Type 1 Diabetes—Autoimmune destruction of pancreatic b cells in genetically susceptible individuals causing insulin deficiency
Type II Diabetes
- Insulin resistance leads to hyperinsulinism to compensate, occurs long before diagnosis
- Hyperinsulinism is associated with hypertension, lipid abnormalities, and acanthosis nigricans.
- Concurrent decrease in glucose uptake by muscle tissue, increased liver gluconeogenesis
- Eventually pancreatic beta cells become unable to produce sufficient insulin to maintain normal glucose levels.
- Obesity strongly associated with an increased insulin resistance because adipose tissue release increased amounts of non-esterified fatty acids, glycerol, hormones, pro-inflammatory cytokines and other factors that promote insulin resistance.
- Insulin levels remain normal-high, and there is ‘relative’ insulin deficiency
- Increased circulating glucose causes glycation of RBCs, platelets, and endothelial cells, neuronal injury, and impaired immune function leading to macrovascular and microvascular complications
- Hyperinsulinemia and T2DM often accompanied by hypertension, dyslipidemia (high LDL, cholesterol, low HDL), leading to macrovascular complications
Worldwide rise in childhood type 2 diabetes in parallel with increase in obesity
Global Projections for the Diabetes Epidemic: 2010-2030
- Obesity —most important risk factor for the development of T2DM
- Genetic susceptilbity—1 parent with T2DM confers 40% risk, 2 parents confer 60% risk
- Ethnicity—Native American, African American, Hispanic, Asian-American, Pacific Island
- Gender — females more likely than males to develop childhood T2DM
- Conditions with insulin resistance—PCOS, maternal gestational diabetes, SGA birth weight
- progression of symptoms more indolent than Type 1, increased levels of glucose may be picked up on routine screening of blood sugar levels or with the presence of glucosuria.
- mild polyuria and polydypsia
- weight loss
- blurred vision
- increased fungal infections
- increased periodontal disease
- numbness and tingling of hands and feet
- Uncommonly may present with ketoacidosis (10-15%)
Screening and Diagnosis
- All children screened through school physical from
- Screen children beginning at 10 years of age or at onset of puberty if overweight or obese (BMI ≥85th percentile) with ≥ 1 of the following risk factors:
- Type 2 DM in a 1st or 2nd degree relative
- Native American, non-Hispanic black, Hispanic, Asian American, or Pacific islander
- Signs of insulin resistance or conditions associated with insulin resistance (hypertension, dyslipidemia, acanthosis nigricans, and polycystic ovary syndrome, or small for gestational age birth weight)
- Maternal history of gestational diabetes during the child's gestation
- Diagnosis of diabetes mellitus in a child or adolescent can be done in one of four ways
- Hemoglobin A1C ≥ 6.5% on 2 occasions (POC testing not preferred)
- Fasting plasma glucose ≥126 mg/dL
- Oral glucose tolerance test (OGTT) plasma glucose ≥200 mg/dL (2 hrs after a glucose challenge of 1.75 g/kg or maximum dose of 75 g)
- Symptoms of hyperglycemia and a random venous plasma glucose ≥200 mg/dL
- Pre-diabetes/impaired glucose tolerance if A1C 5.7-6.4 % of fasting plasma glucose 100 mg/dL – 125 mg/dL, OGTT 140-200mg/dl, these patients should undergo repeat testing
- Evaluate serum lipids and cholesterol
- Dyslipidemia (high LDL, cholesterol and low HDL)
- hypertension and dyslipidemia lead to increased atherosclerosis and adulthood macrovascular complications (stroke, CAD, MI, peripheral vascular disease).
- Nonalcoholic fatty liver disease
- elevated ALT (twice normal) in 20% of patients
- steatosis (increased liver fat without inflammation) or nonalcoholic steatohepatitis (NASH, increased liver fat with inflammation) can occur
- NASH may lead to fibrosis, cirrhosis, and ultimate liver failure if not treated
Microvascular complications include retinopathy, nephropathy, and neuropathy, causing adulthood:
- Visual loss
- Renal failure
- Neuropathy (peripheral, central/mononeuropathy, autonomic)
- Cardiovascular disease
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- Nonpharmacologic therapy: weight loss, increase physical activity, improved diet
- Pharamacologic therapy: insulin, metformin, sulfonylurea, thiazolidenediones
- Asymptomatic patients treated only with nonpharmacologic therapy
- Symptomatic patients (polyuria, polydipsia) with mild hyperglycemia w/o ketosis are treated with metformin and nonpharmacologic therapy
- Patients with severe hyperglycemia (plasma glucose ≥200 mg/dL and/or A1C >8.5%) and/or ketosis are treated with insulin and nonpharmacologic therapy
Goals of Therapy
- Improvement of glycemic control through weight reduction and increased activity has been associated with decreased insulin resistance and reversal of complications.
- Glycemic control:
- HbA1C < 7%
- Fasting glucose 90-130 mg/dL
- OGTT < 180mg/dL
- Monitor and control hypertension
- Prehypertension (systolic and/or diastolic between 90th and 95th percentiles) treated with nonpharmacologic therapy
- Hypertension (systolic and/or diastolic BP ≥95th percentile) treated with pharmacologic therapy–ACE inhibitor
- Monitor and treat hyperlipedemias
- goal LDL<100 mg/dL
- non-pharmacologic therapy initially to manage dyslipidemia
- pharmacologic therapy (statins) for older children (>10yrs) and children who fail non-pharmacologic therapy, have extreme dyslipidemia, or cardiovascular risk factors
- Monitor Neuropathy, Retinopathy, Nephropathy
- Yearly Retinal Fundoscopic exam, foot microfilament exam, UA and microalbumin
- Yearly Influenza vaccine
Resources for Families
Click here for family resources from ADA
- Copeland, K.C., et. al. (2013). Management of newly diagnosed type 2 diabetes mellitus (T2DM) in children and adolescents. Pediatrics, 131, 364-382.
- Cowell, K. (2008). Focus on diagnosis: type 2 diabetes mellitus. Peidatrics in Review, 29(8), 289-292.
- Hannon, T.S., et. al. (2005). Childhood obesity and type 2 diabetes mellitus. Pediatrics, 116(2), 473-480.
- Shah, S., et. al. (2009). Screening for type 2 diabetes in obese youth. Pediatrics in Review, 124, 573-579.