Type 2 Diabetes in Adolescents

Disclosures

bull Paid consultant Eli Lilly Inc Pediatric

Type 2 Diabetes Clinical Trials

Outline

bull The burden of diabetes

bull Treatment and Prevention

bull Youth Diabetes Prevention Clinic

bull PowerHouse

bull Recommendations for clinical care

T2D Epidemiology Adults versus KidsADULTS YOUTH (19 years)

Incidence (new casesy) ~1469000 per year ~5100 per year

Prevalence

Overall

10 - 14 years

15 - 19 years

20 - 44 years

45 - 64 years

65 and older

123 per 100 (123)

41 per 100 (41)

162 per 100 (162)

259 per 100 (259)

05 per 1000 (~1 in 370

obese)

023 per 1000 (0023)

068 per 1000 (0068)

Prevalence by Gender

Male

Female

136 per 100 (136)

112 per 100 (112)

035 per 1000 (0035)

058 per 1000 (0058)

T2D Epidemiology Kids versus AdultsADULTS YOUTH (19 years)

Prevalence by Race Ethnicity

American Indian

Black

Hispanic

Asian Pacific Islander

White

159 per 100 (159)

132 per 100 (132)

128 per 100 (128)

90 per 100 (90)

76 per 100 (76)

12 per 1000 (0120)

11 per 1000 (0106)

079 per 1000 (0079)

034 per 1000 (0034)

017 per 1000 (0017)

Adjusted Prevalence Increase(adults 1995-2010 youth 2001-

2009)

822 300

bull Projections based on 23 increase per year --- quadruples the number in next 4

decades

bull We must collaborate broadly to serve youth with T2D

Rates of New Cases of Type 1 amp Type 2 Diabetes in Youth 2008ndash2009

Source SEARCH for Diabetes in Youth

Study

Development of Diabetes

Normal GT IGT

1st phase insulinIFG Β-Cell Failure DM

Genetic predisposition Beta-cell defect

Environmental influence Puberty

Insulin Resistance

0

5

10

15

20

25

Insu

lin

Sen

sit

ivit

y(m

g k

g F

FM

m

in p

er

U

mL

) P lt 0001

0

50

100

150

200

1s

tP

ha

se

In

su

lin

(U

m

L)

P lt 005

Puberty Increases Risk for Type 2 DiabetesLongitudinal Study of Insulin Sensitivity

Pre-pubertal Pubertal

Insulin Sensitivity and -cell

Function in TODAYInsulin Sensitivity (1fasting insulin) Oral Disposition Index

Disease Progression With Treatment Kids versus Adults

-40

-20

0

20

40

60

Metformin

Fail Rate ()

Met + Rosi

Fail Rate ()

Change in IS

()

Change in B-

Cell Function

()

TODAY ADOPT

Comorbidities

TODAY Study

Prevalence

()(Baseline End of

Study)

CDC Estimated

Prevalence () in Adults

Hypertension 116 338 71

Microalbuminuria 63 166

LDL ge 130 mgdl or LLM 45 107 65

Triglycerides ge 150 mgdl or LLM 210 233

hsCRP gt 03 mgdl 412 463

Retinopathy diabetes 49+15 y 137 285

Summary

bull Numbers of youth lt numbers of adults but projected to continue to increase

bull Non-modifiable factors (puberty genetics epigenetics) and modifiable factors (obesity environmental social) contribute to the increase in youth T2D

bull Youth T2D is characterized by significant insulin resistance

bull -cell deficiency is evident early (even in obese NGT) progressively worsens

bull Treatment failure appears to be more rapid in youth versus adults

bull Microvascular complications and risk markers for macrovascular complications are present early and rapidly progress

Case History

bull Mother had gestational diabetes

bull Maternal grandparents have T2D and CVD

bull Patient with high BP for age and height

bull ldquoHigh insulin levelrdquo

bull HbA1C 65

Risk Factors for T2DM

bull Obese

bull Family History of T2DM

bull Minority Race Ethnic Background

ndash Native Americans African-Americans Hispanic

Americans AsiansSouth Pacific Islanders

bull Signs of Insulin Resistance

ndash puberty acanthosis nigricans high blood pressure

dyslipidemia PCOS

bull Exposure to Hyperglycemia In Utero

Diabetes Care 2000 23381-389

Evaluation and TreatmentCan we help to prevent diabetes progression

bull Does she have pre-diabetes

bull Does she have diabetes

What to DO

bull DONrsquoT delay the diagnosis

bull Diagnosis is often delayed until

complications present

bull Treatment prevents delays complications

The Treatment of Diabetes in

Adolescents and Youth Trial

ldquoTODAYrdquo Study Cohort

bull 65 female 80 racialethnic minority

bull Mean age 140 y

bull 60 with 1st degree relative with T2DM

bull 90 with 1st or 2nd degree relative with T2DM

bull 30 had gestation complicated by diabetes

For Your Patienthellip

What to DObull Diabetes ndash start treatment

ndash Metformin

ndash Diabetes education

bull SMBG pediatric diabetes education

ndash Lifestyle modification

ndash Medical Nutrition Therapy

ndash Prevent pregnancy

bull Insulin is often needed

ndash A1c ge9

ndash Presentation in DKA

PREVENTION

bull T2DM can be delayed prevented in adults

ndash Da Qing IGT and Diabetes Study

ndash Finnish Diabetes Prevention Study

ndash US Diabetes Prevention Program

Incidence of Diabetes in the US DPP

Knowler et al NEJM 2002346(6)393

31 (17-43)

58 (48-66)

N=3234

Disclosures

bull Paid consultant Eli Lilly Inc Pediatric

Type 2 Diabetes Clinical Trials

Outline

bull The burden of diabetes

bull Treatment and Prevention

bull Youth Diabetes Prevention Clinic

bull PowerHouse

bull Recommendations for clinical care

T2D Epidemiology Adults versus KidsADULTS YOUTH (19 years)

Incidence (new casesy) ~1469000 per year ~5100 per year

Prevalence

Overall

10 - 14 years

15 - 19 years

20 - 44 years

45 - 64 years

65 and older

123 per 100 (123)

41 per 100 (41)

162 per 100 (162)

259 per 100 (259)

05 per 1000 (~1 in 370

obese)

023 per 1000 (0023)

068 per 1000 (0068)

Prevalence by Gender

Male

Female

136 per 100 (136)

112 per 100 (112)

035 per 1000 (0035)

058 per 1000 (0058)

T2D Epidemiology Kids versus AdultsADULTS YOUTH (19 years)

Prevalence by Race Ethnicity

American Indian

Black

Hispanic

Asian Pacific Islander

White

159 per 100 (159)

132 per 100 (132)

128 per 100 (128)

90 per 100 (90)

76 per 100 (76)

12 per 1000 (0120)

11 per 1000 (0106)

079 per 1000 (0079)

034 per 1000 (0034)

017 per 1000 (0017)

Adjusted Prevalence Increase(adults 1995-2010 youth 2001-

2009)

822 300

bull Projections based on 23 increase per year --- quadruples the number in next 4

decades

bull We must collaborate broadly to serve youth with T2D

Rates of New Cases of Type 1 amp Type 2 Diabetes in Youth 2008ndash2009

Source SEARCH for Diabetes in Youth

Study

Development of Diabetes

Normal GT IGT

1st phase insulinIFG Β-Cell Failure DM

Genetic predisposition Beta-cell defect

Environmental influence Puberty

Insulin Resistance

0

5

10

15

20

25

Insu

lin

Sen

sit

ivit

y(m

g k

g F

FM

m

in p

er

U

mL

) P lt 0001

0

50

100

150

200

1s

tP

ha

se

In

su

lin

(U

m

L)

