiovascular risk of young people with T2DM is unknown. T2DM in young people is associated with marked visceral obesity, insulin resistance and microalbuminuria. We recently showed that these subjects did not improve in either fitness (maximum volume of oxygen consumption, VO2max) or glucose disposal after exercise training. Seven subjects with early-onset T2DM (aged 26.1+/-0.9 years, body mass index [BMI] 35.6+/-1.2 kg/m2) and 14 age-matched obese subjects with normal glucose tolerance (aged 25.6+/-0.9 years, BMI 34.3+/-1.4 kg/m2) underwent aerobic training for 12 weeks. Serum vascular inflammatory markers (high-sensitivity C-reactive protein [hsCRP], soluble intercellular adhesion molecule [sICAM-1], soluble vascular cell adhesion molecule [sVCAM-1], E-Selectin and P-Selectin) were measured before and after the training programme. At baseline, plasma concentrations of vascular inflammatory markers were significantly elevated in both groups. They did not improve after exercise.

Optimizing the therapeutic benefits of exercise in Type 2 diabetes

Other than diet and medication, exercise is considered one of the three cornerstones of good diabetes treatment. Nevertheless, current clinical guidelines on Type 2 diabetes provide no detailed information on the modalities of effective exercise intervention in the treatment of Type 2 diabetes. Based on a review of currently available literature, exercise modalities are being identified to maximize the benefits of exercise intervention in the treatment of different Type 2 diabetes subpopulations. Both endurance and resistance types of exercise have equal therapeutic strength to improve metabolic control in patients with Type 2 diabetes. When applying endurance-type exercise, energy expenditure should be equivalent to approximately 1.7-2.1 MJ/exercise bout on 3 but preferably 5 days/wk. In sarcopenic or severely deconditioned patients with Type 2 diabetes, focus should lie on the implementation of resistance-type exercise to attenuate and/or reverse the decline in skeletal muscle mass and strength. Before choosing the most appropriate exercise modalities, the patient's disease stage should be well characterized, and an ECG-stress test should be considered. Based on baseline aerobic fitness, level of co-morbidities, body composition, and muscle strength, patients should be provided with an individually tailored exercise intervention program to optimize therapeutic value. A multidisciplinary individualized approach and continued exercise training under personal supervision is essential to enhance compliance and allow long-term health benefits of an exercise intervention program.

The utility of the C-peptide in the phenotyping of patients candidates for pancreas transplantation

It is not unusual for simultaneous pancreas and kidney transplantation (SPK) to be performed in patients with type 2 diabetes (T2D), clinically classified as having type 1 diabetes (T1D). C-peptide determination is useful to identify these patients. We describe the prevalence and characteristics of patients with C-peptide levels >3 ng/mL, classified with T2D in 172 patients referred for SPK from 1998-2006. Nine patients (5.2%) fulfilled this criteria (mean free C-peptide 9.08 ng/mL) and were older at diabetes onset (23.5 vs. 12 yr, p < 0.001) and at assessment (42.2 vs. 37.6 yr, p = 0.047) with shorter time between diabetes onset and renal failure (17.8 vs. 22.7 yr, p = 0.3) compared with T1D patients (mean free C-peptide 0.24 ng/mL). In our experience the prevalence of T2D in candidates for SPK is not negligible. Despite some clinical differences with T1D these T2D patients can phenotypically be confounded with T1D in the absence of C-peptide determination.

Prevalence of impaired glucose regulation in German school-leaving students

The increase in prevalence of obesity in childhood and adolescence appears to be followed by a rise of type 2 diabetes (T2D) cases in youth. Studies from the United States indicated that more than 1 in 10 adolescents may have disturbed glucose metabolism and that ethnicity and socioeconomic status are major determinants of (pre) diabetes prevalence. Since data for European countries are rare, we conducted a cross-sectional survey in 721 school-leaving boys and girls (mean age 15.5 years) in Düsseldorf (Germany). In our population from a predominantly low socioeconomic background, a total of 2.5% had impaired fasting glucose, impaired glucose tolerance or T2D. Hence, our study does not confirm the alarming data from high-risk US. American populations, but, nevertheless provides evidence for the necessity of public health interventions aiming at primary prevention of obesity and T2D in children and adolescents.

