Estimated morbidity and mortality in adolescents and young adults diagnosed with Type 2 diabetes mellitus

Using normalisation process theory to understand implementation of effective early-onset type 2 diabetes treatment and care within England: a qualitative study

BACKGROUND

Despite increasing prevalence, early-onset type 2 diabetes (EOT2D) has received little clinical and qualitative research attention within England. This qualitative study aimed to explore and understand the unmet needs of people living with early-onset type 2 diabetes (PEOT2D) and their diabetes care within England.

METHODS

Using semi-structured interviews, data was collected, transcribed and analysed from 25 PEOT2D and 25 healthcare professionals (HCPs). Taking an abductive approach, data for both cohorts were analysed and interpreted according to four constructs of Normalisation Process Theory (NPT): coherence (sense-making), cognitive participation (engagement), collective action (enactment) and reflexive monitoring (formal and informal appraisal).

RESULTS

Our findings revealed several unmet needs in current treatment and care for PEOT2D. The main unmet need was access to specialist care. Having GP (general practitioner) practices as their main caregivers presented a significant barrier to this population successfully carrying out their diabetes self-care. HCPs in specialist roles expressed similar views and were keen to see PEOT2D receive access to holistic and specialist care via a multidisciplinary team. Data interpretation according to the four constructs of NPT found that implementation of this approach would involve fostering an environment of support that allowed HCPs across the primary and secondary interface to do the following: (1) provide consultations incorporating person-centred care, shared decision-making, and non-judgemental and non-stigmatising behaviours and (2) work in an integrated and synchronous manner using streamlined referrals, interprofessional collaborations and team-based learning. Provision of tailored financial, human (additional staffing) and learning resources was found to be integral to allow creation of tailored multidisciplinary teams, and individual and collective skill enhancement of both specialist and primary care providers.

CONCLUSION

Although both PEOT2D and specialist care providers are keen for young adults with EOT2D to receive access to specialist and holistic care, there are several resource barriers that must be addressed to allow implementation of their desired approach to treatment and care. Further qualitative research with primary care providers (for example, GPs and practice nurses) involved in EOT2D care is needed to understand if (and how) their views and experiences differ from those providing specialist care.

Loneliness, Discrimination, Stress, and Type 2 Diabetes Risk in Young Adults

INTRODUCTION

The aim of this study was to determine the associations between type 2 diabetes or prediabetes and loneliness and related social experiences in young adults, a population at increasingly high risk of type 2 diabetes.

METHODS

This was a cross-sectional analysis using data from adults aged 18-35 years enrolled in the All of Us Research Program. Exposures included loneliness, social support, discrimination, neighborhood social cohesion, and stress, measured by standardized surveys. The main outcome was type 2 diabetes or prediabetes by self-report or linked health record. Logistic regression determined the odds of type 2 diabetes/prediabetes for each survey measure, adjusting for age, sex, race or ethnicity, income, and family history. Latent class analysis evaluated clustering of social experiences. Data were collected from 2018 to 2022 and analyzed in May 2023-June 2024.

RESULTS

The cohort included 14,217 young adults (aged 28.2 ± 4.4 years, 73.1% [n=10,391] women, 64.1% [n=9,111] White, 10.6% [n=1,506] Hispanic, 5.7% [n=806] Black, and 9.1% [n=1,299] multiracial). Overall, 5.5% (n=777) had either prediabetes or type 2 diabetes. The 2 highest loneliness quartiles were associated with increased odds of prediabetes/type 2 diabetes (Q3: OR=1.42 [95% CI=1.15, 1.76] and Q4: OR=1.78 [95% CI=1.45, 2.19]). Greater stress and discrimination and lower social support and neighborhood social cohesion were also associated with increased odds of prediabetes/type 2 diabetes. Latent class analysis revealed 3 distinct phenotypes, with elevated odds of prediabetes/type 2 diabetes in the 2 with the most adverse social profiles (OR=2.32 [95% CI=1.89, 2.84] and OR=1.28 [95% CI=1.04, 1.58]).

CONCLUSIONS

Loneliness and related experiences are strongly associated with type 2 diabetes and prediabetes in young adults. Whether these factors could be leveraged to reduce type 2 diabetes risk should be investigated.

Health-Related Social Needs Intervention for Adolescents and Young Adults With Type 2 Diabetes and Their Caregivers: An Exploratory Study Using Human-Centered Design

Youth-onset type 2 diabetes (T2D) is increasingly common and projected to impact over 200,000 adolescents and young adults by 2060. Youth with T2D frequently experience health-related social needs (HRSN) that increase their risk for poor outcomes. Using human-centered design methodology, we explored how best to address HRSN in pediatric endocrinology clinics. We conducted two parallel, six-session group meetings with youth (n = 4) and caregivers of youth (n = 6), as well as individual interviews with 12 pediatric endocrinology clinicians. An inductive thematic data analysis approach was used. Participants described that HRSN are pervasive for youth with T2D and are especially impactful after diagnosis. Participants thought that addressing HRSN in healthcare settings was important but emphasized that interventions need to be affirming and provide tangible, relevant resources. Engagement with community health workers trained around diabetes management is needed, as is structural change to disrupt health disparities. Future research and clinical transformation are discussed.

Evaluating the incidence of complications among people with diabetes according to age of onset: Findings from the UK Biobank

AIMS

To examine the impact of current age, age at diagnosis, and duration of diabetes on the incidence rate of complications among people with type 2 diabetes.

METHODS

Baseline data from 19,327 individuals with type 2 diabetes in the UK Biobank were analysed. Poisson regression was used to model incidence rates by current age, age at diagnosis, and duration of diabetes for the following outcomes: myocardial infarction (MI), heart failure (HF), stroke, end-stage kidney diseases (ESKD), chronic kidney diseases (CKD), liver diseases, depression, and anxiety.

RESULTS

The mean age at baseline was 60.2 years, and median follow-up was 13.9 years. Diabetes duration was significantly longer among those with younger-onset type 2 diabetes (diagnosed at <40 years) compared to later-onset type 2 diabetes (diagnosed at ≥40 years), 16.2 and 5.3 years, respectively. Incidence rates of MI, HF, stroke, and CKD had strong positive associations with age and duration of diabetes, whereas incidence rates of ESKD liver diseases, and anxiety mainly depended on duration of diabetes. The incidence rates of depression showed minor variation by age and duration of diabetes and were highest among those diagnosed at earlier ages. No clear evidence of an effect of age of onset of diabetes on risk of complications was apparent after accounting for current age and duration of diabetes.

CONCLUSIONS

Our study indicates age at diagnosis of diabetes does not significantly impact the incidence of complications, independently of the duration of diabetes. Instead, complications are primarily influenced by current age and diabetes duration.

Knowledge, attitude and practices of insulin therapy among patients with type 2 diabetes: a cross-sectional study

OBJECTIVES

This study aimed to assess the knowledge, attitude and practices of patients with type 2 diabetes on insulin regarding insulin therapy.

DESIGN

A cross-sectional study.

SETTING

This study was conducted at the Dubai Diabetes Center from 1 December 2018 to 1 March 2020.

PARTICIPANTS

Face-to-face interviews were conducted for 350 participants with type 2 diabetes at the Dubai Diabetes Center. Interviews followed the structured format of a questionnaire designed to obtain demographic details and score participants on knowledge, attitude and practices. We included patients aged >18 years and receiving insulin therapy. Patients with type 1 diabetes, pregnant women with gestational diabetes, those aged <18 years or those with a history of dementia were excluded.

RESULTS

The median age of participants was 61 years (first quartile, 53 years; third quartile, 67 years); 35.7% were male individuals and 64.3% were female individuals. The median percentage scores for knowledge, attitude and practices were 62.5% (62.5%, 75%), 85.7% (71.4%, 100%) and 77.7% (66.6%, 88.8%), respectively. Highly educated participants had a high level of knowledge. Significant negative correlations were found between the percentage knowledge scores and participants' age and between the participants' percentage attitude scores and haemoglobin A1C levels; Spearman's correlations were -0.182 (p<0.001) and -0.14 (p=0.008), respectively. A significant positive Spearman's correlation of 0.123 (p=0.021) was found between the percentage knowledge and percentage practice scores. No correlations were found among knowledge levels, participants' haemoglobin A1c levels and duration of insulin use.

CONCLUSION

Patients with type 2 diabetes receiving insulin therapy and attending the Dubai Diabetes Center had adequate knowledge, a positive attitude and correct practice regarding insulin therapy. However, knowledge of specific facts did not always translate into correct behaviours and practices.

Associations between food insecurity and diabetes risk factors in US adolescents in the National Health and Nutrition Examination Survey (NHANES) 2007-2016

OBJECTIVE

To evaluate the associations between household food insecurity and diabetes risk factors among lower-income US adolescents.

