1. Diabetes in the Pediatric Population
Diabetes - spectrum of pathophysiology
No longer limited to Type 1 diabetes in the pediatric population
Increase in obesity is paralleled with an increase in Type 2 diabetes

2. Spectrum of Diabetes in the Pediatric Population
Type 1– Auto-immune
Rapid autoimmune destruction of beta cells (classic type I diabetes)
Type 2– Non-Autoimmune
Type 3– Autoimmune Islet Destruction (Type I) + Non-Autoimmune (Type II) Insulin Resistance

3. Type II Diabetes Mellitus in Children and Adolescents
Epidemic Proportions, especially in Eastern North Carolina
Ten fold increase nationally between 1982 and 1994, accounting for 33% of all newly diagnosed cases of diabetes mellitus in US
Greater percentage at PCMH in last several years.

4. “Classic Type II” DM (cont) Therapeutic Objectives
Normalization of BG
Diet/Exercise cornerstone of therapy
Oral Agents: Hypoglycemic (sulfonylureas, meglitinides) and/or non-hypoglycemic (Metformin, “glitizones”) agents [some associated with weight gain]
Insulin often necessary in beginning (suppresses BG and inappropriate hepatic glucose release), LEADS TO GREATER OBESITY
Surgery?

5. New Oral Therapies (May have Little or no Experience in Children)
Biguanides Metformin. Major effect is in potentiating the actions of insulin in decreasing hepatic glucose production. It’s use is usually associated with decreased appetite and weight loss.
Glucosidase inhibitors Acarbose, miglitol. Decrease absorption of carbohydrates from GI tract, and hence decrease exogenous caloric uptake. Not associated with weight gain. Little or no experience in children.

6. New Oral Therapies (May have Little or no Experience in Children)
Sulfonylureas Glimepiride, glipizide, glyburide. Oldest class of oral hypoglycemic agents, side effects in adults are well known; Glimepiride is 3rd generation that only stimulates insulin release at meals (not associated with weight gain).

7. Limitations of Oral Agents
Oral agents effectiveness limited to 5-10 years in adults with Type 2 diabetes (if obesity not treated)
Insulin only current option, exacerbates obesity
New approaches to obesity treatment required

8. Mortality 232 Morbidly Obese Diabetics 14/154 (9%)/ 9 yrs78
Operation refused
for Personal or
insurance reasons
Gastric Bypass
Mortality
14/154 (9%)/ 9 yrs
22/78 (28%)/6.2 yrs
1%/yr
4.5%/yr
P<0.0003