The first Australian consensus statement on the management of type 2 diabetes in young adults 18-30 years fills a gap in the guidance which to date has focussed on either T2D in children or in older adults.
The consensus, from the Australian Diabetes Society, Australian Diabetes Educators Association and Australasian Paediatric Endocrine Group, emphasises the importance of early identification and management given the aggressive nature of type 2 diabetes in young adults (YT2D).
“Clinicians should be aware that some diabetes complications are more prevalent in YT2D in comparison to type 1 diabetes, with evidence for more rapid progression and a higher mortality,” it said.
Lead author on the consensus statement Dr Jencia Wong told the limbic that people who presented with complications in their 40s had probably had YT2D for 10 years.
“I think the real message is to increase awareness that type 2 diabetes can happen in young adults and that it’s not all type 1 diabetes,” she said.
“You do have to exclude type 1 diabetes and MODY and then you are left with this entity of YT2D which is strongly driven by obesity.”
Dr Wong, from the Royal Prince Alfred Hospital and the University of Sydney’s Charles Perkins Centre, said while much of the screening would happen in primary care, YT2D warranted specialist input in the same way as type 1 diabetes.
“We really wanted to make sure that GPs didn’t feel they have to manage this on their own and that there are specialist centres dedicated to an holistic approach to everything that happens in YT2D.”
Dr Wong said the consensus recommended a risk based screening approach – basically in anyone who was obese or overweight and with one additional risk factor.
“And the risk factors in youth are quite novel. We know that one of the strongest things in the data is that people with YT2D have usually been exposed to glucose in utero.”
“So they have either had a mother who has experienced GDM or T2D and there is this real generational effect of being exposed to glucose.”
She said ethnicity also feeds into the risk of YT2D quite significantly – putting Aboriginal and Torres Strait Islanders and people of South and Southeast Asian heritage at higher risk.
Management of YT2D
The consensus, published in The MJA, said obesity was the key modifiable risk factor in TY2D so sustained weight loss of 7-10% should provide benefits in terms of glycaemic control and CVD risk factors.
“We are not fatalistic at all about that approach and certainly it is important to have dietetic input,” Dr Wong said. “We’re not saying diet is not important but diet alone may not be enough.”
She said there was evidence that something about the physiology of YT2D made it a little more resistant to lifestyle interventions than obesity alone.
“We do have some good drugs of course for T2D that affect body weight. We are lucky with the SGLT2i and GLP-1 RAs that are weight favourable in terms of diabetes treatments.”
“They have been put up there in the guidelines as preferred second line therapies because of the possible metabolic effects and the cardio-renal protection that we see in older adults and assume but is not proven in young adults.”
“What we really wanted to emphasise to practitioners is just don’t leave it to lifestyle. We just don’t want practitioners to wait for lifestyle to work because there may be physiological barriers to that being an effective intervention.”
“Once they have got to the point where glucose is elevated, you have to treat the diabetes.”
Dr Wong said about 30% of patients have albuminuria at YT2D diagnosis demonstrating that complications are evident early in the disease.
“So you really need to get the glucose down because it’s the glucose that does the vascular damage but a multipronged approach is important. I would think we try an aggressive two-pronged approach.”
She said an incentive for patients was that those who could achieve good glycaemic control with a combination of medications and by working hard on their lifestyle, could possibly be weaned off medications.
Dr Wong emphasised that there was no room for “blame and shame” in the management of YT2D.
“It should not be seen as a failure of personal action. I think that is important from a clinical perspective.”
The consensus statement said clinicians need to be aware of, and ask about, depressive symptoms and diabetes distress to enable appropriate intervention where needed.
“Current data in young adults are limited, but studies including adolescents suggest high rates of diabetes-distress, depression, psychiatric symptoms, and disordered eating, at least equivalent to or more prevalent than those seen in older type 2 diabetes or type 1 diabetes,” it said.
The consensus also provides detailed recommendations on the prevention and management of complications and comorbid conditions in YT2D including nephropathy, retinopathy, CVD and dyslipidaemia, PCOS, NAFLD and obstructive sleep apnoea, and the management of pregnancy.