Shazhan Amed

Type 2 Diabetes, Medication-Induced Diabetes, and Monogenic Diabetes in Canadian Children: A Prospective National Surveillance Study

OBJECTIVE To determine in Canadian children aged <18 years the 1) incidence of type 2 diabetes, medication-induced diabetes, and monogenic diabetes; 2) clinical features of type 2 diabetes; and 3) coexisting morbidity associated with type 2 diabetes at diagnosis. RESEARCH DESIGN AND METHODS This Canadian prospective national surveillance study involved a network of pediatricians, pediatric endocrinologists, family physicians, and adult endocrinologists. Incidence rates were calculated using Canadian Census population data. Descriptive statistics were used to illustrate demographic and clinical features. RESULTS From a population of 7.3 million children, 345 cases of non–type 1 diabetes were reported. The observed minimum incidence rates of type 2, medication-induced, and monogenic diabetes were 1.54, 0.4, and 0.2 cases per 100,000 children aged <18 years per year, respectively. On average, children with type 2 diabetes were aged 13.7 years and 8% (19 of 227) presented before 10 years. Ethnic minorities were overrepresented, but 25% (57 of 227) of children with type 2 diabetes were Caucasian. Of children with type 2 diabetes, 95% (206 of 216) were obese and 37% (43 of 115) had at least one comorbidity at diagnosis. CONCLUSIONS This is the first prospective national surveillance study in Canada to report the incidence of type 2 diabetes in children and also the first in the world to report the incidence of medication-induced and monogenic diabetes. Rates of type 2 diabetes were higher than expected with important regional variation. These results support recommendations that screening for comorbidity should occur at diagnosis of type 2 diabetes.

Clinical management of youth with gender dysphoria in Vancouver.

OBJECTIVE To describe patient characteristics at presentation, treatment, and response to treatment in youth with gender dysphoria. STUDY DESIGN A retrospective chart review of 84 youth with a diagnosis of gender dysphoria seen at BC Childrens Hospital from 1998-2011. RESULTS Of the 84 patients, 45 (54%) identified as female-to-male (FtM), 37 (44%) as male-to-female (MtF), and 2 (2%) as natal males who were undecided. Median age of presentation was 16.9 years (range 11.4-19.8 years) and 16.6 years (range 12.3-22.5 years) for FtM and MtF youth, respectively. Gonadotropin-releasing hormone analog treatment was prescribed in 27 (32%) patients. One FtM patient developed sterile abscesses with leuprolide acetate; he was switched to triptorelin and tolerated this well. Cross-sex hormones were prescribed in 63 of 84 patients (39 FtM vs 24 MtF, P < .02). Median age at initiation of testosterone injections in FtM patients was 17.3 years (range 13.7-19.8 years); median age at initiation of estrogen therapy in MtF patients was 17.9 years (range 13.3-22.3 years). Three patients stopped cross-sex hormones temporarily due to psychiatric comorbidities (2 FtM) and distress over androgenic alopecia (1 FtM). No severe complications were noted in patients treated with testosterone or estrogen. CONCLUSION Treatment with gonadotropin-releasing hormone analog and/or cross-sex hormones, in collaboration with transgender-competent mental health professionals, is an intervention that appears to be appropriate in carefully selected youth with gender dysphoria. Long-term follow-up studies are needed to determine the safety of these treatments in this age group.

Type 2 diabetes in children and adolescents

The emergence of Type 2 diabetes (T2D) in children and adolescents parallels the rising rates of childhood obesity. As a condition of impaired insulin sensitivity and relative insulin deficiency resulting in hyperglycemia, T2D has a complex underlying physiology that is reflected by the multiple approaches used to optimize medical care and prevent the myriad of diabetes-related complications. T2D diagnosed in children and adolescents represents a distinct and challenging condition to evaluate and treat. Here, we highlight the epidemiology, pathophysiology, risk factors, clinical presentation and diagnosis, treatment and public health impact of T2D in children and adolescents.

Validation of classification algorithms for childhood diabetes identified from administrative data

Vanderloo SE, Johnson JA, Reimer K, McCrea P, Nuernberger K, Krueger H, Aydede SK, Collet J‐P, Amed S. Validation of classification algorithms for childhood diabetes identified from administrative data.