P lt 005

Puberty Increases Risk for Type 2 DiabetesLongitudinal Study of Insulin Sensitivity

Pre-pubertal Pubertal

Insulin Sensitivity and -cell

Function in TODAYInsulin Sensitivity (1fasting insulin) Oral Disposition Index

Disease Progression With Treatment Kids versus Adults

-40

-20

0

20

40

60

Metformin

Fail Rate ()

Met + Rosi

Fail Rate ()

Change in IS

()

Change in B-

Cell Function

()

TODAY ADOPT

Comorbidities

TODAY Study

Prevalence

()(Baseline End of

Study)

CDC Estimated

Prevalence () in Adults

Hypertension 116 338 71

Microalbuminuria 63 166

LDL ge 130 mgdl or LLM 45 107 65

Triglycerides ge 150 mgdl or LLM 210 233

hsCRP gt 03 mgdl 412 463

Retinopathy diabetes 49+15 y 137 285

Summary

bull Numbers of youth lt numbers of adults but projected to continue to increase

bull Non-modifiable factors (puberty genetics epigenetics) and modifiable factors (obesity environmental social) contribute to the increase in youth T2D

bull Youth T2D is characterized by significant insulin resistance

bull -cell deficiency is evident early (even in obese NGT) progressively worsens

bull Treatment failure appears to be more rapid in youth versus adults

bull Microvascular complications and risk markers for macrovascular complications are present early and rapidly progress

Case History

bull Mother had gestational diabetes

bull Maternal grandparents have T2D and CVD

bull Patient with high BP for age and height

bull ldquoHigh insulin levelrdquo

bull HbA1C 65

Risk Factors for T2DM

bull Obese

bull Family History of T2DM

bull Minority Race Ethnic Background

ndash Native Americans African-Americans Hispanic

Americans AsiansSouth Pacific Islanders

bull Signs of Insulin Resistance

ndash puberty acanthosis nigricans high blood pressure

dyslipidemia PCOS

bull Exposure to Hyperglycemia In Utero

Diabetes Care 2000 23381-389

Evaluation and TreatmentCan we help to prevent diabetes progression

bull Does she have pre-diabetes

bull Does she have diabetes

What to DO

bull DONrsquoT delay the diagnosis

bull Diagnosis is often delayed until

complications present

bull Treatment prevents delays complications

The Treatment of Diabetes in

Adolescents and Youth Trial

ldquoTODAYrdquo Study Cohort

bull 65 female 80 racialethnic minority

bull Mean age 140 y

bull 60 with 1st degree relative with T2DM

bull 90 with 1st or 2nd degree relative with T2DM

bull 30 had gestation complicated by diabetes

For Your Patienthellip

What to DObull Diabetes ndash start treatment

ndash Metformin

ndash Diabetes education

bull SMBG pediatric diabetes education

ndash Lifestyle modification

ndash Medical Nutrition Therapy

ndash Prevent pregnancy

bull Insulin is often needed

ndash A1c ge9

ndash Presentation in DKA

PREVENTION

bull T2DM can be delayed prevented in adults

ndash Da Qing IGT and Diabetes Study

ndash Finnish Diabetes Prevention Study

ndash US Diabetes Prevention Program

Incidence of Diabetes in the US DPP

Knowler et al NEJM 2002346(6)393

31 (17-43)

58 (48-66)

N=3234

Outline

bull The burden of diabetes

bull Treatment and Prevention

bull Youth Diabetes Prevention Clinic

bull PowerHouse

bull Recommendations for clinical care

T2D Epidemiology Adults versus KidsADULTS YOUTH (19 years)

Incidence (new casesy) ~1469000 per year ~5100 per year

Prevalence

Overall

10 - 14 years

15 - 19 years

20 - 44 years

45 - 64 years

65 and older

123 per 100 (123)

41 per 100 (41)

162 per 100 (162)

259 per 100 (259)

05 per 1000 (~1 in 370

obese)

023 per 1000 (0023)

068 per 1000 (0068)

Prevalence by Gender

Male

Female

136 per 100 (136)

112 per 100 (112)

035 per 1000 (0035)

058 per 1000 (0058)

T2D Epidemiology Kids versus AdultsADULTS YOUTH (19 years)

Prevalence by Race Ethnicity

American Indian

Black

Hispanic

Asian Pacific Islander

White

159 per 100 (159)

132 per 100 (132)

128 per 100 (128)

90 per 100 (90)

76 per 100 (76)

12 per 1000 (0120)

11 per 1000 (0106)

079 per 1000 (0079)

034 per 1000 (0034)

017 per 1000 (0017)

Adjusted Prevalence Increase(adults 1995-2010 youth 2001-

2009)

822 300

bull Projections based on 23 increase per year --- quadruples the number in next 4

decades

bull We must collaborate broadly to serve youth with T2D

Rates of New Cases of Type 1 amp Type 2 Diabetes in Youth 2008ndash2009

Source SEARCH for Diabetes in Youth

Study

Development of Diabetes

Normal GT IGT

1st phase insulinIFG Β-Cell Failure DM

Genetic predisposition Beta-cell defect

Environmental influence Puberty

Insulin Resistance

0

5

10

15

20

25

Insu

lin

Sen

sit

ivit

y(m

g k

g F

FM

m

in p

er

U

mL

) P lt 0001

0

50

100

150

200

1s

tP

ha

se

In

su

lin

(U

m

L)

P lt 005

Puberty Increases Risk for Type 2 DiabetesLongitudinal Study of Insulin Sensitivity

Pre-pubertal Pubertal

Insulin Sensitivity and -cell

Function in TODAYInsulin Sensitivity (1fasting insulin) Oral Disposition Index

Disease Progression With Treatment Kids versus Adults

-40

-20

0

20

40

60

Metformin

Fail Rate ()

Met + Rosi

Fail Rate ()

Change in IS

()

Change in B-

Cell Function

()

TODAY ADOPT

Comorbidities

TODAY Study

Prevalence

()(Baseline End of

Study)

CDC Estimated

Prevalence () in Adults

Hypertension 116 338 71

Microalbuminuria 63 166

LDL ge 130 mgdl or LLM 45 107 65

Triglycerides ge 150 mgdl or LLM 210 233

hsCRP gt 03 mgdl 412 463

Retinopathy diabetes 49+15 y 137 285

Summary

bull Numbers of youth lt numbers of adults but projected to continue to increase

bull Non-modifiable factors (puberty genetics epigenetics) and modifiable factors (obesity environmental social) contribute to the increase in youth T2D

bull Youth T2D is characterized by significant insulin resistance

bull -cell deficiency is evident early (even in obese NGT) progressively worsens

bull Treatment failure appears to be more rapid in youth versus adults

bull Microvascular complications and risk markers for macrovascular complications are present early and rapidly progress

