Youth-Onset Type 2 Diabetes Mellitus: Lessons Learned From the TODAY Study

Abstract

Type 2 diabetes is increasingly diagnosed in obese children and adolescents. Evidence suggests that this disease commonly progresses more rapidly in youth compared to adults, and is associated with high rates of early microalbuminuria, hypertension and dyslipidemia. The Treatment Options for type 2 Diabetes in Adolescents and Youth (TODAY) study was the first multiethnic, multicenter randomized trial in the United States to compare three treatment approaches in new onset type 2 diabetes in obese youth (n=699; ages 10–17): monotherapy with metformin, metformin with roziglitazone, and metformin with an intensive lifestyle intervention. The primary outcome was glycemic control. Diabetes-related complications and cardiovascular risk factors were also examined. Approximately half of the participants were unable to maintain glycemic control using metformin alone. Combination therapy of metformin with rosiglitazone resulted in better durability of glycemic control, and the metformin plus intensive lifestyle was intermediate but not superior to metformin alone. Deterioration in glycemic control was associated with rapid loss of beta cell function, not worsened insulin sensitivity, and could not be explained by differences in adherence or BMI. After 3.9 years, 33.8% of participants had hypertension and 16.6% had microalbuminuria. Only 55.9% of participants had an LDL-cholesterol <100 mg/dl after 3 years and 13.7% had retinopathy. The significance of the findings from this important trial for the management of youth and young adults with youth-onset type 2 diabetes and its complications is discussed. An aggressive multifaceted approach is needed to prevent or forestall premature microvascular and macrovascular complications in youth-onset type 2 diabetes.

Role of a registered dietitian in pediatric type 1 and type 2 diabetes

“…The decline in beta-cell function and onset of diabetes-related complications is accelerated in adolescents with type 2 diabetes compared to adults (2,3,9). MNT can be used to help prevent these processes, thus emphasizing the importance of nutrition-related diabetes education.…”

“…In children with type 2 diabetes, these comorbidities may already be present at diagnosis and should therefore be monitored at the time diabetes diagnosis is confirmed. At the beginning of the TODAY study, 10% of adolescents with type 2 diabetes already had high triglycerides, 80% had low HDL levels, and 13% had elevated microalbuminuria (9). While not related to glycemic control, monitoring for nonalcoholic hepatic steatosis is also crucial in obese youth with type 1 or type 2 diabetes.…”

Service innovation from the edges: enhanced by telemedicine decision support

“…Both problems are dependent on correct interpretation of patient-generated data from self-measurement and laboratory results. The shift in diabetes prevalence and occurrence in younger patients has been challenging for GPs [40,41]. Utilisation of available data produced by patients (blood sugar measurement) for better tailoring of treatment requires both a change in workflow and increased knowledge.…”

Type 2 Diabetes Mellitus in Children and Adolescents: Early Prevention and Non-Drug Therapy

“…While in adults the onset and progress of hyperglycaemia takes years to form, both traits occur faster in youth [89]. The lack of progress may also be related to …”