Depressive symptoms and quality of life in adolescents with type 2 diabetes: baseline data from the TODAY study

Type 2 diabetes in children and adolescents: Challenges for treatment and potential solutions

Historically perceived as a disease mainly affecting adults, the prevalence of type 2 diabetes mellitus (T2DM) among children and adolescents has been rising, mirroring the increasing rates of childhood obesity. Currently, youth-onset T2DM poses a significant public health challenge globally. Treating youth-onset T2DM poses numerous critical challenges, namely limited and inadequate therapeutic options, and difficulties with conducting therapeutic studies. As a result, current treatment guidelines are based on adult studies and expert consensus. Few prominent guidelines on the treatment of youth-onset T2DM have been published recently, i.e., by the American Diabetes Association (ADA) 2024, National Institute for Healthcare and Excellence United Kingdom (NICE UK) 2023, International Society Paediatric and Adolescents Diabetes (ISPAD) 2022, Australasian Paediatric Endocrine Group (APEG) 2020 and Diabetes Canada 2018. This review first explores the unique aspects of youth-onset T2DM. It then summarises the different treatment guidelines, discusses the different treatment modalities based on available evidence and identifies any gaps. The review also explores challenges in the treatment of youth-onset T2DM with potential solutions and discusses recent trials on the treatment of youth-onset T2DM. Continued research aims to optimise treatment, improve outcomes, and alleviate the burden of T2DM on youths.

Qualitative Study Guiding the Design of a Person-Centered Shared Medical Appointment Model to Optimize Diabetes Care Delivery

PURPOSE

The purpose of the study was to explore the shared medical appointment model (SMA) with youth with type 2 diabetes (T2DM) and their caregivers to identify health education needs, access barriers, and recommendations for intervention design.

METHODS

Patient and caregiver focus group interviews were conducted in English and Spanish to address these objectives: (1) identify barriers to participation in group sessions, (2) identify barriers to diabetes self-management, and (3) prioritize preference for SMA themes. Qualitative analysis identified strategies for patient recruitment and engagement and recommendations for curriculum design of a future SMA model for youth with T2DM.

RESULTS

Both adolescents and caregivers supported the development of an SMA model. Adolescents expressed concerns of initial discomfort and nervousness, whereas young adults described stigma as the main barrier to joining a group. Patients emphasized the importance of prioritizing youth comfort and families' convenience. Early adolescents and young adults preferred autonomy in the choice to join a group, whereas mid adolescents and caregivers preferred that the caregivers make that decision. Participants recommended nine topics regarding barriers to diabetes care. The topics that received the most enthusiasm were nutrition, exercise, navigating peer interactions, and stress management.

CONCLUSIONS

Youth with T2DM and their caregivers perceived many benefits of an SMA model and provided feedback to guide the development of a health education curriculum that could be integrated into an SMA clinic.

Semaglutide for management of obesity in adolescents: efficacy, safety, and considerations for clinical practice

PURPOSE OF REVIEW

The purpose of this review is to describe the existing limited data related to the use of semaglutide in adolescents with obesity, supplementing with findings from adult studies of semaglutide use.

RECENT FINDINGS

Semaglutide, as a once weekly subcutaneous injection for weight management, effectively reduces body mass index (BMI) while improving hyperglycemia, elevated alanine aminotransferase levels, hyperlipidemia, and quality of life in youth with obesity. As of this review, only one large randomized clinical trial of semaglutide in youth has been completed, with a follow-up duration of 68 weeks. Thus, long-term data on the safety in adolescents is limited, particularly regarding the risks of cholelithiasis, pancreatitis, suicidal ideation, and disordered eating. Due to the cost of semaglutide, particularly in the United States, limited cost effectiveness analyses have demonstrated unfavorable incremental cost-effectiveness ratios for semaglutide relative to phentermine-topiramate as an alternative antiobesity medication in adolescents.

SUMMARY

Semaglutide represents an important advance in the pediatric obesity management, with clear short-term reductions in BMI and improvement in metabolic parameters. However, its long-term safety and efficacy for youth with obesity remain to be demonstrated. Additional research is needed to assess trends in utilization and adherence to minimize the risk of worsening socioeconomic disparities in pediatric obesity.

Effect of elevated depressive symptoms during adolescence on health-related quality of life in young adulthood-a six-year cohort study with repeated exposure measurements

Objectives

Depression is a major contributor of young people's burden of disease. In this study we aim to estimate the effect of elevated depressive symptoms on physical health-related quality of life.

Design

We used self-reported information from the prospective BELLA cohort study, which included adolescents selected from the general population in Germany. The baseline assessment (2003-2006) and the 1-, 2-, and 6-year follow-up waves provide the data basis.

Participants

The baseline study population consisted of 1,460 adolescents between the ages of 12 and 17 who, according to their caregivers, did not suffer from depression.

Variables

The primary outcome, as measured by the physical component score (PCS) of the SF-36 at a 6-year follow-up (range: 0-100), is physical health-related quality of life. The exposure of interest is depressive symptoms, as measured by the Center for Epidemiological Studies Depression Scale for Children (CES-DC) at baseline, 1-year follow-up and 2-year follow-ups (range: 0-60). We dichotomized the exposure into subthreshold (≤15) and elevated depressive symptoms (>15). For the main analyses we considered a cumulative index for elevated depressive symptoms across the three time points (range: 0-3). Considered confounders are sex, age, socioeconomic status, migrant background, social support, anxiety symptoms, physical activity, chronic diseases, and sleeping problems.

Statistical methods

We used multiple imputation to account for missing values. Within each imputed dataset, we applied inverse probability weighting (IPW) to estimate the effect of the cumulative index for elevated depressive symptoms at baseline, 1- and 2-year follow-up on physical health-related quality of life at 6-year follow-up. We derived 95% confidence intervals by bootstrapping.

Results

After adjusting with IPW, the effect of the cumulative index per one unit increase of elevated depressive symptoms on the physical component score was -1.71 (95% CI: -3.51 to -0.04). The adjusted effect estimates of single exposure of elevated depressive symptoms on physical health-related quality of life were -0.83 (95% CI: -3.69 to 1.87) at baseline, -2.96 (95% CI: -4.94 to -0.52) at 1-year follow-up and -1.32 (95% CI: -3.85 to 1.15) at 2-year follow-up.

Conclusion

Findings suggest that elevated depressive symptoms during adolescence decrease physical health-related quality of life in young adulthood.

Emerging Adults With Type 2 Diabetes: Understanding Illness Experience and Transition to Adult Care

PURPOSE

Youth-onset type 2 diabetes (T2D) is increasingly common and is often diagnosed shortly before transition from pediatric to adult care. Little is known about the experience of emerging adults (EAs) with T2D and the readiness, barriers, and facilitators to transition. This study sought to describe the illness experience of EAs with T2D and perceptions about transition, and explore themes by "transition readiness," measured by the Transition Readiness Assessment Questionnaire (TRAQ).

