Update on nonautoimmune diabetes in children

Projections of Type 1 and Type 2 Diabetes Burden in the U.S. Population Aged <20 Years Through 2060: The SEARCH for Diabetes in Youth Study

OBJECTIVE

To project the prevalence and number of youths with diabetes and trends in racial and ethnic disparities in the U.S. through 2060.

RESEARCH DESIGN AND METHODS

Based on a mathematical model and data from the SEARCH for Diabetes in Youth study for calendar years 2002-2017, we projected the future prevalence of type 1 and type 2 diabetes among youth aged <20 years while considering different scenarios of future trends in incidence.

RESULTS

The number of youths with diabetes will increase from 213,000 (95% CI 209,000; 218,000) (type 1 diabetes 185,000, type 2 diabetes 28,000) in 2017 to 239,000 (95% CI 209,000; 282,000) (type 1 diabetes 191,000, type 2 diabetes 48,000) in 2060 if the incidence remains constant as observed in 2017. Corresponding relative increases were 3% (95% CI -9%; 21%) for type 1 diabetes and 69% (95% CI 43%; 109%) for type 2 diabetes. Assuming that increasing trends in incidence observed between 2002 and 2017 continue, the projected number of youths with diabetes will be 526,000 (95% CI 335,000; 893,000) (type 1 diabetes 306,000, type 2 diabetes 220,000). Corresponding relative increases would be 65% (95% CI 12%; 158%) for type 1 diabetes and 673% (95% CI 362%; 1,341%) for type 2 diabetes. In both scenarios, substantial widening of racial and ethnic disparities in type 2 diabetes prevalence are expected, with the highest prevalence among non-Hispanic Black youth.

CONCLUSIONS

The number of youths with diabetes in the U.S. is likely to substantially increase in future decades, which emphasizes the need for prevention to attenuate this trend.

Challenges in the diagnosis of diabetes type in pediatrics

The incidence of diabetes, both type 1 and type 2, is increasing. Health outcomes in pediatric diabetes are currently poor, with trends indicating that they are worsening. Minority racial/ethnic groups are disproportionately affected by suboptimal glucose control and have a higher risk of acute and chronic complications of diabetes. Correct clinical management starts with timely and accurate classification of diabetes, but in children this is becoming increasingly challenging due to high prevalence of obesity and shifting demographic composition. The growing obesity epidemic complicates classification by obesity's effects on diabetes. Since the prevalence and clinical characteristics of diabetes vary among racial/ethnic groups, migration between countries leads to changes in the distribution of diabetes types in a certain geographical area, challenging the clinician's ability to classify diabetes. These challenges must be addressed to correctly classify diabetes and establish an appropriate treatment strategy early in the course of disease for all. This may be the first step in improving diabetes outcomes across racial/ethnic groups. This review will discuss the pitfalls in the current diabetes classification scheme that is leading to increasing overlap between diabetes types and heterogeneity within each type. It will also present proposed alternative classification schemes and approaches to understanding diabetes type that may improve the timely and accurate classification of pediatric diabetes type.

Increasing burden of type 2 diabetes in Navajo youth: The SEARCH for diabetes in youth study

AIM

SEARCH has recently reported that both prevalence and incidence of youth onset type 2 diabetes (YT2D) increased among most US race/ethnic groups in the early 2000s. This study reports on the incidence (2002-2013) and prevalence (2001, 2009) of YT2D in the Navajo Nation among youth age < 20 years from 2001 to 2013.

METHODS

SEARCH sought to identify prevalent YT2D cases in 2001 (N = 75) and 2009 (N = 70) and all incident YT2D cases in three periods: 2002 to 2005 (N = 53), 2006 to 2009 (N = 68), and 2010 2013 (N = 90) in Navajo Nation. Denominators were based on the active Indian Health Service user population for eligible health care facilities. Prevalence (per 100 000) and period-specific incidence rates (per 100 000 person-years) were computed for youth aged 10 to 19 years. Changes in prevalence were tested with a two-sided skew-corrected inverted score test, while changes in incidence were tested with Poisson regression.

