The 2022 edition of "ISPAD Consensus on the Management of Type 2 Diabetes in Children and Adolescents" was released! List of 104 core recommended contents

With lifestyle changes and increasing obesity rates, the incidence of type 2 diabetes in adolescents is increasing
.
Adolescent type 2 diabetes is different from both type 1 diabetes and adult type 2 diabetes (which progresses faster and is more difficult to treat than adult-onset diabetes), and the prevention and control situation is grim.

Recently, the International Society of Child and Adolescent Diabetes (IS PAD): Consensus on the Management of Type 2 Diabetes in Children and Adolescents (2022 Edition) was released, the Ministry Consensus incorporates the latest evidence-based medical evidence, and updates the 2018 version of the Consensus, covering "screening, diagnosis, drug management, comorbidities/complications management" and other aspects, a total of hundreds of recommendations have been put forward, and this article compiles and shares the core content
。

"Screening" - pay attention to risk factors, obesity is the most "fatal"

The consensus suggests:

➤ Consider T2D screening
after the onset of puberty or after age 10 for children and adolescents with risk factors for type 2 diabetes mellitus (T2D), especially body mass index (BMI) ≥ 85th percentile.
A

➤ Fasting blood glucose (FPG), blood glucose 2 hours after 75g oral glucose tolerance test (OGTT), or glycated hemoglobin (HbA1c) can be used as screening indicators
.
B

➤If the blood sugar is normal, it is recommended to repeat it at least every 3 years
.
Annual screening is recommended if there is significant weight gain, worsening cardiometabolic markers, a strong family history of T2D, or evidence of prediabetes
.
C

➤ Clinical evaluation of other obesity-related comorbidities (hypertension (HTN), dyslipidemia, nonalcoholic fatty liver disease (NAFLD), polycystic ovary syndrome (PCOS), obstructive sleep apnea (OSA)) should be performed during screening
。 A

"Diagnosis" - "6.
5, 7.
0, 11.
1", do not "cross" the red line indicator

Consensus suggests that symptoms of hyperglycemia, any of the following laboratory values, and negative islet autoantibodies confirm the diagnosis of type 2 diabetes
.
B

· HbA1c≥6.
5%

· FPG≥7.
0 mmol/L

· OGTT 2h blood glucose ≥ 11.
1mmol/L (OGTT: anhydrous glucose dose calculation, 1.
75g/kg, maximum dosage 75g)

Random plasma blood glucose ≥ 11.
1mmol/L

"Blood sugar control target" - blood glucose "6 and 8", glycation "6.
5"

The consensus suggests:

➤ The recommended control target for FPGs is 4–6 mmol/L
.
E

➤ A recommended target for postprandial glycaemic control is 4–8 mmol/L
.
E

➤ A control target of <7% HbA1c is recommended, and 6.
5% is recommended in most cases <
.
E

➤ During acute illness, when symptoms of hyperglycemia/hypoglycemia occur, more frequent blood glucose monitoring should be done and their diabetes care team should be contacted for advice
.
E

➤ Adolescents using insulin (or sulfonylureas) need to have more frequent self-monitoring of blood glucose (SMBG) to monitor asymptomatic hypoglycemia, especially at night
.
E

➤ It is recommended to measure HbA1c
every 3 months.
E

"Patient education" – limit calories, reduce sedentary time, get enough sleep

1.
Food education

➤ Do not drink sugary soft drinks and juices
.
B

➤ Reduce your intake
of foods made from refined monosaccharides and high-fructose corn syrup.
B

➤ Limit foods
high in fat and/or calories.
B

➤ Reduce the intake
of processed, prepackaged and convenience foods.
E

➤ Limit the total amount
.
E

➤ Reduce eating
out.
E

➤ Increase vegetable intake and use fruits in moderation instead of high-calorie and low-nutrient foods
.
E

➤ Change the staple food from white rice and white noodles to brown rice and whole grains with a low glycemic index to promote the gradual absorption
of glucose with meals.
E

➤ Teach family members to read and understand nutrition labels
.
E

➤ Emphasize healthy parenting practices related to diet and activity to promote healthy eating habits for parents while avoiding excessive restriction of food intake
.
E

➤ Encourage positive reinforcement of all goals achieved (e.
g.
, no or only minimum weight gain, reduction of high-calorie beverages).

E

➤ It is recommended to develop the habit of eating regularly in a fixed place, preferably family-oriented, avoiding other activities (such as TV, computer, studying) during meals, and minimizing frequent snacking
.
E

➤ Keep food and activity logs, which help raise awareness of food and activity issues and monitor progress
.
E

2.
Sports education

➤ Encourage young people to participate in at least 60 minutes of moderate to vigorous physical activity daily and muscle and bone strength training
at least 3 days a week.
B

➤ Reduce sedentary time (including watching TV, computer-related activities, texting, and playing video games) to less than
2 hours per day.
C

➤ Address sedentary time spent on schoolwork and identify ways
to incorporate physical activity.
E

➤ Promote physical activity as a family activity, including daily efforts to be more physically active, such as using stairs instead of elevators, walking or cycling to school and shopping, and doing housework and yardwork
.
E

➤ Encourage the positive consolidation of all achievements and avoid stigma.

