“During the past two decades, there has been an increase in the incidence of T2D in youth,” explains Kathy Love-Osborne, MD. “We know from the TODAY [Treatment Options for Type 2 Diabetes in Adolescents and Youth] study that youth with T2D often end up with poorly controlled diabetes (defined as an A1C >8%) and require insulin. The concern was that these young people will be living with diabetes for many decades and may experience serious complications such as heart disease, blindness, and kidney disease.”
Screening youth for T2D is not without controversy, however. The U.S. Preventive Services Task Force advisory panel, which makes evidence-based screening recommendations, observed that while there is abundant evidence to support screening adults for T2D, there was not enough evidence to make a similar recommendation for asymptomatic youth. However, many clinicians who treat pediatric and adolescent patients suggest that early identification and prevention of T2D in children is a critical public health priority.
For a study published in Pediatric Diabetes, Dr. Love-Osborne and colleagues retrospectively assessed youth (N=142; aged 8-18) with T2D over the course of a decade. Using extensive chart review, they included only youth with a first elevated A1C at Denver Health and Hospitals, excluding those with prevalent diabetes, T1D, a single elevated A1C recorded, and those without confirmation of diabetes (second test not consistent with diabetes). “We then looked at medications prescribed for diabetes, highest A1C recorded, and last A1C both within our institution and at other local institutions that share the same EHRs,” Dr. Love-Osborne says. “Our aim was to examine predictors of improved diabetes outcomes.”
Endocrinologists Often Treat Young People with Poorly Managed T2D
The study team observed that increased screening for diabetes leads to diagnoses at lower A1C values. “Most youth with diabetes in the second half of the decade had prediabetes first,” she says. “If primary care providers can identify prediabetes, interventions may either prevent the development of T2D, or at least lead to diagnosis of T2D at lower A1C levels, which are associated with improved A1C outcomes.”
Dr. Love-Osborne points out that endocrinologists often treat young people with poorly controlled T2D, many of whom require multiple medications including insulin and other medications not necessarily FDA-approved for use in pediatric patients. “The other important finding, that youth with initial A1C levels less than 7% had improved outcomes if they were prescribed a glucometer, deserves further study,” she says. “Our hypothesis is that use of a glucometer may increase awareness about which foods or drinks lead to elevated blood sugar in an individual patient, which potentially could lead to beneficial lifestyle changes.”
‘Prevention and Early Detection of T2D Are Critical’
Over time, there was an increase in the percentage of youth with obesity that were screened for T2D, the study group notes. The percentage of screened youth with confirmed T2D decreased slightly, and the percentage of new T2D patients with lower A1C (<7%) increased, although there was variability from year to year (Table).
“Since we know that T2D in youth is a serious issue with long-term health implications, prevention and early detection are critical,” says Dr. Love-Osborne. “If providers screen at-risk youth for diabetes, there are opportunities to intervene, either by secondary prevention of T2D in youth with prediabetes, or identification and treatment of youth with lower A1C values that may lead to improved long-term outcomes.”
As mentioned, Dr. Love-Osborne and colleagues concur that further research examining the use of glucometers in youth with A1C less than 7% without the use of medications would be helpful.
“Another area for research would be whether a diagnosis of ‘pubertal diabetes’ may exist, similar to gestational diabetes,” Dr. Love-Osborne notes. “Empirically, we have seen young people (aged 10-12) that have confirmed diabetes, but later have normal A1C results while not on medication. Youth in early puberty are very insulin resistant, so it is possible that if they make life-
style changes, especially if their A1C at diagnosis is less than 7%, that their beta cell function may be able to recover, although they would remain at increased diabetes risk during their adult life. This phenomenon deserves further study.”
