Pay attention to the "sweet burden" of young people, the first consensus of experts on diabetes management for the 18-30-year-old group is released!

Compiled and organized by Yimaitong, please do not reprint without authorization
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Traditionally, type 2 diabetes (T2DM) is considered a disease of old age, but a growing body of data shows that this "sweet burden" is also becoming more prevalent and more aggressive in younger populations
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Data show that in the global adult T2DM population, the proportion of patients with onset in youth is as high as 16%
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Although they belong to adults physically, young diabetic patients are often in a special period such as studying, working hard, and having children.
They are different from middle-aged and elderly people in terms of life>
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Recently, the Australian Diabetes Society (ADS), the Australian Paediatric Endocrinology Group (APEG) and the Australian Association of Diabetes Educators (ADEA) jointly released the first expert consensus on the management of T2DM for people aged 18-30, which provides a reference for the management of the disease in young patients.

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The full text was published in MEDICAL JOURNAL OF AUSTRALIA (IF: 7.
738) Summary of 12 core recommendations ➤ Diabetes screening is recommended for people with overweight/obesity and other risk factors
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➤ Oral glucose tolerance test should be performed if HbA1c 5.
7%–6.
4% or impaired fasting glucose at initial screening
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➤ Considering the high risk of complications, the HbA1c target should be set to ≤6.
5% in the absence of excessive hypoglycemia risk and self-management burden
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➤ Younger patients with T2DM have faster β-cell decline; need frequent review, early intensive treatment, and avoidance of treatment indolence
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➤ The increased likelihood of MODY in the context of diabetes in the young adult population should be considered
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➤ The psychological burden of young adults with T2DM is comparable to that of young adults with type 1 diabetes mellitus (T1DM), and adverse social factors are relatively common in young adults with T2DM; these may influence nursing decisions and need to be considered
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➤ GLP-1RA and SGLT2i may be the best second-line drugs given the higher cardio-renal risk in young T2DM patients and the need to avoid iatrogenic weight gain and hypoglycemia
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➤ With or without proteinuria, the recommended blood pressure target is <130/80mmHg
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➤Consider early statin use
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➤ Pediatric guidelines recommend that lipid-lowering therapy should be performed if the LDL level is >3.
4 mmol/L, with a target value of <2.
6 mmol/L.
This recommendation also applies to young patients with T2DM
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➤ Exercise recommendations are the same as for young adults without T2DM, namely at least 300 minutes of moderate-intensity exercise per week
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➤ When possible, care should be provided by a team of experts including endocrinologists, certified diabetes educators, nutritionists, psychologists, and exercise physiologists
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 Risk Screening and Diagnosis of T2DM Screening for T2DM is recommended in asymptomatic overweight or obese young adults with one or more of the following risk factors: ➤ A history of T2DM or gestational diabetes during pregnancy
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➤ Family history of T2DM in first-degree relatives
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➤High-risk groups: Australian Aboriginal, Torres Strait Islander, South Asia, Southeast Asia, North Africa, Latin America, the Middle East,
etc.

➤ Clinical evidence of insulin resistance (polycystic ovary syndrome, acanthosis nigricans, dyslipidemia, hypertension) or existing macrovascular disease, impaired fasting glucose, impaired glucose tolerance, or a history of gestational diabetes
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➤ The use of antipsychotics
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 Determining the type of diabetes The type of diabetes in young adults can be difficult to determine because clinical overlapping features are common (eg, obesity may be present in patients with T1DM, and ketosis or ketoacidosis may be present in younger patients with T2DM)
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In younger age groups, the clinical distinction is mainly between T1DM and T2DM, and the identification of rarer monogenic diabetes
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 1.
Consider testing for islet cell autoantibodies to rule out autoimmune T1DM (glutamate decarboxylase and insulinoma antigen-2 are the most common tests)
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2.
Consider monogenic diabetes and record family history in detail
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Clinical features suggestive of monogenic diabetes include: ➤ In young adults lacking features of type 1 diabetes (absence of islet autoantibodies, low or no insulin requirements more than 5 years after diagnosis), a family history of diabetes may be present in one parent and among first-degree relatives of affected parents
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➤ Fasting blood glucose 5.
