0921 What’s new in type 2 diabetes?

Paediatric specialists and sub-specialists may well ask why this topic is considered to be relevant, but apart from statistics that show a dramatic increase in the prevalence of type 2 diabetes in children and adolescents, especially in high-risk ethnic populations, it is relevant when considering the mother-infant dyad, particularly when there has been gestational diabetes. In respect of the latter, evidence is mounting that type 2 diabetes is more likely to develop following gestational diabetes than in normoglycaemic controls, with a recent article in the Lancet putting this risk at 7.5 times higher. Having accepted this, the next step is obviously to consider preventative measures that may avoid, minimise or at least delay the onset of type 2 diabetes. One strategy that might have an effect is to promote breast feeding which has been shown to improve glucose tolerance and increase HDL levels in women lactating for 4-12 weeks (the so-called ‘reset hypothesis’ which has shown an association between duration of breast feeding and reduced maternal risk of metabolic disease). During gestation, visceral fat accumulates and insulin resistance and lipid and triglyceride levels increase. Lactation appears to reverse these trends more quickly and more completely. So, in fact there is a role for the paediatrician as educator and advocate. The Lancet article appeared in an issue dedicated to diabetes, and editorials contained some other interesting facts. For example the point is made that while there have been major developments in drug therapy and technology for insulin administration, glucose testing etc, the quality of diabetes care is still unsatisfactory, i.e. the drugs and devices are either not effective or not being used properly. Reference is made to effective use of pharmacies and nurses to ensure that patients are knowledgeable and compliant. Data are also provided showing that drug expenditure in the US rose by 87% between 2001 and 2007 ($6.7 to $12.5bn) while HbA1c levels have shown only a modest improvement. Further, while the drugs introduced over the past 10-15 years are 8-10x more expensive than the drugs available 25 years ago, the older drugs are probably more effective in lowering HbA1c levels. Interestingly, in the US only metformin and insulin are registered by the FDA for paediatric use.

Read more:
Medical Chronicle May 2009: 71
J Pediatr 2008; 153: 112-6
Clin Exp Allergy 2004; 34: 1349-55