RESULTS

YT2D prevalence was high but stable in 2001 and 2009, overall [146.6 (116.8, 184.0) vs 141.5 (112.0, 178.8), P = .65) and in all subgroups. In contrast, incidence rates increased particularly between the second and third periods overall and in most subgroups by age and by sex.

CONCLUSIONS

These data confirm the high burden of YT2D among Navajo youth and suggest an increasing risk in more recent years. However, recent improvements in obesity reduction in this population demonstrate optimism for potential reductions in YT2D in Navajo Nation.

Clinical Implications of Urinary C-Peptide Creatinine Ratio in Patients with Different Types of Diabetes

INTRODUCTION

Urinary C-peptide creatinine ratio (UCPCR) is used as a marker of endogenous insulin secretion. This study aims to assess the effectiveness of UCPCR for distinguishing between type 1 diabetes (T1DM) and non-T1DM (monogenic diabetes and T2DM) and predicting therapeutic choices in type 2 diabetes (T2DM) patients.

METHODS

Twenty-three patients with genetically confirmed monogenic diabetes (median age 35.0 years (interquartile range 30.0-47.0), 13 (56.5%) men), 56 patients with T1DM (median age 46.0 years (interquartile range 26.5-59.5), 28 (50.0%) men), 136 patients with T2DM (median age 53.0 years (interquartile range 42.0-60.0), 87 (64.0%) men), and 59 healthy subjects (median age 36.0 years (30.0-42.0), 26 (44.1%) men) were included. UCPCR was collected in the morning. Receiver operating characteristic (ROC) curves were used to identify optimal UCPCR cut-off values to differentiate T1DM from non-T1DM. This UCPCR cut-off was used to divide T2DM patients into two groups, and the two groups were compared.

RESULTS

The UCPCR was lower in patients with T1DM compared with T2DM, monogenic diabetes, and healthy subjects, while the UCPCR was similar in T2DM and monogenic diabetes. A UCPCR cut-off of ≥0.21 nmol/mmol distinguished between monogenic diabetes and T1DM (area under the curve [AUC], 0.949) with 87% sensitivity and 93% specificity. UCPCR ≥ 0.20 nmol/mmol had 82% sensitivity and 93% specificity for distinguishing between T2DM and T1DM, with an AUC of 0.932. UCPCR was not reliable for distinguishing between monogenic diabetes and T2DM (AUC, 0.605). Twenty-five of 136 (18.4%) T2DM patients had UCPCR ≤ 0.20 nmol/mmol. Compared with T2DM patients with a UCPCR > 0.20 nmol/mmol, T2DM patients with UCPCR ≤ 0.20 nmol/mmol had a lower serum C-peptide (fasting C-peptide, 0.39 nmol/L vs. 0.66 nmol/L, P < 0.001; postprandial C-peptide, 0.93 nmol/L vs. 1.55 nmol/L, P < 0.001), lower BMI (22.8 kg/m² vs. 25.2 kg/m², P = 0.006), and higher percentage of insulin or secretagogue therapy (92.0% vs. 59.5%, P = 0.002).

CONCLUSIONS

UCPCR is a practical and noninvasive marker that can distinguish between TIDM and T2DM or monogenic diabetes. UCPCR ≤ 0.20 nmol/mmol reflects severe impaired beta cell function and the need for insulin or secretagogue therapy in T2DM patients.

Exercise and insulin resistance in youth: a meta-analysis

BACKGROUND AND OBJECTIVES

The prevalence of obesity and diabetes is increasing among children, adolescents, and adults. Although estimates of the efficacy of exercise training on fasting insulin and insulin resistance have been provided, for adults similar estimates have not been provided for youth. This systematic review and meta-analysis provides a quantitative estimate of the effectiveness of exercise training on fasting insulin and insulin resistance in children and adolescents.