DESIGN

Cross-sectional analysis. Household food security status was measured using the 18-item Food Security Survey Module. Simple and multivariable linear and logistic regressions were used to assess the association between food security status and fasting plasma glucose (FPG), oral glucose tolerance test (OGTT), HbA1C and homoeostatic model assessment - insulin resistance (HOMA-IR). The analyses were adjusted for household and adolescent demographic and health characteristics.

SETTING

USA.

PARTICIPANTS

3412 US adolescents aged 12-19 years with household incomes ≤300 % of the federal poverty line from the National Health and Nutrition Examination Survey cycles 2007-2016.

RESULTS

The weighted prevalence of marginal food security was 15·4 % and of food insecurity was 32·9 %. After multivariate adjustment, adolescents with food insecurity had a 0·04 % higher HbA1C (95 % CI 0·00, 0·09, P-value = 0·04) than adolescents with food security. There was also a significant overall trend between severity of food insecurity and higher HbA1C (Ptrend = 0·045). There were no significant mean differences in adolescents' FPG, OGTT or HOMA-IR by household food security.

CONCLUSIONS

Food insecurity was associated with slightly higher HbA1c in a 10-year sample of lower-income US adolescents aged 12-19 years; however, other associations with diabetes risk factors were not significant. Overall, this suggests slight evidence for an association between food insecurity and diabetes risk in US adolescents. Further investigation is warranted to examine this association over time.

Postprandial Metabolite Profiles and Risk of Prediabetes in Young People: A Longitudinal Multicohort Study

OBJECTIVE

Prediabetes in young people is an emerging epidemic that disproportionately impacts Hispanic populations. We aimed to develop a metabolite-based prediction model for prediabetes in young people with overweight/obesity at risk for type 2 diabetes.

RESEARCH DESIGN AND METHODS

In independent, prospective cohorts of Hispanic youth (discovery; n = 143 without baseline prediabetes) and predominately Hispanic young adults (validation; n = 56 without baseline prediabetes), we assessed prediabetes via 2-h oral glucose tolerance tests. Baseline metabolite levels were measured in plasma from a 2-h postglucose challenge. In the discovery cohort, least absolute shrinkage and selection operator regression with a stability selection procedure was used to identify robust predictive metabolites for prediabetes. Predictive performance was evaluated in the discovery and validation cohorts using logistic regression.

RESULTS

Two metabolites (allylphenol sulfate and caprylic acid) were found to predict prediabetes beyond known risk factors, including sex, BMI, age, ethnicity, fasting/2-h glucose, total cholesterol, and triglycerides. In the discovery cohort, the area under the receiver operator characteristic curve (AUC) of the model with metabolites and known risk factors was 0.80 (95% CI 0.72-0.87), which was higher than the risk factor-only model (AUC 0.63 [0.53-0.73]; P = 0.001). When the predictive models developed in the discovery cohort were applied to the replication cohort, the model with metabolites and risk factors predicted prediabetes more accurately (AUC 0.70 [95% CI 40.55-0.86]) than the same model without metabolites (AUC 0.62 [0.46-0.79]).

CONCLUSIONS

Metabolite profiles may help improve prediabetes prediction compared with traditional risk factors. Findings suggest that medium-chain fatty acids and phytochemicals are early indicators of prediabetes in high-risk youth.

The burden of type 2 diabetes in adolescents and young adults in Mexico: analysis from the Global Burden of Disease Study, 1990 to 2019

Purpose

The aim was to analyze the findings from the 2019 Global Burden of Disease (GBD-2019) study on type-2 diabetes in Mexico's adolescents and young adults, at a national and subnational scale from 1990 to 2019, and to assess its association with the socio-demographic, and the healthcare access and quality indices.

Methods

Following the GBD-2019 study, young-onset type 2 diabetes mortality, premature mortality, years lived with disability and disability-adjusted life-years (DALYs) are reported.

Results

A significant increase in the overall number of deaths attributed to young-onset T2D was found. There was a non-significant decrease in mortality rates for both sexes across most age groups. DALYs in men were greater than that in women, with almost half attributed to premature death in males, while disability accounted for two thirds of DALYs in females. The DALY rate increased significantly in most states. Premature mortality decreased, while disability increased across all age-groups, and in all states for both sexes.

Conclusion

The surge in disability corresponded to the upsurge in obesity and overweight rates in Mexico among the younger population. This happened despite improvements in socio-economic status and healthcare access in Mexico which underscores the need for diabetes education in the public health sector.

School-based peer-led diabetes intervention among female adolescents: a cluster randomized trial

BACKGROUND

The prevalence of type 2 diabetes is increasing among adolescents and clear strategies are needed to prevent it. The aim of this study was to determine the effect of peer education on knowledge, health beliefs and preventive behaviors of type 2 diabetes in female adolescents.

METHODS

In this cluster randomized trial study, 168 students (84 people in each group) were enrolled. The data collection instrument was a questionnaire of knowledge (30 questions), health beliefs (16 questions) and behavior (20 questions) whose validity and reliability were confirmed. Then eight capable students were chosen as peer educators after being trained. The intervention group received 8 sessions of 90-min education through training, lectures, question and answer, and group discussion and with teaching aids such as pamphlets, educational clips and text messages. The post-test was administered two months after the treatment. Data collected using software SPSS16 and Chi-Square and ANCOVA test were used.

RESULTS

The result showed that the mean and standard deviation of general knowledge, disease symptoms, behavioral risk factors, mid-term outcomes and long-term outcomes, perceived self-efficacy, behavioral beliefs, perceived susceptibility, perceived severity, prevention of stress, healthy food/healthy diet, unhealthy food/unhealthy diet, high-risk behavior, and self-care in the intervention group has increased significantly 2 months after intervention compared of control group (P < 0.001).

CONCLUSIONS

Peer education increased knowledge and improved adolescents' health beliefs and behaviors. Therefore, training in adolescence in order to prevention of diabetes can be considered as an effective step, and the use of peer-led education in this field is recommended.

TRIAL REGISTRATION

Trial registration number IRCT20200811048361N1 from School of Public Health & Neuroscience Research Center-Shahid Beheshti University of Medical Sciences. Date applied: 30/12/2020. Date assigned: 01/12/2020.

Youth versus adult-onset type 2 diabetic kidney disease: Insights into currently known structural differences and the potential underlying mechanisms

Type 2 diabetes (T2D) is a global health pandemic with significant humanitarian, economic, and societal implications, particularly for youth and young adults who are experiencing an exponential rise in incident disease. Youth-onset T2D has a more aggressive phenotype than adult-onset T2D, and this translates to important differences in rates of progression of diabetic kidney disease (DKD). We hypothesize that youth-onset DKD due to T2D may exhibit morphometric, metabolic, and molecular characteristics that are distinct from adult-onset T2D and develop secondary to inherent differences in renal energy expenditure and substrate metabolism, resulting in a central metabolic imbalance. Kidney structural changes that are evident at the onset of puberty also serve to exacerbate the organ’s baseline high rates of energy expenditure. Additionally, the physiologic state of insulin resistance seen during puberty increases the risk for kidney disease and is exacerbated by both concurrent diabetes and obesity. A metabolic mismatch in renal energetics may represent a novel target for pharmacologic intervention, both for prevention and treatment of DKD. Further investigation into the underlying molecular mechanisms resulting in DKD in youth-onset T2D using metabolomics and RNA sequencing of kidney tissue obtained at biopsy is necessary to expand our understanding of early DKD and potential targets for therapeutic intervention. Furthermore, large-scale clinical trials evaluating the duration of kidney protective effects of pharmacologic interventions that target a metabolic mismatch in kidney energy expenditure are needed to help mitigate the risk of DKD in youth-onset T2D.

ISPAD Clinical Practice Consensus Guidelines 2022: Type 2 diabetes in children and adolescents

Since the 2018 ISPAD guidelines on this topic, follow-up of large cohorts from around the globe have continued informing the current incidence and prevalence of co-morbidities and complications in young adults with youth-onset type 2 diabetes (T2D). This chapter focuses on the risk factors, diagnosis and presentation of youth-onset T2D, the initial and subsequent management of youth-onset T2D, and management of co-morbidities and complications. We include key updates from the observational phase of the multi-center Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY) clinical trial, the SEARCH for Diabetes in Youth (SEARCH) study and new data from the Restoring Insulin Secretion (RISE) study, a head-to-head comparison of youth onset vs adult-onset T2D. We also include an expanded section on risk factors associated with T2D, algorithms and tables for treatment, management, and assessment of co-morbidities and complications, and sections on recently approved pharmacologic therapies for the treatment of youth-onset T2D, social determinants of health, and settings of care given COVID-19 pandemic.

Arterial hypertension is associated with an increased risk of metabolic complications in pediatric patient with obesity

OBJECTIVES

Coexistence of arterial hypertension (AH) in children with obesity increases morbidity and shortens life. Its role as an indicator of coexisting metabolic complications is however less known. The objective of the study was to compare metabolic profiles of children with obesity and with or without AH.

