By- Dr. Jonathan Wood
This month, the American Academy of Pediatrics* published its first Practice Guideline on the management of newly diagnosed Type 2 diabetes mellitus (T2DM) in children and adolescents. This comes in the wake of increasing prevalence of Type 2 diabetes in children, a phenomenon attributed to the epidemic of childhood obesity in North America.
This publication is intended for professionals caring for children with this disease. But, as is usual in the US, the public wants to know about such publications and hopes to understand their significance. This requires (1) knowing the definitions of some key terms and (2) understanding the benefits and limitations of publications such as Practice Guidelines. Neither of these tasks is simple.
Two important definitions:
1. Diabetes Mellitus (DM): The word "diabetes" is derived from both Latin and Greek and essentially means to "pass through." This alludes to the prominent of symptom seen in all forms of DM: increased urination. The word "mellitus" is derived from Latin and essentially means, "honey sweet." Again, this comes from the fact that high blood glucose (sugar) results in high urine glucose. If tasted, which early diagnosticians did, the urine would be sweet.
Confusion comes when people equate all forms of "diabetes". There are three distinct, different diseases:
Type 1 DM - previously known as "juvenile onset DM" (a misnomer, because it is not strictly age dependent) or "insulin-dependent DM" (also a misnomer given that other forms can come to require treatment with insulin). Type 1 DM (T1DM) typically does occur in children and adolescents. And it involves the loss of the pancreatic cells that produce insulin; hence T1DM always requires insulin shots.
Type II DM - previously known as "adult onset DM" or "non-insulin-dependent DM," both misnomers for the same reasons noted above. The main problem in T2DM is insulin resistance, meaning the body does not respond to insulin properly. This often is a complication of obesity and the exact mechanisms are not known. Hence, typically the first approach is to modify behaviors and use medicines that directly reduce blood sugar independent of the insulin mechanism. Sometimes, in T2DM, there is a relative lack of insulin later in the disease and extra insulin (shots) is used in the treatment.
Note: at diagnosis, it is sometime difficult to distinguish between Type I and Type II DM. It will become clear quite quickly, but sometimes the final label needs to wait and during this time there can be overlap of treatment types.
Gestational DM - a transient form diabetes seen in some pregnancies. It is similar to T2DM in that is involves insulin resistance, but it is typically transient and resolves after the pregnancy. That said, it is dangerous to both mother and baby, so it should be treated. Woman who have gestational DM have a higher than usual incidence of developing T2DM later in life.
2. Practice Guideline: A practice guideline is just that: a guideline.
· It is not a set of rules, nor is it a standard which all must follow. A professional society or group of experts in the field typically puts it together.
· The guideline attempts to pull together all the evidence on the chosen subject. The evidence is then "graded" on its quality and validity. If there is no evidence, then "expert opinion" is often invoked.
· The best guidelines detail specific questions or issues to "answer". They then issue a statement based on the graded evidence. Typically, the statements "for" or "against" the issue in question are also given levels of strength. (e.g. strong recommendation, recommendation, option, no recommendation)
Potential Problems:
· When practice guidelines are seen as dictums, rules that must be followed.
· When practitioners (or patients) fail to appreciate the strength of the recommendation or the grading of the evidence that led to this recommendation. This is particularly important in pediatric practice guidelines, because the volume and quality of evidence is frequently lacking in pediatrics. (but that is a topic for another WABI piece…)
· When a guideline is applied to a disease (or a patient) for which the guideline does not fit. Although this seems like an unlikely circumstance, it happens frequently and it can lead to a poor outcome.
What is the point? What about the AAP's T2DM Practice Guideline?
The AAP's Practice Guideline has all the qualities you would want in a guideline, as outlined above.
· Most importantly, it raises awareness of the true increase in T2DM among youth in the US.
· It has an excellent section on definitions to help avoid confusion like those outlined above.
· It explains the evidence grading system and subsequent recommendation strategy.
· It identifies six (6) clear issues and offers clear "action statements": two Strong Recommendations and four Options.
The strongest recommendations are centered on making the diagnosis of T2DM accurately and starting treatment promptly. In the most dramatic presentations, treatment may include insulin, despite my definitions above. But usually the treatment of T2DM stresses lifestyle modification (nutrition and physical activity) and initiating oral medicines to control glucose levels.
The AAP's new Practice Guideline on Type II Diabetes Mellitus is a good one. Patients and practitioners alike will benefit from the teaching it offeres and its judicious application to this increasingly prevalent disease.
* This guideline was published with support from the American Diabetes Association, the Pediatric Endocrine Society, the American Academy of Family Physicians, and the Academy of Nutrition and Dietetics.
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