In addition, there is also a lack of evidence on the impact of screening and early detection and treatment of type 2 diabetes on health outcomes in youth, the same recommendations explain. “Youth with type 2 diabetes have an increased prevalence of associated chronic comorbid conditions, such as hypertension, dyslipidemia, and nonalcoholic fatty liver disease,” report Carol Mangione, MD, David Geffen School of Medicine, University of California at Los Angeles, and colleagues. “[However]clinicians should continue to use their clinical judgment to determine whether screening is appropriate for individual patients,” they advise. The new recommendations were published online Sept. 13 in JAMA. Commenting on the new recommendations in an accompanying article, Lori Laffel, MD, MPH, Joslin Diabetes Center, Boston, Massachusetts, and colleagues point out that the prevalence of type 2 diabetes in children and adolescents has nearly doubled over the past two decades. from 0.34 per 1000 in 2001 to 0.67 per 1000 in 2017, a relative increase of 95% over 16 years. “The COVID-19 pandemic has further magnified the trend of increased numbers of young people developing type 2 diabetes, likely due to many reasons, including the unhealthy lifestyle risk factors of increased sedentary behavior, reduced physical activity and weight gain,” explain the Laffel et al. . Furthermore, the diagnosis of type 2 diabetes in young patients is not straightforward, as increasing evidence suggests that it is associated with higher morbidity and premature mortality in children and adolescents, likely due to the accelerated onset and progression of microvascular and macrovascular complications. “These complications are evident at high rates and at younger ages in those with juvenile type 2 diabetes than in those with juvenile type 1 diabetes or in adults diagnosed with type 2 diabetes,” the authors note.
Systematic Review
The USPSTF commissioned a systematic review of the evidence on screening for prediabetes and type 2 diabetes in asymptomatic, nonpregnant patients younger than 18 years of age. “This review focused on evidence on the benefits and harms of screening for prediabetes and type 2 diabetes and the benefits and harms of interventions for detected prediabetes and type 2 diabetes or newly diagnosed type 2 diabetes,” USPSTF members explain. It also assessed the evidence on the effectiveness of interventions for patients with prediabetes to delay or prevent progression to type 2 diabetes. The definitions of prediabetes and type 2 diabetes are the same in children and adolescents as in adults, with type 2 diabetes to be defined as a fasting plasma glucose of 126 mg/dL (5.6-6.9 mmol/L) and an A1c of 6.5%. or 2-hour postload glucose of 200 mg/dL (11.1 mmol/L) or greater. The Task Force also made several other recommendations for screening for obesity in children and adolescents along with screening for prediabetes and type 2 diabetes in adults. The same group has also made a separate recommendation for screening for gestational diabetes in pregnant women. The US Food and Drug Administration (FDA) has approved three drugs to treat type 2 diabetes in children: metformin, insulin, and liraglutide (Victoza, Novo Nordisk), a peptide-1 (GLP-1) receptor agonist that resembles glucagon. . While metformin is effective for treating type 2 diabetes in younger patients, it has not been approved by the FDA to prevent prediabetes from progressing to diabetes, the authors point out. The Task Force found no studies that addressed the direct benefits of screening for prediabetes and type 2 diabetes on health outcomes in asymptomatic children and adolescents. Similarly, they found no studies that addressed the harms of screening for prediabetes and type 2 diabetes in the same patient population. In fact, because some youth with prediabetes may return to normal glycemia without intervention, the potential harms of screening in this age group include overdiagnosis and overtreatment, and the potential harms of treating type 2 diabetes include causing hypoglycemia and gastrointestinal side effects. such as nausea and vomiting, associated with the use of drugs. Importantly, rates of type 2 diabetes in Native American/Alaska Native, Black, and Hispanic/Latino youth have been shown to be between four and eight times higher compared to non-Hispanic White youth. The authors speculate that structural factors that disproportionately affect nonwhite populations, as well as cultural and environmental influences, plus quality and access to health care, may contribute to differences in diabetes rates by race and ethnicity.
Are lifestyle interventions less effective in youth than adults?
What the Task Force recommends for children and adolescents with prediabetes and type 2 diabetes are lifestyle interventions that promote weight loss, improve nutrition, and increase physical activity.
As they point out, obesity and excess adipose tissue – particularly centrally distributed excess adipose tissue – are the most important risk factors for type 2 diabetes in younger patients. A family history of diabetes, including gestational diabetes, is also a strong risk factor.
Risk assessment tools exist to help identify young patients at increased risk for prediabetes and type 2 diabetes. However, there is limited evidence to confirm their accuracy, task force members cautioned.
In their article, Laffel and colleagues emphasize: “Prevention and early recognition of type 2 diabetes in children is a key public health priority. They also recommend lifestyle intervention, which has been shown to significantly reduce the progression to type 2 diabetes in adults”.
However, they caution that intensive efforts to achieve weight loss through lifestyle appear to be less effective in youth than in adults.
That said, pediatricians and primary care physicians can and should continue to emphasize the importance of a healthy lifestyle for children and their families and to watch closely for symptoms of hyperglycemia.
Physicians should also continue to follow risk-based screening recommendations for type 2 diabetes in overweight and obese youth and at least one additional risk factor for type 2 diabetes who show signs of insulin resistance, including acanthosis nigricans or polycystic ovary syndrome ovaries.
The US Centers for Disease Control and Prevention estimates that 210,000 children and adolescents under the age of 20 had diabetes in 2018, and of those, about 23,000 had type 2 diabetes.
All USPSTF members receive travel reimbursement and a fee for attending USPSTF meetings. Laffel reported receiving funding from Insulet and Boehringer Ingelheim and consulting fees from Janssen, Medtronic, Dompe, Prevention Bio, Eli Lilly, Roche, and Dexcom.
GLASS. Published online on September 13, 2022.
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