METHODS

We included patients aged 10-18 with the BMI Z-score ≥2. Diagnosis of AH was based on the European Society of Hypertension criteria (2016). Metabolic profiles were assessed by glucose and insulin levels taken before and after glucose load, fasting levels of triglycerides (TG), total (TC), low-density lipoprotein (LDL) and high-density lipoprotein (HDL) cholesterol, and HOMA-IR.

RESULTS

Of 534 patients, 33.5% were diagnosed with AH. The AH patients, as compared to non-AH, had higher fasting insulin levels (22 vs. 19.7 mIU/L, p=0.04), HOMA-IR (4.5 vs. 4.0, p=0.029), and post-load glucose level (6.3 vs. 5.7, p=0.000041). No differences in the post-load insulin levels (113 vs. 100 mIU/L, p=0.056), fasting glucose (4.5 vs. 4.5 mmol/L, p=0.5), or lipids were found (TC: 4.4 vs. 4.4 mmol/L, p=0.9; LDL: 2.7 vs. 2.7, p=0.2; TG: 1.4 vs. 1.4 mmol/L, p=0.5; HDL: 1.1 vs. 1.2, p=0.3.

CONCLUSIONS

Concomitance of AH in children with obesity may be an indicator of coexisting metabolic complications.

Diabetic kidney disease in pediatric patients: A current review

In the last decades, a significant increase in the incidence of diabetic kidney disease (DKD) was observed concomitant with rising diabetes mellitus (DM) incidence. Kidney disease associated with DM in children and adolescents is represented by persistent albuminuria, arterial hypertension, progressive decline in estimated glomerular filtration rate to end-stage renal disease and increased cardiovascular and all-cause morbidity and mortality of these conditions. In medical practice, the common and still the "gold standard" marker for prediction and detection of diabetic kidney involvement in pediatric diabetes is represented by microalbuminuria screening even if it has low specificity to detect early stages of DKD. There are some known limitations in albuminuria value as a predictor biomarker for DKD, as not all diabetic children with microalbuminuria or macroalbuminuria will develop end-stage renal disease. As tubular damage occurs before the glomerular injury, tubular biomarkers are superior to the glomerular ones. Therefore, they may serve for early detection of DKD in both type 1 DM and type 2 DM. Conventional and new biomarkers to identify diabetic children and adolescents at risk of renal complications at an early stage as well as renoprotective strategies are necessary to delay the progression of kidney disease to end-stage kidney disease. New biomarkers and therapeutic strategies are discussed as timely diagnosis and therapy are critical in the pediatric diabetic population.

The impact of birthweight on subsequent phenotype of type 2 diabetes in later life

AIMS

It is well established that low birthweight is associated with subsequent risk of type 2 diabetes (T2DM). The aim of our study was to use a large birth cohort linked to a national diabetes registry to investigate how birthweight impacts the phenotype at diagnosis of T2DM and the subsequent rate of glycaemic deterioration.

METHODS

We linked the Walker Birth Cohort (48,000 births, 1952-1966, Tayside, Scotland) to the national diabetes registry in Scotland (SCI-Diabetes). Birthweight was adjusted for gestational age. Simple linear regression was performed to assess the impact of the adjusted birthweight on the diabetes phenotype at diagnosis. This was then built up into a multiple regression model to allow for the adjustment of confounding variables. A cox proportional hazards model was then used to evaluate the impact of birthweight on diabetes progression.

RESULTS

Lower birthweights were associated with a 293 day younger age of diagnosis of T2DM per 1 kg reduction in birthweight, p = 0.005; and a 1.29 kg/m² lower BMI at diagnosis per 1 kg reduction in birthweight, p < 0.001. There was no significant association of birthweight on diabetes progression.

CONCLUSION

For the first time, we have shown that a lower birthweight is associated with younger onset of T2DM, with those with lower birthweight also being slimmer at diagnosis. These results suggest that lower birthweight impacts on T2DM phenotype via reduced beta-cell function rather than insulin resistance.

Considering metformin as a second-line treatment for children and adolescents with prediabetes

Overweight and obesity affect approximately 1/3 of children in the United States and are risk factors for prediabetes and type 2 diabetes. Progression from prediabetes to diabetes carries substantial long-term health burdens, culminating in decreased life-expectancy. Earlier development of type 2 diabetes is associated with poorer prognoses, and children lose glycemic control more rapidly than adults. Metformin is approved by the USFDA for the treatment of type 2 diabetes in children, has limited toxicity, and may help prevent the development of type 2 diabetes. The more rapid disease progression in children and the safety of metformin suggests that initiation of metformin treatment to children with prediabetes who have not effectively responded to lifestyle changes may help prevent short- and long-term health damage resulting from prediabetic and diabetic dysglycemia.

The Relationship Between Lipoproteins and Insulin Sensitivity in Youth With Obesity and Abnormal Glucose Tolerance

CONTEXT

Youth with obesity and abnormal glucose tolerance have an increased risk for atherosclerosis but the relative contributions of insulin resistance and hyperglycemia to dyslipidemia and the development of subclinical atherosclerosis are unknown.

OBJECTIVE

This work aims to determine the association between insulin resistance, dyslipidemia, and carotid intimal thickness (cIMT) in adolescents with normal and abnormal glucose tolerance.

METHODS

An observational cohort study in 155 youth: 44 obese insulin sensitive (OIS; fasting insulin ≤ 20 µM/mL, body mass index [BMI] ≥ 95th percentile), 35 obese insulin resistant (OIR; fasting insulin > 20 µM/mL, BMI ≥ 95th percentile), 34 obese abnormal glucose tolerant (AGT; BMI ≥ 95th percentile), and 42 Lean (BMI 5th-85th percentile). Lipids, lipoprotein particle size and concentration (-P), insulin sensitivity (SI an intravenous glucose test), and CMIT were compared using linear models adjusted for age, race/ethnicity, biological sex, and Tanner stage. Lipid/lipoprotein profile and CMIT were reevaluated in a subset after 2 years.

RESULTS

Compared to OIS and Lean, OIR and AGT had elevated triglycerides and low high-density lipoprotein cholesterol (HDL-C) but similar total cholesterol and low-density lipoprotein cholesterol (LDL-C). Among OIS, OIR, AGT, lower SI was associated with atherogenic lipids (higher triglycerides, LDL-C, non-HDL-C, and lower HDL-C) and lipoproteins (higher total LDL-P and small HDL-P, and lower large HDL-P). There was a steeper decline in the association of SI with HDL-C and large HDL-P in AGT compared with OIR and OIS. cIMT was comparable across groups and inversely correlated with SI, with no change after 2 years.

CONCLUSION

Among youth with obesity, insulin resistance was associated with an atherogenic lipoprotein/lipid profile and cIMT, regardless of glucose tolerance status. Insulin resistance in AGT youth was associated with a shift to smaller HDL-P compared to normoglycemic youth with obesity. Alterations in HDL-P metabolism may be early adverse manifestations of hyperglycemia in youth with obesity.

Early Education and Adult Health: Age 37 Impacts and Economic Benefits of the Child-Parent Center Preschool Program

This paper evaluates the long-term impacts of the Chicago Child-Parent Center (CPC) program, a comprehensive early childhood program launched in the 1960s, on the physical and mental health outcomes. This study follows a cohort of 1539 participants born in 1979-1980 and surveyed most recently at age 35-37 by employing a matched study design created by including all students who were enrolled in kindergarten classrooms in CPC school sites as well as entire kindergarten classrooms in a matched set of similar high-poverty schools. Using propensity score weighting that addresses potential issues with differential attrition and nonrandom treatment assignment, results reveal that CPC preschool participation is associated with significantly lower rates of adverse health outcomes such as smoking and diabetes. Further, evaluating the economic impacts of the preschool component of the program, the study finds a benefit-cost ratio in the range of 1.35 to 3.66 (net benefit: $3,896) indicating that the health benefits of the program by themselves offset the costs of the program even without considering additional benefits arising from increased educational attainment and reduced involvement in crime reported in earlier cost-benefit analyses. The findings are robust to corrections for multiple hypothesis testing, sensitivity analysis using a range of discount rates, and Monte Carlo analysis to account for uncertainty in outcomes.

Critical review of bariatric surgical outcomes in patients with Prader-Willi syndrome and other hyperphagic disorders

OBJECTIVE

The aim of this study was to review bariatric procedure outcomes among patients with Prader-Willi syndrome (PWS), melanocortin 4 receptor (MC4R) mutations, Bardet-Biedl syndrome, and hypothalamic obesity.

METHODS

Systematic published literature review used the following search terms: "Prader-Willi syndrome," "Bardet-Biedl syndrome," "hyperphagia," "bariatric surgery," "MC4R"/"melanocortin 4 receptor", "hypothalamic obesity," and "bariatric procedure." Information collected included demographics, genetics, anthropometry, procedure type, outcomes, and complications, with inclusion of case series and clinical reports given the rarity of the disorders. For PWS, postoperative weight-change percentage and BMI up to 14 years following surgery were analyzed using general linear mixed models, with descriptive outcomes for other conditions.

