Type 2 Diabetes in Children and Adolescents

Preventing type 2 diabetes among Indigenous youth: A systematic review of community-based interventions

A systematic review was conducted to assess evidence on effectiveness of community-based interventions promoting wellbeing and prevention of type 2 diabetes (T2D) among Indigenous youth. A convergent, segregated, mixed methods approach was used, with six databases and four grey literature sites searched from inception to May 2022. Articles selected for inclusion were about community-based interventions related to T2D prevention with Indigenous youth that evaluated effectiveness or youth experience published in English. Reference lists were also searched for relevant sources. Seven quantitative research articles met the inclusion and quality assessment criteria. No qualitative articles were identified. The results were synthesised through narrative analysis, while meta-analysis was not possible due to heterogenous study designs. Common foci across interventions included promoting physical wellness, improving physical activity and healthy eating patterns, enhancing knowledge, and psychosocial wellness. Interventions deemed effective addressed multiple areas, were school-based, and operated for at least a year. Findings support multi-strategy, community-based interventions implemented over longer periods of time. However, gaps in research and reporting included the extent to which interventions are culturally informed and based on community-driven priorities. Future research should include Indigenous, mixed and qualitative methods and Indigenous-driven measures of success to better understand effectiveness in alignment with Indigenous worldviews.

Sleep and insulin sensitivity in adolescents at risk of type 2 diabetes: the Sleep Manipulation in Adolescents at Risk of Type 2 Diabetes randomized crossover study

STUDY OBJECTIVES

To investigate the effect of increasing sleep duration for 1 week, compared to a week of habitual and decreased sleep, on insulin sensitivity (IS) in adolescents at risk for type 2 diabetes (T2D).

METHODS

Adolescents, 13-18 years old, at risk for T2D, with obesity and other risk factors, were recruited for a randomized (1:1), open-label, sex-stratified crossover study, that manipulated time-in-bed to modify sleep duration (measured by actigraphy). Following a week of habitual (HB) sleep, time-in-bed was increased (IN) and decreased (DE) by 1 hour 30 min/night for 1 week, counterbalanced across participants (HBINDE or HBDEIN), and separated by a week of washout sleep. The main outcome measure was IS, obtained via 2-hour oral-glucose-tolerance-test conducted after each sleep week.

RESULTS

Of the 43 participants recruited, 36 (84%) completed all sleep interventions (52.8% female, age = 15.1 years, body mass index = 99.9th percentile, order: HBINDE = 18 and HBDEIN = 18). On average, during the HB week, participants slept 7 hours 31 min/night; sleep duration was 1 hour 02 min/night higher during the IN week and 1 hour 19 min/night lower during the DE week. We found a significant effect of sleep week on IS with a large effect size. Following the IN sleep week, IS was 20% higher compared to after the HB and DE sleep weeks, but there was no significant difference in IS following HB versus DE sleep weeks.

CONCLUSIONS

Whenever possible, clinicians should empower youth at risk of T2D to improve their sleep duration, since even a modest increase in sleep duration of 1 h/night for 1 week can have a positive impact on IS in this population.

CLINICAL TRIALS

Sleep Extension and IS in Adolescents, https://clinicaltrials.gov/study/NCT03754036, November 23rd, 2018.

TRIAL REGISTRATION

ClinicalTrials.gov (ID:NCT03754036).

Diabetes-related instrument to assess preventive behaviors among adolescents (DIAPBA): a tool development and psychometric research

BACKGROUND

Type 2 diabetes is a chronic but preventable disease that is on the rise among adolescents. Evaluating adolescents' behavior and planning to prevent it require a valid and reliable instrument. This study aims at designing a psychometric instrument to measure adolescents' behavior with respect to type-2 diabetes.

RESEARCH DESIGN AND METHODS

In this methodological research, 770 students (adolescent boys and girls aged 13-15 years) participated through multistage sampling. The Inclusion criteria were: junior high school students, students' willingness for participation and not suffering from type-1 or type-2 diabetes. The questionnaire was designed by examining the relevant literature and the existing questionnaires as well as considering the research team's comments. The validity of the study was determined through face validity and content validity both quantitatively and qualitatively. The construct validity was determined through exploratory and confirmatory factor analysis. Reliability was measured via intraclass consistency coefficient (ICC) and internal consistency reliability was measured by Cronbach Alpha. SPSS 16 and Eq. 6.1 were used for data analysis.

RESULTS

At first, a list of 47 initial items was designed and compiled, and after by removing similar (10 questions) or inappropriate sentences (12 questions), a draft questionnaire with 25 questions was designed. No items were removed in the face validity phase. Based on exploratory factor analysis, the number of items in the questionnaire was reduced to 20 items and was categorized in five dimensions of stress management, healthy food/healthy diet, unhealthy food/unhealthy diet, high-risk behavior, and self-care. The results of confirmatory factor analysis confirmed the model. The internal consistency coefficient was confirmed measuring Cronbach Alpha at 0.70 with ICC = 0.80.

CONCLUSION

The questionnaire designed has standard psychometric properties to assess adolescents' behavior with respect to type-2 diabetes prevention. The reliability and the validity of the questionnaire as well as its general structure were confirmed.

Review on the screening of urine glucose for early diagnosis of type 2 diabetes mellitus in school children and adolescents with obesity in Hong Kong

OBJECTIVES

Obesity and type 2 diabetes mellitus (T2DM) are growing health concerns. Since 2005, Student Health Service (SHS) and Hong Kong Paediatric Society formulated a protocol on urine glucose screening (UGS) for early diagnosis of T2DM in students with obesity in Hong Kong. This study reviews students with T2DM captured by this screening program and compare the data with the Hong Kong Children Diabetes Registry (HKCDR) database, to see if the UGS program facilitates early diagnosis of T2DM.

METHODS

Students between the ages of 10-18 years old with age- and sex-specific body mass index (BMI) >97th percentile who attended SHS between the school years from 2005/06 to 2017/18 were recruited for UGS. Those tested positive for random urine glucose underwent diagnostic testing for T2DM according to ADA guidelines. Demographic data and investigatory results from UGS and HKCDR within the same time period were compared.

RESULTS

A total of 216,526 students completed UGS in the said period; 415 (0.19 %) students were tested positive for urine glucose of which 121 students were diagnosed with T2DM. UGS picked up 23 % of the newly diagnosed T2DM cases. When compared to the HKCDR database, students diagnosed via UGS were significantly younger, less obese, and had fewer diabetic related complications. The negative predictive value of UGS is high and can effectively rule out T2DM.

CONCLUSIONS

Urine glucose screening is an inexpensive and simple test that allows for early diagnosis of T2DM among obese school students. Other methods including POCT HbA1c can be explored to improve program effectiveness.

Cardiorespiratory Fitness and Physical Activity in Pediatric Diabetes: A Systemic Review and Meta-Analysis

Importance

It is unclear whether cardiorespiratory fitness (CRF) and physical activity are lower among youths with type 1 diabetes (T1D) and type 2 diabetes (T2D) compared with youths without diabetes.

Objective

To describe the magnitude, precision, and constancy of the differences in CRF and physical activity among youths with and without diabetes.

Data Sources

MEDLINE, Embase, CINAHL, and SPORTDiscus were searched from January 1, 2000, to May 1, 2022, for eligible studies.

Study Selection

Observational studies with measures of CRF and physical activity in children and adolescents aged 18 years or younger with T1D or T2D and a control group were included.

Data Extraction and Synthesis

Data extraction was completed by 2 independent reviewers. A random-effects meta-analysis model was used to estimate differences in main outcomes. The pooled effect estimate was measured as standardized mean differences (SMDs) with 95% CIs. The Preferred Reporting Items for Systematic Review and Meta-Analyses guideline was followed.

Main Outcomes and Measures

The main outcomes were objectively measured CRF obtained from a graded maximal exercise test and subjective or objective measures of physical activity. Subgroup analyses were performed for weight status and measurement type for outcome measures.

Results

Of 7857 unique citations retrieved, 9 studies (755 participants) with measures of CRF and 9 studies (1233 participants) with measures of physical activity for youths with T2D were included; for youths with T1D, 23 studies with measures of CRF (2082 participants) and 36 studies with measures of PA (12 196 participants) were included. Random-effects models revealed that directly measured CRF was lower in youths with T2D (SMD, -1.06; 95% CI, -1.57 to -0.56; I2 = 84%; 9 studies; 755 participants) and in youths with T1D (SMD, -0.39; 95% CI, -0.70 to -0.09; I2 = 89%; 22 studies; 2082 participants) compared with controls. Random-effects models revealed that daily physical activity was marginally lower in youths with T1D (SMD, -0.29; 95% CI, -0.46 to -0.11; I2 = 89%; 31 studies; 12 196 participants) but not different among youths with T2D (SMD, -0.56; 95% CI, -1.28 to 0.16; I2 = 91%; 9 studies; 1233 participants) compared with controls. When analyses were restricted to studies with objective measures, physical activity was significantly lower in youths with T2D (SMD, -0.71; 95% CI, -1.36 to -0.05; I2 = 23%; 3 studies; 332 participants) and T1D (SMD, -0.67; 95% CI, -1.17 to -0.17; I2 = 93%; 12 studies; 1357 participants) compared with controls.

