Type 2 Diabetes in Children and Adolescents.

Abstract

Key Messages•Anticipatory guidance regarding healthy eating, physical activity, limiting screen time and age-appropriate sleep duration/quality is recommended to prevent type 2 diabetes in children and adolescents.•Regular targeted screening for type 2 diabetes is recommended in children at risk.•Children with type 2 diabetes should receive care in consultation with an interprofessional pediatric diabetes health-care team.•Early screening, intervention and optimization of glycemic control are essential, as the onset of type 2 diabetes during childhood is associated with severe and early onset of microvascular and cardiovascular complications.Key Messages for People with Children and Adolescents with Diabetes•There is plenty you can do to help manage or prevent type 2 diabetes in children and adolescents. Encourage your child or adolescent to eat healthy foods, limit sweet drinks (juice, pop), get plenty of physical activity, get a good night's sleep and keep time spent on screens low.•Many children with type 2 diabetes will also require oral glucose-lowering medication and/or insulin for treatment.Note: Unless otherwise specified, the term “child” is used for individuals 0 to 18 years of age, and the term “adolescent” for those 13 to 18 years of age. •Anticipatory guidance regarding healthy eating, physical activity, limiting screen time and age-appropriate sleep duration/quality is recommended to prevent type 2 diabetes in children and adolescents.•Regular targeted screening for type 2 diabetes is recommended in children at risk.•Children with type 2 diabetes should receive care in consultation with an interprofessional pediatric diabetes health-care team.•Early screening, intervention and optimization of glycemic control are essential, as the onset of type 2 diabetes during childhood is associated with severe and early onset of microvascular and cardiovascular complications. •There is plenty you can do to help manage or prevent type 2 diabetes in children and adolescents. Encourage your child or adolescent to eat healthy foods, limit sweet drinks (juice, pop), get plenty of physical activity, get a good night's sleep and keep time spent on screens low.•Many children with type 2 diabetes will also require oral glucose-lowering medication and/or insulin for treatment. Note: Unless otherwise specified, the term “child” is used for individuals 0 to 18 years of age, and the term “adolescent” for those 13 to 18 years of age. Type 2 diabetes in children has increased in frequency around the world over the past 2 decades (1Nadeau K. Dabelea D. Epidemiology of type 2 diabetes in children and adolescents.Endocr Res. 2008; 33: 35-58Crossref PubMed Scopus (40) Google Scholar). Children from ethnic groups at high risk for type 2 diabetes in their adult populations, namely those of African, Arab, Asian, Hispanic, Indigenous or South Asian descent, are disproportionately affected. A Canadian national surveillance study demonstrated a minimum incidence of type 2 diabetes in children and adolescents <18 years of age of 1.54 per 100,000 children per year (2Amed S. Dean H.J. Panagiotopoulos C. et al.Type 2 diabetes, medication-induced diabetes, and monogenic diabetes in Canadian children: A prospective national surveillance study.Diabetes Care. 2010; 33: 786-791Crossref PubMed Scopus (157) Google Scholar). Significant regional variation was observed with the highest minimum incidence seen in Manitoba of 12.45 per 100,000 children per year. In this study, 44% of children with new-onset type 2 diabetes were of Aboriginal heritage, 25% Caucasian, 10.1% Asian, 10.1% African/Caribbean and the remaining of other or mixed ethnic origin (2Amed S. Dean H.J. Panagiotopoulos C. et al.Type 2 diabetes, medication-induced diabetes, and monogenic diabetes in Canadian children: A prospective national surveillance study.Diabetes Care. 2010; 33: 786-791Crossref PubMed Scopus (157) Google Scholar). Recent data from the United States demonstrated an incidence of 8.1 per 100,000 person years in the 10- to 14-year age group and 11.8 per 100,000 person years in the 15- to 19-year age group. In this study, the highest rates were found in American Indian, African American, Asian/Pacific Islander