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Diabetes type 2 in children and adolescents

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On Review of Systems, she says she has gained 40# in a few months, is thirsty ... On direct questioning, SC does report polydipsia and polyuria. BMI is 28.5. ... – PowerPoint PPT presentation

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Title: Diabetes type 2 in children and adolescents


1
Diabetes type 2 in children and adolescents
  • FHC Clinical Staff Meeting
  • April 15, 2004

2
Patient A (Dr. Ward)
  • SB is a 19 yo woman who presents with bilateral
    knee pain and irregular menses. On Review of
    Systems, she says she has gained 40 in a few
    months, is thirsty and urinates frequently
  • VS AF BP 160/88-140/77 HR 76
  • Wt 283lbs (133kg) Ht 5ft 11in BMI 38
  • Obese over trunk and shoulders, hirsuite
  • No hyperpigmentation
  • Cardiac RRR Lungs CTAB GI-benign
  • FHx- HTN, MI, epilepsy in M, DM in MGM

3
Patient A (Dr. Ward)
  • Labs
  • CBC wbc 5/hgb 12/plt 268
  • BMP na 140/k 4.3/cl 102/hco3 26/bun 13/cr
    0.9/gluc 273
  • Hgb A1c 8.7
  • Lipids chol 217/hdl 75/ldl 119/tg 115
  • tsh 1.08/fsh 4.9/lh 8.7/prolactin 2.8/cortisol
    11.9
  • UA 1.025 pr 2/gluc neg
  • Urine albumincr 53

4
Patient 2 (Dr. Dehlendorf)
  • SC is a 16 yo girl who presents with secondary
    amenorrhea
  • Routine labs reveal a blood glucose of 276.
    Follow-up fasting glucose 182 with HbA1c of 12.3.
  • On direct questioning, SC does report polydipsia
    and polyuria. BMI is 28.5.
  • TSH is normal at 1.12, LFTs elevated with an
    AST/ALT of 100/134, and lipids elevated with
    total cholesterol 277, HDL 57 and LDL of 148, TG
    360.
  • FSH/LH is 5.2/16.2, and Prolactin of 24.

5
SC, Continued
  • Treatment is initiated with Metformin, and a gap
    acidosis develops.
  • She is changed to glyburide and rosiglitazone
  • The acidosis resolves
  • Her A1C decreases to 7.2
  • Her LFTs normalize
  • Her creatinine increases to 1.4 in the course of
    treatment, and her microalbumin/creatinine ratio
    is 526.5.
  • She develops severe depression and is referred to
    child crisis for suicidal ideation.

6
Diabetes in children and adolescents Prevalence
  • Estimates of prevalence for both type 1 and type
    2
  • 4/1000 in NHANES III
  • Specific prevalence for type 2 unavailable except
    for certain populations (e.g. 50/1000 among
  • 10-19 year old Pimas)

7
Changing epidemiology
  • Prevalence of type 2 historically less than 2 of
    children diagnosed with DM
  • Newer data indicate this percentage has increased
    in case-based series
  • 8 of newly diagnosed children in Cincinnati
  • 18 in San Antonio, TX
  • 45 in Ventura, CA and Charleston, SC

8
Type 1 or 2?
  • Factors favoring a diagnosis of type 1
  • Symptoms of less than 3 weeks' duration
  • Normal BMI (but 24 may have high BMI at
    presentation)
  • Diabetic ketoacidosis (30-40) or ketosis at
    presentation
  • Family history of type 1 DM (5).
  • Positive test for islet-cell antibodies (85-98)
  • Other auto-immune disorders

9
Type 1 or 2?
  • Factors favoring a diagnosis of type 2
  • Body mass index greater than 25 (85)
  • Glycosuria without ketonuria (but 33 will have
    ketonuria)
  • Family history of type 2 (74 100)
  • Acanthosis nigricans (90)
  • PCOS
  • High insulin levels
  • African, Hispanic, Asian, or American Indian
    descent

10
Other types?
  • Idiopathic type 1 (Atypical, 1.5, Flatbush)
  • Fam Hx early onset, mult generations (AfAm
    preponderance)
  • Ketoacidosis, though not strictly
    insulin-dependent
  • Maturity onset diabetes of the young (MODY)
  • Several disorders, rare
  • Autosomal-dominant inheritance of defects in
    B-cell function
  • Broad presentation asx to severe
  • Testing not readily available

11
Type 1 or 2?
  • In most patients, classification can be made
    reliably on the basis of clinical presentation
    and course. In the unusual circumstance that
    requires a specific classification to be made,
    other tests may be necessary, such as a fasting
    insulin or C-peptide determination, and
    occasionally, Beta-cell autoantibody
    measurements.

ADA Consensus Statement. Type 2 diabetes in
children and adolescents. Diabetes Care 2000
23381-389.
12
ADA Consensus Statement. Type 2 diabetes in
children and adolescents. Diabetes Care 2000
23381-389.
13
Diabetes in children and adolescents Risk Factors
  • Family history
  • Lack of physical activity
  • Nutritional habits
  • Obesity ( 10 of high school students are gt 95th
    percentile BMI)

14
Percentage of high school students who attended
phys. ed. class daily
CDC. Morbidity And Mortality Weekly Report.
Surveillance Summaries, 20025115-61.
15
Percentage of high school students who watched gt
3 hours/day of T.V.
CDC. Morbidity And Mortality Weekly Report.
Surveillance Summaries, 20025115-61.
16
Super size (Young LR, Nestle M. 2002)
17
Early onset DM2 Complications
  • Diagnosed at age 18 - 44 vs. age gt 45
  • 14 x risk for MI
  • Young women account for almost all the increase
    in risk
  • 30 x risk for stroke
  • No difference in risk for microvascular
    complications

18
Screening for type 2 diabetes in children
  • Beginning at age 10 (or puberty, if earlier),
    and every two years IF
  • BMI gt 85th percentile AND at least two others
  • Fam Hx of type 2 (1st or 2nd degree relatives)
  • American Indian, African American, Hispanic
    American, Asian American, Pacific Islander
  • Signs of insulin resistance (acanthosis
    nigricans, hypertension, dyslipidemia)
  • Fasting plasma glucose preferred

19
Treatment
  • Treat hypertension
  • Treat hyperlipidemia
  • Attempt normalization of glucose
  • Lifestyle modifications
  • Oral agents (none FDA approved)
  • Metformin recommended as first choice
  • Insulin

20
References
  • Hillier TA, Pedula KL. Complications in young
    adults with early-onset type 2 diabetes losing
    the relative protection of youth. Diabetes Care
    200326 2999-3005.
  • American Diabetes Association Consensus
    Statement. Type 2 diabetes in children and
    adolescents. Diabetes Care 2000 23381-389.
  • CDC. Morbidity And Mortality Weekly Report.
    Surveillance Summaries, 20025115-61.
  • Scott CR et.al. Characteristics of youth-onset
    noninsulin-dependent diabetes mellitus and
    insulin-dependent diabetes mellitus at diagnosis.
    Pediatrics 1997100(1)84-91.
  • Rosenbloom AL, et.al. Emerging epidemic of type 2
    diabetes in youth. Diabetes Care 1999 22(2)
    345-54.
  • Neufeld ND, et.al. Early presentation of type 2
    diabetes in Mexican-American youth. Diabetes Care
    199821(1)80-6.
  • Fagot-Campagna A et.al. Type 2 diabetes among
    North American children and adolescents an
    epidemiologic review and public health
    perspective. JPediatr, 2000136(5)664-72.
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