Conclusions and Relevance

These findings suggest that deficits in CRF may be larger and more consistent in youths with T2D compared with youths with T1D, suggesting an increased risk for cardiovascular disease-related morbidity in adolescents with diabetes, particularly among those with T2D. The findings reinforce calls for novel interventions to empower youths living with diabetes to engage in regular physical activity and increase their CRF.

Incidence and prevalence of type 2 diabetes in Manitoba children 2009-10 to 2017-18: First Nation versus all other Manitobans

AIM

To describe the incidence and prevalence of type 2 diabetes in children in Manitoba over a ten-year period.

METHODS

Population-based, provincial databases were linked to calculate the incidence and prevalence of type 2 diabetes in children < 18 years of age in Manitoba from 2009-10 to 2017-18. First Nation and all other Manitoban children are described separately.

RESULTS

The incidence of type 2 diabetes increased from 16.0/100,000/year in 2009-10 to 31‧1/100,000/year in 2017-18 (p < 0.001). For First Nation children, the incidence increased from 73‧4 to 121‧2/100,000/year (p < 0.001). For all other Manitoban children, the incidence increased from 3‧3 to 10‧7/100,000/year (p < 0.001). The prevalence of type 2 diabetes rose from 66‧4 to 124‧2/100,000/year between 2009 -10 and 2017-18 (<0.001). The prevalence in First Nation children rose from 282‧8 to 517‧9/100,000/year (p < 0.001) and in all other Manitoban children from 18‧4 to 35.0/100,000/year (p < 0.001).

CONCLUSIONS

The incidence and prevalence of type 2 diabetes is increasing in Manitoban children. While the greatest increase is seen in all other Manitoban children, type 2 diabetes disproportionally affects First Nation children. Understanding the prevalence and incidence of type 2 diabetes in children is necessary for resource allocation and to inform program planning, aimed at both prevention and management.

24-h ambulatory blood pressure readings and associations with albuminuria in youth with type 2 diabetes: A cross sectional analysis from the iCARE cohort

AIMS

To evaluate associations between 24-h ambulatory blood pressure monitor (ABPM) data vs. single casual blood pressure (BP) and albuminuria in youth with type 2 diabetes.

METHODS

A cross-sectional analysis of youth with type 2 diabetes 10-<18 yrs. from the iCARE cohort.

MAIN EXPOSURES

daytime HTN (+/- nocturnal), isolated nocturnal HTN and single casual BP.

MAIN OUTCOME

non-orthostatic urine albumin: creatinine ratio (ACR) ≥ 3 mg/mmol and log-transformed urine ACR. Regressions evaluated associations between 1. HTN status based on ABPM and log-transformed urine ACR (continuous) and 2. ABPM-derived BP z-scores and casual BPcentiles and albuminuria status (categorical).

RESULTS

Of 281 youth included, 19.6 % had daytime HTN (+/- nocturnal), and 28.5 % isolated nocturnal HTN on 24-h ABPM. In multivariate linear regression, HTN (ABPM) (ß = 0.553; p = 0.001), duration of diabetes (ß = 0.857; p = 0.02), HbA1c (ß = 1.172; p ≤0.0001) and ACEI/ARB use (ß = 3.94; p < 0.0001) were positively associated with log-transformed ACR; (R2 = 0.184). In logistic regression analysis, all ABPM LMS z-scores were positively associated with albuminuria; casual BPcentile was not significant.

CONCLUSIONS

Youth with type 2 diabetes have high rates of HTN based on 24-ABPM data. ABPM-derived measures of BP are associated with albuminuria. These data support the routine use of ABPM devices to diagnose hypertension in youth with type 2 diabetes.

Factors Associated With the Development of Dyslipidemia Among Pediatric Patients With Diabetes: A Single-centre-based Study

OBJECTIVES

The prevalence of pediatric diabetes is increasing. Dyslipidemia is an important modifiable cardiovascular disease risk factor often present in children with diabetes. In this study, we evaluated the adherence to Diabetes Canada 2018 lipid screening guidelines in a pediatric diabetes program to determine the prevalence of dyslipidemia in youth with diabetes and to identify risk factors related to dyslipidemia.

METHODS

This retrospective chart review included patients at McMaster Children's Hospital with diabetes (types 1 and 2), who were at least 12 years of age as of January 1, 2019. Extracted data included age, sex, family history of diabetes or dyslipidemia, date of diagnosis, body mass index, glycemia monitoring system used, lipid profile, glycated hemoglobin (A1C), and thyroid-stimulating hormone values at the time the lipid profile was measured. Statistical methods included descriptive statistics and logistic regression modelling.

RESULTS

Of the 305 patients included, 61% had a lipid profile measured according to guidelines, 29% had lipid screening completed outside of the recommended window, and 10% had no lipid profile on record. Among screened patients, 45% had dyslipidemia, most commonly hypertriglyceridemia (35%). Dyslipidemia was highest amongst those with type 2 diabetes, obesity, older age, short duration of diabetes, higher A1C, and those who used capillary blood glucose for monitoring (p<0.05).

CONCLUSIONS

A high proportion of patients were screened for dyslipidemia, but many outside the recommended window. Dyslipidemia is highly prevalent in this patient population and was associated with the presence of obesity, but 44% of patients without obesity also had dyslipidemia.

Household food insecurity and changes in BMI z-score in a pediatric obesity management clinic

BACKGROUND

Multicomponent lifestyle interventions are fundamental in pediatric obesity management. However, whether household food insecurity influences the efficacy of such interventions remains undocumented.

OBJECTIVE

The objective was to compare changes in body mass index z-score (BMIz) among children whose family received lifestyle counseling at a pediatric obesity management clinic in Montreal (Canada) according to their household food security status.

METHODS

This is a retrospective, longitudinal analysis of medical records of children (2-17 years) with overweight or obesity who received lifestyle counseling at a pediatric obesity management clinic. The number of visits at the clinic and the duration of the follow-up were individualized. Household food security status was assessed using Health Canada's Household Food Security Survey Module at the first visit at the clinic. BMIz was calculated and updated at each visit. A reduction of ≥0.25 in BMIz between the last and the first visit at the clinic was considered clinically meaningful. Statistical significance was considered at P<0.05.

RESULTS

Among the 214 children included in the study, 83 (38.8%) lived in a food insecure household. In multivariable-adjusted analyses, differences in BMIz between the last and the first appointment tended to be smaller among children who lived in a food insecure household compared with those in a food secure household [ΔBMIz_{food insecurity}=-0.432 (95% confidence interval (CI): -0.672, -0.193) vs ΔBMIz_{food security}=-0.556 (95% CI: -0.792, -0.319; P=0.14)]. Differences were most notable in the first 6 months of follow-up. The odds ratio of achieving a clinically significant reduction in BMIz over follow-up associated with household food insecurity, compared with household food security, was 0.57 (95% CI: 0.31, 1.05; P=0.07).

CONCLUSIONS

In this sample of children followed at a pediatric obesity clinic, those who lived in a food insecure household experienced smaller BMIz reductions compared with those who lived in a food secure household.

High prevalence of periodontitis in children and adolescents with type 2 diabetes

BACKGROUND

The aim of the present study was to determine the prevalence of periodontitis in children and adolescents with type 2 diabetes, and if poor glycemic control is associated with increasing prevalence of the disease.

METHODS

This is a cross-sectional study involving children and adolescents with type 2 diabetes. A questionnaire related to oral health care history and oral health behaviors was administered to each participant and they then underwent a full-mouth oral evaluation. In addition, clinical and metabolic parameters were extracted from the clinical chart.

RESULTS

One hundred and twenty one children and adolescents (8-17 years, 11 months) participated. Overall, 45.5% presented some degree of periodontitis, with 10 (8.3%) mild, 36 (29.8%) moderate, and nine (7.4%) severe. The periodontitis group (PD-group) had higher mean gingival and plaque indexes, periodontal probing depth, and clinical attachment loss than the group without periodontitis (NoPD-group) (p<0.05). A statistically significant relationship between the prevalence of periodontitis and glycosylated hemoglobin (HbA1c) was verified in the bivariate (odds ratio [OR] 1.31 [95% CI, 1.13-1.53], p = 0.001) and multivariate (OR, 1.29 [95% CI, 1.03-1.61], p = 0.03) analysis. For the adjustment variables, associations were verified for duration of diabetes, age, body mass index z-score, lack of running water, insulin use, and acanthosis nigricans.

CONCLUSIONS

Children and adolescents with type 2 diabetes presented high rates of periodontitis comparable with that seen in previous studies in youth with diabetes. Uncontrolled HbA1c influences prevalence of periodontal disease. The lack of matched control group and radiographs are limitations of the study. Comprehensive periodontal examination is essential for children and adolescents with type 2 diabetes to prevent, identify, and treat periodontitis early.