RESULTS

A total of 54 publications were identified, with variable follow-up periods for 202 patients (114 with PWS, 43 with MC4R mutations, 7 with Bardet-Biedl syndrome, and 38 with hypothalamic obesity) among bariatric procedures. Weight loss of patients with PWS was greatest within 1 year of surgery, with weight-change percentage not significantly different from 0 at 5 years. Long-term results in other conditions were variable and featured suboptimal weight loss and increased reoperation risk.

CONCLUSIONS

Bariatric procedures among hyperphagic individuals, including those with PWS, report variable results and outcomes. Benefits of bariatric surgery may be less durable in hyperphagic disorders in comparison with other patients with severe obesity.

Text Messages and Financial Incentives to Increase Physical Activity in Adolescents With Prediabetes and Type 2 Diabetes: Web-Based Group Interviews to Inform Intervention Design

BACKGROUND

Physical activity is a major component of treatment for adolescents with obesity and prediabetes or type 2 diabetes; however, sedentary behavior remains pervasive. An SMS text message-based intervention paired with financial incentives may be an effective way to promote physical activity in this population.

OBJECTIVE

This study aims to obtain end-user feedback on SMS text message content and assess the acceptability of a planned SMS text messaging intervention with financial incentives to motivate youth with prediabetes or type 2 diabetes to increase physical activity.

METHODS

Adolescents with overweight or obesity and prediabetes or type 2 diabetes who attended a large academic pediatric endocrinology clinic were recruited to participate in group interviews (2-4/group) via videoconferencing. Participants were asked to share their thoughts on the use of SMS text messages and financial incentives to remind and motivate them to be more physically active. They rated and provided feedback on specific messages to be used in clinical trials. Participants were also asked about their personal experience with rewards to motivate behavior change and their anticipated reactions to rewards provided for goal attainment (gain-framing) versus those provided and then taken away if a goal was not met (loss-framing). The interviews were conducted by 2 trained interviewers and a note-taker. Content analysis was used to explore themes.

RESULTS

Group interviews were completed with 20 participants (11/20, 55% women; 15/20, 75% with type 2 diabetes; 5/20, 25% with prediabetes) with a mean age of 15 (SD 1; range 12-18) years and a mean BMI of 41 (SD 5) kg/m² (all >95th percentile for age and sex). Most participants were non-Hispanic Black (14/20, 70%) and 10% (2/20) were Hispanics. Participants frequently cited near-continuous smartphone use and agreed that SMS text messages would serve as good reminders to be physically active, but the consensus about the need for short messages was strong. Favorable content included references to what they were likely to be doing when messages were sent (eg, homework or watching television) and messages that were upbeat or informative. Specific physical activity suggestions were rated favorably. Attitudes toward financial incentives varied, with differing opinions about whether loss-framed incentives would be motivating or discouraging. Many participants highlighted the role of intrinsic, rather than extrinsic, motivation in achieving and sustaining behavior change.

CONCLUSIONS

The engagement of adolescents with obesity and diabetes or prediabetes allowed for the refinement of SMS text messages for our planned intervention, with an emphasis on short, upbeat, relatable, and informative messages. Although an SMS text messaging intervention using financial incentives to motivate youth with prediabetes or type 2 diabetes to be more physically active is theoretically acceptable, the impact on actual activity levels in this population requires prospective evaluation in a clinical trial.

Prevalence of Type 2 Diabetes Mellitus among Korean Children, Adolescents, and Adults Younger than 30 Years: Changes from 2002 to 2016

BACKGROUND

Despite the importance of and social concern regarding prevention of diabetes at younger ages, limited data are available. This study sought to analyze changes in the prevalence of type 2 diabetes mellitus (T2DM) in Koreans younger than 30 years according to sex, age, and level of income.

METHODS

The dataset analyzed in this study was derived from health insurance claims recorded in the National Health Insurance Service (NHIS) database. Participants' level of income was categorized as low (quintile 1, <20% of insurance premium) or others (quintile 2-5).

RESULTS

In males and females, the prevalence of T2DM per 10,000 people steadily increased from 2.57 in 2002 to 11.41 in 2016, and from 1.96 in 2002 to 8.63 in 2016. The prevalence of T2DM in girls was higher in the age group of 5 to 14 years. Even though the prevalence was higher among those older than 20 years, the increase had started earlier, in the early 2000s, in younger age group. Adolescents aged 10 to 19 years in low-income families showed a remarkable increase in prevalence of T2DM, especially in boys.

CONCLUSION

The prevalence of T2DM in young Koreans increased more than 4.4-fold from 2002 to 2016, and the increase started in the early 2000s in younger age groups and in low-income families. This is the first study to examine the trend in prevalence of T2DM in children, adolescents, and young adults in Korea. Future studies and collaborations with social support systems to prevent T2DM at an early age group should be performed.

Young adult onset type 2 diabetes versus type 1 diabetes: Progression to and survival on renal replacement therapy

BACKGROUND

Young-onset type 2 diabetes is an aggressive disease characterized by development of diabetic complications, including nephropathy, early in the disease course. However, within the cohort of young-onset type 1 and type 2 diabetes there are limited comparative data regarding progression to ESKD requiring renal replacement therapy or renal-related death (RRT/RRD).

METHODS

Probabilistic linkage of data from the RPAH Diabetes Centre, National Death Index and Australian and New Zealand Dialysis and Transplant Registry was undertaken. Cumulative Incidence Competing Risk and Cox Proportional Hazards Modelling approaches were utilized to examine progression to ESKD in young-onset type 1 and type 2 diabetes (age of diagnosis 15-35 years).

FINDINGS

Unadjusted incidence rates (95% CI) of RRT/RRD in young-onset type 1 and type 2 diabetes were 3.1 (2.3-4.0) and 4.6 (3.7-5.7) per 1000 person years respectively. After adjustment for gender, ethnicity and duration of diabetes, the HR (95% CI) of RRT/RRD in young-onset type 2 diabetes was 2.0 (1.4-2.9). The HR remained higher after further adjustment for first available cholesterol, HbA1c and systolic blood pressure but not BMI. For those who progressed to RRT, prognosis was similar irrespective of diabetes type; cumulative incidence of mortality was 40% in both young-onset type 1 and type 2 diabetes after 6 years of dialysis.

INTERPRETATION

Progression to RRT/RRD is greater in young-onset type 2 diabetes than in young-onset type 1 diabetes. The increased progression is associated with increased BMI. However, once ESKD is reached, individuals with young-onset type 1 and type 2 diabetes do equally poorly.

Glycemic control is associated with dyslipidemia over time in youth with type 2 diabetes: The SEARCH for diabetes in youth study

BACKGROUND

Dyslipidemia has been documented in youth with type 2 diabetes. There is a paucity of studies examining dyslipidemia over time in youth with type 2 diabetes and associated risk factors.

OBJECTIVE

To evaluate lipids at baseline and follow-up and associated risk factors in youth with type 2 diabetes.

METHODS

We studied 212 youth with type 2 diabetes at baseline and after an average of 7 years of follow-up in the SEARCH for Diabetes in Youth Study. Abnormal lipids were defined as high-density lipoprotein cholesterol (HDL-C) < 35, low-density lipoprotein cholesterol (LDL-C) > 100, or triglycerides >150 (all mg/dl). We evaluated participants for progression to abnormal lipids (normal lipids at baseline and abnormal at follow-up), regression (abnormal lipids at baseline and normal at follow-up), stable normal, and stable abnormal lipids over time for HDL-C, LDL-C, and triglycerides. Associations between hemoglobin A1c (HbA1c) and adiposity over time (area under the curve [AUC]) with progression and stable abnormal lipids were evaluated.

RESULTS

HDL-C progressed, regressed, was stable normal, and stable abnormal in 12.3%, 11.3%, 62.3%, and 14.2% of participants, respectively. Corresponding LDL-C percentages were 15.6%, 12.7%, 42.9%, and 28.8% and triglycerides were 17.5%, 10.8%, 55.7%, and 16.0%. Each 1% increase in HbA1c AUC was associated with a 13% higher risk of progression and stable abnormal triglycerides and a 20% higher risk of progression and stable abnormal LDL-C. Higher adiposity AUC was marginally (p = 0.049) associated with abnormal HDL-C.

CONCLUSIONS

Progression and stable abnormal LDL-C and triglycerides occur in youth with type 2 diabetes and are associated with higher HbA1c.

Identifying and Reducing Disparities in Young Adults With Diabetes

This article outlines how social and health care determinants can affect young adults with diabetes. The authors provide a detailed description of each determinant's influence on diabetes self-management and offer solutions to help mitigate these harmful effects.

The increasing trend of Type 2 diabetes in youth: An overview

INTRODUCTION

Pediatric Type 2 Diabetes Mellitus (T2DM) is increasing in incidence, largely in correlation with global childhood obesity crisis.

