Vol. 16 •Issue 11
• Page 43
Type 2 Diabetes in Children and Adolescents
Literature Shows Screening Is Overlooked
by David Cox, NP, and Karen J. Polvado, NP
Once believed to be a disease of adults, we now know that type 2 diabetes affects children and adolescents.1Since 1999, studies have documented an increased incidence of impaired glucose tolerance in America's children and teens.2,3 The upsurge in childhood obesity appears to correlate with the rise in type 2 diabetes in this population.4What's more, studies show that many children and adolescents with type 1 diabetes who were obese at the time of diagnosis actually had type 2 diabetes.5
The American Diabetes Association (ADA) has issued recommendations for screening children and adolescents for type 2 diabetes (see table).1 The primary indicator is obesity. The ADA recommends screening for type 2 diabetes when obesity is identified and the child or adolescent has two or more of the risk factors listed in the table accompanying this article.1The preferred testing method is fasting plasma glucose, and it should be collected every 2 years as long as risk factors are present.1
Despite the publication of type 2 diabetes screening recommendations for the pediatric population, screening rates in children and adolescents with risk factors is suboptimal.6-8The recognition of the relationship between obesity and type 2 diabetes in children and adolescents is an important first step in the identification of children and adolescents at risk.7,8A review of the literature suggests that health care providers are not familiar with the ADA recommendations or the appropriate time to initiate screening.6,8In addition, there is a paucity of research about the screening practices of primary care providers with regard to type 2 diabetes in this population. Screening for type 2 diabetes is important because untreated or poorly treated diabetes can lead to coronary artery disease, peripheral vascular disease, blindness and end-stage renal disease.9
Background
In 2005, the Centers for Disease Control and Prevention and the National Center for Chronic Disease Prevention and Health Promotion issued a report about the epidemiology of type 2 diabetes in children and adolescents.10Type 2 diabetes is not limited to one ethnic group, but it has a higher prevalence in nonwhite groups. The Pima Indians, for example, have the highest prevalence of type 2 diabetes in their pediatric population, with an incidence of 51 per 1,000.10,11A large-scale longitudinal study is under way to determine the prevalence of type 2 diabetes in other ethnic groups.10
The International Diabetes Federation Workshop reported on the incidence of type 2 diabetes in children and adolescents in 2004 and concluded that type 2 diabetes is a global issue.12Foreign studies have reinforced this finding.13Additional studies suggest a rise in type 2 diabetes incidence in middle-aged adults.10Whether this increase includes cases of undiagnosed type 2 diabetes left over from childhood or adolescence is not known; one-third to one-half of cases go undiagnosed for years.9 Nurse practitioners in primary care settings are in an ideal position to identify children and adolescents at risk for type 2 diabetes and to initiate appropriate screening. But studies reveal that primary care providers, including nurse practitioners, fail to recognize the primary indication for type 2 diabetes screening: obesity.7,8
The U.S. Preventive Services Task Force recognized the obesity problem in America's pediatric population (6 to 19 years old) in its recent statement on screening and interventions for overweight children.14The task force observed that the prevalence of obese children has doubled in the last 30 years, and it concurred with prior panels that evidence does not support type 2 diabetes screening for all obese children.1,4,14Based on ADA screening recommendations, the obese child or adolescent is not automatically eligible for screening; excess body weight is a cue to assess the patient for additional risk factors.4
Pathophysiology
The link between obesity and type 2 diabetes is related to the effect obesity has on insulin resistance and glucose metabolism. In most cases, obesity has a simple cause: Caloric intake exceeds calories burned.15 large amount of visceral fat over the body contributes to insulin resistance through a decrease in the adipokines TNF-alpha and peptide resistin. These substances interfere with insulin's action on normal glucose metabolism and eventually cause hyperplasia of pancreatic beta cells. This action leads to a progressive decrease in the secretion of insulin and results in type 2 diabetes.16