METHODS

In this mixed-methods study, we conducted semi-structured interviews with EAs with T2D using a guide grounded in the health belief model, administered the TRAQ, and collected disease metrics from the electronic medical record. We developed a coding scheme using a directed content-analysis approach and triangulated qualitative and quantitative data to compare themes stratified by mean TRAQ score.

RESULTS

Participants described modifying factors like adjusting to life with a chronic illness and coping with mental health issues as critical elements of the illness experience that influence transition. Individual beliefs emerged including the perceived risk of disease complications being informed by experience of family members, self-efficacy in diabetes care hinging on the ability to be highly organized, and transition as a daunting obstacle with numerous emotional and logistical barriers. Participants emphasized the need for support from caregivers and providers throughout transition. Themes did not vary significantly by TRAQ score.

DISCUSSION

Experiences of EAs with T2D suggest more assistance is needed in the transition period to address factors such as mental health, organizational skills, and identifying support people to facilitate care.

Associations between polygenic risk scores for cardiometabolic phenotypes and adolescent depression and body dissatisfaction

BACKGROUND

Adolescents with elevated body mass index (BMI) are at an increased risk for depression and body dissatisfaction. Type 2 diabetes (T2D) is an established risk factor for depression. However, shared genetic risk between cardiometabolic conditions and mental health outcomes remains understudied in youth.

METHODS

The current study examined associations between polygenic risk scores (PRS) for BMI and T2D, and symptoms of depression and body dissatisfaction, in a sample of 827 community adolescents (Mage = 13.63, SDage = 1.01; 76% girls). BMI, depressive symptoms, and body dissatisfaction were assessed using validated self-report questionnaires.

RESULTS

BMI-PRS was associated with phenotypic BMI (β = 0.24, p < 0.001) and body dissatisfaction (β = 0.17, p < 0.001), but not with depressive symptoms. The association between BMI-PRS and body dissatisfaction was significantly mediated by BMI (indirect effect = 0.10, CI [0.07-0.13]). T2D-PRS was not associated with depression or body dissatisfaction.

CONCLUSIONS

The results suggest phenotypic BMI may largely explain the association between genetic risk for elevated BMI and body dissatisfaction in adolescents. Further research on age-specific genetic effects is needed, as summary statistics from adult discovery samples may have limited utility in youth.

IMPACT

The association between genetic risk for elevated BMI and body dissatisfaction in adolescents may be largely explained by phenotypic BMI, indicating a potential pathway through which genetic predisposition influences body image perception. Furthermore, age-specific genetic research is needed to understand the unique influences on health outcomes during adolescence. By identifying BMI as a potential mediator in the association between genetic risk for elevated BMI and body dissatisfaction, the current findings offer insights that could inform interventions targeting body image concerns and mental health in this population.

Psychosocial Factors and Glycemic Control in Young Adults With Youth-Onset Type 2 Diabetes

Importance

Youth-onset type 2 diabetes is associated with poor glycemic control and early onset of complications. Identification of psychosocial factors associated with poor glycemic control is needed to inform efficacious interventions.

Objective

To identify psychosocial factors associated with glycated hemoglobin (HbA1c) levels in young adults with youth-onset type 2 diabetes.

Design, Setting, and Participants

For the iCount cohort study, HbA1c levels were measured twice (at baseline [T1] and at 1 year [T2]) during the last years (2017-2019) of the observational phase of the multicenter Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY2) study. Participants were young adults who had been diagnosed with type 2 diabetes during childhood or adolescence. Data were analyzed from December 2021 to September 2023.

Main Outcomes and Measures

Glycemic control was examined categorically (high [≥8.0%] vs low [<8.0%] HbA1c), continuously (HbA1c level), and over time (change in HbA1c: decreased ≥0.5%, remained stable, or increased ≥0.5%). Psychosocial measures included beliefs about medicines, depression and anxiety symptoms, diabetes distress, diabetes self-efficacy, self-management support, and unmet material needs. Multivariable logistic and linear regression models evaluated the association of each psychosocial factor with the probability of T2 HbA1c of 8.0% or greater, T2 HbA1c level, and change in HbA1c.

Results

Of the 411 TODAY2 participants approached, 381 enrolled in the iCount study, and 348 with T1 and T2 HbA1c data comprised the analysis group. The 348 participants had a mean (SD) age of 26.1 (2.5) years and a mean (SD) HbA1c of 9.4% (2.8%). Most participants (229 [65.8%]) were women. In adjusted multivariable regressions, greater beliefs that diabetes medicines are necessary (odds ratio [OR], 1.19 [95% CI, 1.03-1.37]; P = .02), concerns about medicines (OR, 1.20 [95% CI, 1.00-1.45]; P = .049), diabetes distress (OR, 1.08 [95% CI, 1.02-1.15]; P = .006), and high distress (OR, 2.18 [95% CI, 1.15-4.13]; P = .02) increased the odds of high HbA1c at T2. Greater support (OR, 0.67 [95% CI, 0.46-0.97]; P = .04) and diabetes self-efficacy (OR, 0.91 [95% CI, 0.84-0.99]; P = .02) decreased the odds of high HbA1c at T2. Diabetes distress was associated with higher HbA1c level at T2 (coefficient, 0.08 [95% CI, 0.02-0.13]; P = .01). Beliefs that diabetes medicines are necessary (OR, 1.20 [95% CI, 1.03-1.39]; P = .02) and concerns about medicines (OR, 1.22 [95% CI, 1.00-1.47]; P = .048) increased the odds of an HbA1c decrease of at least 0.5% over 1 year.

Conclusions and Relevance

In this cohort study of young adults with youth-onset type 2 diabetes, beliefs about medicines, high diabetes distress, low diabetes self-efficacy, and self-management support were associated with high HbA1c over time. Future research should assess whether interventions that address these factors result in improved glycemic control in this at-risk group.