COMPLICATIONS

Early detection and treatment are vital as diabetes has been shown to progress rapidly and aggressively amongst children.

ETIOLOGY

Higher than expected insulin levels compared to adults, leads to more rapid β cell decline.

TREATMENTS

New treatments to control glycemic levels among youth with T2DM are being evaluated. This review summarizes the current understanding of causes, complications, and treatments for youth diagnosed with T2DM. OR. Pediatric Type 2 Diabetes Mellitus (T2DM) is increasing in incidence, largely in correlation with the global childhood obesity crisis. With increase in cases comes new challenges for medical professionals. Early detection and treatment are vital as the disease has been shown to progress aggressively and bring complications to children at a rapid rate. New treatments are currently being studied to control glycemic levels among youth with T2DM, as current options are not as effective chronically in children as in adults. This review summarizes the current understanding of causes, complications, and treatments for youth diagnosed with T2DM.

Young-onset type 2 diabetes in South Korea: a review of the current status and unmet need

The prevalence of young-onset (diagnosis at age < 40 years) type 2 diabetes mellitus (T2DM) is increasing globally. Young-onset T2DM has a common pathophysiology of glucose dysregulation as in late-onset T2DM. However, it presents a greater association with obesity and a more rapid decline in β-cell function than late-onset T2DM. Accumulating evidence indicates that disease progression in young-onset T2DM is rapid, resulting in early and frequent development of microvascular and macrovascular complications, as well as premature death. Improper management and low adherence to medical therapy are important issues in young-onset T2DM. This review discusses the epidemiology, disease entity, and clinical issues associated with young-onset T2DM. We also present the prevalence and clinical characteristics of patients with young-onset T2DM in South Korea.

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.

Treatment of type 2 diabetes in children: what are the specific considerations?

Introduction: The number of individuals under 18 years of age with type 2 diabetes is increasing at an alarming rate worldwide. These patients are often characterized by obesity and they often experience a more rapid disease progression than adults with type 2 diabetes. Thus, focus on prevention and management of complications and comorbidities is imperative. With emphasis on weight loss and optimal glycemic control, treatment includes lifestyle changes and pharmacotherapy, which in this patient group is limited to metformin, liraglutide and insulin. In selected cases, bariatric surgery is indicated.Areas covered: This perspective article provides an overview of the literature covering pathophysiology, diagnosis, characteristics and treatment of pediatric type 2 diabetes, and outlines the gaps in our knowledge where further research is needed. The paper draws on both mechanistic studies, large scale intervention trials, epidemiological studies and international consensus statements.Expert opinion: Type 2 diabetes in pediatric patients is an increasing health care problem, and the current treatment strategies do not successfully meet the many challenges and obstacles in this patient group. Treatments must be early, intensive, multifaceted and durable. Also, prevention of obesity and type 2 diabetes in at-risk children should be addressed and prioritized on all levels.

Aversion to Off-label Prescribing in Clinical Pediatric Weight Management: The Quintessential Double Standard

CONTEXT

Pediatric obesity is now recognized as a chronic disease; yet few treatment options exist besides lifestyle modification therapy and bariatric surgery. We describe the limited availability of United States Food and Drug Administration (FDA)-approved antiobesity medications for adolescents and compare this to what is available for adults. We offer a rationale for off-label prescribing to assist with lifestyle modification therapy. We also highlight the need for more pharmacotherapy options and additional research into novel treatments for pediatric obesity.

CASE DESCRIPTION

We describe a patient who is struggling with managing her weight and starting to develop complications of obesity. We offer a framework in which off-label prescribing may be beneficial to patients who have been engaging in lifestyle modification therapy yet fail to see improvement.

CONCLUSION

Lifestyle modification therapy is necessary but often insufficient in stimulating clinically meaningful weight loss when used alone in children and adolescents who struggle with weight management. Until more FDA-approved antiobesity medications are available, pediatricians may be able to help more patients achieve weight reduction goals by familiarizing themselves with the responsible use of off-label medications and implementing these tools to improve clinical outcomes. There is a critical need for more pharmacotherapy options to help pediatric patients in managing their weight and preventing or improving the insidious complications resulting from untreated obesity.

Health disparities in cardiometabolic risk among Black and Hispanic youth in the United States

Cardiometabolic risk factors in children and adolescents track into adulthood and are associated with increased risk of atherosclerotic cardiovascular disease. The purpose of this review is to examine the pervasive race and ethnic disparities in cardiometabolic risk factors among Black and Hispanic youth in the United States. We focus on three traditional cardiometabolic risk factors (obesity, type 2 diabetes mellitus, and dyslipidemia) as well as on the emerging cardiometabolic risk factor of non-alcoholic fatty liver disease. Additionally, we highlight interventions aimed at improving cardiometabolic health among these minority pediatric populations. Finally, we advocate for continued research on effective prevention strategies to reduce cardiometabolic risk and avert further disparities in cardiovascular morbidity and mortality.

Disease related changes in vocal parameters of patients with type 2 diabetes mellitus

BACKGROUND

As the duration of diabetes progresses, various disease related complications might occur in patients. The main goal of this paper is to compare acoustic and aerodynamic measures of patients with type 2 diabetes mellitus (T2DM) with a control group of healthy subjects.

METHODS

A total of 91 subjects, 51 individuals with type 2 diabetes mellitus (DM group) and 40 healthy volunteers (HV group) were participated in the study. Maximum phonation time (MPT) was captured for assessing phonatory mechanics. Acoustic voice parameters, including mean fundamental frequency (mean fo), jitter local (Jlocal), jitter absolute (Jabs), shimmer local (Slocal), shimmer decibel (SdB), and harmonics to noise ratio (HNR) were detected using the Praat software program.

RESULTS

Only for Jabs, statically significant difference was found between the groups. There were no statically significant differences between any voice parameters of HV versus those with the duration of diabetes ≥10 years and the HbA1c level ≥7%. However, statically significant differences for MPT and Slocal were found between patients with neuropathy versus HV. In addition, a comparison between patients with voice complaint versus HV showed significant differences for Slocal and SdB.

CONCLUSIONS

The findings of the present study do not provide strong evidence about the possible effect of DM on the human voice. However, diabetic neuropathy is considered to be a factor affecting the voice parameters in the target population. The physicians should pay attention to the acoustic and aerodynamic voice parameters in patients with diabetes, particularly in those with neuropathy or voice complaints.

COVID-19 and metabolic diseases: a heightened awareness of health inequities and a renewed focus for research priorities

Chronic metabolic disorders such as diabetes and obesity are major public health issues in the United States. However, significant disparities in their prevalence and incidence place a greater burden on US racial and ethnic minority groups, contributing to worse COVID-19 outcomes in many. Improving treatment and prevention of diabetes and obesity is critical to the NIDDK. In this Perspective, we will review the burden of metabolic diseases in the United States, the observed disparities for metabolic diseases in relation to COVID-19, and research opportunities to address underlying causes of metabolic diseases, their associated health disparities, and COVID-19.

Diabetes Prevention in Adolescents: Co-design Study Using Human-Centered Design Methodologies

BACKGROUND

The rise in pediatric obesity and its accompanying condition, type 2 diabetes (T2D), is a serious public health concern. T2D in adolescents is associated with poor health outcomes and decreased life expectancy. Effective diabetes prevention strategies for high-risk adolescents and their families are urgently needed.

OBJECTIVE

The aim of this study was to co-design a diabetes prevention program for adolescents by using human-centered design methodologies.

METHODS

We partnered with at-risk adolescents, parents, and professionals with expertise in diabetes prevention or those working with adolescents to conduct a series of human-centered design research sessions to co-design a diabetes prevention intervention for youth and their families. In order to do so, we needed to (1) better understand environmental factors that inhibit/promote recommended lifestyle changes to decrease T2D risk, (2) elucidate desired program characteristics, and (3) explore improved activation in diabetes prevention programs.

RESULTS

Financial resources, limited access to healthy foods, safe places for physical activity, and competing priorities pose barriers to adopting lifestyle changes. Adolescents and their parents desire interactive, hands-on learning experiences that incorporate a sense of fun, play, and community in diabetes prevention programs.

CONCLUSIONS

The findings of this study highlight important insights of 3 specific stakeholder groups regarding diabetes prevention and lifestyle changes. The findings of this study demonstrate that, with appropriate methods and facilitation, adolescents, parents, and professionals can be empowered to co-design diabetes prevention programs.

