Expert Perspective

Type 2 Diabetes in Adolescents: We Must Do Better

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Risk Factors That Should Prompt Diabetes Screening 11

Screening is recommended in children who are overweight (≥85%) or obese (≥95%) and who also have ≥1 of the following risk factors:

  • Family history of T2D in a first- or second-degree relative
  • Maternal history of gestational diabetes
  • Low birth weight for gestational age
  • Physical signs of insulin resistance or related conditions (eg, hypertension, dyslipidemia, polycystic ovary syndrome)
  • High-risk race/ethnicity (Native American, African American, Pacific Islander, Latino)

Diagnostic Criteria for Diabetes Mellitus 11

Testing method

Normal range


Diabetes mellitus

Fasting glucose

<100 mg/dL

100-125 mg/dL

≥126 mg/dL

2-hour glucose tolerance test

<140 mg/dL

140-199 mg/dL

≥200 mg/dL





A childhood or adolescent T2D diagnosis should be taken seriously and communicated to the patient and family in a timely manner. Treatment should start immediately. There are several factors that make managing T2D in adolescents more challenging. Children do not control key aspects of their life, including nutrition and, often, free time activity. There are a lot of social pressures to be “normal,” and having a chronic disease will definitely make the child feel “different” and potentially feel socially isolated. There are high rates of mood disorders in children with diabetes, which can make self-management even harder. 12

As mentioned above, treatment should begin immediately upon diagnosis. This is because T2D in younger people tends to be more progressive and less responsive to treatment options, and patients are much more likely to develop. 1,13,14 These same complications can be seen in adult patients, but in younger patients they develop earlier in the disease; specifically, renal and neurologic complications occur at even higher rates. 14

The initial treatment should include both family-based therapeutic lifestyle changes (ie, nutrition, physical activity intervention) and medication. 11 There are fewer US Food and Drug Administration–approved medication options for children and adolescents, and those treatments that have been approved are less durable in this population.

Metformin and insulin are the most-used medications, but their initiation is often delayed, as therapeutic lifestyle change is tried first. This has not been shown to be an effective strategy and may even undermine the value of therapeutic lifestyle change if the family is told later that medication may still need to be added.

Recent studies have shown the benefit of select glucagon-like peptide-1 receptor agonists (GLP-1 RAs) as important therapeutic tools to treat T2D in adolescence. Dulaglutide, exenatide, and liraglutide have been shown to be safe and effective in trials for adolescents with T2D. 15-17 These agents reduce glucose and body weight and may be important tools to help reduce extra glycemic risks (eg, cardiovascular disease, kidney disease), but they have not been studied for this purpose yet.

Further, there is good support for the use of bariatric surgery for adolescents. While this is a relatively new treatment option, early and mid-term results are favorable compared with medication-based strategies. 18 Further studies are needed to determine the long-term benefits.

Take home points:

  1. T2D is becoming increasingly common in our youth.
  2. T2D, when diagnosed earlier in life, is more progressive, less responsive to treatment options, and associated with earlier complications.
  3. New studies support the use of novel therapies such as GLP-1 RAs and metabolic surgery in this age group.

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