Validation of diabetes case definitions using administrative claims data

Diabet. Med. 28, 424–427 (2011)

Risk Factors for Medication-Induced Diabetes and Type 2 Diabetes

OBJECTIVE To compare the prevalence of risk factors in children aged <18 years diagnosed with medication-induced diabetes mellitus versus those diagnosed with type 2 diabetes. STUDY DESIGN This retrospective observational study used data from a Canadian prospective surveillance study in which clinical features of new cases of type 2 diabetes (n = 225) and medication-induced diabetes (n = 58) were reported over a 2-year period. The presence of risk factors for type 2 diabetes (eg, obesity, family history of type 2 diabetes, ethnicity, acanthosis nigricans, hypertension, polycystic ovarian syndrome) was compared in the 2 groups using descriptive statistics and logistic regression. RESULTS Compared with the children with type 2 diabetes, the children with medication-induced diabetes were more likely to be Caucasian (P < .0001) and less likely to be obese (P < .0001), to have a positive family history of type 2 diabetes (P = .0001), to have acanthosis nigricans (P < .0001) on clinical examination, and to have an obesity-related comorbidity, such as polycystic ovarian syndrome (P = .04), dyslipidemia (P = .02), hypertension (P = .04), or an elevated alanine aminotransferase level (P = .05). CONCLUSIONS Evaluating for the typical risk factors for type 2 diabetes is not sufficient to identify all children at risk for developing medication-induced diabetes. Further studies are needed to help inform guidelines on screening for and prevention of medication-induced diabetes in children.

Differing clinical features in Aboriginal vs. non‐Aboriginal children presenting with type 2 diabetes

Childhood type 2 diabetes (T2D) is increasing and may present differently across various populations. This study compares clinical features of T2D at diagnosis in Aboriginal children with Caucasian children and children from other high‐risk ethnic groups.

The Future of Treating Youth-Onset Type 2 Diabetes: Focusing Upstream and Extending Our Influence into Community Environments

Type 2 diabetes (T2D) in youth is on the rise and many of these youth already have comorbidity at disease onset. The TODAY trial clearly demonstrated the challenges of treating this disease. Obesity is a key risk factor in the development of youth-onset T2D, and its prevention can mitigate the risk for developing T2D. However, childhood obesity prevention efforts to date have shown only modest effectiveness. Considering the larger, complex socioeconomic and cultural contexts that influence health behaviors among children and their families can enhance prevention efforts. Community-based participatory, multi-component, multi-setting childhood obesity prevention initiatives designed using the socio-ecological model and systems theory have been effective in sustainably decreasing childhood overweight and obesity. To advance our progress in treating and preventing T2D in youth, we must apply this new knowledge on community-wide childhood obesity prevention to enhance the impact of individual-level therapeutic strategies such as the TODAY intervention.

Care delivery in youth with type 2 diabetes – are we meeting clinical practice guidelines?

Studies indicate high rates of treatment failure and early onset diabetes‐related complications in youth‐onset type 2 diabetes (T2D). We aim to describe the quality of care provided to children and youth with T2D.

Persistent Albuminuria in Children with Type 2 Diabetes: A Canadian Paediatric Surveillance Program Study.

OBJECTIVE To determine the prevalence and the clinical features associated with persistent albuminuria in Canadian children aged <18 years with type 2 diabetes. STUDY DESIGN This national prospective surveillance study involved a network of pediatricians and pediatric endocrinologists. Cases of persistent albuminuria in children with type 2 diabetes were reported during a 24-month period from 2010 to 2012. Persistent albuminuria was defined as an elevated albumin-to-creatinine ratio in a minimum of 2 out of 3 urine samples obtained at least 1 month apart over 3-6 months and confirmed with a first morning sample. Descriptive statistics were used to illustrate demographic and clinical features of the population. The prevalence of persistent albumuria was estimated using data from a previous national surveillence study of type 2 diabetes in children. RESULTS Fifty cases were reported over the 24-month study period. The estimated prevalence of persistent albuminuria in children with type 2 diabetes in Canada was 5.1%. The median duration of diabetes at the time of diagnosis of albuminuria was 21 days (IQR, 0-241 days). Almost two-thirds (64%) were female, 80% were of Canadian First Nations heritage, and 76% were from Manitoba. Exposure to gestational or pregestational diabetes in utero occurred in 65%, and 48% had a family history of diabetes-related renal disease. Structural anomalies of the kidney were found in 37%. CONCLUSION Persistent albuminuria occurs in youths with type 2 diabetes in the first year after diagnosis, demonstrates regional variation, and is associated with First Nations heritage and exposure to maternal diabetes during pregnancy.