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04-24-2019 | Primary care | Commentary | Article

Diagnosis age matters when it comes to type 2 diabetes

Author:
Jay Shubrook

Jay Shubrook disclosures

Recent trials have shown that age at type 2 diabetes diagnosis is an important factor when it comes to how progressive this disease will be. As noted in the linked summary, the age of your patient at diagnosis of type 2 diabetes predicts how virulent the disease will be, affects their response to treatment, and will likely help advise how we should approach the treatment of this person.

Diabetes has become the world’s first non-communicable pandemic. We know this disease affects first world nations, but with the globalization of our economy we are seeing rapid growth even in third world countries. We are also seeing that diabetes affects young populations. We know that in the SEARCH for diabetes study up to a third of children with diabetes have type 2 diabetes. We have also seen that in the younger population the disease progresses more quickly (RISE, Swedish national study) to complications and is less responsive to treatment (TODAY study).

A call to action for primary care

How can we respond? First, we must have a high index of suspicion to look for diabetes and prediabetes in our younger populations. There are guidelines to direct these efforts. There are no reliable early signs of symptoms of type 2 diabetes; 90% of people with prediabetes and 25% of people with diabetes do not know that they have it. We must therefore rely on screening programs to find new cases in a timely manner (Table).

Screening recommendations from the ADA Standards of Care 2019

Recommendations for children

Screen from age 10 years or onset of puberty in any child who is overweight or obese AND has:

  • Family history in first- or second-degree relative
  • First American, Black, Hispanic, Asian, or Pacific Islander ethnicity
  • Any sign of insulin resistance:
    • Acanthosis
    • Hypertension
    • Dyslipidemia
    • Polycystic ovary syndrome

Repeat screening every 2 years
Fasting glucose is preferred in youth

Recommendations for adults

Screening is recommended to start at age 45 years regardless of risk factors.

Can use fasting glucose, oral glucose tolerance test, or glycated hemoglobin with repeated measure.

From http://care.diabetesjournals.org/content/42/Supplement_1/S13

Next we must initiate treatment as early as possible. We have learned that intensive lifestyle treatment is more effective the earlier you start. We see this clearly in the Diabetes Prevention Program versus the Look AHEAD study. We also need to continue to advance treatment to get control as quickly as possible. I advocate for providing intensive control upfront, shooting for a lower glycated hemoglobin with multiple agents if needed, and stepping down therapy once control is achieved.

We have also learned that those people diagnosed later in life are much less likely to suffer increased risk of complications and the treatment can therefore be less intensive. Specifically, those adults diagnosed after age 50 are much less likely to have an increased risk for diabetes-related complications. In these adults, treatment goals have been suggested to be higher (<8%–8.5% based on life expectancy) and treatment might be better focused on conditions such as hypertension.

Take-home messages

  1. Use systematic screening programs for diabetes
  2. Take early diagnosis of type 2 diabetes seriously
  3. Treat aggressively to gain control quickly and then “step-down” therapy in younger adults
  4. Older adults newly diagnosed with diabetes are less likely to suffer from complications from this disease
  5. Use life expectancy as key measure to determine treatment goals and intensity

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