TYPE 2 DIABETES MELLITUS

in Child and adolescent

(PREVENTION AND CURRENT MANAGEMENT)

Aditiawati
Pediatric endocrinology division,
Faculty of medicine Sriwijaya University-Moh Hoesin Hospital
 INTRODUCTION
• T2DM is difficult to differentiate from the more common type
1 diabetes mellitus (T1DM) in the paediatric population.
• Type 2 Diabetes Melitus (T2DM) in children and adolescents
(youth-onset T2D) has become an increasingly important
public health  equivalent with the increasing of obesity
• In Australia : the incidence of T2DM in patients under the age
of 17 years was approximately two per 100,000 person-years,
with a 27% rise in average annual
• USA : 15 years ago accounted for less than 3% of all cases of
new-onset diabetes in children and adolescents, today
accounts for up to 45% of new-onset cases among adolescents
• Taiwan : 50%, japan 60%, Indonesia ???

• Pediatric Diabetes 2014: 15 (Suppl. 20): 26–46

 DEFINITION
• T2DM : insulin secretion is inadequate insulin resistance,
 leading to relative insulin deficiency and is generally
associated with other metabolic abnormalities, characteristic
of insulin resistance (dyslipidemia, hypertension, polycystic
ovary syndrome, fatty liver)
• There is no identified autoimmune process
• Inadequate insulin secretion appears to result from genetic,
environmental, behavioral risk factors
• Recent data from the TODAY (Treatment Options for T2DM
in Adolescents and Youth) study suggest that the loss of
insulin secretion is even more rapid when T2D presents in
adolescents
•
 Risk factors for T2DM

• obesity,
• ethnicity and
• family history,
physiological insulin resistance.
Early-onset T2DM is more associated with
shorter duration to insulin requirement,
development of diabetic complications and
cardiovascular disease than adult-onset T2DM
and T1DM.
 Onset T2DM
• Early-onset T2DM most commonly occurs during
adolescence and rarely beforehand.
• Plasma insulin levels rise steadily from pre-pubertal
baseline, peaking during puberty then returning to pre-
pubertal levels by the third decade of life.
• Insulin sensitivity decreases by around 30% during
puberty.It is no coincidence therefore that this
physiological, puberty-associated insulin resistance
coincides with the peak age of early-onset T2DM
presentation, and that pre-pubertal T2DM is much less
common.
• Among the 1.2 million youth in the SEARCH for Diabetes
study, there were no children aged 4 years or younger
with T2DM, and only 19 cases of children aged 5–9 years
with T2DM between 2002 and 2003
Pathophysiology
 DIAGNOSIS

The diagnosis of T2D requires two steps:

a. confirmation of the presence of diabetes

b. determination of diabetes type
A. CONFIRMATION OF THE
PRESENCE OF DIABETES

1. measurement of
glycemia and
2. the presence of
symptoms.
1. The Diagnosis criteria for Diabetes Mellitus
(ISPAD & ADA)
2. DETERMINATION OF DIABETES TYPE

• After the diagnosis of diabetes is established,

diabetes autoantibody testing should be considered
in all pediatric patients.
• Studies have shown that autoantibodies are
present in 10–20% of patients clinically diagnosed
with T2D.
• ( Antibodies  predict rapid development of
insulin requirement)
• A diagnosis of T1DM should be made in the acute
setting if there is any doubt regarding diabetes
subclassifications.
Classification of Diabetes Mellitus Adapted from WHO
and ADA
 from Sabin MA. Type 2 diabetes in children. Clin Obes 2013;3(3–4):112–6
T1DM T2DM
.
Age range Any age – often young More often seen in peri-
children pubertal and post-pubertal
youth
Ethnic All groups Increased in certain groups
(eg Hispanic, Polynesian,
Aboriginal and Torres Strait
Islander, Indian and Chinese
peoples)

Sex Equal between sexes More common in females

Symptom duration Often insidious – rarely

severe
Obesity As in population Varies according to ethnicity,
but up to 85%

Family history Present in 3–5% Present in 75–100%

Acanthosis nigricans 12%, can vary in different 50–90% – can vary in
population different population
 T1DM
Circulating insulin Usually low
Ketosis at presentation More likely to be present
Islet autoimmunity IAA, ICA, glutamic acid
decarboxylase (GAD), tyrosine
phosphatase (insulinoma
associated) antibody (IA-2 and
IA-2β), or zinc channel
antibody (ZnT8) are present at
diagnosis in
85–98% of patients with
T1DM
T2DM
Usually elevated
Less likely, but can be present
in up to 25%
Usually negative, but can be
present in up to 10–20% of
patients. If present, islet cell
antibodies predict a more
rapid requirement of insulin
and development of other
autoimmune disorders.

