An Obese Teen: More Than Meets the Eye

Shannon Patrick, ARNP, MSN; Janet Silverstein, MD

Disclosures

June 18, 2013

Making the Diagnosis of Type 2 Diabetes

On the basis of her initial work-up, you advise Ashley and her mother that Ashley has blood glucose and A1c values consistent with diabetes and will need to begin treatment with blood glucose-lowering medications. The American Diabetes Association defines diabetes as:

  • An A1c value ≥ 6.5%, or

  • A fasting blood glucose level ≥ 126 mg/dL, or

  • A 2-hour postprandial glucose level ≥ 200 mg/dL on a 2-hour oral glucose tolerance test, or

  • A random blood glucose level ≥ 200 mg/dL, accompanied by symptoms of hyperglycemia or hyperglycemic crisis.[1]

Initial Management of Type 2 Diabetes

Primary care providers (PCPs) will be increasingly called upon to care for youth with type 2 diabetes mellitus (T2DM), given the rising incidence of T2DM and the shortage of pediatric endocrinologists in the United States. It is imperative that the PCP be able to distinguish between the child with uncomplicated T2DM and the child who requires the care of a pediatric endocrinologist.

The American Academy of Pediatrics (AAP) recently released the clinical practice guideline Management of Newly Diagnosed Type 2 Diabetes Mellitus (T2DM) in Children and Adolescents. The guideline provides evidence-based recommendations that can assist the PCP in caring for youth with T2DM.[2]

As children and adolescents with type 1 diabetes have obesity proportional to the prevalence in the general population, approximately 30% will be either overweight or obese. Thus, it is not always easy to distinguish type 1 from type 2 diabetes on the basis of phenotypic appearance, particularly if the child presents with significant hyperglycemia.

A proportion of children with phenotypic T2DM may also have some degree of autoimmunity, although data from the SEARCH trial indicate that children with positive antibodies have low levels of antibodies, lower C-peptide levels, and earlier insulin requirements than youth who are antibody-negative.[3] The TODAY study group found antibody positivity in a smaller proportion of participants screened using the newer standardized assays for GAD-65 and insulinoma-associated protein 2 antibodies.[4] Those who were antibody-positive had lipid levels, ethnicity, sex ratio, and family history more consistent with type 1 diabetes. They also had lower C-peptide levels and BMI z-scores than the antibody-negative group.

Because hyperglycemia results in glucose toxicity, children who present with an A1c value > 9% (indicating an average blood glucose level of 212 mg/dL) or a random blood glucose value ≥ 250 mg/dL, or who are ketotic, should be managed with insulin and their care supervised by a clinician with expertise in caring for children receiving insulin. Up to 25% of children with T2DM are in ketoacidosis at the time of diagnosis and should be treated with insulin in an inpatient setting. Insulin therapy should also be initiated if there is any doubt as to the diagnosis of type 1 vs type 2 diabetes, because an erroneous diagnosis of T2DM in a child with type 1 diabetes could result in diabetic ketoacidosis.

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