Literature Review
A 10-year study of 89 black and Caribbean-Hispanic youths with type 2 diabetes examined clinical presentation at the time of diagnosis.17Participants had a mean body mass index (BMI) of 34 and a mean age of 14, and all were pubertal. Eighty-nine percent had acanthosis nigricans, 48% had polyuria and polydipsia, 22% had weight loss, and 30% were asymptomatic. The authors documented a tenfold increase in the number of participants diagnosed with type 2 diabetes during the study period.17
A study of 1,242 youths in the Chicago Childhood Diabetes Registry compared the epidemiology of type 1 and type 2 diabetes in this population.5The research team reviewed medical records in 37 children's hospitals over 17 years. Thirty-two percent of the patients had been diagnosed with type 2 diabetes, and within that group, 73% of the children were obese. Obesity was a prevalent characteristic in children who were newly diagnosed with type 2 diabetes.5A medical records review in Florida examined trends in the diagnosis of type 2 diabetes in children and adolescents from 1994 to 1998.3The study included 661 subjects across three university-based pediatric diabetes centers in Florida. In 1994, 9.4% of the children were diagnosed with type 2 diabetes. In 1998, 20% were diagnosed with type 2 diabetes. These patients had an average BMI in the 85thto 94thpercentile. They were more likely to be adolescent, Hispanic and female.3
A study of 167 obese children examined impaired glucose tolerance among children and adolescents with obesity.2 he study participants were patients in the Yale University Pediatric Obesity Clinic, and they all had a BMI greater than the 95thpercentile for age and sex. Researchers assessed the subjects for pubertal stage and overall health. Approximately 40% of the adolescent girls showed signs of polycystic ovarian syndrome, and 58% of them were of non-Hispanic white heritage. Each participant underwent glucose tolerance testing and provided blood samples for glucose, insulin and C-peptide level testing. The researchers measured fasting proinsulin to determine each patient's level of insulin resistance. The results: 25% of the children and 21% of the adolescents had impaired glucose tolerance, and 4% of the adolescent group had type 2 diabetes. Thirty percent of the group with impaired glucose tolerance and diabetes had a parent with type 2 diabetes.2A retrospective study examined the rates at which obesity was identified in a pediatric primary care setting in Pittsburgh.7 he study included a medical records review of all visits made over 3 months. Two hundred forty-four patients met diagnostic criteria for obesity. In these patient encounters, providers recorded obesity in the physical exam notes for 64% of these children. They screened 13% of these patients for type 2 diabetes. The authors identified a need for increased provider awareness and identification of obesity in the pediatric primary care setting.7sup>
n Boston, a study determined the rate of type 2 diabetes screening in children and adolescents in a primary care pediatric clinic.6The researchers conducted a retrospective medical record review over 2 years. A total of 7,710 patients were identified as in need of additional risk factor assessment based on weight alone. The researchers screened 1,642 patients, and a bias was apparent for the older adolescent group (16 to 19 years old). Six hundred seventy-two children and adolescents met the ADA criteria for screening, and approximately 50% of those were screened. When screening did occur, only 4.6% of the patients received a fasting plasma glucose test.6Results
These studies confirm the increased incidence of type 2 diabetes in the pediatric population.3,6,17 They also confirm that children and adolescents at risk for type 2 diabetes are not being screened adequately.6,7Despite the ADA recommendations, primary health care providers — including those in pediatric settings — are not identifying children at risk.6,7Obesity is the primary cue to assess for additional risk factors.1-3,7,15,17 lack of provider knowledge about the ADA recommendations for type 2 diabetes screening may be contributing to the lack of screening.6,7
Discussion
The ADA screening recommendations for type 2 diabetes in children provide an easy reference for identifying patients at risk for the disease. An increase in the incidence of type 2 diabetes in children and adolescents is anticipated as more health care providers follow the screening recommendations and make appropriate diagnoses. Earlier diagnosis of type 2 diabetes can help prevent the long-term consequences of untreated or poorly treated diabetes.
