Youth Onset Type 2 Diabetes

According to the research presented by Dr. Petter Bjornstad from the University of Colorado Anschutz Medical Campus, the risk of microvascular complications increases by the time of young adulthood in patients who have diabetes in youth.

 The onset of type 2 diabetes has increased consistently with the rise of children dealing with obesity in the united states. The incidence of type 2 diabetes has risen by 4.8% each year between 2002 and 2012. Recent studies such as the SEARCH registry study suggests a higher prevalence for developing type 2 diabetes over developing type 1 diabetes. Another study based in Canada showed a higher prevalence for developing hypertension, peripheral artery disease, and diabetic kidney disease in this same population. The lack of longitudinal data has presented a challenge to produce guidelines to help prevent complications that can occur in youth who have type 2 diabetes.

This trial, referred to as the TODAY (Treatment Options for Type 2 Diabetes in Adolescents and Youth) clinical trial, hypothesized that follow-up in these patients would show an accumulation of diabetes-related issues and potential organ damage. Dr. Bjornstad and his colleagues submitted this research to the New England of Journal of Medicine on July 29^th, 2021. The TODAY study refers to the preliminary study that was a clinical trial, while the TODAY2 focus on the follow-up. Six hundred ninety-nine participants were enrolled in the TODAY study from 2004 to 2009. Eligible participants in the study ranged from 10 to 17 years old, had type 2 diabetes, and had a BMI above the 85^th percentile. These patients received either metformin, metformin and rosiglitazone, or metformin and other lifestyle interventions. A total of 319 patients dealt with a lack of glycemic control. In 2011, the authors enrolled 572 participants from the TODAY trial into the TODAY2 study. These participants were observed from March 2014 to January 2020 to see if adverse events would occur. The total time participants were followed was 10.2 years to see complications in hypertension, dyslipidemia, albuminuria, nerve and eye disease. Hypertension was defined as at least 130/80 on three consecutive occasions. Dyslipidemia was defined as 150 mg per deciliter on consecutive values. Albuminuria was defined as a ratio of at least 300 in two or more instances. Nerve disease was evaluated using the Michigan Neuropathy Screening Instrument. Scores were considered abnormal if the score was higher than two or more assessments. Eye disease was defined as scores of at least 20 based on the Early Treatment Diabetic Retinopathy Study. Cox proportional hazard regressions were used to estimate the risk of any microvascular complications occurring.

The results from this study showed that by the time of the final assessment, 270 of 677 participants had no complications, 215 had one complication, 144 had two complications, and 48 had one complication. According to Dr. Bjornstad, the factors most correlated with complications were race, hyperglycemia, high BMI, low insulin sensitivity, hypertension, and dyslipidemia. The rate of cardiovascular events to occur was 3.73 per 1000 persons. The rate of all eye disease events occurring was 12.17 per 1000 persons. The rate of nerve disease events occurring was 2.35 per 1000 persons, and kidney events were 0.44 per 1000 persons.

In conclusion, more studies showed be done to investigate how early changes in youth onset diabetes could lead to better health outcomes in the future. Youth onset diabetes has increased despite the use of currently recommended strategies. Other issues that arise are the adherence to medications and problems that occur due to age and socioeconomic factors. Strengths of this study include using large sample size, all having youth onset type 2 diabetes. Another strength is the amount of time the participants were followed which is up to 15 years, as well as a good sample representing the United States. Limitations of the study include almost a quarter of the original participants not completing the study. Also, having data on adolescents with diabetes but still having vascular complications would have greatly strengthened the study.

Practice Pearls:

• The onset of type 2 diabetes has increased consistently with the rise of children dealing with obesity in the United States.
• The incidence of type 2 diabetes has risen by 4.8% each year between 2002 and 2012.
• The factors most correlated with complications were race, hyperglycemia, high BMI, low insulin sensitivity, hypertension, and dyslipidemia.

References

Bjornstad, Petter. “Long-Term Complications in Youth-Onset Type 2 Diabetes.” New England Journal of Medicine, vol. 385, no. 5, 2021, pp. 416–426., link

Al-Saeed, Abdulghani H., et al. “An inverse relationship between age of type 2 diabetes onset and complication risk and mortality: the impact of youth-onset type 2 diabetes.” Diabetes care 39.5 (2016): 823-829.

TODAY Study Group. “A clinical trial to maintain glycemic control in youth with type 2 diabetes.” New England Journal of Medicine 366.24 (2012): 2247-2256.

Kmeone Kingdom, MPH, PharmD Candidate, South College School of Pharmacy