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Another relevant issue is that most cases of DM2 in the young occur in ethnic subgroups such as African Americans&#44; Hispanics&#44; Asian Americans and Native Americans &#40;22&#46;3&#47;1000 in children 10&#8211;14 years of age&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">15</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Obesity is the main risk factor for developing DM2&#46; As with adults&#44; central obesity increases insulin resistance and promotes the development of DM2&#46; Excess weight and obesity in children 2&#8211;19 years of age is classified according to the percentile of the body mass index &#40;BMI&#44; kg&#47;m<span class="elsevierStyleSup">2</span>&#41; by age and sex as follows&#58; low weight &#40;BMI<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>5 percentile&#41;&#44; normal &#40;BMI within 5&#8211;85 percentile&#41;&#44; excess weight &#40;BMI within 85&#8211;95 percentile&#41;&#44; obesity &#40;BMI<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>95 percentile&#41; and severe obesity &#40;BMI<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>120&#37; of the 95 percentile or BMI<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>99 percentile&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The increase in excess weight and obesity rates in school-age children has been occurring worldwide in recent decades&#44; reaching 34&#37; and 10&#37;&#44; respectively&#44; in America&#46;<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">16</span></a> A third of adolescents with DM2 had not been previously diagnosed&#44; and these patients had more obesity &#40;BMI&#44; 35&#46;7<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#41; than those who did know the diagnosis of DM2 &#40;BMI&#44; 29&#46;1<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">17</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">According to the cutoffs of the International Obesity Task Force&#44; the highest excess weight and obesity rates in Europe among 7 to 11-year-old children are in Malta &#40;35&#37;&#41; and Spain &#40;34&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">18</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In Spain&#44; obesity has grown exponentially in recent decades&#46; According to data from the 2012 National Survey of Health in Spain&#44; the prevalence of excess weight and obesity among 2&#8211;17 year olds is currently 27&#46;6&#37;&#44; with the autonomous community of the Canary Islands in first place with 34&#46;5&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">19</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Pediatric obesity is intimately tied to changes in eating habits&#44; physical activity&#44; physical inactivity&#44; socioeconomic level and length of sleep&#46; A study conducted with Spanish schoolchildren showed that BMI was inversely proportional to how often they performed physical activity&#46;<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">20</span></a> Likewise&#44; the study observed an increase in BMI in the schoolchildren who spent more than 2<span class="elsevierStyleHsp" style=""></span>h a day watching television and in those who slept less than 8<span class="elsevierStyleHsp" style=""></span>h daily&#46; Other factors that influenced BMI were of a financial and educational nature in the family environment&#44; such that families with higher incomes and education levels had a lower rate of excess weight and obesity&#46;<a class="elsevierStyleCrossRef" href="#bib0500"><span class="elsevierStyleSup">21</span></a> It has also been reported that adverse experiences during childhood&#44; such as threats to the child&#39;s physical&#44; family or social safety and childhood violence and abuse and school bullying were associated with an increased risk of DM2 in adulthood&#46;<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">22</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Pathophysiology</span><p id="par0055" class="elsevierStylePara elsevierViewall">DM2 is a complex metabolic disorder in which various societal&#44; behavioral and environmental risk factors act on a foundation of genetic susceptibility&#46; The disease has a strong hereditary component &#40;probably polygenic&#41;&#44; which is responsible for the differences in the prevalence of DM2 in different racial groups&#46;<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">23</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">DM2 is characterized not only by hyperglycemia and insulin resistance but also by a relative reduction in insulin secretion&#46; Both characteristics are influenced by genetic and environmental factors&#46; Insulin resistance explains the clinical association of DM2 with obesity&#46; Patients have a combination of differing degrees of insulin resistance and reduced insulin concentrations&#46; Hyperglycemia by itself can change the function of pancreatic beta cells and exacerbate insulin resistance&#44; resulting in a vicious cycle that worsens the metabolic condition&#46; Adolescents and adults typically have lost 80&#37; of the function of pancreatic beta cells before the diagnosis of DM2&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">1</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">The progression of a normal blood glucose condition to that of impaired glucose tolerance &#40;IGT&#41; is associated with a worsening of insulin resistance&#46; IGT is an intermediate stage in the natural history of DM2 and is a predictor of the risk of developing DM and cardiovascular diseases&#46;<a class="elsevierStyleCrossRefs" href="#bib0515"><span class="elsevierStyleSup">24&#44;25</span></a> Likewise&#44; it has been proposed that hyperglycemia can worsen both insulin resistance and insulin secretion&#44; facilitating the transition of IGT to diabetes&#46;<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">25</span></a> However&#44; a high rate of spontaneous conversion to normal glucose tolerance has been observed in children and adolescents with IGT within 3&#8211;5 years&#46;<a class="elsevierStyleCrossRefs" href="#bib0520"><span class="elsevierStyleSup">25&#8211;27</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Puberty appears to play an important role in the development of DM2 in children&#46;<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">23</span></a> It has been postulated that an increase in growth hormone secretion could be responsible for insulin resistance during this period of development&#46;<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">28</span></a> This hypothesis could explain why the presentation of DM2 in children coincides with the mean age of puberty&#46;<a class="elsevierStyleCrossRefs" href="#bib0520"><span class="elsevierStyleSup">25&#8211;29</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">The adverse effect of obesity on glucose metabolism is already apparent in childhood&#46; Children with obesity have hyperinsulinemia and an approximately 40&#37; lower insulin-stimulated glucose metabolization &#40;assessed by blood glucose under fasting conditions and 2<span class="elsevierStyleHsp" style=""></span>h after eating&#41; than children who have no obesity&#46;<a class="elsevierStyleCrossRef" href="#bib0545"><span class="elsevierStyleSup">30</span></a> The inverse relationship between insulin sensitivity and abdominal fat distribution is stronger for visceral fat than for subcutaneous fat&#46;<a class="elsevierStyleCrossRefs" href="#bib0545"><span class="elsevierStyleSup">30&#44;31</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The adipose tissue that increases with obesity synthesizes and secretes metabolites and signaling proteins such as leptin&#44; adiponectin and tumor necrosis factor alpha&#46;<a class="elsevierStyleCrossRef" href="#bib0555"><span class="elsevierStyleSup">32</span></a> These factors change insulin secretion and sensitivity and can even cause insulin resistance in experimental and clinical conditions&#46;<a class="elsevierStyleCrossRef" href="#bib0560"><span class="elsevierStyleSup">33</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">The racial differences in insulin sensitivity are well-established&#46; African-American children 7&#8211;11 years of age have significantly higher insulin concentrations than white children of the same age&#46;<a class="elsevierStyleCrossRefs" href="#bib0565"><span class="elsevierStyleSup">34&#44;35</span></a> These data suggest that certain ethnic groups have a genetic predisposition