Pediatric Diabetes 2012: 13: 291–293doi: 10.1111/j.1399-5448.2012.00871.xAll rights reserved

© 2012 John Wiley & Sons A/S

Pediatric Diabetes

Editorial

Dancing with a ghost revisited

Ten years ago, in an editorial titled ‘Dancing withMany Different Ghosts’, I made a passionate pleathat we move beyond the biomedical paradigmsof diet, exercise, and metformin for treatment oftype 2 diabetes in children to include considerationof ‘the diverse linguistic, geographic, cultural, social,economic and political barriers that influence theaccess to, acceptance of, and outcomes of treatment’(1). A similar message was published recently bythree Canadian scholars in Aboriginal health in aneloquent review in which they proposed ‘a broad-basedsocioecological framework to understand weight-related issues in Aboriginal children’ (2). Althoughthe relevance of the Canadian experience with obesityand type 2 diabetes in Aboriginal children may notbe readily apparent to urban-based pediatric diabetesprograms around the world, there are remarkablesimilarities that encourage reflection on the causesof the rapid evolution of type 2 diabetes in childrenglobally and inspire us to be creative and to challengecurrent dogma regarding treatment paradigms.

The demographic of type 2 diabetes in children ischanging more rapidly than anyone predicted whenit was first described in the early 1990s. Carefuldescriptive population-based clinical studies remainthe foundation of our understanding of this rapidevolution of type 2 diabetes in children globally andare critical primary sources of evidence to informthe design of future clinical intervention trials. Theimportant role of regional pediatric diabetes programsin countries with national health care systems cannotbe overstated. These population-based programs, thatwere established originally to provide comprehensiveservices for children with type 1 diabetes, have evolvedto include children with type 2 diabetes and arethe most reliable sources of data on the type ofdiabetes during childhood. This clinical data can belinked to population-level administrative health systemdata to explore many of the complex individual,family, social, and environmental factors that influencetreatment outcomes. This data linkage between clinicdatabases and population administrative databasesobviates the need for complex algorithms to diagnoseand classify diabetes in children using ICD-10 codesand prescription data (3, 4).

In this issue of Pediatric Diabetes, the regionalpediatric diabetes team at the Starship Pediatricdiabetes service in Auckland New Zealand presenta descriptive study of incident cases of type 2 diabetesin children age 0–14 yr over a 13-yr period 1995–2007(5). The three main conclusions are a doubling ofthe incidence rate, the preponderance (>90%) of theaffected children having Maori and Pacific Islandheritage and the early but transient effect of insulin usedin 58% of the children at diagnosis. At first glance, thegeneralizability of this experience to other populationsseems limited. However, there are three importantobservations that serve to emphasize the remarkablesimilarities with other Indigenous populations.

The first observation is the rapidity of increase ofthe incidence rate of type 2 diabetes 1995–2007. Inmaking comparisons of different populations withinand between countries, it is imperative to be aware ofthe population age group that is used to calculate theincidence rate. In this study, the population studiedwas children 0–14 yr and then, specifically, childrenwith Maori or Pacific Island heritage. The overallincidence of type 2 diabetes of 1.3/100 000 children0–14 yr in Auckland appears to be similar to theincidence of type 2 diabetes in a national surveillancestudy 2006–2008 in Canada at 1.5/100 000 children,but the Canadian rate is for children 0–18 yr (6). Ofnote, the incidence rates in the children with Indigenousheritage appear to be markedly different at 3.4/100 000children age 0–14 yr in Auckland vs. 23.2 per 100 000children age 0–18 yr in Canada, but direct comparisonis difficult because of the different age ranges included(6). A previous publication from a different DiabetesCenter in Auckland reported their experience witholder adolescents age 14–20 yr (7). One recurring gapin our global effort to understand the rapid evolution oftype 2 diabetes in children is the frequent exclusion ofthe 15–19-yr old age group in pediatric epidemiologicalanalyses especially in regional clinic-based studies.The average age at diagnosis of type 2 diabetes isrelatively consistent at 13–14 yr, yet many pediatricepidemiological systems report 5 yr age groups inchildren 0–4, 5–9, and 10–14 yr, with adults definedas persons 20 yr of age and older. This omission ofthe 15–19 yr group for type 2 diabetes needs special

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attention as was done in the SEARCH study to avoidoverlooking this important age group.

The second important observation in the AucklandStarship experience is the high rate of microalbumin-uria (MAU > 30 mg/g), hypertension (>95 percentile)and low socioeconomic status at diagnosis in the chil-dren 0–14 yr with type 2 diabetes. There is remarkablesimilarity in other clinical parameters at diagnosisbetween the Auckland Starship cohort and the mul-tiethnic cohort of children recruited to the TODAYtreatment study (Treatment Options for T2DM inAdolescents and Youth) in the USA (8). This includespercentage of females (66% vs. 65%), mean age (13vs. 14 yr), body mass index z-score (2.30 vs. 2.15), andpositive family history of type 2 diabetes in the nuclearfamily (68% vs. 60%). In contrast, the rate of microal-buminuria was approximately threefold higher and therate of hypertension was fourfold higher in the Auck-land Starship cohort compared to the TODAY cohort.The observation of higher rates of MAU may reflectthe high rate of underlying congenital and acquiredrenal diseases in cohorts with a high number of chil-dren from Indigenous populations (9). The high rates ofearly renal failure and death in Indigenous populationsrequire special attention to the complex environmen-tal factors including, but not limited, to acceleratedprogression of underlying primary renal disease, com-plex socioecological factors, and exposure to maternaldiabetes in early pregnancy.