E

3.
Sleep recommendations

➤ Focus on rest time, sleep time and quality
.
E

➤ It is recommended to ensure adequate quality sleep of 8-11 hours per night (9-11 hours for children aged 5-13 and 8-10 hours for adolescents aged 14-17).

C

➤ Encourage regular wake-up and
bedtime times.
E

"Drug Treatment" - Lifestyle changes, metformin is the first choice

1.
Initiation of treatment

➤ If HbA1c < 8.
5%, "metformin combined with healthy lifestyle changes" is the preferred treatment strategy
.
A

➤ For 8.
5% of patients with ketosis/ketouria/ketoacidosis or HbA1c≥ insulin therapy is initially required, intermediate-acting or long-acting basal insulin (starting dose 0.
25-0.
5/kg) once
daily.
B

➤ It is usually possible to transition to metformin treatment within 2-6 weeks, reducing the insulin dose by 30% to 50% each time the metformin dose
is increased.
Insulin therapy
can be phased out if optimal glycaemic control can be achieved.
B

2.
Follow-up treatment

➤ The initial treatment target is recommended to be HbA1c<7.
0%, and in some cases can be <6.
5% in the absence of hypoglycemia
.
C

➤ If the HbA1c control target of <7.
0% is not met, consider adding a second agent
.
C

➤ The choice of the second agent should consider the desired degree of glucose reduction, mechanism of action, cost and scope of payment, regulatory approval, route of administration, dosing regimen, expected weight loss, side effects, and impact on
comorbidities and complications.
E

➤ If HbA1c >10%, basal insulin
should be started or restarted.
C

Figure 1 Initial management and follow-up treatment of T2D in children/adolescents

"Management of comorbidities and complications" – blood pressure, lipids, kidney function.
.
.
Focus on 9 types of diseases

1.
High blood pressure

➤ Blood pressure (BP) should be measured in a sitting position at each subsequent visit, with your feet on the floor, arms supported at heart level, and a properly sized cuff
after a 5-minute break.
A

➤ Ideally, recent stimulants, caffeine, or smoking
should be avoided when measuring blood pressure.
B

➤Blood pressure
should be measured using a mercury sphygmomanometer, aneroid sphygmomanometer, or oscilloscope.
Abnormal oscilloscope values should be confirmed
by auscultation.
B

➤ If white coat HTN is suspected or HTN is confirmed, ambulatory blood pressure monitoring (ABPM)
may be considered.
ABPM can also be used to assess response
to treatment.
B

➤ For young people diagnosed with HTN, echocardiographic evaluation is recommended to assess for left ventricular target organ damage
.
C

➤ Initial management should include improvements in eating habits, such as the DASH diet
.
B

➤ Initial drug therapy should be monotherapy with an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker (ARB), and the dose should be increased to bring blood pressure into the normal range
.
A

➤ If ACE inhibitors are not tolerated due to adverse effects (mainly cough), ARB, calcium channel blockers, or diuretics
may be selected.
E

➤ If HTN does not return to normal after monotherapy, combination therapy
may be required.
However, due to the plethora of adverse events and no additional clinical benefit, the combination of
ACE inhibitors with ARBs is not recommended.
E

➤ If HTN does not respond to initial medical therapy, evaluate the secondary cause
of HTN.
E

➤The potential teratogenic effects of ACEi and ARB in sexually active adolescent women must be added to the discussion
.
E

2.
Dyslipidemia

➤ For young people with T2D, dyslipidemia testing should be performed after blood glucose is controlled or 3 months after starting medication, regardless of HbA1c value, and annually
thereafter.
B

➤ If cholesterol levels are above target, medications should be optimized to improve blood sugar levels and recommended diets are followed by the American Heart Association Step 2 Diet and the Cardiovascular Health Integrated Lifestyle Diet (CHILD-2 diet
).
B

➤ After a 6-month trial of lifestyle modification interventions, statins should be started in adolescents with T2D who still > 3.
4 mmol/L LDL cholesterol levels
.
B

➤ Statin therapy has been shown to be safe and effective in young people and should be used as the drug of choice
.
A

➤ Statins should be started
with the lowest available dose.
A

➤ Lipid examination
4-12 weeks after the first 4-12 weeks and dose change.
B

➤ If the LDL cholesterol target level is not reached after at least 3 months of regular statin use, the dose can be further increased (usually 10 mg).

