Type 2 Diabetes in Children and Adolescents - The Next Epidemic?

Eva M. Vivian

Disclosures

Curr Med Res Opin. 2006;22(2):297-306. 

In This Article

Other Related Complications

Obesity

Maintaining euglycemia is insufficient to prevent or delay macrovascular disease. Overweight children and adolescents are at risk of developing the metabolic syndrome and are likely to acquire the metabolic complications associated with obesity in adulthood. The metabolic syndrome is a combination of cardiovascular risk factors associated with type 2 diabetes and cardiovascular disease. Central obesity, or increased abdominal (visceral) fat, insulin resistance, elevated free fatty acids levels, and hypertension have been implicated in the metabolic syndrome.[48]

The National Cholesterol Education Program (NCEP) has published criteria which defines the metabolic syndrome in adults as having three or more of the following risk factors: central obesity (with a waist circumference > 102 cm for men and > 88 cm for women); hypertriglyceridemia (≥ 150 mg/dL); hypertension (≥ 130/85 mmHg or antihypertensive medication use); low HDL cholesterol (< 40 mg/dL in men and < 50 mg/dL in women); and elevated fasting glucose (≥ 110 mg/dL or antidiabetic medication use).[49]

Although the metabolic syndrome has been studied extensively in adults, less is known about the metabolic syndrome in youth. There are currently no established criteria or definition of the metabolic syndrome in children.

Ferranti et al.[50] proposed a definition of the metabolic syndrome in children aged between 12-19 years that is similar to the established NCEP guidelines for adults. Their proposed pediatric criteria defines the metabolic syndrome in children as having three of the following risk factors: fasting triglycerides ≥ 100 mg/dL; HDL < 50 mg/dL (HDL < 45 mg/dL for boys aged 15-19 years); fasting blood glucose ≥ 110 mg/dL; waist circumference > 75th percentile for age and gender; and systolic blood pressure > 90th percentile for gender, age and height.

Duncan et al.[51] found that the prevalence of a metabolic syndrome phenotype had increased significantly over the past decade among US adolescents and was particularly prevalent (> 30%) in overweight adolescents. The metabolic syndrome was determined using the NCEP definition, modified for age.[51]

Hypertriglyceridemia, reduced HDL, and increased levels of small, dense LDLs are often seen in adolescents with type 2 diabetes. A lipid profile should be obtained at the time of diagnosis of type 2 diabetes and then every two years, regardless of age.[52]

Hyperlipidemia

The NCEP guidelines recommend a LDL goal of < 110 mg/dL, HDL > 45 mg/dL, and triglycerides < 125 mg/dL for children.[49] The American Diabetes Association (ADA)[52] recommends that LDL levels for children with and without diabetes should be < 100 mg/dL and < 130 mg/dL, respectively. Children with elevated cholesterol levels (total cholesterol > 200 mg/dL, LDL cholesterol > 130 mg/dL) should have their dietary cholesterol limited to < 200 mg/day with < 7% of total calories from saturated fat. Follow up fasting lipid profiles should be performed at 3 and 6 months to determine the effects of dietary changes and exercise. Drug therapy has been recommended in children > 10 years of age if, after an adequate trial of dietary therapy, LDL levels remain ≥ 190 mg/dL in those with no CVD risk factors or > 160 mg/dL in those with CVD risk factors, such as a positive family history, hypertension, obesity, and diabetes. Bile acid sequestrants are recommended as first line treatment for dyslipidemia in children. The 3-hydroxy3-methylglutaryl coenzyme-A reductase inhibitors (statins) should be considered if therapeutic goals are not achieved with a bile acid sequestrant. A few studies have reported favorable benefits in using statins in children.[53,54,55] Lovastatin (10-20 mg per day), pravastatin (20-40 mg per day), and atorvastatin (10-20 mg per day) are currently approved for use in children aged 10 years and older. Treatment should start with the lowest dose and be titrated based on LDL levels and side effects. If the triglycerides levels are greater than 1000 mg/dL, treatment with a fibric acid medication should be initiated to decrease the risk of pancreatitis.[52]

Hypertension

Obesity and hyperinsulinemia can contribute to the development of hypertension in children and adolescents. If left untreated, hypertension can increase the risk of atherosclerotic injury. Treatment of hypertension in children can be approached in the same manner as adults, selecting the appropriate agent for specific compelling indications.[55] Dosages of antihypertensive medication should be adjusted for children based on age and weight.[56] The treatment goals should be selected from a blood pressure nomogram for children and adolescents, based on height, sex, and age.[57]

Angiotensin converting enzyme inhibitors (ACEIs) are recommended to decrease blood pressure and reduce the risk of microalbuminuria in children.[56] Angiotensin receptor blockers (ARBs) are considered second line since there are limited data regarding the safety and efficacy of this class of drugs in the pediatric population. Other antihypertensives, such as calcium channel blockers, thiazide diuretics, and beta-blockers, can also beadded if blood pressure goals are not achieved with an ACEI or ARB or if there are compelling indications for their use.[56]

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