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Type 2 Diabetes in Children

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Type 2 Diabetes in Children Dr. Abdulmoein Al-Agha, MBBS,DCH,CABP, MRCP(UK) Consultant, Pediatric Endocrinologist, King AbdulAziz University Hospital, Jeddah. – PowerPoint PPT presentation

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Title: Type 2 Diabetes in Children


1
Type 2 Diabetes in Children
Dr. Abdulmoein Al-Agha, MBBS,DCH,CABP, MRCP(UK)
Consultant, Pediatric Endocrinologist, King
AbdulAziz University Hospital, Jeddah.
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  • Diabetes mellitus type 2
  • Is a metabolic disorder that is primarily
    characterized by insulin resistance, relative
    insulin deficiency hyperglycemia
  • It is rapidly increasing in the developed world
  • Has characterized the increase as an epidemic
  • Unlike type 1 diabetes, there is little tendency
    toward ketoacidosis in Type 2 diabetes, though it
    is not unknown
  • Complex and multi-factorial metabolic changes
    lead to damage function impairment of many
    organs, most importantly the cardiovascular system

4
Criteria for the Diagnosis of Diabetes
  • Symptoms of diabetes plus random plasma glucose
    concentration ? 200 mg/dl (11.1 mmol/l).
  • The classic symptoms of diabetes include
  • polyuria, polydepsia, and unexplained weight
    loss.
  • OR
  • FPG ? 126 mg/dl (7.0 mmol/l).
  • Fasting is defined as no caloric intake for at
    least 8 h.
  • OR
  • 2-h PG ? 200 mg/dl (11.1 mmol/l) during OGTT
  • The test should be performed as described by W HO
    using a glucose load containing equivalent of
    75-g anhydrous glucose dissolved in water.

5
  • Pathophysiology
  • Insulin resistance means that body cells do not
    respond appropriately when insulin is present
  • Other important contributing factors
  • increased hepatic glucose production (e.g., from
    glycogen degradation), especially at
    inappropriate times
  • decreased insulin-mediated glucose transport in
    (primarily) muscles adipose tissues (receptor
    and post-receptor defects)
  • impaired beta-cell functionloss of early phase
    of insulin release in response to hyperglycemic
    stimuli

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Underlying causes of type 2 diabetes
Insulin resistance
Hyperinsulinaemia
?-cell defect
Impaired glucose tolerance
Decreased insulin secretion
Obesity
Early diabetes
?-cell failure
Late diabetes
Adapted from Saltiel AR. J Clin Invest
2000106163164.
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Obesity Type 2 Diabetes
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Too large meals ! Too high Calories !
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Sedentary life style!!
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The progressive nature of type 2 diabetes
Normal
Impaired glucose tolerance
Type 2 diabetes
Late type 2 diabetes complications
Insulin sensitive
Hyperglycaemia
Normal insulin secretion
Insulin resistance
Normoglycaemia
ß-cell exhaustion
Fasting plasma glucoseInsulin sensitivityInsulin
secretion
Adapted from Bailey CJ et al. Int J Clin Pract
200458867876. Groop LC. Diabetes Obes Metab
19991 (Suppl. 1)S1S7.
20
Type 2
Genetic susceptibility
Obesity Insulin resistance
21
Type 2 Diabetes in Children
  • Clinical presentation
  • Children with type 2 diabetes are usually
    diagnosed over age of 10 years
  • Middle to late puberty
  • Milder symptoms than type 1 with mild polydepsia,
    polyuria, little or no weight loss
  • Glucosuria with / without ketonuria
  • Up to 33 have ketonuria at diagnosis
  • 525 of patients with type 2 diabetes have
    ketoacidosis at presentation

22
Associated problems with type 2 DM
  • Obesity
  • Insulin resistance
  • Hyperinsulinism
  • Arterial hypertension
  • Hyperlipidemia
  • Acanthosis Nigerians
  • Macro microangiopathy
  • PCOS

23
Acanthosis Nigricans
  • Acanthosis nigricans is a cutaneous finding
    frequently in darker-skinned obese individuals
  • Characterized by velvety hyperpigmented patches
    most prominent in intertriginous areas and is
    present in as many as 90 of children with type
    II diabetes

24
Screening for type 2 DM in Children
Adolescents
25
Why to screen for type 2 DM?
  • As in adults, a substantantial number of children
    with type 2 can be detected in A
    symptomatic state
  • In type 2, there is a prolonged latency period
    without symptoms during which abnormality can be
    detected
  • Only children at risk for the presence or
    development of type 2 should be screened

26
Criteria of screening for Type 2 DM in Children
Adolescents
  • overweight which is defined as (WHO)
  • body mass index (BMI) gt 85th percentile for age
    and sex
  • weight for height gt 85th ile
  • weight gt120th ile of ideal (50) for height
  • Plus two of the following risk factors
  • Family history of type 2 DM in first or
    second-degree relative

