Jay H. Shubrook, DO; Tyree M.S. Winters, DO


January 12, 2018

Jay H. Shubrook, DO: Hi. I'm Jay Shubrook, DO, family physician, diabetologist, and a professor at Touro University, California. We are continuing our series on Everyday Diabetes: Practical Management for Primary Care.

Today I am delighted to have Dr Tyree Winters with us. He is an osteopathic physician and a board-certified pediatrician with extensive clinical experience in pediatric weight management and adolescent medicine. He's the associate program director at the pediatric residency program at the Goryeb Children's Hospital and Medical Center at the HealthStart Clinic in Morristown, New Jersey. Welcome, Dr Winters. Thanks for being with us today.

Tyree M.S. Winters, DO: Thank you for having me.

Dr Shubrook: Our topic today is type 2 diabetes in children and adolescents. I have to tell you, when I was in training, that was not something I thought of. I actually thought of juvenile diabetes type 1 and adult diabetes type 2. What's the story with type 2 diabetes in kids?

Dr Winters: That's a great question. Up until about the mid-'90s, only about 4% of new onset cases of type 2 diabetes occurred in children.[1] Until then, it was safe to assume that if a child had diabetes, it was more likely to be type 1; that's why we refer to it as juvenile diabetes. However, in the '90s, we started to see an increase in the incidence of obesity in children and an increased prevalence of type 2 diabetes around that time as well. Now, unfortunately, there has been almost a tripling in the number of children who are diagnosed with type 2 diabetes. Now, calling type 1 diabetes juvenile diabetes is unfortunately incorrect because of the fact that we're seeing an increase in the prevalence of type 2 diabetes in children.

Why Are Kids at Higher Risk for Type 2 Diabetes?

Dr Shubrook: How is type 2 diabetes different in children versus adults?

Dr Winters: Interesting question. The pathophysiology of type 2 diabetes in children and adults is pretty similar. The hallmark is insulin resistance, with a decrease in insulin production in the body. Children who are diagnosed with type 2 diabetes will have an approximately 80% decrease in the number of beta islet cells at the time of their diagnosis.

But you also have a different process that is going on in the body at this time, which is puberty.

Around the age of 10 years, children have a physiologic insulin resistance. When added to obesity, you can see serious comorbidity like that found in children diagnosed with type 2 diabetes. So obesity combined with the fact that the body naturally is physiologically less sensitive to insulin at the start of puberty is a setup for worsening insulin resistance. Around the age of 14-19 years, you see an increase in growth hormone that will lead to insulin resistance as well. All of those factors aligning is the reason why children have a greater chance, especially if they are obese, to have type 2 diabetes.

Dr Shubrook: I think those are really important points. I think the physiology is really a setup—which, while wonderful for growth and development, is horrible when you have insulin resistance. Then you stack on top of that that they are adolescents who have free will, and then having a chronic disease makes it so hard. My experience has been that it is quite hard to treat adolescents with type 2 diabetes. What are your suggestions?

Dr Winters: There are a couple of suggestions. The first one is making sure that we educate our patients. Even at the age of 10 years, the thought processes of children have changed, and there is less concrete and more abstract thinking. At this point in time, the children are starting to understand the ramifications of having a diagnosis. It's been studied quite well that teenagers exhibit reasoning and thought processes that are very similar to those of an adult. The first thing is education, making sure our patients understand what is going on because it is a very devastating diagnosis to give when the child doesn't understand.

The next thing, in addition to educating about the diagnosis, is educating about the treatment options and plans. One of the main focal points of treatment for type 2 diabetes, in conjunction with pharmacologic therapy, is lifestyle modification. It's important for us to have a sense of the lifestyle modification programs that these kids should undergo. That can be through the primary care doc or more intensive stage 3 or 4 weight management programs, which are multidisciplinary programs. There are programs that can have an effect and help these children along the way.

Screening for Type 2 Diabetes in Children

Dr Shubrook: It sounds like it is a serious condition. You need to put on a full-court press for the child and for the family, if we are really going to focus on lifestyle, right? I think that is important. Who should we be screening? It seems to me that everybody is overweight or obese now. Should I be screening everybody? What guidance do you have?

Dr Winters: There are actually guidelines from the American Diabetes Association. We want to begin with children who are at higher risk for type 2 diabetes because obviously we can't just screen everyone.

The criteria that should trigger screening include a body mass index greater than the 85th percentile, a first-generation family member that has the diagnosis of type 2 diabetes, and the presence of other comorbid conditions. Those other conditions may include hypertension, particularly essential hypertension that is now more prevalent in these overweight or obese adolescents and younger children.

Children from at-risk cultural groups (African Americans, Latino Americans, Native Americans, and Asian Americans) have a higher risk for type 2 diabetes and should also be screened.

The other risk factor that you want to look for is a history of small-for-gestational age or gestational diabetes during the mother's pregnancy. As pediatricians, we are very used to taking a very thorough history, especially birth history. While we tend to stop asking about gestational history around the age of 3 or 4 years, we should be asking these questions even for teenagers because I want to be able to understand some of those risk factors that can later play a role.

Dr Shubrook: We should be looking for our kids who are overweight and those who are at high risk for type 2 diabetes because of family history. Can we screen the same way that we do in adults?

Dr Winters: There used to be a time where we didn't use hemoglobin A1c in children. This has recently changed, and we have evolved to using A1c testing both as a diagnostic tool and a screening tool. However, we have to be careful for several reasons because there can be some false positives with A1c tests. Several of the groups I mentioned—African Americans, Latino Americans, Asian Americans—may have blood dyscrasias that can affect the A1c such as sickle cell anemia and thalassemia.

We can screen using either A1c[1] or a fasting blood glucose level.[2] We can also consider an oral glucose tolerance test. If the A1c, fasting blood glucose, or serum glucose is within the prediabetes range, we can't rule out that these children do not have type 2 diabetes. We need to do further testing because a lot of times these tests may suggest prediabetes, when it is more likely that we're catching these kids at a very early stage of type 2 diabetes.

That's where the oral glucose tolerance test is helpful. That's a more reliable test that we can use for diagnosis. If the oral glucose tolerance test shows that the child has prediabetes, then we can now be more aggressive with the weight management and more regular testing.

There are some recommendations to test every 3 years, but I must say, in my own practice, especially dealing with obese children, I usually test these children every year just to make sure I am catching them at an early stage. Even though we can maybe prolong the period of time until diagnosis, unfortunately some children will still later on develop type 2 diabetes.

Dr Shubrook: I think that's so important. What I heard you say today is that we need to have a higher index of suspicion and look for kids at risk for prediabetes and type 2 diabetes. Type 2 diabetes is more common than we used to think. We can use the same screening tests [that we use in adults]. But we need to remember that there are limitations to the A1c, and you need to know the child's background hematology. The best test to diagnose diabetes in children is still the glucose tolerance test.

A family-based lifestyle intervention is the mainstay of treatment in type 2 diabetes in adolescents. There are some medications, but there fewer than what are available for treatment in adults.

Really important points, Dr Winters. We are so glad you were here today. Thank you for sharing these great insights.

Dr Winters: Thank you for having me.


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