to insulin resistance&#44; which can increase their risk of developing DM2&#46; These racial differences have also been observed in Europe&#44; where Swedish children with obesity have higher glucose concentrations under fasting conditions than German children with obesity&#46;<a class="elsevierStyleCrossRef" href="#bib0570"><span class="elsevierStyleSup">35</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">It has also been observed that a low pancreatic reserve and a high glycated hemoglobin &#40;HbA1c&#41; level are independent predictors for the loss of glycemic control in patients undergoing drug treatment&#46;<a class="elsevierStyleCrossRefs" href="#bib0575"><span class="elsevierStyleSup">36&#44;37</span></a> The deterioration in pancreatic beta cell function is also observed in adults with DM2&#44; although it is not as accelerated as in the young&#46;<a class="elsevierStyleCrossRefs" href="#bib0585"><span class="elsevierStyleSup">38&#8211;41</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Clinical presentation</span><p id="par0095" class="elsevierStylePara elsevierViewall">DM2 in the young occurs predominantly in the female sex&#46; The mean age at diagnosis is 13&#46;5 years&#44; although DM2 almost always starts at the age of 10 years&#44; unlike DM1&#44; which starts before the age of 10 years in 50&#37; of cases&#46;<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">29</span></a> In most cases&#44; DM2 is associated with obesity as the main determinant&#46;<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">29</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">The clinical presentation in children can be diverse and varies from asymptomatic hyperglycemia to ketoacidosis &#40;6&#37; of cases in patients between 10&#8211;19 years of age&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0605"><span class="elsevierStyleSup">42</span></a> Unlike the onset of DM1&#44; the cardinal symptoms of DM2 are unclear&#46; Thus&#44; children with DM2 usually present glycosuria without ketonuria&#44; mild or nonexistent polyuria&#44; polydipsia and little or no weight loss&#46; Although it is uncommon&#44; children with DM2 are at risk of presenting nonketotic hyperosmolar hyperglycemic decompensation&#44; which is associated with high mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0610"><span class="elsevierStyleSup">43</span></a> Differing clinical characteristics&#44; depending on the patients&#8217; ethnicity and race&#44; have also been observed&#44; with a predominance of DM1 in whites and DM2 in at-risk ethnic groups<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">29</span></a> &#40;African Americans&#44; American Hispanics&#44; Asians and Native Americans&#41;&#46; The differential characteristics between the two types of diabetes are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;<a class="elsevierStyleCrossRef" href="#bib0615"><span class="elsevierStyleSup">44</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">One of the characteristics of adult-onset DM2 is the lack of beta cell antibodies&#46; However&#44; a number of studies have observed the presence of these antibodies in almost 30&#37; of children and adolescents with DM2 in Europe&#46;<a class="elsevierStyleCrossRef" href="#bib0620"><span class="elsevierStyleSup">45</span></a> This group of adolescents does not usually require insulin therapy&#44; at least during the first year&#46; It has been postulated that this clinical form is an early presentation of latent autoimmune diabetes mellitus in adulthood&#46;<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">46</span></a> In adolescents&#44; the term &#8220;latent autoimmune diabetes mellitus in youth&#8221; has been proposed&#46;<a class="elsevierStyleCrossRef" href="#bib0630"><span class="elsevierStyleSup">47</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Maturity-onset diabetes of the young &#40;MODY&#41; is a form of maturity diabetes that occurs in children&#46; MODY is an uncommon form of diabetes in children that includes several forms caused by monogenic defects in beta cell function &#40;the most common of which are the hepatocyte nuclear factor 4 alpha gene mutation and the glucokinase gene mutation&#41;&#46; Patients with MODY have dominant genetic traits&#44; do not have obesity and have low insulin concentrations under fasting conditions&#46; These genetic anomalies are believed to be rare and require molecular diagnostic techniques&#46; Recent studies have suggested that the clinical presentation spectrum of MODY is broad and ranges from asymptomatic hyperglycemia to severe acute onset&#46;<a class="elsevierStyleCrossRef" href="#bib0635"><span class="elsevierStyleSup">48</span></a> This variety of diabetes has been reported in all races and ethnicities&#46; The main characteristics of MODY are listed in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Diabetes mellitus can be classified reliably&#44; in most patients&#44; based on the clinical presentation and progression&#46;<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">24</span></a> In the unusual situation in which a more precise classification is needed&#44; other specific measurements might be required&#44; such as insulin and peptide <span class="elsevierStyleSmallCaps">C</span> concentrations under fasting conditions and&#44; occasionally&#44; beta cell antibody levels&#46;<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">14</span></a> The diagnostic criteria for DM in children and adolescents does not differ from those established by the American Diabetes Association &#40;ADA&#41; for adults&#46;<a class="elsevierStyleCrossRef" href="#bib0640"><span class="elsevierStyleSup">49</span></a><a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> shows a flow diagram for classifying DM in children and adolescents&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Diabetes screening in childhood</span><p id="par0120" class="elsevierStylePara elsevierViewall">Most white European children and adolescents with DM2 and a third of children in the US were asymptomatic at the time of diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">29</span></a> Accordingly&#44; DM2 screening studies appear to be necessary&#44; given that hyperglycemia can go unnoticed and contribute to long-term microvascular and macrovascular damage&#46; A DM2 screening for the entire young population is currently not cost effective&#59; it is therefore only advisable to study patients at greater risk&#46; Due to the close direct relationship with obesity&#44; the ADA recommends DM2 screening for children and adolescents with excess weight at the onset of puberty who also have other risk factors &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0640"><span class="elsevierStyleSup">49</span></a> The screening test of choice is measuring fasting plasma glucose and the oral glucose overload test &#40;OGTT&#41;&#46; However&#44; these recommendations have a number of drawbacks&#46; Fasting plasma glucose is a comfortable&#44; simple and inexpensive procedure but failed in a quarter of patients in a European study&#46;<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">29</span></a> The OGTT can be a better screening method but costs more&#44; is more labor intense and at times has little reproducibility&#46;<a class="elsevierStyleCrossRef" href="#bib0645"><span class="elsevierStyleSup">50</span></a> We also do not know if the cutoffs for OGTT established for adulthood are applicable for childhood&#46; With regard to the use of HbA1c for diagnosing DM2&#44; the ADA continues to recommend it despite its limitations for children and adolescents due to its low sensitivity and high cost&#46;<a class="elsevierStyleCrossRefs" href="#bib0650"><span class="elsevierStyleSup">51&#8211;53</span></a></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Treatment</span><p id="par0125" class="elsevierStylePara elsevierViewall">The American Academy of Pediatrics has published guidelines on treating DM2 in children and adolescents&#46;<a class="elsevierStyleCrossRef" href="#bib0665"><span class="elsevierStyleSup">54</span></a> Most of these recommendations have been extrapolated from experience with adults&#46;<a class="elsevierStyleCrossRef" href="#bib0670"><span class="elsevierStyleSup">55</span></a> The 3 main treatment objectives are lifestyle changes&#44; blood glucose normalization and control of associated comorbidities&#46;<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">24</span></a> The final treatment objective is to decrease the risk of acute and