1. Overview & Epidemiology
Type 2 diabetes (T2D) in youth is a growing epidemic, disproportionately affecting specific ethnic groups. It is an aggressive disease with early onset of complications.
High-Risk Populations: Incidence is highest among children of Indigenous, African, Arab, Asian, Hispanic, and South Asian descent.
Pathophysiology: Characterized by insulin resistance (usually obesity-related) combined with rapid beta-cell failure.
Complications: Microvascular and macrovascular complications (nephropathy, hypertension, dyslipidemia) appear earlier and progress faster in youth-onset T2D compared to type 1 diabetes or adult-onset T2D.
2. Screening & Diagnosis
Screening is targeted at high-risk individuals rather than universal screening.
Who to Screen? Screening should be considered every 2 years using A1C (or FPG) in children who have:
3 risk factors in prepubertal children.
2 risk factors in pubertal children.
The Risk Factors:
Obesity (BMI 95th percentile).
High-risk ethnic group (Indigenous, African, Arab, Asian, Hispanic, South Asian).
Family history of type 2 diabetes (first or second degree) or exposure to diabetes in utero.
Signs of insulin resistance (acanthosis nigricans, hypertension, dyslipidemia, NAFLD, PCOS).
Note: Screening typically begins at onset of puberty or age 10 years, whichever is earlier.
3. Management Strategies
Management requires an interprofessional approach involving lifestyle and pharmacotherapy.
A. Lifestyle Intervention
Goal: Healthy behaviour changes for the entire family, not just the child.
Activity: Aim for 60 minutes of moderate-to-vigorous activity daily.
Diet: Limit sugar-sweetened beverages, increase fiber, regular meals.
Screen Time: Limit recreational screen time to < 2 hours/day.
B. Pharmacotherapy
First Line: Metformin is the drug of choice.
Insulin:
Start insulin immediately with metformin if there is metabolic decompensation (DKA, severe hyperglycemia, unexpected weight loss) or if the diagnosis (T1D vs T2D) is unclear.
Once metabolic stability is achieved, wean insulin while introducing metformin.
Targets: A1C target is 7.0% for most adolescents.
4. Comorbidities Surveillance
Youth with T2D are at very high risk for comorbidities. Screening should occur at diagnosis and regularly thereafter.
| Comorbidity | Screening Tool | Frequency |
| Hypertension | BP Measurement | Every visit |
| Dyslipidemia | Lipid Profile (Fasting) | At diagnosis, then annually |
| Nephropathy | Urine ACR | At diagnosis, then annually |
| Retinopathy | Dilated Eye Exam | At diagnosis, then annually |
| Neuropathy | Foot Exam | At diagnosis, then annually |
| Fatty Liver (NAFLD) | ALT (Enzymes) | At diagnosis, then annually |
| PCOS | Menstrual History | Every visit |
| OSA | Sleep History | Every visit |
Note: This differs from T1D (where screening often starts 5 years post-diagnosis). In T2D, you screen at diagnosis.
5. Diabetes Canada 2018 Clinical Practice Guidelines Recommendations
Key takeaways from the “Recommendations” section (Page S253).
Screening: Targeted screening (A1C/FPG) every 2 years for children with risk factors (pubertal + 2 factors, or prepubertal + 3 factors) [Grade D, Consensus].
Management:
Metformin is the first-line oral agent [Grade A, Level 1A].
Insulin should be used for severe metabolic decompensation (DKA, A1C 9.0%) [Grade D, Consensus].
Complications: Screen for nephropathy, retinopathy, neuropathy, dyslipidemia, and hypertension at diagnosis and annually thereafter [Grade D, Consensus].
Mental Health: Screen for diabetes distress and mental health issues regularly [Grade D, Consensus].
PCOS: Adolescent females with T2D should be assessed for menstrual irregularities and hyperandrogenism [Grade D, Consensus].