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what’s new in type 2?

what’s new in type 2?. We are in a diabesity epidemic! Prevalence of type 2 diabetes and metabolic syndrome is increasing in children and their parents Risk of complications of type 2 are higher in type 2 with onset 18-45 than in older adults

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what’s new in type 2?

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  1. what’s new in type 2? • We are in a diabesity epidemic! • Prevalence of type 2 diabetes and metabolic syndrome is increasing in children and their parents • Risk of complications of type 2 are higher in type 2 with onset 18-45 than in older adults • Most children with diabetes are cared for by their primary doctors

  2. JCEM 88:1417,2003, Goran

  3. Obesity Visceral Adiposity Androgens Adipocytokines Puberty Inflammation Insulin Resistance Hypertension Dyslipidemia Cardiovascular Disease

  4. Prevalence of obesity is increasing • Prevalence of overweight in US children doubled from 1980-1994 • Overweight 50% higher in poor US teens • 17%US children and teens overweight (BMI >95%ile) 2004 NHANES • 4% US children BMI>99%ile • 1:17,741 pedi endos to obese kids in US • Waist circumference increased 3.7 cm in teens 1994-2004 NHANES

  5. Factors contributing to the obesity epidemic • Increase in intake of regular soda (high fructose corn syrup), fast foods, increase in portion size of fast foods, Increase in high carb snacks • Decrease in physical activity • Increase in physical inactivity (TV, video, computer time) • each hour TV time=+167 kcal/day, Wiecha,Arch Ped Adol Med 160:436,2006

  6. The metabolic syndrome • Insulin resistance • Hypertension • Dyslipidemia

  7. Ford et al, Diabetes Care 31:587,2008 • Metabolic syndrome prevalence by IDF definition 4.5% US teens National health and nutrition examination survey 1999-2004 of 2014 teens age 12-17

  8. Type 1 diabetes • beta cell destruction leading to absolute insulin deficiency • Autoimmune • idiopathic

  9. Type 2 diabetes mellitus: • Both insulin resistance and relative insulin insufficiency: • Secretory defect with insulin resistance • Insulin resistance and insufficient compensatory increase in insulin production

  10. Other specific types of diabetes • Genetic defects in beta cell function (MODY, mitochondrial DM) • Genetic defects in insulin action (type A) • Diseases of exocrine pancreas (CF etc) • Endocrinopathies (Cushing’s etc) • Drug induced (steroids etc) • Immune mediated ( insulin receptor antibodies ) • Genetic syndromes associated with DM • Gestational diabetes

  11. Definition of impaired fasting glucose/ glucose intolerance • Fasting plasma glucose 100-125 mg/dl (5.6-6.9 mmol/l) • 2 h plasma glucose 140 mg/dl-199 mg/dl (7.8-11 mmol/l) on OGTT

  12. Prevalence of diabetes in children under 18 years • Overall 1/300 (all types) (incidence 15/100,000) • Type 2 diabetes 4-30% depending on ethnic mix of population • Prevalence of Type 2 diabetes is rapidly increasing with increase of obesity and inactive lifestyle

  13. Risk factors for type 2 diabetes • Obesity with signs of insulin resistance (acanthosis nigricans, polycystic ovary syndrome) usually post pubertal • Ethnic heritage (African American, Native American, Asian, Latino, pacific islander) • Family history of type 2 • history of SGA or LGA

  14. Screening for type 2 diabetes • BMI of 85%ile or weight > 120% above ideal body weight, age 10 or above or pubertal and: • Family history of type 2 diabetes • At risk ethnic group • Signs or conditions associated with insulin resistance (acanthosis nigricans, hypertension, hyperlipidemia, PCOS)

  15. Screening obese children for diabetes • Fasting blood sugar • consider fasting lipids • consider insulin level : fasting glucose/insulin > 4.5 normal (insulin not always accurate in commercial labs) • Glucose 2 hour post 75 gm (1.75 gm/kg) glucose load (not yet the official recommendation of the AAP, ADA)

  16. Impaired glucose tolerance in children with marked obesity • Impaired glucose tolerance in 25% of very obese children ages 4-10 years • Impaired glucose tolerance in 21% very obese adolescents, 4% silent diabetes • Fasting blood glucose screening would miss many individuals with impaired glucose tolerance (N Eng J Med 2002;346:802)

  17. Teen diabetes and the pediatrician • Coordinate care with an endocrinologist • Address adolescent health issues • Acute infections (including STDs) • Contraceptive needs • Smoking cessation • Depression • Family support issues

  18. Diabetes Specialty visits • At least every 3 months for education, review of blood sugars, med adjustment • Monitor growth, blood pressure (<130/80) • Glucose control goals (individualize): • Hemoglobin A1c<7% (ideal) (lower in type 2): • Preprandial plasma glucose 90-130 mg/dl • Post prandial <180 mg/dl • Yearly microalbumin, lipids, retinopathy screen

