Tuesday, February 27, 2024

A look at the changing phase of paediatric diabetes

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The past generation has witnessed a surge in the number of children with diabetes. It is important to know two types of diabetes that are more common in children: type 1 diabetes (T1DM) and type 2 diabetes (T2DM). Although there are other variants, they are less common.
In T1DM, the complete deficiency of insulin is more common at an early age and carries a high genetic cause, whereas in T2DM, there is a relative insulin deficiency encountered in a child’s later years due to a combination of genetic causes and obesity encountered due to poor lifestyle practices. In most cases, T2DM illness begins with excess weight gain, which can pose challenges to insulin and cholesterol metabolism. One can vary from having mild glucose elevations to severe glucose values, which are defined as impaired glucose tolerance, to true diabetes, where there are elevated levels of fasting or post-meal glucose elevations.
In T1DM, the illness is picked up very early since it is more symptomatic, like poor growth, significant weight loss, increased thirst, and passing urine more frequently since it is an autoimmune reaction where the body attacks its own cells. Concerns are with T2DM, especially in children, where alarming symptoms are not seen initially until the condition progresses to a more serious situation. Many times, it is picked up when a child presents to a doctor with some other problem and blood or urine tests show elevated glucose levels. So, it is very necessary to screen high-risk children early in life. In either case, young people who develop diabetes have a higher risk of health challenges throughout their lives.
If we focus on T2DM here, since it is a condition where reversible causes can be worked with, recent studies delineate risk factors for the development of T2DM in children and young adults. Incidence rates of T2DM increase with age, as puberty is associated with a challenge in insulin production. Emerging evidence suggests that lifestyle intervention and ideal medical intervention may reduce the rates of development of type 2 diabetes in subjects at the highest risk, which mainly include obesity, a strong diabetes history in the family, diabetes affecting the mother during pregnancy, ethnicity, like we as Asians have increased risk, low birth weight, and most importantly, dietary factors like excess caloric intake, a low-fibre diet, high trans-fatty acids, and saturated fat, which increase risk, and reduced intake of fibre, polyunsaturated fat, and long-chain n-3 fatty acids, which may have a protective role.
The American Diabetes Association recommends risk-based screening for type 2 diabetes after the onset of puberty or age 10 years in children who are overweight or obese and have one or more additional risk factors as mentioned earlier. In high school, screening is recommended every 3 years, and if tests are normal, recheck more frequently if BMI increases. The definitions of diabetes in children and adolescents are the same as in adults.
Screening for children with risk factors and who do not have symptoms of diabetes requires a single fasting blood test, which tests glucose levels (FBG) and average glucose over 3 months (what we call HbA1c), and if abnormal levels are found, doctors do a 2-hour glucose challenge test to confirm diabetes.
Management of diabetes varies between T1DM and T2DM. For T2DM prevention and treatment of diabetes, a structured management plan is recommended with the provision of extensive education on promoting self-management skills and establishing individualised plans for self-monitoring of glucose. Lifestyle interventions aimed at achieving desired weight loss, which include improving diet standards with special importance given to nutrition and increasing physical activity, are often recommended. The role of medications in children with T2DM options is limited, which includes oral antidiabetic medication and insulin. Other injectable options aimed at weight and glucose control are being tried.
In T1DM, the answer is only insulin, since the body cannot produce it. Management is straightforward when administering insulin. Here, two types of insulin are commonly used by doctors: one type of insulin for meals, which is short-acting only for meals, and another type of insulin as a background cover, which should last round the clock, meaning a long-acting insulin. Room for oral medications usually doesn’t exist unless the child is obese, which is less common with T1DM.
T2DM management can be challenging as there are limited oral medications used in children. If that fails, the only option remaining is to administer insulin. More importance is being placed on lifestyle measures like encouraging physical activity and having a well-balanced diet.

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