Case History

bull Mother had gestational diabetes

bull Maternal grandparents have T2D and CVD

bull Patient with high BP for age and height

bull ldquoHigh insulin levelrdquo

bull HbA1C 65

Risk Factors for T2DM

bull Obese

bull Family History of T2DM

bull Minority Race Ethnic Background

ndash Native Americans African-Americans Hispanic

Americans AsiansSouth Pacific Islanders

bull Signs of Insulin Resistance

ndash puberty acanthosis nigricans high blood pressure

dyslipidemia PCOS

bull Exposure to Hyperglycemia In Utero

Diabetes Care 2000 23381-389

Evaluation and TreatmentCan we help to prevent diabetes progression

bull Does she have pre-diabetes

bull Does she have diabetes

What to DO

bull DONrsquoT delay the diagnosis

bull Diagnosis is often delayed until

complications present

bull Treatment prevents delays complications

The Treatment of Diabetes in

Adolescents and Youth Trial

ldquoTODAYrdquo Study Cohort

bull 65 female 80 racialethnic minority

bull Mean age 140 y

bull 60 with 1st degree relative with T2DM

bull 90 with 1st or 2nd degree relative with T2DM

bull 30 had gestation complicated by diabetes

For Your Patienthellip

What to DObull Diabetes ndash start treatment

ndash Metformin

ndash Diabetes education

bull SMBG pediatric diabetes education

ndash Lifestyle modification

ndash Medical Nutrition Therapy

ndash Prevent pregnancy

bull Insulin is often needed

ndash A1c ge9

ndash Presentation in DKA

PREVENTION

bull T2DM can be delayed prevented in adults

ndash Da Qing IGT and Diabetes Study

ndash Finnish Diabetes Prevention Study

ndash US Diabetes Prevention Program

Incidence of Diabetes in the US DPP

Knowler et al NEJM 2002346(6)393

31 (17-43)

58 (48-66)

N=3234

T2D Epidemiology Adults versus KidsADULTS YOUTH (19 years)

Incidence (new casesy) ~1469000 per year ~5100 per year

Prevalence

Overall

10 - 14 years

15 - 19 years

20 - 44 years

45 - 64 years

65 and older

123 per 100 (123)

41 per 100 (41)

162 per 100 (162)

259 per 100 (259)

05 per 1000 (~1 in 370

obese)

023 per 1000 (0023)

068 per 1000 (0068)

Prevalence by Gender

Male

Female

136 per 100 (136)

112 per 100 (112)

035 per 1000 (0035)

058 per 1000 (0058)

T2D Epidemiology Kids versus AdultsADULTS YOUTH (19 years)

Prevalence by Race Ethnicity

American Indian

Black

Hispanic

Asian Pacific Islander

White

159 per 100 (159)

132 per 100 (132)

128 per 100 (128)

90 per 100 (90)

76 per 100 (76)

12 per 1000 (0120)

11 per 1000 (0106)

079 per 1000 (0079)

034 per 1000 (0034)

017 per 1000 (0017)

Adjusted Prevalence Increase(adults 1995-2010 youth 2001-

2009)

822 300

bull Projections based on 23 increase per year --- quadruples the number in next 4

decades

bull We must collaborate broadly to serve youth with T2D

Rates of New Cases of Type 1 amp Type 2 Diabetes in Youth 2008ndash2009

Source SEARCH for Diabetes in Youth

Study

Development of Diabetes

Normal GT IGT

1st phase insulinIFG Β-Cell Failure DM

Genetic predisposition Beta-cell defect

Environmental influence Puberty

Insulin Resistance

0

5

10

15

20

25

Insu

lin

Sen

sit

ivit

y(m

g k

g F

FM

m

in p

er

U

mL

) P lt 0001

0

50

100

150

200

1s

tP

ha

se

In

su

lin

(U

m

L)

P lt 005

Puberty Increases Risk for Type 2 DiabetesLongitudinal Study of Insulin Sensitivity

Pre-pubertal Pubertal

Insulin Sensitivity and -cell

Function in TODAYInsulin Sensitivity (1fasting insulin) Oral Disposition Index

Disease Progression With Treatment Kids versus Adults

-40

-20

0

20

40

60

Metformin

Fail Rate ()

Met + Rosi

Fail Rate ()

Change in IS

()

Change in B-

Cell Function

()

TODAY ADOPT

Comorbidities

TODAY Study

Prevalence

()(Baseline End of

Study)

CDC Estimated

Prevalence () in Adults

Hypertension 116 338 71

Microalbuminuria 63 166

LDL ge 130 mgdl or LLM 45 107 65

Triglycerides ge 150 mgdl or LLM 210 233

hsCRP gt 03 mgdl 412 463

Retinopathy diabetes 49+15 y 137 285

Summary

bull Numbers of youth lt numbers of adults but projected to continue to increase

bull Non-modifiable factors (puberty genetics epigenetics) and modifiable factors (obesity environmental social) contribute to the increase in youth T2D

bull Youth T2D is characterized by significant insulin resistance

bull -cell deficiency is evident early (even in obese NGT) progressively worsens

bull Treatment failure appears to be more rapid in youth versus adults

bull Microvascular complications and risk markers for macrovascular complications are present early and rapidly progress

Case History

bull Mother had gestational diabetes

bull Maternal grandparents have T2D and CVD

bull Patient with high BP for age and height

bull ldquoHigh insulin levelrdquo

bull HbA1C 65

Risk Factors for T2DM

bull Obese

bull Family History of T2DM

bull Minority Race Ethnic Background

ndash Native Americans African-Americans Hispanic

Americans AsiansSouth Pacific Islanders

bull Signs of Insulin Resistance

ndash puberty acanthosis nigricans high blood pressure

dyslipidemia PCOS

bull Exposure to Hyperglycemia In Utero

Diabetes Care 2000 23381-389

Evaluation and TreatmentCan we help to prevent diabetes progression

bull Does she have pre-diabetes

bull Does she have diabetes

What to DO

bull DONrsquoT delay the diagnosis

bull Diagnosis is often delayed until

complications present

bull Treatment prevents delays complications

The Treatment of Diabetes in

Adolescents and Youth Trial

ldquoTODAYrdquo Study Cohort

bull 65 female 80 racialethnic minority

bull Mean age 140 y

bull 60 with 1st degree relative with T2DM

bull 90 with 1st or 2nd degree relative with T2DM

bull 30 had gestation complicated by diabetes

For Your Patienthellip

What to DObull Diabetes ndash start treatment

ndash Metformin

ndash Diabetes education

bull SMBG pediatric diabetes education

ndash Lifestyle modification

ndash Medical Nutrition Therapy

ndash Prevent pregnancy

bull Insulin is often needed

ndash A1c ge9

ndash Presentation in DKA

PREVENTION

bull T2DM can be delayed prevented in adults

ndash Da Qing IGT and Diabetes Study

ndash Finnish Diabetes Prevention Study

ndash US Diabetes Prevention Program

Incidence of Diabetes in the US DPP

Knowler et al NEJM 2002346(6)393

31 (17-43)

58 (48-66)

N=3234

T2D Epidemiology Kids versus AdultsADULTS YOUTH (19 years)

Prevalence by Race Ethnicity

American Indian

Black

Hispanic

Asian Pacific Islander

White

159 per 100 (159)

132 per 100 (132)

128 per 100 (128)

90 per 100 (90)

76 per 100 (76)

12 per 1000 (0120)

11 per 1000 (0106)

079 per 1000 (0079)

034 per 1000 (0034)

017 per 1000 (0017)

Adjusted Prevalence Increase(adults 1995-2010 youth 2001-

2009)