and Hispanic youth (in descending order), and the lowest incidence occurred in non-Hispanic white youth (3Dabelea D. Bell R.A. et al.Writing Group for the SEARCH for Diabetes in Youth Study GroupIncidence of diabetes in youth in the United States.JAMA. 2007; 297: 2716-2724Crossref PubMed Scopus (763) Google Scholar). Type 2 diabetes is a highly heritable condition, with 90% of children and youth affected having a first- or second-degree relative who also has type 2 diabetes (4Copeland K.C. Zeitler P. Geffner M. et al.Characteristics of adolescents and youth with recent-onset type 2 diabetes: The TODAY cohort at baseline.J Clin Endocrinol Metab. 2011; 96: 159-167Crossref PubMed Scopus (299) Google Scholar). A significant proportion of youth with type 2 diabetes live below the poverty line or come from low-resourced homes (5Hamman R.F. Bell R.A. Dabelea D. et al.The SEARCH for Diabetes in Youth study: Rationale, findings, and future directions.Diabetes Care. 2014; 37: 3336-3344Crossref PubMed Scopus (242) Google Scholar). Breastfeeding has been shown to reduce the risk of youth-onset type 2 diabetes in some populations (6Taylor J.S. Kacmar J.E. Nothnagle M. et al.A systematic review of the literature associating breastfeeding with type 2 diabetes and gestational diabetes.J Am Coll Nutr. 2005; 24: 320-326Crossref PubMed Scopus (93) Google Scholar). Obesity is a major risk factor for the development of type 2 diabetes (2Amed S. Dean H.J. Panagiotopoulos C. et al.Type 2 diabetes, medication-induced diabetes, and monogenic diabetes in Canadian children: A prospective national surveillance study.Diabetes Care. 2010; 33: 786-791Crossref PubMed Scopus (157) Google Scholar). The prevalence of obesity among Canadian children aged 5 to 17 years is 12% (7Body mass index of Canadian children and youth. Health Statistics Division: Statistics Canada, Ottawa (ON)2012http://www.statcan.gc.ca/pub/82-625-x/2012001/article/11712-eng.pdfGoogle Scholar). Studies on the prevention of obesity in children are limited and have generally not demonstrated long-term effectiveness (8Oude Luttikhuis H. Baur L. Jansen H. et al.Interventions for treating obesity in children.Cochrane Database Syst Rev. 2009; (CD001872)PubMed Google Scholar, 9Parkin P. Connor G.S. et al.Canadian Task Force on Preventive Health CareRecommendations for growth monitoring, and prevention and management of overweight and obesity in children and youth in primary care.CMAJ. 2015; 187: 411-421Crossref PubMed Scopus (75) Google Scholar). Efforts to improve sleep quality and quantity, decrease sedentary behaviours and increase both light and vigorous physical activity can result in significant metabolic health benefits (10Tremblay M.S. Carson V. Chaput J.P. et al.Canadian 24-hour movement guidelines for children and youth: An integration of physical activity, sedentary behaviour, and sleep.Appl Physiol Nutr Metab. 2016; 41: S311-S327Crossref PubMed Scopus (873) Google Scholar, 11Henderson M. Benedetti A. Barnett T.A. et al.Influence of adiposity, physical activity, fitness, and screen time on insulin dynamics over 2 years in children.JAMA Pediatr. 2016; 170: 227-235Crossref PubMed Scopus (40) Google Scholar). Health Canada has endorsed the Canadian 24-hour Movement Guidelines for children and youth (available at http://www.csep.ca/en/guidelines/get-the-guidelines) (12CSEP Canadian 24-hour movement guidelines for children and youth: An integration of physical activity, sedentary behaviour, and sleep. Canadian Society for Exercise Physiology (CSEP), Ottawa2017http://www.csep.ca/CMFiles/Guidelines/24hrGlines/Canadian24HourMovementGuidelines2016.pdfGoogle Scholar). Interventions aimed at reducing sugar-sweetened beverage consumption among children and youth should also be considered as consumption of these beverages has been linked to both obesity and incident type 2 diabetes (13Te Morenga L. Mallard S. Mann J. Dietary sugars and body weight: Systematic review and meta-analyses of randomised controlled trials and cohort studies.BMJ. 2013; 346: e7492Crossref Scopus (801) Google Scholar, 14Greenwood D.C. Threapleton D.E. Evans C.E. et al.Association between sugar-sweetened and artificially sweetened soft drinks and type 2 diabetes: Systematic review and dose-response meta-analysis of prospective studies.Br J Nutr. 2014; 112: 725-734Crossref PubMed Scopus (225) Google Scholar, 15Laverty A.A. Magee L. Monteiro C.A. et al.Sugar and artificially sweetened beverage consumption and adiposity changes: National longitudinal study.Int J Behav Nutr Phys Act. 2015; 12: 137Crossref PubMed Scopus (55) Google Scholar). Screen time use should be limited, given its relationship to greater insulin resistance and adiposity (16Nightingale C.M. Rudnicka A.R. Donin A.S. et al.Screen time is associated with adiposity and insulin resistance in children.Arch Dis Child. 