by Meredith Jackson
In Middle Tennessee, where roughly one-third of children are overweight or obese, the risk of developing pediatric type 2 diabetes is high and the consequences can be serious.
The risk of death is 36 percent higher in patients diagnosed with type 2 diabetes in their late teens and 20s than it is among adults diagnosed in their 30s.
“Type 2 diabetes is much more aggressive in children and we don’t understand why,” said Ashley Shoemaker, M.D., MSCI, assistant professor of Pediatrics in the Division of Endocrinology and Diabetes at Vanderbilt.
Shoemaker and her colleagues direct the Vanderbilt Pre-Diabetes Clinic, which aims to prevent or manage type 2 diabetes in young people.
Her colleagues include Cassie Brady, M.D., assistant professor of Pediatrics, Tamasyn Nelson, D.O., assistant professor of Pediatrics, and nurse practitioner Sharon Karp, MSN, Ph.D., assistant professor of Nursing.
They are particularly interested in borderline cases — patients who have some potential signs or symptoms of early type 2 diabetes but who don’t fit the diagnostic criteria of patients served by other clinics.
The clinic’s collaborative environment provides patients with access to lab tests, endocrinologists, weight management physicians and dietitians — all in one place.
“We try to figure out which kids need medical intervention right now and which are at high risk but can really focus on lifestyle and weight management,” Shoemaker said.
The clinic also is the only site in Tennessee where patients can enroll in clinical trials of potential new treatments for pediatric type 2 diabetes.
“We want to catch (patients) early before they’ve already lost the ability to make insulin,” Shoemaker said. “We get them the medical evaluation that the families and pediatricians often want but also physician-led, lifestyle management that they really need.”
Type 2 diabetes results from an inadequate supply of insulin, a hormone that normally moves glucose from the bloodstream into muscle where it is used for energy, or from the body’s “resistance” to the actions of insulin. Either way, bloodstream levels of glucose rise.
Although in type 2 diabetes the beta cells of the pancreas are still able to produce insulin, eventually they begin to fail. This progression happens faster in children than adults.
Patients may require metformin, a drug that can increase the sensitivity of tissues to insulin, or insulin shots to supplement the body’s supply of the hormone. There are side effects to both treatments, including weight gain.
In addition, drug treatment does not delay progression of diabetes for as long in children as it does in adults.
“Over half the pediatric patients will fail one drug in the first two years or so,” Shoemaker said. “This is especially concerning because in adults the time to disease progression is much longer, typically five years.”
This spring, the pre-diabetes clinic began enrolling patients in two clinical trials testing a class of drugs called GLP-1 receptor agonists. These drugs require fewer injections than insulin and can actually lead to weight loss rather than weight gain.
While these drugs have been used to treat adults with type 2 diabetes since 2005, they have yet to garner FDA approval in children. One reason for the slow progress is that young patients are often lost to follow-up.
This month in the journal Hormone Research in Pediatrics, Shoemaker and colleagues in the Pediatric Diabetes Consortium reported that 55 percent of 496 teenage patients enrolled in seven diabetes clinics around the country were lost to follow-up after about a year.
Type 2 diabetes “requires a new clinic model that is specifically designed for these adolescent patients and addresses the unique socioeconomic, cultural and language barriers of this population,” the researchers concluded. “We also recommend investigating telemedicine, as distance from the clinic was an identifiable barrier to care.”
To improve retention rates, the Vanderbilt Pre-Diabetes Clinic is in the process of setting up outreach clinics in Murfreesboro, Jackson, Cookeville and Franklin.
Lifestyle changes can have a profound effect on the progression of type 2 diabetes.
“We’ve had patients who we’ve been able to take off medicine after a year because they’ve been able to exercise more or lose weight,” Shoemaker said.
For more information about the clinical trials, contact the study coordinator, Jenny Leshko at Jenny.Leshko@vanderbilt.edu or 615-875-7803.