822 300

bull Projections based on 23 increase per year --- quadruples the number in next 4

decades

bull We must collaborate broadly to serve youth with T2D

Rates of New Cases of Type 1 amp Type 2 Diabetes in Youth 2008ndash2009

Source SEARCH for Diabetes in Youth

Study

Development of Diabetes

Normal GT IGT

1st phase insulinIFG Β-Cell Failure DM

Genetic predisposition Beta-cell defect

Environmental influence Puberty

Insulin Resistance

0

5

10

15

20

25

Insu

lin

Sen

sit

ivit

y(m

g k

g F

FM

m

in p

er

U

mL

) P lt 0001

0

50

100

150

200

1s

tP

ha

se

In

su

lin

(U

m

L)

P lt 005

Puberty Increases Risk for Type 2 DiabetesLongitudinal Study of Insulin Sensitivity

Pre-pubertal Pubertal

Insulin Sensitivity and -cell

Function in TODAYInsulin Sensitivity (1fasting insulin) Oral Disposition Index

Disease Progression With Treatment Kids versus Adults

-40

-20

0

20

40

60

Metformin

Fail Rate ()

Met + Rosi

Fail Rate ()

Change in IS

()

Change in B-

Cell Function

()

TODAY ADOPT

Comorbidities

TODAY Study

Prevalence

()(Baseline End of

Study)

CDC Estimated

Prevalence () in Adults

Hypertension 116 338 71

Microalbuminuria 63 166

LDL ge 130 mgdl or LLM 45 107 65

Triglycerides ge 150 mgdl or LLM 210 233

hsCRP gt 03 mgdl 412 463

Retinopathy diabetes 49+15 y 137 285

Summary

bull Numbers of youth lt numbers of adults but projected to continue to increase

bull Non-modifiable factors (puberty genetics epigenetics) and modifiable factors (obesity environmental social) contribute to the increase in youth T2D

bull Youth T2D is characterized by significant insulin resistance

bull -cell deficiency is evident early (even in obese NGT) progressively worsens

bull Treatment failure appears to be more rapid in youth versus adults

bull Microvascular complications and risk markers for macrovascular complications are present early and rapidly progress

Case History

bull Mother had gestational diabetes

bull Maternal grandparents have T2D and CVD

bull Patient with high BP for age and height

bull ldquoHigh insulin levelrdquo

bull HbA1C 65

Risk Factors for T2DM

bull Obese

bull Family History of T2DM

bull Minority Race Ethnic Background

ndash Native Americans African-Americans Hispanic

Americans AsiansSouth Pacific Islanders

bull Signs of Insulin Resistance

ndash puberty acanthosis nigricans high blood pressure

dyslipidemia PCOS

bull Exposure to Hyperglycemia In Utero

Diabetes Care 2000 23381-389

Evaluation and TreatmentCan we help to prevent diabetes progression

bull Does she have pre-diabetes

bull Does she have diabetes

What to DO

bull DONrsquoT delay the diagnosis

bull Diagnosis is often delayed until

complications present

bull Treatment prevents delays complications

The Treatment of Diabetes in

Adolescents and Youth Trial

ldquoTODAYrdquo Study Cohort

bull 65 female 80 racialethnic minority

bull Mean age 140 y

bull 60 with 1st degree relative with T2DM

bull 90 with 1st or 2nd degree relative with T2DM

bull 30 had gestation complicated by diabetes

For Your Patienthellip

What to DObull Diabetes ndash start treatment

ndash Metformin

ndash Diabetes education

bull SMBG pediatric diabetes education

ndash Lifestyle modification

ndash Medical Nutrition Therapy

ndash Prevent pregnancy

bull Insulin is often needed

ndash A1c ge9

ndash Presentation in DKA

PREVENTION

bull T2DM can be delayed prevented in adults

ndash Da Qing IGT and Diabetes Study

ndash Finnish Diabetes Prevention Study

ndash US Diabetes Prevention Program

Incidence of Diabetes in the US DPP

Knowler et al NEJM 2002346(6)393

31 (17-43)

58 (48-66)

N=3234

Rates of New Cases of Type 1 amp Type 2 Diabetes in Youth 2008ndash2009

Source SEARCH for Diabetes in Youth

Study

Development of Diabetes

Normal GT IGT

1st phase insulinIFG Β-Cell Failure DM

Genetic predisposition Beta-cell defect

Environmental influence Puberty

Insulin Resistance

0

5

10

15

20

25

Insu

lin

Sen

sit

ivit

y(m

g k

g F

FM

m

in p

er

U

mL

) P lt 0001

0

50

100

150

200

1s

tP

ha

se

In

su

lin

(U

m

L)

P lt 005

Puberty Increases Risk for Type 2 DiabetesLongitudinal Study of Insulin Sensitivity

Pre-pubertal Pubertal

Insulin Sensitivity and -cell

Function in TODAYInsulin Sensitivity (1fasting insulin) Oral Disposition Index

Disease Progression With Treatment Kids versus Adults

-40

-20

0

20

40

60

Metformin

Fail Rate ()

Met + Rosi

Fail Rate ()

Change in IS

()

Change in B-

Cell Function

()

TODAY ADOPT

Comorbidities

TODAY Study

Prevalence

()(Baseline End of

Study)

CDC Estimated

Prevalence () in Adults

Hypertension 116 338 71

Microalbuminuria 63 166

LDL ge 130 mgdl or LLM 45 107 65

Triglycerides ge 150 mgdl or LLM 210 233

hsCRP gt 03 mgdl 412 463

Retinopathy diabetes 49+15 y 137 285

Summary

bull Numbers of youth lt numbers of adults but projected to continue to increase

bull Non-modifiable factors (puberty genetics epigenetics) and modifiable factors (obesity environmental social) contribute to the increase in youth T2D

bull Youth T2D is characterized by significant insulin resistance

bull -cell deficiency is evident early (even in obese NGT) progressively worsens

bull Treatment failure appears to be more rapid in youth versus adults

bull Microvascular complications and risk markers for macrovascular complications are present early and rapidly progress

Case History

bull Mother had gestational diabetes

bull Maternal grandparents have T2D and CVD

bull Patient with high BP for age and height

bull ldquoHigh insulin levelrdquo

bull HbA1C 65

Risk Factors for T2DM

bull Obese

bull Family History of T2DM

bull Minority Race Ethnic Background

ndash Native Americans African-Americans Hispanic

Americans AsiansSouth Pacific Islanders

bull Signs of Insulin Resistance

ndash puberty acanthosis nigricans high blood pressure

dyslipidemia PCOS

bull Exposure to Hyperglycemia In Utero

Diabetes Care 2000 23381-389

Evaluation and TreatmentCan we help to prevent diabetes progression

bull Does she have pre-diabetes

bull Does she have diabetes

What to DO

bull DONrsquoT delay the diagnosis

bull Diagnosis is often delayed until

complications present

bull Treatment prevents delays complications

The Treatment of Diabetes in

Adolescents and Youth Trial

ldquoTODAYrdquo Study Cohort

bull 65 female 80 racialethnic minority

bull Mean age 140 y

bull 60 with 1st degree relative with T2DM

bull 90 with 1st or 2nd degree relative with T2DM

bull 30 had gestation complicated by diabetes

For Your Patienthellip

What to DObull Diabetes ndash start treatment

ndash Metformin

ndash Diabetes education

bull SMBG pediatric diabetes education

ndash Lifestyle modification

ndash Medical Nutrition Therapy

ndash Prevent pregnancy

bull Insulin is often needed

ndash A1c ge9

ndash Presentation in DKA

PREVENTION

bull T2DM can be delayed prevented in adults

ndash Da Qing IGT and Diabetes Study

ndash Finnish Diabetes Prevention Study

ndash US Diabetes Prevention Program

Incidence of Diabetes in the US DPP

Knowler et al NEJM 2002346(6)393

31 (17-43)

