Objective

  • Differentiate the disease characteristics of type 2 diabetes from those of type 1 diabetes.

Identifying Children with Type 2 Diabetes

Type 2 diabetes is uncommon in children under 10 years old, regardless of ethnicity or race. After that age, however, the disease is increasingly prevalent, especially among minority populations. In newly diagnosed diabetes cases, type 2 diabetes accounts for:

Unlike type 1 diabetes, which usually produces fairly acute and dramatic symptoms within the two to three weeks before diagnosis, the progressive course of type 2 diabetes in children, adolescents, and adults involves the gradual development of glucose intolerance.

Fast Fact

Glucose intolerance refers to a reduced ability to clear ingested and absorbed glucose from the blood and body fluids for use in the cells, resulting in a slow but steady rise in blood glucose. When blood glucose levels reach an average of 180–200 mg/dl, the kidney’s ability to reabsorb glucose is exceeded and glucose spills into the urine, causing increased urination, thirst, and dehydration, the classic symptoms of diabetes.

When those classic symptoms of diabetes emerge and a random blood glucose level is 180–200 mg/dl or higher, a diagnosis of diabetes can be made without further testing.

However, if blood glucose is very elevated and ketoacidosis is present (as is the case in 15 to 30 percent of children who present with new-onset type 2 diabetes), classifying the diabetes as type 1 or type 2 may be challenging. Test for antibodies because 15 to 30 percent of children with type 2 diabetes will have one or more of the three common antibodies, GAD, IAA, and ICA.

Most children and adolescents with type 2 diabetes are overweight or obese and have a family history of the disease. Because that type of diabetes develops over a relatively long period (months or years), with symptoms that may be mild at onset, the best way to efficiently diagnose children with prediabetes or early asymptomatic type 2 diabetes is through annual screening, based on specific criteria.

The American Academy of Pediatrics and the American Diabetes Association have developed testing criteria for children who may be at risk for the disease. Children who meet those criteria should begin diabetes testing at age 10 or at puberty, whichever comes first. A fasting plasma glucose measurement is preferred for that screening, with repeat testing every two years in high-risk children.

Testing Criteria for Children

AND

  1. Family history of type 2 diabetes in a first- or second-degree relative.
  2. Native American, African American, Latino, Asian American, or Pacific Island ethnicity.
  3. Symptoms or conditions associated with insulin resistance, such as acanthosis nigricans, hypertension, dyslipidemia, and polycystic ovary syndrome.
  4. Maternal history of diabetes or gestational diabetes.

For more information about those recommendations, refer to Standards of Medical Care in Diabetes—2008 on the American Diabetes Association website. Although the American Diabetes Association favors fasting blood glucose as a type 2 diabetes screening tool for children, any of the following are acceptable diagnostic criteria:

Although the OGTT is less commonly used for children, it can be useful for those with a high index of risk (such as children with obesity, severe acanthosis nigricans, and strong family history) in whom fasting or random glucose tests/screenings give inconsistent results.

Diagnostic Criteria for Prediabetes

Some children who are screened for type 2 diabetes because they have symptoms or meet the criteria described above will have blood glucose levels higher than normal but not above the threshold for diagnosis. That condition is referred to as prediabetes. It may also be called impaired glucose tolerance (IGT) or impaired fasting glucose (IFG), depending on the type of blood test performed.

The criteria for prediabetes are:

or

or

For adults, abundant data supports the value of lifestyle change to prevent the progression of prediabetes to diabetes, with or without the use of oral medications. However, for children with prediabetes, the risks of progression to diabetes without intervention have not been well quantified and the efficacy of interventions, including nutrition and physical activity, has not been well defined. More research is also needed to justify the use of medications for primary prevention in this age group.

Although the data do not yet support an official endorsement of lifestyle interventions for children, modifications in nutrition and physical activity are recommended by the ADA and other diabetes experts for all high-risk youth. More information about nutrition and physical activity is provided in Sections 5 and 6.

The Role of Insulin Resistance in the Development of Type 2 Diabetes

Blood glucose elevation at any level occurs when insulin activity does not meet the body’s needs. In type 1 diabetes, insulin supply is deficient because the beta cells, attacked by the immune system, simply cannot make enough insulin. In type 2 diabetes, increasing evidence shows that the insulin-producing capacity of beta cells may also be compromised. Genetic and other non-autoimmune causes may be involved, but a major factor appears to be the “resistance,” or decreased sensitivity, of the cells to insulin action.

