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Type 2 diabetes is a serious and costly disease affecting more than 15 million adult Americans. The chronic complications of diabetes include accelerated development of cardiovascular disease, end-stage renal disease, loss of visual acuity, and limb amputations. All of these complications contribute to the excess morbidity and mortality in individuals with diabetes. Moreover, the prevalence of type 2 diabetes in adults is increasing. Superimposed on this disturbing picture in adults are the recent reports of the emerging problem of type 2 diabetes in children and adolescents.
If the incidence and prevalence of type 2 diabetes in children are increasing and if this increase cannot be reversed, our society will face major challenges. That is, the burden of diabetes and its complications will affect many more individuals than currently anticipated, and the cost of diabetes to our society will cause us to consume enormous resources. Also, many more Americans will be taking potent medications, which have attendant risks, for most of their lives.
Despite the wealth of experience and knowledge concerning the epidemiology, pathophysiology, and medical management of type 2 diabetes in adults, we know little about the disease in children. To assess our present knowledge and understanding and to provide guidance to practitioners on medical management, the American Diabetes Association (ADA) convened a consensus development conference on type 2 diabetes in children and adolescents from 30 August 1999 to 1 September 1999.
reverses diabetes type 2 natural (🔥 fruit) | reverses diabetes type 2 breakfasthow to reverses diabetes type 2 for An eight-member panel of experts in diabetes in children, complemented by representatives from the National Institute of Diabetes and Digestive and Kidney Diseases, the Division of Diabetes Translation at the Centers for Disease Control and Prevention, and the American Academy of Pediatrics, developed a consensus position on the following six questions:
What is the classification of diabetes in children and adolescents?
What is the epidemiology of type 2 diabetes in children the 1 last update 25 May 2020 and adolescents?What is the epidemiology of type 2 diabetes in children and adolescents?
What is the pathophysiology of type 2 diabetes in children and adolescents?
Who should be tested for diabetes?
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Can type 2 diabetes in children and adolescents be prevented?
The diagnostic criteria and etiologic classification (Table 1) of diabetes (Table 2) outlined by the ADA''s for 1 last update 25 May 2020 clinical course during the initial 1–3 years after diagnosis. IM, immune-mediated.The diagnostic criteria and etiologic classification (Table 1) of diabetes (Table 2) outlined by the ADA''s clinical course during the initial 1–3 years after diagnosis. IM, immune-mediated.
Specific autoantibodies to insulin, to GAD, or to the tyrosine phosphatases insulin antibody (IA)-2 and IA-2β are found at presentation in 85–98% of individuals with immune-mediated type 1 diabetes. To achieve a high degree of sensitivity, a combination of tests is required, which greatly increases the cost of classification. In the future, these tests may be standardized, more reliable, and less expensive. Immune-mediated type 1 diabetes also has a strong HLA association; however, HLA typing is not a useful diagnostic tool. Endogenous fasting insulin and C-peptide production in type 1 patients is low, with little or no increase after oral or intravenous glucose administration or after ingestion of a mixed meal. Specific laboratory evaluation to classify diabetes in children should only be used by diabetologists with pediatric expertise and only when a definitive classification is clinically required.
Patients with immune-mediated type 1 diabetes more frequently develop autoimmune disorders that may cause thyroid or adrenal disease, vitiligo, or pernicious anemia. Individuals with autoimmune diabetes are also more prone to celiac disease. The presence of other autoimmune disorders or celiac disease may suggest the need for further evaluation of a patient classified as having non-type 1 diabetes. Patients classified as having type 1 diabetes may also need to be reevaluated if their clinical course or family history is more consistent with type 2 diabetes.
The limited amount of information about the epidemiology of type 2 diabetes in children is in large part due to the relatively recent recognition of its emergence in this age-group. Table 3 summarizes the studies and reports that provide estimates of the frequency of type 2 diabetes in children (A. Fagot-Campagna, D. J. Pettitt, M. M. Engelgau, N. R. Burrows, L. S. Geiss, R. Valdez, G. Beckles, J. Saaddine, E. W. Gregg, D. F. Williamson, K. M. Venkat Narayan,J Pediatrics. In press). The Pima Indians in Arizona, known to have a high prevalence of type 2 diabetes, have been extensively studied. An analysis from 1992 to 1996 revealed a prevalence of type 2 diabetes of 22.3 per 1,000 in the 10- to 14-year-old age-group and 50.9 per 1,000 in the 15- to 19-year-old age-group. Affected individuals were identified in the course of clinical care or by having a 2-h blood glucose value ≥200 mg/dl during an oral glucose tolerance test (OGTT) (2-h plasma glucose [2-h PG]).