chronic complications&#46;</p><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Nondrug therapy&#58; lifestyle changes</span><p id="par0130" class="elsevierStylePara elsevierViewall">Weight control is essential to achieving the therapeutic objectives&#46; The dietary recommendations consist of eliminating soft drinks and juices with high sugar content&#44; increasing the intake of fruits and vegetables&#44; controlling portion sizes&#44; changing the family eating behaviors and eliminating unhealthy food from the home&#46;<a class="elsevierStyleCrossRef" href="#bib0675"><span class="elsevierStyleSup">56</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Regular exercise&#44; even without caloric restriction and without weight loss&#44; is associated with a reduction in insulin resistance in the young with excess weight or obesity&#44; regardless of whether they previously had DM2&#46;<a class="elsevierStyleCrossRefs" href="#bib0680"><span class="elsevierStyleSup">57&#8211;59</span></a> The current recommendations for children&#39;s physical activity include 60<span class="elsevierStyleHsp" style=""></span>min a day of moderate-vigorous activity&#44; which can be performed all at once or divided into sessions&#46;<a class="elsevierStyleCrossRef" href="#bib0695"><span class="elsevierStyleSup">60</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Despite the efforts&#44; the results achieved with lifestyle changes are very limited&#46; In one study&#44; only 17&#37; of the patients managed to reduce their BMI 1 year after implementing a diet program plus exercise&#44; and only 23&#37; managed to withdraw the medication after more than 2 years&#46;<a class="elsevierStyleCrossRef" href="#bib0700"><span class="elsevierStyleSup">61</span></a> Another study observed that less than 10&#37; of young individuals with DM2 reached their blood glucose objectives exclusively with lifestyle changes&#46;<a class="elsevierStyleCrossRefs" href="#bib0705"><span class="elsevierStyleSup">62&#44;63</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">Although observational studies on young individuals with DM2<a class="elsevierStyleCrossRef" href="#bib0715"><span class="elsevierStyleSup">64</span></a> have suggested that higher activity levels are associated with improved blood glucose control&#44; the only large-scale therapeutic trial to assess the effects of lifestyle changes in 699 young individuals with DM2 did not support this assumption&#46;<a class="elsevierStyleCrossRef" href="#bib0565"><span class="elsevierStyleSup">34</span></a> The study showed that&#44; after 24 months&#44; the intense lifestyle changes &#40;200&#8211;300<span class="elsevierStyleHsp" style=""></span>min of moderate-to-intense exercise per week and a daily intake of 1200&#8211;1500 calories&#41;&#44; compared with metformin in monotherapy did not improve the long-term blood glucose control&#46; Other cardiovascular risk factors&#44; such as dyslipidemia and inflammatory markers&#44; also did not improve with lifestyle changes compared with monotherapy with metformin&#46;<a class="elsevierStyleCrossRef" href="#bib0720"><span class="elsevierStyleSup">65</span></a> These poor results could be related to the follow-up loss rates&#44;<a class="elsevierStyleCrossRefs" href="#bib0725"><span class="elsevierStyleSup">66&#44;67</span></a> factors related to the socioeconomic status and high rates of depression&#46;<a class="elsevierStyleCrossRef" href="#bib0735"><span class="elsevierStyleSup">68</span></a></p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Pharmacotherapy</span><p id="par0150" class="elsevierStylePara elsevierViewall">Pharmacotherapy is indicated if the treatment objective &#40;HbA1c &#60;7&#46;5&#37; and blood glucose under fasting conditions &#60;130<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41; is not achieved through nutritional education and exercise&#46; There are many available drugs for treating diabetes&#44; although only metformin and insulin have been approved by regulatory agencies for use in patients younger than 18 years&#46;<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">24</span></a> Most pediatric diabetologists use oral agents as the first therapeutic approach because they facilitate therapeutic compliance&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Metformin&#44; a biguanide&#44; is unquestionably the most appropriate starting point for the pharmacotherapy of DM2 in children&#44; as it is for adults&#46;<a class="elsevierStyleCrossRef" href="#bib0740"><span class="elsevierStyleSup">69</span></a> The drug reduces hepatic glucose production and increases hepatic and muscle sensitivity to insulin without a direct effect on beta cell function&#46; Metformin has the advantage of slightly reducing weight&#44; improving the lipid profile without increasing the risk of hypoglycemia and is easy to use and inexpensive&#46; The initial dose is 500<span class="elsevierStyleHsp" style=""></span>mg&#47;d and is increased progressively to 1000<span class="elsevierStyleHsp" style=""></span>g&#47;12<span class="elsevierStyleHsp" style=""></span>h within 4 weeks&#44; unless there are adverse gastrointestinal effects&#46; The drug&#39;s most common adverse effects are gastrointestinal abnormalities &#40;bloating and diarrhea&#41; and&#44; although it has a good safety profile&#44; should not be administered in cases of hypoxemia&#44; severe infection&#44; severe liver or kidney disease or alcohol abuse&#44; due to the risk of lactic acidosis&#46; Metformin should be used with caution and its dosage adjusted if the patient has impaired renal function&#46; If monotherapy with metformin is ineffective after 3&#8211;6 months&#44; combining another drug should be considered&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">The efficacy of metformin in adolescents has been tested in 2 clinical trials&#46;<a class="elsevierStyleCrossRefs" href="#bib0565"><span class="elsevierStyleSup">34&#44;70</span></a> In the Treatment Options for type 2 Diabetes in Adolescents and Youth &#40;TODAY&#41; trial&#44;<a class="elsevierStyleCrossRef" href="#bib0565"><span class="elsevierStyleSup">34</span></a> children and adolescents were distributed to the 3 treatment arms &#40;metformin&#44; metformin plus rosiglitazone and metformin plus lifestyle changes&#41;&#46; The results suggest that in standard clinical practice a large portion of young patients with DM2 could require combined therapy with insulin a few years after the diagnosis&#46; In this study&#44;<a class="elsevierStyleCrossRef" href="#bib0565"><span class="elsevierStyleSup">34</span></a> monotherapy with metformin was associated with adequate blood glucose control in approximately half of the patients with DM2&#46; The marketing of rosiglitazone was restricted by the Food and Drug Administration in 2010 after a slight increase in cardiovascular risk was observed&#46; Another study that compared metformin versus placebo observed a 1&#8211;2&#37; reduction in HbA1c after 4 weeks of therapy&#44; with a similar tolerance to that reported in adults&#46;<a class="elsevierStyleCrossRef" href="#bib0745"><span class="elsevierStyleSup">70</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">The use of insulin is preferred for patients with ketosis or intense hyperglycemia and who have mixed characteristics of DM1 and DM2&#46; The new guidelines recommend insulin therapy when the plasma glucose concentrations are &#8805;250<span class="elsevierStyleHsp" style=""></span>mg&#47;dL or HbA1c levels are &#62;9&#44; with monitoring every 3 months to adjust the dosage or withdraw it if the control is optimal&#46;<a class="elsevierStyleCrossRef" href="#bib0750"><span class="elsevierStyleSup">71</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">There is no specific contraindication for insulin therapy in children&#44; and the most appropriate administration regimen for each patient&#39;s lifestyle should be selected&#46; The most common adverse effects are weight gain and hypoglycemia&#46; NPH insulin once a day or basal insulin &#40;glargine&#44; detemir or degludec&#41; at an initial dose of 0&#46;25&#8211;0&#46;5<span class="elsevierStyleHsp" style=""></span>units&#47;kg is often effective for metabolic control&#46;<a class="elsevierStyleCrossRef" href="#bib0755"><span class="elsevierStyleSup">72</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">Although studies have been conducted on the use of other hypoglycemic agents &#40;thiazolidinediones&#44; sulfonylureas&#44; meglitinides&#44; alpha-glucosidase inhibitors&#44; dipeptidyl peptidase-4 