In December 2018, the American Diabetes Association (ADA) published a position statement on evaluating and managing youth-onset Type 2 diabetes (T2D) in response to the worrying increase in the number of children and adolescents being diagnosed.
This trend, reflected internationally, shows that indigenous children and those from disadvantaged backgrounds bear the major burden. In indigenous Australians, the age-specific rate for T2D is eight times higher for those aged 10 to 14 years, and four times higher for those 15 to 19, compared to non-indigenous Australians. The rise in T2D parallels increased obesity as a major global public health problem.
Start risk-based screening from the onset of puberty or after age 10, whichever comes first – consider in youth who are overweight or obese and have at least one other risk factor (e.g. maternal history of diabetes or GDM, family history, high risk ethnic/racial group, or signs of insulin resistance). There is no validated approach to screening in this age group, so clinicians need to maintain a ‘high index of suspicion’.
While overweight or obesity is a consistent feature of youth-onset T2D, it is no longer a clear differentiating feature from T1D or monogenic diabetes, as many of those children are more likely to be overweight or obese than previously.
Accurate diagnosis is important as it has a major impact on management and outcome. Pancreatic autoantibody testing can differentiate T1D, and genetic evaluation can differentiate monogenic diabetes. It is best to consider hyperglycaemia in children and adolescents a medical emergency, and all should be immediately referred to a specialist centre or paediatric endocrinologist.
Management and outcome
Weight loss is fundamental to management. Our lack of success reflects poorly on current management strategies. Medication options are limited with only insulin and metformin approved for those under 18.
The longest running study of youth-onset T2D has been the Today 2 Study (presented at 2019 ADA meeting). This confirmed that it is a much more aggressive disease than older onset T2D with both microvascular and macrovascular complications occurring much earlier and accelerating more rapidly. Life expectancy is reduced by 10 or more years.
Tackling obesity is the key to preventing this new public health problem in the young. Clinicians have a role in recognising those at risk and providing both the youth and their families developmentally and culturally appropriate lifestyle advice. Long-term support and involvement of a multidisciplinary team is an appropriate strategy.
The final word is from an editorial from The Lancet published December 2018 – “If the growing prevalence of obesity and type 2 diabetes in youth is accepted as the new normal, society will have grossly failed the next generation.”
key messages
- Youth obesity and Type 2 diabetes are major public health issues
- Accurate diagnosis is critical
- Multidisciplinary and culturally appropriate management is key
References available on request.
Questions? Contact the editor.
Author competing interests: nil relevant disclosures.
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