children and adolescents with type 2 diabetes andor metabolic syndrome pathophysiology and treatment

International Diabetes CenterWeight Maintenance or Weight Loss: Age/ Morbidity Related Recommendations* *US Centers for Disease Control and Prevention 2-7 Years of Age > 7 Years of Age B

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Children and Adolescents with Type

2 Diabetes and/or Metabolic Syndrome:

Pathophysiology and Treatment

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International Diabetes Center

Components of the Metabolic Syndrome

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Master DecisionPath for Metabolic Syndrome

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Fat Mass

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Role of Obesity In Metabolic Syndrome

• Central obesity is critical factor

– Waist to hip ratio >1

• Abdominal adipose tissue is more metabolically active than subcutaneous fat

• Increased release of FFA, TNF-leading to insulin resistance

FFA TNF- Others (Resistin)

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Obesity and Complications 97%

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.

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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

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Significance of Problem:

Ep idemic 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

6-11 years of age and 15.5% of 12-

19 years of age

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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

Comparison of Asian and Caucasian

Children

Caucasian Asian

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Weight Maintenance or Weight Loss: Age/

Morbidity Related Recommendations*

*US Centers for Disease Control and Prevention

2-7 Years of Age > 7 Years of Age

BMI 83-93 Percentile BMI >93 Percentile BMI 83-93 Percentile BMI >93 Percentile

No complications Complications No complications Complications

Weight Loss

Weight Maintenance

Weight Loss

Weight Maintenance

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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

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Weight Maintenance: a Balancing Act

Behavior

Energy Intake

Energy Output

Weight Loss

Weight Gain

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

Replace: Simple carbohydrates

and high fat foods

Medical Nutrition Strategies to Maintain

Current Weight: Replace, Reduce, Restrict

Reduce: Portion size

Increase complex carbohydrates (whole fruits, vegetables

and whole grain foods)

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

R

e

Restrict: Caloric intake

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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

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Weight Loss: a Balancing Act

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Weight Loss

#1 Goal = 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

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

Replace: Simple carbohydrates

and high fat foods

Medical Nutrition Strategies to Lose Weight:

Replace, Reduce, Restrict

Reduce: Portion size

Increase complex carbohydrates (whole fruits, vegetables

and whole grain foods)

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

R

e

Restrict: Caloric intake

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Primarily non-weight-bearing: swimming, cycling, circuit

training, arm-specific aerobic chair dancing, recline bike,

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Hyperglycemia

Type 1, Type 2 or MODY?

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Differentiating Between Type 1 and Type

2

• Classic signs/symptoms

• Profound weight loss

over a short time period

• Classic signs and

symptoms may occur

• Often asymptomatic

• Weight loss only occurs if

significant and prolonged hyperglycemia

• Ketones generally not

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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

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Risks Associated with the Development of

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

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Therapies for Type 2 Diabetes

• Medical Nutrition Therapy (MNT)

– Activity/Exercise

• Pharmacologic Therapies

– Metformin

– Insulin

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0 50

Beta cell dysfunction

Post Meal Glucose

At risk for 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.

Medical Nutrition Insulin

Metformin

(11.1 mmol/L) (7.0 mmol/L)

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Type 2 Master DecisionPath for Children and Adolescents

Food Plan and Exercise

Replace foods and drinks

high in calories

and carbohydrates

Restrict carbohydrates to less than 50% of total caloric intake

Reduce meal portions and

food between meals

Increase activity level

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Metformin

Approved in children more

than 10 years of age

Serum creatinine <1.4

No liver or heart disease

Not used in pregnancy

Start with 250 mg, slowly

increase dose and assess for

gastrointestinal discomfort

Used for treatment of Polycystic

Ovary Syndrome

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Physiologic Insulin

Start with 0.1U/kg total daily dose of

Glargine administered in the evening

Increase dose by 2 units until fasting BG is

at target or 0.3U/kg is reached.

Add 0.1 U/kg RA or R before each meal

based on pattern of hyperglycemia.

Do not exceed 1U/kg total daily dose of

insulin

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Hypertension

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Diagnosis of Hypertension in Children and Adolescents

• Blood pressure >90th percentile for gender, age

and height

• Question— Is a 13 year old boy at the 50th

percentile in height with a BP of 124/75 mmHg

(1st reading) and 125/72 mmHg (2nd reading)

hypertensive? Hint- see page 3-8 Q.G.

130 129

128 126

124 122

121

95 th % BP

126 125

124 122

120 119

118

90 th % BP

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Blood Pressure Management

In Children and Adolescents

Blood Pressure Management

In Children and Adolescents

Non-Pharmacologic Therapies

Weight management Physical activity Sodium restriction Smoking cessation

Thiazide Diuretics

(HCTZ)

Thiazide Diuretics

(HCTZ)

- Blocker

(Atenolol)

Avoid if severe hypoglycemia

- Blocker

(Atenolol)

Avoid if severe hypoglycemia

Ca ++ Channel Blocker

(Amlodipine, Nifedipine)

Use in combination

Ca ++ Channel Blocker

(Amlodipine, Nifedipine)

Hypertension

with Nephropathy

Hypertension

ACE Inhibitor (Captopril, Enalpril, Ramipril)

or Angiotensin II Receptor Blocker (Losartan

ACE Inhibitor (Captopril, Enalpril, Ramipril)

or Angiotensin II Receptor Blocker (Losartan

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Dyslipidemia

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Principles of Treatment

• Medical Nutrition Therapy

– Weight management

• Prevent weight gain

• Assist weight control

• Target weight reduction– Dietary management (Replace, Reduce, Restrict)

– Bile Acid Sequestrants

– Statins and Fibrates ?

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Treating Dyslipidemia in Children and

*Therapeutic lifestyle changes recommended for all patients

No lipid management

Medical Nutrition

with Planned Activity

(Add Statin in Consultation)

No lipid management

Bile AcidSequestrants

(Add Statin in Consultation)

Age

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- Great risk of medical morbidity and disability

- Great risk of social disability/reduced professional potential

- Early screening, detection and treatment of children and

adolescents with Type 2 Diabetes and/or Metabolic

Syndrome

Tiêu đề	Children and Adolescents with Type 2 Diabetes and/or Metabolic Syndrome: Pathophysiology and Treatment
Trường học	International Diabetes Center
Chuyên ngành	Children and Adolescents with Type 2 Diabetes and/or Metabolic Syndrome
Thể loại	essay

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