Associated disorders Autoimmune disorders such as Other comorbidities of obesity

autoimmune thyroiditis, (eg non-alcoholic fatty liver
coeliac disease disease, obstructive sleep
apnoea, hyperlipidaemia,
polycystic ovarian syndrome)
Boy, 14 years, 6 month,
Family history +
BW 88 kg, Height 171 cm
BMI >30
BP 110/70 mmHg
• Blood Glucose are 340
mg/dL and 291mg/dL
• Fasting plasma glucose
(FPG) is141 mg/Dl
• Postchallenge plasma
glucose is 260 mg/Dl
• Hipertrigliserida
• Low HDL cholesterol
• HbA1c is 10,2
• C-Peptide 6.7 ng/ml (Normal
1.1-4.4 ng/ml)
• ICA in normal range
(< 1:2)
Follow up 3 month after admission
tanggal pagi siang malam tangg pagi siang malam tanggal pagi siang malam
al

1 119 11 - 21 error

Body weight
2 110 12 120 22 108

3 130 13 90 23 84
1st month: 87Kg
4 92 14 155 24 112
2nd month: 86Kg
5 134 15 114 25 90 3rd month : 85
Kk
6 139 16 106 26 113

7 80 17 129 27 106 Lab :

HbA1c : 7.1%
8 97 18 122 28 97

9 126 19 137 29 error

10 104 20 150 30 108

 Acanthosis nigricans

Girl, 14 years 3 month

BW 98 kg, height 168 cm
BMI > 30
Management of T2DM in children and
adolescents
The three main goals in the management of
T2DM in children and adolescents are
• lifestyle modification,
• normalisation of glycaemia and
• management of comorbidities
 TREATMENT OF YOUTH ONSET T2DM

1. Management differences between T1D & T2D :

a. Differences in socioeconomic status
b. Older age
c. More family experience
d. Prevalence of associated comorbidities and
complications early in the course of
disease
e. Lifestyle education
2. Management goal
a. Education for diabetes self-management
b. Normalization of glycemia
c. Weight loss
d. Reduction in carbohydrate and calorie intake
e. Increase in exercise capacity
f. Control of comorbidities, including hypertension,
dyslipidemia, nephropathy, sleep disorders, and
hepatic steatosis.
3. Education

a. Ideally should include a nutritionist, psychologist

and/or social worker, and exercise physiologist
b. Emphasis on behavioral, dietary, and physical activity
changes,
c. Team members
d. Culturally sensitive and age-appropriate manner,
e. Familly
f. to understand the principles of treatment of T2D and
the critical importance of the lifestyle changes, the
importance of normalizing blood glucose metab
4. Behavioral change
a. Healthy lifestyle
b. Nutrition
c. Exercise training
d. Weight management
e. no smoking
 5. Dietary management
Dietary recommendations should be culturally
appropriate, sensitive to family resources, and should be provided to
all caregivers.

• Initial focus on eliminating sugar-containing soft drinks and juices,

• Increasing fruit and vegetable intake,
• Reducing the use of processed, prepackaged, and convenience
food,
• Reducing the intake of foods made out of refined simple sugars,
• Portion control,
• Reducing meals eaten away from home,
• Asian diets that primarily consist of high carbohydrate meals
should be modified,
• Changing staple foods from enriched white rice and white flour to
brown rice and whole grain items to lower glycemic index, and
• Changing family diet behaviors.
6. Exercise management
a. Youth with T2D should be encouraged to engage in
moderate-to-vigorous exercise for at least 60 min daily
b. Reduction in sedentary time, including TV, computer-
related activities, texting, and video games,
c. Promotion of stable household routines, particularly
increasing sleep duration and reducing TV viewing,
d. Addressing sedentary time spent doing school work
and identifying ways to incorporate physical activity
as breaks,
e. Promotion of physical activity as a family event, and
f. Encouragement of positive reinforcement of all
achievements and avoidance of shaming.
7. Smoking and tobacco use.

Patients should be asked at each visit if they are

smoking and counseled against initiation of
smoking. Those youth who are smoking should
be counseled on the importance of smoking
cessation and provided resources for support.
8. Glycemic monitoring
a. Self monitoring blood glucose (SMBG)
SMBG should be performed regularly. The
frequency of SMBG should be individualized,
and include a combination of fasting and
postprandial glucose measurements,
b. Patients on insulin or sulfonylureas need to
monitor for asymptomatic hypoglycemia, and

c. HbA1c concentration should be determined at

least twice a year.
9. Pharmacologic therapy
The aim of therapy in youth-onset T2D is to
decrease insulin resistance, increase endogenous insulin
secretion, or provide exogenous insulin.
a. Initial treatment : metformin and/or insulin alone or in
combination.
b. If the patient is metabolically stable (HbA1c < 9 and
no symptoms), metformin monotherapy is the treatment
of choice.
c. If the patient is not metabolically stable, insulin
will be required at least initially.
d. Transition onto metformin monotherapy can
usually be achieved safely over 2–6 wk by
decreasing the insulin dose 30–50% each time the
metformin is increased with a goal of eliminating
insulin therapy.
 Subsequent therapy