58 (48-66)

N=3234

Development of Diabetes

Normal GT IGT

1st phase insulinIFG Β-Cell Failure DM

Genetic predisposition Beta-cell defect

Environmental influence Puberty

Insulin Resistance

0

5

10

15

20

25

Insu

lin

Sen

sit

ivit

y(m

g k

g F

FM

m

in p

er

U

mL

) P lt 0001

0

50

100

150

200

1s

tP

ha

se

In

su

lin

(U

m

L)

P lt 005

Puberty Increases Risk for Type 2 DiabetesLongitudinal Study of Insulin Sensitivity

Pre-pubertal Pubertal

Insulin Sensitivity and -cell

Function in TODAYInsulin Sensitivity (1fasting insulin) Oral Disposition Index

Disease Progression With Treatment Kids versus Adults

-40

-20

0

20

40

60

Metformin

Fail Rate ()

Met + Rosi

Fail Rate ()

Change in IS

()

Change in B-

Cell Function

()

TODAY ADOPT

Comorbidities

TODAY Study

Prevalence

()(Baseline End of

Study)

CDC Estimated

Prevalence () in Adults

Hypertension 116 338 71

Microalbuminuria 63 166

LDL ge 130 mgdl or LLM 45 107 65

Triglycerides ge 150 mgdl or LLM 210 233

hsCRP gt 03 mgdl 412 463

Retinopathy diabetes 49+15 y 137 285

Summary

bull Numbers of youth lt numbers of adults but projected to continue to increase

bull Non-modifiable factors (puberty genetics epigenetics) and modifiable factors (obesity environmental social) contribute to the increase in youth T2D

bull Youth T2D is characterized by significant insulin resistance

bull -cell deficiency is evident early (even in obese NGT) progressively worsens

bull Treatment failure appears to be more rapid in youth versus adults

bull Microvascular complications and risk markers for macrovascular complications are present early and rapidly progress

Case History

bull Mother had gestational diabetes

bull Maternal grandparents have T2D and CVD

bull Patient with high BP for age and height

bull ldquoHigh insulin levelrdquo

bull HbA1C 65

Risk Factors for T2DM

bull Obese

bull Family History of T2DM

bull Minority Race Ethnic Background

ndash Native Americans African-Americans Hispanic

Americans AsiansSouth Pacific Islanders

bull Signs of Insulin Resistance

ndash puberty acanthosis nigricans high blood pressure

dyslipidemia PCOS

bull Exposure to Hyperglycemia In Utero

Diabetes Care 2000 23381-389

Evaluation and TreatmentCan we help to prevent diabetes progression

bull Does she have pre-diabetes

bull Does she have diabetes

What to DO

bull DONrsquoT delay the diagnosis

bull Diagnosis is often delayed until

complications present

bull Treatment prevents delays complications

The Treatment of Diabetes in

Adolescents and Youth Trial

ldquoTODAYrdquo Study Cohort

bull 65 female 80 racialethnic minority

bull Mean age 140 y

bull 60 with 1st degree relative with T2DM

bull 90 with 1st or 2nd degree relative with T2DM

bull 30 had gestation complicated by diabetes

For Your Patienthellip

What to DObull Diabetes ndash start treatment

ndash Metformin

ndash Diabetes education

bull SMBG pediatric diabetes education

ndash Lifestyle modification

ndash Medical Nutrition Therapy

ndash Prevent pregnancy

bull Insulin is often needed

ndash A1c ge9

ndash Presentation in DKA

PREVENTION

bull T2DM can be delayed prevented in adults

ndash Da Qing IGT and Diabetes Study

ndash Finnish Diabetes Prevention Study

ndash US Diabetes Prevention Program

Incidence of Diabetes in the US DPP

Knowler et al NEJM 2002346(6)393

31 (17-43)

58 (48-66)

N=3234

0

5

10

15

20

25

Insu

lin

Sen

sit

ivit

y(m

g k

g F

FM

m

in p

er

U

mL

) P lt 0001

0

50

100

150

200

1s

tP

ha

se

In

su

lin

(U

m

L)

P lt 005

Puberty Increases Risk for Type 2 DiabetesLongitudinal Study of Insulin Sensitivity

Pre-pubertal Pubertal

Insulin Sensitivity and -cell

Function in TODAYInsulin Sensitivity (1fasting insulin) Oral Disposition Index

Disease Progression With Treatment Kids versus Adults

-40

-20

0

20

40

60

Metformin

Fail Rate ()

Met + Rosi

Fail Rate ()

Change in IS

()

Change in B-

Cell Function

()

TODAY ADOPT

Comorbidities

TODAY Study

Prevalence

()(Baseline End of

Study)

CDC Estimated

Prevalence () in Adults

Hypertension 116 338 71

Microalbuminuria 63 166

LDL ge 130 mgdl or LLM 45 107 65

Triglycerides ge 150 mgdl or LLM 210 233

hsCRP gt 03 mgdl 412 463

Retinopathy diabetes 49+15 y 137 285

Summary

bull Numbers of youth lt numbers of adults but projected to continue to increase

bull Non-modifiable factors (puberty genetics epigenetics) and modifiable factors (obesity environmental social) contribute to the increase in youth T2D

bull Youth T2D is characterized by significant insulin resistance

bull -cell deficiency is evident early (even in obese NGT) progressively worsens

bull Treatment failure appears to be more rapid in youth versus adults

bull Microvascular complications and risk markers for macrovascular complications are present early and rapidly progress

Case History

bull Mother had gestational diabetes

bull Maternal grandparents have T2D and CVD

bull Patient with high BP for age and height

bull ldquoHigh insulin levelrdquo

bull HbA1C 65

Risk Factors for T2DM

bull Obese

bull Family History of T2DM

bull Minority Race Ethnic Background

ndash Native Americans African-Americans Hispanic

Americans AsiansSouth Pacific Islanders

bull Signs of Insulin Resistance

ndash puberty acanthosis nigricans high blood pressure

dyslipidemia PCOS

bull Exposure to Hyperglycemia In Utero

Diabetes Care 2000 23381-389

Evaluation and TreatmentCan we help to prevent diabetes progression

bull Does she have pre-diabetes

bull Does she have diabetes

What to DO

bull DONrsquoT delay the diagnosis

bull Diagnosis is often delayed until

complications present

bull Treatment prevents delays complications

The Treatment of Diabetes in

Adolescents and Youth Trial

ldquoTODAYrdquo Study Cohort

bull 65 female 80 racialethnic minority

bull Mean age 140 y

bull 60 with 1st degree relative with T2DM

bull 90 with 1st or 2nd degree relative with T2DM

bull 30 had gestation complicated by diabetes

For Your Patienthellip

What to DObull Diabetes ndash start treatment

ndash Metformin

ndash Diabetes education

bull SMBG pediatric diabetes education

ndash Lifestyle modification

ndash Medical Nutrition Therapy

ndash Prevent pregnancy

bull Insulin is often needed

ndash A1c ge9

ndash Presentation in DKA

PREVENTION

bull T2DM can be delayed prevented in adults

ndash Da Qing IGT and Diabetes Study

ndash Finnish Diabetes Prevention Study

ndash US Diabetes Prevention Program

Incidence of Diabetes in the US DPP

Knowler et al NEJM 2002346(6)393

31 (17-43)