2017; 102: 612-616Crossref PubMed Scopus (39) Google Scholar). In children with obesity, family-based healthy behaviour interventions, which include physical activity, healthy nutrition and mental health supports have been shown to result in a modest decrease in body mass index (BMI) and improvements in metabolic health parameters. The most effective interventions were those delivered by a specialized interdisciplinary team that included group sessions with parent and family involvement (9Parkin P. Connor G.S. et al.Canadian Task Force on Preventive Health CareRecommendations for growth monitoring, and prevention and management of overweight and obesity in children and youth in primary care.CMAJ. 2015; 187: 411-421Crossref PubMed Scopus (75) Google Scholar). In adolescents with obesity, pharmacotherapy (i.e. orlistat or metformin) in combination with healthy behaviour interventions, demonstrate a very modest additional reduction in BMI over the short term, with frequent gastrointestinal side effects (17Boland C.L. Harris J.B. Harris K.B. Pharmacological management of obesity in pediatric patients.Ann Pharmacother. 2015; 49: 220-232Crossref PubMed Scopus (36) Google Scholar). Long-term studies are absent, and no pediatric studies have been performed to assess the prevention of diabetes or long-term complications using these medications (17Boland C.L. Harris J.B. Harris K.B. Pharmacological management of obesity in pediatric patients.Ann Pharmacother. 2015; 49: 220-232Crossref PubMed Scopus (36) Google Scholar). In adolescents with obesity and evidence of severe insulin resistance, pharmacological therapy with metformin or orlistat should only be considered after a comprehensive evaluation of the child's metabolic status, family history and review of healthy behaviour interventions. Due to a lack of data in prepubertal children, the use of weight management medications should only be considered in this population within the context of a supervised clinical trial (17Boland C.L. Harris J.B. Harris K.B. Pharmacological management of obesity in pediatric patients.Ann Pharmacother. 2015; 49: 220-232Crossref PubMed Scopus (36) Google Scholar, 18McDonagh M.S. Selph S. Ozpinar A. et al.Systematic review of the benefits and risks of metformin in treating obesity in children aged 18 years and younger.JAMA Pediatr. 2014; 168: 178-184Crossref PubMed Scopus (105) Google Scholar, 19Laffel L. Chang N. Grey M. et al.Metformin monotherapy in youth with recent onset type 2 diabetes: Experience from the prerandomization run-in phase of the TODAY study.Pediatr Diabetes. 2012; 13: 369-375Crossref PubMed Scopus (37) Google Scholar). Bariatric surgery may be considered in adolescents with severe obesity (BMI ≥35 kg/m2 with severe comorbidities or ≥40 kg/m2 with less severe comorbidities), who have reached their final adult height and have undergone a comprehensive assessment by an expert interprofessional team, affirming their understanding of the risks and benefits of the procedure, demonstrating their ability to adhere to the necessary pre- and post-operative care, and have appropriate family and social supports (20Michalsky M. Reichard K. Inge T. et al.ASMBS pediatric committee best practice guidelines.Surg Obes Relat Dis. 2012; 8: 1-7Abstract Full Text Full Text PDF PubMed Scopus (160) Google Scholar) (see Weight Management in Diabetes chapter, p. S124). The long-term effectiveness of bariatric surgery remains unknown. The microvascular complications of type 2 diabetes have been identified at diagnosis, implying long-term, unrecognized hyperglycemia (21Pinhas-Hamiel O. Zeitler P. Acute and chronic complications of type 2 diabetes mellitus in children and adolescents.Lancet. 