Estimates of the Magnitude of Type 2 Diabetes in North American Children
The Third National Health and Nutrition Examination Survey (NHANES III) constitutes a representative sample of the American population including 2,867 individuals aged 12–19 years who had blood glucose measurements between 1988 and 1994. Thirteen of those sampled had diabetes: nine based on insulin treatment, two based on treatment with oral agents, and two based on elevated blood glucose levels. These results projected a national prevalence estimate for all types of diabetes of 4.1 per 1,000 in this age-group, which can be compared with a prevalence of 0.3 per 1,000 for cystic fibrosis, one of the most common inherited disorders in U.S. children (6).
Additional information comes from reports of diagnosed cases in different areas of the U.S. For example, in Cincinnati, Ohio, the incidence of type 2 diabetes in 10- to 19-year-old patients increased from 0.7 per 100,000 in 1982 to 7.2 per 100,000 in 1994.
Evidence is accumulating suggesting that type 2 diabetes is increasing in children and adolescents in the U.S. The population-based data derived from the Pima Indians show a statistical increase in prevalence from 1967 to 1996 for those aged 10–14 and 15–19 years. Between 1988 and 1996, the Indian Health Service also documented a 54% increase in prevalence of reported diabetes in 15- to 19-year-old adolescents. Registry data from Allegheny County, Pennsylvania, and Chicago, further suggest an increase in type 2 diabetes. Finally, in other case series, type 2 diabetes constituted an increasing percentage of incident pediatric cases of diagnosed diabetes, with fewer than 4% reported before the 1990s and up to 45% in recent studies.
reverses diabetes type 2 onset (☑ ketoacidosis) | reverses diabetes type 2 experiencehow to reverses diabetes type 2 for The emergence of type 2 diabetes in children is not limited to North America. The annual incidence of type 2 diabetes among junior high school children in Tokyo, detected by urine glucose screening and confirmed by glucose tolerance testing, increased from 7.3 per 100,000 in 1976–1980 to 12.1 per 100,000 in 1981–1985, and to 13.9 per 100,000 in 1991–1995. Data from Libya, Bangladesh, and aboriginal children in Australia and Canada indicate that childhood type 2 diabetes is occurring in these populations as well. One possible explanation for the emergence of type 2 diabetes in children is the increase of obesity and decreasing physical activity in children. Obesity is now reaching epidemic proportions in the U.S. and elsewhere.
Obesity is a very common finding in children with type 2 diabetes (A. Fagot-Campagna, D. J. Pettitt, M. M. Engelgau, N. R. Burrows, L. S. Geiss, R. Valdez, G. Beckles, J. Saaddine, E. W. Gregg, D. F. Williamson, K. M. Venkat Narayan,J Pediatrics. In press). In a young Pima Indian cohort with diabetes, 85% were obese. This association has been consistent in all reports, although the criteria for obesity and its severity have varied. The reported mean BMI ranges from 27 to 38 kg/m2, and in most patients, the BMI was greater than the 85th percentile for age and sex. Although it has been well established in adults and in many populations that a “Westernized” lifestyle is associated with an increased frequency of type 2 diabetes, there are no well-controlled studies that have examined this issue in children. Decreased exercise and increased calorie and fat intake have been implicated as risk factors.
Family history of diabetes is strongly associated with type 2 diabetes in children. The frequency of a history of type 2 diabetes in a first- or second-degree relative has ranged from 74 to 100%. Among Pima Indians below the age of 25 years, diabetes has been reported exclusively in individuals with at least one diabetic parent. In the Pimas, offspring of mothers who had diabetes during pregnancy had a markedly increased prevalence of diabetes compared with offspring of mothers without diabetes and those whose mothers developed diabetes after the child''s standards of medical care (11). Screening for microalbuminuria should also be performed yearly. It is unclear whether foot examinations are important in this age-group; however, these examinations are painless, inexpensive, and provide an opportunity for education about foot care.
Other than testing for and treating elevated blood pressure and lipid abnormalities, studies to detect macrovascular disease are probably not indicated, although there are no data in this age-group.
Careful control of hypertension in children is critical. ACE inhibitors are the agents of choice in children with microalbuminuria; because of the beneficial effects of ACE inhibitors on preventing diabetic nephropathy, many diabetologists consider ACE inhibitors the first line of therapy. The Joint National Committee VI report (16) also recommends α-blockers, calcium antagonists (long-acting), and low-dose diuretics. Although there has long been concern that use of β-blockers may worsen hypoglycemia and mask hypoglycemic symptoms, their benefits may outweigh their risks in selected patients. If normotension (for age and sex) is not achieved, combination therapy may be needed.