58 (48-66)

N=3234

Insulin Sensitivity and -cell

Function in TODAYInsulin Sensitivity (1fasting insulin) Oral Disposition Index

Disease Progression With Treatment Kids versus Adults

-40

-20

0

20

40

60

Metformin

Fail Rate ()

Met + Rosi

Fail Rate ()

Change in IS

()

Change in B-

Cell Function

()

TODAY ADOPT

Comorbidities

TODAY Study

Prevalence

()(Baseline End of

Study)

CDC Estimated

Prevalence () in Adults

Hypertension 116 338 71

Microalbuminuria 63 166

LDL ge 130 mgdl or LLM 45 107 65

Triglycerides ge 150 mgdl or LLM 210 233

hsCRP gt 03 mgdl 412 463

Retinopathy diabetes 49+15 y 137 285

Summary

bull Numbers of youth lt numbers of adults but projected to continue to increase

bull Non-modifiable factors (puberty genetics epigenetics) and modifiable factors (obesity environmental social) contribute to the increase in youth T2D

bull Youth T2D is characterized by significant insulin resistance

bull -cell deficiency is evident early (even in obese NGT) progressively worsens

bull Treatment failure appears to be more rapid in youth versus adults

bull Microvascular complications and risk markers for macrovascular complications are present early and rapidly progress

Case History

bull Mother had gestational diabetes

bull Maternal grandparents have T2D and CVD

bull Patient with high BP for age and height

bull ldquoHigh insulin levelrdquo

bull HbA1C 65

Risk Factors for T2DM

bull Obese

bull Family History of T2DM

bull Minority Race Ethnic Background

ndash Native Americans African-Americans Hispanic

Americans AsiansSouth Pacific Islanders

bull Signs of Insulin Resistance

ndash puberty acanthosis nigricans high blood pressure

dyslipidemia PCOS

bull Exposure to Hyperglycemia In Utero

Diabetes Care 2000 23381-389

Evaluation and TreatmentCan we help to prevent diabetes progression

bull Does she have pre-diabetes

bull Does she have diabetes

What to DO

bull DONrsquoT delay the diagnosis

bull Diagnosis is often delayed until

complications present

bull Treatment prevents delays complications

The Treatment of Diabetes in

Adolescents and Youth Trial

ldquoTODAYrdquo Study Cohort

bull 65 female 80 racialethnic minority

bull Mean age 140 y

bull 60 with 1st degree relative with T2DM

bull 90 with 1st or 2nd degree relative with T2DM

bull 30 had gestation complicated by diabetes

For Your Patienthellip

What to DObull Diabetes ndash start treatment

ndash Metformin

ndash Diabetes education

bull SMBG pediatric diabetes education

ndash Lifestyle modification

ndash Medical Nutrition Therapy

ndash Prevent pregnancy

bull Insulin is often needed

ndash A1c ge9

ndash Presentation in DKA

PREVENTION

bull T2DM can be delayed prevented in adults

ndash Da Qing IGT and Diabetes Study

ndash Finnish Diabetes Prevention Study

ndash US Diabetes Prevention Program

Incidence of Diabetes in the US DPP

Knowler et al NEJM 2002346(6)393

31 (17-43)

58 (48-66)

N=3234

Disease Progression With Treatment Kids versus Adults

-40

-20

0

20

40

60

Metformin

Fail Rate ()

Met + Rosi

Fail Rate ()

Change in IS

()

Change in B-

Cell Function

()

TODAY ADOPT

Comorbidities

TODAY Study

Prevalence

()(Baseline End of

Study)

CDC Estimated

Prevalence () in Adults

Hypertension 116 338 71

Microalbuminuria 63 166

LDL ge 130 mgdl or LLM 45 107 65

Triglycerides ge 150 mgdl or LLM 210 233

hsCRP gt 03 mgdl 412 463

Retinopathy diabetes 49+15 y 137 285

Summary

bull Numbers of youth lt numbers of adults but projected to continue to increase

bull Non-modifiable factors (puberty genetics epigenetics) and modifiable factors (obesity environmental social) contribute to the increase in youth T2D

bull Youth T2D is characterized by significant insulin resistance

bull -cell deficiency is evident early (even in obese NGT) progressively worsens

bull Treatment failure appears to be more rapid in youth versus adults

bull Microvascular complications and risk markers for macrovascular complications are present early and rapidly progress

Case History

bull Mother had gestational diabetes

bull Maternal grandparents have T2D and CVD

bull Patient with high BP for age and height

bull ldquoHigh insulin levelrdquo

bull HbA1C 65

Risk Factors for T2DM

bull Obese

bull Family History of T2DM

bull Minority Race Ethnic Background

ndash Native Americans African-Americans Hispanic

Americans AsiansSouth Pacific Islanders

bull Signs of Insulin Resistance

ndash puberty acanthosis nigricans high blood pressure

dyslipidemia PCOS

bull Exposure to Hyperglycemia In Utero

Diabetes Care 2000 23381-389

Evaluation and TreatmentCan we help to prevent diabetes progression

bull Does she have pre-diabetes

bull Does she have diabetes

What to DO

bull DONrsquoT delay the diagnosis

bull Diagnosis is often delayed until

complications present

bull Treatment prevents delays complications

The Treatment of Diabetes in

Adolescents and Youth Trial

ldquoTODAYrdquo Study Cohort

bull 65 female 80 racialethnic minority

bull Mean age 140 y

bull 60 with 1st degree relative with T2DM

bull 90 with 1st or 2nd degree relative with T2DM

bull 30 had gestation complicated by diabetes

For Your Patienthellip

What to DObull Diabetes ndash start treatment

ndash Metformin

ndash Diabetes education

bull SMBG pediatric diabetes education

ndash Lifestyle modification

ndash Medical Nutrition Therapy

ndash Prevent pregnancy

bull Insulin is often needed

ndash A1c ge9

ndash Presentation in DKA

PREVENTION

bull T2DM can be delayed prevented in adults

ndash Da Qing IGT and Diabetes Study

ndash Finnish Diabetes Prevention Study

ndash US Diabetes Prevention Program

Incidence of Diabetes in the US DPP

Knowler et al NEJM 2002346(6)393

31 (17-43)

58 (48-66)

N=3234

Comorbidities

TODAY Study

Prevalence

()(Baseline End of

Study)

CDC Estimated

Prevalence () in Adults

Hypertension 116 338 71

Microalbuminuria 63 166

LDL ge 130 mgdl or LLM 45 107 65

Triglycerides ge 150 mgdl or LLM 210 233

hsCRP gt 03 mgdl 412 463

Retinopathy diabetes 49+15 y 137 285

Summary

bull Numbers of youth lt numbers of adults but projected to continue to increase

bull Non-modifiable factors (puberty genetics epigenetics) and modifiable factors (obesity environmental social) contribute to the increase in youth T2D

bull Youth T2D is characterized by significant insulin resistance

bull -cell deficiency is evident early (even in obese NGT) progressively worsens

bull Treatment failure appears to be more rapid in youth versus adults

bull Microvascular complications and risk markers for macrovascular complications are present early and rapidly progress