Youth-onset type 2 diabetes mellitus: an urgent challenge

The incidence and prevalence of youth-onset type 2 diabetes mellitus (T2DM) and its complications are increasing worldwide. Youth-onset T2DM has been reported in all racial and ethnic groups, but Indigenous peoples and people of colour are disproportionately affected. People with youth-onset T2DM often have a more aggressive clinical course than those with adult-onset T2DM or those with type 1 diabetes mellitus. Moreover, the available treatment options for children and adolescents with T2DM are more limited than for adult patients. Intermediate complications of youth-onset T2DM, such as increased albuminuria, often develop in late childhood or early adulthood, and end-stage complications, including kidney failure, develop in mid-life. The increasing frequency, earlier onset and greater severity of childhood obesity in the past 50 years together with increasingly sedentary lifestyles and an increasing frequency of intrauterine exposure to diabetes are important drivers of the epidemic of youth-onset T2DM. The particularly high risk of the disease in historically disadvantaged populations suggests an important contribution of social and environmental factors, including limited access to high-quality health care, healthy food choices and opportunities for physical activity as well as exposure to stressors including systemic racism and environmental pollutants. Understanding the mechanisms that underlie the development and aggressive clinical course of youth-onset T2DM is key to identifying successful prevention and management strategies.

Mental health comorbidity and youth onset type 2 diabetes: A systematic review of the literature

BACKGROUND

Type 2 diabetes (T2D) is a burgeoning epidemic in children and adolescents. Adult T2D doubles the risk of depression and mental health comorbidity, makes it more difficult to make the lifestyle, medication adherence and health behavior changes needed to optimize outcomes. There is limited research on the impact of depression and depressive symptoms on youth T2D.

METHODS

A search of the literature in the last 10 years regarding youth with depression and T2D was conducted. Abstracts were screened by 2 randomly assigned authors for inclusion, and disagreement was resolved by a third author. Selected full-text articles were divided among all authors for review.

RESULTS

13 publications from 8 studies (N=2244, age 6-17) were included. 6 of 13 publications utilized Treatment Options for Type 2 Diabetes in Youth (TODAY) study data. While studies included evaluation of depressive symptoms, most did not formally assess for major depressive disorder (MDD) and excluded participants with a previous diagnosis of MDD. Depressive symptoms were common in this population and were associated with negative T2D outcomes.

CONCLUSIONS

While there is a growing body of adult literature highlighting the extensive relationship between T2D and mental health, there is a dearth of data in youth. Future studies are needed that include, 1.) youth with diagnosed MDD, 2.) treatment studies of both T2D and MDD, 3.) larger, more racially diverse samples of youth with T2D, and 4.) studies that evaluate the impact of social determinants of health, including mental health comorbidity on outcomes of T2D.

Mental health comorbidity is common in children with type 2 diabetes

OBJECTIVE

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

RESEARCH DESIGN AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Anti-obesity pharmacotherapy for treatment of pediatric type 2 diabetes: Review of the literature and lessons learned from adults

Type 2 diabetes mellitus (T2DM) in adolescents is a more rapidly progressive disease, associated with earlier and higher rates of microvascular complications than in adults. As obesity is a significant risk factor for T2DM development and progression, the American Diabetes Association (ADA) recommends anti-obesity medications (AOMs) as adjuvant therapy for adults with both T2DM and overweight/obesity. In adults, the addition of AOMs to a diabetes regimen can improve glycemic control, reduce weight, and decrease anti-diabetes medication use. The ADA recommends considering bariatric surgery for adolescents with T2DM who have a BMI >35 kg/m2, but did not mention the use of AOMs in their 2022 updated guidelines. Currently, there are three FDA-approved AOMs available for chronic use in adolescents with obesity. Other medications are used in an "off-label" fashion for appetite suppression and BMI reduction. As additional AOMs are being developed and FDA-approved for the pediatric population, new treatment options with novel mechanisms of action will become available for adolescents with T2DM and obesity. In this review, we will discuss the evidence for the use of AOMs in the treatment of T2DM in adolescents, including lessons learned from the adult T2DM literature.

Glycemic control, depression, diabetes distress among adolescents with type 2 diabetes: effects of sex, race, insurance, and obesity

AIMS

To determine (1) differences in depression and distress scores between adolescents with type 1 (T1D) and type 2 diabetes (T2D), (2) how socioeconomic factors, obesity, race, and treatment regimen affect depression and diabetes distress in adolescent T2D, (3) the relationships between depression and diabetes distress scores in adolescents with T2D, and (4) how depression and diabetes distress scores relate to current and future glycemic control in adolescents with T2D.

BACKGROUND

Diabetes distress is a negative emotional reaction to diabetes complications, self-management demands, unresponsive providers, poor interpersonal relationships, and to diabetes itself. It is frequently mistaken for depression and the two are interrelated. Increases in both predict poor glycemic control in adolescents with T1D.

METHOD

Depression (PHQ-9) and diabetes distress (PAID-T) scores from self-administered tests were studied in 364 patients with diabetes between the ages of 13-17. Kruskal-Wallis test was used to assess differences between types of diabetes, sexes, races, and insurance status. Spearman correlations, and robust rank order multivariable regression analysis were used to assess relationships. Medical records were reviewed for follow-up hemoglobin A1c (HbA1c) levels over 3 years.

RESULTS

HbA1c was significantly lower in females with T2D than with T1D (p  =  0.019) but not in males. It, also, did not differ between females and males with T2D. Median PHQ-9 score in females with T2D was significantly greater than in females with T1D (p = 0.007) but did not differ between females and males with T2D. PHQ-9 scores did not differ between males with T2D and T1D. PAID-T scores, however, were higher in males with T2D than in males with T1D but did not differ between females. PHQ-9 scores and PAID-T scores were significantly related in T2D (r_s = 0.65, p < 0.001). Neither was related to HbA1c in T2D.

CONCLUSIONS

As in adolescents with T1D, depression and diabetes distress screening scores are closely related in adolescent T2D. However, unlike T1D, they are not related to glycemic control in T2D. Depression and diabetes distress may be more closely related to weight and lifestyle concerns.

Longitudinal Association of Depressive Symptoms, Binge Eating, and Quality of Life With Cardiovascular Risk Factors in Young Adults With Youth-Onset Type 2 Diabetes: The TODAY2 Study

OBJECTIVE

To report the prevalence of depression, eating disorder symptoms, and impaired health-related quality of life (HRQOL) and examine their longitudinal associations with glycemia and diabetes complications in young adults with youth-onset type 2 diabetes.

RESEARCH DESIGN AND METHODS

Participants recruited over a 4-year period were enrolled at 15 clinical diabetes centers in the follow-up observational Treatment Options for type 2 Diabetes in Adolescents and Youth (TODAY2) study. From 2014-2020, prevalence of symptoms of depression, eating disorders, and HRQOL by sex, race/ethnicity, and baseline family income were assessed annually. Longitudinal relationships between assessments of glycemia and complications with psychiatric symptoms and HRQOL were evaluated in adjusted models.

