Rising rates of gestational diabetes suggest dramatic increase in children with early onset type 2 diabetes; aggressive attention is warranted.
About one in 10 pregnant women develop gestational diabetes, on of the most common medical complications during pregnancy.1
That bodes poorly not only for their own future diabetes risk, but also for that of their offspring,2 according to Sonia Caprio, MD, professor of pediatric endocrinology at Yale University School of Medicine, New Haven. She focused on the long-term health outcomes of offspring of mothers with gestational diabetes, making some sobering predictions and suggesting the need for more intensive screening during her presentation at the 14th World Congress on Insulin Resistance, Diabetes & Cardiovascular Disease.
"Children whose mothers had gestational diabetes should be screened for impaired glucose tolerance,'' Dr Caprio said, and “preventive strategies to forestall type 2 diabetes (T2D) should be launched from an early age.”
The prevalence of T2D has risen in the last two decades, now accounting for one-third of the diabetes diagnoses among 10 to 19 year olds, Dr. Caprio said, making it the most commonly occurring, chronic childhood disease.3 While well known, this growing public health concern disproportionally affects minority populations, necessitating heightened attention of clinicians caring for these populations, Dr. Caprio said.
In particular, the risk of T2D in other-than-Caucasian children, ages 10 to 19, is as follows:
Youth with T2D are more adversely affected by macrovascular complications than adults, based on study findings. Researchers compared the prevalence of complications in 354 patients with T2D between 15 and 30 years old, and 1,062 individuals diagnosed between ages 40 and 50.4 The younger group had more severe albuminuria (P=0.004) and neuropathy (P=0.003).
Not surprising, obesity in the youth is a strong predictor, driving the trend of early-onset diabetes, Dr. Caprio said. "I haven't seen a youth with T2D who wasn’t obese, not yet," she told Congress attendees.
The two main risk factors driving the latency period from the onset of obesity to the development of T2D, she said, are: (1) the duration of obesity and (2) degree of obesity. There are other factors, of course, including genetics and prenatal exposure to gestational diabetes.
Studies in Pima Indian children have found that exposure to diabetes in utero was the strongest single risk factor for them developing it (OR 10.4, 95% CI 4.31-25.12).5,6
The evidence has been less strong in non-Indian populations, according to Dr. Caprio. Her team set out to see if exposure to hyperglycemia in utero would increase the risk of impaired glucose tolerance in obese teens.
They hypothesized that the altered glucose metabolism would be driven by an impairment of beta cell secretion relative to insulin sensitivity.
The researchers evaluated 255 obese teens with normal glucose tolerance at the start;5 they evaluated phenotypes for the insulin axis using OGTT: whole body insulin sensitivity index, insulinogenic index and oral disposition index.
Of the 255, 45 were exposed to gestational diabetes in utero; 210 were not. Over the 3-year follow up, 31% of those exposed developed impaired glucose tolerance or diabetes, but just 8.6% of those not exposed developed T2D.
Just as in adults, the onset of diabetes in children is preceded by a finding of impaired glucose tolerance (IGT). Therefore, children whose mothers were diagnosed with gestational diabetes should be screened for impaired glucose tolerance, and preventive strategies should be initiated—the sooner, the better, Dr. Caprio said.
Gestational diabetes is expected to continue rising—perhaps to 18% of pregnant women—so unless action is taken, Dr. Caprio said, the future will be challenge families and the health care system with even more children with early-onset diabetes, requiring decades of care and the prospect of numerous comorbid complications.
“The take-home points are clear,” said Ralph DeFronzo, MD, professor of medicine and chief of the diabetes division, University of Texas Health Science Center at San Antonio, who attended the presentation. "All women during pregnancy should be tested for diabetes and treated," he said.
Beyond that, physician education is clearly needed, Dr. DeFronzo said. Pediatricians must gain insights from and training by pediatric endocrinologists to care for obese toddlers and children more effectively, he said, and to be aware of the potential for early concerns, such as impaired glucose tolerance.
"These kids need to be followed," he said. And, at the first signs of glucose irregularities, they should receive early intervention
Dr. Caprio reports disclosures with Novo-Nordisk, Sanofi-Regeneron and Daichi Sankio.
1. DeSisto CL, Kim SY, Sharma AJ. Prevalence Estimates of Gestational Diabetes Mellitus in the United States, Pregnancy Risk Assessment Monitoring System (PRAMS), 2007–2010. Prev Chronic Dis 2014;11:130415
2. Caprio S. Offspring of mothers with gestational diabetes: a prediabetic condition. Presented at the 14th World Congress on Insulin Resistance, Diabetes & Cardiovascular Risk. Dec. 1-3, 2016, Universal City, California.
3. Centers for Disease Control and Prevention. Diabetes Report Card, 2014. Atlanta, GA: Centers for Disease Control and Prevention, US Dept of Health and Human Services; 2015. Available at: http://www.cdc.gov/diabetes/library/reports/congress.html
4. Abdulghani H. et. al. An Inverse Relationship Between the Age of Type 2 Diabetes Onset and Complication Risk and Mortality: The Impact of Youth-Onset Type 2 Diabetes. Diabetes Care. 2016;May; 39(5)823-829.
5. Leslie O. Schulz LO, Bennett PH, Ravussin E, et al. Effects of Traditional and Western Environments on Prevalence of Type 2 Diabetes in Pima Indians in Mexico and the U.S. Diabetes Care 2006; 29(8): 1866-1871
6. Pavkov ME, Hanson RL, Knowler WC, et al. Changing Patterns of Type 2 Diabetes Incidence Among Pima Indians. Diabetes Care 2007 Jul; 30(7): 1758-1763