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3	Prevalence of Diabetes and IFG in US Adolescents – NHANES 1999-2002 Type 2 Diabetes 0.5% of adolescents have diabetes 71% type 1 and 29% type 2 Determined by insulin use vs no insulin use 39,005 US teens with T2D Impaired Fasting Glucose 11% had IFG 2,769,736 teens with IFG Diabetes Increased 41% from 4.9 to 6.9/1000 from 1997 to 2003 - adults Duncan, Arch Pediatr Adolesc Med 2006;160:523; Geiss, Am J Prevent Med 2006;30:371
4	Is it an epidemic? The incidence is increasing and probably underestimated Population based estimates indicate an ~10-fold increase in incident cases over the past 10-15 years 8% to 43% of all new cases of diabetes in the United States depending on ethnicity The SEARCH Trial What about prevalence?? Bloomgarden ZT. Diabetes Care. 2004;27:998-1010 Centers for Disease Control. Diabetes Fact Sheet. 2005
5	Controversies as to the Nature of this Epidemic Difficult to recruit for the TODAY trial 13 centers across the country Presence of antibodies The SEARCH Trial 19,000 new patients with T1D 4,100 new patients with T2D
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9	Natural History of Type 2 Diabetes
10	Pre-diabetes (IGT) and T2D
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13	OGTT Feasibility Study Pre-diabetes and Diabetes by ADA Cut-offs
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20	Differentiation Between Type 1 and 2 48 with type 2 vs 39 with type 1 Type 2 Ethnicity, 1^st degree relative, BMI>24, +C-peptide, acanthosis
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22	Diagnosis with Type 2 Fagot-Campagna et al J Pediatr 2000 Mean Age 12-14 years Girls > Boys 1.7:1 Obese BMI >85^th % Minority Groups 94% Strong Family History 74-100% Acanthosis Nigricans 56-92%
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24	TREATMENT GOALS Glucose control, HbA1c <7% Eliminate symptoms of hyperglycemia Maintenance of reasonable body weight Improve cardiovascular risk factors Reduce microvascular complications Improvement in physical and emotional well-being
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28	LWPES Survey 130 Clinical Practices 48% treated with insulin alone 2 injections 44% with oral agents 71% metformin 46% sulfonylurea 9% TZD 4% meglitinide 8% lifestyle
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30	Intensive Therapy for Diabetes: Reduction in Incidence of Complications
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34	Studies to Treat Or Prevent Pediatric Type 2 Diabetes STOPP-T2D Funded by National Institute of Diabetes and Digestive and Kidney Diseases National Institutes of Health
35	STOPP-T2 TREATMENT PRIMARY AIM To compare the efficacy of 3 treatment regimens Metformin Metformin + lifestyle Metformin + TZD On Time to Treatment Failure and on Glycemic Control
36	Primary Outcomes Treatment goal HbA1c < 6% (glycemic control) Treatment failure HbA1c ³ 8.0% over 6 consecutive months OR Inability to wean from temporary insulin therapy due to metabolic decompensation
37	Outcome Measures Glycemia HbA1c, fasting and postprandial glucose by home monitoring Insulin sensitivity and secretion OGTT, HOMA, QUICKI, proinsulin, C-peptide Body composition BMI, DEXA, waist circumference, abdominal height Fitness and physical activity PDPAR, PWC 170, accelerometer
38	Outcome Measures (continued) Nutrition food frequency questionnaire Cardiovascular disease risk BP, lipids, inflammatory markers, coagulation factors Microvascular complications microalbuminuria, neuropathy Quality of life Cost
39	Inclusion Criteria Age 10 to 17 years Duration of diabetes < 2 years BMI ³ 85^th percentile Adult involved in the daily activities of the child agrees to participate in the intervention Absence of pancreatic autoimmunity Fasting C-peptide > 0.6 mmol/L Fluency in English or Spanish
40	National Diabetes Education Program’s Tip Sheets for Kids with Type 2 What is Diabetes? Be Active Stay at a Healthy Weight Eat Healthy Foods
41	Helping the Student with Diabetes Succeed
42	Conclusion Increased incidence Difficult to distinguish from type 1 Occurs at the time of intense insulin resistance due to puberty Does not appear to be preceded by long asymptomatic period More insulin deficiency and requirement for exogenous insulin early Safety and efficacy of therapeutic agents Rapid progression of co-morbidities and complications
43	Thank you Fkaufman@chla.usc.edu