RESULTS

Participants (n = 514) were 21.7 ± 2.5 years old with a diabetes duration of 8.6 ± 1.5 years in year 1 of TODAY 2 (2014). Symptoms of depression and impaired HRQOL were common and increased significantly over 6 years (14.0% to 19.2%, P = 0.003; and 13.1% to 16.7%, P = 0.009, respectively). Depression and impaired HRQOL were more common in women and those with lower baseline family income but did not differ by race/ethnicity. Rates of binge eating were stable over time; self-reported purging increased. Over time, symptoms of depression were associated with higher HbA1c, hypertension, and retinopathy progression; impaired HRQOL was associated with higher BMI, systolic blood pressure, hypertension, and retinopathy progression; and symptoms of eating disorders were associated with higher BMI.

CONCLUSIONS

Significant psychiatric symptoms and impaired HRQOL are common among emerging adults with youth-onset type 2 diabetes and are positively associated with glycemia, hypertension, and retinopathy progression in this group that is at ongoing risk for medical morbidity.

Type 2 diabetes mellitus and its effect on quality of life in adolescents: A retrospective cohort study in Saudi Arabia

INTRODUCTION

Quality of life (QoL) in adolescent patients suffering from type 2 diabetes mellitus (T2DM) has not been thoroughly explored in Saudi Arabia. Herein, we aimed to measure the health-related quality of life (HRQoL) in adolescent patients suffering from T2DM and explore the correlation between adolescents' self- and parent-reporting of QoL scores, and glycaemic control (HbA1c).

MATERIAL AND METHODS

A retrospective multi-centre cohort study was conducted at 4 hospitals in Riyadh, Saudi Arabia. The Paediatric Quality of Life Inventory (PedsQLTM) Diabetes Module 3.0 was completed by children and their parents in a confidential and anonyms manner through a phone interview.

RESULTS

We recruited 49 paediatric patients for this study (mean age: 18.45 years; male: 55%). Both children and parents reported low cumulative mean scores for PedsQL™ (58.65 and 57.38, respectively) as compared to previous international studies. The lowest obtained score was noted for the diabetes symptoms domain (53.4). Comparing the magnitude of discrepancy between the adolescents' and parents' subscale scores revealed a non-significant difference, except for the 'worry' subscale, in which parents reported significantly higher mean scores (76.73 vs. 60.54, p = 0.02). Comparison of mean scores reported by adolescents who met the target HbA1c goal (<7%) and their counterparts revealed a non-significant difference, suggesting an irrelevant impact of this parameter on their perspectives or experiences.

CONCLUSIONS

The study findings emphasized the need to initiate further intensive awareness programs concerning this disease and its clinical implications in T2DM children to improve treatment adherence and symptoms, and consequently improve the perception of the patient and the family for HRQoL.

Mental health comorbidities in adolescents and young adults with type 2 diabetes

BACKGROUND

Screening for mental health comorbidities is recommended in adolescents and young adults (AYAs) with diabetes. There is a paucity of data on mental health comorbidities in AYAs with type 2 diabetes (T2D).

OBJECTIVE

To assess rates of depression, suicidal ideation, and diabetes distress (DD) in AYAs with T2D overall and by sociodemographic and clinical factors.

METHODS

AYAs with T2D ages 13-21 years seen in a pediatric diabetes clinic between March 2018 and June 2019 completed the Patient Health Questionnaire-9 (PHQ-9) for depression screening and the Problem Areas in Diabetes - teen version (PAID-T) survey to assess DD. Chi-square tests were used to assess whether rates of depression and DD were associated with participant characteristics.

RESULTS

The sample consisted of 64 AYAs with T2D (58% female, mean age 15.8 ± 2.0 years, mean HbA1c 8.3% ± 2.6%, mean BMI z-score 2.2 ± 0.6, 59% on insulin). Overall, 31% of participants had high depression and/or DD. Twenty-two percent of participants reported high depressive symptoms and 9% endorsed suicidal ideation on the PHQ-9. There were no differences in rates of depression by sociodemographic factors. Twenty-three percent of participants reported high DD. Rates of DD were higher among those on insulin (p = 0.014) and on public health insurance (p = 0.014).

CONCLUSIONS

Almost 1 in 3 AYAs with T2D endorsed depression and/or DD. Our findings support the importance of mental health screening in AYAs with T2D, as well as the need for strategies to address psychological comorbidities in this population.

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.

Treatment options and current guidelines of care for pediatric type 2 diabetes patients: a narrative review

CONTEXT

Type 2 diabetes (T2D) mellitus, which was once considered a disease affecting adults, is a growing problem among youths. Research now shows that T2D in youths is more progressive and associated with earlier onset of complications than adult-onset T2D.

OBJECTIVES

To update practicing clinical physicians on what is currently known about pediatric T2D and share current guidelines to care for these patients.

METHODS

The authors conducted a literature review through the MEDLINE/PubMed, Google Scholar, and clinicaltrials.gov databases in July 2019 using the following search phrases: "youth-onset type 2 diabetes," "pediatric type 2 diabetes," "diabetes in youth," and "FDA-approved pediatric diabetes medications." Items published between 2010 and 2019 and written in English were included.

RESULTS

A total of 65 items were included after database review, including 44 articles, 10 FDA product inserts, six clinicaltrials.gov listings, three position statements/guideline documents, one website, and one FDA announcement.

CONCLUSIONS

There are very limited treatment options available to manage pediatric T2D. Prevention of pediatric T2D is paramount, which requires a high index of suspicion, routine screening of children and adolescents, and willingness to engage in family-based interventions for those at risk for prediabetes and T2D. Osteopathic physicians have a unique opportunity to help by applying the osteopathic principles to the whole person - including environmental, societal, and lifestyle factors - to help patients achieve their health and wellness goals.

Multisite Examination of Depression Screening Scores and Correlates Among Adolescents and Young Adults With Type 2 Diabetes

OBJECTIVES

Our aim was to evaluate self-reported depressive symptoms and clinical outcomes during routine screening for adolescents and young adults with type 2 diabetes (T2D), and examine associations among depressive symptoms and demographic and clinical characteristics.

METHODS

The Patient Health Questionnaire (PHQ) was administered to 197 adolescents and young adults with T2D using the PHQ-2 or PHQ-9 in routine pediatric diabetes care at 4 academic medical centres. Data from electronic health records were extracted from the screening date and 12 months earlier.

RESULTS

Adolescents and young adults with T2D (mean age, 16.85 years; 57% male; 77.2% non-Caucasian) completed the PHQ as part of routine diabetes care. On the PHQ, 19.3% of adolescents and young adults endorsed elevated depressive symptoms (PHQ score ≥10) and, among a subsample with item-level data (n=53), 18.9% endorsed thoughts of self-harm. Subsequently, 50.0% of those with depressive symptoms had a documented referral for mental health treatment in the electronic health record after the positive screening outcome. Older age, shorter diabetes duration, higher glycated hemoglobin level, being non-Hispanic white, more blood glucose checks per day and being prescribed oral medications were significantly associated with more depressive symptoms.

