There is insufficient evidence to assess the balance of benefits versus harms of screening for type 2 diabetes in children and adolescents, new recommendations from the US Preventive Services Task Force (USPSTF) indicate.
Moreover, there is also a lack of evidence on the effect of screening for, and early detection and treatment of, type 2 diabetes on health outcomes in youth, the same recommendations explain.
“Youth with type 2 diabetes have an increased prevalence of associated chronic comorbid conditions including hypertension, dyslipidemia, and nonalcoholic fatty liver disease,” Carol Mangione, MD, ziagen benefits David Geffen School of Medicine, University of California in Los Angeles, and colleagues report.
“[However], clinicians should continue to use their clinical judgment to determine if screening is appropriate for individual patients,” they advise.
The new recommendations were published online September 13 in JAMA.
Commenting on the new recommendations in an accompanying editorial, Lori Laffel, MD, MPH, Joslin Diabetes Center, Boston, Massachusetts, and colleagues, point out that the prevalence of type 2 diabetes in children and adolescents has almost doubled over the past two decades, from a rate of 0.34 per 1000 in 2001 to a rate of 0.67 per 1000 in 2017, a relative increase of 95% over 16 years.
“The COVID-19 pandemic has further magnified the trend of increased numbers of youth developing type 2 diabetes, likely due to multiple reasons, including unhealthful lifestyle risk factors of increased sedentary behavior, decreased physical activity, and weight gain,” Laffel and colleagues elaborate.
Moreover, the diagnosis of type 2 diabetes in young patients is not a lightweight one, as mounting evidence shows that it is associated with higher morbidity and premature mortality in children and adolescents, likely due to the accelerated onset and progression of microvascular and macrovascular complications.
“These complications are evident at high rates and at younger ages in those with youth-onset type 2 diabetes than those with youth-onset type 1 diabetes or in adults diagnosed with type 2 diabetes,” the editorialists observe.
The USPSTF commissioned a systematic review of the evidence on screening for prediabetes and type 2 diabetes in asymptomatic, nonpregnant patients under the age of 18.
“This review focused on evidence of the benefits and harms of screening for prediabetes and type 2 diabetes and the benefits and harms of interventions for screen-detected prediabetes and type 2 diabetes or recently diagnosed type 2 diabetes,” the USPSTF members explain.
It also assessed the evidence on the effectiveness of interventions for patients with prediabetes to delay or prevent progression to type 2 diabetes. The definitions of prediabetes and type 2 diabetes are the same in children and adolescents as they are for adults, with type 2 diabetes defined as a fasting plasma glucose of 126 mg/dL (5.6-6.9 mmol/L) and an A1c of 6.5% or a 2-hour post-load glucose of 200 mg/dL (11.1 mmol/L) or greater.
The Task Force also made several other recommendations on screening for obesity in children and adolescents along with screening for prediabetes and type 2 diabetes in adults.
The same group has also made a separate recommendation on screening for gestational diabetes in pregnant women. The US Food and Drug Administration (FDA) has approved three drugs for the treatment of type 2 diabetes in children: metformin, insulin, and liraglutide (Victoza, Novo Nordisk), a glucagon-like peptide-1 (GLP-1) receptor agonist.
While metformin is effective for the treatment of type 2 diabetes in younger patients, it is not approved by the FDA to prevent the progression of prediabetes to diabetes, the authors stress.
The Task Force found no studies that addressed the direct benefits of screening for prediabetes and type 2 diabetes on health outcomes in asymptomatic children and adolescents.
Similarly, they found no studies that addressed the harms of screening for prediabetes and type 2 diabetes in the same patient population. In fact, because some youth with prediabetes may revert to normal glycemia without intervention, the potential harms of screening in this age group include overdiagnosis and overtreatment, and potential harms caused by treatment of type 2 diabetes include the induction of hypoglycemia and gastrointestinal side effects, such as nausea and vomiting, related to medication use.
Importantly, type 2 diabetes rates in American Indian/Alaska Native, Black, and Hispanic/Latino youth have been shown to be between four- and eight-times higher compared with non-Hispanic White youth.
The authors speculate that structural factors that disproportionately affect non-White populations, as well as cultural and environmental influences, plus quality of and access to healthcare, may contribute to differences in diabetes rates by race and ethnicity.
Lifestyle Interventions Less Effective in Youth Than Adults?
What the Task Force does recommend for children and adolescents with prediabetes and type 2 diabetes are lifestyle interventions that promote weight loss, improve diet, and enhance physical activity.
As they point out, obesity and excess adipose tissue — especially centrally distributed excess adipose tissue — are the most important risk factors for type 2 diabetes in younger patients. Family history of diabetes, including gestational diabetes, is also a strong risk factor.
Risk assessment tools exist to help identify young patients at increased risk for prediabetes and type 2 diabetes; however, there is limited evidence confirming their accuracy, as Task Force members caution.
In their editorial, Laffel and colleagues stress: “Prevention and early identification of type 2 diabetes in children is a key public health priority. They too recommend lifestyle intervention, which has been shown to significantly reduce progression to type 2 diabetes in adults.”
Nevertheless, they caution that intensive efforts to achieve weight loss through lifestyle appear to be less effective in youth than in adults.
That said, pediatricians and primary care physicians can and should continue to emphasize the importance of healthy lifestyles for children and their families and keep a watchful eye out for symptoms of hyperglycemia.
Physicians should also continue to follow risk-based screening recommendations for type 2 diabetes in overweight and youth with obesity and at least one additional risk factor for type 2 diabetes who show signs of insulin resistance including acanthosis nigricans or polycystic ovary syndrome.
The US Centers for Disease Control and Prevention estimates that 210,000 children and adolescents under the age of 20 had diabetes in 2018, and of these, approximately 23,000 had type 2 diabetes.
All members of the USPSTF receive travel reimbursement and an honorarium for participating in USPSTF meetings. Laffel has reported receiving grant funding from Insulet and Boehringer Ingelheim and consulting fees from Janssen, Medtronic, Dompe, Provention Bio, Eli Lilly, Roche, and Dexcom.
JAMA. Published online September 13, 2022.
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