AAP offers first clinical guidance for type 2 diabetes

New clinical practice guidelines intend to help physicians better care for the growing number of youths who have a chronic disease that long was thought to be an adult problem — type 2 diabetes.

The guidance, which was issued by the American Academy of Pediatrics and posted online Jan. 28 on the site of its journal, Pediatrics, recommends that doctors integrate lifestyle modifications, such as diet and exercise, with medication for patients ages 10 to 18 who have type 2 diabetes.

The guidelines were composed by a 10-person subcommittee convened by the AAP that included dietitians, epidemiologists, family physicians, pediatricians and pediatric endocrinologists.

This is believed to be the first clinical practice guidance to address management and treatment of the chronic condition in children and adolescents, the AAP said.

“Because we're seeing so much more type 2 diabetes [in youths] compared to a decade ago, it's important that there be guidelines so practitioners and pediatric endocrinologists feel comfortable initiating treatment and monitoring these children appropriately,” said Janet Silverstein, MD, co-chair of the subcommittee that wrote the recommendations.

Up to one in three new diabetes cases diagnosed in people younger than 18 is type 2 diabetes, noted the AAP in its clinical guidelines. Health experts link the growing prevalence of this condition among youths to the rising prevalence of childhood obesity.

Seventeen percent of children and adolescents in the U.S., or 12.5 million people, age 2 to 19 are obese, according to the Centers for Disease Control and Prevention. Since 1980, the prevalence of obesity in this age group has nearly tripled, the CDC says.

“When we see a child with obesity, we need to consider they might have type 2 diabetes,” said Dr. Silverstein, division chief of Pediatric Endocrinology at the University of Florida.

The AAP subcommittee examined 84 English-language studies on treatment of type 2 diabetes in youths and the screening of type 2 diabetes comorbidities. The studies were published between Jan. 1, 1990, and July 1, 2009.

Recommended physical activity

Key among the subcommittee's recommendations is helping patients with the condition modify their lifestyles, Dr. Silverstein said. The guidelines suggest that doctors discuss nutrition with patients when they are diagnosed with type 2 diabetes and during treatment. When possible, physicians should refer patients to a registered dietitian with expertise in the nutritional needs of youths with type 2 diabetes, the AAP said.

The guidelines suggest that physicians encourage young people to limit nonacademic screen time to less than two hours a day and partake in one hour of moderate-to-vigorous exercise each day. Doctors can tell patients that moderate exercise is defined as intense enough so a person can talk but not sing. During vigorous physical activity, one can't talk without pausing to catch his or her breath, the AAP said.

Adherence to physical activity recommendations might be improved if the physician writes the patient an exercise prescription that describes the ideal duration, intensity and frequency, the guidelines said.

Despite the importance of lifestyle modification, that alone “is not successful for long-term management of type 2 diabetes” based on current data, Dr. Silverstein said. “Children do need to be started on a medication.”

One challenge in developing the guidelines was the limited number of studies on medical interventions for children with the chronic condition, the subcommittee said.

The guidelines call for further research on whether the associated comorbidities and complications of diabetes are more aggressive in pediatric populations than among adults. Studies also should examine whether using lifestyle options without medication is a reliable first step in treating children with type 2 diabetes.

The AAP said its clinical guidance is not intended to replace physician's clinical judgement or establish a protocol for the care of all children with type 2 diabetes. The academy also encourages primary care physicians who feel unable to adequately treat a youth with the chronic disease, to refer the patient to a pediatric medical subspecialist.