Management of psychiatric disorders in children and adolescents with atypical antipsychotics: a systematic review of published clinical trials

We aimed to provide a descriptive review of treatment studies of atypical antipsychotics in paediatric psychiatric disorders. A systematic review of the literature used Medline and EMBASE databases to identify clinical trials of atypical antipsychotics in children and adolescents between 1994 and 2006. Trials were limited to double-blind studies and open-label studies of > or = 8 weeks duration that included > or = 20 patients. Nineteen double-blind and 22 open-label studies were identified. Studies included use of clozapine, olanzapine, quetiapine, risperidone, and ziprasidone in the treatment of disruptive behavioural disorders (DBDs), pervasive developmental disorders (PDDs), tic disorder, psychotic disorders, and mania. These medications generally reduced the severity of a variety of psychiatric symptoms in children and adolescents. Less frequent adverse events included extrapyramidal symptoms, hyperglycaemia and diabetes, and endocrine effects. The review of published scientific data suggests that most of the atypical antipsychotics, excluding clozapine, have a favourable risk/benefit profile and effectively reduce disabling behaviours in paediatric psychiatric patients. While there is a body of evidence published of treatment of DBDs and PDDs, there is a lack of controlled data to guide clinical practice for the use of atypical antipsychotics for paediatric psychotic disorders and bipolar disorder. While there have been studies with duration up to 2 years, no definitive data are available that suggest long-term safety; additional studies are warranted.

Role of metformin in the initiation of pharmacotherapy for type 2 diabetes: an Asian-Pacific perspective

Increases in the prevalence of type 2 diabetes of 30-60% will occur in many Asian-Pacific countries by 2025, driven by urbanisation, sedentary habits and energy-rich diets. Obesity, insulin resistance, metabolic syndrome and diabetes are closely interrelated. Optimal control of diabetes and associated risk factors has reduced the risk of diabetes-related complications. In the UK Prospective Diabetes Study (UKPDS), metformin reduced the risk of macrovascular complications and retrospective analyses have confirmed the efficacy of metformin in improving clinical outcomes in type 2 diabetic patients with a history of cardiovascular disease. This growing body of evidence has led to the recommendation of metformin as optimum initial pharmacotherapy in overweight type 2 diabetic patients. Obesity is less prevalent in the Asian-Pacific population than in Caucasian populations. Nevertheless, metformin has multiple beneficial metabolic effects, which provide sufficient rationale for it to be recommended as the initial oral anti-diabetic pharmacotherapy, alone or in combination, irrespective of body mass index. This recommendation is consistent with global guidelines and regional recommendations for the Asian-Pacific region from the International Diabetes Federation. These recommendations can serve as templates for development of local guidelines for Asian people with diabetes, given the ethnic and cultural diversity within the region.

Preventing microalbuminuria in patients with type 2 diabetes

The public health burden of type 2 diabetes mellitus has been dramatically increasing world-wide. The chronic complications of type 2 diabetes play an important role in decreasing life expectancy and adversely affecting quality of life. Diabetic nephropathy, which is originally microvascular in nature, is widely considered an important complication of diabetes. In prospective clinical investigations, increased urinary albumin excretion proved to be associated not only with subsequent renal outcomes but also with cardiovascular morbidity/mortality independently of other risk factors. Therefore, microalbuminuria as an early sign of increased urinary albumin excretion should be considered important for both treatment and even for prevention. Preventing microalbuminuria might diminish progression to overt nephropathy and, hopefully, might limit cardiovascular events. Regarding primary prevention of diabetic nephropathy, therapeutic intervention should optimally be initiated at the stage of normoalbuminuria. Although additional factors such as smoking cessation, reduction of protein intake, and treatment of lipid abnormalities are important, providing optimal diabetic control as well as targeting optimal blood pressure are the key elements of a prevention strategy in diabetic patients. Recently, the Bergamo Nephrologic Diabetes Complications Trial (BENEDICT) documented that a significant decrease of the development of persistent microalbuminuria could be achieved by using an ACE-inhibitor, trandolapril alone or in combination with verapamil SR, a non-dihydropyridine calcium-channel blocker in hypertensive type 2 diabetic patients with normoalbuminuria. The results of this primary-prevention strategy should be corroborated by further investigations to determine whether these beneficial changes could later result in improvement of renal clinical outcomes, macrovascular complications, or both.

Effect-modifications by age and sex on the risks of coronary artery disease and revascularization procedures in relation to diabetes

Using the National Health Insurance (NHI) claim data, we assessed the effect-modifications by age and sex on the risks of coronary artery disease and revascularization procedures in relation to diabetes in Taiwan. Diabetic patients (n=500,868) and the age-and sex-matched control group (n=500,248) were linked to the inpatient claims (1997-2002) to identify hospitalizations of acute myocardial infarction, ischemic heart disease, coronary revascularization procedures. The effects of age and sex on the risks of such coronary-endpoints were evaluated by Cox proportional hazard regression model adjusted for demographics and regional area. Older ages and being males had absolutely elevated risks of all coronary-related complications, but younger and female diabetic patients had higher relative risks compared to their controls. Effect-modification by age was significant in younger patients especially in subjects <35 years for ischemic heart disease (hazard ratio [HR]=11.1; 95% confidence interval [CI]: 7.3-18.1), and coronary revascularization procedures (HR=42.9; 95% CI: 6.0-309.3). Female diabetic patients also had increased HRs of all coronary endpoints particularly for revascularization procedures. In Taiwan, very high relative hazards of coronary complications were observed in younger and female diabetic patients. We must provide an aggressive diabetic care program emphasized to those high-risk groups.