5–8.
5 mmol/L, and OGTT2h blood glucose elevation <3.
5 mmol/L indicates GCK MODY
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➤ Extremely sensitive to sulfonylurea drugs, and the elevated blood glucose value in the OGTT test >5mmol/L indicates HNF1A or HNF4A MODY
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➤Lack of overt obesity and other features of the metabolic syndrome (eg, acanthosis nigricans)
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➤ Accompanied by specific features, such as urogenital tract abnormalities or renal cysts, pancreatic atrophy, hyperuricemia, or gout, suggestive of HNF1B MODY
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➤History of neonatal hyperglycemia
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➤ Maternal inheritance and associated hearing loss suggestive of mitochondrial diabetes
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Diet management and physical activity should be used as first-line therapy Recommendations for dietary and physical activity interventions in young patients with T2DM: 1.
Obesity is a key modifiable risk factor
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Sustained weight loss of 7%–10% in overweight individuals is expected to provide glycemic and cardiovascular risk-related benefits
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2.
Cultural programs that promote healthy eating and increase physical activity are needed
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3.
Current evidence suggests that dietary and physical activity interventions have modest effects on weight loss and glycemia, which may be partly attributable to physiological underpinnings and inefficiencies
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If necessary, drug intervention should be intensified to improve blood sugar
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4.
Patients in this age group may already have an eating disorder, and maintaining healthy eating habits is critical
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5.
Nutritional recommendations ➤ Lack of long-term data on optimal dietary patterns or methods to support specific macronutrients
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➤ Reduce total energy intake, intake of low-nutrient energy-dense foods, and control the frequency and size of snacks
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➤ Quit sugary drinks
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➤ Make sure you eat enough fruits (two servings per day) and vegetables (five servings per day)
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➤ Reduce saturated fat intake
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➤ Have a good understanding of carbohydrates and consume low-glycemic index and high-fiber foods appropriately
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6.
Physical activity and exercise ➤ At least 300 minutes of moderate-intensity exercise per week is recommended
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➤ Another focus is to reduce sedentary time, limit the use of electronic products to < 2 hours a day, and ensure adequate sleep
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 Focus on psychosocial factors in young patients In Australia, young people with T2DM often face multiple stressors, including employment and housing insecurity
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Clinical care needs to be individualized for psychological conditions during this period
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Recommendations for psychosocial aspects of young people with T2DM: ➤ Emotional health problems (eg, diabetes distress, depression, eating disorders, and psychiatric symptoms) are relatively common among young people with T2DM
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In addition, clinicians need to be aware that young people may be vulnerable to and internalize the social stigma surrounding T2DM
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➤ Clinicians need to know and ask about depressive symptoms and diabetes distress so that appropriate interventions can be made when needed
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➤Alcohol and drug abuse by patients need to be vigilant
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 Glycemic management and pharmacotherapy strategies The pathophysiology of young-onset T2DM is thought to be similar to late-onset T2DM
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However, early-onset T2DM is considered more aggressive than late-onset T2DM
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Rapid decline in beta-cell function (up to 20%–35% per year) may lead to faster failure of metformin monotherapy and require earlier additional therapy
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Recommendations for glycemic management and pharmacotherapy in young T2DM patients: ➤ Given the high risk of complications, the HbA1c target should be set to ≤6.
