COMMENTARY

Youth-Onset Type 2 Diabetes 'Needs Aggressive Intervention'

Philip S. Zeitler, MD, PhD; Mark Harmel, MPH

Disclosures

June 21, 2019

This transcript has been edited for clarity.

The TODAY study,[1] which started in 2004, enrolled 699 kids with youth-onset type 2 diabetes who were then randomized to receive one of three treatments: metformin, metformin plus rosiglitazone, or metformin plus lifestyle intervention.

Among the many things this study taught us, we learned that youth-onset type 2 diabetes is more aggressive than type 2 diabetes with onset later in life, with higher rates of medication failure in all of the treatment groups, as well as more rapid beta-cell loss and rapid accumulation of comorbidities and complications.

At the end of the first phase of the trial, in 2011, all of the kids were invited to enroll in an observational follow-up study that we called TODAY-2.[2] In the first phase of TODAY-2, the kids continued to receive their diabetes care through the clinical studies center and were seen every 3 months, but they were no longer on their randomized treatment.

Starting in 2014, the kids returned to care through the community and were seen once a year for follow-up at TODAY's centers for annual assessment of comorbidities and complications.

'A Very Serious Trajectory'

From this second part of TODAY, we have found that these kids are continuing to accumulate very high rates of comorbidities and complications. We are seeing accelerating rates of cardiovascular disease, renal disease, eye disease, and nerve disease, as well as very high rates of poor pregnancy complications for both the mother and the offspring.

Taken together, TODAY is giving us a picture of a very aggressive disease, both in terms of difficult-to-control glycemia as well as progressive accumulation of life-altering cardiovascular, renal, eye, and nerve abnormalities, suggesting that this disease continues to have a very serious trajectory with important personal and public health implications as these individuals transition into emerging adulthood.

Current American Diabetes Association guidelines[3] are now supporting a much more aggressive approach to the management of these patients, with earlier interventions. Too often, we as pediatricians are hesitant to add medications or to expose young kids to medications that we feel they maybe don't need. But I think the data from today suggest that, in fact, these kids need a more aggressive intervention than is recommended for older people because they have a more serious trajectory and will be living with these cardiovascular risks for a very long time.

Therefore, we need to be thinking about ways to more aggressively intervene while we develop a stronger evidence base.

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