Addressing type 2 diabetes in the pediatric and adolescent population

Abstract

Youth-onset type 2 diabetes (T2D) has emerged as a major challenge in pediatric endocrinology. Its incidence continues to rise in parallel with the increasing prevalence of childhood obesity and currently accounts for approximately 8% of all pediatric diabetes cases, exceeding 40% of new diagnoses in certain high-risk ethnic groups. In Argentina, no national epidemiological registry is currently available. In Brazil, the ERICA study, which included nearly 38,000 adolescents, reported a prevalence of 22% for prediabetes and 3.3% for T2D.

Unlike adult-onset disease, youth-onset T2D follows a more aggressive clinical course, characterized by accelerated β-cell function decline, more severe insulin resistance, and the early development of both microvascular and macrovascular complications. The TODAY and TODAY2 studies, which enrolled 699 adolescents with recently diagnosed T2D and followed them for more than 13 years, demonstrated that diabetes-related complications develop early and progress rapidly. After five years of disease duration, approximately one-third of participants had developed hypertension, while more than 10% had diabetic kidney disease or diabetic retinopathy. By young adulthood (mean age, 26 years), 60% of participants had developed at least one diabetes-related complication and nearly 30% had two or more, highlighting the substantial burden of early morbidity associated with youth-onset T2D.

Accordingly, current international guidelines recommend an intensive, multidisciplinary approach beginning at diagnosis, including screening for metabolic dysfunction–associated steatotic liver disease (MASLD), diabetic retinopathy, diabetic kidney disease, dyslipidemia, and hypertension, together with comprehensive lifestyle intervention involving both the patient and family, psychological support, and early individualized pharmacological therapy. Although metformin remains the recommended first-line agent for metabolically stable patients, the introduction of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) and sodium-glucose cotransporter-2 (SGLT2) inhibitors has expanded treatment options, providing benefits not only in glycemic control but also in body mass index (BMI), with the potential to modify disease progression.

Therapeutic perspectives continue to evolve. The SURPASS-PEDS trial evaluating tirzepatide and the PIONEER TEENS trial evaluating oral semaglutide represent major advances that are likely to influence the management of youth-onset T2D in the coming years. Overall, current evidence supports an early, individualized treatment strategy aimed at long-term cardiometabolic and kidney risk reduction from the time of diagnosis.