Incidence and Predictors of Dysglycemia and Regression to Normoglycemia in Indian Adolescents and Young Adults: 10-Year Follow-Up of the ORANGE Study

Background: The prevalence of diabetes in youth is increasing worldwide in parallel with the obesity epidemic. This study aimed to determine the incidence rates of dysglycemia (diabetes or prediabetes) and evaluate the predictors of its progression or regression to normal glucose tolerance (NGT) in a cohort of children and adolescents studied in Chennai, South India. Methods: A longitudinal follow-up of the Obesity Reduction and Awareness of Noncommunicable Diseases through Group Education (ORANGE) cohort was performed after a median of 7.1 years (n = 845; 5928 person-years of follow-up). To determine their diabetes status at follow-up, participants underwent an oral glucose tolerance test (n = 811 with NGT and 34 with prediabetes at baseline), excluding those with diabetes at baseline. Incidence rates for dysglycemia were reported per 1000 person-years of follow-up. Cox proportional hazards model was used to estimate the predictors of progression and regression. Results: Out of 811 individuals with NGT at baseline, 115 developed dysglycemia giving an incidence rate of 20.2 per 1000 person-years (95% confidence interval: 16.8-24.2). Among those with prediabetes at baseline, 70.6% of the individuals converted to NGT and the remaining 29.4% either got converted to diabetes or remained as prediabetes. Higher age, body mass index, fasting plasma glucose, 2-hour plasma glucose (2-h PG), positive family history of diabetes, and systolic blood pressure (BP) were independent predictors of incident dysglycemia, whereas lower age, waist circumference, 2-h PG, systolic BP, and triglycerides predicted regression to normoglycemia. Conclusions: This study highlights the growing burden of dysglycemia in Asian Indian youth and emphasizes the need for targeted preventive actions.

Circulating Ligands of the Receptor for Advanced Glycation End Products and the Soluble Form of the Receptor Modulate Cardiovascular Cell Apoptosis in Diabetes

We determined whether plasma concentrations of the receptor for advanced glycation end products (RAGE) and the soluble (s) form of RAGE (sRAGE) in healthy individuals and patients with type 2 diabetes (T2D) modulate vascular remodeling. Healthy individuals and patients with T2D were divided into two age groups: young = <35 years old or middle-aged (36-64 years old) and stratified based on normal glucose tolerance (NGT), impaired (IGT), and T2D. Plasma titers of sRAGE, the RAGE ligands, AGEs, S100B, S100A1, S100A6, and the apoptotic marker Fas ligand Fas(L) were measured by enzyme-linked immunosorbent assay (ELISA). The apoptotic potential of the above RAGE ligands and sRAGE were assessed in cultured adult rat aortic smooth muscle cells (ASMC). In NGT individuals, aging increased the circulating levels of AGEs and S100B and decreased sRAGE, S100A1 and S100A6. Middle-aged patients with T2D presented higher levels of circulating S100B, AGEs and FasL, but lower levels of sRAGE, S100A1 and S100A6 than individuals with NGT or IGT. Treatment of ASMC with either AGEs or S100B at concentrations detected in T2D patients increased markers of inflammation and apoptosis. Responses attenuated by concomitant administration of sRAGE. In middle-aged patients with T2D, lower circulating plasma levels of sRAGE may limit decoy and exogenous trapping of deleterious pro-apoptotic/pro-inflammatory RAGE ligands AGEs and S100B, increasing the risk for diabetic complications.

Association of early-onset diabetes, prediabetes and early glycaemic recovery with the risk of all-cause and cardiovascular mortality

AIMS/HYPOTHESIS

The increasing incidence of diabetes among young adults is a disease burden; however, the effects of early-onset diabetes, prediabetes and glycaemic recovery on CVD or mortality remain unclear. We aimed to investigate the association of these factors with 10 year all-cause mortality, CVD mortality and CVD incidence in Korean young adults.

METHODS

This large and longitudinal cohort study included data from the Korean National Health Insurance Service-National Health Information Database; 2,502,375 young adults aged 20-39 years without diabetes mellitus and CVD at baseline were included. Glycaemic status was measured twice, first in 2002-2003 and second in 2004-2005. Changes in fasting glucose levels were evaluated according to fasting glucose status: normal fasting glucose (NFG; <5.5 mmol/l), impaired fasting glucose (IFG; 5.5-6.9 mmol/l), and diabetic fasting glucose (DFG; ≥7.0 mmol/l). Primary outcomes were all-cause and CVD mortality risk. The secondary outcome was incidence of CVD, including acute myocardial infarction and stroke. All outcomes arose from the 10 year follow-up period 1 Jan 2006 to 31 December 2015.

RESULTS

Individuals with NFG at baseline, who were subsequently newly diagnosed with diabetes and prediabetes (IFG), had increased all-cause mortality (HR [95% CI] 1.60 [1.44, 1.78] and 1.13 [1.09, 1.18], respectively) and CVD incidence (1.13 [1.05, 1.23] and 1.04 [1.01, 1.07], respectively). In those with DFG at baseline, early recovery to NFG and IFG was associated with decreased all-cause mortality (0.57 [0.46, 0.70] and 0.65 [0.53, 0.81], respectively) and CVD incidence (0.70 [0.60, 0.81] and 0.78 [0.66, 0.91], respectively). Among patients with IFG at baseline, early recovery to NFG was associated with decreased CVD mortality (0.74 [0.59, 0.93]).

CONCLUSIONS/INTERPRETATION

Early-onset diabetes or prediabetes increased CVD risks and all-cause mortality after the 10 year follow-up. Furthermore, recovery of hyperglycaemia could reduce the subsequent 10 year risk for CVD incidence and all-cause mortality. Graphical abstract.

Glycemic control in youth-onset type 2 diabetes correlates with weight loss

OBJECTIVE

To identify risk factors for glycemic failure in youth with type 2 diabetes (T2D).

METHODS

A retrospective review of HbA1c, anthropomorphic measures, medication records, and laboratory studies was performed using registry data from a dedicated pediatric T2D clinic. Latent profile analysis (LPA) was performed to model longitudinal trajectory of HbA1c over 5 years.

RESULTS

The registry includes 229 youth with T2D, of whom 80% self-identify as Latinx. The odds ratio (OR) for uncontrolled diabetes 5 years after diagnosis correlated with diagnostic HbA1c, with OR of 2.41 if HbA1c at diagnosis >8.5% (sensitivity 68%, specificity 54%, P = .015). LPA modeling identified three HbA1c profiles: (a) mean HbA1c <8% throughout the 5 years, (b) persistent elevation of mean HbA1c >9%, and (c) mean HbA1c of 12% at diagnosis, rapid decline to 6.4% by 4 to 6 months, and increase to 11% by 18 months. Our analysis of medication regimen showed that, amongst patients treated with metformin, the addition of multiple daily injections (MDI) did not improve HbA1c compared to those on basal insulin. Finally, weight loss over the 1 year after diagnosis correlated with improvement in HbA1c in both subjects prescribed metformin monotherapy, as well as insulin-containing regimen.

CONCLUSION

Youth with T2D exhibit distinct HbA1c profiles. Patients with diagnostic HbA1c >8.5% are at high risk for glycemic failure, irrespective of short-term improvement in HbA1c. Weight management has the potential to improve short-term HbA1c outcome in youth with T2D. Additional studies are needed to determine the role of medication adherence on glycemic control.

Diabetes Is Associated With Worse Long-term Outcomes in Young Adults After Myocardial Infarction: The Partners YOUNG-MI Registry

OBJECTIVE

We sought to determine the prevalence of diabetes and associated cardiovascular outcomes in a contemporary cohort of young individuals presenting with their first myocardial infarction (MI) at age ≤50 years.

RESEARCH DESIGN AND METHODS

We retrospectively analyzed records of patients presenting with a first type 1 MI at age ≤50 years from 2000 to 2016. Diabetes was defined as a hemoglobin A1c ≥6.5% (48 mmol/mol) or a documented diagnosis of or treatment for diabetes. Vital status was ascertained for all patients, and cause of death was adjudicated.

RESULTS

Among 2,097 young patients who had a type 1 MI (mean age 44.0 ± 5.1 years, 19.3% female, 73% white), diabetes was present in 416 (20%), of whom 172 (41%) were receiving insulin. Over a median follow-up of 11.2 years (interquartile range 7.3-14.2 years), diabetes was associated with a higher all-cause mortality (hazard ratio 2.30; P < 0.001) and cardiovascular mortality (2.68; P < 0.001). These associations persisted after adjusting for baseline covariates (all-cause mortality: 1.65; P = 0.008; cardiovascular mortality: 2.10; P = 0.004).

CONCLUSIONS

Diabetes was present in 20% of patients who presented with their first MI at age ≤50 years and was associated with worse long-term all-cause and cardiovascular mortality. These findings highlight the need for implementing more aggressive therapies aimed at preventing future adverse cardiovascular events in this population.

Racial-Ethnic Inequity in Young Adults With Type 1 Diabetes

CONTEXT

Minority young adults (YA) currently represent the largest growing population with type 1 diabetes (T1D) and experience very poor outcomes. Modifiable drivers of disparities need to be identified, but are not well-studied.

OBJECTIVE

To describe racial-ethnic disparities among YA with T1D and identify drivers of glycemic disparity other than socioeconomic status (SES).