5%, without the risk of excessive hypoglycemia and the burden of self-management
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➤In the presence of symptomatic hyperglycemia, insulin may contribute to rapid metabolic improvement at the time of diagnosis, and some individuals may subsequently be able to discontinue insulin
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➤Metformin is recommended as first-line therapy, but the duration of drug failure may be shorter than in older adults
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➤ Evidence for the use of new drugs (GLP-1RA, SGLT2i, and DPP-4i) in young patients with T2DM is limited but emerging
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Given the low risk of hypoglycemia and a neutral or beneficial effect on body weight, early consideration is recommended
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Female patients should use effective contraception because there is limited evidence on the safety of newer drugs during pregnancy
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➤ The cardio-renal benefit of novel antidiabetic agents has not been demonstrated in young patients with T2DM; however, GLP-1RA or SGLT2i may be preferentially used in patients with persistent proteinuria or chronic kidney disease or established cardiovascular disease
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➤ SGLT2i should be used with caution in patients with a history of DKA
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➤ Given the risk of treatment failure and progressive β-cell decline, regular HbA1c monitoring every 3 months is necessary
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 Obesity management Obesity is an important modifiable risk factor for young patients with T2DM
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Weight loss improves glycemic control and obesity-related conditions, and despite limited evidence for diabetes remission in young T2DM patients, early intervention is warranted
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Obesity Management Recommendations: ➤ People who are obese/overweight face weight stigma and prejudice (weight bias) in many aspects of their lives that may affect treatment outcomes
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Clinicians are encouraged to self-examine for weight bias and avoid biased language
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➤As weight gain is common in this age group, annual BMI/BMI assessments are recommended and privacy is required when weighing
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➤ Reducing energy intake includes supervised low-calorie diets and meal replacements
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➤ If necessary, adjuvant therapy with approved weight loss drugs can be given
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➤Bariatric or metabolic surgery is effective for obesity and improving metabolic index, but long-term data in adolescents and young T2DM patients are lacking
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In experienced units, metabolic surgery may be considered an option for young adults with obesity and persistent hyperglycemia, despite the need for nonoperative management
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➤ Evaluation of obesity-related complications is recommended, including those that may benefit from weight loss (eg, nonalcoholic steatohepatitis, obstructive sleep apnea, polycystic ovary syndrome, fertility effects, and hypertension)
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 Treatment recommendations for diabetic complications and comorbidities Clinicians should be aware that some diabetic complications are more prevalent, progress more rapidly, and have a higher mortality rate in patients with T2DM than in patients with T1DM
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Furthermore, complications occurred at an earlier age and had a greater impact on mortality compared with later-onset T2DM
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There is some evidence that younger age of onset is an independent risk factor for T2DM retinopathy; younger age of onset is associated with a higher long-term risk of end-stage renal disease
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Recommendations for the prevention and management of complications and comorbidities in young T2DM patients: 1.
Nephropathy and hypertension ➤ The prevalence of proteinuria in young adults with T2DM is high at diagnosis; eGFR and ACR should be assessed at diagnosis and annually thereafter once, and confirm proteinuria on duplicate samples (preferably with three morning ACR assessments)
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➤ A blood pressure target of <130/80mmHg is recommended regardless of the presence or absence of proteinuria
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➤ Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers are first-line treatment options for hypertension, especially if ACR is elevated; calcium channel blockers can be used as an alternative or in combination
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➤ If associated with persistent proteinuria or chronic kidney disease, consider using angiotensin-converting enzyme inhibitors or angiotensin receptor blockers to lower blood pressure and use SGLT2i to lower blood sugar
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If SGLT2i is intolerant or contraindicated, GLP-1RA can be used
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➤ Early referral to a nephrologist is recommended if there is concern about the cause, or if ACR worsens or eGFR declines
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➤Consider non-diabetic etiologies, especially if ACR > 300 mg/g
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➤ Attention should be paid to the potential teratogenic effects of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, SGLT2i, and GLP1RA, and effective contraception should be provided where appropriate
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 2.
Retinopathy ➤ Screening should be performed when diabetes is diagnosed
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➤ Given the propensity for rapid progression, screening should be performed annually even if baseline testing is normal
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➤ Glycemic control should be optimized to prevent and slow progression
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➤ Fenofibrate or anti-VEGF therapy may appear in the management of diabetic retinopathy, and contraception is recommended given the potential for teratogenicity and adverse pregnancy outcomes
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 3.
Peripheral neuropathy ➤Check for neuropathy and foot problems at diagnosis and annually thereafter
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➤ Primary management should focus on achieving glycemic goals
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➤ Emphasize foot care early
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 4.