CONCLUSIONS

Screening for depressive symptoms identifies individuals in need of referral for mental health treatment. A focus on self-harm assessment, standardized methods for documentation of symptoms and mental health referrals and increased referral resources are needed.

Depression in Youth-Onset Type 2 Diabetes

PURPOSE OF REVIEW

The current review summarizes extant knowledge regarding the prevalence of depression in youth-onset type 2 diabetes (T2D) and how depression might impact glycemic control through stress-related behavioral and physiological mechanisms. The current review also discusses depression intervention studies in adult-onset T2D, as there are no such studies in youth-onset T2D, and provides recommendations for clinical research.

RECENT FINDINGS

The prevalence of elevated depression symptoms in youth-onset T2D is approximately 20%. Some studies suggest depression may negatively impact glycemic control through inadequate medication adherence and disordered eating, but there is a dearth of studies investigating associations with depression and physical activity/sedentary time, sleep, and stress-related physiological mechanisms. In adult-onset T2D, evidence-based behavioral interventions tailored to address diabetes-related issues have shown positive effects for depression and glycemic control. Future research is needed to characterize the epidemiology of depression in youth-onset T2D and test interventions to improve depression, glycemic control, and health outcomes in this specific pediatric population.

Depression in Girls With Obesity and Polycystic Ovary Syndrome and/or Type 2 Diabetes

OBJECTIVES

Polycystic ovary syndrome (PCOS) is a common reproductive/metabolic condition associated with obesity, type 2 diabetes (T2D) and depression in adult women. Depression in adults is related to PCOS dermatologic manifestations. Adolescents with obesity with or without T2D have elevated depression symptoms, but data from youth with PCOS and obesity with/without T2D are limited.

METHODS

Our study included girls, aged 11 to 17 years, with obesity and PCOS, PCOS+T2D or T2D, who were newly seen in an obesity complications clinic after March 2016. All participants had Center for Epidemiologic Studies-Depression (CES-D, 20 items) scores obtained within 6 months of PCOS or T2D diagnosis. Data on history of psychiatric diagnosis and treatment, metabolic syndrome and severity of acne and hirsutism were collected through chart review.

RESULTS

One hundred five girls (47 with PCOS, 14 with PCOS+T2D, 44 with T2D) had similar age (15±1.8 years) and body mass index z scores (2.2±0.4). CES-D scores ≥16, indicating elevated depression symptoms, and CES-D scores ≥24, indicating severe depression symptoms, were observed in 60% and 30% of girls with PCOS, 78% and 71% of those with PCOS+T2D and 39% and 21% of those with T2D, respectively (p<0.0001 for both cutpoints). A higher CES-D score was not associated with severity of hirsutism or acne (p>0.05 for both).

CONCLUSIONS

Adolescents with PCOS and obesity have higher rates of elevated depression symptoms compared with girls with T2D, which is not related to worse dermatologic symptoms. Because depression may impact both PCOS and T2D management and adherence to therapy, greater efforts should be made to screen for and address mental health in adolescents with PCOS and obesity, especially if T2D is present.

Metabolic outcomes of surgery in youth with type 2 diabetes

Youth-onset type 2 diabetes (T2D) is a formidable threat to the health of obese adolescents because of its potential for early-onset and aggressive co-morbidities and complications. The physiology of youth-onset T2D differs from T2D in adults and is associated with a greater degree of insulin resistance, a more rapid decline in pancreatic β-cell function, and a poorer response to medications. Medical management in youth is focused on combining lifestyle intervention and pharmacological treatment, but these therapies have yet to demonstrate improvements in disease progression. Metabolic bariatric surgery (MBS) is now recommended for the treatment of T2D in adults largely because of the beneficial effects on weight, ability to improve glycemic control, and, in a large proportion of people, induce diabetes remission. MBS is now being performed in adolescents with severe obesity and T2D, with initial results also showing high rates of T2D remission. Here, we review the state of medical management of youth-onset T2D and the outcomes of MBS studies in youth with T2D published to date.

A Holistic Approach to Risk for Early Kidney Injury in Indigenous Youth With Type 2 Diabetes: A Proof of Concept Paper From the iCARE Cohort

Background:

Indigenous youth with type 2 diabetes (T2D) are disproportionately affected by early onset albuminuria and are at high risk of kidney failure in early adulthood. Traditional biological approaches have failed to fully explain the renal morbidity seen in this population. The improving renal Complications in Adolescents with type 2 diabetes through REsearch cohort (iCARE) study was therefore designed in collaboration with patients, to more holistically evaluate risk factors for renal morbidity. We hypothesize that both biological factors and mental health influence renal outcomes, mediated via inflammatory pathways.

Objective:

The objective of this study was to evaluate the iCARE analytic framework which evaluates relationships between biological factors, mental health, inflammation, and albuminuria utilizing a structural equation modeling (SEM) approach.

Methods:

The first 187 youth with T2D (10-25 years) from the Manitoba iCARE cohort are presented here to evaluate our theoretical and analytic framework. An SEM was chosen to evaluate the statistical significance of proposed associations. The primary outcome was a nonorthostatic urine albumin:creatinine ratio ≥2 mg/mmol. Main exposures (ie, latent factors) included psychological health (distress, perceived stress, positive mental health and resilience), hypertension (24 hour monitored), and inflammatory markers (C-reactive protein [CRP], erythrocyte sedimentation rate [ESR], fibrinogen). Hemoglobin A1c (HbA1c) and duration of diabetes were covariates.

Results:

Within the initial cohort (median age = 15 years, duration of diabetes = 2.3 years, 66.8% female), 30.5% (n = 57) had nonorthostatic albuminuria (ALB), and the majority of ALB was persistent (confirmed in 2/3 samples over a 6-month period; n = 47). Youth with ALB had higher HbA1c (10.9% vs 8.9%; P < .001), more hypertension (94.2% vs 78·2%; P = .02), longer duration of diabetes (3.4 vs 2.4 years; P = .01), higher distress (9.2 vs 7.3; P = .02), and stress scores (28.7 vs 26.4; P = .03), and elevated inflammatory markers (CRP: 4.9 vs 3.1 mg/L; P = .01, fibrinogen: 3.7 vs 3.3 µmol/L; P = .02). Factors directly associated with ALB in the SEM were hypertension (0.28; P = .001), inflammation (0.41; P < .001), and HbA1c (0.50; P < .001). Psychological health was independently associated with inflammation (−0.20; P < .001) but not directly associated with ALB.