METHODS

Potential sources were limited to peer-reviewed articles published before June 25, 2013, and gathered from the PubMed, SPORTDiscus, Physical Education Index, and Web of Science online databases. Analysis was limited to randomized controlled trials by using combinations of the terms adolescent, child, pediatric, youth, exercise training, physical activity, diabetes, insulin, randomized trial, and randomized controlled trial. The authors assessed 546 sources, of which 4.4% (24 studies) were eligible for inclusion. Thirty-two effects were used to estimate the effect of exercise training on fasting insulin, with 15 effects measuring the effect on insulin resistance. Estimated effects were independently calculated by multiple authors, and conflicts were resolved before calculating the overall effect.

RESULTS

Based on the cumulative results from these studies, a small to moderate effect was found for exercise training on fasting insulin and improving insulin resistance in youth (Hedges' d effect size = 0.48 [95% confidence interval: 0.22-0.74], P < .001 and 0.31 [95% confidence interval: 0.06-0.56], P < .05, respectively).

CONCLUSIONS

These results support the use of exercise training in the prevention and treatment of type 2 diabetes.

Comparison of autoantibody-positive and autoantibody-negative pediatric participants enrolled in the T1D Exchange clinic registry

OBJECTIVE

To compare characteristics of autoantibody (aAb)-positive and -negative cases of type 1 diabetes (T1D) <18 years old in the T1D Exchange clinic registry.

METHODS

An aAb-positive status (n = 6239) required at least one of the aAbs to be positive; an aAb-negative status (n = 485) required negative results on testing of at least two different aAbs.

RESULTS

The percentage of males was higher (58% vs. 51%; P = 0.002) and total daily insulin dose lower (P = 0.003) in aAb-negative compared with aAb-positive groups, but both groups had similar distributions of race-ethnicity, diagnosis age, family history of T1D, ketoacidosis at diagnosis, body mass index at diagnosis and at most recent office visit, and current HbA1c.

CONCLUSIONS

Male gender and lower total daily insulin dose were more likely in aAb-negative than aAb-positive children with T1D, but no other distinguishing characteristics were identified. Further examination of characteristics of aAb-negative cases may help characterize the heterogeneous nature of T1D.

Home urine C-peptide creatinine ratio (UCPCR) testing can identify type 2 and MODY in pediatric diabetes

BACKGROUND

Making the correct diabetes diagnosis in children is crucial for lifelong management. Type 2 diabetes and maturity onset diabetes of the young (MODY) are seen in the pediatric setting, and can be difficult to discriminate from type 1 diabetes. Postprandial urinary C-peptide creatinine ratio (UCPCR) is a non-invasive measure of endogenous insulin secretion that has not been tested as a diagnostic tool in children or in patients with diabetes duration <5 yr. We aimed to assess whether UCPCR can discriminate type 1 diabetes from MODY and type 2 in pediatric diabetes.

METHODS

Two-hour postprandial UCPCR was measured in 264 patients aged <21 yr (type 1, n = 160; type 2, n = 41; and MODY, n = 63). Receiver operating characteristic curves were used to identify the optimal UCPCR cutoff for discriminating diabetes subtypes.

RESULTS

UCPCR was lower in type 1 diabetes [0.05 (<0.03-0.39) nmol/mmol median (interquartile range)] than in type 2 diabetes [4.01 (2.84-5.74) nmol/mmol, p < 0.0001] and MODY [3.51 (2.37-5.32) nmol/mmol, p < 0.0001]. UCPCR was similar in type 2 diabetes and MODY (p = 0.25), so patients were combined for subsequent analyses. After 2-yr duration, UCPCR ≥ 0.7 nmol/mmol has 100% sensitivity [95% confidence interval (CI): 92-100] and 97% specificity (95% CI: 91-99) for identifying non-type 1 (MODY + type 2 diabetes) from type 1 diabetes [area under the curve (AUC) 0.997]. UCPCR was poor at discriminating MODY from type 2 diabetes (AUC 0.57).