Insulin acts by binding to the cell membrane. The act of binding triggers a biochemical chain reaction in which glucose molecules (and free fatty acids) move from the bloodstream into cells in an amount proportional to the amount of bound insulin. The number of insulin molecules needed to trigger the movement of a given amount of glucose from blood to cells is a measure of insulin sensitivity. The fewer molecules of insulin needed, the more “sensitive” the cells are to insulin.

If more than a normal amount of insulin is needed to clear glucose from the blood into the cells, an individual is said to be “insulin resistant.” He or she will need higher than normal levels of insulin to trigger glucose entry into cells and to normalize blood glucose. People who are insulin resistant may not be able to produce the increased amount of insulin quickly enough to normalize blood glucose promptly and efficiently after a meal, so an abnormally high level of blood glucose is present even two hours after eating. That is called “impaired glucose tolerance.” Diabetes is diagnosed when the glucose level remains above 200 mg/dl two hours or longer after eating.

Quick Question

A person’s insulin sensitivity or resistance is genetically determined. Children from families with members who have diabetes, particularly with mothers who had diabetes during pregnancy, or from certain ethnic groups are at higher risk to be more resistant to insulin, primarily because of their inherited tendency.

Although genetic influences cannot be controlled, evidence for adults and emerging evidence for children suggests that the impact of other risk factors can be modified. What behavior could contribute to modifying other risk factors of insulin resistance?

Your answer is correct!

Other risk factors for insulin resistance are inactivity and excess body fat, especially in the abdomen. The impact of both can be modified behaviorally, with regular physical activity, better nutrition, and weight control. (Certain hormones, especially cortisol, growth hormones, and sex hormones, can also increase insulin resistance.) Families with diabetic members can choose to take responsibility for factors they can control. For instance, a young person who is prediabetic but behaves in a manner that increases insulin sensitivity—stays physically active, eats appropriately, manages weight—will need less insulin to maintain normal blood glucose and may delay the development of diabetes.

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Acute Management of Type 2 Diabetes

When diabetes is diagnosed, initial therapy is dictated by the degree of elevation of blood glucose, not by the classification of the patient as type 1 or type 2. In some cases, the subtype of diabetes may not be clear. Up to 30 percent of children who otherwise fit the profile for type 2 diabetes also have antibodies that are characteristic of type 1 diabetes, and 25 percent will present with ketoacidosis.

Although many patients with type 2 diabetes may eventually be controlled on oral agents or injectable medication other than insulin (see Diabetes Medications, below), insulin therapy is indicated for acute treatment (days to months) in all patients with glucose over 250 mg/dl (with or without DKA) and in patients with HbA1c over 8 percent, regardless of subtype. All non-insulin therapy requires a certain degree of beta cell function, and when blood glucose is high, even healthy or “mildly ill” beta cells cannot secrete insulin properly. That phenomenon is called “glucose toxicity.”

Rehydration can help decrease hyperglycemia, but rapid-acting insulin frequently is needed to reduce the blood glucose level to a desirable range (preferably under 150 mg/dl). After that, a long-acting insulin (detemir or glargine), given once daily, may be sufficient to control blood glucose and allow beta cells to recover function.

Oral medications may be started while a child is still on insulin therapy, as long as the child is able to eat and has normal hydration and kidney function. As the requirement for insulin declines (indicated by the need to reduce the insulin dosage because of lower glucose readings), insulin may be decreased or even stopped, and many patients may fully transition to non-insulin therapy.

While blood glucose is being normalized, the patient and family should be educated about type 2 diabetes at a level they can understand. That education includes:

Red Flag

Because most young patients with diabetes have at least one close relative with type 2 diabetes, the condition should be approached as a family disease. Recommendations for weight management, healthy eating, and regular physical activity are appropriate for parents and children, and adherence is more likely when the entire family participates.

For more information about initial and ongoing management of type 2 diabetes, refer to the Texas Diabetes Council’s Algorithms and Guidelines page for the Insulin Algorithm for Type 2 Diabetes Mellitus in Children and Adults.

Case Study

Fourteen-year-old Jerome comes to you, his primary care provider, accompanied by his mother, who reports that her son has lost 15 pounds and has been very tired lately. Jerome says he also feels thirsty a lot. He weighs 220 pounds, and you note acanthosis nigricans on his neck. Jerome’s blood glucose is 273 mg/dl, he has no ketones in his urine, and he appears fairly well hydrated. His A1C is 8.2 percent. You ask Jerome to return the next day for a second blood glucose test, and the result is 262 mg/dl. Jerome’s mother says she takes “pills” for her type 2 diabetes, and she asks if she can get the same pills for Jerome.

