Adolescents with type 2 diabetes, especially those from underserved communities, are at high risk of developing serious complications early in adulthood, new research shows.
Type 2 diabetes was once thought to be a metabolic disorder exclusively of adulthood. Now, however, with about a third of youth in America being overweight, it has become increasingly more frequent in adolescents in the last two decades. According to the Centers for Disease Control and Prevention, between 2002 and 2015, nearly 4,000 adolescents between 10 and 19 were newly diagnosed with the condition.
To better understand the pathophysiology and treatment of youth onset type 2 diabetes, the National Institute of Diabetes and Digestive and Kidney Diseases launched the TODAY study in 2004. It showed that youth-onset type 2 diabetes is exceedingly difficult to manage. Led by Sonia Caprio, MD, professor of pediatrics (endocrinology), Yale was among the 15 centers in the U.S. participating in the study. To conduct this randomized clinical trial, nearly 700 kids ages 10 to 17 were recruited to better understand how to treat the condition. The trial, named Treatment Options for Type 2 Diabetes in Adolescents in Youth (TODAY), finished in 2012 and found that only half of participants were able to manage their condition and maintain durable glycemic control. Now, the team is uncovering further concerning results as it follows the adolescents into adulthood. In an observational follow-up study, TODAY2, the team continued to study participants from 2011 to 2020—to see whether they developed complications due to the disease.
“This is the first group that has received this detailed series of analyses,” says Caprio.
TODAY2 follows 518 of the participants from the initial study who are now in their young adulthood. As with TODAY, 15 centers across the country collaborated, including Yale, under the overall direction of scientists at George Washington University. The researchers called them in yearly to undergo tests looking for microvascular and macrovascular complications, including diabetic kidney disease, hypertension, dyslipidemia (a metabolic disorder), nerve disease, and retinal disease. The annual tests included obtaining the participants’ fasting lipid profiles, measuring blood pressure, taking urine samples, and evaluating levels of nerve conduction. They checked for diabetic eye disease twice during the observation period.
The results were sobering—60% of the participants displayed one complication, and nearly 30% had two complications. Sixty-seven percent had high blood pressure, 55% suffered from kidney disease, 51% had dyslipidemia, 32% experienced nerve complications, and 51% had retinal damage. At the end of the study, the average age of the participants was only 26, and the average time since their diagnoses was around 13 years. The research team published its findings in the New England Journal of Medicine.
“The gravity of the situation is that they’re very young,” says Caprio. “If they continue to live like that, their quality of life is going to be extremely poor because it’s very hard to treat these complications.”
The complications will have serious, lifelong consequences. Caprio says many of these participants will need dialysis, while others will be blind. Their ability to work may be compromised, and the cost of keeping them alive may as much as triple. “This disease requires enormous effort, from us as well as the patients and their families,” she says.
Caprio says the findings show that complications are more severe than in type 1 diabetes, where they begin much longer after the initial diagnosis and aren’t as widely present. Experts currently don’t know why the complications of youth-onset type 2 diabetes are much more common and widespread. “There are a number of scientific knowledge gaps that remain to be studied,” says Caprio.
The presence of complications was also far greater in participants from underserved communities, emphasizing the presence of societal problems including poverty and lack of access to proper treatment that disproportionately burden minority groups.
In the future, Caprio hopes to develop and find better drugs for treating the condition. Many drugs prescribed for adults, for example, are not FDA-approved for children and adolescents. She also hopes to better understand the role of the liver in contributing to the onset of insulin resistance in kids. Many youth with type 2 diabetes also suffer from fatty liver disease, and she hopes that treating this disease may prevent or delay the onset of diabetes.
Caprio hopes to spread the message to the world that treating youth-onset type 2 diabetes is an urgent issue, because of how devastating it can be to those it affects both physically and mentally. “We need to act promptly now,” Caprio urges researchers as she watches young patients struggle with mounting obstacles as they age. “It is a serious problem.”