KEYSTONE, COLO. — Adherence to therapy is dismal among adolescents with type 2 diabetes, in part because of a widespread mistaken notion that their condition requires less attention than does type 1.
“We need to understand that this is a very serious disorder. I think many patients get the message that, 'Whew, I don't have type 1 diabetes.' Unfortunately, they should have just the opposite reaction,” Dr. Phil Zeitler said
Dr. Zeitler serves as study chair for Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY), a large, ongoing, multicenter National Institutes of Health–sponsored study. At entry, participants were generally in good glycemic control, yet already about 15% had moderate to severe hypertension, 12% had microalbuminuria, 20% had hypertriglyceridemia, and 60% had low high-density lipoproteins.
Moreover, 17% of the participants had both dyslipidemia and hypertension above the 95th percentile. Given the central role obesity plays in type 2 diabetes, this meant they also met criteria for the metabolic syndrome, added Dr. Zeitler of the department of pediatrics and clinical science at the University of Colorado, Denver, and medical director of the Children's Hospital Clinical Translational Research Center.
Several years ago, he coauthored an analysis of published studies that showed that hypertension and nephropathy occur earlier and progress more aggressively in teens with type 2 diabetes than with type 1 (Lancet 2007;369:1823-31). For example, one study showed hypertension was already present at the time diabetes was diagnosed in 30% of the adolescents with type 2, compared with 4% with type 1. Microalbuminuria was present at diagnosis in 14% with type 2 and 0% with type 1.
In an Australian study, hypertension was present in 36% of type 2 diabetic patients and microalbuminuria in 28% a mean of only 1.3 years after diagnosis, compared with 16% for hypertension and 6.8% for microalbuminuria at 6.8 years' follow-up in adolescents with type 1 diabetes.
Dr. Zeitler said the available evidence indicates that a 15-year-old with type 2 diabetes develops nephropathy at the same rate as an adult diagnosed with type 2 diabetes at age 50 or older. Thus, 15 years after diagnosis of type 2 diabetes, the incidence of nephropathy is as high as 100 cases per 1,000 person-years—but someone diagnosed with type 2 disease at age 15 confronts this high rate of nephropathy at a mere 30 years of age.
Teens with type 2 diabetes have increased rates of numerous cardiovascular abnormalities, including greater carotid intima-media thickness than age- and body mass index–matched peers, higher mean nighttime systolic and diastolic blood pressures, diminished nocturnal decline in blood pressure, increased arterial stiffness, and left ventricular hypertrophy.
Diabetes in an adult is so potent a CV risk factor that it is considered a coronary heart disease equivalent. Noting that the average time from diagnosis of type 2 diabetes to a first CV event is 10–15 years in adults, Dr. Zeitler cautioned that if the time course of CV disease related to diabetes in adolescents is similar, “we can anticipate that adolescents with type 2 diabetes will begin having substantial cardiovascular morbidity and mortality in their 30s or 40s.”
And now for the really bad news: Adherence to treatment in adolescents with type 2 diabetes is “terrible,”he said. Most TODAY participants don't consistently attend clinic appointments. They also report discontinuing antidiabetic drugs periodically, said Dr. Zeitler at the meeting, which was sponsored by the University of Colorado, Denver, and the Children's Diabetes Foundation at Denver.
Dr. Zeitler serves as an adviser to several pharmaceutical companies.
Hypertension was present in 30% of adolescents diagnosed with type 2 diabetes, compared with 4% with type 1.
Source DR. ZEITLER