The current issue of AFP includes a review on Type 2 Diabetes Mellitus in Children, reviewing current guidelines for screening, diagnosis, and treatment. Children with type 2 diabetes mellitus (DM2) have optimal success with their treatment regimens when their families are engaged in their care. This engagement is crucial to success with both lifestyle and pharmacologic treatments.
Improving nutrition and exercise can lower A1Cs and improve clinical outcomes in children with DM2. Physicians can guide these changes by providing dietician referrals, exercise prescriptions, and screen time limits. Just as children and adolescents with DM2 tend to be obese, their families also tend to have similarly elevated body mass indices along with "high fat intake, minimal physical activity, and a high incidence of binge eating." Encouraging the entire family to work together to improve their nutrition and exercise improves the pediatric diabetic patient's chance of success with these changes.
Sometimes, though, engaging children and families in the office alone is insufficient. Interdisciplinary interventions, such as multi-systemic therapy led by a trained family therapist, lowers A1Cs, reduces hospitalizations, and reduces costs in children with type 1 diabetes mellitus; though these interventions have not been systematically studied in children with DM2, it seems reasonable to assume that they would be similarly effective. Interestingly, parents often under-estimate their children's health-related quality of life; it may be that these interdisciplinary interventions help younger diabetic patients better understand the severity of their disease and, consequently, increase their adherence.
Unfortunately, children initially prescribed only lifestyle change after a DM2 diagnosis rarely succeed at sustained blood sugar improvement; lifestyle measures alone only effect meaningful change in hemoglobin A1C values in 10% of pediatric DM2 patients. As such, the American Academy of Pediatrics recommends that all children be started on metformin, in addition to lifestyle counseling, at the time of diagnosis. Pairing medication taking with daily family routines significantly increases medication adherence, as does multi-systemic therapy as outlined above. Encouraging parents to adopt a more permissive parenting style may be another technique to increase adherence to both lifestyle and medication recommendations; "[y]outh with T2DM who perceive more autonomy (less parental control) in day-to-day and diabetes tasks are more likely to adhere to medication regimens."
