Type 2 diabetes (T2D) in youth is a growing pediatric health concern. Once thought to be a condition limited to adulthood, the number of children and teens with T2D has steadily increased over the past 20 years along with the number of children and teens that are overweight or obese,1 and projections using SEARCH database estimate that the number of people with T2D under the age of 20 will quadruple in the next 20 years.1,2 Like adults, T2D in youth occurs across all populations but disproportionately impacts youth of color and lower socioeconomic status.
Accurate diagnosis of T2D is crucial to the child receiving appropriate treatment. In practice, type 1 diabetes (T1D) should be presumed until a T2D diagnosis is confirmed to reduce the risk of escalation of glucose and potentially diabetesrelated ketoacidosis. Generally, a T2D diagnosis can be confirmed by the absence of insulin autoantibodies.3
This is the second in a series of 3 articles that highlight the updated practice paper titled “The Role of the Diabetes Care and Education Specialist in Pediatric Diabetes Regardless of Etiology.”
Best-practice guidelines for treating youth with T2D continue to evolve as more research becomes available. In fact, since the time of publication of “The Role of Diabetes Care and Education Specialist in Pediatric Diabetes Regardless of Etiology” practice paper, another glucagon-like peptide receptor agonist (dulaglutide) and a sodium-glucose cotransporter 2 inhibitor (empagliflozin) have received FDA approval in patients ages 10 and up. The recent additions expand “on-label” pharmacotherapy options for youth with T2D to a total of 4 classes—insulin, metformin, glucagon-like peptide receptor agonist, and sodium-glucose cotransporter 2 inhibitor.2
Initial treatment of T2D in youth should address blood glucose management and management of comorbidities, such as obesity, dyslipidemia, hypertension, and other microvascular complications.2-4 Glucose targets for youth with T2D are the same as those for youth with T1D.3,4 Treatment recommendations include lifestyle interventions, including healthy diet and regular physical activity, and medications as indicated by A1C level and comorbidities.2-4 T2D lifestyle interventions should be family based because the child/adolescent will not have total autonomy regarding food choices or access to physical activity.
It is recommended that all newly diagnosed youth with T2D, regardless of therapy, monitor glucose before meals and at bedtime until they achieve reasonable glucose levels.4 Frequency of glucose monitoring can then be individualized based on diabetes care regimen and whether glycemic goals have been achieved.
Dietary recommendations for youth with T2D align with pediatric weight management evidence-based nutrition practice guidelines focusing on healthy eating principles and emphasize increasing intake of nutrient-dense foods while decreasing intake of nutrient-poor foods—especially sugar-sweetened beverages.5 Working with the family to develop healthy eating plans that are affordable, moderate in portions, and personally acceptable is especially important.
Physical activity should be encouraged to decrease sedentary behavior. Youth with T2D and their families would benefit from education about the positive impact of regular physical activity on glucose management, insulin resistance, and weight management. Youth with T2D should be encouraged to participate in at least 60 minutes of moderate to vigorous physical activity per day and strength training at least 3 days per week.2-4 Activity may be completed in shorter segments throughout the day. Also, nonacademic screen time should be limited to 2 hours per day to help reduce sedentary time.3 Families may need guidance and support for starting an exercise routine or tips for incorporating more physical activity into their daily lives. Education about exercise safety should also be provided, especially if insulin therapy is required.
Early data about the long-term outcomes for youth with T2D is alarming. T2D in youth appears to be much more aggressive than T2D in adults—with a more rapid decline in beta cell function and earlier onset of diabetes-related complications.3 This worrisome evidence coupled with the rising incidence of youth with T2D serves as an urgent call to action for diabetes care professionals to expand research, intensify prevention efforts, and invest in treatment approaches to improve long-term management strategy options for this vulnerable population.
Like youth with T1D, youth with T2D should have medical management plans, 504 plans, or individualized education programs in place to ensure their safety at school. Age-specific considerations for youth with T2D are like those described for their same-age peers with T1D—such as school environment challenges, peer relationships, independence and selfmanagement, risk-taking behaviors, body-image concerns, and safe transition to adult care.