Developing a risk assessment tool for insulin resistance in European adolescents: the HELENA-IR score

OBJECTIVES

To develop and validate an easy-to-use screening tool for identifying adolescents at high-risk for insulin resistance (IR).

METHODS

Α total of 1,053 adolescents (554 females), aged 12.5 to 17.5 years with complete data on glucose and insulin levels were included. Body mass index (BMI), fat mass index (FMI) and the homeostasis model assessment for insulin resistance (HOMA-IR) were calculated. VO₂max was predicted using 20 m multi-stage fitness test. The population was randomly separated into two cohorts for the development (n=702) and validation (n=351) of the index, respectively. Factors associated with high HOMA-IR were identified by Spearman correlation in the development cohort; multiple logistic regression was performed for all identified independent factors to develop a score index. Finally, receiver operating characteristic (ROC) analysis was performed in the validation cohort and was used to define the cut-off values that could identify adolescents above the 75th and the 95th percentile for HOMA-IR.

RESULTS

BMI and VO₂max significantly identified high HOMA-IR in males; and FMI, TV watching and VO₂max in females. The HELENA-IR index scores range from 0 to 29 for males and 0 to 43 for females. The Area Under the Curve, sensitivity and specificity for identifying males above the 75th and 95th of HOMA-IR percentiles were 0.635 (95%CI: 0.542-0.725), 0.513 and 0.735, and 0.714 (95%CI: 0.499-0.728), 0.625 and 0.905, respectively. For females, the corresponding values were 0.632 (95%CI: 0.538-0.725), 0.568 and 0.652, and 0.708 (95%CI: 0.559-0.725), 0.667 and 0.617, respectively. Simple algorithms were created using the index cut-off scores.

CONCLUSIONS

Paediatricians or physical education teachers can use easy-to-obtain and non-invasive measures to apply the HELENA-IR score and identify adolescents at high risk for IR, who should be referred for further tests.

The Prevalence of Obesity Among Children With Type 2 Diabetes: A Systematic Review and Meta-analysis

Importance

The childhood obesity epidemic is presumed to drive pediatric type 2 diabetes (T2D); however, the global scale of obesity in children with T2D is unknown.

Objectives

To evaluate the global prevalence of obesity in pediatric T2D, examine the association of sex and race with obesity risk, and assess the association of obesity with glycemic control and dyslipidemia.

Data Sources

MEDLINE, Embase, CINAHL, Cochrane Library, and Web of Science were searched from database inception to June 16, 2022.

Study Selection

Observational studies with at least 10 participants reporting the prevalence of obesity in patients with pediatric T2D were included.

Data Extraction and Synthesis

Following the Meta-analysis of Observational Studies in Epidemiology reporting guideline, 2 independent reviewers in teams performed data extraction and risk of bias and level of evidence analyses. The meta-analysis was conducted using a random-effects model.

Main Outcomes and Measures

The primary outcomes included the pooled prevalence rates of obesity in children with T2D. The secondary outcomes assessed pooled prevalence rates by sex and race and associations between obesity and glycemic control and dyslipidemia.

Results

Of 57 articles included in the systematic review, 53 articles, with 8942 participants, were included in the meta-analysis. The overall prevalence of obesity among pediatric patients with T2D was 75.27% (95% CI, 70.47%-79.78%), and the prevalence of obesity at diabetes diagnosis among 4688 participants was 77.24% (95% CI, 70.55%-83.34%). While male participants had higher odds of obesity than female participants (odds ratio, 2.10; 95% CI, 1.33-3.31), Asian participants had the lowest prevalence of obesity (64.50%; 95% CI, 53.28%-74.99%), and White participants had the highest prevalence of obesity (89.86%; 95% CI, 71.50%-99.74%) compared with other racial groups. High heterogeneity across studies and varying degrees of glycemic control and dyslipidemia were noted.

Conclusions and Relevance

The findings of this systematic review and meta-analysis suggest that obesity is not a universal phenotype in children with T2D. Further studies are needed to consider the role of obesity and other mechanisms in diabetes genesis in this population.

Mental health comorbidity is common in children with type 2 diabetes

OBJECTIVE

To describe the prevalence of mental health comorbidity in children with type 2 diabetes compared to a matched population without diabetes and children with type 1 diabetes.

RESEARCH DESIGN AND METHODS

Population-based cohorts of 528 youth (7-18 years of age) with prevalent type 2 diabetes, 1519 matched children without diabetes and 778 youth with type 1 diabetes were identified from a clinical registry and linked to provincial health care records to assess the prevalence of mental health comorbidity using ICD-9CM, ICD-10CA and ATC codes.

RESULTS

The majority of children with type 2 diabetes were of First Nations heritage. Compared to their matched peers, children with type 2 diabetes where more likely to have a mood or anxiety disorder before and after diagnosis [RR 2.38 (1.63, 3.48) p < 0.001 and 1.70 (1.39, 2.08) p < 0.001 respectively], to attempt/complete suicide [RR 3.18 (1.30, 7.81) p = 0.012 and 2.18 (1.32, 3.60) p = 0.0002 respectively] and be prescribed an antipsychotic [RR 2.33 (1.23, 4.39) p = 0.009 and 1.76 (1.23, 2.52) p = 0.002 respectively]. Following adjustment for age and sex, children with type 2 diabetes, compared to children with type 1 diabetes where more likely to have a mood or anxiety disorder and be prescribed an antipsychotic after diagnosis [RR 1.43 (1.07, 1.91) p = 0.015; RR 2.41 (1.44, 4.06) p = 0.0009 respectively].

CONCLUSIONS

Children with type 2 diabetes have high rates of comorbid mental illness. Programs to provide care, support, and education must address the mental health comorbidity in the context of the demographic, socioeconomic, and psycho-cultural characteristics of the population.

Hospitalization and comorbidity in children with type 2 diabetes

OBJECTIVE

To describe hospitalization rates and reasons for hospitalization in children with type 2 diabetes (T2D) and to compare these rates to a matched cohort without diabetes and to children with type 1 diabetes (T1D).

METHODS

Population-based cohorts of 528 children (7-18 years of age) with prevalent T2D, 1519 matched control children without diabetes and 778 children with T1D were identified from a clinical registry and linked to health care records to assess hospitalizations and reasons for hospitalizations using ICD-9CM and ICD-10CA codes.

RESULTS

Children with T2D are more likely than their matched controls and children with T1D to be admitted to hospital in the year prior to diagnosis {RR 2.83 (1.77, 4.53) p < 0.0001 and 8.05 (4.05, 16.00) p < 0.0001, respectively}, in the first year post diagnosis {RR 3.19 (2.08, 4.89) p < 0.0001 and 3.04 (1.86, 4.98) p < 0.0001, respectively} and in the 5 year post diagnosis period {RR 1.99 (1.56, 2.53) p < 0.0001 and 1.91 (1.48, 2.46) p < 0.0001, respectively}. Mental illness was the most common cause for hospital admission in both children with T2D and their matched controls.

CONCLUSIONS

This differs from children with T1D where endocrine causes constitute the most common reason for hospital admission. This analysis provides novel data on hospitalization rates and diagnoses in the increasing population of children with T2D. This information is important to inform health care programming and health policy planning to best meet the needs of this population.

Honoring the voices of families: An interpretive description of parents' understandings of, and insights into preventing type 2 diabetes in adolescents

Background

The incidence of type 2 diabetes (T2D) in adolescents is increasing, affecting the overall health and quality of life of adolescents and their families. Despite the serious health consequences of T2D, few studies have explored the role of parents in the prevention of prediabetes and T2D in adolescents. Thus, the purpose was to better understand parents’ insights into strategies needed for the development of interventions to prevent prediabetes and T2D in their adolescents and families.

Methods

Thorne’s Interpretive Description approach was used to guide this second phase of a two-phase study. Using purposeful sampling, parents (n = 12) of adolescents at high risk for developing T2D were interviewed. This study was conducted in accordance with the standards for reporting qualitative research.

Results

Two themes and multiple subthemes emerged: Parents’ Understanding of T2D (High Blood Sugar, Severe Health Impacts, and Managing Your Diet) and It Takes a Village (The Onus is on the Adolescent, Starts at Home with the Parents, We Need More Support, and Getting the Message in Their Face).

Conclusions

These qualitative data were insightful as findings highlighted the parents’ predominant lack of basic knowledge, life skills, and/or resources to prevent prediabetes and T2D in adolescents. The results provided target areas for education and emphasized the importance of using social media as an approach to disseminate important information to adolescents. Parents also identified strategies for prevention interventions for adolescents surrounding prediabetes and T2D that may be effective. Given the increased prevalence of T2D in adolescents, these results are timely and confirm the urgent need for interventions to prevent pediatric prediabetes and T2D. Future research will include the co-design, piloting, and evaluation of feasible family-centered interventions grounded in participants’ experiences and suggestions that are reflective of person-centred goals and needs of adolescents.