CONCLUSIONS

UCPCR testing can be used in diabetes duration greater than 2 yr to identify pediatric patients with non-type 1 diabetes. UCPCR testing is a practical non-invasive method for use in the pediatric outpatient setting.

Variation of C peptide decay rate in diabetic patients with positive glutamic acid decarboxylase antibody: better discrimination with initial fasting C peptide

BACKGROUND

Diabetic patients with positive glutamic acid decarboxylase antibody (GAD-Ab) could be classified as autoimmune diabetes, which is discriminated into acute-onset classical type 1 diabetes (T1DM) and latent autoimmune diabetes in adults (LADA). However, whether the decay rate of beta cell function is relevant with the mode of onset (acute or latent-onset) is unclear. We aimed to investigate whether initial C peptide levels could help differentiate variation of C peptide decay rate.

METHODS

Five hundred and twenty-seven newly diagnosed GAD-Ab positive diabetic patients were followed up to assess the natural course of beta cell function. Beta cell function failure was defined as fasting C peptide and postprandial C peptide levels less than 100 pmol/L and 150 pmol/L respectively.

RESULTS

All these diabetic patients were discriminated according to initial fasting C peptide of 300 pmol/L, that is B+ (larger than 300 pmol/L) and B- (less than 300 pmol/L) group. The proportion of developing beta cell function failure was 13.1% in B+ group and 90.5% in B- group, which suggested that fasting C peptide levels made a good distinction of the heterogeneity in autoimmune diabetes. Receiver operator characteristic (ROC) analysis suggested that the fasting C peptide level of 300 pmol/L was optimal for determining beta cell function failure with sensitivity of 90.5% and specificity of 86.9%.

CONCLUSIONS

Initial level of fasting C peptide is a good indicator for predicting beta cell function failure in GAD-Ab positive diabetic patients.

Sitagliptin and Vildagliptin Efficacy on Carbohydrate and Lipid Metabolism in Elderly Patients with Type 2 Diabetes

Background and Aims: For many patients with type 2 diabetes (T2DM) classic oral anti-diabetic treatment is not effective and patients don’t meet the currently recommended therapeutic goals. The aim of our study was to evaluate the efficacy of dipeptydil peptidase 4 (DPP-4) inhibitors as add-on therapy to oral antidiabetics in reducing HbA1c in elderly patients with poorly controlled T2DM. Material and methods: The study included 75 elderly patients with poorly controlled T2DM, treated with known oral antihyperglycemic agents. DPP-4 inhibitors were added to current oral treatment and patients were followed for 12 months, evaluating clinical and biological parameters at baseline and after 3 months, 6 months and 12 months of therapy. Results: After the first 3 months of treatment with DPP-4 inhibitors, fasting glucose (mg/dl) decreased from 148.27 ± 44.68 to 128.94 ± 22.71, and HbA1c (%) from 7.40 ± 1.39 to 6.93 ± 0.78. Values of these two parameters continued to decline until month 12 of follow-up, but to a lesser extent, up to mean fasting glucose (mg/dl) of 127.58 ± 20.91 and HbA1c (%) of 6.72 ± 0.52. Conclusion: Glycemic profile was significantly improved after 12 months of DPP-4 treatment, with a significant decrease of HbA1c.

Insulin resistance in type 2 diabetic youth

PURPOSE OF REVIEW

This review focuses on recent literature on insulin resistance in youth with type 2 diabetes mellitus (T2DM). Insulin resistance is associated with a variety of cardiometabolic problems leading to increased morbidity and mortality across the lifespan.