Case History

bull Mother had gestational diabetes

bull Maternal grandparents have T2D and CVD

bull Patient with high BP for age and height

bull ldquoHigh insulin levelrdquo

bull HbA1C 65

Risk Factors for T2DM

bull Obese

bull Family History of T2DM

bull Minority Race Ethnic Background

ndash Native Americans African-Americans Hispanic

Americans AsiansSouth Pacific Islanders

bull Signs of Insulin Resistance

ndash puberty acanthosis nigricans high blood pressure

dyslipidemia PCOS

bull Exposure to Hyperglycemia In Utero

Diabetes Care 2000 23381-389

Evaluation and TreatmentCan we help to prevent diabetes progression

bull Does she have pre-diabetes

bull Does she have diabetes

What to DO

bull DONrsquoT delay the diagnosis

bull Diagnosis is often delayed until

complications present

bull Treatment prevents delays complications

The Treatment of Diabetes in

Adolescents and Youth Trial

ldquoTODAYrdquo Study Cohort

bull 65 female 80 racialethnic minority

bull Mean age 140 y

bull 60 with 1st degree relative with T2DM

bull 90 with 1st or 2nd degree relative with T2DM

bull 30 had gestation complicated by diabetes

For Your Patienthellip

What to DObull Diabetes ndash start treatment

ndash Metformin

ndash Diabetes education

bull SMBG pediatric diabetes education

ndash Lifestyle modification

ndash Medical Nutrition Therapy

ndash Prevent pregnancy

bull Insulin is often needed

ndash A1c ge9

ndash Presentation in DKA

PREVENTION

bull T2DM can be delayed prevented in adults

ndash Da Qing IGT and Diabetes Study

ndash Finnish Diabetes Prevention Study

ndash US Diabetes Prevention Program

Incidence of Diabetes in the US DPP

Knowler et al NEJM 2002346(6)393

31 (17-43)

58 (48-66)

N=3234

Summary

bull Numbers of youth lt numbers of adults but projected to continue to increase

bull Non-modifiable factors (puberty genetics epigenetics) and modifiable factors (obesity environmental social) contribute to the increase in youth T2D

bull Youth T2D is characterized by significant insulin resistance

bull -cell deficiency is evident early (even in obese NGT) progressively worsens

bull Treatment failure appears to be more rapid in youth versus adults

bull Microvascular complications and risk markers for macrovascular complications are present early and rapidly progress

Case History

bull Mother had gestational diabetes

bull Maternal grandparents have T2D and CVD

bull Patient with high BP for age and height

bull ldquoHigh insulin levelrdquo

bull HbA1C 65

Risk Factors for T2DM

bull Obese

bull Family History of T2DM

bull Minority Race Ethnic Background

ndash Native Americans African-Americans Hispanic

Americans AsiansSouth Pacific Islanders

bull Signs of Insulin Resistance

ndash puberty acanthosis nigricans high blood pressure

dyslipidemia PCOS

bull Exposure to Hyperglycemia In Utero

Diabetes Care 2000 23381-389

Evaluation and TreatmentCan we help to prevent diabetes progression

bull Does she have pre-diabetes

bull Does she have diabetes

What to DO

bull DONrsquoT delay the diagnosis

bull Diagnosis is often delayed until

complications present

bull Treatment prevents delays complications

The Treatment of Diabetes in

Adolescents and Youth Trial

ldquoTODAYrdquo Study Cohort

bull 65 female 80 racialethnic minority

bull Mean age 140 y

bull 60 with 1st degree relative with T2DM

bull 90 with 1st or 2nd degree relative with T2DM

bull 30 had gestation complicated by diabetes

For Your Patienthellip

What to DObull Diabetes ndash start treatment

ndash Metformin

ndash Diabetes education

bull SMBG pediatric diabetes education

ndash Lifestyle modification

ndash Medical Nutrition Therapy

ndash Prevent pregnancy

bull Insulin is often needed

ndash A1c ge9

ndash Presentation in DKA

PREVENTION

bull T2DM can be delayed prevented in adults

ndash Da Qing IGT and Diabetes Study

ndash Finnish Diabetes Prevention Study

ndash US Diabetes Prevention Program

Incidence of Diabetes in the US DPP

Knowler et al NEJM 2002346(6)393

31 (17-43)

58 (48-66)

N=3234

Case History

bull Mother had gestational diabetes

bull Maternal grandparents have T2D and CVD

bull Patient with high BP for age and height

bull ldquoHigh insulin levelrdquo

bull HbA1C 65

Risk Factors for T2DM

bull Obese

bull Family History of T2DM

bull Minority Race Ethnic Background

ndash Native Americans African-Americans Hispanic

Americans AsiansSouth Pacific Islanders

bull Signs of Insulin Resistance

ndash puberty acanthosis nigricans high blood pressure

dyslipidemia PCOS

bull Exposure to Hyperglycemia In Utero

Diabetes Care 2000 23381-389

Evaluation and TreatmentCan we help to prevent diabetes progression

bull Does she have pre-diabetes

bull Does she have diabetes

What to DO

bull DONrsquoT delay the diagnosis

bull Diagnosis is often delayed until

complications present

bull Treatment prevents delays complications

The Treatment of Diabetes in

Adolescents and Youth Trial

ldquoTODAYrdquo Study Cohort

bull 65 female 80 racialethnic minority

bull Mean age 140 y

bull 60 with 1st degree relative with T2DM

bull 90 with 1st or 2nd degree relative with T2DM

bull 30 had gestation complicated by diabetes

For Your Patienthellip

What to DObull Diabetes ndash start treatment

ndash Metformin

ndash Diabetes education

bull SMBG pediatric diabetes education

ndash Lifestyle modification

ndash Medical Nutrition Therapy

ndash Prevent pregnancy

bull Insulin is often needed

ndash A1c ge9

ndash Presentation in DKA

PREVENTION

bull T2DM can be delayed prevented in adults

ndash Da Qing IGT and Diabetes Study

ndash Finnish Diabetes Prevention Study

ndash US Diabetes Prevention Program

Incidence of Diabetes in the US DPP

Knowler et al NEJM 2002346(6)393

31 (17-43)

58 (48-66)

N=3234

Risk Factors for T2DM

bull Obese

bull Family History of T2DM

bull Minority Race Ethnic Background

ndash Native Americans African-Americans Hispanic

Americans AsiansSouth Pacific Islanders

bull Signs of Insulin Resistance

ndash puberty acanthosis nigricans high blood pressure

dyslipidemia PCOS

bull Exposure to Hyperglycemia In Utero

Diabetes Care 2000 23381-389

Evaluation and TreatmentCan we help to prevent diabetes progression

bull Does she have pre-diabetes

bull Does she have diabetes

What to DO

bull DONrsquoT delay the diagnosis

bull Diagnosis is often delayed until

complications present

bull Treatment prevents delays complications

The Treatment of Diabetes in

Adolescents and Youth Trial

ldquoTODAYrdquo Study Cohort

bull 65 female 80 racialethnic minority

bull Mean age 140 y

bull 60 with 1st degree relative with T2DM

bull 90 with 1st or 2nd degree relative with T2DM

bull 30 had gestation complicated by diabetes

For Your Patienthellip

What to DObull Diabetes ndash start treatment

ndash Metformin

ndash Diabetes education

bull SMBG pediatric diabetes education

ndash Lifestyle modification

ndash Medical Nutrition Therapy

ndash Prevent pregnancy

bull Insulin is often needed

ndash A1c ge9

ndash Presentation in DKA

PREVENTION

bull T2DM can be delayed prevented in adults

ndash Da Qing IGT and Diabetes Study

ndash Finnish Diabetes Prevention Study

ndash US Diabetes Prevention Program

Incidence of Diabetes in the US DPP

Knowler et al NEJM 2002346(6)393

31 (17-43)