inhibitors&#44; glucagon-like peptide-1 analogs and amylin analogs&#41; in this population group&#44; their use has still not been approved&#46;<a class="elsevierStyleCrossRef" href="#bib0760"><span class="elsevierStyleSup">73</span></a></p><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Surgical treatment</span><p id="par0180" class="elsevierStylePara elsevierViewall">Bariatric surgery can be a useful therapeutic option&#44; although the experience with adolescents with DM2 is very limited&#46; In a retrospective series of 11 postpubertal adolescents with DM2 who underwent gastric bypass with jejunal Roux-en-Y anastomosis&#44; significant improvements were achieved in BMI&#44; blood glucose control&#44; serum lipid concentrations and blood pressure compared with 67 adolescents who underwent medical treatment for 1 year&#46;<a class="elsevierStyleCrossRef" href="#bib0765"><span class="elsevierStyleSup">74</span></a> In particular&#44; 10 of the 11 patients treated surgically had remission of the diabetes without the need for medication&#46; The recommended selection criteria for bariatric surgery in the young are as follows&#58; BMI &#62;35&#44; advanced puberty development &#40;Tanner stage IV or V&#41; and skeletal maturity&#46;<a class="elsevierStyleCrossRef" href="#bib0770"><span class="elsevierStyleSup">75</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">Other techniques such as tubular gastrectomy and gastric band surgery have also been put into practice&#44; but there is little experience with children and adolescents&#44; and more studies are needed to offer concrete recommendations&#46;<a class="elsevierStyleCrossRef" href="#bib0775"><span class="elsevierStyleSup">76</span></a></p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Comorbidities</span><p id="par0190" class="elsevierStylePara elsevierViewall">The comorbidities that accompany DM2 in the young are very common and need to be properly approached to prevent the development of vascular complications&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">The SEARCH study observed that 92&#37; of the adolescents with DM2 met the criteria of metabolic syndrome by presenting 2 risk factors for cardiovascular disease&#44; as well as DM&#44; compared with 14&#37; of the patients with DM1&#46;<a class="elsevierStyleCrossRef" href="#bib0780"><span class="elsevierStyleSup">77</span></a> In addition to obesity&#44; the presence of other comorbidities such as arterial hypertension&#44; dyslipidemia&#44; retinopathy&#44; nephropathy and depression should be ruled out&#46; The recommendations for their screening and treatment are shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46;<a class="elsevierStyleCrossRef" href="#bib0785"><span class="elsevierStyleSup">78</span></a></p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0200" class="elsevierStylePara elsevierViewall">In a study conducted in the US that included children and adolescents with DM1 or DM2 with a mean disease duration of 7&#46;9 years&#44; the patients with DM2 had a higher prevalence &#40;adjusted for age&#41; of diabetic nephropathy&#44; retinopathy&#44; peripheral neuropathy&#44; arterial stiffness and hypertension than those with DM1&#46;<a class="elsevierStyleCrossRef" href="#bib0790"><span class="elsevierStyleSup">79</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">We therefore need to pay attention to preventing excess weight and obesity in this population group through public education in healthy life habits and early detection in consultations&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Conflicts of interest</span><p id="par0210" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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          "identificador" => "xpalclavsec1031522"
          "titulo" => "Keywords"
        ]
        2 => array:3 [
          "identificador" => "xres1087559"
          "titulo" => "Resumen"
          "secciones" => array:1 [
            0 => array:1 [
              "identificador" => "abst0010"
            ]
          ]
        ]
        3 => array:2 [
          "identificador" => "xpalclavsec1031523"
          "titulo" => "Palabras clave"
        ]
        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Background"
        ]
        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Epidemiology"
        ]
        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Pathophysiology"
        ]
        7 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "Clinical presentation"
        ]
        8 => array:2 [
          "identificador" => "sec0025"
          "titulo" => "Diabetes screening in childhood"
        ]
        9 => array:3 [
          "identificador" => "sec0030"
          "titulo" => "Treatment"
          "secciones" => array:1 [
            0 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "Nondrug therapy&#58; lifestyle changes"
            ]
          ]
        ]
        10 => array:3 [
          "identificador" => "sec0040"
          "titulo" => "Pharmacotherapy"
          "secciones" => array:1 [
            0 => array:2 [
              "identificador" => "sec0045"
              "titulo" => "Surgical treatment"
            ]
          ]
        ]
        11 => array:2 [
          "identificador" => "sec0050"
          "titulo" => "Comorbidities"
        ]
        12 => array:2 [
          "identificador" => "sec0055"
          "titulo" => "Conflicts of interest"
        ]
        13 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2017-12-10"
    "fechaAceptado" => "2018-03-22"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1031522"
          "palabras" => array:6 [
            0 => "Type 2 diabetes mellitus"
            1 => "Obesity"
            2 => "Childhood"
            3 => "Adolescence"
            4 => "Comorbidities"
            5 => "Treatment"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec1031523"
          "palabras" => array:6 [
            0 => "Diabetes mellitus tipo 2"
            1 => "Obesidad"
            2 => "Infancia"
            3 => "Adolescencia"
            4 => "Comorbilidades"
            5 => "Tratamiento"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">In recent years&#44; we have witnessed an increase in the number of cases of type 2 diabetes mellitus &#40;DM2&#41; in children and adolescents&#44; which has paralleled the increase in the worldwide prevalence of obesity&#46; Although screening the general population does not appear to be cost-effective&#44; special attention should be paid to children with excess weight&#44; obesity or other factors that predispose them to a state of insulin resistance&#46; When faced with the diagnosis of childhood DM2&#44; the presence of comorbidities &#40;such as hypertension&#44; dyslipidemia and microalbuminuria&#41; should be assessed&#44; and appropriate treatment and follow-up should be administered to prevent the onset of complications&#44; given that the DM2 in this population group will last longer than that started in adulthood&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">En los &#250;ltimos a&#241;os asistimos a un aumento en el n&#250;mero de casos de diabetes mellitus tipo 2 &#40;DM2&#41; en ni&#241;os y adolescentes&#44; que ocurre de forma paralela al aumento de la prevalencia de obesidad en todo el mundo&#46; A pesar de que un cribado de la poblaci&#243;n general no parece coste-efectivo&#44; deber&#237;a prestarse especial atenci&#243;n a los ni&#241;os con sobrepeso&#44; obesidad u otros factores que predispongan a un estado de resistencia a la insulina&#46; Ante el diagn&#243;stico de DM2 en la infancia debe evaluarse la presencia de comorbilidades&#44; como la hipertensi&#243;n&#44; la dislipidemia y la microalbuminuria&#44; as&#237; como llevar a cabo un adecuado tratamiento y seguimiento para evitar la aparici&#243;n de complicaciones&#44; pues en este grupo de poblaci&#243;n la duraci&#243;n de la DM2 ser&#225; mayor que en la iniciada en el adulto&#46;</p></span>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Please cite this article as&#58; Calero Bernal ML&#44; Varela Aguilar JM&#46; Diabetes tipo 2 infantojuvenil&#46; Rev Clin Esp&#46; 2018&#59;218&#58;372&#8211;381&#46;</p>"
      ]
    ]
    "apendice" => array:1 [
      0 => array:1 [
        "seccion" => array:1 [
          0 => array:4 [
            "apendice" => "<p id="par0220" class="elsevierStylePara elsevierViewall">The following are the supplementary data to this article&#58;<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>"
            "etiqueta" => "Appendix A"
