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Valerie Wilson outlines the issues resulting from the ongoing rise in the number of children and young people diagnosed with this disorder
Correspondence drvwilson@gmail.com Valerie Wilson is honorary research fellow at the Centre for Nursing and Healthcare Research at the University of Greenwich, and head of research for the Insulin Pump Therapy (INPUT) group Date of submission March 5 2012 Date of acceptance July 17 2012 Peer review This article has been subject to open peer review and has been checked using antiplagiarismsoftware Author guidelines www.nursingchildrenand youngpeople.co.uk

Increasing numbers of children and adolescents are developing type 2 diabetes. Symptoms of this condition include obesity, a sedentary lifestyle, insulin resistance and hypertension. Type 2 diabetes is more common in girls and families with a positive history of the disease. Diagnosis is often delayed and may identify the presence of chronic complications. An oral glucose tolerance test and a two-hour plasma glucose assessment are the best screening and diagnostic investigations. Treatment is based on weight reduction with diet and exercise, glycaemia monitoring and medication if necessary. Keywords Children and adolescents, insulin resistance, obesity, type 2 diabetes mellitus TYPE 2 DIABETES is characterised by insulin resistance (Ehtisham et al 2000, 2004), a problem that is becoming a global youth health issue (Rosenbloom et al 2009). Insulin resistance in the young is occurring for the same reasons as most type 2 diabetes cases in adults: obesity and a sedentary lifestyle. Undiagnosed type 2 diabetes can lead to chronic complications, such as heart disease, due to prolonged increase in blood glucose levels. Despite the fact that more young people are being diagnosed with type 2 diabetes around the world, there is little progress in developing a screening programme or finding the most effective treatment methods for this condition. Although type 1 diabetes remains the most prevalent form of the condition in children and young people, with the growing incidence of obesity, type 2 diabetes is expected to

become the most common form in adolescents in the next ten years (Diabetes UK 2012).

Incidence and prevalence

In the past, the only kind of diabetes seen in childhood was type 1, a condition caused by autoimmune destruction of the insulin-producing cells of the pancreas. Data on the number of children developing type 2 diabetes in Europe are comparatively scarce (Haines et al 2007), but studies and observations from clinicians in the UK suggest that the incidence of type 2 diabetes in children and young adults is growing (Wilmot et al 2010, Diabetes UK 2012, Gregory 2012). This is consistent with similar trends observed in the US, Japan and South America showing that 50 per cent of all new cases of diabetes globally are now type 2 and are associated with childhood obesity and sedentary lifestyles. It follows that, if UK children get fatter and less active, the consequences will be the same. The incidence of new cases of type 2 diabetes in the UK is increasing most rapidly among the youth of minority ethnic groups (Ehtisham et al 2004), a trend that has also been seen in the US (Kaufman 2002). A prevalence of 0.21 new cases of type 2 diabetes per 100,000 children in the UK was estimated in 2004 (Ehtisham et al 2004). In 2007, Haines et al concluded that, over a one-year period, 0.53 new cases per 100,000 17 year olds were diagnosed in the UK and Republic of Ireland. In 2010, the estimate of type 1 diabetes among UK children was 1 per 700 to 1,000, which is equal to a total population of 25,000 under-25s with type 1 diabetes. Therefore, local authorities and primary care trusts could expect a prevalence of 100 to 150 children with type 1 diabetes in their

Pictured opposite: the islet cells of the pancreas, where insulin is usually manufactured

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areas (Diabetes UK 2012). In 2009, of the total 22,000 persons under the age of 17 years in England with diabetes, 97 per cent had type 1, 1.5 per cent had type 2 and 1.5 had another type of diabetes (Royal College of Paediatrics and Child Health 2009). In the UK in 2000, type 2 diabetes was first seen in overweight girls aged nine to 16 years and of Pakistani, Indian or Arab origin; the condition was first reported among white adolescents in 2002 (Ehtisham et al 2004). In 2002, it was estimated that children of South Asian origin were 13 times more likely to develop type 2 diabetes than white children (Drake et al 2002). Due to the relatively recent emergence of type 2 diabetes in children over the past ten years, longitudinal studies showing incidence and prevalence rates in the UK are not common. However, there is little doubt that type 2 is a growing problem, with consequences for all. disease due to increased blood glucose levels (Rosenbloom et al 2009). The associated morbidity and mortality risks of type 2 diabetes and the relation between hyperglycaemia and chronic complications are well documented in adults (Diabetes Control and Complications Trial Study Group 1993, 1995, UK Prospective Diabetes Study Group 1998a, 1998b), but less so for children (Eppens et al 2006). Diabetes is also one of the leading causes of blindness due to the retinal damage caused by hyperglycaemia (Diabetes UK 2005), in children and in adults (Chizu Agwu 2008).

