Type 2 Diabetes in Adolescents: A Complex Issue

March 03, 2014

DOHA, Qatar — The diagnosis of type 2 diabetes among adolescents aged 12 through 18 years is "not easy" and, once established, requires a very different approach to management compared with type 1 diabetes in the same age group, says one expert.

"You need to screen early for complications in type 2 diabetes in teenagers, compared with type 1 diabetes, when you would normally wait around 8 years before screening for things like dyslipidemia, hypertension, nephropathy, and retinopathy," Talal Muzaffar, MD, FRCPC, of Alseef Hospital, Kuwait City, told the Excellence in Diabetes meeting in Doha this weekend.

"You have to screen these kids as if they were adults," he observed.

Recent data from the United States indicate that 1 in 3 cases of diabetes diagnosed there in those aged under 18 is now type 2 diabetes, said Dr. Muzaffar, and while "we don't have solid data from our Gulf region — making it hard to know the prevalence — I see 2 to 3 new cases of type 2 diabetes in adolescents every week," he noted.

He explained that in the Kuwaiti healthcare system, children of 12 years and over are considered adults, so as an adult endocrinologist, "I have more experience of treating this age group than pediatricians."

He stressed that diagnosis of diabetes is further complicated in this age group because of puberty, during which insulin resistance can transiently increase by up to 30%, as a result of the effects of growth hormone: "The set point for glucose metabolism is changing as they grow up," he explained.

And management is not always easy, because "you are treating not only the child but the whole family. You have to tell the parent that they need to follow a good lifestyle, too."

Another speaker confirmed the problem with type 2 diabetes in adolescents in the Gulf region. Bariatric surgeon Davit Sargsyan, MD, from Hamad Medical Corporation, Doha, Qatar, said he has performed weight-loss surgery, primarily gastric sleeve, in more than 100 adolescents in just his one hospital, in Doha.

Differential Diagnosis: Type 1 vs Type 2

Dr. Talal Muzaffar

One of the main obstacles when it comes to diagnosing diabetes in adolescents is that the oral glucose tolerance test, as used in adults, is not very well validated in teens and may give misleading results because of the effects of puberty, Dr. Muzaffar said.

And although it "can be difficult to differentiate between type 1 diabetes and type 2 diabetes" in this age group, he advises using the following criteria.

Risk factors for type 2 diabetes in teens include: obesity, a family history of type 2 diabetes, physical inactivity, low birth weight, intrauterine exposure to maternal diabetes, puberty, and conditions predisposing to insulin resistance, such as polycystic ovary syndrome (PCOS) in females.

In addition, girls are more susceptible to type 2 diabetes than boys, and certain ethnic groups are at higher risk, including American Indians, Asian/Pacific Islanders, African Americans, and Hispanics. Anecdotally, Dr. Muzaffar said he is seeing, in his own practice in Kuwait, "more and more patients from an Asian background, Indian or Pakistani."

Other features that will help distinguish type 2 diabetes from type 1 include: a slow, asymptomatic onset (in contrast with an acute, symptomatic onset for type 1 diabetes), Acanthosis nigricans (a skin pigmentation disorder; dark patches of skin with a thick, velvety texture that may appear in various locations on the body and is thought to be associated with insulin resistance); and the absence of other autoimmune conditions and ketosis, as opposed to the frequent presence of both of these in type 1 diabetes.

And on the issue of using HbA1c to diagnose type 2 diabetes during adolescence, "there is conflicting advice" from different organizations, he notes.

Screen for Complications at Diagnosis

Dr. Muzaffar stressed that it is vital that screening for complications of type 2 diabetes "should begin at diagnosis" in adolescents because up to a third of these patients will develop early complications, and "it's not unusual to see them at the time of diagnosis," he observed.

And it's important to recognize that the onset of type 2 diabetes in an adolescent will place an individual at risk for morbidity and mortality "during their most productive life years," he said, noting, for example, that up to a 14-fold relative increase in myocardial infarction risk has been observed in such patients.

Moving on to the issue of treatment, Dr. Muzaffar said just 1% of adolescents get pharmacological treatment. The only therapies routinely used in this age group for type 2 diabetes are lifestyle management, metformin, and insulin, he noted, which he believes are "sufficient" for the time being, because of the concerns regarding side effects and the sheer number of years such patients would be taking chronic therapy.

Treat Pharmacologically, or Not? What about Surgery?

However, there is debate on this issue, he acknowledged. "The management is very difficult; there are no data available for the new drugs in this age group. Should we be giving statins to a 13-year-old? I personally think it is a nightmare to start a patient on a statin at this age."

However, one audience member said she thought endocrinologists are perhaps somewhat conservative in this area, noting that many pediatric nephrologists she had encountered "are using statins more frequently than endocrinologists" in this age group.

Dr. Davit Sargsyan

And last year, the authors of a whole series of reports from the US TODAY study, which sounded an alarm regarding type 2 diabetes presenting in youth, called for much more research into the effects of newer drugs for diabetes, calling for a break "in the logjam of unapproved drugs for adolescents with type 2 diabetes."

Meanwhile Dr. Sargsyan, the bariatric surgeon, told Medscape Medical News that while weight-loss surgery in this age group "is debatable and a sensitive issue," he has performed 104 gastric-sleeve procedures in such patients "without any major problems." It is "an option, and there is some literature to support it," he added.

Dr. Muzaffar has reported no relevant financial relationships.

Excellence in Diabetes 2014. Presented March 1, 2014.

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