The third important observation from the StarshipAuckland cohort is the high rate of treatment with twicedaily premix biphasic insulin at diagnosis and rapid,albeit transient, success in achieving glycemic targetswithout weight gain or hypoglycemia, an experienceshared by other groups for children with symptoms,DKA or hemoglobin A1c (HbA1c) > 9% at diagnosisof type 2 diabetes (10).

Consensus-based clinical practice guidelines pub-lished by ISPAD (11) acknowledge that the evidencefor making drug treatment recommendations is insuf-ficient. The results of the TODAY study are eagerlyanticipated in 2012. Clinical drug treatment trials inchildren with type 2 diabetes have been challenged bysmall numbers for recruitment by site, poor adherenceto protocol, high rates of exclusion criteria related toco-morbidities, and lack of consensus on degree andtype of support needed for aggressive lifestyle mod-ification. In the Starship Auckland cohort, lifestylemonotherapy was recommended in only 10% of chil-dren at diagnosis of type 2 diabetes by a pediatricdiabetes center with physician, diabetes nurse educa-tor, dietitian and ‘social work review as needed’. Is thissufficient support for families undertaking aggressivelifestyle modification? There is emerging experienceto support the role of aggressive lifestyle monother-apy at diagnosis in children with HbA1c < 9% (12).

Perhaps the appropriate pediatric team to providesupport for these families should include a fitnesstrainer, motivational expert, and behavioral therapist.The TODAY protocol includes a robust family-basedlifestyle intervention (13). A socioecological approachto the treatment of children with type 2 diabetes wouldexpand the focus from the family to include broad inter-ventions in the child’s community and environment.Modification of these multiple environments that influ-ence behavior, weight status, and glycemic control atdifferent times during childhood all must be consideredin the unique historical context of colonization that hasinfluenced regional and national public policy (2). Thisis a challenging new direction for traditional pediatricdiabetes teams requiring re-evaluation of our clinicalprograms for cultural safety and awareness. The mosteffective interventions for type 2 diabetes in childrenwill likely be created in broad-based public healthinnovations that address the complex interaction ofthe social determinants of health and acknowledge theunique cultural, socioecological, and historical contextof each population (14).

Heather DeanDepartment of Pediatrics,

Faculty of Medicine, University of Manitoba,Winnipeg, MB, R3E 0Z2, Canada

e-mail: hdean@hsc.mb.ca

References

1. Dean HJ. Dancing with many different ghosts:treatment of youth with type 2 diabetes (guest editorial).Diabetes Care 2002: 25: 237–238.

2. Willows ND, Hanley AJG, Delormier T. Asocioecological framework to understand weight-related issues in Aboriginal children in Canada. ApplPhysiol Nutr Metab 2012: 37: 1–13.

3. Vanderloo SE, Johnson JA, Reimer K et al. Validationof classification algorithms for childhood diabetesidentified from administrative data. Pediatr Diabetes2011: 13: 229–234.

4. Dart AB, Martens PJ, Sellers EA, Brownell MD,Rigatto C, Dean HJ. Validation of a pediatric diabetescase definition using administrative health data inManitoba, Canada. Diabetes Care 2011: 34: 898–903.

5. Jeffries C, Carter P, Reed PW, Cutfield W,Mouat F, Hofman P, Gunn AJ. The incidence, clinicalfeatures and treatment of type 2 diabetes in children<15 years in a population-based cohort from Auckland,New Zealand, 1995–2007. Pediatr Diabetes 2012: 13:294–300.

6. Amed S, Dean HJ, Pangiotopolous C, Sellers EAC,Hadjiyannakis S, Laubscher TA, Dannebaum DD,Shah BR, Booth GL, Hamilton HK. Type 2 diabetes,medication-induced diabetes and monogenic diabetes inCanadian children: a prospective national surveillancestudy. Diabetes Care 2010: 33: 786–791.

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7. Hotu S, Carter B, Watson PD, Cutfiled WS,Cundy T. Increasing prevalence of type 2 diabetes inadolescents. J Paediatr Child Health 2004: 40: 201–204.

8. Copeland KC, Zeitler P, Geffner M, Guandalini C,Higgins J, Hirst K, Kaufman FR, Linder B,Marcovina S, McGuigan P, Pyle L, Tamborlane W,Willi S, for the TODAY Study Group. Characteristicsof adolescents and youth with recent-onset type 2diabetes: the TODAY cohort at baseline. J ClinEndocrinol Metab 2011: 96: 159–167.

9. Dart A, Sellers EAC, Brownell M, Rigatto C,Dean HJ, Martens P. High burden of renalcomplications in youth onset type 2 diabetes. DiabetesCare. In press.

10. Sellers EAC, Dean HJ. Short-term insulin therapyin adolescents with type 2 diabetes mellitus. J PediatrEndocrinol Metab 2004: 17: 1561–1564.

11. Rosenbloom AL, Silverstein JH, Amemiya S,Zeitler P, Klingensmith GJ. Type 2 diabetes mellitusin the child and adolescent. ISPAD Clinical PracticeConsensus Guidelines. Pediatr Diabetes 2009: 10 Suppl.12: 17–32.

12. Wittmeier KDM, Wicklow BA, Sellers EAC,Griffith ATR, Dean HJ, McGavock JM. Success withlifestyle monotherapy in youth with new-onset type 2diabetes. J Paediatr Child Health 2012: 17: 129–132.

13. The TODAY study group. Design of a family-basedlifestyle intervention for youth with type 2 diabetes: theTODAY study. Int J Obes 2010: 34: 217–226.

14. Sellers EAC, Moore K, Dean HJ. Clinical manage-ment of type 2 diabetes in indigenous youth. In healthissues in Indigenous children. Pediatr Clin North Am2009: 56: 1441–1459.

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