2007; 369: 1823-1831Abstract Full Text Full Text PDF PubMed Scopus (313) Google Scholar). Children may also present with acute decompensation in diabetic ketoacidosis (DKA) and/or hyperosmolar hyperglycemic state (HHS). This argues for a systematic screening program in children at high risk for type 2 diabetes in order to prevent an acute, life-threatening presentation and to decrease the development of chronic complications. Although not proven in children, it is generally assumed that earlier diagnosis of diabetes will lead to interventions that will improve glycemic control and reduce the related short- and long-term complications (21Pinhas-Hamiel O. Zeitler P. Acute and chronic complications of type 2 diabetes mellitus in children and adolescents.Lancet. 2007; 369: 1823-1831Abstract Full Text Full Text PDF PubMed Scopus (313) Google Scholar). Risk factors for the development of type 2 diabetes in children include a history of type 2 diabetes in a first- or second-degree relative (1Nadeau K. Dabelea D. Epidemiology of type 2 diabetes in children and adolescents.Endocr Res. 2008; 33: 35-58Crossref PubMed Scopus (40) Google Scholar, 2Amed S. Dean H.J. Panagiotopoulos C. et al.Type 2 diabetes, medication-induced diabetes, and monogenic diabetes in Canadian children: A prospective national surveillance study.Diabetes Care. 2010; 33: 786-791Crossref PubMed Scopus (157) Google Scholar, 3Dabelea D. Bell R.A. et al.Writing Group for the SEARCH for Diabetes in Youth Study GroupIncidence of diabetes in youth in the United States.JAMA. 2007; 297: 2716-2724Crossref PubMed Scopus (763) Google Scholar, 4Copeland K.C. Zeitler P. Geffner M. et al.Characteristics of adolescents and youth with recent-onset type 2 diabetes: The TODAY cohort at baseline.J Clin Endocrinol Metab. 2011; 96: 159-167Crossref PubMed Scopus (299) Google Scholar, 22Pinhas-Hamiel O. Dolan L.M. Daniels S.R. et al.Increased incidence of non-insulin-dependent diabetes mellitus among adolescents.J Pediatr. 1996; 128: 608-615Abstract Full Text PDF PubMed Scopus (945) Google Scholar), being a member of a high-risk population (e.g. people of African, Arab, Asian, Hispanic, Indigenous or South Asian descent) (1Nadeau K. Dabelea D. Epidemiology of type 2 diabetes in children and adolescents.Endocr Res. 2008; 33: 35-58Crossref PubMed Scopus (40) Google Scholar, 2Amed S. Dean H.J. Panagiotopoulos C. et al.Type 2 diabetes, medication-induced diabetes, and monogenic diabetes in Canadian children: A prospective national surveillance study.Diabetes Care. 2010; 33: 786-791Crossref PubMed Scopus (157) Google Scholar, 3Dabelea D. Bell R.A. et al.Writing Group for the SEARCH for Diabetes in Youth Study GroupIncidence of diabetes in youth in the United States.JAMA. 2007; 297: 2716-2724Crossref PubMed Scopus (763) Google Scholar, 4Copeland K.C. Zeitler P. Geffner M. et al.Characteristics of adolescents and youth with recent-onset type 2 diabetes: The TODAY cohort at baseline.J Clin Endocrinol Metab. 2011; 96: 159-167Crossref PubMed Scopus (299) Google Scholar); obesity (2Amed S. Dean H.J. Panagiotopoulos C. et al.Type 2 diabetes, medication-induced diabetes, and monogenic diabetes in Canadian children: A prospective national surveillance study.Diabetes Care. 2010; 33: 786-791Crossref PubMed Scopus (157) Google Scholar); impaired glucose tolerance (IGT) (23Weiss R. Taksali S.E. Tamborlane W.V. et al.Predictors of changes in glucose tolerance status in obese youth.Diabetes Care. 2005; 28: 902-909Crossref PubMed Scopus (298) Google Scholar); polycystic ovary syndrome (PCOS) (24Palmert M.R. Gordon C.M. Kartashov A.I. et al.Screening for abnormal glucose tolerance in adolescents with polycystic ovary syndrome.J Clin Endocrinol Metab. 2002; 87: 1017-1023Crossref PubMed Scopus (303) Google Scholar); exposure to diabetes in utero (25Dabelea D. Hanson R.L. Lindsay R.S. et al.Intrauterine exposure to diabetes conveys risks for type 2 diabetes and obesity: A study of discordant sibships.Diabetes. 2000; 49: 2208-2211Crossref PubMed Scopus (955) Google Scholar, 26Young T.K. Martens P.J. Taback S.P. et al.Type 2 diabetes mellitus in children: Prenatal and early infancy risk factors among native canadians.Arch Pediatr Adolesc Med. 2002; 156: 651-655Crossref PubMed Scopus (172) Google Scholar, 27Mendelson M. Cloutier J. Spence L. et al.Obesity and type 2 diabetes mellitus in a birth cohort of First Nation children born to mothers with pediatric-onset type 2 diabetes.Pediatr Diabetes. 