The most recently available study of children and adolescents with type 2 diabetes states that there is no current test specifically designed for early detection of the asymptomatic condition (Chizu Agwu 2008). Urgent attention is required, given the recent increase in incidence and prevalence of the condition in the young. Obesity management is indicated, particularly in those at risk, for example in ethnic minority groups or in cases where there is a family history of type 2 diabetes. This would seem preferable to screening, which can create stress and anxiety and also false-positive results (Eborall et al 2007, Chizu Agwu 2008). In addition to a family history of type 2 diabetes, obesity and evidence of insulin resistance, there are other early indicators that the child or adolescent may go on to develop type 2 diabetes. The skin condition acanthosis nigricans is common among Asian, Hispanic and black populations (Haworth 2006). This does not require treatment, but 90 per cent of cases are associated with insulin resistance (Haines et al 2007). Polycystic ovary syndrome has been observed in girls and young women who go on to develop type 2 diabetes in association with obesity (Haines et al 2007, Chizu Agwu 2008, Gregory 2012). Hypertension and dyslipidaemia a disorder of lipid metabolism are also signs of possible type 2 diabetes in children and adolescents (Gregory 2012). The presence of non-alcoholic fatty liver disease in children may indicate type 2 diabetes or its precursor, insulin resistance (Gregory 2012). If insulin resistance and two of the previously mentioned signs are present, an oral glucose tolerance test and a two-hour plasma glucose assessment are the best diagnostic investigations (Chizu Agwu 2008). The normal range of blood glucose levels in a non-diabetic individual is 4.0-7.0mmol/L. Plasma glucose levels are 1.5-2.0mmol/L lower than whole blood glucose levels (Burtis 2007). A plasma glucose level of

Type 2 diabetes in the young is distinct from the genetic condition monogenic maturity-onset diabetes in the young (MODY). MODY is caused by a dysfunction of the insulin-producing beta cells of the pancreas that does not require treatment with insulin (Ehtisham et al 2004). Type 2 diabetes is largely due to insulin resistance where the body is unable to use insulin correctly in the presence of increased body fat. Saad et al (2005) have shown that insulin resistance is an abnormality that is accompanied by the gradual deterioration of insulin secretion, eventually leading to diabetes. Impaired glucose tolerance has been shown to be highly significant in obese children and adolescents. In a groundbreaking study of 117 obese children and young adults aged 4 to 18 years, almost one third (28.2 per cent) had impaired glucose tolerance at the beginning of the study. Almost two years later, nearly one quarter (24 per cent) of these had gone on to develop type 2 diabetes: predominantly those with higher body mass index scores who had continued to gain weight (Weiss et al 2005). Risks Several studies have reported that type 2 diabetes is more common in young female adults and in those with a family history of the condition (Ehtisham et al 2004, Chizu Agwu 2008). As symptoms, such as thirst and frequent urination, manifest later in type 2 than in type 1 diabetes, the former may take longer to diagnose and in adults may not be recognised for up to 12 years (Diabetes UK 2008). This delay has been shown to be similar among the young (Wabitsch et al 2004). Children and adolescents with impaired glucose tolerance are at risk of developing cardiovascular 16 March 2013 | Volume 25 | Number 2

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7.8-11.1mmol/L indicates impaired glucose tolerance (World Health Organization 1999). For adults and children, the HbA1c (glycosylated haemoglobin) test measures the amount of glucose that sticks to the red blood cells during their average three-month lifespan. This test has been shown to be 97.4 per cent effective in detecting undiagnosed diabetes of either type (Chizu Agwu 2008). However, the HbA1c test on its own may not be sufficient to diagnose type 2 diabetes if there is a normal fasting glucose level (Chizu Agwu 2008). Positive oral glucose tolerance tests and HbA1c measurements taken on two separate occasions are required to confirm the diagnosis. Type 2 diabetes as a differential diagnosis in children and young adults should be considered if two of the following are present: obesity; insulin resistance; hyperlipidaemia; increased blood pressure; acanthosis nigricans; polycystic ovary syndrome; and non-alcoholic fatty liver disease.

With a diagnosis of type 2 diabetes in adults and children, the emphasis is on lifestyle modification, blood glucose monitoring and medication (Rosenbloom et al 2009). The key goals are weight reduction with diet and regular sustained exercise to return glucose metabolism to normal

while managing the condition with glucose-reducing drugs, and are achievable in 90 per cent of cases. Reversal of type 2 diabetes has been demonstrated in several studies with adults (Boden et al 2005, Westman et al 2008, Holford 2011) but not specifically with children and adolescents. Treatment of hypertension and dyslipidaemia notably high levels of triglycerides and low levels of highdensity lipoprotein cholesterol, characteristic of type 2 diabetes, is also important. Although insulin resistance and hyperinsulinaemia (overproduction of insulin to compensate for the reduced effectiveness of that already secreted) are present in type 2 diabetes, small doses of injected insulin have been shown to reduce blood glucose levels to within the normal range (Rosenbloom et al 2009). Gastric surgery for morbid obesity may also be considered for adolescents, and has been shown to be effective in reversing type 2 diabetes following weight loss, but has significant contraindications such as nutritional malabsorption and even death (Rosenbloom et al 2009).

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For related information, visit our online archive of more than 7,000 articles and search using thekeywords Conflict of interest None declared

Adopting a healthy lifestyle is the key to addressing the emerging problem of type 2 diabetes among obese children and young people a condition that may remain asymptomatic for up to 12 years.

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