27
Criteria of screening for Type 2 DM in Children
Adolescents
  • Race/ethnicity (Pima Indian, African-American,
    Hispanic, Asian / Pacific Islander)
  • Signs of insulin resistance or conditions
    associated with insulin resistance
  • acanthosis nigricans
  • polycystic ovary syndrome
  • hypertension
  • dyslipidemia

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Type 2 diabetes is NOT a mild disease
Stroke
Diabeticretinopathy
1.2- to 1.8-fold increase in stroke3
Leading cause of blindness in working-age adults1
Cardiovasculardisease
75 diabetic patients die from CV events4
Diabetic nephropathy
Diabeticneuropathy
Leading cause of end-stage renal disease2
Leading cause of non-traumatic lower extremity
amputations5
1Fong DS, et al. Diabetes Care 200326 (Suppl.
1)S99S102. 2Molitch ME, et al. Diabetes Care
200326 (Suppl. 1)S94S98. 3Kannel WB, et al.
Am Heart J 1990120672676. 4Gray RP Yudkin
JS. In Textbook of Diabetes 1997. 5Mayfield JA,
et al. Diabetes Care 200326 (Suppl. 1)S78S79.
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Prevention of type 2 DM
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Prevention of obesity
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Prevention of type 2 DM
  • Public health measures
  • 1. Media
  • 2. School
  • 3. Community
  • 4. Family
  • Increase physical activity
  • Reduce caloric intake/obesity
  • Decrease sedentary life style
  • I. Computer
  • 2. Video games
  • 3. Television

36
Treatment of type 2 diabetes
  • There are limited data available regarding
    management of type 2 diabetes in children
  • As a result, the goals of treatment in type 2
    diabetes in adults have been applied to children
    and adolescents
  • These goals include
  • achieving psychological physical well-being
  • long term glycemic control
  • defined as a fasting plasma glucose lt 130mg/dL
  • HbA1c lt 7
  • preventing microvascular macrovascular
    complications

37
  • Initial treatment of type 2 DM, will vary
    depending on clinical presentation
  • Wide range from A symptomatic hyperglycemia to
    DKA
  • Children who are not ill at diagnosis can be
    managed with diet ,exercise oral agents
  • Children who are ill, dehydrated, presence of
    ketosis and acidosis need insulin therapy
  • When stabilized, tapering of insulin gradually
    and introduction oral agents
  • In all patients, identification treatment of
    co-morbid conditions are important

38
How can insulin resistance be managed?
  • Improve insulin resistance through
  • Diet
  • Exercise
  • Pharmacological intervention with agents that
    target insulin resistance

39
Oral hypoglycemic agents
  • Biguanides Metformin
  • The first oral agent used should be metformin.
  • decrease hepatic glucose output
  • enhance hepatic muscle insulin sensitivity
    without a direct effect on b-cell function
  • Sulfonylureas chlorpropamide, gliclazide,
    glimepiride, glipizide, tolazamide, tolbutamide
  • promote insulin secretion from islet cells
  • Thiazolidenediones troglitazone, rosiglitazone
  • improve peripheral insulin sensitivity
  • Troglitazone has been associated with fatal
    hepatic
  • failure its use in children is not
    recommended

40
Metformin
  • The first oral agent should be used in type 2
  • Metformin has advantage over sulfonylureas of a
    similar reduction in HbA1c without the risk of
    hypoglycemia
  • Metformin normalizes ovulatory abnormalities in
    girls with PCOS
  • Because of concerns about lactic acidosis,
    Metformin is contraindicated in patients with
  • impaired renal function
  • should be discontinued with the administration
    of radiocontrast material.
  • should not be used in patients with known hepatic
    disease, hypoxemic conditions, severe infections,
    or alcohol abuse

41
Metformin
  • The most common side effects of Metformin
  • Gastrointestinal disturbances
  • Because proper dosing in children has not been
    evaluated because most patients are near or at
    adult weight, it is reasonable to use the doses
    recommended for adults
  • If monotherapy with Metformin is not successful
    over a period of time (36 months), Some
    clinicians would add a sulfonylurea, whereas
    others might add insulin

42
  • Sulfonylureas stimulate insulin secretion and
    reduce HbA1c levels by 12
  • Sulfonylureas may cause weight gain and are
    associated with the highest incidence of
    hypoglycemia among the oral antidiabetic agents.
  • Glucosidase inhibitors slow the hydrolysis of
    complex carbohydrates and carbohydrate absorption
    (acarbose and miglitol)
  • The glucosidase inhibitors reduce HbA1c by
    0.50.9

43
  • The thiazolidinediones improve peripheral insulin
    sensitivity reduce HbA1c by 0.51.5
  • The thiazolidinediones do not cause hypoglycemia
    when used as monotherapy, but may cause edema
    weight gain
  • The sulfonylureas, nonsulfonylureas, glucosidase
    inhibitors thiazolidinediones have not received
    approval by FDA for use in the pediatric
    population

44
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