DESIGN

Cross-sectional multicenter collection of patient and chart-reported variables, including SES, social determinants of health, and diabetes-specific factors, with comparison between non-Hispanic White, non-Hispanic Black, and Hispanic YA and multilevel modeling to identify variables that account for glycemic disparity apart from SES.

SETTING

Six diabetes centers across the United States.

PARTICIPANTS

A total of 300 YA with T1D (18-28 years: 33% non-Hispanic White, 32% non-Hispanic Black, and 34% Hispanic).

MAIN OUTCOME

Racial-ethnic disparity in HbA1c levels.

RESULTS

Non-Hispanic Black and Hispanic YA had lower SES, higher HbA1c levels, and much lower diabetes technology use than non-Hispanic White YA (P < 0.001). Non-Hispanic Black YA differed from Hispanic, reporting higher diabetes distress and lower self-management (P < 0.001). After accounting for SES, differences in HbA1c levels disappeared between non-Hispanic White and Hispanic YA, whereas they remained for non-Hispanic Black YA (+ 2.26% [24 mmol/mol], P < 0.001). Diabetes technology use, diabetes distress, and disease self-management accounted for a significant portion of the remaining non-Hispanic Black-White glycemic disparity.

CONCLUSION

This study demonstrated large racial-ethnic inequity in YA with T1D, especially among non-Hispanic Black participants. Our findings reveal key opportunities for clinicians to potentially mitigate glycemic disparity in minority YA by promoting diabetes technology use, connecting with social programs, and tailoring support for disease self-management and diabetes distress to account for social contextual factors.

Leptin, adiponectin, and their ratio as markers of insulin resistance and cardiometabolic risk in childhood obesity

BACKGROUND

It is imperative to develop markers for risk stratification and detection of cardiometabolic comorbidities in children with obesity. The adipokines leptin and adiponectin are both involved in fat mass regulation and the development of obesity-related disorders; furthermore, their ratio (leptin/adiponectin ratio) is suggested to be associated with insulin resistance and cardiometabolic risk.

OBJECTIVE

To evaluate associations between fasting serum concentrations of the adipokines (total leptin and adiponectin as well as the L/A ratio) and cardiometabolic comorbidities in children with overweight/obesity.

METHODS

A total of 2258 children with overweight/obesity or normal weight aged 6 to 18 years were studied. Differences in anthropometrics and adipokine concentrations were tested using Wilcoxon rank-sum test. Associations between the adipokines and cardiometabolic risk were tested using Spearman's correlation and logistic regression, adjusted for age and body mass index SD score (BMI-SDS).

RESULTS

Compared to normal weight children; children with overweight/obesity exhibited higher leptin concentrations, lower adiponectin concentrations, and higher L/A ratios. After adjusting for age and degree of obesity, girls with overweight/obesity in the upper quartile range for the L/A ratio, when compared with girls in the lower quartile range, were more likely to have insulin resistance (odds ratio [OR]: 7.78 [95% confidence interval [CI], 3.78-16.65]), dysglycemia (OR: 3.08 [95% CI, 1.35-7.31]), and dyslipidemia (OR: 2.53 [95% CI, 1.18-5.59]); while boys were more likely to have insulin resistance (OR: 4.45 [95% CI, 2.03-10.10]).

CONCLUSIONS

Independent of the degree of obesity, leptin, adiponectin, and the L/A ratio were associated with insulin resistance and other cardiometabolic comorbidities in children with overweight/obesity, but the L/A ratio exhibited stronger associations than the respective adipokines.

Rapid progression of type 2 diabetes and related complications in children and young people-A literature review

Type 2 diabetes (T2D) is suggested to progress faster in children and young people vs type 1 diabetes (T1D) in the same age group and T2D in adults. We reviewed the evidence base for this. A literature search was performed of PubMed-indexed publications between 2000 and 2018, for the terms "pediatric" and "T2D." Results were combined and filtered for those relating to "progression." Searches of abstract books from Latin American and Asian congresses were performed to include these populations. Pediatric populations were defined as <25 completed years of age. Of the articles and congress abstracts found, 30 were deemed relevant. Dividing the studies into categories based on how T2D progresses, we found the following: (a) yearly beta-cell function deterioration was shown to be 20% to 35% in children with T2D compared with 7% to 11% in adults with T2D, despite similar disease durations; (b) retinopathy progression was likely dependent on diabetes duration rather than diabetes type; however, nephropathy, neuropathy and probably hypertension progressed faster in youth-onset T2D vs T1D. Nephropathy progression was similar to adults with T2D, allowing for disease duration. Youth with T2D had a worse cardiovascular (CV) risk profile than youth with T1D, and a faster progression to CV death. (c) Progression to treatment failure was faster in youth-onset T2D vs adult-onset T2D. Substantial evidence exists for faster progression of T2D in pediatric patients vs T1D or adult-onset T2D. New treatments targeting the pathology are needed urgently to address this issue.

GIP as a Potential Therapeutic Target for Atherosclerotic Cardiovascular Disease-A Systematic Review

Glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide-1 (GLP-1) are gut hormones that are secreted from enteroendocrine L cells and K cells in response to digested nutrients, respectively. They are also referred to incretin for their ability to stimulate insulin secretion from pancreatic beta cells in a glucose-dependent manner. Furthermore, GLP-1 exerts anorexic effects via its actions in the central nervous system. Since native incretin is rapidly inactivated by dipeptidyl peptidase-4 (DPP-4), DPP-resistant GLP-1 receptor agonists (GLP-1RAs), and DPP-4 inhibitors are currently used for the treatment of type 2 diabetes as incretin-based therapy. These new-class agents have superiority to classical oral hypoglycemic agents such as sulfonylureas because of their low risks for hypoglycemia and body weight gain. In addition, a number of preclinical studies have shown the cardioprotective properties of incretin-based therapy, whose findings are further supported by several randomized clinical trials. Indeed, GLP-1RA has been significantly shown to reduce the risk of cardiovascular and renal events in patients with type 2 diabetes. However, the role of GIP in cardiovascular disease remains to be elucidated. Recently, pharmacological doses of GIP receptor agonists (GIPRAs) have been found to exert anti-obesity effects in animal models. These observations suggest that combination therapy of GLP-1R and GIPR may induce superior metabolic and anti-diabetic effects compared with each agonist individually. Clinical trials with GLP-1R/GIPR dual agonists are ongoing in diabetic patients. Therefore, in this review, we summarize the cardiovascular effects of GIP and GIPRAs in cell culture systems, animal models, and humans.

Cardiovascular risk factors in offspring exposed to gestational diabetes mellitus in utero: systematic review and meta-analysis

Gestational diabetes mellitus (GDM) is a pregnancy complication that affects one in seven pregnancies. Emerging evidence demonstrates that children born of pregnancies complicated by GDM may be at increased risk of cardiovascular disease (CVD) in adulthood. Therefore, the aim of this study was to determine cardiovascular risk factors in offspring exposed to GDM in utero. PubMed, CINAHL, SCOPUS, and EMBASE databases were searched. Information was extracted on established CVD risk factors including blood pressure, lipids, blood glucose, fasting insulin, body mass index (BMI), and endothelial/microvascular function. The review protocol is registered in PROSPERO (CRD42018094983). Prospective and retrospective studies comparing offspring exposed to GDM compared to controls (non-GDM pregnancies) were considered. We included studies that defined GDM based on the International Association of Diabetes and Pregnancy Study Groups (IADPSG) definition, or prior definitions. The PRISMA guidelines were followed in conducting this systematic review. Methodological quality was assessed using the Newcastle-Ottawa Quality Assessment Scale. Study selection, data extraction, and quality assessment were done by two independent reviewers. The data were pooled using a random-effects model. Of 59 eligible studies, 24 were included in the meta-analysis. Offspring exposed to GDM had higher systolic blood pressure (mean difference (MD): 1.75 mmHg, 95% CI 0.57-2.94; eight studies, 7264 participants), BMI z-score (MD 0.11, 95% CI 0.02-0.20; nine studies, 8759 participants), and glucose (standard MD 0.43, 95% CI 0.08-0.77; 11 studies, 6423 participants) than control participants. In conclusion, offspring exposed to GDM have elevated systolic blood pressure, BMI, and glucose. Those exposed to GDM in utero may benefit from early childhood blood pressure measurements.

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.

Muscle Insulin Resistance in Youth with Obesity and Normoglycemia is Associated with Altered Fat Metabolism

OBJECTIVE

This study aimed to phenotype and compare adipose, hepatic, and muscle insulin sensitivity (IS) in a diet- and physical activity-controlled cohort of normoglycemic youth with obesity with that of participants without obesity (controls) to distinguish early metabolic abnormalities in pediatric obesity.