Or a second preparation, such as bile acid isolate or cholesterol absorption inhibitor
, can be added.
E

➤Initial treatment strategies for elevated triglycerides (TG) (≥1.
7 mmol/L) focus on improving blood glucose levels, limiting fat and simple sugar intake, and losing weight
.
C

➤ If LDL-C < 130 mg/dl but TG levels > 400 mg/dl, fibrates should be started
.
C

➤ Fish oil concentrate may be considered, but lipid profiles should be carefully monitored as high doses of docosahexaenoic acid (DHA) can increase LDL-C
.
C

➤ Combination therapy with statins and fibrates is generally not recommended
.
E

➤ Young people with low HDL-C levels that cannot be directly controlled by drugs should be encouraged to exercise, avoid smoking, and eat a healthy diet
.
E

➤ The potential teratogenic effects of statins in sexually active adolescent women must be added to the discussion
.
E

3.
Kidney disease

➤ Screening for albuminuria (3 morning urination) should be performed at the time of diagnosis and annually
after diagnosis.
A

➤ If "urine albumin/creatinine ratio > 30 mg/g and blood pressure increases" or "urine albumin/creatinine ratio >300 mg/g, regardless of blood pressure", ACEi or ARB should be initiated and blood pressure normalized
.
B

➤ If a severe increase in proteinuria (albumin/creatinine ratio > 300 mg/g) or HTN occurs, other causes of kidney disease should be considered and consultation with a nephrologist
.
E

➤ After 6 months of taking ACEi or ARB blockers, repeated urine albumin/creatinine ratios may help ensure normalization
of proteinuria.
E

➤ If proteinuria is present, serum potassium concentration and renal function
should be assessed annually.
E

➤ Cystatin C is not currently recommended as a marker of glomerular filtration rate because they are highly variable and are affected by age, sex, BMI, and HbA1c levels
.
E

4.
Non-alcoholic fatty liver

➤ Liver enzymes (alanine aminotransferase [ALT], aspartate aminotransferase [CAST]) should be measured at diagnosis, annually thereafter, and as early as possible if abnormal
.
B

➤ If liver enzymes are still more than 3 times the upper limit of normal after 6 months, consult a pediatric gastroenterologist to rule out other causes of elevated liver enzymes using imaging and/or liver biopsy
.
B

➤The presence of NAFLD does not prevent the use of
metformin.
B

➤ Adequate management of NAFLD requires optimizing blood sugar levels and improving body weight
.
C

5.
Obstructive sleep apnea

➤ The symptoms of obstructive sleep apnea syndrome (OSA) should be evaluated at the time of diagnosis and annually after diagnosis, unless excessive weight gain requires advance examination
.
C

➤ OSA can be initially assessed
by symptoms such as snoring, sleep quality, apnea, morning headache, daytime sleepiness, nocturia, and enuresis.
E

➤ If symptoms suggest OSA, it is recommended to make the diagnosis
by referral to a sleep specialist.
C

6.
Polycystic ovary syndrome

➤ At the time of diagnosis and at every subsequent visit, every girl with T2D should be tested
for menstrual history.
B

➤ PCOS screening should be performed at the time of diagnosis in adolescent girls and annually thereafter, and assessed for menstrual history (primary or secondary amenorrhea) and evidence of hyperandrogenism (hirsutism and/or moderate to severe acne and/or elevated free testosterone levels).

B

➤ The diagnosis of PCOS is based on clinical or biochemical evidence of oligomenorrhea or amenorrhea with hyperandrogenemia after exclusion of other possible causes
.
B

➤ Pelvic ultrasound is not recommended for the diagnosis of PCOS within 8 years of
menarche.
B

7.
Retinopathy

➤ Adolescent patients with T2D are screened for retinopathy at the initial consultation, followed by a comprehensive eye examination
by an ophthalmologist or optometrist by dilated pupils or retinal photography every year.
A

➤ If retinopathy is present or progressive, more frequent examinations
by an ophthalmologist may be required.
C

➤Treatment of retinopathy should also include optimization of blood glucose levels and treatment of dyslipidemia and HTN
, if present.
E

8.
Neuropathy

➤ A foot examination (including sensation, vibration, light touch, and ankle reflexes) is recommended at the time of diagnosis and annually to detect neuropathy
.
C

➤ Young people with diabetes should be taught proper foot care
.
E

➤ Individualized treatment based on signs and symptoms; If there are abnormal neurological signs, referral to a neurologist
should be considered.
E

9.
Mental health

➤ Youth with T2D should be screened for psychological comorbidities, including depression, diabetic distress, and eating disorders, at diagnosis and at regular follow-up
intervals.
B

➤ Mental health support
should be provided to youth identified as having mental health issues in conjunction with clinics or through community mental health programs.
E

➤ Providers should avoid stigmatizing language and promote contextualization and understanding of the complexities of childhood T2D, which encompasses more than just lifestyle-based behaviors
.
E

Full version of consensus: https://guide.
medlive.
cn/guideline/26871

References: Shah AS, Zeitler PS, Wong J, et al.
ISPAD Clinical Practice Consensus Guidelines 2022: Type 2 diabetes in children and adolescents.
PEDIATRIC DIABETES.
2022 Sep 25.
DOI: 10.
1111/pedi.
13409, PMID:36161685