RECENT FINDINGS

Functional pancreatic β-cell changes play a role in the transition from obesity to impaired glucose tolerance (IGT). Insulin resistance drives islet cell upregulation, manifested by elevated glucagon and c-peptide levels, early in the transition to IGT. Surrogate measurements of insulin resistance and insulin secretion exist but their accuracy compared to clamp data is imperfect. Recent large longitudinal studies provide detailed information on the progression from normoglycemia to T2DM and on the phenotype of T2DM youth. Defining prediabetes and T2DM remains a challenge in youth. Lifestyle interventions do not appear as effective in children as in adults. Metformin remains the only oral hypoglycemic agent approved for T2DM in youth.

SUMMARY

New insights exist regarding the conversion from insulin resistance to T2DM, measurement of insulin resistance and phenotypes of insulin resistance youth, but more information is needed. Surrogate measurements of insulin resistance, additional treatment options for insulin resistance and individualization of treatment options for T2DM adolescents in particular require further investigation.

Type 2 diabetes in childhood: clinical characteristics and role of β-cell autoimmunity

The global obesity epidemic has led to dramatic increases in the incidence and prevalence of type 2 diabetes mellitus (T2DM) among youth worldwide. In today's clinical practice it has become increasingly difficult to distinguish type 1 diabetes mellitus (T1DM) from T2DM as many children with T1DM are overweight at diagnosis. Numerous recent publications note a significant proportion of physician-diagnosed T2DM youth with evidence of pancreatic autoimmunity, exemplifying the challenges in distinguishing between T1DM and T2DM. The clinical implications of the phenomenon of antibody positivity in phenotypic T2DM youth, also referred to as "type 1.5 diabetes" (T1.5 DM), "double diabetes," "latent autoimmune diabetes in youth" (LADY), and "hybrid diabetes," are unclear at present. Current and future work should determine if the presence of autoantibodies in phenotypic T2DM youth/children affects clinical course; this will facilitate the development of optimal treatment strategies.

Glucagon-like peptide-1 analogues for Type 2 diabetes mellitus: current and emerging agents

Novel therapeutic options for type 2 diabetes mellitus based on the action of the incretin hormone glucagon-like peptide (GLP)-1 were introduced in 2005. As injectable GLP-1 receptor agonists acting on the GLP-1 receptor, exenatide and liraglutide are available in many countries. In type 2 diabetes treatment, incretin-based therapies are attractive and more commonly used because of their mechanism of action and safety profile. Stimulation of insulin secretion and inhibition of glucagon secretion by these agents occur in a glucose-dependent manner. Therefore, incretin-based therapies have no intrinsic risk for hypoglycaemia. Furthermore, GLP-1 receptor agonists allow weight loss and lower systolic blood pressure. This review gives a brief overview of the mechanism of action and summarizes the clinical data available on exenatide and liraglutide as established substances. It further highlights the clinical study data of exenatide once weekly as the first long-acting GLP-1 receptor agonist and covers other new long acting GLP-1 receptor agonists currently in clinical development. The placement of GLP-1 receptor agonists in the treatment algorithm of type 2 diabetes is discussed.

GLP-1 agonists and dipeptidyl-peptidase IV inhibitors

Novel therapeutic options for type 2 diabetes based on the action of the incretin hormone glucagon-like peptide-1 (GLP-1) were introduced in 2005. Incretin-based therapies consist of two classes: (1) the injectable GLP-1 receptor agonists solely acting on the GLP-1 receptor and (2) dipeptidyl-peptidase inhibitors (DPP-4 inhibitors) as oral medications raising endogenous GLP-1 and other hormone levels by inhibiting the degrading enzyme DPP-4. In type 2 diabetes therapy, incretin-based therapies are attractive and more commonly used due to their action and safety profile. Stimulation of insulin secretion and inhibition of glucagon secretion by the above-mentioned agents occur in a glucose-dependent manner. Therefore, incretin-based therapies have no intrinsic risk for hypoglycemias. GLP-1 receptor agonists allow weight loss; DPP-4 inhibitors are weight neutral. This review gives an overview on the mechanism of action and the substances and clinical data available.