2011; 12: 219-228Crossref PubMed Scopus (33) Google Scholar); acanthosis nigricans (28Stoddart M.L. Blevins K.S. Lee E.T. et al.Association of acanthosis nigricans with hyperinsulinemia compared with other selected risk factors for type 2 diabetes in Cherokee Indians: The Cherokee Diabetes Study.Diabetes Care. 2002; 25: 1009-1014Crossref PubMed Scopus (86) Google Scholar); hypertension and dyslipidemia (29Weiss R. Dziura J. Burgert T.S. et al.Obesity and the metabolic syndrome in children and adolescents.N Engl J Med. 2004; 350: 2362-2374Crossref PubMed Scopus (2666) Google Scholar); and non-alcoholic fatty liver disease (NAFLD) (30Perseghin G. Bonfanti R. Magni S. et al.Insulin resistance and whole body energy homeostasis in obese adolescents with fatty liver disease.Am J Physiol Endocrinol Metab. 2006; 291: E697-E703Crossref PubMed Scopus (89) Google Scholar). Atypical antipsychotic medications are associated with significant weight gain, insulin resistance and impaired fasting glucose (IFG) or type 2 diabetes in children (31Panagiotopoulos C. Ronsley R. Davidson J. Increased prevalence of obesity and glucose intolerance in youth treated with second-generation antipsychotic medications.Can J Psychiatry. 2009; 54: 743-749Crossref PubMed Scopus (60) Google Scholar, 32Ronsley R. Nguyen D. Davidson J. et al.Increased risk of obesity and metabolic dysregulation following 12 months of second-generation antipsychotic treatment in children: A prospective cohort study.Can J Psychiatry. 2015; 60: 441-450Crossref PubMed Scopus (40) Google Scholar, 33Galling B. Roldan A. Nielsen R.E. et al.Type 2 diabetes mellitus in youth exposed to antipsychotics: A systematic review and meta-analysis.JAMA Psychiatry. 2016; 73: 247-259Crossref PubMed Scopus (160) Google Scholar). Neuropsychiatric disorders and the use of neuropsychiatric medications are more common in children with obesity and type 2 diabetes compared to the general pediatric population (34Levitt Katz L.E. Swami S. Abraham M. et al.Neuropsychiatric disorders at the presentation of type 2 diabetes mellitus in children.Pediatr Diabetes. 2005; 6: 84-89Crossref PubMed Scopus (60) Google Scholar). In a recent national Canadian diabetes incidence study, the mean age of diagnosis of type 2 diabetes in youth was 13.7 years (2Amed S. Dean H.J. Panagiotopoulos C. et al.Type 2 diabetes, medication-induced diabetes, and monogenic diabetes in Canadian children: A prospective national surveillance study.Diabetes Care. 2010; 33: 786-791Crossref PubMed Scopus (157) Google Scholar). However, 8% of all newly diagnosed children with type 2 diabetes were less than 10 years of age. In children of Aboriginal, Caucasian and Asian origin, 11%, 8.8% and 8.7%, respectively, presented at less than 10 years of age. Thus, consideration should be given for screening at a younger age in those at high risk (2Amed S. Dean H.J. Panagiotopoulos C. et al.Type 2 diabetes, medication-induced diabetes, and monogenic diabetes in Canadian children: A prospective national surveillance study.Diabetes Care. 2010; 33: 786-791Crossref PubMed Scopus (157) Google Scholar). A fasting plasma glucose (FPG) is the recommended routine screening test for children, although ensuring a fasting state may be a challenge. The reproducibility of the FPG is high (35Libman I.M. Barinas-Mitchell E. Bartucci A. et al.Reproducibility of the oral glucose tolerance test in overweight children.J Clin Endocrinol Metab. 2008; 93: 4231-4237Crossref PubMed Scopus (131) Google Scholar). The oral glucose tolerance test (OGTT) may have a higher detection rate (36Sinha R. Fisch G. Teague B. et al.Prevalence of impaired glucose tolerance among children and adolescents with marked obesity.N Engl J Med. 2002; 346: 802-810Crossref PubMed Scopus (1412) Google Scholar, 37Reinehr T. Andler W. Kapellen T. et al.Clinical characteristics of type 2 diabetes mellitus in overweight European caucasian adolescents.Exp Clin Endocrinol Diabetes. 