Introduction of publicly funded pharmacare and socioeconomic disparities in glycemic management in children and youth with type 1 diabetes in Ontario, Canada: a population-based trend analysis

BACKGROUND

We evaluated the impact of publicly funded pharmacare (Ontario Health Insurance Plan [OHIP]+), which was introduced in Ontario on Jan. 1, 2018, for youth less than 25 years of age, on temporal trends in hemoglobin A_1c (HbA_1c, a measure of glycemic management) and the differential effect on the change in temporal trends in HbA_1c according to socioeconomic status (SES).

METHODS

We conducted a trend analysis using administrative data sets. We included youth aged 21 years, 9 months or younger, residing in Ontario on Jan. 1, 2016, with diabetes diagnosed before age 15 years and before Jan. 1, 2015. We used claims for insulin to measure pharmacare use. We evaluated the change in HbA_1c (%) per 90 days before (Jan. 1, 2016, to Dec. 31, 2017) the introduction of and during (Apr. 1, 2018, to Mar. 31, 2019) OHIP+ coverage, and the difference in the change in HbA_1c according to SES, using segmented regression analysis.

RESULTS

Of 9641 patients, 7041 (73.0%) made an insulin claim. We found a negligible difference in the temporal change in HbA_1c during compared with before OHIP+ coverage that was not statistically significant (β estimate -0.0002, 95% confidence interval [CI] -0.0004 to 0.0000). The size of the effect was slightly greater in those individuals with the lowest SES than in those with the highest SES (β estimate -0.0008, 95% CI -0.0015 to -0.0001).

INTERPRETATION

We found that the effect of OHIP+ on the change in HbA_1c was slightly greater for youth in the lowest SES than for those in the highest SES. Our findings suggest that publicly funded pharmacare may be an effective policy tool to combat worsening socioeconomic disparities in diabetes care and outcomes.

Could Polyphenolic Food Intake Help in the Control of Type 2 Diabetes? A Narrative Review of the Last Evidence

Background:

Diabetes is one of the largest global public health concerns, imposing a heavy global burden on public health as well as socio-economic development, and about 90% of adults with this condition have type 2 diabetes (T2D).

Introduction:

Beyond the hereditary factor, there are several risk factors connected to the development of this syndrome; the lifestyles play, increasingly, a predominant role in the development of the metabolic complications related to T2D and a significant role in the onset of this syndrome is played from an unbalanced diet. Polyphenolic food is plant-based food including vegetables, fruits, whole grains, tea, coffee, and nuts. In recent years, there is growing evidence that plant-foods polyphenols, due to their biological properties, may be nutraceuticals and supplementary treatments for various aspects of T2D. Polyphenols may influence glycemia and T2D through hypoglycemic properties as reduction of insulin resistance, reduced fasting blood glucose, and glycosylated hemoglobin value. Based on several in vitro, animal models and some human studies, is has been detected that polyphenol-rich products modulate carbohydrate and lipid metabolism, attenuate hyperglycemia, dyslipidemia, and insulin resistance, improve adipose tissue metabolism, and alleviate oxidative stress and stress-sensitive signaling pathways and inflammatory processes.

Methods:

This manuscript summarizes human clinical trials issued within the last 5 years linking dietary polyphenols to T2D, with a focus on polyphenolic-foods typical of the Mediterranean diet.

Results:

Polyphenolic food can also prevent the development of long-term diabetes complications including cardiovascular disease, neuropathy, nephropathy, and retinopathy.

Conclusion:

Further investigations as other human clinical studies are needed to obtain the best dose and duration of supplementation with polyphenolic food in T2D patients.

Sociodemographic determinants of chronic kidney disease in Indigenous children

Rates of chronic kidney disease (CKD) are disproportionately increased in Indigenous peoples. The focus has traditionally been on adults, as they experience the highest rates of kidney failure requiring kidney replacement therapy. The impacts of colonization, systemic racism, and sociodemographic marginalization however impact the health of Indigenous peoples across the lifespan. This review presents the social context within which Indigenous children develop and the impact relevant to kidney health across the developmental stages. In utero exposures impact nephron endowment which can manifest in glomerular hyperfiltration and sclerosis as well as an increased risk of congenital anomalies of the kidney and urinary tract. Young children are at increased risk of autoimmune conditions, secondary to infectious and environmental exposures, and are also exposed to the impacts of a Western lifestyle manifesting early onset overweight/obesity. Adolescents begin to manifest more severe metabolic complications such as type 2 diabetes. The impacts of early onset diabetes are associated with aggressive kidney complications and high rates of kidney failure in young adulthood. Finally, the key elements of successful prevention and treatment strategies are discussed including the importance of screening for asymptomatic, modifiable early disease, linked with clinical primary and tertiary care follow-up, and culturally relevant and safe care.

Metformin therapy in pediatric type 2 diabetes mellitus and its comorbidities: A review

Type 2 diabetes (T2D) rates in children and adolescents are rising globally. T2D is a complex and aggressive disease in children with several comorbidities, high treatment failure rates, and insulin needs within a few years from diagnosis. While myriads of pharmacotherapies are licensed to treat adults with T2D, treatments accessible to children and adolescents have been limited until recently. Metformin is an old drug with multiple beneficial metabolic health effects beyond glycemic control. This review discusses Metformin's origins, its mechanisms of action, and evidence for its use in the pediatric population to treat and prevent T2D. We also explore the evidence for its use as an obesity therapy, which is the primary driver of T2D, and T2D-driven comorbidities. While emerging therapies create new horizons for managing pediatric T2D, Metformin remains an inexpensive and safe part of the treatment plans of many T2D children globally for its beneficial metabolic effects.

Patient Centered Studies Focused on Type 2 Diabetes Management, Education, and Family Support: A Scoping Review

BACKGROUND

Although a large amount of research has been conducted in diabetes management, many of the articles do not focus on patient-centered questions and concerns. To address this shortcoming, patients and various other stakeholders from three northern Mississippi communities co-created research questions focused on Type 2 diabetes management.

OBJECTIVE

To identify the diabetes management literature pertaining to each of the six patient-developed research questions from March 2010 to July 2020.

METHODS

A scoping review was conducted via PubMed to identify research articles from March 2010 to July 2020 focused on patient-centered Type 2 diabetes studies relevant to the six research questions.

RESULTS

A total of 1,414 studies were identified via the search strategy and 34 were included for qualitative analysis following article exclusion. For one of the research questions, there were no articles included. For the remaining research questions, the number of articles identified ranged from two to eleven. After analysis of the included articles, it was found that these questions either lacked extensive data or had not been implemented in the practice of diabetes management.

CONCLUSION

Additional research is warranted for three of the five questions, as current evidence is either lacking or contradictory. In the remaining two questions, it seems that adequate current research exists to warrant transitioning to implementation focused studies wherein data may be generated to improve sustainability and scaling of current programming.

Beyond "Watching the Sweets": An interpretive description of adolescent's understandings and insights into preventing prediabetes and type 2 diabetes

PURPOSE

The purpose of this study was to explore adolescents' experiences and knowledge of type 2 diabetes (T2D) and identify appropriate T2D education and prevention interventions for this population.

DESIGN AND METHODS

This interpretive description study was conducted at two urban high schools in midwestern Canada. Participants had been previously screened and considered at high risk for T2D, prediabetes, or as having T2D. Individual, semistructured interviews were conducted with twelve adolescents between the age of 14-19 years meeting these criteria. Thematic analysis was completed using interview transcripts.

RESULTS

Themes and subthemes identified included (1) Type 2 Diabetes: More Than Too Many Sweets (Mostly Diet but Insulin Does Play a Role, and A Serious but Common Disease); (2) Who Holds the Power? (Personal Responsibility for Health, Family as Role Models, and Community Connections); and (3) Bringing Home the Message (Our Considerations for Schools, I need the Expert's Support, and Using Technology to Get the Points Across).

PRACTICE IMPLICATIONS

Findings from this study provide target areas for education and prevention interventions and approaches for working with adolescents surrounding prediabetes and T2D that may be effective.

Prevalence of and risk factors for diabetes mellitus in the school-attending adolescent population of the United Arab Emirates: a large cross-sectional study

OBJECTIVES

The prevalence of diabetes has reportedly increased among adolescents in low-income and middle-income countries of the Middle East and may be linked to social, demographic and economic contextual factors. This study aimed: (1) to estimate the prevalence of self-reported diagnosis of diabetes in the adolescent population of the United Arab Emirates (UAE); (2) to assess differences in the prevalence based on gender and (3) to identify other characteristics of those with diabetes including parental marital status, smoking/illegal drug use, quality of life and nationality.

DESIGN

A secondary data analysis was performed on data from the National Study of Population Health in the UAE, conducted between 2007 and 2009.

SETTING

Large cross-sectional population-based survey study.

PARTICIPANTS

Survey was administered to a stratified random sample of 151 public and private schools from the UAE, across 7 emirates. 6365 school-attending adolescents (12-22 years; mean=16 years) participated.

