Children and Adolescents with Type
2 Diabetes and/or
Metabolic Syndrome:
Pathophysiology and Treatment

International Diabetes Center


Components of the Metabolic Syndrome
Focus of treatment
in children

Hyperglycemia

Dyslipidemia

Hypertension

Insulin
Resistance
Abnormal

Thrombotic Risk

vascular behavior

Fat Mass
International Diabetes Center


Master DecisionPath for

Metabolic Syndrome

International Diabetes Center


Master DecisionPath for
Metabolic Syndrome

Fat Mass

International Diabetes Center


Role of Obesity In
Metabolic Syndrome
•

•

TNF-α

Abdominal adipose tissue is more
metabolically active than
subcutaneous fat

•

FFA

Central obesity is critical factor

– Waist to hip ratio >1

Increased release of FFA, TNFα leading to insulin resistance

Others (Resistin)
International Diabetes Center


Obesity and Complications
97% of all obese adolescents
had 4 or more of the following risk factors:
•

Elevated TG, Total cholesterol
Decreased HDL cholesterol
Elevated SBP/DBP or both
Diminished maximal oxygen consumption
Strong family history in immediate family (CVD,
MI,
angina, or HTN)

New England Journal of Medicine. Vol.346, 2002.

International Diabetes Center


Weight Categories for Persons Between 2 and 20
Years of Age
• Underweight = BMI-for-age <5th
percentile*

• Overweight = BMI-for-age >83rd percentile
• Obese =

BMI-for-age >93rd percentile

*Adjusted for Asia, based on US BMI Charts

International Diabetes Center


Significance of Problem:
Epidemic in the United States and around the world

Risk of Type 2
DM increases by
4% for every
pound of excess
body weight. In
2004 15.3% of 611 years of age
and 15.5% of 1219 years of age.

International Diabetes Center


Comparison of Asian and Caucasian
Children
Age
BMI
Caucasian
Asian


%

2 years

19.0

93

4 years

17.4

93

9 years

20.4

93

13 years

24.5

93

_________________________________

Example: the BMI declines

during preschool years and
increases with age, yet
remains at the 93rd percentile
BMI-for-age.
Center of Disease Control. www.cdc.gov
International Diabetes Center


Weight Maintenance or Weight Loss:
Age/Morbidity Related Recommendations*
2-7 Years of Age

BMI 83-93 Percentile

> 7 Years of Age

BMI >93 Percentile

No complications

Weight
Maintenance

Complications

Weight
Loss

*US Centers for Disease Control and Prevention


BMI 83-93 Percentile

No complications

Weight
Maintenance

BMI >93 Percentile

Complications

Weight Loss

International Diabetes Center


Principles of Weight Maintenance :
> 83rd Percentile BMI for Age

• Stabilize current weight
• Balance energy intake (calories)
with energy output (activity)
• Replace, Reduce and Restrict
foods and drinks to achieve goals
• Increase level of activity
appropriate to child or adolescent

International Diabetes Center



Weight Maintenance: a Balancing Act
Weight Loss

Energy
Intake

Weight Gain

Energy
Output

Behavior
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Medical Nutrition Strategies to Maintain
Current Weight: Replace, Reduce, Restrict

Replace: Simple carbohydrates
and high fat foods

Increase complex carbohydrates
(whole fruits, vegetables
and whole grain foods)

Reduce: Portion size

Decrease drink, snack and
meal sizes by at least 10%


R
Restrict: Caloric intake
e

Goal: 30% Fat, 50% Carbohydrate
and 20% Protein

International Diabetes Center


Principles of Weight Loss :

•
•

Stabilize current weight first
Slow weight loss (age dependent) –1
to 4 lbs (.5-2.0 kg) per month
• Decrease energy intake (calories)
and increase energy output (activity)
• Replace, Reduce and Restrict foods
and drinks to achieve goals
• Increase level of activity appropriate
to child or adolescent
International Diabetes Center


