Study reveals global burden of early T2DM

Research published in the BMJ shows that the age-standardised incidence rate for type 2 diabetes mellitus (T2DM) in adolescents and young adults (ages 15–39) reached 183 per 100,000 people in 2019, up from 117 per 100,000 in 1990.
 
Using data from the Global Burden of Disease 2019, Chinese researchers also found the age-standardised disability adjusted life years (DALY) rate increased from 106 per 100,000 to 150 per 100,000 over the same period.
 
It is the first study to specifically investigate the global burden of early onset T2DM and also includes Australian data.
 
Dr Angela Titmuss, a paediatric endocrinologist and youth-onset diabetes researcher, told newsGP the rising rates of T2DM in the young are worrying.
 
‘There is increasing concern within Australia regarding increasing rates of diabetes among younger populations,’ she said.
 
‘We know that T2DM that occurs before the age of 40 is associated with approximately 10–15 years reduction in life expectancy, from international modelling.
 
‘Youth-onset T2DM is more rapidly progressive than later-onset T2DM and is associated with more complications such as high blood pressure or kidney disease, starting right from the time of diagnosis.
 
‘The majority of those affected will have at least one diabetes related complication within 15 years of diagnosis.’
 
The Global Burden of Disease 2019 project estimated incidence, mortality and DALY associated with 369 diseases and injuries from 204 countries and territories from 1990–2019.
 
When investigating T2DM in the young specifically, the researchers found body mass index (BMI) to be the main attributable risk factor in all regions.
 
Dr Gary Deed, Chair of RACGP Specific Interests Diabetes, told newsGP that BMI is a useful population measure in clinical trials, but on a one-to-one basis extra measurements are required.
 
‘We need to incorporate waist circumference to see if there is visceral obesity,’ he said.
 
‘Plus, in younger adults we need clearer guidelines on what is a normal for that age.’
 
He said there are also variations in how BMI should be interpreted in different populations.
 
‘This is a dilemma as some culturally diverse groups have differing cut-off points for what an average BMI should be,’ he said.
 
‘For instance, in southern, southeast and east Asian populations, the BMI for overweight and obesity are set lower, so overweight is over 25, not a BMI of 27, and obesity is over 27 versus 30.’
 
According to the Australian Institute of Health and Welfare (AIHW), in 2020 there were 1.3 million Australians living with diabetes and an increase in age-standardised prevalence rate from 2.4% in 2000 to 4.3% in 2020.
 
Dr Titmuss works as a researcher within the Diabetes across the LIFECOURSE Partnership at Menzies School of Health Research and says the increasing rates of T2DM in the young is a focus of the 2021–2030 Australian National Diabetes Strategy.
 
‘We need to consider systemic approaches that address the underlying risk factors at a population level, particularly among vulnerable groups,’ she said.
 
‘Population level approaches would include consideration of access and marketing of sweetened beverages and highly processed foods, safe physical environments, and policies and structures that encourage and facilitate physical activity throughout the life course.
 
‘For people that are diagnosed with T2DM at a younger age, we need to adequately resource primary healthcare and outreach services to provide healthcare in a way that engages and empowers to achieve long-term lifestyle changes.’

Body mass index was the main attributable risk factor across all regions, but on a one-to-one basis extra measurements are required to assess T2DM risk.
 
The BMJ research found countries with a low-middle and middle sociodemographic index had the highest age-standardised incidence rate and age standardised DALY rate in 2019, whereas countries with a low sociodemographic index had the lowest age-standardised incidence rate but the highest age-standardised mortality rate.
 
Dr Titmuss works in the Northern Territory and says this is also borne out in certain Australian demographics.
 
‘We know that in developed countries such as Australia, T2DM occurs predominantly in socioeconomically vulnerable young people. The prevalence reflects socioeconomic and systemic inequities,’ she said.
 
‘It also disproportionately affects culturally and linguistically diverse communities, including Aboriginal and Torres Strait Islander youth.
 
‘Therefore, any attempts to reverse the trend of rising incidence need to be broader than focusing on the individual patient, their diet and exercise patterns.
 
‘We need to consider issues such as intergenerational transmission of cardiometabolic risk, food security, support of vulnerable populations and families … and environments that encourage physical activity.
 
‘In doing this, we need to ensure that the possible stigma of having T2DM at a younger age is overcome and that comorbidities, such as poor mental health, are also addressed.’
 
Dr Gary Deed said better monitoring of children of mothers with gestational diabetes would also be beneficial.
 
‘Improved follow up of these mothers to check health status and also monitor children’s health status could be better funded and coordinated, thus we might pick up at-risk individuals earlier,’ he said.
 
‘Improved education on diet and lifestyle in younger Australians may assist some of the modifiable risk factors.’
 
Dr Titmuss echoes the significant effect of gestational diabetes on offspring.
 
‘Younger people with T2DM, particularly those who develop it in childhood or adolescence, may have been at increased risk of developing diabetes due to exposures during pregnancy and so may not necessarily be overweight,’ she said.
 
‘It is therefore important to carefully consider the phenotype and diagnosis of a younger person with diabetes so as to determine the most appropriate management advice.’
 
Metformin and insulin are the only approved medications for children under 18 in Australia, although other medications can be used off-label.
 
Meanwhile, drugs like semaglutide are used routinely for T2DM in adults and are being increasingly prescribed for off-label use in obesity.
 
However, Dr Deed says drugs like this are not a panacea.
 
‘There is no simple one-stop shop solution and an extremely expensive drug such as semaglutide will never fit the gaps. In fact, it may make inequality worse due to the high costs,’ he said.
 
‘All studies on weight loss with this drug and others were based upon healthier diet approaches, reduced kilojoules and lifestyle changes.’
 
Encouragingly, Dr Titmuss says weight loss can cause T2DM remission in some people.
 
‘We do know that weight loss can be effective in achieving diabetes remission, particularly in the first five years after diagnosis,’ she said.
 
‘Even 5–10% weight loss can have a positive impact on glucose levels and other cardiometabolic conditions.
 
‘[But] weight loss can also be difficult to sustain and we need to consider how we support patients in these goals, particularly if they are already a vulnerable young person.’
 
Dr Titmus points to the 2020 Australian-NZ guidelines as a helpful tool containing screening, assessment and management pathways for children and adolescents with T2DM.
 
‘It is important to consider prevention strategies across the life course, such as pre-conception and in early childhood,’ she said.
 
‘It is also important to be aware of the differences between youth- and later-onset diabetes. Youth-onset T2DM is associated with more complications, a worse prognosis and is more rapidly progressive than later-onset T2DM. The underlying pathogenesis is different.
 
‘Different medications are also used and there is potential risk for future generations. We therefore need to focus on engagement of affected young people and intensive management to improve glucose levels and long-term outcomes.’
 
The National Diabetes Services Scheme (NDSS) has created a succinct guide for young people with diabetes.
 
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