OUTCOMES

Multivariable logistic regression analysis was used to examine the relationships between diabetes diagnosis and characteristics of participants after adjusting for confounding from other predictors.

RESULTS

The overall prevalence of self-reported diabetes was 0.9% (95% CI 0.7% to 1.2%) and was higher in males 1.5% (95% CI 1.0% to 2.1%) than females 0.5% (95% CI 0.3% to 0.8%), (p<0.001). Children of parents who were not currently married had more than twice the odds of self-reporting diabetes (p=0.031) compared with those with married parents. Adolescents who reported ever smoking/using illegal drugs had more than three times the odds of diabetes (p<0.001).

CONCLUSION

We found a positive association between certain characteristics of adolescents and their diabetes status, including male gender, parental marital status and smoking/illegal drug use. The high prevalence of smoking/illegal drug use among those reporting a diagnosis of diabetes suggests the need for behavioural and mental health interventions for adolescents with diabetes, as well as strong parental support and involvement.

The Aggressive Diabetic Kidney Disease in Youth-Onset Type 2 Diabetes: Pathogenetic Mechanisms and Potential Therapies

Youth-onset Type 2 Diabetes Mellitus (T2DM) represents a major burden worldwide. In the last decades, the prevalence of T2DM became higher than that of Type 1 Diabetes Mellitus (T1DM), helped by the increasing rate of childhood obesity. The highest prevalence rates of youth-onset T2DM are recorded in China (520 cases/100,000) and in the United States (212 cases/100,000), and the numbers are still increasing. T2DM young people present a strong hereditary component, often unmasked by social and environmental risk factors. These patients are affected by multiple coexisting risk factors, including obesity, hyperglycemia, dyslipidemia, insulin resistance, hypertension, and inflammation. Juvenile T2DM nephropathy occurs earlier in life compared to T1DM-related nephropathy in children or T2DM-related nephropathy in adult. Diabetic kidney disease (DKD) is T2DM major long term microvascular complication. This review summarizes the main mechanisms involved in the pathogenesis of the DKD in young population and the recent evolution of treatment, in order to reduce the risk of DKD progression.

Effective oral delivery of Exenatide-Zn2+ complex through distal ileum-targeted double layers nanocarriers modified with deoxycholic acid and glycocholic acid in diabetes therapy

The oral administration route is popular with T2DM patients because they need convenience in lifelong medication. At present, oral Exenatide is not available on the market and therefore the relevant studies are valuable. Herein, we constructed a novel dual cholic acid-functionalized nanoparticle for oral delivery of Exenatide, which was based on the functionalized materials of deoxycholic acid-low molecular weight protamine and glycocholic acid-poly (ethylene glycol)-b-polysialic acid. The hydrophobic deoxycholic acid strengthened the nanoparticles and the hydrophilic glycolic acid targeted to specific transporter. We first condensed Exenatide-Zn²⁺ complex with deoxycholic acid-low molecular weight protamine to prepare nanocomplexes with ζ-potentials of +8 mV and sizes of 95 nm. Then, we used glycocholic acid-poly (ethylene glycol)-b-polysialic acid copolymers masking the positive charge of nanocomplexes to prepare nanoparticles with negative charges of -22 mV and homogeneous sizes of 140 nm. As a result, this dual cholic acid-functionalized nanoparticle demonstrated enhanced uptake and transport of Exenatide, and a special targeting to apical sodium-dependent cholic acid transporter in vitro. Moreover, in vivo studies showed that the nanoparticle effectively accumulated in distal ileum, raised the plasma concentration of Exenatide, prolonged hypoglycemic effect, reduced blood lipid levels, and lightened organ lesions.

Type 2 Diabetes in Youth

The incidence of type 2 diabetes in children and adolescents in the United States rose at an annual rate of 4.8% between 2002-2003 and 2014-2015. Type 2 diabetes progresses more aggressively to complications than type 1 diabetes. For example, in one large epidemiological study, proliferative retinopathy affected 5.6% and 9.1% of children with type 1 and type 2 diabetes, respectively. Screening begins at age 10 or at onset of puberty, and is recommended among children with a BMI% ≥85 with risk factors such as a family history and belonging to a high risk racial or ethnic or racial group. HbA1C% is preferred for screening as it does not require fasting. As distinguishing between type 1 and type 2 diabetes is not straightforward, all children with new onset disease should undergo autoantibody testing. Results of lifestyle interventions for control of type 2 diabetes have been disappointing, but are still recommended for their educational value and the potential impact upon some participants. There is limited evidence for the benefit of newer mediations. Liraglutide, a GLP-1 agonist, however, has been shown to significantly reduce HbA1C% in one study and is now approved for children. Liraglutide should be considered as second line therapy.

Physical activity and cardiometabolic health in adolescents with type 2 diabetes: a cross-sectional study

INTRODUCTION

Youth living with type 2 diabetes display increased risk of cardiovascular disease (CVD). It is unclear if regular physical activity (PA) modifies this risk.

RESEARCH DESIGN AND METHODS

We compared CVD risk factors in a cross-sectional study of 164 youth with type 2 diabetes stratified according to weekly vigorous-intensity PA. Outcomes were hemoglobin A1c (HbA1c), ambulatory blood pressure (BP; ambulatory 24-hour readings), plasma lipoproteins, and albuminuria. The main exposure, vigorous-intensity PA, was quantified with the Adolescent Physical Activity Recall Questionnaire.

RESULTS

Youth were 15±3 years, and 78% lived rurally and 68% were female, with a mean body mass index (BMI) Z-score of 2.4±1.1 and a mean HbA1c of 9.6% ±2.6%. Youth who participated in regular vigorous-intensity PA (40%; n=67) achieved nearly twice the dose of PA than peers who did not (62 vs 34 metabolic equivalent score-hour/week, p=0.001). After adjusting for duration of diabetes, BMI Z-score, sex, and smoking, youth who engaged in vigorous-intensity PA displayed lower HbA1c (9.1% vs 9.9%, p=0.052), diastolic BP (70 mm Hg vs 73 mm Hg, p=0.002), diastolic load (20% vs 26%, p=0.023), and mean arterial pressure (87.3 mm Hg vs 90.3 mm Hg, p<0.01), compared with youth who did not. Compared with youth who did not participate in regular vigorous-intensity PA, those who did also displayed lower odds of albuminuria after adjusting for duration of diabetes, sex, smoking, rural residence, and BMI Z-score (adjusted OR: 0.40, 95% CI 0.19 to 0.84).

CONCLUSIONS

Among youth with type 2 diabetes, participation in vigorous-intensity PA is associated with lower CVD risk.

The Tri-ponderal Mass Index is associated with adiposity in adolescent type 2 diabetes mellitus: a cross-sectional analysis

Pediatric type 2 diabetes mellitus (T2DM) patients are often overweight or obese, yet there are no validated clinical measures of adiposity to stratify cardiometabolic risk in this population. The tri-ponderal mass index (TMI, kg/m³) has recently been reported as a measure of adiposity in children, but there has been no validation of the association of TMI with adiposity in pediatric T2DM. We hypothesized that in children with T2DM, the TMI can serve as a more accurate measure of adiposity when compared to BMI z-score, and that it is associated with components of the metabolic syndrome. This is a cross-sectional secondary data analysis from the Improving Renal Complications in Adolescents with Type 2 Diabetes Through REsearch (iCARE) study (n = 116, age 10.20–17.90 years). Spearman’s correlations and multivariable regression were used in the analyses. When compared to DXA, TMI demonstrated significant correlation with total adiposity versus BMI z-score (TMI r = 0.74, p-value < 0.0001; BMI z-score r = − 0.08, p-value 0.403). In regression analyses, TMI was associated with WHtR (B = 35.54, 95% CI 28.81, 42.27, p-value < 0.0001), MAP dipping (B = 1.73, 95% CI 0.12, 3.33, p-value = 0.035), and HDL (B = − 5.83, 95% CI − 10.13, − 1.54, p-value = 0.008). In conclusion, TMI is associated with adiposity and components of the metabolic syndrome in pediatric T2DM patients.

Cardiovascular Comorbidity Associated With Albuminuria in Youth-Onset Type 2 Diabetes: Analyses From the iCARE Study

OBJECTIVES

Little is known about the relationship between albuminuria in youth with type 2 diabetes (T2D) and cardiovascular risk. We aimed to determine whether youth with T2D and albuminuria have evidence of increased cardiovascular risk and/or early cardiovascular dysfunction compared with youth with T2D without albuminuria.

METHODS

Youth with T2D were stratified by albuminuria status. Cardiovascular risk factors, including body mass index (BMI), 24-hour blood pressure, lipid profile, smoking and smoking exposure, habitual physical activity and screen time, were compared between groups. Left ventricular structure and function and carotid intima-media thickness (cIMT) were evaluated in participants who underwent cardiac imaging.

