A practical evidence-based approach to management of type 2 diabetes in children and young people (CYP): UK consensus.

BACKGROUND: Type 2 diabetes in young people is an aggressive disease with a greater risk of complications leading to increased morbidity and mortality during the most productive years of life. Prevalence in the UK and globally is rising yet experience in managing this condition is limited. There are no consensus guidelines in the UK for the assessment and management of paediatric type 2 diabetes. METHODS: Multidisciplinary professionals from The Association of Children's Diabetes Clinicians (ACDC) and the National Type 2 Diabetes Working Group reviewed the evidence base and made recommendations using the Grading Of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. RESULTS AND DISCUSSION: Young people with type 2 diabetes should be managed within a paediatric diabetes team with close working with adult diabetes specialists, primary care and other paediatric specialties. Diagnosis of diabetes type can be challenging with many overlapping features. Diabetes antibodies may be needed to aid diagnosis. Co-morbidities and complications are frequently present at diagnosis and should be managed holistically. Lifestyle change and metformin are the mainstay of early treatment, with some needing additional basal insulin. GLP1 agonists should be used as second-line agents once early ketosis and symptoms are controlled. Glycaemic control improves microvascular but not cardiovascular risk. Reduction in excess adiposity, smoking prevention, increased physical activity and reduction of hypertension and dyslipidaemia are essential to reduce major adverse cardiovascular events. CONCLUSIONS: This evidence-based guideline aims to provide a practical approach in managing this condition in the UK.

Type 2 diabetes in adolescents: a severe phenotype posing major clinical challenges and public health burden.

Type 2 diabetes in adolescence manifests as a severe progressive form of diabetes that frequently presents with complications, responds poorly to treatment, and results in rapid progression of microvascular and macrovascular complications. Although overall still a rare disease, adolescent type 2 diabetes now poses major challenges to paediatric and adult diabetes services in many countries. Therapeutic options are heavily curtailed by a dearth of knowledge about the condition, with low numbers of participants and poor trial recruitment impeding research. Together with lifestyle modification, metformin remains the first-line therapy for adolescents with type 2 diabetes, although the majority rapidly progress to treatment failure and insulin therapy. Early bariatric surgery is controversial but has great potential to transform outcomes. Health systems must respond by both concentrating patients in specialist clinical services integrated with translational research programmes, but also by joining up with local health and social care services to improve engagement and uptake of services.

Improving communication with adolescents.

Communication with young people (YP) can be problematic. However, effective communication can improve health outcomes and there is randomised clinical trial-level evidence that communication skills can be learnt. Key issues when communicating with YP: (1) The young person should be central in the communication, with discussions primarily focused on him/her; (2) The young person should be offered time alone with the clinician; (3) Conditional confidentiality should be discussed, and does not reduce rates of disclosure; (4) Ambivalence is normal--techniques can be learnt to help the young person resolve ambivalence and change behaviour; (5) A psychosocial history is a key part of the adolescent consultation, and should include resilience factors as well as risk. We also discuss pragmatic techniques to use in busy consultations to improve communication and promote behaviour change in YP.

Survey of antiobesity drug prescribing for obese children and young people in UK primary care.

OBJECTIVES: Antiobesity drug (AOD) prescribing in children and young people (CYP) in primary care is rising with high rates of discontinuation. Little is known about prescribing in this group in terms of patient demographics and comorbidities, reasons for initiation and discontinuation, or adherence to national guidelines. DESIGN: Questionnaire survey to general practitioners (GPs) identified using a nationally representative primary care database covering 6% of UK population. SETTING: UK-wide primary care. PARTICIPANTS: Patients were eligible if prescribed an AOD aged ≤18 years between 2010 and 2012. A total of 151 patients from 108 unique practices were identified via national prescribing database, with responses for 119 patients (79%) from 84 practices; 94 of 119 (79%) were eligible for inclusion. PRIMARY AND SECONDARY OUTCOMES: Survey of GP prescribing habits of AODs to CYP. We audited orlistat usage against the National Institute for Health and Care Excellence (NICE) guidance. RESULTS: 47% were prescribed metformin, 59% orlistat and 5% both drugs. Orlistat was largely prescribed by GPs independently (49/55 prescriptions, 89%) and metformin by GPs on specialist recommendation (12/44, 27%). Orlistat was largely prescribed in those over 16 years of age without physical comorbidities. Metformin was initiated for treatment of polycystic ovarian syndrome (70%), insulin resistance (25%) and impaired glucose control (9%). Median supply of metformin was 10.5 months (IQR 4-18.5 months) and 2.0 months (1.0-4.0) for orlistat (p≤0.001). Drug terminations were largely due to families not requesting repeat prescriptions. NICE guidance adherence was low; 17% of orlistat prescriptions were initiated by specialists, and 56% had evidence of obesity-related comorbidity. GPs reported lower confidence in prescribing AOD to CYP compared with adults (10-point Likert score median 3 vs 8, p<0.001). CONCLUSIONS: Prescribing of AOD in primary care is challenging with low adherence to NICE guidance. Further work is needed to better support GPs in the use of AOD in CYP.

Outcomes of 50 patients entering an adolescent bariatric surgery programme.

OBJECTIVE: Bariatric surgery is the most effective intervention for weight loss and obesity-related comorbidities currently available. Little is known about adolescents entering National Health Service (NHS) bariatric programmes. We aimed to characterise those entering a pathway and report their outcomes. DESIGN: Prospective service evaluation of patients assessed within a single NHS adolescent bariatric service. RESULTS: 50 patients assessed between 26 July 2007 and 27 January 2014; 6 (12%) were not eligible for surgery, 7 (14%) actively opted out, 8 (16%) were lost to follow-up and 29 (58%) underwent surgery (18 sleeve gastrectomy (SG) 11 Roux-en-y gastric bypass (RYGB) and 0 adjustable gastric band). Mean (SD) age at initial assessment was 16.0 (1.3) years and 18.3 (1.3) at surgery (youngest 15.7 years). Mean time taken to surgery was 1.8 years; longer in those with higher body mass index (BMI) and aged below 14 at first assessment. Mean (SD) BMI at surgery was 53.1 (8.3) kg/m2, lower in those undergoing RYGB (-5.2, 95% CI -11.6 to 1.13). Follow-up was inconsistent and challenging; 1/29 (3.5%) was transferred to a regional centre, 10/29 (34.5%) attended ongoing follow-up within our protocol, 6/29 (20.7%) had intermittent monitoring and 12/29 (41.4%) were lost to follow-up. Mean BMI change at 1 year (-14.0 kg/m2) and complications were similar to published cohorts. Data from 11 lost to follow-up were obtained and outcomes appeared similar to those who actively followed up. CONCLUSION: Adolescent bariatric surgery in the NHS appears effective, with outcomes similar to those reported internationally. Further work is needed to optimise postsurgical surveillance and reduce age at surgery.