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Type 2 diabetes in young people: a serious disease requiring improved understanding and care
May 2008

Opinion of the International Diabetes Federation
The prevalence of type 2 diabetes in children and adolescents is growing worldwide, and mirrors the increase of the condition in adults. Type 2 diabetes in young people is a severe disease with very poor outcomes over 10 to 20 years. The International Diabetes Federation (IDF) recommends that provisions be made to deliver the best possible care, prevent long–term complications, and promote further research in order to reach a better understanding of the condition.

 

Type 2 diabetes in children and adolescents, as in adults, is due to a combination of insensitivity to insulin and the relative failure of beta–cell secretion. There are a number of genetic and environmental risk factors for insensitivity to insulin and limited beta–cell reserve, including ethnicity, obesity, sedentary behaviour, family history of type 2 diabetes, puberty, low birth weight, exposure to diabetes in the uterus, and female gender. There is ample evidence that certain ethnic groups have greater susceptibility than others.

Environmental factors play a key role in the development of type 2 diabetes. Globalization and industrialization are the underlying cause for the excess of high–density, low–nutrient food and drink throughout the world, and an increasing tendency for children to be sedentary and unfit. This has led to a global epidemic of obesity as a major risk factor for type 2 diabetes.

Type 2 diabetes is a serious disease in children and adolescents. It requires the involvement of an informed healthcare team and ongoing and frequent access to diabetes healthcare assessments. Adequate treatment requires resources equal to those required for the treatment of type 1 diabetes. As type 2 diabetes emerges as a worldwide public health problem, improved understanding of its pathogenesis, and identification of evidence–based care for young people with the condition must be coupled with a focus on prevention.

IDF’s position is that

 



Background information
Prevalence
In Japan, the incidence of type 2 diabetes in children almost doubled from 7.3 per 100 000 between 1976 and 1980 to 13.9 per 100 000 between 1991 and 1995.1 In Taiwan, the incidence has been found to be 8.3 and 12.0 per 100 000 for boys and girls, respectively.2 In First Nation Canadian young people, a 4% prevalence of type 2 diabetes among adolescent girls has been reported,3 in Indigenous Australian children, there was a two–fold increase in the prevalence of type 2 diabetes to 1.3% over the 5–year period from 1989 to 1994.4

In the USA, the SEARCH study showed that the overall prevalence of diabetes was 1.82 per 1000 young people in 2001, with higher rates in older children (2.80 cases per 1000 young people aged between 10 and 19 years) compared to younger children (0.79 cases per 1000 aged between 0 and 9 years). In younger children, type 1 diabetes accounted for more than 80% of diabetes, while in older children, type 2 diabetes accounted for 6% in non–Hispanic white young people and 76% in Native American young people.5

Diagnosis of type 2 diabetes in children and adolescents
The diagnosis is made with the same glucose criteria as those used in adults. It is often difficult to determine the type of diabetes that a child or adolescent may have, and in addition to attempting to differentiate on clinical grounds between type 1 diabetes, type 2 diabetes, secondary diabetes and monogenic forms of diabetes, laboratory investigation with islet and insulin autoantibodies, assessment of residual c–peptide and molecular genetic techniques should be performed when indicated and possible.

Treatment
The treatment goals for type 2 diabetes in children and adolescents are to achieve physical and psychological well–being and long–term blood glucose control, and prevent micro–vascular complications and macro–vascular disease. There is limited evidence as to the best treatment modalities for type 2 diabetes, although many more children and adolescents with the condition appear to require insulin therapy than adults.

Lifestyle counselling is important. However, the role of lifestyle alterations and optimum blood glucose targets for treatment are not known. It appears that children and their families need the involvement of a multidisciplinary team, ongoing healthcare visits, perhaps quarterly, and family–centred education where these are possible.

Co–morbidities and complications
The available data as to the long–term complications of type 2 diabetes in young people underscore the severity of the disease. In Japan, it was reported that after 30 years of type 2 diabetes, 44% of those diagnosed when they were under 30 years of age had kidney disease (nephropathy).6 In the Native American Pima community, those diagnosed with type 2 diabetes under 20 years of age were found to have nephropathy at a rate of 13 per 1000 person years.7

In a study of 164 First Nation Canadians with early–onset type 2 diabetes, 69 were followed into adulthood – a mean age of 23, with 9 years duration of diabetes. The mortality rate was 9%, 35% had microalbuminuria, 6% required dialysis, 45% had hypertension requiring treatment, 38% of the women who had become pregnant had pregnancy loss. Over the follow–up period, 35% were lost to clinical follow–up and of those followed, 67% had poor blood glucose control with an average HbA1c of 10.9%.8

In Australia, a study compared outcomes in young people with type 1 diabetes to those with type 2 diabetes. It was found that young people with type 2 diabetes had significantly higher rates of microalbuminuria and hypertension, despite a shorter duration of diabetes and lower HbA1c.9

Screening
The value of screening asymptomatic young people for type 2 diabetes depends on rates of prevalence of the disease in different regions of the world, cost–effectiveness and available screening methods.



Research
Due to the global rise of type 2 diabetes in youth, it is imperative to determine, through investigation, the following:

References
1. Kitagawa T, Owada M, Urakami T, et al. Increased incidence of non–insulin dependent diabetes mellitus among Japanese schoolchildren correlates with an increased intake of animal protein and fat. Clin Pediatr (Phila) 1998, 37: 111–5.
2. Chuang LM, Sung FC, Lee CY, et al. Incidence and prevalence of childhood diabetes in Taiwan – an experience with nation–wide screening [abstract]. Diabetes Res Clin Pract 2002, 56: S16.
3. Harris SB, Gittelsohn J, Hanley A, et al. The prevalence of NIDDM and associated risk factors in native Canadians. Diabetes Care 1997, 20: 185–7.
4. Braun B, Zimmermann MB, Kretchmer N, et al. Risk factors for diabetes and cardiovascular disease in young Australian aborigines. A 5–year follow–up study. Diabetes Care 1996, 19: 472–9.
5. SEARCH for Diabetes in Youth Study Group. The burden of diabetes mellitus among US youth: prevalence estimates from the SEARCH for Diabetes in Youth Study. Pediatrics 2006, 118, 1510–8.
6. Yokoyama H, Okudaira M, Otani T, et al. Higher incidence of diabetic nephropathy in type 2 than type 1 diabetes in early–onset diabetes in Japan. Kidney Int 2000, 58: 302–11.
7. Krakoff J, Lindsay RS, Looker HC, et al. Incidence of retinopathy and nephropathy in youth–onset compared with adult–onset type 2 diabetes. Diabetes Care 2003, 26: 76–81.
8. Dean HJ, Flett B. Natural history of type 2 diabetes diagnosed in childhood long term follow–up in young adult years [abstract]. Diabetes 2002, 51: A24.
9. Eppens MC, Craig ME, Cusumano J, et al. Prevalence of diabetes complications in adolescents with type 2 compared with type 1 diabetes. Diabetes Care 2006, 29: 1300–6.


Source: International Diabetes Federation