Which is the best response?

Your answer is correct!

Jerome meets diagnostic criteria for diabetes, based on two random elevated blood glucose results. Because his glucose level is over 250 mg/dl, Jerome needs insulin to reduce glucose toxicity before his beta cells can respond better to an oral medication.

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Jerome meets diagnostic criteria for diabetes, based on two random elevated blood glucose results. Because his glucose level is over 250 mg/dl, Jerome needs insulin to reduce glucose toxicity before his beta cells can respond better to an oral medication.

Diabetes Medications

Although nutrition and physical activity modifications are necessary for the management of type 2 diabetes, they are rarely sufficient to regulate blood glucose on their own. Some individuals may eventually achieve weight loss and/or physical conditioning that allow them to maintain normal blood glucose without oral agents, but most patients require at least one medication.

Insulin can be used as a single therapy (monotherapy) for type 2 diabetes, but its tendency to cause weight gain and the increased risk of hypoglycemia suggest using the smallest dose necessary. With the oral medications listed below, many children with type 2 diabetes can reduce or eliminate the need for insulin injections, at least temporarily.

Medications approved for children:

Medications not approved for children:

Although the oral agents listed above are not officially approved for use in children, experienced pediatric diabetes health-care providers may prescribe them for use on an individual basis with close monitoring, which includes self-monitored blood glucose data and hemoglobin A1C levels performed quarterly to assess overall effectiveness.

Download the National Diabetes Education Program publication Diabetes Medications Supplement for more information about each of the medications.

A new class of non-insulin injectable therapy, the GLP-1 mimetics (exenatide and liraglutide), has been approved for once- or twice-daily injections for patients with type 2 diabetes who are age 18 and older. GLP-1 mimetics stimulate insulin secretion by the beta cells only when blood glucose is elevated, so the risk of hypoglycemia is minimized. These agents assist with gastric emptying, which curbs appetite and blunts high blood glucose after meals. They may also promote beta cell regeneration. GLP-1 mimetics may be approved for use in the future in children age 17 and younger.

Chronic Management of Type 2 Diabetes

Managing insulin resistance—and, therefore, managing weight—is the main goal of type 2 diabetes treatment. Type 2 diabetes is a family disease. Often multiple family members have diabetes or are at risk for developing it. The best outcome for patients relies on engagement by and participation from the family. Factors to consider include:

Health-care providers must help families, caregivers, and young patients understand that it may take time to find the right balance of food, physical activity, and medication to keep blood glucose levels as close to normal as possible. Achieving that goal requires accurate daily records of carbohydrate consumption, physical activity, and blood glucose levels. That information helps the health-care provider to determine how much carbohydrate is needed for a child’s age and activity level and to adjust insulin therapy and oral medications accordingly.

Patients with type 2 diabetes tend to have less variability in glucose levels than patients with type 1 diabetes, and those who take little or no insulin usually have less risk of hypoglycemia. For those reasons, the recommended frequency of glucose testing ranges from four times a day for poorly controlled patients to twice a day for older teens on oral therapy and with stable glucose. To be sure the treatment plan is controlling post-meal glucose, blood sugar should be checked two hours after eating, with a glucose goal of less than 140 mg/dl.

Ongoing Diabetes Management

Diabetes self-care is rigorous for the patient and family, taking up to an hour each day, excluding exercise, for planning meals, coordinating appointments, and using necessary skills such as preparing and injecting insulin, checking blood sugar, and analyzing trends in glucose fluctuations. All of that requires ongoing education and counseling for the family.

Some family members display poor adherence to treatment plans, which can be frustrating for primary care providers and specialists. Poor adherence often results from the negative psychological impact of the disease. Families with multiple members who have diabetes may deny the disease and avoid care, which perpetuates the disease progression in the family. Some family members may not adjust their behavior in regard to nutrition and activity or not take their medications. They may not be able to provide mentoring for their newly diagnosed children. Many families with type 2 diabetes tend to be in the lower socioeconomic bracket and have less formal education, so ongoing counseling and training can help them manage their condition. However, patients often get lost to follow-up because they miss appointments. Other obstacles to treatment are language barriers, geographical distance for appointments, and financial and insurance issues.

Click the following link to the HealthDay website to read how Diabetes Education Seems to Help Improve Blood Sugar Control.

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