In children with type 2 diabetes, treatment is best accomplished through the combined efforts of a multidisciplinary team.11 Ideally, patients should have access to dietitians, nurse educators, psychologists, social workers, and physicians. Type 2 diabetes has a significant impact on the entire family, and support should be offered if needed. Lifestyle modifications should involve all family members so that everyone can benefit from healthy eating habits and exercise.
Table 4 outlines available treatment options. The most appropriate and cost-effective treatment is decreased caloric intake and increased physical activity. In fact, strategies aimed at healthy lifestyle habits for children are the best way to prevent type 2 diabetes. Improved insulin sensitivity can be gained from weight loss, exercise, and maintaining an ideal body weight.12
Some studies have shown that metformin(Drug information on metformin) is an effective treatment for adolescents with type 2 diabetes.13,14 A recent survey found that pediatric endocrinologists in the United States and Canada treat 44% of children who have type 2 diabetes with oral hypoglycemic agents. Among these children, 71% received metformin, 46% sulfonylureas, 9% thiazolidinediones, and 4% meglitinide.15 Unfortunately, many oral hypoglycemic agents used in adults with type 2 diabetes have not been licensed for use in the pediatric population. Until the safety and efficacy of these drugs is established, they cannot be recommended for routine clinical use.
There is a lot of experience with subcutaneous insulin injections in type 1 diabetes. Recently, such injections have been used in the early treatment of type 2 diabetes to decrease glucose toxicity and achieve target blood glucose levels.16 If appropriate lifestyle modification cannot be achieved and blood glucose targets are not maintained, it is reasonable to consider a short course of insulin therapy or metformin.
Follow-up for pediatric patients with type 2 diabetes should involve the family and a multidisciplinary team (Table 5). Children often feel well and do not see the benefits of rigorous blood glucose monitoring or dietary restrictions and exercise. The long-term risks of type 2 diabetes and the benefits of treatment are often not tangible to children. This can lead to frustration and poor compliance with treatment plans. Ongoing education and support is therefore essential in managing type 2 diabetes.
A unique situation faced by pediatric patients with type 2 diabetes is the transition to adult services. Issues that may arise include less frequent follow-up, different expectations of the patient, and compliance problems as the adolescent assumes sole care of his or her diabetes.
Are We Meeting The Challenge?
As the prevalence of childhood obesity increases in North America, we can expect the incidence of insulin resistance and type 2 diabetes to increase as well. Early detection of type 2 diabetes is difficult because children are often asymptomatic. Few medical options are available for pediatric patients with type 2 diabetes; the optimal therapy focuses on diet and exercise.
Management of diabetes involves changes in daily lifestyle that need to be consistent in the long term. However, health care professionals often face many barriers when treating children with diabetes.17 As noted, children may feel well and do not see any immediate benefits from treatment. Families may have socioeconomic constraints or cultural differences that can make it difficult to implement healthy lifestyles. Positive role models need to be in place to encourage children to exercise and eat healthy foods. Widespread societal adjustments must be made, including increased activity in school, changed accessibility to healthy food choices, different infrastructures to favor physical activity, safe outdoor play areas for children, and changes in advertising trends.18
In attempting to stop the development of type 2 diabetes and its complications, physicians need to focus on preventing obesity in all children--not just children in seemingly high-risk populations. The real challenge will be in overcoming barriers to implementing strategies for healthy lifestyles in our communities so that all children will benefit.