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Very-low-energy diets: The future first-line intensive treatment for youth-onset type 2 diabetes?

Juliana Agwu
The rise in childhood obesity has been associated with more children and young people being diagnosed with type 2 diabetes. Other risk factors for developing youth-onset type 2 diabetes include minority ethnic origin, family history of type 2 diabetes and the presence of signs of insulin resistance. Previous studies have shown that early-onset type 2 diabetes appears to be more aggressive than the adult-onset form of the condition, as people diagnosed with type 2 diabetes in youth have a much higher risk of cardiovascular events than those with who are diagnosed in adulthood (Hillier and Pedula, 2003).

The rise in childhood obesity has been associated with more children and young people being diagnosed with type 2 diabetes. Other risk factors for developing youth-onset type 2 diabetes include minority ethnic origin, family history of type 2 diabetes and the presence of signs of insulin resistance. Previous studies have shown that early-onset type 2 diabetes appears to be more aggressive than the adult-onset form of the condition, as people diagnosed with type 2 diabetes in youth have a much higher risk of cardiovascular events than those with who are diagnosed in adulthood (Hillier and Pedula, 2003). Compared to age-matched controls, young people with type 2 diabetes lose approximately 15 years from average remaining life expectancy and may experience severe, chronic complications of the condition by their forties (Rhodes et al, 2012). In addition, people who developed type 2 diabetes in their youth have been shown to have a significantly increased risk of microvascular complications compared to age-matched controls with type 1 diabetes, despite good glycaemic control (Hillier and Pedula, 2003).

Metformin and insulin are currently the only licensed therapeutic agents for early-onset type 2 diabetes; however, the TODAY (Treatment Options for type 2 Diabetes in Adolescents and Youth) study showed that lifestyle modification in conjunction with metformin was not effective in half of the young people enrolled (Narasimhan and Weinstock, 2014). The treatment failure rate of metformin reported in TODAY appears to be higher than that which is observed in older adults with type 2 diabetes.

Given the rather grim prognosis of youth-onset type 2 diabetes, the study by Gow et al (summarised alongside), which suggests that a very-low-energy diet (VLED) can reverse type 2 diabetes in young people, is very encouraging. In this pilot study, eight young people aged 7–16 years with type 2 diabetes and obesity followed a VLED (~800 kcal/day) for 8 weeks and then changed to a hypocaloric diet (~1500 kcal/day) until follow-up at 34 weeks. Five of the eight participants adhered to the diets and lost an average of 12.3% of body weight at 34 weeks. Compared with baseline, there was a significant improvement in glycaemic control. All of the three participants who were on insulin therapy at baseline were able to discontinue it during the 8-week VLED and remained off therapy throughout the trial. More significantly, four of the five completers no longer met any diagnostic criteria for type 2 diabetes at the end of the study.

These findings are similar to studies in adults, which have shown that VLEDs are capable of reversing type 2 diabetes. Although this was a very small study with no control arm and of a short duration, the findings are very encouraging. The benefits of reversing type 2 diabetes in the long term may include fewer complications, with a reduction in healthcare costs as well as an extended lifespan for the individual. The only other therapy previously shown to reverse youth-onset type 2 diabetes is bariatric surgery. However, the long-term physical and psychological effects of this are unknown. VLEDs may be a safer option and could thus become the first-line treatment for young people who are able to adhere to such a strict regimen.

To read the article summaries, please download the PDF

REFERENCES:

Hillier TA, Pedula KL (2003) Complications in young adults with early-onset type 2 diabetes: losing the relative protection of youth. Diabetes Care 26: 2999–3005
Narasimhan S, Weinstock RS (2014) Youth-onset type 2 diabetes mellitus: lessons learned from the TODAY study. Mayo Clin Proc 89: 806–16
Rhodes ET, Prosser LA, Hoerger TJ et al (2012) Estimated morbidity and mortality in adolescents and young adults diagnosed with type 2 diabetes mellitus. Diabet Med 29: 453–63

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