The American Diabetes Association convened a panel to address classification of diabetes in children, epidemiology and pathophysiology of type 2 diabetes in children, testing and treatment, and prevention. The 17-page report is available on-line through www.diabetes.org.
Recent reports find that more children with newly-diagnosed diabetes have nonimmune-mediated diabetes representing type 2 diabetes. At diagnosis, the children are usually overweight (obese) at diagnosis with little or no weight loss, have no or mild polyuria and polydipsia (excessive thirst), and exhibit glycosuria without ketonuria.
Research suggests that the initial problem is impaired insulin action, followed by beta-cell failure. There is a transition from insulin resistance (with hyperinsulinemia but normal blood sugar) to clinical diabetes (fasting hyperglycemia). For youth who are predisposed to insulin resistance and obese, increased growth hormone during early adolescence which normally increases insulin resistance somewhat during puberty may lead to insufficient insulin secretion and glucose intolerance past puberty.
With limited research to date, testing is recommended at about age 10 (or onset of puberty) and every 2 years after for children with BOTH of the following:
- overweight (weight for height over the 85%ile or weight more than 120% of ideal for height). Note: The amount of visceral fat (as compared to subcutaneous fat) is associated with hyperinsulinemia.
- any two other risk factors: a) family history of type 2 diabetes, b) ethnicity group with high prevalence (American Indian, African-American, Hispanic American, Asian/South Pacific Islanders), c) conditions found with insulin resistance, namely acanthosis nigricans (velvety hyperpigmented patches found in skin folds including the neck), polycystic ovarian syndrome (chronic anovulation and hyperadrogenism not due to disorder of ovaries, adrenals or pituitary gland), high blood pressure or high blood lipids.
At present, the preferred testing is a fasting (8-hour) blood glucose or a 2-hour blood glucose measure during an oral glucose tolerance test. Large group studies are needed to examine the value of these tests and others, e.g., random glucose.
Treatment and prevention strategies include weight, blood pressure and blood lipid reduction through diet and exercise. Oral hypoglycemic agents are indicated for those diagnosed with diabetes type 2. None have yet been approved by the FDA for children, but the first choice is metformin which enhances insulin sensitivity without an effect on beta-cell function.
Primary prevention should take a public health approach - reduce the prevalence of obesity through active lifestyles (daily exercise, sports, limits on sedentary activity) and calorie-balanced diets.
(American Diabetes Association. Diabetes Care 2000;23(3):381-389)
COMMENT: The 17-page report would be a helpful resource for your school health department. As predicted (SHA, Nov 1999), school nurses can be in leadership roles for school-based initiatives in screening, prevention and follow-up. -J.O.
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