            "titulo" => "Supplementary data"
            "identificador" => "sec0065"
          ]
        ]
      ]
    ]
    "multimedia" => array:5 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Flow diagram for the classification of diabetes mellitus in children and adolescents&#46;</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>&#58; DM1&#58; type 1 diabetes mellitus&#59; DM2&#58; type 2 diabetes mellitus&#59; MODY&#58; maturity onset of diabetes mellitus in youth&#46;</p> <p id="spar0025" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Source</span>&#58; Reinehr&#46;<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">14</span></a></p>"
        ]
      ]
      1 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
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            "identificador" => "at1"
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          "leyenda" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>&#58; anti-GAD&#58; glutamic acid decarboxylase antibodies&#59; DM1&#58; type 1 diabetes mellitus&#59; DM2&#58; type 2 diabetes mellitus&#59; ICA&#58; islet cell autoantigen&#59; MODY&#58; maturity onset of diabetes mellitus in youth&#59; ODD&#58; oral diabetes drugs&#59; PCOS&#58; polycystic ovary syndrome&#46;</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Source</span>&#58; Alberti et al&#46;<a class="elsevierStyleCrossRef" href="#bib0615"><span class="elsevierStyleSup">44</span></a></p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">DM1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">DM2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">MODY&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age at onset&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Preschool-Adolescent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#62;10 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;25 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Female<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Female<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Female<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ethnic group&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">White&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">At-risk ethnic groups&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">All races&#47;ethnicities&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Obesity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Uncommon &#40;20&#8211;25&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Frequent &#40;&#62;80&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Uncommon&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Onset&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Acute-symptomatic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Insidious-asymptomatic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">From asymptomatic hyperglycemia to acute severe presentation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Symptoms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Weight loss<br>Polyuria<br>Polydipsia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Variable<br>Family history of DM2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Family history of diabetes in more than 2 generations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ketosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Frequent &#40;30&#8211;40&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Typically absent &#40;Hispanics and African Americans&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Low risk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Peptide C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8595; &#8595;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Normal or &#8593;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Antibodies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ICA&#43;<br>Anti-GAD&#43;<br>ICA 512&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ICA&#8722;<br>Anti-GAD&#8722;<br>ICA 512&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Absent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Insulin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ODD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Depending on the genetic defect&#58; diet&#44; sulfonylureas or insulin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Associated diseases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Autoimmune &#40;thyroid&#44; adrenal&#44; vitiligo&#41;&#44; celiac disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">PCOS&#44; acanthosis nigricans&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Low birth weight&#44; agenesis or severe pancreatic hypoplasia&#44; nephropathy&#44; acanthosis nigricans&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Differential characteristics of type 1 and type 2 diabetes mellitus in adolescence&#46;</p>"
        ]
      ]
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        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "detalles" => array:1 [
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            "identificador" => "at2"
            "detalle" => "Table "
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        "tabla" => array:2 [
          "tablatextoimagen" => array:1 [
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Criteria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Excess weight defined as</span> &#8230;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>BMI<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>85 percentile for sex and age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Weight<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>120&#37; of ideal for height&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Weight&#47;height<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>85 percentile 85&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Two or more of the following risk factors&#58;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Family history of DM2 in first or second-degree relatives&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>At-risk ethnic group &#40;Native American&#44; African&#44; Latino&#44; Asian&#44; Pacific Islander&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Signs of insulin resistance or conditions associated with insulin resistance &#40;acanthosis nigricans&#44; AHT&#44; dyslipidemia&#44; polycystic ovaries or low birth weight&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Maternal history of diabetes or gestational diabetes during child&#39;s gestation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Age of onset&#58; at 10 years or at the onset of puberty&#44; whichever comes first</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Frequency&#58; every 3 years</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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          "notaPie" => array:1 [
            0 => array:3 [
              "identificador" => "tblfn0005"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Individuals<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>18<span class="elsevierStyleHsp" style=""></span>years of age&#46;</p> <p class="elsevierStyleNotepara" id="npar0010"><span class="elsevierStyleItalic">Abbreviations</span>&#58; AHT&#58; arterial hypertension&#59; BMI&#58; body mass index&#59; DM2&#58; type 2 diabetes mellitus&#46;</p> <p class="elsevierStyleNotepara" id="npar0015"><span class="elsevierStyleItalic">Source</span>&#58; Standards of Medical Care in diabetes 2017&#46;<a class="elsevierStyleCrossRef" href="#bib0640"><span class="elsevierStyleSup">49</span></a></p>"
            ]
          ]
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Screening for type 2 diabetes mellitus and prediabetes in asymptomatic children&#46;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a></p>"
