CE/CME

Pediatric T2DM: A Growing Threat to US Health

Clinician Reviews. 2015 March;25(3):34-42

References

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3. Dabelea D, Bell RA, D’Agostino Jr RB, et al; the SEARCH for Diabetes in Youth Writing Group. Incidence of diabetes in youth in the United States. JAMA. 2007;297(24):2716-2724.
4. Copeland KC, Silverstein J, Moore KR, et al. Management of newly diagnosed type 2 diabetes mellitus (T2DM) in children and adolescents. Pediatrics. 2013;131(2):364-382.
5. American Diabetes Association. Children and adolescents. Sec. 11. In: Standards of Medical Care in Diabetes—2015. Diabetes Care. 2015;38(suppl 1):S70-S76.
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DIAGNOSIS
Identification of children at risk for T2DM is the first step in delaying or preventing pediatric T2DM and its complications. The American Diabetes Association’s Standards of Medical Care in Diabetes—2015 indicate that asymptomatic children and adolescents who are overweight (BMI above the 85th percentile for age and sex, weight for height above the 85th percentile, or weight greater than 120% of ideal for height) and who meet at least two of the following criteria should be tested for T2DM¹⁵:

• Family history of T2DM in first- or second-degree relative (74% to 100% have a first- or second-degree relative with diabetes¹⁴)
• Non-European ancestry (Native American, African-American, Latino, Asian American, Pacific Islander)
• Signs of insulin resistance or associated conditions (acanthosis nigricans, hypertension, dyslipidemia, polycystic ovary syndrome [PCOS], or small-for-gestational-age birth weight)
• Maternal history of diabetes or gestational diabetes during pregnancy.

Screening should begin when the child is 10 or when puberty is attained, with retesting every three years thereafter.

Testing
The diagnosis of diabetes may be confirmed by any one of the following test results^4,15• A1C level ≥ 6.5%
• Fasting blood glucose (FBG) ≥ 126 mg/dL
• Two-hour oral glucose tolerance test (OGTT) level ≥ 200 mg/dL
• Random serum glucose ≥ 200 mg/dL with symptoms of hyperglycemia.

Type 1 or type 2?
In some newly diagnosed pediatric patients with diabetes, distinguishing T1DM from T2DM may be difficult; 25% of cases of T2DM are misclassified as T1DM.^4,14For example, an obese child who presents with ketosis appears to have features of both T1DM and T2DM.⁴ The distinction needs to be made as soon as possible because management of the diseases is quite different.

Measurement of C-peptide level (low in T1DM, normal or high in T2DM) is suggestive but not 100% reliable for this purpose. Similarly, ketosis is an unreliable indicator; adolescents with T2DM present with ketoacidosis in 5% to 25% of cases.^4,14

Another means to differentiate T1DM and T2DM is determining the levels of diabetes autoantibodies (DAA) to insulin. Pediatric patients with suspected DM can be screened for the islet cell autoantibodies GAD (glutamic acid decarboxylase)-65 and IA (insulin antibody)-2. In addition, a new DAA assay that tests for the zinc transporter 8 autoantibody [ZnT8Ab] was recently approved by the FDA for marketing.¹⁶ Detection of these antibodies is generally—but not always—an indicator of T1DM, an autoimmune disease of the pancreas.⁵

The Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY) Study Group found that, of 1,206 obese (BMI in the 85th percentile or higher) participants with T2DM, 9.8% tested positive for either or both of the GAD-65 and IA-2 antibodies. It was unclear if the DAA-positive patients had both T1DM and T2DM or T1DM with insulin resistance due to obesity. They concluded that testing for islet cell autoantibodies was needed to reliably identify patients with autoimmune diabetes.¹⁷

In addition to establishing the correct diagnosis, the clinician should order tests to rule out a concomitant thyroid disorder and to assess the patient for diabetic complications. Testing should include a thyroid panel, lipid panel, urine microalbumin level, and renal and hepatic function tests.¹⁸

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