  19. Treatment goals for diabetes • Hemoglobin A1c <7% • Preprandial blood glucose 90-130 mg/dl • Postprandial blood glucose < 180 mg/dl • Blood pressure < 130/80 • LDL cholesterol < 100 mg/dl • Triglycerides < 150 mg/dl • HDL cholesterol > 40 mg/dl

  20. Management of hyperlipidemia • Dietary counseling, repeat lipids in 3 months • LDL 130-159 mg/dl consider medication (family history, blood pressure, smoking) • LDL> 160 mg/dl : begin statin at low dose, monitor LFTs, watch for persistent muscle pains, use with extreme caution in sexually active females (Diabetes Care 26:2194,2003)

  21. Barriers to good diabetes control • Expense of blood glucose monitoring, medications • Cultural bias against insulin or medical intervention: fatalistic attitude toward illness • Insufficient parental supervision of medications and monitoring • Normal adolescent development (denial) • Depression • Increasing obesity

  22. Encouraging optimum diabetes control • Give credit for honesty and effort • Diabetes visit should build self esteem • Support parental involvement • Set realistic goals with teen and family • Keep it interesting (new technologies) • Encourage regular visits and contact • Group programs for teens (camps)

  23. Presentation of type 2 diabetes • most teens with type 2 diabetes are identified by screening • Polyuria/ polydipsia/ nocturia common symptoms but not always complaints • Girls may present with recurrent yeast infections • 5-25% present in DKA or hyperosmolar dehydration • up to 33% have ketones at presentation

  24. Is it type 1 or type 2? More likely type 2 if overweight and: Pubertal Milder symptoms Acanthosis nigricans Family history of type 2 High risk ethnic group

  25. Features of type 2 diabetes • Insulin /C peptide over upper limit of normal for assay • Negative pancreatic antibody panel • Initial insulin requirements 1.3-1.5 units/kg/day falling to little or no insulin requirement over 1-2 months • Ketosis seldom occurs spontaneously

  26. 14 year old male with ? diabetes • 2 weeks ago, vomiting, diarrhea,fatigue • Glucosuria, random blood sugar in 180s • Repeat BG=286 mg/dl occasional nocturia, no thirst, 6 lb weight loss • BW 7 lb, MGM, MGGM type 2 diabetes • Maternal aunt low thyroid • BMI 35, 99%ile, 101kg ht 170 cm • SMR 3, acanthosis, psoriasis

  27. Idiopathic diabetes • African American / Asian teens with negative antibodies • Insulinopenia: ketosis prone (episodic ketosis) • Family history positive for early onset of diabetes in multiple generations • Absolute requirement for insulin replacement may come and go between episodes of ketosis • Control is usually poor without insulin

  28. Healthy eating and activity • Avoid regular soda/ large amounts of fruit juice • Encourage whole fruits, vegetables, low fat milk, (? low glycemic index choices, increased fiber) • Have healthy foods for all at home • Limit inactivity (TV off), encourage activity (30 minutes per day, 5+ days /week) • ?discuss cigarette smoking

  29. Management of type 2 diabetes in teens • If presenting in DKA or severe hyper osmolar state, start with insulin (be aware of cultural biases against insulin) • Teach blood sugar monitoring from the beginning (pre and some post meal) • Teach healthy eating and exercise • Begin metformin at low dose increasing over several weeks if no contraindications • Address lipid issues

  30. Use of metformin in type 2 diabetes • Start low (500 mg with meal, go slow) • Increase slowly to max 1000 mg bid, 850 mg tid with meals (or Glucophage XR) • GI side effects common (nausea, diarrhea, abdominal discomfort) in first two weeks • Avoid dehydration (stop if vomiting) • Home BG monitoring premeal and some 2 h post meal • Yearly CBC, BUN, creat, ALT,AST • ? multivitamin

  31. Advantages of metformin • Mild weight loss (teens love this) • Decreased insulin requirement/ decreased insulin resistance • Not associated with hypoglycemia • Beneficial effects on cardiovascular disease shown in adults

  32. When to begin insulin rather than oral agent in type 2: • Ketones present • Marked hyperglycemia with dehydration • Contraindications to metformin (significantly abnormal LFTs, elevated BUN/ creatinine, pregnancy)

  33. When metformin is not enough: • Add insulin (NPH, glargine,detemir, or short acting insulin with meals or combinations) • Add a second oral agent • Take a look at lifestyle again (food and beverage choices, activity) • Enlist more adult support

  34. Prevention of type 2 diabetes • Lifestyle modification (exercise, healthy eating) • Treatment of prediabetic conditions with metformin or other insulin sensitizing agents? • Glucose intolerance • Extreme obesity with insulin resistance • Polycystic ovary syndrome

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