Clinical focus on young adults with type 2 diabetes

The landscape of type 2 diabetes (T2DM) is changing with increasing numbers of people aged less than 40 years being affected. Until recently T2DM has been considered the milder type of diabetes however recent evidence, including research from our local area has highlighted the poor prognosis associated with young type 2 diabetes (YT2DM) with outcomes much worse than for type 1 diabetes (T1DM) or diabetes of onset beyond middle age. It is clear that a paradigm shift is required.

The lifetime risk of complications is high in YT2DM, not only due to a long duration of disease but also the co-occurrence of poor glycaemic control and the high burden of atherogenic risk factors seen even at diagnosis. A more rapid progression to insulin, to end stage renal failure and premature cardiovascular disease (as early as 30-40 years of age) have been described. Alarmingly, mortality in YT2DM has been found to be at least double that seen in T1DM. The impact of T2DM on mortality is much higher in young onset, compared to middle-age or older onset (Figures 1 and 2) and especially so for women. High rates of co-incident depression and poorer follow up attendances add to the challenges for this high risk group.

These observations have important ramifications for clinical practice. Strategies for the primary prevention of complications in YT2DM should be a priority despite younger age, particularly in the context of the less frequent intervention with cardio-protective drugs and poorer glycaemic control observed. Case finding in families with a high incidence of T2DM and early obesity would offer the best chance for early intervention.

With respect to service provision, the traditional focus on T1DM will need to be expanded to include YT2DM. To this end and in support of primary clinicians a Young Adult Diabetes Service; a multidisciplinary specialist clinic at Royal Prince Alfred Hospital and a healthpathway for YT2DM are in development. Please watch this space!

Fig 1

Fig 1. Kaplan Meier Survival curve for age of onset matched cohorts and showing reduced survival for young onset type 2 diabetes (Constantino MI et al Diabetes Care 2013;36:3863-3869)

 

Fig 2

Fig 2. Standardised Mortality Ratio by age for diabetes patients stratified by age of onset, to show highest SMR for young onset type 2 diabetes for any given duration of disease (Constantino MI et al Diabetes Care 2016 May; 39(5): 823-829)

 

Article submitted by Associate Professor Jencia Wong, Associate Professor Marg McGill and Dr Ted Wu.