Putting It Into Practice
Screening for type 2 diabetes in children and adolescents is the responsibility of all health care providers who treat these populations. A paradigm shift is needed: We must view type 2 diabetes as a disease that affects children as well as adults.
References
1. American Diabetes Association. Type 2 diabetes in children and adolescents. Diabetes Care. 2000;23(3):381-389.
2. Sinha R, et al. Prevalence of impaired glucose tolerance among children and adolescents with marked obesity. N Engl J Med. 2002 ;346(11):802-810.
3. Macaluso C, et al. Type 2 diabetes mellitus among Florida children and adolescents, 1994 through 1998. Public Health Rep. 2002;117(4):373-379.
?4. Cara J. The epidemic of type 2 diabetes in children. Available at: http://www.medscape.com/viewarticle/447138. Accessed Aug. 11, 2008.
5. Lipton R, et al. Obesity at the onset of diabetes in an ethnically diverse population of children: what does it mean for epidemiologists and clinicians? Pediatrics. 2005;115(5):553-560.
6. Anand S, et al. Diabetes mellitus screening in pediatric primary care. Pediatrics. 2006;118(5):1888-1895.
7. O'Brien S, et al. Identification, evaluation, and management of obesity in an academic primary care center. Pediatrics. 2004;114(2):154-159.
8. Drobac S, et al. Evaluation of a type 2 diabetes screening protocol in an urban pediatric clinic. Pediatrics. 2004;114(1):141-148.
9. Engelgau M, et al. Screening for type 2 diabetes. Diabetes Care. 2000;23(10):1563-1594.
10. Centers for Disease Control and Prevention. Children and diabetes. Available at: http://www.cdc.gov/diabetes/projects/diab_children.htm. Accessed Aug. 11, 2008.
11. Acton KJ, et al. Trends in diabetes prevalence among American Indian and Alaska native children, adolescents and young adults. Am J Public Health. 2002;92(9):1485-1491.
12. Alberti G, et al. Type 2 diabetes in the young: the evolving epidemic: the international diabetes federation consensus workshop. Diabetes Care. 2004;27(17):1798-1811.
13. Hotu S, et al. Increasing prevalence of type 2 diabetes in adolescents. J Paediatr Child Health. 2004;40(4):201-204.
14. US Preventive Services Task Force. Screening and interventions for overweight in children and adolescents: recommendation statement. Am Fam Physician. 2006;73(8):115-119.
15. Dunphy L, Winland-Brown J. Primary Care: The Art and Science of Advanced Practice Nursing. Philadelphia, Pa.: F.A. Davis; 2001.
16. Tierney L, et al. Current Medical Diagnosis & Treatment. 44thsup> d. New York, N.Y.: McGraw-Hill; 2005.
17. Grinstein G, et al. Presentation and 5-year follow-up of type 2 diabetes mellitus in African-American and Caribbean-Hispanic adolescents. Horm Res. 2003;60(3):121-126.
David Cox is a family nurse practitioner at Family Practice Associates in Wichita Falls, Texas. Karen Polvado is a family nurse practitioner who has a doctorate in nursing practice. She is coordinator of the family nurse practitioner program at Midwestern State University in Wichita Falls, Texas, where she is an assistant professor.
Screening Criteria for Type 2 Diabetes in Children and Adolescents
CRITERIA FOR DIAGNOSIS:
Overweight or Obesity
BMI > 85th percentile for age and sex
or
> 85th percentile in weight for height
or
>120% of ideal weight for height
Plus Any Two of the Following Risk Factors:
1. Family history of type 2 diabetes in first- or second-degree relative
2. Racial or ethnic background of Native American, African American, Latino, Asian American or Pacific Islander
3. Signs of insulin resistance or conditions associated with insulin resistance (acanthosis nigricans, hypertension, dyslipidemia, polycystic ovarian syndrome)
4. Age: 10 years or at onset of puberty if puberty occurs at a younger age
TYPE OF TEST:
Fasting plasma glucose (FPG)
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