58 (48-66)

N=3234

Evaluation and TreatmentCan we help to prevent diabetes progression

bull Does she have pre-diabetes

bull Does she have diabetes

What to DO

bull DONrsquoT delay the diagnosis

bull Diagnosis is often delayed until

complications present

bull Treatment prevents delays complications

The Treatment of Diabetes in

Adolescents and Youth Trial

ldquoTODAYrdquo Study Cohort

bull 65 female 80 racialethnic minority

bull Mean age 140 y

bull 60 with 1st degree relative with T2DM

bull 90 with 1st or 2nd degree relative with T2DM

bull 30 had gestation complicated by diabetes

For Your Patienthellip

What to DObull Diabetes ndash start treatment

ndash Metformin

ndash Diabetes education

bull SMBG pediatric diabetes education

ndash Lifestyle modification

ndash Medical Nutrition Therapy

ndash Prevent pregnancy

bull Insulin is often needed

ndash A1c ge9

ndash Presentation in DKA

PREVENTION

bull T2DM can be delayed prevented in adults

ndash Da Qing IGT and Diabetes Study

ndash Finnish Diabetes Prevention Study

ndash US Diabetes Prevention Program

Incidence of Diabetes in the US DPP

Knowler et al NEJM 2002346(6)393

31 (17-43)

58 (48-66)

N=3234

What to DO

bull DONrsquoT delay the diagnosis

bull Diagnosis is often delayed until

complications present

bull Treatment prevents delays complications

The Treatment of Diabetes in

Adolescents and Youth Trial

ldquoTODAYrdquo Study Cohort

bull 65 female 80 racialethnic minority

bull Mean age 140 y

bull 60 with 1st degree relative with T2DM

bull 90 with 1st or 2nd degree relative with T2DM

bull 30 had gestation complicated by diabetes

For Your Patienthellip

What to DObull Diabetes ndash start treatment

ndash Metformin

ndash Diabetes education

bull SMBG pediatric diabetes education

ndash Lifestyle modification

ndash Medical Nutrition Therapy

ndash Prevent pregnancy

bull Insulin is often needed

ndash A1c ge9

ndash Presentation in DKA

PREVENTION

bull T2DM can be delayed prevented in adults

ndash Da Qing IGT and Diabetes Study

ndash Finnish Diabetes Prevention Study

ndash US Diabetes Prevention Program

Incidence of Diabetes in the US DPP

Knowler et al NEJM 2002346(6)393

31 (17-43)

58 (48-66)

N=3234

The Treatment of Diabetes in

Adolescents and Youth Trial

ldquoTODAYrdquo Study Cohort

bull 65 female 80 racialethnic minority

bull Mean age 140 y

bull 60 with 1st degree relative with T2DM

bull 90 with 1st or 2nd degree relative with T2DM

bull 30 had gestation complicated by diabetes

For Your Patienthellip

What to DObull Diabetes ndash start treatment

ndash Metformin

ndash Diabetes education

bull SMBG pediatric diabetes education

ndash Lifestyle modification

ndash Medical Nutrition Therapy

ndash Prevent pregnancy

bull Insulin is often needed

ndash A1c ge9

ndash Presentation in DKA

PREVENTION

bull T2DM can be delayed prevented in adults

ndash Da Qing IGT and Diabetes Study

ndash Finnish Diabetes Prevention Study

ndash US Diabetes Prevention Program

Incidence of Diabetes in the US DPP

Knowler et al NEJM 2002346(6)393

31 (17-43)

58 (48-66)

N=3234

For Your Patienthellip

What to DObull Diabetes ndash start treatment

ndash Metformin

ndash Diabetes education

bull SMBG pediatric diabetes education

ndash Lifestyle modification

ndash Medical Nutrition Therapy

ndash Prevent pregnancy

bull Insulin is often needed

ndash A1c ge9

ndash Presentation in DKA

PREVENTION

bull T2DM can be delayed prevented in adults

ndash Da Qing IGT and Diabetes Study

ndash Finnish Diabetes Prevention Study

ndash US Diabetes Prevention Program

Incidence of Diabetes in the US DPP

Knowler et al NEJM 2002346(6)393

31 (17-43)

58 (48-66)

N=3234

PREVENTION

bull T2DM can be delayed prevented in adults

ndash Da Qing IGT and Diabetes Study

ndash Finnish Diabetes Prevention Study

ndash US Diabetes Prevention Program

Incidence of Diabetes in the US DPP

Knowler et al NEJM 2002346(6)393

31 (17-43)

58 (48-66)

N=3234

Incidence of Diabetes in the US DPP

Knowler et al NEJM 2002346(6)393

31 (17-43)

58 (48-66)

N=3234

Weight Physical Activity Changes

Knowler et al NEJM 2002346(6)393

SECONDARY PREVENTION

Procedures to detect and treat pre-clinical pathology and control disease progression

Individual

bull Pediatric

ndash Screening

Population-based

bull Community level programs

Can this intervention improve health outcomes in youth diagnosed with prediabetes or T2D

Recommendations for Clinical Care

bull Identify risk and do not delay diagnosis

bull Treatment of children at highest risk with

treatments shown to have some efficacy

ndash Obesity programs

ndash Metformin for PCOS pre-diabetes

bull Address other modifiable risk factors

bull Prospective studies of children at highest risk

Recommendations for Clinical Care

bull Currently there is insufficient evidence

to recommend treatment with

metformin in obese children without

pre-diabetes PCOS or T2D

bull Lifestyle intervention should be more

strongly supported

Can this intervention improve health outcomes in youth diagnosed with prediabetes or T2D

Recommendations for Clinical Care

bull Identify risk and do not delay diagnosis

bull Treatment of children at highest risk with

treatments shown to have some efficacy

ndash Obesity programs

ndash Metformin for PCOS pre-diabetes

bull Address other modifiable risk factors

bull Prospective studies of children at highest risk

Recommendations for Clinical Care

bull Currently there is insufficient evidence

to recommend treatment with

metformin in obese children without

pre-diabetes PCOS or T2D

bull Lifestyle intervention should be more

strongly supported

Recommendations for Clinical Care

bull Identify risk and do not delay diagnosis

bull Treatment of children at highest risk with

treatments shown to have some efficacy

ndash Obesity programs

ndash Metformin for PCOS pre-diabetes

bull Address other modifiable risk factors

bull Prospective studies of children at highest risk

Recommendations for Clinical Care

bull Currently there is insufficient evidence

to recommend treatment with

metformin in obese children without

pre-diabetes PCOS or T2D

bull Lifestyle intervention should be more

strongly supported

Recommendations for Clinical Care

bull Currently there is insufficient evidence

to recommend treatment with

metformin in obese children without

pre-diabetes PCOS or T2D

bull Lifestyle intervention should be more

strongly supported