Conclusions:

Albuminuria is highly prevalent in Indigenous youth with T2D. This preliminary analysis supports a theoretical framework linking glycemic control, hypertension, and inflammation, potentially mediated by psychological factors with albuminuria. These data support the need for more holistic models of evaluation and care for youth with T2D and multifactorial interventions to prevent complications.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Impact of lifestyle behavior change on glycemic control in youth with type 2 diabetes

BACKGROUND

Little is known about the feasibility and impact of lifestyle intervention, determined by change in diet and cardiovascular fitness (CRF), on glycemic control in youth who are overweight with type 2 diabetes. This was examined in the Treatment Options for type 2 Diabetes in Adolescents and Youth (TODAY) clinical trial cohort from across 15 US centers.

SUBJECTS

TODAY enrolled 699 youth aged 10 to 17 years with type 2 diabetes <2 years and body mass index ≥85th percentile at baseline.

METHODS

Dietary data were collected by an interviewer-administered food frequency questionnaire; CRF was assessed using a submaximal cycle ergometer test. Change from baseline in these variables was analyzed using generalized linear mixed models for both continuous and categorical measures. Models were adjusted for age, baseline HbA1c, treatment group, and medication adherence. Data were collected at baseline, 6, and 24 months. Trial registration ClinicalTrials.gov NCT00081328.

RESULTS

At 6 months, ~25% of females and ~33% of males improved CRF. In males, this was related to a decreased HbA1c (P = .001) and a lower percent experiencing glycemic failure (HbA1c ≥8%; P = .007). Females who decreased their saturated fat intake and/or increased their fiber intake had lower HbA1c at month 24 (P = .01 and P = .007, respectively). Males who increased their sweetened beverage intake at 6-month follow-up were at a 1.6-fold higher risk of experiencing glycemic failure (P = .04).

CONCLUSIONS

Few youth improved fitness and/or diet over time, although those who did showed a beneficial impact on glycemic outcomes. Although lifestyle behaviors are difficult to change in youth with type 2 diabetes, interventions are needed that are feasible (in scope, complexity, and demands), sustainable, and clinically meaningful.

Mental health issues in children and adolescents with chronic illness

Purpose

The purpose of this paper is to consider mental health issues in children and adolescents with chronic illness or health conditions, including their treatment, and issues related to delivery of services.

Design/methodology/approach

A selective review of the literature was conducted to highlight significant mental health issues and their treatment in youth with various types of chronic illness.

Findings

A significant portion of youth experience mental health problems related to their chronic health conditions. While evidence-based treatments are available to address these problems, significant barriers exist that impede the delivery of psychological and behavioral interventions for many youth.

Research limitations/implications

More controlled studies are needed to demonstrate the effectiveness and cost offset of delivering psychological and behavioral interventions for the population of youth with various types of chronic health conditions, particularly in clinical and community settings.

Social implications

Policy reform can ensure that mental health issues are effectively addressed for children with chronic illness. Policy is needed that promotes integrated health care, whereby psychological and behavioral interventions are delivered in health care settings along with medical interventions to reduce barriers to care.

Originality/value

Significant numbers of children and adolescents have chronic health conditions and many experience mental health problems related to their conditions. While evidence-based treatments are available to address these problems, significant barriers impede the delivery of psychological and behavioral interventions for many youth. Health care policy promoting integrated health care to deliver psychological and behavioral interventions in health care settings along with medical interventions should reduce barriers to care and improve both physical and mental health outcomes for youth.

Correlates of Medication Adherence in the TODAY Cohort of Youth With Type 2 Diabetes

OBJECTIVE

To identify factors that predict medication adherence and to examine relationships among adherence, glycemic control, and indices of insulin action in TODAY (Treatment Options for Type 2 Diabetes in Adolescents and Youth).

RESEARCH DESIGN AND METHODS

A total of 699 youth 10-17 years old with recent-onset type 2 diabetes and ≥80% adherence to metformin therapy for ≥8 weeks during a run-in period were randomized to receive one of three treatments. Participants took two study pills twice daily. Adherence was calculated by pill count from blister packs returned at visits. High adherence was defined as taking ≥80% of medication; low adherence was defined as taking <80% of medication. Depressive symptoms, insulin sensitivity (1/fasting insulin), insulinogenic index, and oral disposition index (oDI) were measured. Survival analysis examined the relationship between medication adherence and loss of glycemic control. Generalized linear mixed models analyzed trends in adherence over time.

RESULTS

In this low socioeconomic cohort, high and low adherence did not differ by sex, age, family income, parental education, or treatment group. Adherence declined over time (72% high adherence at 2 months, 56% adherence at 48 months, P < 0.0001). A greater percentage of participants with low adherence had clinically significant depressive symptoms at baseline (18% vs. 12%, P = 0.0415). No adherence threshold predicted the loss of glycemic control. Longitudinally, participants with high adherence had significantly greater insulin sensitivity and oDI than those with low adherence.

CONCLUSIONS

In the cohort, the presence of baseline clinically significant depressive symptoms was associated with subsequent lower adherence. Medication adherence was positively associated with insulin sensitivity and oDI, but, because of disease progression, adherence did not predict long-term treatment success.

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

Type 2 diabetes is a significant and increasing burden in adolescents and young adults. Clear strategies for research, prevention, and treatment of the disease in these vulnerable patients are needed. Evidence suggests that type 2 diabetes in children is different not only from type 1 but also from type 2 diabetes in adults. Understanding the unique pathophysiology of type 2 diabetes in youth, as well as the risk of complications and the psychosocial impact, will enable industry, academia, funding agencies, advocacy groups, and regulators to collectively evaluate both current and future research, treatment, and prevention approaches. This Consensus Report characterizes type 2 diabetes in children, evaluates the fundamental differences between childhood and adult disease, describes the current therapeutic options, and discusses challenges to and approaches for developing new treatments.

Diabetes complications in childhood and adolescent onset type 2 diabetes-a review

Diabetes mellitus is one of the most common endocrine disorders in children. Earlier, diabetes in children was almost exclusively type 1 diabetes. Recently, the scenario has changed and increasing numbers of children and adolescent T2DM are being diagnosed. As the epidemic of T2DM shifts to children and adolescents, there is an increased risk of development of micro and macrovascular complications. This could potentially affect the economy of the nation apart from posing a large burden to the individual and his or her family. Prevention and treatment are especially important, given the fact that onset at an early age increases the risk of developing micro and macrovascular complications due to increased duration of exposure to hyperglycemia and other metabolic abnormalities. Diagnosing children and adolescents with T2DM early and instituting good control of all risk factors could yield good results in the prevention of long term complications of diabetes. This review focuses on the prevalence of complications of diabetes among children and adolescents with T2DM.