2005; 113: 167-170Crossref PubMed Scopus (28) Google Scholar) in children who have severe obesity (BMI ≥99th percentile for age and gender) and who have multiple risk factors for type 2 diabetes, but it has poor reproducibility (35Libman I.M. Barinas-Mitchell E. Bartucci A. et al.Reproducibility of the oral glucose tolerance test in overweight children.J Clin Endocrinol Metab. 2008; 93: 4231-4237Crossref PubMed Scopus (131) Google Scholar). A glycated hemoglobin (A1C) ≥6.0% is able to identify children with type 2 diabetes at 86% sensitivity and 85% specificity and had similar screening efficacy to FPG, when compared to the gold standard 2-hour OGTT (38Shah S. Kublaoui B.M. Oden J.D. et al.Screening for type 2 diabetes in obese youth.Pediatrics. 2009; 124: 573-579Crossref PubMed Scopus (47) Google Scholar), using laboratory-based, DCCT-aligned, National Glycohemoglobin Standardization program-certified methodology. In children with insulin resistance, the screening efficacy of A1C improved to 99% sensitivity and 96% specificity (38Shah S. Kublaoui B.M. Oden J.D. et al.Screening for type 2 diabetes in obese youth.Pediatrics. 2009; 124: 573-579Crossref PubMed Scopus (47) Google Scholar). A1C offers a more practical alternative to fasting blood work and/or a 2-hour OGTT, and is predictive of future diabetes-related complications (39American Diabetes Association Standards of medical care in diabetes—2014.Diabetes Care. 2014; 37: S14-S80Crossref PubMed Scopus (3691) Google Scholar). Limitations include heterogeneous assay methodologies, inaccuracy in the presence of hemoglobinopathies or hemolysis and an inability to accurately predict IGT or IFG. The use of A1C as a screening test for pediatric diabetes is controversial because it diverges to some extent from fasting blood glucose values and post-glucose challenge values. Therefore, A1C should not be relied upon as the sole diagnostic test to screen for type 2 diabetes but rather used in combination with FPG and/or 2-hour OGTT. Given the aforementioned limitations, we recommend using a combination of A1C and fasting or random blood glucose to screen for type 2 diabetes in children and youth with risk factors. A 2-hour OGTT may be considered as an initial screening test in children and youth with 3 or more risk factors and should be done in those in whom there is a discrepancy between the A1C and fasting or random blood glucose results. In most children, the presence of clinical risk factors, mode of presentation and early course of the disease indicate whether the child has type 1 or type 2 diabetes. However, differentiation may be difficult in some. Children with type 2 diabetes can present with DKA (40Pinhas-Hamiel O. Dolan L.M. Zeitler P.S. Diabetic ketoacidosis among obese African-American adolescents with NIDDM.Diabetes Care. 1997; 20: 484-486Crossref PubMed Scopus (136) Google Scholar, 41Sellers E.A. Dean H.J. Diabetic ketoacidosis: A complication of type 2 diabetes in Canadian aboriginal youth.Diabetes Care. 2000; 23: 1202-1204Crossref PubMed Scopus (38) Google Scholar). Testing for diabetes autoantibodies should be considered in all children and adolescents with a clinical diagnosis of type 2 diabetes because of evidence that up to 10% to 20% of these children are autoantibody positive, suggesting that they, in fact, have type 1 diabetes with insulin deficiency and are at risk for other autoimmune conditions (42Klingensmith G.J. Pyle L. Arslanian S. et al.The presence of GAD and IA-2 antibodies in youth with a type 2 diabetes phenotype: Results from the TODAY study.Diabetes Care. 2010; 33: 1970-1975Crossref PubMed Scopus (121) Google Scholar). In addition, the absence of islet autoantibodies may be useful in supporting the diagnosis of type 2 diabetes (43Dabelea D. Palmer J.P. Bennett P.H. et al.Absence of glutamic acid decarboxylase antibodies in Pima Indian children with diabetes mellitus.Diabetologia. 1999; 42: 1265-1266Crossref PubMed Scopus (33) Google Scholar, 44Sellers E. Eisenbarth G. Young T.K. et al.Diabetes-associated autoantibodies in aboriginal children.Lancet. 2000; 355: 1156Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar, 45Hathout E.H. Thomas W. El-Shahawy M. et al.Diabetic autoimmune markers in children and adolescents with type 2 diabetes.Pediatrics. 