RESULTS

Two hundred sixty-five youth participated, 83 (31.3%) of whom had albuminuria. Ethnicity, sex, BMI z score, age at diagnosis, duration of diabetes and hepatocyte nuclear factor-1alpha status did not differ between youth stratified by albuminuria. Smoking, exposure to second-hand smoke and low physical activity levels did not differ between groups. Youth with albuminuria were more likely to have hypertension, dyslipidemia and poor glycemic control. Left ventricular structure and carotid cIMT did not differ between groups, but youth with albuminuria had evidence of early left ventricular diastolic dysfunction.

CONCLUSIONS

We found evidence of increased cardiovascular disease risk factors and left ventricular diastolic dysfunction in youth with T2D and albuminuria compared with those without albuminuria, despite a relatively short duration of disease. Thus, albuminuria may serve as a marker of early cardiovascular disease risk in youth with T2D.

Youth perceptions and experiences of type 2 diabetes: Protocol for a collaborative knowledge translation approach and qualitative study

AIMS

The aim of this study is to generate an in-depth understanding of youth perceptions and experiences of living with type 2 diabetes to inform knowledge translation, research and intervention development.

DESIGN

Interpretive descriptive qualitative study.

METHODS

Twenty to 25 youth aged 10-18 years with a diagnosis of type 2 diabetes will be purposively recruited through the Diabetes Education Resource for Children and Adolescents in Winnipeg, Manitoba, and through the Improving Renal Complications in Adolescents With Type 2 Diabetes Through the REsearch [iCARE] cohort. Socio-demographic information will be collected. Semi-structured interviews will occur iteratively with inductive thematic analysis. Data will be professionally transcribed and managed using NVivo 1.0 software. The University Ethics Committee approved this study (May 2020).

DISCUSSION

There is a critical gap in understanding youth experiences of type 2 diabetes. Research involving youth with type 2 diabetes is predominantly quantitative in nature, largely reflecting risk factors, underlying mechanisms and treatment outcomes associated with diabetes management. In-depth qualitative research on youth experiences can help identify youth priorities, provide insight into critical misalignments between stakeholder perspectives, and drive forward a more consolidated youth-centred research agenda.

IMPACT

Understanding and applying knowledge of youth experiences is critical as the prevalence of, and challenges associated with, youth onset type 2 diabetes continues to increase worldwide. This research will generate a robust interpretive description of youth lived experiences and perceptions of type 2 diabetes where such research is lacking, to inform basic and applied research within an interdisciplinary investigative and clinical research team with relevance to other jurisdictions. In response to calls for youth-oriented research in type 2 diabetes, this work will catalyse collaborative knowledge translation using creative and youth-directed initiatives.

Prevalence of Hypertension and Albuminuria in Pediatric Type 2 Diabetes: A Systematic Review and Meta-analysis

Importance

Hypertension and albuminuria are markers of diabetes-related nephropathy and important factors associated with kidney outcomes in pediatric type 2 diabetes. However, their prevalence in these patients is unknown.

Objective

To measure the prevalence of hypertension and albuminuria in pediatric patients with type 2 diabetes and to evaluate the association of sex and race/ethnicity with these conditions.

Data Sources

MEDLINE, Embase, CINAHL, Cochrane Library, Web of Science, the gray literature, and references of the screened articles were searched for human studies from date of database inception to February 20, 2020.

Study Selection

Observational studies with at least 10 participants reporting the prevalence of hypertension and/or albuminuria in pediatric patients with type 2 diabetes were included. Three teams of 2 independent reviewers screened 7614 papers, of which 60 fulfilled the eligibility criteria.

Data Extraction and Synthesis

Three teams of 2 independent reviewers performed data extraction, risk of bias analysis, and level of evidence analyses. The meta-analysis was conducted using a random-effects model and followed the Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines.

Main Outcomes and Measures

The primary outcomes included the pooled prevalence rates (percentages with 95% CI) for hypertension and albuminuria. The secondary outcomes assessed pooled prevalence rates by sex and racial/ethnic group.

Results

Sixty studies were included in the systematic review. Diabetes duration varied from inclusion at diagnosis to 15.0 years after diagnosis, and the reported mean age at diagnosis ranged from 6.5 to 21.0 years. Hypertension prevalence among 3463 participants was 25.33% (95% CI, 19.57%-31.53%). Male participants had higher hypertension risk than female participants (odds ratio [OR], 1.42 [95% CI, 1.10-1.83]), with Pacific Islander and Indigenous youth having the highest prevalence of all racial/ethnic groups (Pacific Islander youth: 26.71% [95% CI, 14.54%-40.72%]; Indigenous youth: 26.48% [95% CI, 17.34%-36.74%]; White youth: 20.95% [95% CI, 12.65%-30.57%]; African American youth: 19.04% [95% CI, 12.01%-27.23%]; Hispanic/Latino youth: 15.11% [95% CI, 6.56%-26.30%]; Asian youth: 18.37% [95% CI, 9.49%-29.23%]). Albuminuria prevalence among 2250 participants was 22.17% (95% CI, 17.34%-27.38%). Pacific Islander youth, Indigenous youth, and Asian youth had higher prevalence rates than White youth (Pacific Islander youth: 31.84% [95% CI, 11.90%-55.47%]; Indigenous youth: 24.27% [95% CI, 14.39%-35.73%]; Asian youth: 23.00% [95% CI, 18.85%-27.41%]; White youth: 12.59% [95% CI, 7.75%-18.33%]), with no sex differences (OR for male vs female participants, 0.68 [95% CI, 0.46-1.01]). Heterogeneity was high among studies, with a low to moderate risk of bias.

Conclusions and Relevance

In this study, markers of diabetes-related nephropathy were commonly detected in pediatric patients with type 2 diabetes, with a disproportionate burden noted among Pacific Islander and Indigenous youth. Personalized management strategies to target kidney outcomes are urgently needed in pediatric patients with type 2 diabetes to alleviate the burden of this condition on the kidneys.

Metformin as a potential therapeutic for neurological disease: mobilizing AMPK to repair the nervous system

Introduction:

Metformin is currently first line therapy for type 2 diabetes (T2D). The mechanism of action of metformin involves activation of AMP-activated protein kinase (AMPK) to enhance mitochondrial function (for example, biogenesis, refurbishment and dynamics) and autophagy. Many neurodegenerative diseases of the central and peripheral nervous systems arise from metabolic failure and toxic protein aggregation where activated AMPK could prove protective.

Areas covered:

The authors review literature on metformin treatment in Parkinson’s disease, Huntington’s disease and other neurological diseases of the CNS along with neuroprotective effects of AMPK activation and suppression of the mammalian target of rapamycin (mTOR) pathway on peripheral neuropathy and neuropathic pain. The authors compare the efficacy of metformin with the actions of resveratrol.

Expert opinion:

Metformin, through activation of AMPK and autophagy, can enhance neuronal bioenergetics, promote nerve repair and reduce toxic protein aggregates in neurological diseases. A long history of safe use in humans should encourage development of metformin and other AMPK activators in preclinical and clinical research. Future studies in animal models of neurological disease should strive to further dissect in a mechanistic manner the pathways downstream from metformin-dependent AMPK activation, and to further investigate mTOR dependent and independent signaling pathways driving neuroprotection.

Adults with diabetes mellitus in Newfoundland and Labrador: a population-based, cross-sectional analysis

BACKGROUND

Although the province of Newfoundland and Labrador has the highest rates of chronic disease in Canada, the current state of many chronic diseases in the province, including diabetes mellitus, has not been well explored. We profiled the demographic characteristics associated with, and the management of, diabetes in Newfoundland and Labrador, including any rural-urban differences.

METHODS

We performed a population-based, cross-sectional analysis using data from the provincial Chronic Disease Registry for fiscal year 2015/16. Patients in the study sample were 20 years of age or older, with documented identifiers for age, sex and geographic location. We examined demographic characteristics, results of screening and diabetes clinical tests (glycated hemoglobin [HbA1c], low-density lipoprotein [LDL] cholesterol and urine albumin-to-creatinine ratio) and hospitalization rates. We described and compared demographic, clinical and hospitalization variables across urban and rural residents of the province.

RESULTS

The study sample consisted of 66 325 individuals with diabetes in Newfoundland and Labrador (mean age 64.1 yr; 56.3% rural residents). Larger proportions of rural than urban residents with diabetes were aged 65 to 79 years (41.2% v. 37.5%), were female (50.2% v. 48.7%) and were identified as having the disease by laboratory tests only (19.6% v. 13.1%). Rural residents had worse clinical test outcomes than their urban counterparts, specifically with respect to HbA1c (mean and standard deviation [SD], 7.41% [SD 1.49] v. 7.26% [SD 1.50]) and LDL cholesterol (mean 2.46 [SD 0.95] v. mean 2.36 [SD 0.94] mmol/L). A total of 13.7% of individuals were admitted to hospital during the cohort year, with slightly more rural residents admitted for renal disease (standardized difference 0.021, 95% confidence interval 0.005 to 0.036).