Depression in type 2 diabetes mellitus: prevalence, impact, and treatment

Clinically significant depression is present in one of every four people with type 2 diabetes mellitus (T2DM). Depression increases the risk of the development of T2DM and the subsequent risks of hyperglycemia, insulin resistance, and micro- and macrovascular complications. Conversely, a diagnosis of T2DM increases the risk of incident depression and can contribute to a more severe course of depression. This linkage reflects a shared etiology consisting of complex bidirectional interactions among multiple variables, a process that may include autonomic and neurohormonal dysregulation, weight gain, inflammation, and hippocampal structural alterations. Two recent meta-analyses of randomized controlled depression treatment trials in patients with T2DM concluded that psychotherapy and antidepressant medication (ADM) were each moderately effective for depression and that cognitive behavior therapy (CBT) had beneficial effects on glycemic control. However, the number of studies (and patients exposed to randomized treatment) included in these analyses is extremely small and limits the certainty of conclusions that can be drawn from the data. Ultimately, there is no escaping the paucity of the evidence base and the need for additional controlled trials that specifically address depression management in T2DM. Future trials should determine both the effects of treatment and the change in depression during treatment on measures of mood, glycemic control, and medical outcome.

Depressive Symptoms and Social Support in Adolescents With Type 2 Diabetes

INTRODUCTION

Disease management outcomes, depressive symptoms, and levels of social support may differ between early and middle adolescents. The purpose of this study was to explore the relationships between depressive symptomatology, perceived social support, body mass index, hemoglobin A1c (A1C), and months since diagnosis for adolescents with type 2 diabetes ages 13 to 17 years.

METHODS

This cross-sectional, descriptive, correlational study surveyed adolescents at an endocrinology clinic regarding depressive symptoms and perceived social support.

RESULTS

Depressive symptoms were not significantly related to other variables; however, mean depressive symptoms scores were higher among early adolescents. Middle adolescents had lower body mass index percentiles but higher A1C levels. Early adolescents had greater mean scores of social support and reported that this support was more important compared with middle adolescents.

DISCUSSION

The results show that differences exist in perceived social support, depressive symptoms, and A1C levels among early and middle adolescents.

Effects of comorbid conditions on health-related quality of life in youth with Type 2 diabetes: the TODAY clinical trial

AIM

To explore associations between health-related quality of life (HRQOL) and comorbidities in youth with Type 2 diabetes.

PATIENTS & METHODS

Of 699 youth in the TODAY study, 685 (98%) had baseline HRQOL data, 649 (93%) at 6 months and 583 (83%) at 24 months. Comorbidities were defined by sustained abnormal values and treatment regimens.

RESULTS

At baseline, 22.2% of participants demonstrated impaired HRQOL. Only depressive symptoms distinguished those with versus without impaired HRQOL and were significantly related to later impaired HRQOL (p < 0.0001). A significant correspondence between impaired HRQOL and number of comorbidities (p = 0.0003) was noted, but was driven by the presence of depressive symptoms.

CONCLUSION

Results emphasize the need for evaluation of depressive symptoms. Other comorbidities did not have a significant impact on HRQOL in this cohort.

Parental Characteristics Associated With Outcomes in Youth With Type 2 Diabetes: Results From the TODAY Clinical Trial

OBJECTIVE

This study examined parental factors associated with outcomes of youth in the Treatment Options for type 2 Diabetes in Adolescents and Youth (TODAY) clinical trial.

RESEARCH DESIGN AND METHODS

Of 699 youth with type 2 diabetes in the TODAY cohort, 623 (89.1%) had a parent participate and provide data at baseline, including weight, HbA1c, blood pressure, symptoms of depression, binge eating (BE), and medical history. Youth were followed 2-6.5 years. Data were analyzed using regression models and survival curve methods.

RESULTS

Parental diabetes (43.6% of parents) was associated with higher baseline HbA1c (P < 0.0001) and failure of youths to maintain glycemic control on study treatment (53.6% vs. 38.2% failure rate among those without a diabetic parent, P = 0.0002). Parental hypertension (40.6% of parents) was associated with hypertension in youth during TODAY (40.4% vs. 27.4% of youth with and without parental hypertension had hypertension, P = 0.0008) and with higher youth baseline BMI z scores (P = 0.0038). Parents had a mean baseline BMI of 33.6 kg/m(2). Parental obesity (BMI >30 kg/m(2)) was associated with higher baseline BMI z scores in the youth (P < 0.0001). Depressive symptoms in parents (20.6% of parents) were related to youth depressive symptoms at baseline only (P = 0.0430); subclinical BE in parents was related to the presence of subclinical BE (P = 0.0354) and depressive symptoms (P = 0.0326) in youth throughout the study period.

CONCLUSIONS

Parental diabetes and hypertension were associated with lack of glycemic control, hypertension, and higher BMI z scores in youth. Further research is needed to better understand and address parental biological and behavioral factors to improve youth health outcomes.

Complications and comorbidities of T2DM in adolescents: findings from the TODAY clinical trial

With the rise in childhood obesity, type 2 diabetes mellitus (T2DM) has been recognized to occur in adolescents with increasing frequency. Although much is known about T2DM in adults, few studies have examined the treatment and complications of T2DM in youth. The Treatment Options for type 2 Diabetes in Adolescents and Youth (TODAY) study was designed to evaluate the efficacy of various treatments and provided a unique opportunity to study the disease progression and appearance of complications in a pediatric cohort with recent onset of the disease. In the TODAY study, hypertension was present in 11.6% of the population at baseline and increased to 33.8% by the end of the study. Prevalence of high-risk LDL-cholesterol rose from 4.5% at baseline to 10.7% at the end of the study. Microalbuminuria was found in 6.3% of the cohort at baseline and increased to 16.6%. Retinopathy was not assessed upon entry into TODAY, but was present in 13.9% of the TODAY cohort at the end of the study. Experience to date indicates that these complications and comorbidities are similar to those seen in adults, but occur on an accelerated timeline. The early manifestation of diabetes complications in youth-onset T2DM suggests that this group will be burdened with the tangible consequences of cardiovascular disease, nephropathy, and retinopathy in the third and fourth decades of life. It is hoped that through an early, aggressive approach to treatment and prevention, we may be able to curb the onset and progression of these potentially devastating outcomes.

Type 2 diabetes in youth in South Asia

People of South Asian origin are at a high risk of developing diabetes compared to that of other ethnic groups. Recent evidence suggests an emerging epidemic of youth-onset type 2 diabetes (T2DM) in the region, in parallel with the childhood obesity epidemic. Many risk factors such as foetal and early-life influences, the South Asian phenotype, family history of diabetes and environment factors are responsible for the early occurrence of T2DM in South Asia. The high risk supports the need for the opportunistic screening of children and adolescents for diabetes in South Asian countries. Early detection, lifestyle modification, weight reduction and drugs are central to the care of children with T2DM. Both population-based preventive strategies and interventions targeting children and adolescents with obesity and impaired glucose tolerance are required to combat the epidemic of youth-onset T2DM in South Asia.

