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Early engagement, intervention ‘crucial’ for children diagnosed with type 2 diabetes

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September 17, 2018

Children newly diagnosed with type 2 diabetes are at high risk for disease-related complications, including a fourfold increase in microalbuminuria over 1 year; however, weight loss and taking medications as prescribed can improve long-term outcomes, according to findings published in Pediatric Diabetes.

Toby Candler

In children, type 2 diabetes has an aggressive clinical course and is associated with an accelerated loss of beta cells and rapid development of diabetes-related complications, Toby Candler, MBBS MRCPCH, a research fellow with the NIHR Biomedical Research Centre at the University of Bristol, United Kingdom, and colleagues wrote in the study background.

“Weight loss and treatment adherence are the key to better outcomes a year from diagnosis for type 2 diabetes, and that can be a positive message for young people,” Candler told Endocrine Today. “However, an observed increased prevalence in microalbuminuria is worrisome, and lack of screening is a concern, as microalbuminuria is associated with poorer metabolic control.”

Candler and colleagues analyzed data from 106 children diagnosed with type 2 diabetes between April 2015 and April 2016, with planned follow-up 1 year after diagnosis, identified through the British Paediatric Surveillance Unit based at the Royal College of Paediatrics and Child Health (mean age, 15 years; 67% girls; 45% white; 33% Asian). Clinicians completed questionnaires at the 1-year follow-up that assessed evidence of comorbidities, including hypertension, renal disease, polycystic ovary syndrome, neuropathy or retinopathy. Clinicians were also asked about concerns regarding the ability of patients to take their prescribed medications and attend all follow-up visits, as well as social care involvement. Researchers used linear regression analysis to investigate the associations between HbA1c (outcome) and potential risk factors (predictors), including age, sex, race, social care involvement, problems taking medications and clinic visit attendance, as well as BMI standard deviation score (SDS) and BMI SDS change over 1 year.

At follow-up, 94 patient cases were available for review. Among those included at follow-up, 74.2% had obesity and 19.8% had overweight; median HbA1c was 7%. Over 1 year, median weight increase was 2.5 kg, whereas 15% of children reduced body weight by at least 5%. Median BMI SDS at follow-up was 2.91 for girls and 2.7 for boys.

The most common treatment at diagnosis was metformin, used as monotherapy for 51.4% of children at diagnosis and in 62.8% of children at 1 year. The number of children prescribed insulin fell from 31.4% at baseline to 22.3% at follow-up.

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Researchers observed the incidence of several comorbidities fell over 1 year, including incidence of hypertension, which fell from 21.1% at baseline to 14% at 1 year, and retinopathy, which fell from 5.7% at baseline to 2.1% at 1 year. Incidence of PCOS remained the same during follow-up at nearly 16%, whereas dyslipidemia fell from 8.6% at baseline to 1.1% at 1 year.

However, incidence of microalbuminuria rose markedly for the cohort, from 4.2% at baseline to 16.4% at 1 year, according to the researchers.

“The rise in cases of microalbuminuria is concerning, with a fourfold increase over 1 year,” the researchers wrote. “Those with microalbuminuria had higher HbA1c levels, suggesting early-onset nephropathy may associate with poorer early diabetes control.”

Researchers found that the strongest predictors of change in HbA1c over 1 year were change in BMI SDS at follow-up, formal social care involvement and concerns regarding clinic attendance and ability to take medications as prescribed. Each 1-U increase in BMI SDS score at follow-up, HbA1c was increased by 34.9%, according to researchers.

Researchers also found that concerns regarding clinic attendance and ability to take medications as prescribed and BMI SDS change at 1 year were associated with HbA1c after adjustment for sex, age, race, child protection concerns, clinic appointments attended and current BMI SDS. Clinician-reported concerns about attendance and treatment were associated with a 32.1% higher HbA1c vs. children whose clinicians did not report such concerns, according to the researchers.

“Young people with [type 2 diabetes] are at significant risk of diabetes-related complications, and therefore, early engagement, treatment and achieving optimal glycemic control are crucial to achieve better long-term clinical outcomes,” the researchers wrote. “The key messages from our study is that adherence to treatment and a reduction in BMI is strongly associated with a lower HbA1c. This can be a reassuring and simple message to young people with [type 2 diabetes]; adhere to treatment and you will see an improvement in your HbA1c and help reduce long-term complications.”

In a previous study published in February in Diabetic Medicine, Candler and colleagues found that the number of cases of type 2 diabetes among children in the United Kingdom rose during the past decade, with evidence of an increasing trend among girls and children of South Asian ethnicity. As Endocrine Today previously reported, the researchers determined the national U.K. incidence of type 2 diabetes in children was 0.72 per 100,000, based on the estimated U.K. population of 13,008,432 in mid-2015. South Asian children (incidence rate, 2.92 per 100,000) and black children (incidence rate, 1.67 per 100,000) had a higher incidence rate of type 2 diabetes vs. white children (incidence rate, 0.44 per 100,000), according to researchers. Researchers also observed a trend toward increased incidence of type 2 diabetes (incidence rate ratio = 1.35; 95% CI, 0.99-1.84); however, the number did not rise to statistical significance.

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“Further research into best treatments in this age group are needed, as the evidence base limited,” Candler said. – by Regina Schaffer

For more information:

Toby Candler, MBBS, MRCPCH, can be reached at the NIHR Bristol BRC Nutrition Theme, Level 3, University Hospitals Bristol Education & Research Centre, Upper Maudlin Street, Bristol, BS2 8AE, UK; email: toby.candler@gmail.com.

Disclosures: The authors report no relevant financial disclosures.

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Author Name
Perspective

We know weight loss and physical activity reduces the risk for complications, lowers HbA1c and, many times, decreases the need for medication or, at the very least, allows for a reduction in dose. We also know that in order for a child to improve his or her health, we need to address the family culture and dynamics as well. There are so many variables when dealing with children. Diabetes is a disease that affects the entire family. By having the family implement positive behavior changes, such as engaging in physical activity, healthy meal planning, etc., the whole family will benefit, not just the child with type 2 diabetes.   

Lucille Hughes, DNP, MSN/Ed, CDE, BC-ADM, FAADE

Director of Diabetes Education and Treasurer,
American Association of Diabetes Educators

 

Disclosure: Hughes reports no relevant financial disclosures.