INTERPRETATION

For many individuals with diabetes in Newfoundland and Labrador, recommended targets for diabetes management are not being met, and residents in rural areas have poorer clinical outcomes. To inform the development and implementation of targeted provincial strategies for chronic disease management, further research is needed to determine how outcomes relate to the availability of primary health care services.

Country-Specific Prevalence and Incidence of Youth-Onset Type 2 Diabetes: A Narrative Literature Review

BACKGROUND

With increased awareness of type 2 diabetes (T2D) in children and adolescents, an overview of country-specific differences in epidemiology data is needed to develop a global picture of the disease development.

SUMMARY

This study examined country-specific prevalence and incidence data of youth-onset T2D published between 2008 and 2019, and searched for national guidelines to expand the understanding of country-specific similarities and differences. Of the 1,190 articles and 17 congress abstracts identified, 58 were included in this review. Our search found the highest reported prevalence rates of youth-onset T2D in China (520 cases/100,000 people) and the USA (212 cases/100,000) and lowest in Denmark (0.6 cases/100,000) and Ireland (1.2 cases/100,000). However, the highest incidence rates were reported in Taiwan (63 cases/100,000) and the UK (33.2 cases/100,000), with the lowest in Fiji (0.43 cases/100,000) and Austria (0.6 cases/100,000). These differences in epidemiology data may be partly explained by variations in the diagnostic criteria used within studies, screening recommendations within national guidelines and race/ethnicity within countries. Key Messages: Our study suggests that published country-specific epidemiology data for youth-onset T2D are varied and scant, and often with reporting inconsistencies. Finding optimal diagnostic criteria and screening strategies for this disease should be of high interest to every country.

TRIAL REGISTRATION

Not applicable.

Incorporating Risk Stratification Into the Practice of Pediatric Preventive Cardiology

Atherosclerosis in its earliest stages is associated with the same traditional cardiovascular disease (CVD) risk factors as are associated with manifest CVD events in adulthood. Clustering of risk factors is associated with exponential increases in atherosclerotic burden from a young age. Some medical conditions and risk behaviours occurring in children can either increase the likelihood of higher levels of risk factors (such as chronic kidney disease) or the presence of risk factor clustering (such as obesity and cardiometabolic syndrome) or are associated with acquired coronary artery pathology (such as Kawasaki disease). This creates a milieu for-or increases the impact of-accelerated atherosclerosis that, in turn, increases the likelihood of premature CVD. This review highlights the importance of considering the total risk factor and risk-condition profile of pediatric patients. An algorithm is provided for stratifying patients into high-, moderate-, and at-risk categories, and practical examples are provided as to how the evaluation and management of 1 risk factor or risk condition might need to be intensified in the context of additional risk factors or risk conditions. For example, for treatment of an adolescent with familial hypercholesterolemia, the target low-density lipoprotein cholesterol level might be lowered by the concomitant presence of low high-density lipoprotein cholesterol or elevated lipoprotein(a) levels. As awareness of cardiovascular risk and atherosclerosis in pediatric patients increases, new at-risk conditions that warrant consideration are emerging. The identification and management of high-risk individuals is an important part of the overall practice of pediatric preventive cardiology.

Undiagnosed prehypertension/hypertension in Canadian adolescents: The critical role of the public health nurse

OBJECTIVE

To investigate the prevalence of undiagnosed prehypertension/hypertension and other associated comorbidities in adolescents living in rural and urban settings in a mid-Western Canadian province.

DESIGN AND MEASURES

Data reported herein were derived from two cross-sectional studies, whereby adolescents attending either a rural (N = 143) or urban (N = 253) school were screened for blood pressure, anthropometric measures, and blood glucose measurements. Data analysis included descriptive and inferential statistics in addition to chi-square analyses.

RESULTS

Notable prevalence of undiagnosed prehypertension/hypertension was found. Adolescents living in urban settings (49%, N = 123) were significantly more likely to have prehypertension/hypertension than rural (23%, N = 33) living adolescents. With regard to other comorbidities, the prevalence of elevated HbA1c in the urban group (32%) was significantly higher than the rural adolescents (19%); however, there was similar prevalence of overweight/obese adolescents between the urban (37%) and rural (36%) groups.

CONCLUSIONS

The prevalence of adolescent undiagnosed prehypertension/hypertension, elevated blood glucose measurements, and overweight/obesity is concerning in both urban and rural settings. Public health nurses are uniquely positioned in health care to facilitate interventions focused on preventing and managing adolescent prehypertension/hypertension and its associated comorbidities.

Insights on the current status and advancement of diabetes mellitus type 2 and to avert complications: An overview

Type 2 diabetes mellitus (T2DM) is an endocrine metabolic disorder, occurring worldwide due to aging, advancement in lifestyle by modernization. T2DM is characterized by higher levels of glucose in the blood due to unresponsive secretion of pancreatic insulin and insulin activity or altogether. T2DM is regarded as a powerful genetic susceptible disease that leads to high risk with insulin resistance and β-cell dysfunction. To manage and overcome type 2 diabetes, physical activity, diet strategies, and other therapeutic medications along with usage of antiglycemic agents are developed and attempted appropriately. In the present review, attention has been focused on the understanding of T2DM outcomes, complications with possible management strategies, and pathophysiology of T2DM. Further, a detailed note on antiglycemic agents in use and other possible drugs of choice was discussed in the light of current preventive strategies are presented in this review.

The prevalence of undiagnosed Prediabetes/type 2 diabetes, prehypertension/hypertension and obesity among ethnic groups of adolescents in Western Canada

Background

An increased incidence of type 2 diabetes in youth is occurring worldwide. While diverse ethnic groups are disproportionately affected by type 2 diabetes, studies that explore ethnic differences and undiagnosed prediabetes/type 2 diabetes in adolescents are scarce. This paper compares the prevalence of undiagnosed prediabetes and type 2 diabetes and the associated risk factors among various ethnic groups of adolescents living in Western Canada.

Methods

The data for this study were derived from two previous studies in which 396 adolescents, aged 14 to 19 years and living in a western Canadian province, were screened for undiagnosed prediabetes, diabetes, and any associated risk factors. Risk was determined by demographics, family history, anthropometric measurements (body mass index, BMI), blood pressure (BP), and HbA1c. Descriptive and inferential statistics (SPSS) were used to establish both risk and prevalence for prediabetes and type 2 diabetes. Chi-square analyses were done to determine if the risk factors occurred at higher frequencies in certain ethnicities.

Results

Based on BP, BMI, and HbA1c measurements, several statistically significant differences were identified in relation to ethnicity. Many of the adolescents had increased HbA1c levels, with 27.3% considered high risk and 2.3% in the prediabetes range; these high risk and prediabetes groups were heavily represented by Filipino (46%), Indigenous (22%), and European (10%) adolescents. Notable prevalence of prehypertension (17.7%) and hypertension (21.7%) were reported in European (59%) followed by Filipino (50%) and Indigenous (26%) adolescents. Higher numbers of adolescents in the European and Filipino ancestry groups had two or more risk factors (BP, BMI, & HbA1c) for developing type 2 diabetes in relation to the adolescents from the Indigenous group.

Conclusions

Ethnic adolescent groups demonstrate a notable prevalence of undiagnosed prediabetes and type 2 diabetes. Specifically, a significant number of Filipino adolescents had both increased HbA1c and blood pressure that has gone undetected. Earlier onset of type 2 diabetes is congruent with an increased risk of developing diabetes-associated complications and, ultimately, diabetes-related morbidity and mortality at a younger age. Future studies should explore how genetic and/or environmental factors among ethnic groups may contribute to early onset hypertension and prediabetes/type 2 diabetes.

Prevalence, incidence and outcomes of diabetes in Ontario First Nations children: a longitudinal population-based cohort study

BACKGROUND

First Nations people are known to have a higher risk of childhood-onset type 2 diabetes, yet population-level data about diabetes in First Nations children are unavailable. In a partnership between Chiefs of Ontario and academic researchers, we describe the epidemiologic features and outcomes of diabetes in First Nations children in Ontario.

METHODS

We created annual cohorts from 1995/96 to 2014/15 using data from the Registered Persons Database linked with the federal Indian Register. We used the Ontario Diabetes Database to identify children with all types of diabetes and calculated the prevalence and incidence for First Nations children and other children in Ontario. We describe glycemic control in First Nations children and other children in 2014.

RESULTS

In 2014/15, there were 254 First Nations children and 10 144 other children with diagnosed diabetes in Ontario. From 1995/96 to 2014/15, the prevalence increased from 0.17 to 0.57 per 100 children, and the annual incidence increased from 37 to 94 per 100 000 per year among First Nations children. In 2014/15, the prevalence of diabetes was 0.62/100 among First Nations girls and 0.36/100 among other girls. The mean glycosylated hemoglobin level among First Nations children was 9.1% (standard deviation 2.7%) and for other children, 8.5% (standard deviation 2.1%).