Lifestyle therapy for the treatment of youth with type 2 diabetes

Type 2 diabetes (T2D) in youth is a relatively novel condition facing paediatric health care providers. Few experimental trials exist to guide clinical management in this population. Supporting and prescribing modifiable lifestyle behaviours is cornerstone in the management of T2D in adults. Clinical trials in obese adolescents suggest that intensive lifestyle interventions that include both dietary changes and increased physical activity elicit clinically meaningful reductions in weight and improve cardiovascular risk profiles. Observational studies in youth with T2D suggest that better diet quality and increased physical activity are associated with better metabolic control; however, the limited experimental data available does not support these observations. Trials evaluating lifestyle monotherapy for the treatment of hyperglycaemia in youth with T2D do not exist, and the only study evaluating combined lifestyle and pharmacologic therapy did not show additional benefit over pharmacologic treatment with metformin alone. Physiological and psychosocial differences between youth and adults with T2D likely contribute to the differences in the effectiveness of lifestyle therapy for improving glycaemic control. The current review describes these topics in detail and provides recommendations for paediatric health care providers for the promotion of lifestyle therapy for the management of hyperglycaemia and cardiovascular risk factors for youth with T2DM.

Relationships among stressful life events and physiological markers, treatment adherence, and psychosocial functioning among youth with type 2 diabetes

OBJECTIVE

To examine the relationships between stressful life events and physiological measures, adherence to prescribed oral medication regimens, depressive symptoms, and impaired quality of life (QoL) in adolescents with recent-onset type 2 diabetes (T2D).

STUDY DESIGN

Data were collected from 497 ethnically diverse participants (66% female) in the final year of the Treatment Options for Type 2 Diabetes in Adolescents and Youth multicenter clinical trial. Exposure to 32 possible events over the previous year and rating of subsequent distress were collected by self-report and summarized as a major stressors score. This score was analyzed for relationship to glycemic control (hemoglobin A1c and treatment failure), body mass index, diagnosis of hypertension or triglyceride dyslipidemia, adherence to a prescribed oral medication regimen, presence of depressive symptoms, and impaired QoL.

RESULTS

The total number of major stressful life events in the adolescents with T2D was calculated, with 33% reporting none, 67% reporting ≥ 1, 47% reporting ≥ 2, 33% reporting ≥ 3, and 20% reporting ≥ 4. There were no associations between the major stressors score and physiological measures or diagnosis of comorbidities. The odds of medication nonadherence increased significantly from those reporting ≥ 1 major stressor (OR, 1.58; P = .0265) to those reporting ≥ 4 major stressors (OR, 2.70; P = .0009). Significant odds of elevated depressive symptoms and impaired QoL were also found with increased reporting of major stressors.

CONCLUSION

Exposure to major stressful life events is associated with lower adherence to prescribed oral medication regimens and impaired psychosocial functioning in adolescents with T2D.

Obesity and type 2 diabetes in children: epidemiology and treatment

The incidence of overweight and obesity among children has increased dramatically in recent decades, with about one-third of children in the U.S. currently being either overweight or obese. Being overweight in early childhood increases risk for later obesity. There is evidence for the efficacy of family-based behavioral treatment to control weight and improve health outcomes. Obesity-related health risks have been documented, including metabolic syndrome. There is also increasing incidence of type 2 diabetes (T2D) among youth in recent years, with obesity and family history of T2D generally present. Lower income and ethnic minority status are associated with both obesity and T2D in youth. Most youth with T2D do not achieve optimal glycemic control, and are at high risk for later health complications. Obesity and T2D represent significant public health issues with potentially great personal and societal cost. Research addressing the prevention of obesity and T2D among youth is urgently needed.

NIDDK international conference report on diabetes and depression: current understanding and future directions

Comorbid diabetes and depression are a major clinical challenge as the outcomes of each condition are worsened by the other. This article is based on the presentations and discussions during an international meeting on diabetes and depression convened by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) in collaboration with the National Institute of Mental Health and the Dialogue on Diabetes and Depression. While the psychological burden of diabetes may contribute to depression in some cases, this explanation does not sufficiently explain the relationship between these two conditions. Shared biological and behavioral mechanisms, such as hypothalamic-pituitary-adrenal axis activation, inflammation, autonomic dysfunction, sleep disturbance, inactive lifestyle, poor dietary habits, and environmental and cultural risk factors, are important to consider in understanding the link between depression and diabetes. Both individual psychological and pharmacological depression treatments are effective in people with diabetes, but the current range of treatment options is limited and has shown mixed effects on glycemic outcomes. More research is needed to understand what factors contribute to individual differences in vulnerability, treatment response, and resilience to depression and metabolic disorders across the life course and how best to provide care for people with comorbid diabetes and depression in different health care settings. Training programs are needed to create a cross-disciplinary workforce that can work in different models of care for comorbid conditions.

Longitudinal associations between sex, diabetes self-care, and health-related quality of life among youth with type 1 or type 2 diabetes mellitus

OBJECTIVE

To examine the longitudinal associations between sex, diabetes self-care, and the health-related quality of life (HRQL) of children and adolescents with type 1 or type 2 diabetes.

STUDY DESIGN

The sample included 910 participants with type 1 and 241 participants with type 2, ages 10-22 years at baseline, from the SEARCH for Diabetes in Youth Study, a longitudinal observational study. The primary outcome measure was the Pediatric Quality of Life Inventory. Repeated measures, mixed-model regression analysis was conducted with the use of data from baseline and at least one follow-up assessment, spanning approximately 4 years.

RESULTS

HRQL was greater among those with type 1 versus type 2 diabetes. Among participants with type 1, greater (better) Pediatric Quality of Life Inventory total scores over time were related to greater parent education (P = .0007), lower glycated hemoglobin values (P < .0001), and greater physical activity during the past 7 days (P = .0001). There was a significant interaction between sex and age (P < .0001); girls' HRQL remained stable or decreased over time, whereas males' HRQL increased. For participants with type 2 diabetes, there was no significant interaction by age and sex, but lower total HRQL was related to being female (P = .011) and greater body mass index z-scores (P = .014).

CONCLUSIONS

HRQL in this cohort varied by diabetes type. The interaction between sex and age for type 1 participants, coupled with poorer HRQL among female than male participants with type 2 diabetes, suggests the impacts of diabetes on HRQL differ by sex and should be considered in clinical management. Encouraging physical activity and weight control continue to be important in improving HRQL.