• Fails to reach target HbA1c<6.5%  3-4 months

 metformin addition of basal insulin
Other available agents :
• Sulfonylurea ( side effect : Hypoglycemia and a
greater degree of weight gain, may accelerasi the
loss of beta-cell function)
• Meglitinilrepagline, Thiazolidinedion,alfa-
glucosidase inhibitors, Incretin mimetics,DPP-IV
inhibitors, sodium glucose co-transportasi/SGLT-2
inhibitors  not approved for use in those < 18
yr of age)
Approach to initial and subsequent treatment of youth with type 2 diabetes.
10. Gastric surgery

Bariatric surgery may be considered for

adolescents with obesity-related comorbidities,
including T2D, particularly when patients have
been unsuccessful with medical therapy alone.
T2D and insulin resistance:
comorbidities & complications

 Hypertension
 Nephropathy
 Dyslipidemia
 Atherosclerosis
 Vascular
dysfunction
 PCOS
 Non alkoholic
fatty liver disease
 Systemic
inflamation
 OSA
 Depression
o Orthopedic problem
o Pancreatitis
o Cholescystitis
o Deep tissue ulcers
o Pseudotumor cerebri
 Comorbidities of diabetes and obesity need to be
screened at diagnosis
For diabetes:
• urine microalbuminuria for diabetic nephropathy
• serum lipids for hyperlipidaemia
• blood pressure
• retinal photography for diabetic retinopathy
For obesity:
• liver function tests for non-alcoholic fatty liver disease
• clinical screening for symptoms of obstructive sleep apnoea
• depression
• polycystic ovarian syndrome in adolescent females.
Zeitler P, Fu J, Tandon N, Nadeau K, Urakami T, Barrett T, Maahs D: Type 2
diabetes in the child and adolescent. Pediatr Diabetes 2014;15 Suppl 20:26–46 .

•
Management guidelines for complications of T2DM in
children and adolescent

Comorbidity prevalence screening management

Hypetension Up 36% of youth At dx and every Liefestyle
within 1.3 years of subsequent clinic modification, ACE
T2DM visit inhibitor treatment
or angiotension
reseptor blocker
Dyslipidaemia HyperTG is in 60- At dx and every 2 Diietitian
65% of youth with years. Closer follow evaluasion and
T2DM, Low HDL in up if abnormal modification
73% -Statin if LDL .3,4
mmol/L
-Niacin if TG >9.3-
13 mmol/L and if
>10 years of age as
risk of acut
pancreatitis
Comorbidity prevalence screening management
Retinopathy 9.3% at diagnosis Dilated pupil exam Refer to
12.7% have by optometrist or ophthalmology if
proliferative ophthalmologist at evidence of
retinopathy diagnosis. Annual retinopathy. May
by 35 years of age examination if require laser
23.7% blind by a normal and more therapy
mean age of frequent if proliferative
32 years examination if retinopathy,
abnormal clinically significant
macular oedema or
severe non-
proliferative
retinopathy
Comorbidity prevalence screening management
Nephropathy Often present at Spot urine: 30–299 If persistent (>2
diagnosis mg/g samples), start ACE
14–22% in cross- 24-hour urine: 20– inhibitor therapy
sectional studies 199 mcg/min even if BP normal
Can be elevated Aim to normalise
due to smoking, microalbuminuria
exercise and Treat hypertension
menstruation
Exclude orthostatic
proteinuria and
renal causes
 Kung Ting Kao,Mattew AS, AFP,vo; 45 no 6, june 2016

Comorbidity prevalence screening management

Depression Up to 14.7% and is Screen for Refer to mental
more common symptoms of health clinician
in girls depression at
diagnosis and
periodically,
especially in those
with poor
glycaemic control
and/or frequent
visits to emergency
department
Screening for T2D
in high-risk youth

There are currently a single set

of recommendations for
screening and case-finding,
which were issued by the ADA
in 2000
Prediabetes
 Prediabetes
• There are individuals whose glucose levels do
not meet the criteria for diabetes, but are too
high to be considered normal. The ADA had
designated this physiologic state prediabetes
to recognize the high risk of progression of
these individuals to diabetes.
 Prediabetes
• Prediabetes is diagnosed
when:
◦ IFG: FPG is 5.6–6.9 mmol/L
(100–125 mg/dL)

◦ IGT: Postchallenge plasma

glucose 7.8–11.1 mmol/L
(140–199 mg/dL)

◦ HbA1c 5.8–6.4%
Management of T2DM
 CONCLUSION
• T2DM in children and adolescents is a serious
medical concern that is more aggressive than the
adult-onset form, more challenging to diagnose, and
has limited available treatment options. It is also
associated with high rates of complications related to
diabetes and obesity.
• A family-based approach is required to
comprehensively address all medical, lifestyle and
psychosocial aspects of care, as well as involvement
of specific services such as paediatrics, diabetes
education, nutrition, psychology and social work as a
multidisciplinary team so as to streamline their care
to maximise compliance and optimise outcomes.
Thank you