CE/CME

Pediatric T2DM: A Growing Threat to US Health

Clinician Reviews. 2015 March;25(3):34-42

References

1. Fryar CD, Carroll MD, Ogden CL. Prevalence of obesity among children and adolescents: United States, trends 1963-1965 through 2009-2010. CDC. National Center for Health Statistics, Health E-Stat, September 2012.
2. Cote AT, Harris KC, Panagiotopoulos C, et al. Childhood obesity and cardiovascular dysfunction. J Am Coll Cardiol. 2013;62(15):1309-1319.
3. Dabelea D, Bell RA, D’Agostino Jr RB, et al; the SEARCH for Diabetes in Youth Writing Group. Incidence of diabetes in youth in the United States. JAMA. 2007;297(24):2716-2724.
4. Copeland KC, Silverstein J, Moore KR, et al. Management of newly diagnosed type 2 diabetes mellitus (T2DM) in children and adolescents. Pediatrics. 2013;131(2):364-382.
5. American Diabetes Association. Children and adolescents. Sec. 11. In: Standards of Medical Care in Diabetes—2015. Diabetes Care. 2015;38(suppl 1):S70-S76.
6. Constantino MI, Molyneaux L, Limacher-Gisler F, et al. Long-term complications and mortality in young-onset diabetes. Diabetes Care. 2013;36:3863-3869.
7. CDC. National Diabetes Statistics Report, 2014: Estimates of Diabetes and its Burden in the United States. www.cdc.gov/diabetes/pubs/statsre port14/national-diabetes-report-web.pdf. Accessed February 17, 2015.
8. Pettitt DJ, Talton J, Dabelea D, et al; for the SEARCH for Diabetes in Youth Study Group. Prevalence of diabetes in US youth in 2009: the SEARCH for Diabetes in Youth Study. Diabetes Care. 2014;37:402-408.
9. Imperatore G, Boyle JP, Thompson TJ, et al; for the SEARCH for Diabetes in Youth Study Group. Projections of type 1 and type 2 diabetes burden in the U.S. population aged < 20 years through 2050. Diabetes Care. 2012;35:2515-2520.
10. Dabelea D, Mayer-Davis EJ, Saydah S, et al; for the SEARCH for Diabetes in Youth Study Group. Prevalence of type 1 and type 2 diabetes among children and adolescents from 2001 to 2009. JAMA. 2014;311(17):1778-1786.
11. Lifshitz F (ed). Pediatric Endocrinology. Vol 1. 5th ed. New York; Informa Healthcare: 2006.
12. DeFronzo RA. From the triumvirate to the ominous octet: a new paradigm for the treatment of type 2 diabetes. Diabetes. 2009;58:773-795.
13. Flint A, Arslanian B. Treatment of type 2 diabetes in youth. Diabetes Care. 2011;34(suppl 2):S177-S183.
14. American Diabetes Association. Type 2 diabetes in children and adolescents: consensus statement. Diabetes Care. 2000;23(3):381-389.
15. American Diabetes Association. Classification and diagnosis of diabetes. Sec. 2. In: Standards of Medical Care in Diabetes—2015. Diabetes Care. 2015;38(suppl 1):S8-S16.
16. FDA. FDA allows marketing of first ZnT8Ab autoantibody test to help diagnose type 1 diabetes. Press release. August 20, 2014.
17. Klingensmith GJ, Pyle L, Arslanian S, et al; the TODAY Study Group. The presence of GAD and IA-2 antibodies in youth with a type 2 diabetes phenotype-results from the TODAY study. Diabetes Care. 2010;33(9):1-6.
18. Silverstein J, Klingensmith G, Copeland K, et al. American Diabetes Association. Care of children and adolescents with type 1 diabetes. Diabetes Care. 2005;28(1):186-212.
19. Academy of Nutrition and Dietetics. Pediatric weight management guideline (2007). www.andeal.org/topic.cfm?cat=2721. Accessed February 17, 2015.
20. Glucophage [package insert]. Princeton, NJ: Bristol-Myers Squibb Company; 2009.
21. American Association of Clinical Endocrinologists/American College of Endocrinology. Consensus statement by the AACE/ACE insulin pump management task force. Endocr Prac. 2014;20(5):463-489.
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TREATMENT OF T2DM
Because relevant clinical data are limited, blood glucose (BG) goals should be individualized for each child with T2DM. As a rule of thumb, guidelines for BG goals in pediatric T1DM can serve as a reference for establishing BG goals in T2DM. Once adulthood is reached, BG goals reflect adult ranges.

FBG and A1C goals in pediatric T1DM are
• Younger than 4 years: 80 to 200 mg/dL and < 8.5%
• Between 5 and 11: 70 to 180 mg/dL and < 8.0%
• 12 and older: 70 to 150 mg/dL and < 7.5%.¹⁸

Primary care clinicians who manage pediatric patients with T2DM should consult with diabetes specialists at diagnosis and at least annually thereafter. Consultation is encouraged when treatment goals are not met.⁴

Lifestyle changes
The cornerstone of pediatric T2DM treatment is effective lifestyle intervention aimed at achievement of the patient’s BG goals and reduction of risks for microvascular and macrovascular complications.

Dietary modification methods can vary, depending on the caregivers’ and patient’s previous knowledge of nutrition. For families with little nutritional knowledge, the clinician may recommend the “plate method,” with half a plate designated for vegetables, one quarter for lean meats and protein, and one quarter for carbohydrates. As an alternative, the clinician may advise simple portion control, including smaller plate sizes and only one serving per meal. In addition, all sugared beverages should be avoided and daily milk intake should be limited.¹⁹

Behaviors surrounding meal preparation and snacking may also contribute to excessive caloric intake. Each day’s meals should be planned, and eating while at the computer, doing homework, or watching TV should be avoided.⁴

As time and the family’s comfort level permit, intensification of nutritional therapy can improve glycemic control through specific instruction regarding calorie counting and selection of low-fat and low-carbohydrate foods. Calorie intake of 900 to 1,200 kcal/d for children ages 6 to 12 and a minimum of 1,200 kcal/d for adolescents ages 13 to 18 are recommended for weight loss and improved body composition (see "Resources for Weight Management and Nutrition").⁴

Physical activity in the pediatric population can be derived from multiple sources, including physical education classes, after-school programs, sports and dance programs, and walks with the family or the dog. When discussing exercise recommendations, it is essential to consider any limitations imposed by the family’s finances and family members’ schedules.

Cardiovascular activity is recommended for 30 to 60 min or more every day or most days.^4,14 To decrease excessive pursuit of sedentary activities, parents are urged to limit children’s nonacademic “screen time” to a maximum of two hours per day and to discourage the placement of video screens and television sets in children’s bedrooms.⁴

While lifestyle intervention remains the first-line treatment choice for pediatric T2DM, expert consensus is that less than 10% of pediatric patients reach glycemic control goals with lifestyle modifications alone.⁴

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Pediatric T2DM: A Growing Threat to US Health

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