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          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>&#58; ACEI&#58; angiotensin-converting enzyme inhibitors&#59; ARB-II&#58; angiotensin-receptor blockers&#59; BP&#58; blood pressure&#59; HDL&#58; high density lipoprotein&#59; LDL&#58; low density lipoprotein&#46;</p><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Source</span>&#58; Kao and Sabin&#46;<a class="elsevierStyleCrossRef" href="#bib0785"><span class="elsevierStyleSup">78</span></a></p>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Comorbidity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Prevalence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Screening&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Therapeutic recommendation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hypertension&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Affects up to 36&#37; of the young within 1&#46;3 years of the diagnosis&#59; up to 66&#37; in a number of cross-sectional studies&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">At the time of the diagnosis and at every subsequent visit&#46; Use the appropriate cuff size and adjust the readings according to age&#44; sex and height&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lifestyle modifications&#58; Treatment with ACEI if the lifestyle modification is not successful after 6 months&#46;<br>ARB-II if ACEI is not tolerated&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Dyslipidemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hypertriglyceridemia in 60&#8211;65&#37;&#46;<br>Reduction in HDL-cholesterol in 73&#37;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">At the time of diagnosis&#46; If monitoring every 2 years is normal&#46;<br>If more frequent follow-up is abnormal&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Evaluation and change in diet&#46; If failure after 6 months&#44; consider&#8230;<br>Treatment with statins if LDL<span class="elsevierStyleHsp" style=""></span>&#62;130<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#46;<br>Therapy with fibrates if triglycerides<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>800&#8211;1000<span class="elsevierStyleHsp" style=""></span>mg&#47;dL and if patient is &#62;10 years of age due to risk of acute pancreatitis&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Retinopathy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&#46;3&#37; at the time of diagnosis&#46;<br>12&#46;7&#37; have proliferative retinopathy at 35 years&#46;<br>23&#46;7&#37; go blind at a mean age of 32 years&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Examination with pupil dilation by ophthalmologist at the time of the diagnosis&#46; Annual examination if the examination results are normal and more often if abnormal&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Consult an ophthalmologist if there is evidence of retinopathy&#46; Laser therapy might be required if there is proliferative retinopathy&#44; clinically significant macular edema or severe nonproliferative retinopathy&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Kidney disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Frequently present in the diagnosis&#46;<br>14&#8211;22&#37; in cross-sectional studies&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Microalbuminuria in urine sample&#58; 30&#8211;299<span class="elsevierStyleHsp" style=""></span>mg&#47;g&#46;<br>Proteinuria in 24-h urine&#58; 20&#8211;199<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;min&#46;<br>Can be increased by tobacco use&#44; exercise and menstruation&#46;<br>Rule out orthostatic proteinuria&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">If condition persists &#40;&#62;2 samples&#41;&#44; start with ACEI&#44; even with normal BP&#46;<br>The objective is to normalize proteinuria&#46;<br>Treat the hypertension&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Depression&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Up to 14&#46;7&#37;&#59; more common in women&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Detect symptoms of depression at the time of the diagnosis and periodically&#44; especially in those with deficient blood glucose control and&#47;or frequent visits to the emergency department&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Consult with a mental health specialist&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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Review
Infant-juvenile type 2 diabetes
Diabetes tipo 2 infantojuvenil
M.L. Calero Bernala,b,
Corresponding author
mirota96@hotmail.com

Corresponding author.
, J.M. Varela Aguilarb,c,d
a Servicio de Medicina Interna, Hospital San Juan de Dios del Aljarafe, Bormujos, Sevilla, Spain
b Grupo de trabajo de Diabetes y Obesidad de SEMI, Spain
c Servicio de Medicina Interna, Hospital Virgen del Rocío, Sevilla, Spain
d CIBER de Epidemiología y Salud Pública, Sevilla, Spain
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Flow diagram for the classification of diabetes mellitus in children and adolescents&#46;</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>&#58; DM1&#58; type 1 diabetes mellitus&#59; DM2&#58; type 2 diabetes mellitus&#59; MODY&#58; maturity onset of diabetes mellitus in youth&#46;</p> <p id="spar0025" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Source</span>&#58; Reinehr&#46;<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">14</span></a></p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Background</span><p id="par0005" class="elsevierStylePara elsevierViewall">Until recently&#44; diabetes mellitus in childhood and adolescence was synonymous with diabetes mellitus type 1 &#40;DM1&#41;&#46; However&#44; this concept has changed in recent years with the onset of type 2 diabetes mellitus &#40;DM2&#41; in this population group&#46; DM2 has ceased being a rare disease in the pediatric population&#46; It is currently estimated that between 15&#37; and 45&#37; of new cases of diabetes in childhood and adolescence correspond to DM2&#44;<a class="elsevierStyleCrossRefs" href="#bib0400"><span class="elsevierStyleSup">1&#44;2</span></a> disproportionately affecting certain ethnic and racial minorities and disadvantaged societal environments&#46;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">3</span></a> In a study conducted in the United States between 2002 and 2012&#44; the relative annual increase in the incidence rate was 1&#46;8&#37; for DM1 and 4&#46;8&#37; for DM2&#46;<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The epidemic of DM2 in childhood is the result of a variety of factors&#44; the most important of which is the increase in pediatric obesity rates&#44; which started in the 1960s&#44; although it appears to be reaching a plateau&#46;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">5</span></a> Another determinant is that DM2 in young patients occurs in complex cultural and psychosocial environments&#44; which makes it difficult to implement lifestyle changes and ensure compliance with medical recommendations&#46; These complexities also hinder the success and completion of research programs and clinical trials&#44;<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">6</span></a> leaving large gaps in our understanding of the treatment pathophysiology and optimization&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">In this review&#44; we highlight the most relevant epidemiological&#44; pathophysiological&#44; clinical and therapeutic aspects of DM2 in children and adolescents&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Epidemiology</span><p id="par0020" class="elsevierStylePara elsevierViewall">Over the past 20 years&#44; we have witnessed a true epidemic of DM2 in children and adolescents&#46;<a class="elsevierStyleCrossRefs" href="#bib0430"><span class="elsevierStyleSup">7&#8211;9</span></a> At the beginning of the 1990s&#44; DM2 represented 3&#37; of cases of pediatric diabetes in the US&#46;<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">10</span></a> By 2003&#44; however&#44; DM2 represented 20&#37; of cases of pediatric diabetes&#44; and&#44; depending on the geographical area&#44; almost 50&#37; of cases of diabetes among adolescents aged 15&#8211;19 years&#46;<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">11</span></a> This increase in DM2 has been confirmed both in developed and developing countries and parallels the increased prevalence of obesity in childhood and adolescence&#46;<a class="elsevierStyleCrossRefs" href="#bib0455"><span class="elsevierStyleSup">12&#44;13</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The prevalence of DM2 in children and adolescents is estimated at 12&#47;100&#44;000 in the US and 2&#46;5&#47;100&#44;000 in Europe&#46;<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">14</span></a> Screening studies on adolescents with obesity 12 years of age or older have observed a DM2 prevalence of 0&#46;4&#8211;1&#37;&#46; Another relevant issue is that most cases of DM2 in the young occur in ethnic subgroups such as African Americans&#44; Hispanics&#44; Asian Americans and Native Americans &#40;22&#46;3&#47;1000 in children 10&#8211;14 years of