Children with type 2 diabetes may be hyperlipidemic. Weight loss, increased activity, and improvement in glycemic control often results in improvement in lipid levels. Changing food choices and their preparation may also be helpful. If these actions fail, medications should be used (17). Dyslipidemia far outweighs all other risk factors for cardiovascular disease in adults with type 2 diabetes, and this may also be true for children with type 2 diabetes. HMG CoA reductase inhibitors (“statins”) are absolutely contraindicated in pregnancy and should not be used in females of childbearing potential unless highly effective for 1 last update 25 May 2020 contraception is in use and the patient has been extensively counseled.Children with type 2 diabetes may be hyperlipidemic. Weight loss, increased activity, and improvement in glycemic control often results in improvement in lipid levels. Changing food choices and their preparation may also be helpful. If these actions fail, medications should be used (17). Dyslipidemia far outweighs all other risk factors for cardiovascular disease in adults with type 2 diabetes, and this may also be true for children with type 2 diabetes. HMG CoA reductase inhibitors (“statins”) are absolutely contraindicated in pregnancy and should not be used in females of childbearing potential unless highly effective contraception is in use and the patient has been extensively counseled.
Attempts to prevent type 2 diabetes in children should follow the same general paradigm as those to prevent type 2 diabetes in adults. Primary prevention efforts can be directed to high-risk individuals or to the overall population of children. Prevention of type 2 diabetes in high-risk children requires the ability to accurately identify those at an increased risk and provide them with the service they need. Prevention of type 2 diabetes should be considered at two stages in its natural history. Intervention can take place at an early stage when blood glucose levels are still normal or at the stage of impaired glucose tolerance (IGT)/impaired fasting glucose (IFG) when glucose levels are elevated but not yet diagnostic of diabetes. To whatever degree hyperinsulinemia and insulin resistance contribute to long-term cardiovascular morbidity and mortality, early lifestyle intervention may have long-term beneficial effects.
Primary care providers have an obligation to encourage lifestyle modifications that might delay or prevent the onset of type 2 diabetes in children at high risk. Lifestyle interventions focusing on weight management and increasing physical activity should be promoted in all children at high risk for the development of type 2 diabetes. For those who have progressed to IGT/IFG, these lifestyle interventions should be more aggressively implemented, along with regular assessment and follow-up.
In the adult population at risk for type 2 diabetes, intervention strategies that have been considered include lifestyle changes in diet and physical activity and pharmacologic interventions. Results of prevention trials using drugs are not likely to become available for several years. Until the results of current trials with oral hypoglycemic agents in children are available, intervention using glucose-lowering drugs for prevention of diabetes in children is not recommended.
In obese adults, weight reduction is known to reduce insulin resistance and circulating insulin levels. This reduction is beneficial in the treatment of the obese type 2 diabetic subject. It is also possible that weight reduction will slow the progression of IGT/IFG to type 2 diabetes. In adults, reduction of calorie and fat intake and increased consumption of fruits and vegetables have been associated with weight loss and a reduced risk of progression to type 2 diabetes. However, sustained weight reduction in adults is unusual. Dietary intervention data in pediatric populations are limited, but nutritional surveys have demonstrated that children eat more fat and fewer servings of fruits and vegetables than is recommended in dietary guidelines.
Nutritional interventions in children should be guided by a health care provider with knowledge and expertise in growth and development in children. The most effective dietary approach has been appropriate reduction of energy intake along with exercise to increase energy expenditure. Specific recommendations need to be individualized, and continued evaluation is crucial for long-term success. Individualized plans need to be based on assessment of food preferences, timing and location of meals and snacks, food preparation, and willingness to change behaviors. Drug therapy to reduce weight (i.e., anti-obesity agents) is not recommended in children until more safety and efficacy data are available. Use of very-low-calorie or high-protein diets as well as other fad diets is also not recommended. Quick-fix weight loss programs are unsafe for children and rarely result in long-term weight control. In addition, they do not promote long-term healthy eating behavior. Weight loss programs with the best results have been those combining exercise and dietary components, along with behavior modification. In the 6-year Da Qing IGT and Diabetes Study (18), 126 Chinese men with IGT who were randomized to a program including both dietary and exercise intervention developed type 2 diabetes 32% less frequently than 133 men in a control group. Although results of other randomized controlled clinical trials of lifestyle interventions to reduce or delay the onset of type 2 diabetes in adults are not yet available, successful programs to promote improved nutrition and increased physical activity are likely to reduce the risk of type 2 diabetes.
Lack of physical activity is strongly associated with the development of obesity, type 2 diabetes, and cardiovascular morbidity and mortality. Despite information on the importance of exercise, only 25% of high school students participate in daily physical education classes, according to a 1995 survey conducted by the Centers for Disease Control and Prevention''highwire-article-citation-variant-list''minipanel-dialog-wrapper''minipanel-dialog-link-link''minipanel-dialog-link-mini''display:none''minipanel-dialog-wrapper''minipanel-dialog-link-link''minipanel-dialog-link-mini''display:none''minipanel-dialog-wrapper''minipanel-dialog-link-link''minipanel-dialog-link-mini''display:none''highwire-list-footer''highwire-list-footer''highwire-list-footer'>Show more AMERICAN ACADEMY OF PEDIATRICS