An Obese Teen: More Than Meets the Eye

Shannon Patrick, ARNP, MSN; Janet Silverstein, MD

Disclosures

June 18, 2013

Should Kids With T2DM Be Screened for Comorbidities and Complications?

Comorbidities occur in youth with T2DM and are presumed to be similar to those found in adults. Expert recommendations for screening and treatment are based on guidelines for adults and have not been studied in randomized controlled trials in children and adolescents. Ashley should have her blood pressure monitored at each visit with an appropriate-sized cuff and the values evaluated according to standards used for youth. If lifestyle intervention is insufficient to control her blood pressure after 3-6 months, therapy with angiotensin-converting enzyme (ACE) inhibitors should be initiated to treat persistent hypertension above the 95th percentile for age, sex, and height, with the goal being to reduce blood pressure to less than the 90th percentile. Dosing recommendations can be found in the Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents.[6]

The urine microalbumin-to-creatinine ratio should be checked on a yearly basis; if this value is elevated on 3 occasions, including at least 1 first morning void, therapy with ACE inhibitors should be initiated, even in normotensive children. If chronic cough is associated with use of an ACE inhibitor, an angiotensin-II receptor blocker can be used.

Metformin therapy has been shown to improve fatty liver in insulin-resistant and obese adolescents.[8] Ashley's alanine aminotransferase and aspartate aminotransferase levels should be rechecked, along with a repeat fasting lipid profile, at the next visit.

Bullying and depression are common in obese and overweight children and teens. Vigilance for signs of depression should be maintained, and children referred to a counselor as necessary.

Because Ashley has only mild snoring with no excessive daytime sleepiness, no early-morning headaches, and no pauses in breathing during sleep according to her mother, you do not refer her for a sleep study at this time, although you maintain vigilance for signs of obstructive sleep apnea.

A lipid panel should be obtained at baseline once treatment is initiated and should be repeated every 2 years for patients with normal lipid levels. T2DM is considered a tier 2 risk factor for development of atherosclerosis in the AAP Technical Report[9] that accompanied the 2013 clinical guidelines, although the Expert Panel report released in 2012 considers it a tier 1 risk factor.[10] Elevation of low-density lipoprotein levels above 130-160 mg/dL despite nutritional counseling by a registered dietitian and lifestyle modification warrants initiation of statin therapy in children older than 10 years.[9,10]

Monitoring of A1c should be continued at Ashley's visits every 3 months. Self-monitoring of blood glucose can be continued on a less frequent basis. However, frequency of monitoring should be increased during illness, if blood glucose and A1c values are not at goal, or if insulin therapy is initiated.

Ashley and her mother were taught the signs and symptoms of high blood glucose levels and were advised to increase the frequency of monitoring and contact the provider in the case of persistent high blood glucose values or signs of metabolic decompensation, such as nocturia, unintentional weight loss, polydipsia, or polyphagia. Deteriorating metabolic control should be treated aggressively with more frequent monitoring, more frequent clinic visits, and initiation of insulin therapy. A single injection of basal insulin can be given in the evening in combination with metformin and adjusted to target recommended fasting blood glucose levels. Referral to a subspecialist may be warranted in the child with declining metabolic control.[2]

Summary

The rate of T2DM in children and adolescents is increasing in the United States. PCPs can safely initiate and monitor treatment for youth with uncomplicated T2DM, provided that they can identify those children who need insulin therapy at diagnosis. Referral to a pediatric endocrinologist should be initiated if the diagnosis of type 1 vs type 2 diabetes is unclear, because misdiagnosis can lead to diabetic ketoacidosis.

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