Clinical management of type 2 diabetes in indigenous youth

The Significance of Exposure to Pregestational Type 2 Diabetes in Utero on Fetal Renal Size and Subcutaneous Fat Thickness

Objectives. To determine the relationship between exposure to pregestational type 2 diabetes (T2D) and renal size and subcutaneous fat thickness in fetuses during routine obstetrical ultrasound. Methods. This was a case-control study (January 1, 2019 to December 31, 2019). Routine obstetrical ultrasounds performed between 18 and 22 weeks’ gestation at a tertiary-care fetal assessment unit were reviewed. “Cases” comprised ultrasounds of fetuses exposed to pregestational T2D in utero. The control group was assembled from ultrasounds of healthy controls. Postprocessing measurements of fetal renal size and abdominal wall thickness from stored images were performed by two independent observers, and findings were compared between groups. Results. There were 54 cases and 428 ultrasounds of healthy controls. The mean maternal age of cases was 32.1 years (SD 6.2) compared to 33.2 years (SD 5.3) for healthy controls, and the majority of ultrasounds were performed in multiparous patients (83%). At the 18 to 22 week ultrasound, there was a significant reduction in renal size amongst fetuses exposed to maternal T2D in utero compared to controls; among cases, the mean renal width was 8.0 mm (95% CI 7.8–8.1) compared to 11.4 mm (95% CI 10.6–12.7) in controls ( $p<0.0001$ ); the mean renal thickness among cases was 8.1 mm (95% CI 7.9–8.2) compared to 11.5 mm (95% CI 10.7–12.9) in controls ( $p=0.001$ ). There was no obvious difference in estimated fetal weight between groups, yet fetuses exposed to maternal T2D had increased subcutaneous abdominal wall fat thickness at this early gestational age ( $p=0.008$ ). Conclusions. Fetal renal size in cases exposed to pregestational T2D is significantly smaller compared to controls, and subcutaneous abdominal wall fat is significantly thicker. Given emerging evidence about the developmental origins of disease, further study is needed to correlate the association between fetal renal size and fat distribution in the fetus and the long-term risk of chronic renal disease and diabetes in these offspring.

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.

The Mountain of Health: The Perceptions and Perceived Expectations of Youth Living With Type 2 Diabetes in Winnipeg, Manitoba, Canada, Through a Grounded Theory Study

OBJECTIVE

The objective of this study was to explore youth's perceptions of diabetes management.

METHODS

The study included 8 Manitoban youth with type 2 diabetes (n=7 girls). Each youth participated in a semistructured interview in person, via Skype or over the phone. The constructivist grounded theory methodologic approach guided the analysis of the data.

RESULTS

Discussions about diabetes and health and its management revealed 2 viewpoints: 1) youth's perceptions and 2) youth's perceptions of health-care providers' expectations. The Mountain of Health was used to conceptualize the complex nature of diabetes management. Youth perceived that health-care providers prioritized physical health-behaviour changes in order to achieve successful diabetes management. Conflictingly, many youth described their mental and emotional health as taking precedence over their physical health.

CONCLUSION

Future interventionists should be aware of the vast incongruence in patients' perceptions of health in type 2 diabetes and their perceptions of health-care providers' expectations during the development of interventions.

The incidence, clinical features, and treatment of type 2 diabetes in children <15 yr in a population-based cohort from Auckland, New Zealand, 1995–2007

BACKGROUND

The incidence of type 2 diabetes mellitus (T2DM) is increasing in adolescents in most western countries. The time-course of glycemic control and impact of early treatment remain poorly understood.

OBJECTIVES

To determine the change in incidence of T2DM, and the time-course of glycemic control in a regional pediatric cohort with T2DM.

METHODS

Retrospective analysis of prospectively collected data on 52 patients with T2DM from a population-based treatment referral cohort from 1 January 1995 to 31 December 2007.

RESULTS

The annual incidence of new cases of T2DM in children <15 yr increased fivefold in the Auckland region of New Zealand from 1995 [0.5/100,000; 95% confidence interval (CI) 0.0–2.2] to 2007 (2.5/100,000; 95% CI 1.0–5.5). The average annual incidence per 100,000 over the entire period was 1.3 (95% CI 1.0–1.8) overall, 0.1 (0.0–0.4) in Europeans, and 3.4 in both Maori (2.0–5.3) and Pacifica (2.2–5.0). Fifty-seven percent of children were symptomatic at presentation. Fifty-eight percent of patients were treated with insulin from diagnosis, most of whom were symptomatic (p = 0.003). Follow-up data were available for 48 patients with a mean of 2.4 yr. Although insulin therapy was associated with a greater fall in HbA1c values in the first 12 months of treatment (to a nadir of 7.1 vs. 8.1%, p < 0.05), there was a rapid deterioration after 12 months, and subsequent mean HbA1c values were >9% in both groups. Therapy did not affect body mass index standard deviation score (BMI SDS).

