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GUIDELINES ADDRESS SCREENING, TREATMENT OF TYPE
2 DIABETES
With the rise in childhood obesity and the “epidemic” of
type 2 diabetes in children and youth, much is being written about
the association between obesity and insulin resistance and the progression
of this to pre-diabetes and diabetes.
A consensus statement of the American Diabetes
Association (ADA) and the American Academy of Pediatrics (AAP) titled
Type 2 Diabetes in
Children and Adolescents give recommendations on how to approach the
pediatric subject at risk for type 2 diabetes (1).
Following are some answers to some common questions
based on the consensus statements:
Who should be screened?
The consensus statement recommends that asymptomatic children and youth
older than 10 years with two or more risk factors be evaluated for
diabetes every two years.
What are the risk factors for type 2 diabetes?
The risk factors include body mass index greater than 85th percentile
for gender and age; family history of type 2 diabetes; being a member
of a racial/ethnic group at risk for type 2 diabetes (i.e., African
American, Hispanic American, Native American, and Asian American);
and signs of insulin resistance such as dyslipidemia, hypertension,
polycystic ovarian syndrome, and acanthosis nigricans.
What tests should be done?
If two or more risk factors are present, testing should be considered.
Fasting plasma glucose is the preferred test to diagnose diabetes,
although this diagnosis can also be made with an oral glucose tolerance
test (OGTT). The diagnosis of diabetes in youth is made per the following
criteria established by the American Diabetes Association: 1) symptoms
of diabetes plus a plasma glucose greater than or equal to 200 mg/dL;
2) fasting plasma glucose > 126 mg/dL; 3) two-hour plasma glucose > mg/dL
during an OGTT. If the diagnosis of diabetes is made in someone who
is asymptomatic, the diagnosis must be confirmed by repeat tests on
another day.
How should type 2 diabetes be treated?
Lifestyle intervention is the first line of therapy in those who
are asymptomatic with mild elevation of the glucose level. In those
with
moderate elevation of blood glucose level and without ketosis, oral
hypoglycemic agents can be used. Metformin is the first line agent
preferred by pediatric endocrinologists. If there is moderate to
severe elevation of the blood glucose level and ketosis, insulin
therapy should
be initiated.
What about insulin resistance in pediatric patients?
Much has been written about insulin resistance in pediatric patients.
To date, however, there are no established criteria to make this
diagnosis, particularly because there is innate insulin resistance
as children
progress through puberty. There are no set levels for fasting insulin
or the two-hour insulin level during an OGTT that absolutely equate
with insulin resistance.
How should insulin resistance be treated?
The implication that children and youth should be treated for insulin
resistance beyond lifestyle intervention is premature. At this
time, we lack not only sufficient evidence on how to diagnose
this syndrome
but also how to treat it. In fact, during a recent meeting of
the American Association of Clinical Endocrinologists on insulin
resistance,
it
was decided to not make recommendations concerning children and
youth at this time since there is no evidence that pharmacologic
intervention
is effective, safe or protective against cardiovascular risk
later in life. In addition, no group has specifically correlated
fasting
and the two-hour post-OGTT insulin levels, lipids or blood pressure
with cardiovascular risk as has been done in adults.
It would be a grave mistake at this point to apply
adult recommendations to children and youth without adequate evidence.
It would be
unjustified on the clinical care basis to perform OGTTs on
patients simply
to make the diagnosis of insulin resistance until compelling
evidence exists
as to the benefit of pharmacologic therapy. Pediatricians should
focus on identifying patients at risk and on the early intervention
with
counseling on the benefits of appropriate nutrition and physical
activity. At this time, it would be inappropriate to exceed
the recommendations
of the ADA and the AAP, particularly regarding pharmacologic
intervention unless as a part of a study protocol. Instead,
pediatricians should
be advocating for change from a public health perspective,
looking to improve schools and communities as the safest and most effective
long-term strategy to stem the epidemic of type 2 diabetes.
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