Therapeutic outcomes data from youth with T2D, compared with T1D, are more limited, but the same principles (lifestyle modification in conjunction with pharmacologic intervention) have been adopted.70,71 Recommendations from the AAP clinical practice guideline for management of T2D are shown in the text box.72 Reducing risk for development of T2D in children with prediabetes is based on the same principles of weight management and improving insulin sensitivity with MNT and physical activity utilized in the treatment of T2D. Dietary modification, as part of a lifestyle modification program, can be an effective means of decreasing BMI, insulin resistance, and other metabolic abnormalities (dyslipidemia, hypertension). Reducing carbohydrate intake from added sugars, sweetened beverages, and juices is associated with better obesity, diabetes, and cardiovascular health outcomes and is strongly recommended to reduce hyperglycemia.12,28,73,74,75 If youth with T2D or their families choose to follow a low- or very low-carbohydrate diet, it is recommended that they work with pediatric diabetes care team and a pediatric dietitian.
AAP Recommendations for Treatment of Type 2 Diabetes72
Clinicians must ensure that insulin therapy is initiated for children and adolescents with T2D who are ketotic or in diabetic ketoacidosis and in whom the distinction between T1D and T2D is unclear; and, in usual cases should initiate insulin therapy for patients:
Who have random venous or plasma blood glucose concentrations ≥250 mg/dL; or
Whose HbA1c is >9%.
In all instances, clinicians should initiate a lifestyle modification program, including nutrition and physical activity, and start metformin as first-line therapy for children and adolescents at the time of diagnosis of T2D.
The committee suggests that clinicians monitor HBA1c concentrations every 3 months and intensify treatment if treatment goals for blood glucose and HbA1c concentrations are not being met.
The committee suggests that clinicians advise patients to monitor finger-stick blood glucose concentrations in those who:
Are taking insulin or other medications with a risk of hypoglycemia; or
Are initiating or changing their diabetes treatment goals; or
Have not met treatment goals; or
Have intercurrent illness.
The committee suggests that clinicians incorporate the Academy of Nutrition and Dietetics Pediatric Weight Management Evidence Based Nutrition Practice Guidelines in the nutrition counseling of patients with T2D both at the time of diagnosis and as part of ongoing management.
The committee suggests that clinicians encourage children and adolescents with T2D to engage in moderate-to-vigorous exercise for at least 60 minutes daily and to limit nonacademic screen time to less than 2 hours per day.
Youth with T2D should be treated with lifestyle modification; pharmacotherapy should be initiated without delay, simultaneously with MNT and lifestyle modification counseling.71 Although lifestyle modification is still considered a critical component of treatment in youth-onset T2D, in a multicenter trial of treatment options for T2D in adolescents, the combined intervention of metformin with an intensive lifestyle intervention program was not superior to metformin alone with respect to the rate of progression to glycemic failure (HbA1c >8% or inability to wean from insulin).76 In addition to metformin, glucagon-like peptide 1 receptor agonists (multiple formulations) have been approved by the FDA for the treatment of T2D in youth aged 12 years and up. Additional trials investigating other pharmaceutical agents are underway.
Given the strong association of obesity and insulin resistance as inherent risk factors and key elements of the pathogenesis of youth-onset T2D, recommendations are aimed at weight management, increased physical activity, and pharmacotherapy to improve insulin sensitivity and provide adequate insulin to euglycemia. The goals of management are to (1) achieve euglycemia and HbA1c targets (<7%, or <6.5% if this can be achieved without significant hypoglycemia); (2) maintain normal linear growth without continued excessive weight gain; and (3) reduce comorbidities (dyslipidemia, hypertension) that are frequently present. Dietary modifications in all forms of diabetes should be a family-based effort whenever possible, but older adolescents and young adults may benefit from individual MNT and counseling especially when family members are not supportive. Parents and other family members can serve as models for healthy eating behavior in conjunction with guidance from a dietitian. Scheduled mealtimes with the entire family are integral to establishing healthy eating behaviors in children. Efforts should focus on increasing vegetable, plants, and fiber intake, reducing saturated fat intake, and targeting portion sizes that result in a healthy BMI or halt in excessive weight gain. Specific recommendations from an expert committee on therapy in pediatric obesity can also be applied to the pediatric T2D or prediabetes population (see Table 28.6).9,10
Table 28.6. Evidence-Based Initial Lifestyle Interventions to Treat Pediatric Obesity9,10
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