Fellow’s Corner: Primary Care Pediatricians Critical in Screening for Type 2 Diabetes

“How could my child have type 2 diabetes? Doesn’t that only happen in adults?”

As a pediatric endocrinologist, my unfortunate answer to parents perplexed by their child’s diagnosis is: “No.” Related to rising rates of obesity, the incidence of youth-onset type 2 diabetes (T2D) has been increasing by 5% annually in the United States, with the greatest increase among racial and ethnic minorities. Youth-onset T2D is often more aggressive than adult-onset T2D: Even in adolescence, youth with T2D have high rates of cardiometabolic complications such as dyslipidemia, hypertension, and microalbuminuria, and progression to insulin dependence happens at a faster rate than in adult-onset disease.

Fortunately, youth who present with shorter diabetes duration and lower hemoglobin A1c at diagnosis are more likely to be successfully treated with metformin without the need for insulin, suggesting the benefit of early diagnosis. In 2000, the American Diabetes Association (ADA) and American Academy of Pediatrics released a joint recommendation to screen for T2D in youth who meet risk-based criteria (see Table 2 below) at least every 3 years. Recommended tests include fasting plasma glucose, hemoglobin A1c, or 2-hour oral glucose tolerance test.

Screening may identify either prediabetes or diabetes (see Table 3 below). The prevalence of prediabetes is high, occurring in approximately 30% of obese youth, whereas the prevalence of T2D is approximately 0.5 per 1000 youth. Because no medication or specific therapy is currently available for youth prior to the onset of diabetes, the diagnosis of prediabetes should be used as an opportunity to counsel about the importance of lifestyle modification to address diabetes risk and the need for ongoing close monitoring for development of diabetes.

Management of pediatric T2D includes far fewer options than are available for adults with T2D. The mainstays of therapy are metformin and insulin. Unfortunately, insulin has the negative consequence of weight gain if dietary interventions are not also pursued. In addition, it carries a risk of hypoglycemia and may be associated with poor compliance. In June 2019, the Food and Drug Administration approved the first new medication for youth with T2D since 2000: the glucagon-like peptide agonist liraglutide, which is given as a subcutaneous injection. Liraglutide (in higher doses) is used to promote weight loss in adults, working in part through slowing digestion, as well as to treat T2D through reduction in hepatic glucose production and increase in insulin production. Due to its recent approval, its use in pediatric T2D will likely increase significantly.

Unfortunately, T2D screening rates are low in pediatric practice, with fewer than half of patients who meet ADA criteria being screened. Remembering the screening criteria alone can be challenging, particularly in the setting of a busy primary care visit. In addition, requesting labs, fasting or not, does not mean that a patient will obtain them. However, given the value of early diagnosis of T2D, as well as the opportunity to prevent progression from prediabetes, improving T2D screening in at-risk youth is an especially valuable goal that may have life-long benefits. (Mary Ellen Vajravelu, MD, is a former fellow, now a CHOP attending endocrinologist.)

Table 2. Risk-Based Type 2 Diabetes Screening Criteria

Age ≥10 years (or pubertal if younger), AND overweight or obesity (BMI >85th percentile or BMI Z-score >1.04 based on sex- and age-specific references), plus at least 1 additional risk factor based on the strength of association with diabetes:

• (A) Maternal history of diabetes or gestational diabetes mellitus during the child’s gestation
• (A) Family history of T2D in 1st or 2nd-degree relative
• (A) Higher-risk race/ethnicity: African American, Latino, Native American, Asian American, Pacific Islander
• (B) Signs of or condition associated with insulin resistance (acanthosis nigricans, hypertension, dyslipidemia, polycystic ovary syndrome, or small-for-gestational-age)

Table 3. Criteria for the diagnosis of prediabetes and diabetes

• Fasting plasma glucose
  • Prediabetes: 100-125 mg/dL
  • Diabetes: ≥126 mg/dL
• Hemoglobin A1c
  • Prediabetes: 5.7-6.4%
  • Diabetes: ≥6.5%
• 2-hour plasma glucose on oral glucose tolerance test
  • Prediabetes: 140-199 mg/dL
  • Diabetes: ≥200 mg/dL
• Random plasma glucose, with classic symptoms of hyperglycemia (mg/dL)
  • Prediabetes: N/A
  • Diabetes: ≥200 mg/dL

References and Selected Readings

• Mayer-Davis EJ, Lawrence JM, Dabelea D, et al. Incidence Trends of type 1 and type 2 diabetes among youths, 2002-2012. N Engl J Med. 2017;376(15):1419-1429.
• Copeland KC, Zeitler P, Geffner M, et al. Characteristics of adolescents and youth with recent-onset type 2 diabetes: the TODAY cohort at baseline. J Clin Endocrinol Metab. 2011;96(1):159-167.
• TODAY Study Group. A clinical trial to maintain glycemic control in youth with type 2 diabetes. N Engl J Med. 2012;366(24):2247-2256.
• Bacha F, Cheng P, Gal RL, et al. Initial presentation of type 2 diabetes in adolescents predicts durability of successful treatment with metformin monotherapy: insights from the Pediatric Diabetes Consortium T2D Registry. Horm Res Paediatr. 2018;89(1):47-55.
• American Diabetes Association. Type 2 diabetes in children and adolescents. Diabetes Care. 2000;23(3):381-389.
• Dabelea D, Mayer-Davis EJ, Saydah S, et al. Prevalence of type 1 and type 2 diabetes among children and adolescents from 2001 to 2009. JAMA. 2014;311(17):1778-1786.
• Weiss R, Taksali SE, Tamborlane WV, Burgert TS, Savoye M, Caprio S. Predictors of changes in glucose tolerance status in obese youth. Diabetes Care. 2005;28(4):902-909.
• Love-Osborne KA, Sheeder J, Svircev A, Chan C, Zeitler P, Nadeau KJ. Use of glycosylated hemoglobin increases diabetes screening for at-risk adolescents in primary care settings. Pediatr Diabetes. 2013;14(7):512-518.
• Hannon TS, Dugan TM, Saha CK, McKee SJ, Downs SM, Carroll AE. Effectiveness of computer automation for the diagnosis and management of childhood type 2 diabetes: a randomized clinical trial. JAMA Pediatr. 2017;171(4):327-334.
• American Diabetes Association. 2. Classification and diagnosis of diabetes: Standards of Medical Care in Diabetes-2019. Diabetes Care. 2019;42(Suppl 1):S13-S28.