With over 400 million people living with
the disease and accounting for around 90% of diabetes cases worldwide,
type 2 diabetes is complex and costly. It can cause blindness,
cardiovascular disease, kidney failure, lower limb amputation, and other
long-term consequences that substantially impact quality of life and
years of life lived with disability. Worryingly, the global prevalence
of type 2 diabetes is estimated to have doubled over the past 30 years
and now includes rapidly rising numbers of children and adolescents. The
condition is much more complex in young people, who have a higher
overall risk of life-time complications with much earlier onset. Up
until 2002, type 2 diabetes was not considered a paediatric condition;
today, there are an estimated 3600 children and young adults diagnosed
with the condition each year in the USA. In the UK, nearly 7000 cases
were reported in 2018, as noted by Diabetes UK on Nov 21. Disturbingly, this trend is reflected internationally.
Recognising
the shift in type 2 diabetes prevalence toward increasingly younger
populations, on Nov 13, the American Diabetes Association (ADA)
published new guidelines
for the assessment and management of youth-onset type 2 diabetes. Young
people with type 2 diabetes have a more aggressive form of the
disease—including poorer response to glucose-lowering medication and
greater insulin resistance. However, given evidence that young people
with type 2 diabetes are less likely to become hypoglycaemic when
treated with oral agents alone, the new guidelines recommend more
stringent HbA1c targets than previously, and lower than those generally
recommended for adults. The guidelines prioritise lifestyle management
tailored to the patients and their families, as most children with type 2
diabetes also have obesity. These recommendations take into account the
developmental growth stage of the child. Importantly, mental health and
cultural aspects are also considered, as obesity is often associated
with discrimination and stigma, and cultural norms can affect diet and
lifestyle.
Although the ADA
guidelines will be helpful for practising clinicians, there are still
many knowledge gaps. For example, there is not enough evidence on the
benefits of interventions such as metabolic surgery, intensive physical
activity, and educational support programmes in young patients.
Moreover, the only glucose-lowering drug other than insulin approved for
patients younger than 18 years is metformin. Other therapies, such as
SGLT2 inhibitors and GLP-1 receptor agonists, which are associated with
cardiovascular and renal protection in adults, have not been approved
for children or adolescents. Finally, there is the issue of screening
and early detection of type 2 diabetes in this age group. Approaches to
screen and diagnose adults who are at risk have not been thoroughly
validated in young people. There is an urgent need to include young
patients in future research to develop and inform strategies targeted at
prevention and treatment of type 2 diabetes.
Type
2 diabetes is a progressive disease, meaning that treatment
intensification, with insulin being a last resort, is required over time
in a substantial proportion of patients. For patients with early-onset
disease, this is more likely to be needed earlier in life. Even by
prioritising lifestyle treatments and new-generation drugs, insulin will
maintain a central place in the treatment of many patients with type 2
diabetes. With this fast expanding population of people who will have
diabetes for longer, an increase in the demand for insulin is
inevitable. According to the results of a modelling study published last
week in The Lancet Diabetes & Endocrinology, it is
expected that 20% more insulin will be required to treat the global type
2 diabetes population by 2030. A key concern highlighted by this study
is that availability and affordability of insulin are already inadequate
in low-income and middle-income countries.
The
primary risk factor for development of type 2 diabetes across all ages
is obesity, which is largely preventable starting early in life. Some
countries have already taken steps to tackle obesity by introducing
sugar taxes and reducing exposure of children to unhealthy food
advertisements. Despite these positive approaches, much more needs to be
done as a matter of urgency. Diabetes is a global public health problem
and can only be tackled with a concerted action to develop effective
prevention strategies. Surely children and adolescents cannot be held
responsible for living in obesogenic environments. If the growing
prevalence of obesity and type 2 diabetes in youth is accepted as the
new normal, society will have grossly failed the next generation.
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