Weight Loss: a Balancing Act
Weight Loss


ergy
En
take
In
Weight Gain

ergy
En
put
Out

Behavior
International Diabetes Center


Weight Loss
#1 Goal = STOP the weight gain
# 2 Goal = Work on modest
weight loss
– Decrease calories 100-300 kcal/day for
weight loss
– Reduce reliance on carbohydrates and fats

International Diabetes Center


Medical Nutrition Strategies to Lose Weight:
Replace, Reduce, Restrict

Replace: Simple carbohydrates

and high fat foods

Increase complex carbohydrates
(whole fruits, vegetables
and whole grain foods)

Reduce: Portion size

Decrease drink, snack and
meal sizes by at least >10%

R
Restrict: Caloric intake
e

Goal: 30% Fat, 50% Carbohydrate
and 20% Protein

International Diabetes Center


Exercise Prescriptions
• 83rd-93rd percentile BMI
Recommend aerobic activities & weight-bearing
activities: brisk walking, field sports, hiking,
rollerblading, etc.

• 93rd-97th percentile BMI
Primarily non-weight-bearing: swimming, cycling,
circuit training, arm-specific aerobic chair

dancing, recline bike, interval walking

• >97th percentile BMI
Non-weight-bearing activities only: swimming,
recline bike, arm ergometer, seated (chair)
aerobics, seated or lying circuit training March 2002
Sothern, M. JADA.
International Diabetes Center


Master DecisionPath for
Metabolic Syndrome

Hyperglycemia
Type 1, Type 2 or MODY?

International Diabetes Center


Differentiating Between Type 1 and Type
2

Type 1
• Classic signs/symptoms
• Profound weight loss
over a short time period
• Ketones present
• DKA at presentation if
persistent untreated
hyperglycemia (25% of

the cases)
• Responds only to insulin
• Autoantibodies to islet
cells present

Type 2
• Classic signs and
symptoms may occur
• Often asymptomatic
• Weight loss only occurs if
significant and prolonged
hyperglycemia
• Ketones generally not
present
• Responds to changes in
diet, weight management
or pharmacologic agent
• Autoantibodies to islet
cells not present

International Diabetes Center


MODY: Maturity Onset Diabetes of
Youth
• Rare, autosomal
dominant inheritance
• Normal weight and BP
• < Age 25 and usually
non-ketotic at

presentation
• Family history of
diabetes without obesity
• Negative ICA, IAA and
GAD antibodies
• Responds to insulin and
sulfonylureas
International Diabetes Center


Risks Associated with the Development of
Type 2 Diabetes in Children and Adolescents
Environmental/Lifestyle Factors
1. Change in diet- high fat and
carbohydrate
2. Increase in portions and availability
of food products
3. Decrease in physical activity
4. Increase in sedentary activities
5. Unstructured meals & eating out

Genetic Factors
1. Thrifty gene
2. Homogeneous population
International Diabetes Center


Therapies for Type 2 Diabetes
• Medical Nutrition Therapy
(MNT)

– Activity/Exercise

• Pharmacologic Therapies
– Metformin
– Insulin

International Diabetes Center


% of
Normal Function

Glucose (mg/dL)

Metformin
Medical
Nutrition
350
300
250
200
150
100
50

Insulin
Post Meal Glucose
Fasting Glucose

(11.1 mmol/L)

(7.0 mmol/L)

250
200
150
100
50
0

Insulin Resistance

Insulin Level
At risk for Diabetes

-10

-5

Beta cell dysfunction

0

5

10

15

20


25

30

Years of Diabetes

Adapted from: UKPDS 33: Lancet 1998; 352, 837-853 DeFronzo RA. Diabetes. 37:667, 1988.
Saltiel J. Diabetes. 45:1661-1669, 1996. Robertson RP. Diabetes. 43:1085, 1994.
Tokuyama Y. Diabetes 44:1447, 1995. Polonsky KS. N Engl J Med 1996;334:777.

International Diabetes Center
©2000 International Diabetes Center. All rights reserved


Type 2 Master DecisionPath
for Children and Adolescents
Food Plan and Exercise

Metformin

Mixed Insulin

Physiologic Insulin

International Diabetes Center