METHODS

Thirty-eight participants (17 in the control group [BMI < 85th percentile] and 21 youth with obesity [BMI ≥ 95th percentile]; age: 12-21 years; 76% female; Tanner stage 4-5; sedentary) were enrolled. Tissue-specific IS was measured using a four-phase hyperinsulinemic-euglycemic clamp with glucose and glycerol isotope tracers to assess suppression of endogenous glucose release and lipolysis by insulin. Intramyocellular lipid content was assessed by 1 H-magnetic resonance spectroscopy, and hepatic fat fraction (HFF) and visceral fat were assessed by magnetic resonance imaging. Calf-muscle mitochondrial activity was measured with exercise-stimulated 31 P-magnetic resonance spectroscopy.

RESULTS

Youth with obesity had higher HFF (P < 0.001), visceral fat (P = 0.024), and intramyocellular lipid content (P = 0.017) and lower muscle (glucose clearance rate [P < 0.001]), adipose (P < 0.0001), and hepatic IS (P < 0.003). Mitochondria postexercise response was not different. In participants with obesity, muscle IS inversely correlated with HFF (r = 0.700, P = 0.002) and suppressed free fatty acid concentrations (r = -0.65, P = 0.003).

CONCLUSIONS

Inactive normoglycemic youth with obesity had decreased muscle, adipose, and hepatic IS. Free fatty acids and liver fat were inversely associated with muscle IS, which argues for lipid-targeted interventions.

Magnetic resonance imaging of obesity and metabolic disorders: Summary from the 2019 ISMRM Workshop

More than 100 attendees from Australia, Austria, Belgium, Canada, China, Germany, Hong Kong, Indonesia, Japan, Malaysia, the Netherlands, the Philippines, Republic of Korea, Singapore, Sweden, Switzerland, the United Kingdom, and the United States convened in Singapore for the 2019 ISMRM-sponsored workshop on MRI of Obesity and Metabolic Disorders. The scientific program brought together a multidisciplinary group of researchers, trainees, and clinicians and included sessions in diabetes and insulin resistance; an update on recent advances in water-fat MRI acquisition and reconstruction methods; with applications in skeletal muscle, bone marrow, and adipose tissue quantification; a summary of recent findings in brown adipose tissue; new developments in imaging fat in the fetus, placenta, and neonates; the utility of liver elastography in obesity studies; and the emerging role of radiomics in population-based "big data" studies. The workshop featured keynote presentations on nutrition, epidemiology, genetics, and exercise physiology. Forty-four proffered scientific abstracts were also presented, covering the topics of brown adipose tissue, quantitative liver analysis from multiparametric data, disease prevalence and population health, technical and methodological developments in data acquisition and reconstruction, newfound applications of machine learning and neural networks, standardization of proton density fat fraction measurements, and X-nuclei applications. The purpose of this article is to summarize the scientific highlights from the workshop and identify future directions of work.

Pathological Role of Advanced Glycation End Products (AGEs) and their Receptor Axis in Atrial Fibrillation

Accumulating evidence has shown that the incidence of atrial fibrillation (AF) is higher in patients with diabetes, especially those with poor glycemic control or long disease duration. Nonenzymatic glycation of amino acids of proteins, lipids, and nucleic acids has progressed under normal aging process and/or diabetic condition, which could lead to the formation and accumulation of advanced glycation end products (AGEs). AGEs not only alter the tertiary structure and physiological function of macromolecules, but also evoke inflammatory and fibrotic reactions through the interaction of cell surface receptor for AGEs (RAGE), thereby being involved in aging-related disorders. In this paper, we briefly review the association of chronic hyperglycemia and type 1 diabetes with the risk of AF and then discuss the pathological role of AGE-RAGE axis in AF and its thromboembolic complications.

The Cardiometabolic Risk Profile of Young Adults With Diabetes in the U.S

OBJECTIVE

We examined young adults with and young adults without diabetes by using demographic data and cardiometabolic risk profiles and compared the risk profiles of younger versus older (aged ≥45 years) adults with diabetes.

RESEARCH DESIGN AND METHODS

Data were obtained from the National Health and Nutrition Examination Survey (NHANES) 2007-2016. Diabetes was defined by self-report of health care provider diagnosis or by A1C levels of 6.5% or higher among those without a self-reported diagnosis. The cardiometabolic risk profile included adiposity, blood pressure, serum lipids, healthy eating, physical activity (PA), and exposure to tobacco smoke. Adjusted difference in difference was calculated as the difference among younger adults with and younger adults without diabetes minus the difference among older adults with and older adults without diabetes.

RESULTS

Adults with diabetes in both age-groups had higher levels of adiposity, hypertension, and cholesterol and lower levels of healthy eating and leisure-time PA. However, the differences in high cholesterol and adiposity by diabetes status were greater among young adults compared with older adults after adjustment for demographics and health insurance status. Elevated lipids were 9.6 percentage points higher (95% CI 4.6, 14.5) and obesity was 37.3 percentage points higher (95% CI 31.8, 42.7) among young adults with diabetes compared with those without diabetes than among older adults with diabetes compared with those without diabetes.

CONCLUSIONS

Young adults with diabetes have high rates of cardiometabolic risk factors, which can lead to an increased disease prevalence and mortality rate among these individuals as they age.

Prevalence and Risk Factors for Undiagnosed Glucose Intolerance Status in Apparently Healthy Young Adults Aged <40 Years: The Korean National Health and Nutrition Examination Survey 2014-2017

Background: Early-onset diabetes results in longer lifetime hyperglycemic exposure that consequently leads to earlier chronic diabetes complications and premature death. The aim of this study was to quantify the prevalence and risk factors of undiagnosed diabetes and undiagnosed prediabetes in apparently healthy young adults aged <40 years. Methods: This study used data from the Korean National Health and Nutrition Examination Survey, a cross-sectional, nationally representative survey conducted by the Korean Ministry of Health and Welfare from 2014 to 2017. A total of 4442 apparently healthy young adults enrolled in this study. Multivariate logistic regression analyses were conducted separately to evaluate associated risk factors with undiagnosed diabetes and undiagnosed prediabetes in groups stratified by sex. Results: The prevalence of undiagnosed diabetes and undiagnosed prediabetes was 1.2% and 25.0%, respectively. Obesity (body mass index ≥ 30.0 kg/m²) was a significant risk factor of undiagnosed diabetes regardless of sex (men, odds ratio (OR): 9.808, 95% confidence interval (CI): 1.619–59.412; women, OR: 7.719, 95% CI: 1.332–44.747). Family history of diabetes was significantly associated with undiagnosed diabetes (OR: 3.407, 95% CI: 1.224–9.481) in women only. Increased age, obesity status, and family history of diabetes were significant risk factors for undiagnosed prediabetes. Alcohol consumption was found to be negatively associated with undiagnosed prediabetes in women. Conclusions: Increased attention and implementation of precise strategies for identifying young adults at high risk for undiagnosed diabetes would allow for increased wellbeing as well as reduced healthcare burdens associated with diabetes.

Premature death and risk of cardiovascular disease in young-onset diabetes: a 23-year follow-up of the Da Qing Diabetes Study

OBJECTIVE

This study aimed to investigate premature mortality and the risk of cardiovascular disease (CVD) in Chinese adults with diabetes diagnosed before the age of 45 years.

METHODS

A total of 519 participants with normal glucose tolerance (NGT) and 630 with newly diagnosed diabetes mellitus (DM) were recruited in 1986 in the Da Qing Diabetes Study. In 2009, the participants were followed up to assess mortality and CVD events. The subjects were stratified into four subgroups according to age and diabetes status: age <45 years with NGT (NGT_<45y), age <45 years with DM (DM_<45y), age ≥45 years with NGT (NGT_≥45y), and age ≥45 years with DM (DM_≥45y). The risk of death and CVD events in patients with young-onset DM and elder subjects with NGT were compared to show the extent of premature death and CVD in the DM participants.

RESULTS

During the 23-year follow-up, 26 (10.40%) participants in NGT_<45y, 72 (34.12%) in DM_<45y, 74 (30.58%) in NGT_≥45y, and 266 (68.73%) in DM_≥45y died, including 13 (5.20%), 36 (17.06%), 24 (9.92%), and 128 (33.07%) death attributed to CVD. The corresponding rates of CVD events were 56 (22.40%), 90 (42.65%), 89 (36.78), and 213 (55.04%). It also showed that the risk of all-cause death (HR 1.23, 95% CI 0.88-1.71) or CVD events (HR 1.25, 95% CI 0.93-1.69) did not differ significantly between the DM_<45y and NGT_≥45y groups after adjusting for sex, smoking, body mass index, systolic blood pressure, total cholesterol and previous history of CVD. Of note, participants in the DM_<45y group had an higher risk of CVD mortality compared with that in the NGT_≥45y group (HR 1.76, 95% CI 1.04-2.98), although the mean age in the former group was 12 years lesser than that in the latter group (39.01 ± 5.00 vs 51.45 ± 5.14).

CONCLUSIONS

Young-onset diabetes is a risk factor for the premature death and cardiovascular disease. Early prevention and intensive treatment are warrented in patients with young-onset diabetes.