Type 2 diabetes in children and young people: extending our reach to prevent disease in those most at risk
Prevention of type 2 diabetes in high-risk groups will avoid catastrophic comorbid consequences. It is essential to use our resources more effectively to identify and help children and young people who are most in danger.
The national paediatric diabetes audit 2015–2016 in England and Wales reported 621 cases of type 2 diabetes in children and young people, up 14% from the previous year. This is an alarming but perhaps not surprising rise in type 2 diabetes in children and young people. In the UK, it is closely linked to rates of childhood obesity, with more than 86% of the children and young people with type 2 diabetes found to be overweight or obese.
Adults newly diagnosed with type 2 diabetes have been found to already have a 50% reduction in beta cells, often leading to insulin treatment within a few years. Microvascular and macrovascular complications are common at the time of diagnosis in adults such as hypertension, retinopathy, nephropathy, and neuropathy. Beta cell depletion and acquisition of comorbidities in children and young people appear accelerated compared with adults, leading to an even more complex management of these patients,,,,,.
Prevention of type 2 diabetes in those groups at risk will avoid catastrophic comorbid consequences. It is essential to use our resources more effectively to identify and help those most in danger.
Health perceptions and behavioural change
In the 2015 Health Survey for England, only 26% of overweight and obese children were aware that they were too heavy. This misconception seemed to be compounded by the children’s parents, as it was also noted that 91% of mothers and 80% of fathers would describe their overweight children as “being about the right weight”. This highlights the need for work around health perceptions. Parents and communities need to know and acknowledge what ‘unhealthy’ looks like. This may require challenging some of the cultural taboos associated with objective criticism of children. Youth type 2 diabetes occurs most often in families where there is a high prevalence of type 2 diabetes among first and second degree relatives,,, suggesting an embedded belief system within families that leads to unhealthy choices.
Clinicians who target those at risk will need to work closely with whole families to tackle these misconceptions to aid understanding of the serious health implications associated with obesity and type 2 diabetes. This is time consuming, especially given that those at risk are more likely to have a low educational status,,. Educating families and communities about health and diabetes may also need to be culturally considerate; there is a much higher prevalence of cases among those of non-white European descent, and education should reflect this. In the future, more resources will be needed to maintain progress in these areas. In particular, development of appropriate educational tools for clinicians and families, and age-appropriate resources for children and young people should be funded.
Lifestyle interventions are well documented to have beneficial effects on the incidence of impaired glucose tolerance in high-risk patients, but without buy-in from families, sustained behavioural change is unlikely to occur,. Reward systems are often needed to incentivise this sort of change. The ‘Healthy Start Scheme’ was re-launched by the government and is a good example of a reward system that supports a behavioural change, allowing low income families to exchange vouchers for fresh fruit, vegetables and milk,. This scheme reaches out to those of low socio-economic status and is a great example of placing resource to target those most at risk.
It is not just individuals who are being targeted to make a behavioural change: schools with the support of OFSTED will be given a new ‘healthy school rating’. Public Health England will help give advice to schools on how to deliver more activity to children with use of breaks, extracurricular activities, active lessons, and others. School-based programmes will only aid if attendance is good among those at risk. Statistics suggest that those of lower socio-economic standing (those on benefits and those who live in more deprived areas) have poorer school attendance and, therefore, may not benefit fully from programmes targeted at schools.
Behavioural change can be slow, which is perhaps why some of the government plans aim to circumvent the need for behavioural change. For example, by changing the balance of ingredients or product size, which has been proven to improve diets,,.
Legislative action and other government plans
The soft drinks levy was passed in the 2017 Finance Bill,. This tax on industrial producers of soft drinks is dependent on sugar content and should make some good progress in reducing rates of obesity. The revenue from the levy is to be invested in programmes to reduce obesity by encouraging physical activity and promoting healthier diets. Some levy revenue is to be spent on expansion of the breakfast club programme in schools. This programme has many benefits, and may work synergistically with other targeted approaches: encouraging academic accomplishment, increasing attendance rates and promoting health.
Local councils who fund government public health initiatives are seeking increased budgets to tackle the problem, especially in areas where there are large numbers of at-risk ethnic minorities. Although in principle these aspirational plans will make the changes needed, there are concerns that the budget will not stretch or last to achieve it all. The government should be encouraged to pledge more money, which will make differences year on year.
The Royal College of Paediatrics and Child Health acknowledges the progress being made, but is petitioning with the support of Diabetes UK for the government to take a firmer stance on junk food advertising that targets children,. This is not something covered in the 2016 Childhood Obesity: Plan for Action, but the government does intend to update the outdated nutrient profile model, which should aid this in the future. It is still a concern, that given the huge incremental rise in cases of type 2 diabetes in children and young people, this will be too little too late.
The myriad of programmes mentioned to avoid, abate, or treat the problem of type 2 diabetes in children and young people may not be able to match how fast the problem is growing.
Not all obese children go on to develop type 2 diabetes and the question of what makes the difference in those who do is likely multifactorial and is still being answered. Despite the dramatic rise in cases of type 2 diabetes in children and young people in the UK, there is still only limited prevalence. This is compounded by the complications of running clinical trials in this cohort; has led to limited research; and, in turn, poses a challenge for those producing best practice guidelines. Diabetes UK recommends that the International Society for Paediatric and Adolescent Diabetes Consensus Guideline is followed,. This provides insight into where to target prevention and gives guidance on diagnosis and treatment of type 2 diabetes in children and young people. NICE has also published guidelines.
In order to correctly identify those at risk and to facilitate preventative action, it is essential that we know and understand the risk factors. The cluster of insulin-resistance induced risk factors, often collectively referred to as a ‘metabolic syndrome,’ is clearly defined in the adult population; a concentrated effort has been made to define in guidelines what this ‘metabolic syndrome’ is in children and young people. No standard definition has been provided; however, the international diabetes federation published their consensus opinion in 2007, drawing on over 46 published definitions at that time,. This definition is supported by the International Society for Paediatric and Adolescent Diabetes.
The guidelines available, although comprehensive in their coverage of the evidence available, do highlight the overall lack of evidence to support our decision-making in the treatment of children and young people with type 2 diabetes. There is a great need for much more collaborative research, and funding must be found to support these efforts.
Thoughts for the future
As we work toward preventing cases of type 2 diabetes in children and young people, we must critically appraise the work being done, and best practice should remain dynamic as new information is gathered.
Screening of patients at risk may be an option in the future; however, the low prevalence of type 2 diabetes in children and adolescents would likely lead to results being undermined by false positives. A study in the USA screening for dysglycaemia in high-risk minority adolescents at peak age of onset identified less than 1% of patients. The associated morbidity and mortality, and the prolonged latent period of the disease where morbidity could be prevented, does however produce a strong argument for a screening programme. Future programmes may have better outcomes by focusing on screening for cohorts of symptoms belonging to the ‘metabolic syndrome’ in target populations.
The question of how far we will go to prevent type 2 diabetes in at-risk patients remains unanswered. Gastric surgery options are already being looked at as a viable option in treatment of type 2 diabetes, including gastric banding and sleeve gastrectomy, and may be considered more in the future for prevention. This treatment is still currently uncommon in young people, and specialist knowledge would need to be gained for established centres to be developed with outcome collection as a prerequisite.
Hannah Beba is senior clinical pharmacist, Diabetes and Endocrinology, County Durham and Darlington NHS Foundation Trust.
Citation: The Salvadore DOI: 10.1211/PJ.2017.20203553
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