age&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">15</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Obesity is the main risk factor for developing DM2&#46; As with adults&#44; central obesity increases insulin resistance and promotes the development of DM2&#46; Excess weight and obesity in children 2&#8211;19 years of age is classified according to the percentile of the body mass index &#40;BMI&#44; kg&#47;m<span class="elsevierStyleSup">2</span>&#41; by age and sex as follows&#58; low weight &#40;BMI<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>5 percentile&#41;&#44; normal &#40;BMI within 5&#8211;85 percentile&#41;&#44; excess weight &#40;BMI within 85&#8211;95 percentile&#41;&#44; obesity &#40;BMI<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>95 percentile&#41; and severe obesity &#40;BMI<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>120&#37; of the 95 percentile or BMI<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>99 percentile&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The increase in excess weight and obesity rates in school-age children has been occurring worldwide in recent decades&#44; reaching 34&#37; and 10&#37;&#44; respectively&#44; in America&#46;<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">16</span></a> A third of adolescents with DM2 had not been previously diagnosed&#44; and these patients had more obesity &#40;BMI&#44; 35&#46;7<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#41; than those who did know the diagnosis of DM2 &#40;BMI&#44; 29&#46;1<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">17</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">According to the cutoffs of the International Obesity Task Force&#44; the highest excess weight and obesity rates in Europe among 7 to 11-year-old children are in Malta &#40;35&#37;&#41; and Spain &#40;34&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">18</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In Spain&#44; obesity has grown exponentially in recent decades&#46; According to data from the 2012 National Survey of Health in Spain&#44; the prevalence of excess weight and obesity among 2&#8211;17 year olds is currently 27&#46;6&#37;&#44; with the autonomous community of the Canary Islands in first place with 34&#46;5&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">19</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Pediatric obesity is intimately tied to changes in eating habits&#44; physical activity&#44; physical inactivity&#44; socioeconomic level and length of sleep&#46; A study conducted with Spanish schoolchildren showed that BMI was inversely proportional to how often they performed physical activity&#46;<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">20</span></a> Likewise&#44; the study observed an increase in BMI in the schoolchildren who spent more than 2<span class="elsevierStyleHsp" style=""></span>h a day watching television and in those who slept less than 8<span class="elsevierStyleHsp" style=""></span>h daily&#46; Other factors that influenced BMI were of a financial and educational nature in the family environment&#44; such that families with higher incomes and education levels had a lower rate of excess weight and obesity&#46;<a class="elsevierStyleCrossRef" href="#bib0500"><span class="elsevierStyleSup">21</span></a> It has also been reported that adverse experiences during childhood&#44; such as threats to the child&#39;s physical&#44; family or social safety and childhood violence and abuse and school bullying were associated with an increased risk of DM2 in adulthood&#46;<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">22</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Pathophysiology</span><p id="par0055" class="elsevierStylePara elsevierViewall">DM2 is a complex metabolic disorder in which various societal&#44; behavioral and environmental risk factors act on a foundation of genetic susceptibility&#46; The disease has a strong hereditary component &#40;probably polygenic&#41;&#44; which is responsible for the differences in the prevalence of DM2 in different racial groups&#46;<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">23</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">DM2 is characterized not only by hyperglycemia and insulin resistance but also by a relative reduction in insulin secretion&#46; Both characteristics are influenced by genetic and environmental factors&#46; Insulin resistance explains the clinical association of DM2 with obesity&#46; Patients have a combination of differing degrees of insulin resistance and reduced insulin concentrations&#46; Hyperglycemia by itself can change the function of pancreatic beta cells and exacerbate insulin resistance&#44; resulting in a vicious cycle that worsens the metabolic condition&#46; Adolescents and adults typically have lost 80&#37; of the function of pancreatic beta cells before the diagnosis of DM2&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">1</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">The progression of a normal blood glucose condition to that of impaired glucose tolerance &#40;IGT&#41; is associated with a worsening of insulin resistance&#46; IGT is an intermediate stage in the natural history of DM2 and is a predictor of the risk of developing DM and cardiovascular diseases&#46;<a class="elsevierStyleCrossRefs" href="#bib0515"><span class="elsevierStyleSup">24&#44;25</span></a> Likewise&#44; it has been proposed that hyperglycemia can worsen both insulin resistance and insulin secretion&#44; facilitating the transition of IGT to diabetes&#46;<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">25</span></a> However&#44; a high rate of spontaneous conversion to normal glucose tolerance has been observed in children and adolescents with IGT within 3&#8211;5 years&#46;<a class="elsevierStyleCrossRefs" href="#bib0520"><span class="elsevierStyleSup">25&#8211;27</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Puberty appears to play an important role in the development of DM2 in children&#46;<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">23</span></a> It has been postulated that an increase in growth hormone secretion could be responsible for insulin resistance during this period of development&#46;<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">28</span></a> This hypothesis could explain why the presentation of DM2 in children coincides with the mean age of puberty&#46;<a class="elsevierStyleCrossRefs" href="#bib0520"><span class="elsevierStyleSup">25&#8211;29</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">The adverse effect of obesity on glucose metabolism is already apparent in childhood&#46; Children with obesity have hyperinsulinemia and an approximately 40&#37; lower insulin-stimulated glucose metabolization &#40;assessed by blood glucose under fasting conditions and 2<span class="elsevierStyleHsp" style=""></span>h after eating&#41; than children who have no obesity&#46;<a class="elsevierStyleCrossRef" href="#bib0545"><span class="elsevierStyleSup">30</span></a> The inverse relationship between insulin sensitivity and abdominal fat distribution is stronger for visceral fat than for subcutaneous fat&#46;<a class="elsevierStyleCrossRefs" href="#bib0545"><span class="elsevierStyleSup">30&#44;31</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The adipose tissue that increases with obesity synthesizes and secretes metabolites and signaling proteins such as leptin&#44; adiponectin and tumor necrosis factor alpha&#46;<a class="elsevierStyleCrossRef" href="#bib0555"><span class="elsevierStyleSup">32</span></a> These factors change insulin secretion and sensitivity and can even cause insulin resistance in experimental and clinical conditions&#46;<a class="elsevierStyleCrossRef" href="#bib0560"><span class="elsevierStyleSup">33</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">The racial differences in insulin sensitivity are well-established&#46; African-American children 7&#8211;11 years of age have significantly higher insulin concentrations than white children of the same age&#46;<a class="elsevierStyleCrossRefs" href="#bib0565"><span class="elsevierStyleSup">34&#44;35</span></a> These data suggest that certain ethnic groups have a genetic predisposition to insulin resistance&#44; which can increase their risk of developing DM2&#46; These racial differences have also been observed in Europe&#44; where Swedish children with obesity have higher glucose concentrations under fasting conditions than German children with obesity&#46;<a class="elsevierStyleCrossRef" href="#bib0570"><span