2001; 107: E102Crossref PubMed Scopus (134) Google Scholar). Fasting insulin levels are not helpful at diagnosis, as levels may be low due to glucose toxicity (46Ferrannini E. Insulin resistance versus insulin deficiency in non-insulin-dependent diabetes mellitus: Problems and prospects.Endocr Rev. 1998; 19: 477-490Crossref PubMed Scopus (392) Google Scholar). DNA diagnostic testing for genetic defects in beta cell function (monogenic diabetes) should be considered in children who have a strong family history suggestive of autosomal dominant inheritance and who are lacking features of insulin resistance. This may be helpful when diabetes classification is unclear and may lead to more appropriate management (47Sellers E.A. Triggs-Raine B. Rockman-Greenberg C. et al.The prevalence of the HNF-1alpha G319S mutation in Canadian aboriginal youth with type 2 diabetes.Diabetes Care. 2002; 25: 2202-2206Crossref PubMed Scopus (54) Google Scholar, 48Hattersley A.T. Molecular genetics goes to the diabetes clinic.Clin Med (Lond). 2005; 5: 476-481Crossref PubMed Scopus (45) Google Scholar). Children with type 2 diabetes should receive care in conjunction or consultation with an interprofessional pediatric diabetes health-care team that should include either a pediatric endocrinologist or pediatrician with diabetes expertise, dietitian, diabetes nurse educator and mental health professional. The target A1C for most children with type 2 diabetes should be ≤7.0%. However, there is evidence to suggest that achieving an A1C of <6.0% within the first 6 months of diagnosis may reduce the risk of treatment failure (49Zeitler P. Hirst K. Copeland K.C. et al.HbA1c after a short period of monotherapy with metformin identifies durable glycemic control among adolescents with type 2 diabetes.Diabetes Care. 2015; 38: 2285-2292Crossref PubMed Scopus (40) Google Scholar). To be effective, treatment programs for adolescents with type 2 diabetes need to address the lifestyle and health habits of the entire family, emphasizing healthy eating and physical activity (50Pinhas-Hamiel O. Standiford D. Hamiel D. et al.The type 2 family: A setting for development and treatment of adolescent type 2 diabetes mellitus.Arch Pediatr Adolesc Med. 1999; 153: 1063-1067Crossref PubMed Scopus (116) Google Scholar), and promoting smoking prevention/cessation strategies. In adolescent females with type 2 diabetes, proactive contraceptive counselling to avoid pregnancy is warranted given the high rates of congenital anomalies reported in this population (51Klingensmith G.J. Pyle L. Nadeau K.J. et al.Pregnancy outcomes in youth with type 2 diabetes: The TODAY study experience.Diabetes Care. 2016; 39: 122-129Crossref PubMed Scopus (47) Google Scholar). A recent quality improvement initiative using anonymized data from 578 adolescents with type 2 diabetes in Germany and Austria found that more than half of these adolescents did not perform regular physical activity, and increasing physical activity was associated with a lower A1C, a lower body mass index-standard deviation score (BMI-SDS) and a higher high-density lipoprotein cholesterol (HDL-C) (52Herbst A. Kapellen T. Schober E. et al.Impact of regular physical activity on blood glucose control and cardiovascular risk factors in adolescents with type 2 diabetes mellitus—a multicenter study of 578 patients from 225 centres.Pediatr Diabetes. 2015; 16: 204-210Crossref PubMed Scopus (24) Google Scholar). In addition, the SEARCH for Diabetes in Youth Study found that decreased time spent watching television was associated with a significantly attenuated 5-year increase in A1C among adolescents with type 2 diabetes (53Li C. Beech B. Crume T. et al.Longitudinal association between television watching and computer use and risk markers in diabetes in the SEARCH for Diabetes in Youth study.Pediatr Diabetes. 2015; 16: 382-391Crossref PubMed Scopus (15) Google Scholar). Thus, it is reasonable to recommend (in the absence of direct evidence for this population [54Johnson S.T. Newton A.S. Chopra M. et al.In search of quality evidence for lifestyle management and glycemic control in children and adolescents with type 2 diabetes: A systematic review.BMC Pediatr. 2010; 10: 97Crossref PubMed Scopus (17) Google Scholar]) that children with type 2 diabetes strive to achieve the same activity level recommended for childre