INTERPRETATION

First Nations children have substantially higher rates of diabetes than non-Aboriginal children in Ontario; this is likely driven by an increased incidence of type 2 diabetes and increased risk for diabetes among First Nations girls. There is an urgent need for strategies to address modifiable factors associated with the risk of diabetes, improve access to culturally sensitive diabetes care and improve outcomes for First Nations children.

Metabolic Syndrome and Prediabetes Among Yemeni School-Aged Children

PURPOSE

In view of the high rate of obesity and physical inactivity as well as the rising incidence of Type 2 DM among children in the neighboring Gulf countries and Middle East region; the aim of this study was, therefore, to determine the prevalence of metabolic syndrome (MetS) and prediabetes in Yemeni school-aged children.

PATIENTS AND METHODS

In this study, 1402 school children aged 12-13 years old (grade 7) were recruited from public schools in the capital Sana'a during the period April-May 2013. Anthropometric measurements and BP were recorded and BMI was calculated. Fasting venous blood (5 mL) was collected for biochemical analysis including FBG, HbA1c, insulin and lipids profile. Insulin resistance (HOMA-IR) and β-cell function (HOMA-β) were calculated.

RESULTS

The prevalence of prediabetes (as defined by impaired fasting glucose) and MetS (as classified by the IDF 2007) were 0.86% and 0.5%, respectively. Our results also showed 5.21% and 20.26% of the children to have two or one factor(s) of the MetS criteria fulfilled, respectively, with low HDL-c (17%) being the most prevalent MetS component, followed by metabolic glucose (8%), raised TG (5.3%), DBP (1.4%), and high WC (0.5%). Moreover, the prevalence of overweight and obesity was 4.2% and 2.8%, respectively; and about 1.2% of children had abnormal high insulin levels. Children with impaired fasting glucose (IFG) had increased HOMA-IR (p = 0.016) and SBP (p = 0.042) and decreased HDL-c (p = 0.034) and HOMA-β (p < 0.001); whereas obese children had increased WC (p < 0.001) and TG (p = 0.049).

CONCLUSION

The main finding of this study is that Yemeni children are at potential risk of obesity, metabolic syndrome and prediabetes despite their low prevalences. These results highlight the need for early identification and close monitoring of children at risk of later Type 2 DM as an important primary care strategy that can effectively prevent or delay the onset of such condition.

Exploring the Prevalence of Undiagnosed Prediabetes, Type 2 Diabetes Mellitus, and Risk Factors in Adolescents: A Systematic Review

PROBLEM

The prevalence of prediabetes and type 2 diabetes (T2D) is increasing in adolescents worldwide. Most studies have focused on the clinical features, treatment, and complications for adolescents and so the need to generate insight into the risk factors and prevalence of undiagnosed prediabetes and T2D in adolescents across the globe remains.

ELIGIBILITY CRITERIA

Relevant articles that were published from 2007 up to and including January 2017 were identified through electronic searches of CINAHL, Cochrane, Medline, PsycInfo, PubMed, Scopus, Web of Science, and Sociological Abstracts (Proquest). Four independent researchers examined the articles for eligibility.

SAMPLE

Sixteen studies were included that investigated the risk and prevalence of undiagnosed prediabetes and T2D in adolescents aged 12-19.

RESULTS

The most commonly measured risk factors included obesity/overweight, family history, and ethnicity. Other studies measured risk factors associated with insulin resistance, including hypertension, acanthosis nigricans, and dyslipidemia. Prevalence of undiagnosed prediabetes and T2D varied among regions globally with rates ranging from 3.3 to 14.3% and 0.1 to 2.2%, respectively.

CONCLUSIONS

Undiagnosed prediabetes and T2D and the associated risk factors are prevalent in many regions in countries worldwide, significantly impacting adolescents and their families.

IMPLICATIONS

Future research is required to inform interventions aimed at preventative measures for early screening and detection of prediabetes and T2D in adolescents, as well as the development of multi-disciplinary teams that include pediatric nurses and the specialized care they provide.

Translating knowledge into action to prevent pediatric and adolescent diabesity: a meeting report

Background

The obesity and Type 2 Diabetes Mellitus (T2DM) rates are at an all-time high globally. This diabesity epidemic is increasingly impacting children and adolescents, and there is scarce evidence of interventions with favourable long-term outcomes.

Purpose

In order to understand the determinants of diabesity and how to address them, multiple stakeholders were invited to a meeting to discuss current state of knowledge and to help design a program to prevent pediatric and adolescent diabesity.

Participants and methods

The meeting was held at McMaster University on March 4th, 2015. The event involved presentations to deliver state-of-the-art knowledge about diabesity, and roundtable discussions of several domains including nutrition, physical activity, sleep, and mental health. Discussion transcripts were analyzed using NVivo.

Results

Forty-nine participants took part in the workshop. They included clinical healthcare professionals, public health, Aboriginal Patient Navigator, research scientists, students, and patients with family members. A total of 628 reference counts from the roundtable discussions were coded under 20 emerging themes. Participants believed that the most important elements of the program involve the provision of knowledge and education, family involvement, patient motivation, location of program delivery, and use of surveys and questionnaires for outcome measurement.

Conclusion

Effective pediatric and adolescent diabesity prevention programs should be conceptualized by multidisciplinary stakeholders and embrace the complexity of diabesity with multiprong interventions. This meeting provided a framework for developing such interventions.

Metabolic implications of low muscle mass in the pediatric population: a critical review

Skeletal muscle is recognized as a tissue with high metabolic capacity given its key roles in glucose and lipid metabolism. Although low muscle mass has been associated with metabolic disorders in adults, it is not clear if this body composition phenotype is related to metabolic health status earlier in life. In this review, we aim to clarify whether having low muscle mass is associated with increased risk of metabolic dysregulation in the pediatric population. Fifteen original articles investigating the relationship between body composition measures of muscle mass and single or clustered metabolic risk factors in children and adolescents were critically evaluated. Despite a growing body of evidence supporting low muscle mass as a risk factor for metabolic health in children and adolescents, conflicting associations were reported. Differences in body composition techniques, muscle mass indices, and clinical methods used to assess metabolic biomarkers may have contributed to a lack of a consistent conclusion. Moreover, most studies did not control for potential biological and lifestyle confounders. Future studies using precise, reproducible techniques to evaluate body composition and metabolic biomarkers are required to determine the implications of low muscle mass on metabolic health during childhood and adolescence.

Prediabetes: An emerging public health concern in adolescents

OBJECTIVES

To identify the presence of risk factors for type 2 diabetes (ethnicity, body mass index, blood glucose tolerance and blood pressure) and to determine the prevalence of prediabetes and type 2 diabetes in Canadian adolescents attending two multicultural urban high schools.

METHODS

A total of 266 multicultural urban high school students who live in a mid-sized Western Canadian city, aged 14-21, were screened for risk factors of prediabetes and type 2 diabetes in March-April 2018. Data with respect to demographics, family history of diabetes, anthropometrics, blood pressure and haemoglobin A1c (HbA1c) were collected. Data analysis was done using descriptive and inferential statistics in addition to chi-square analyses.

RESULTS

Based on body mass index, 38% of the adolescents were classified as either overweight or obese. Overweight rates for females (69.8%) were double than males (30.2%); however, males (52.2%) were more likely to obese than the females (47.8%). Based on HbA1c levels, 29.3% were at high risk to develop either diabetes or prediabetes and 2.6% were classified in the prediabetes range. Prehypertension/hypertension rates of 47% in the sample increased to 51% in those adolescents with elevated HbA1c; the majority of these prehypertensive/hypertensive participants were male.

CONCLUSION

High rates of overweight/obesity and prehypertension/hypertension were found in the adolescents studied and indicated the presence of prediabetes and an increased risk to develop type 2 diabetes and associated complications. Obesity and hypertension are major risk factors for developing type 2 diabetes, resulting in earlier exposure to metabolic consequences and, ultimately, long-term complications. Thus, timely research is needed to identify age-appropriate strategies that address risks and to develop recommendations for routine screening of adolescents for prediabetes.

Listen… and Speak: A Discussion of Weight Bias, its Intersections with Homophobia, Racism, and Misogyny, and Their Impacts on Health

This article is a version of the Ryley–Jeffs Memorial Lecture, delivered on 8 June 2018. It discusses weight bias and the intersections with homophobia, racism, and misogyny, and how these impact health. While the dominant discourse attests that people can lose weight and keep it off, evidence informs us that maintenance of weight loss is unlikely. Using a flawed epistemological framework, obesity has been declared a disease, and weight bias been perpetuated. Weight bias is pervasive, both in the general public and amongst health professionals, often using inappropriate tools to assess the impact of weight on health. This contributes to overlooking the life circumstances that truly cause morbidity: social determinants of health such as income, social connectedness and isolation, adverse childhood experiences, and cultural erasure. A variety of tools dietitians can use to appropriately assess health risk are provided, along with examples of actions that can be taken to reduce weight bias. Dietitians who are leading the profession in taking action against weight bias and stigma are profiled.