The impact of sex, gender and pregnancy on 2009 H1N1 disease

Children and young adults of reproductive age have emerged as groups that are highly vulnerable to the current 2009 H1N1 pandemic. The sex of an individual is a fundamental factor that can influence exposure, susceptibility and immune responses to influenza. Worldwide, the incidence, disease burden, morbidity and mortality rates following exposure to the 2009 H1N1 influenza virus differ between males and females and are often age-dependent. Pregnancy and differences in the presentation of various risk factors contribute to the worse outcome of infection in women. Vaccination and antiviral treatment efficacy also vary in a sex-dependent manner. Finally, sex-specific genetic and hormonal differences may contribute to the severity of influenza and the clearance of viral infection. The contribution of sex and gender to influenza can only be determined by a greater consideration of these factors in clinical and epidemiological studies and increased research into the biological basis underlying these differences.

Multidisciplinary management of type 2 diabetes in children and adolescents

Although once considered a disease of adults, the prevalence of type 2 diabetes in youth is increasing at a significant rate. Similar to adults, youth with type 2 diabetes are at increased risk for developing hypertension, lipid abnormalities, renal disease, and other diabetes-related complications. However, children and adolescents with type 2 diabetes also face many unique management challenges that are different from adults with type 2 diabetes or children with type 1 diabetes. To deliver safe, effective, high-quality, cost-effective health care to adolescents with type 2 diabetes, reorganization and redesign of health care systems are needed. Multidisciplinary health care teams, which allow individuals with specialized training to maximally utilize their skills within an organized diabetes treatment team, may increase efficiency and effectiveness and may improve outcomes in children with type 2 diabetes. This review article provides a brief review of type 2 diabetes in children and adolescents, provides an overview of multidisciplinary health care teams, and discusses the role of multidisciplinary health care management in youth with type 2 diabetes.

The evolving place of incretin-based therapies in type 2 diabetes

Treatment options for type 2 diabetes based on the action of the incretin hormone glucagon-like peptide-1 (GLP-1) were first introduced in 2005. These comprise the injectable GLP-1 receptor agonists solely acting on the GLP-1 receptor on the one hand and orally active dipeptidyl-peptidase inhibitors (DPP-4 inhibitors) raising endogenous GLP-1 and other hormone levels by inhibiting the degrading enzyme DPP-4. In adult medicine, both treatment options are attractive and more commonly used because of their action and safety profile. The incretin-based therapies stimulate insulin secretion and inhibit glucagon secretion in a glucose-dependent manner and carry no intrinsic risk of hypoglycaemia. GLP-1 receptor agonists allow weight loss, whereas DPP-4 inhibitors are weight neutral. This review gives an overview of the mechanism of action and the substances and clinical data available.

Insulin detemir: A historical perspective on a modern basal insulin analogue

Insulin detemir provides prolonged, reproducible blood glucose reduction through a mechanism unique among basal insulins. It was originally studied clinically in predominantly basal + bolus regimens and found to be associated with a low risk of hypoglycaemia compared to insulin NPH, and reduced weight gain compared to other basal insulins. Insulin detemir has been increasingly studied in basal-only insulin regimens in type 2 diabetes, in which an understanding of how to optimize its use has been built incrementally. Glycaemic control and limitation of weight gain tend to be maximized by once-daily (evening) dosing, earlier initiation and careful titration to appropriate fasting glucose targets.

Bariatric surgery in young massively obese diabetic patients

Obesity is the most important lifestyle-related risk factor for type 2 diabetes (T2DM). The prevalence of T2DM in adolescents is increasing in parallel with the increasing incidence of major obesity. In adult obese subjects, the greatest degree of T2DM prevention, improvement or recovery has been reported in patients who have undergone bariatric surgery. However, few studies are available on the benefits and risks of bariatric surgery in adolescents with T2DM. The indications for obesity surgery in this population are unusual, and should only be considered in academic settings after comprehensive interdisciplinary evaluation.