Because youth-onset T2D rarely occurs before puberty and impacts vulnerable populations at a higher rate, youth patients with T2D are often adolescents living in homes with many competing priorities. Adolescents with T2D may be spending a lot of time at home alone and become responsible for their own diabetes care a significant amount of time. The diabetes care and education specialist (DCES) and medical team should be sure to have discussions with the teen and their family about the importance of caregiver support and work with each family to identify realistic ways adults can support the teen in diabetes care while meeting other responsibilities. Discussions about age-appropriate care and developmentally appropriate decisionmaking might also be helpful to ensure realistic expectations.
All youth with T2D, their parents or guardians, and other care providers should receive comprehensive, individualized diabetes selfmanagement education and support (DSMES) that is culturally sensitive. DSMES should occur at diagnosis; once a year for continued assessment of education, nutrition, and emotional support needs; when new complicating factors arise that impact self-management; and when transitions in care occur.
Initial and ongoing DSMES for youth-onset T2D should focus on an agreed-on nutrition and activity plan, the safe administration of prescribed medications, and glucose monitoring as needed with the option of a continuous glucose monitor or insulin pump when appropriate.3,4 Caregivers of youth with T2D also need to understand how to interpret home glucose monitoring data for daily decision-making and to identify when an adjustment in therapy may be needed.
Throughout the education process and through the stages of the child’s life, the DCES should be considerate of the challenges youth with T2D often face that could impact their ability to follow through with recommended medical care, such as unstable housing, food insecurity, safe spaces to engage in physical activity, financial strains on the household, and transportation barriers. The DCES must tailor DSMES to the needs of the patient and their family and be well versed in support services and resources whether within their institution or within the broader community to help families overcome barriers to ensure the best possible outcomes.
Additionally, children and teens with T2D frequently have a family history of T2D and may already be familiar with other family members’ experiences with diabetes. This can positively or negatively affect how the teen views diabetes management or how empowered they feel about their care and ability to impact their outcomes. Including the child or teen in age-appropriate conversations reinforcing the power of good selfmanagement and individual decision-making may help to foster habits that will put the child in the best possible position to minimize future diabetesrelated complications.
Managing diabetes requires daily engagement to achieve agreed-on goals and glucose targets. The DCES should provide self-management education in a nonjudgmental way and provide a safe space for open communication to help youth with T2D and their families successfully navigate the challenges of managing T2D and any comorbid conditions.
Amy Poetker MS, RDN, CDCES, is with Cincinnati Children’s Hospital Medical Center in Cincinnati, OH.
The authors declare having no professional or financial association or interest in an entity, product, or service related to the content or development of this article.
The authors declare having received no specific grant from a funding agency in the public, commercial, or not-for-profit sectors related to the content or development of this article.
Lawrence JM, Divers J, Isom S, et al.; SEARCH for Diabetes in Youth Study Group. Trends in prevalence of type 1 and type 2 diabetes in children and adolescents in the US, 2001-2017. JAMA 2021;326:717-727.
American Diabetes Association Professional Practice Committee. 14. Children and adolescents: Standards of Care in Diabetes—2024. Diabetes Care. 2024;47(suppl 1):S258-S281. doi:10.2337/dc24-S014
Shah AS, Zeitler PS, Wong J, et al. ISPAD clinical practice consensus guidelines 2022: type 2 diabetes in children and adolescents. Pediatr Diabetes. 2022;23(7):872-902. doi:10.1111/pedi.13409
American Diabetes Association. 14. Children and adolescents: Standards of Medical Care in Diabetes—2022. Diabetes Care. 2022;45(suppl 1):S208-S231. doi:10.2337/dc22-S014
Smart CE, Annan F, Higgins LA, Jelleryd E, Lopez M, Acerini CL. ISPAD clinical practice consensus guidelines 2018: nutritional management in children and adolescents with diabetes. Pediatr Diabetes. 2018;19(suppl 27):136-154. doi:10.1111/pedi.12738