CVD and dyslipidemia ➤ The following populations are considered to be at particularly high lifetime risk and should be considered for statin therapy: Australian Aboriginal and Torres Strait Islander; young adults with T2DM and elevated ACR; duration of diabetes >10 years; young adults with T2DM and cardiovascular disease
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➤ Lipid levels should be checked, preferably after initial blood sugar levels are as optimized as possible (since lipid levels may improve as hyperglycemia improves), and then annually
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➤Statin therapy should be considered in patients aged <30 years and with total cholesterol levels >7.
5 mmol/L
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Also, consider the possibility of familial hypercholesterolemia
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➤ Pediatric guidelines recommend that lipid-lowering therapy should be performed if the LDL level is >3.
4 mmol/L, with a target value of <2.
6 mmol/L.
This recommendation also applies to young patients with T2DM
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➤ In patients with severe hypertriglyceridemia (triglyceride level >4 mmol/L), fibrates should be retained in the treatment regimen to reduce the risk of pancreatitis
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➤ Smoking cessation is recommended
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➤ Aspirin is not recommended for primary prevention of cardiovascular disease in young adults with T2DM
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➤ CVD screening in asymptomatic young patients is not necessary
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 5.
Ovarian cyst syndrome ➤ All young adult women with T2DM should be evaluated for hyperandrogenemia
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➤ Weight loss and metformin improve menstrual disorders
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If hormonal contraception is used, lipid and insulin effects should be considered in drug selection
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 6.
Non-alcoholic fatty liver disease ➤ Young adults with T2DM should be assessed for the possibility of non-alcoholic fatty liver disease with aspartate aminotransferase and alanine aminotransferase testing at diagnosis and then annually
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Gastroenterological testing is recommended if persistent abnormalities or lack of response to weight loss are present
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 7.
Obstructive Sleep Apnea ➤ Sleep disturbance and symptoms should be assessed at the time of diagnosis
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 Pregnancy and Antenatal Care Gestational diabetes or pregnancies with diabetes are associated with higher rates of adverse events, particularly congenital malformations, preeclampsia, preterm birth, large-for-gestational-age infants, and miscarriage, compared with non-diabetic groups
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Furthermore, gestational hyperglycemia may be a risk factor for early-onset T2DM in the next generation
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Optimal perinatal and antenatal blood glucose levels, and avoidance of excessive gestational weight gain, can reduce these risks
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Pregnancy-related recommendations for young T2DM patients: ➤Beginning in adolescence, preconception counseling and contraceptive advice should be incorporated into routine care recommendations for young women with diabetes of reproductive potential
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➤ Folic acid should be given 3 months before pregnancy
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➤ Ideally, preconception and gestational glycated hemoglobin concentrations should be ≤6.
5% while minimizing the risk of hypoglycemia
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➤ All antidiabetic drugs except insulin and metformin should be discontinued prior to pregnancy and blood sugar control optimized prior to pregnancy
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➤ In patients with unplanned pregnancies, sudden discontinuation of metformin and/or sulfonylureas early in pregnancy may result in a rapid drop in blood sugar levels
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It is recommended to continue using metformin and/or sulfonylureas until advised by a doctor
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➤GLP1 receptor agonists, SGLT2 inhibitors, and other oral medications (except metformin or sulfonylureas) should be discontinued immediately because there is limited evidence of their safety during pregnancy
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➤Encouraging breastfeeding because breastfeeding can prevent early-onset T2DM in the next generation to a certain extent
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 Patient Self-Education Diabetes self-management and diabetes education are the cornerstones of diabetes care
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For young people with T2DM, the main barriers to self-management include lack of time, lack of motivation for rigorous diabetes self-management, and lack of understanding of the severity of their condition to allow follow-up
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Currently, 50 customized structured education programs that are person-centred rather than disease-centred are being developed and evaluated
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In the future, it is expected that this structured education will be integrated into every clinical consultation
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 Yimaitong compiled and compiled from: Wong J, Ross GP, Zoungas S, et al.
Management of type 2 diabetes in young adults aged 18-30 years: ADS/ADEA/APEG consensus statement[J].
MEDICAL JOURNAL OF AUSTRALIA.
2022 Apr 17.
DOI: 10.
5694/mja2.
51482, PMID:35430745