CONCLUSIONS

The incidence of T2DM in childhood or adolescence increased markedly over a 13-yr period in the Auckland region. Long-

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

OBJECTIVES

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

STUDY DESIGN

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

METHODS

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

RESULTS

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

CONCLUSION

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

Poor food and nutrient intake among Indigenous and non-Indigenous rural Australian children

BACKGROUND

The purpose of this study was to describe the food and nutrient intake of a population of rural Australian children particularly Indigenous children. Participants were aged 10 to 12 years, and living in areas of relative socio-economic disadvantage on the north coast of New South Wales.

METHODS

In this descriptive cross-sectional study 215 children with a mean age of 11.30 (SD 0.04) years (including 82 Indigenous children and 93 boys) completed three 24-hour food recalls (including 1 weekend day), over an average of two weeks in the Australian summer of late 2005.

RESULTS

A high proportion of children consumed less than the Australian Nutrient Reference Values for fibre (74-84% less than Adequate Intake (AI)), calcium (54-86% less than Estimated Average Requirement (EAR)), folate and magnesium (36% and 28% respectively less than EAR among girls), and the majority of children exceeded the upper limit for sodium (68-76% greater than Upper Limit (UL)). Energy-dense nutrient-poor (EDNP) food consumption contributed between 45% and 49% to energy. Hot chips, sugary drinks, high-fat processed meats, salty snacks and white bread were the highest contributors to key nutrients and sugary drinks were the greatest per capita contributor to daily food intake for all. Per capita intake differences were apparent by Indigenous status. Consumption of fruit and vegetables was low for all children. Indigenous boys had a higher intake of energy, macronutrients and sodium than non-Indigenous boys.

CONCLUSIONS

The nutrient intake and excessive EDNP food consumption levels of Australian rural children from disadvantaged areas are cause for concern regarding their future health and wellbeing, particularly for Indigenous boys. Targeted intervention strategies should address the high consumption of these foods.

A socioecological framework to understand weight-related issues in Aboriginal children in Canada

Obesity prevention efforts in Aboriginal (First Nations, Métis, or Inuit) communities in Canada should focus predominantly on children given their demographic significance and the accelerated time course of occurrence of type 2 diabetes mellitus in the Aboriginal population. A socioecological model to address childhood obesity in Aboriginal populations would focus on the numerous environments at different times in childhood that influence weight status, including prenatal, sociocultural, family, and community environments. Importantly, for Aboriginal children, obesity interventions need to also be situated within the context of a history of colonization and inequities in the social determinants of health. This review therefore advocates for the inclusion of a historical perspective and a life-course approach to obesity prevention in Aboriginal children in addition to developing interventions around the socioecological framework. We emphasize that childhood obesity prevention efforts should focus on promoting maternal health behaviours before and during pregnancy, and on breastfeeding and good infant and child nutrition in the postpartum and early childhood development periods. Ameliorating food insecurity by focusing on improving the sociodemographic risk factors for it, such as increasing income and educational attainment, are essential. More research is required to understand and measure obesogenic Aboriginal environments, to examine how altering specific environments modifies the foods that children eat and the activities that they do, and to examine how restoring and rebuilding cultural continuity in Aboriginal communities modifies the many determinants of obesity. This research needs to be done with the full participation of Aboriginal communities as partners in the research.

Developmental origins of type 2 diabetes in aboriginal youth in Canada: it is more than diet and exercise

Type 2 diabetes mellitus (T2DM) is classically viewed as a disease of adults caused by poor nutrition, physical inactivity, and obesity. However, with increasing awareness of the heterogeneity of T2DM, new risk factors are being identified that add complexity. Some of these new risk factors have been identified in Canadian people with Aboriginal Oji-Cree heritage, a group that demonstrates one of the highest rates of T2DM in the world. This high prevalence may be due to the rapid change, over the past 50 years, away from their traditional way of life on the land. Another environmental change is the increased rate of pregnancies complicated by obesity, gestational diabetes, or T2DM, resulting in more children being exposed to an abnormal intrauterine environment. Furthermore, the Oji-Cree of central Canada possesses the unique HNF-1α G319S polymorphism associated with reduced insulin secretion. We propose that intrauterine exposure to maternal obesity and T2DM, associated with the HNF-1α G319S polymorphism, results in fetal programming that accelerates the progression of early-onset T2DM. This paper describes the evolution of T2DM in children with a focus on the Oji-Cree people over the past 25 years and the unique prenatal and postnatal gene-environment interaction causing early-onset T2DM.