class="elsevierStyleSup">35</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">It has also been observed that a low pancreatic reserve and a high glycated hemoglobin &#40;HbA1c&#41; level are independent predictors for the loss of glycemic control in patients undergoing drug treatment&#46;<a class="elsevierStyleCrossRefs" href="#bib0575"><span class="elsevierStyleSup">36&#44;37</span></a> The deterioration in pancreatic beta cell function is also observed in adults with DM2&#44; although it is not as accelerated as in the young&#46;<a class="elsevierStyleCrossRefs" href="#bib0585"><span class="elsevierStyleSup">38&#8211;41</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Clinical presentation</span><p id="par0095" class="elsevierStylePara elsevierViewall">DM2 in the young occurs predominantly in the female sex&#46; The mean age at diagnosis is 13&#46;5 years&#44; although DM2 almost always starts at the age of 10 years&#44; unlike DM1&#44; which starts before the age of 10 years in 50&#37; of cases&#46;<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">29</span></a> In most cases&#44; DM2 is associated with obesity as the main determinant&#46;<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">29</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">The clinical presentation in children can be diverse and varies from asymptomatic hyperglycemia to ketoacidosis &#40;6&#37; of cases in patients between 10&#8211;19 years of age&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0605"><span class="elsevierStyleSup">42</span></a> Unlike the onset of DM1&#44; the cardinal symptoms of DM2 are unclear&#46; Thus&#44; children with DM2 usually present glycosuria without ketonuria&#44; mild or nonexistent polyuria&#44; polydipsia and little or no weight loss&#46; Although it is uncommon&#44; children with DM2 are at risk of presenting nonketotic hyperosmolar hyperglycemic decompensation&#44; which is associated with high mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0610"><span class="elsevierStyleSup">43</span></a> Differing clinical characteristics&#44; depending on the patients&#8217; ethnicity and race&#44; have also been observed&#44; with a predominance of DM1 in whites and DM2 in at-risk ethnic groups<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">29</span></a> &#40;African Americans&#44; American Hispanics&#44; Asians and Native Americans&#41;&#46; The differential characteristics between the two types of diabetes are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;<a class="elsevierStyleCrossRef" href="#bib0615"><span class="elsevierStyleSup">44</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">One of the characteristics of adult-onset DM2 is the lack of beta cell antibodies&#46; However&#44; a number of studies have observed the presence of these antibodies in almost 30&#37; of children and adolescents with DM2 in Europe&#46;<a class="elsevierStyleCrossRef" href="#bib0620"><span class="elsevierStyleSup">45</span></a> This group of adolescents does not usually require insulin therapy&#44; at least during the first year&#46; It has been postulated that this clinical form is an early presentation of latent autoimmune diabetes mellitus in adulthood&#46;<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">46</span></a> In adolescents&#44; the term &#8220;latent autoimmune diabetes mellitus in youth&#8221; has been proposed&#46;<a class="elsevierStyleCrossRef" href="#bib0630"><span class="elsevierStyleSup">47</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Maturity-onset diabetes of the young &#40;MODY&#41; is a form of maturity diabetes that occurs in children&#46; MODY is an uncommon form of diabetes in children that includes several forms caused by monogenic defects in beta cell function &#40;the most common of which are the hepatocyte nuclear factor 4 alpha gene mutation and the glucokinase gene mutation&#41;&#46; Patients with MODY have dominant genetic traits&#44; do not have obesity and have low insulin concentrations under fasting conditions&#46; These genetic anomalies are believed to be rare and require molecular diagnostic techniques&#46; Recent studies have suggested that the clinical presentation spectrum of MODY is broad and ranges from asymptomatic hyperglycemia to severe acute onset&#46;<a class="elsevierStyleCrossRef" href="#bib0635"><span class="elsevierStyleSup">48</span></a> This variety of diabetes has been reported in all races and ethnicities&#46; The main characteristics of MODY are listed in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Diabetes mellitus can be classified reliably&#44; in most patients&#44; based on the clinical presentation and progression&#46;<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">24</span></a> In the unusual situation in which a more precise classification is needed&#44; other specific measurements might be required&#44; such as insulin and peptide <span class="elsevierStyleSmallCaps">C</span> concentrations under fasting conditions and&#44; occasionally&#44; beta cell antibody levels&#46;<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">14</span></a> The diagnostic criteria for DM in children and adolescents does not differ from those established by the American Diabetes Association &#40;ADA&#41; for adults&#46;<a class="elsevierStyleCrossRef" href="#bib0640"><span class="elsevierStyleSup">49</span></a><a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> shows a flow diagram for classifying DM in children and adolescents&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Diabetes screening in childhood</span><p id="par0120" class="elsevierStylePara elsevierViewall">Most white European children and adolescents with DM2 and a third of children in the US were asymptomatic at the time of diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">29</span></a> Accordingly&#44; DM2 screening studies appear to be necessary&#44; given that hyperglycemia can go unnoticed and contribute to long-term microvascular and macrovascular damage&#46; A DM2 screening for the entire young population is currently not cost effective&#59; it is therefore only advisable to study patients at greater risk&#46; Due to the close direct relationship with obesity&#44; the ADA recommends DM2 screening for children and adolescents with excess weight at the onset of puberty who also have other risk factors &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0640"><span class="elsevierStyleSup">49</span></a> The screening test of choice is measuring fasting plasma glucose and the oral glucose overload test &#40;OGTT&#41;&#46; However&#44; these recommendations have a number of drawbacks&#46; Fasting plasma glucose is a comfortable&#44; simple and inexpensive procedure but failed in a quarter of patients in a European study&#46;<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">29</span></a> The OGTT can be a better screening method but costs more&#44; is more labor intense and at times has little reproducibility&#46;<a class="elsevierStyleCrossRef" href="#bib0645"><span class="elsevierStyleSup">50</span></a> We also do not know if the cutoffs for OGTT established for adulthood are applicable for childhood&#46; With regard to the use of HbA1c for diagnosing DM2&#44; the ADA continues to recommend it despite its limitations for children and adolescents due to its low sensitivity and high cost&#46;<a class="elsevierStyleCrossRefs" href="#bib0650"><span class="elsevierStyleSup">51&#8211;53</span></a></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Treatment</span><p id="par0125" class="elsevierStylePara elsevierViewall">The American Academy of Pediatrics has published guidelines on treating DM2 in children and adolescents&#46;<a class="elsevierStyleCrossRef" href="#bib0665"><span class="elsevierStyleSup">54</span></a> Most of these recommendations have been extrapolated from experience with adults&#46;<a class="elsevierStyleCrossRef" href="#bib0670"><span class="elsevierStyleSup">55</span></a> The 3 main treatment objectives are lifestyle changes&#44; blood glucose normalization and control of associated comorbidities&#46;<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">24</span></a> The final treatment objective is to decrease the risk of acute and chronic complications&#46;</p><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Nondrug therapy&#58; lifestyle changes</span><p id="par0130" class="elsevierStylePara elsevierViewall">Weight control is essential to achieving the therapeutic objectives&#46; The dietary recommendations consist of eliminating soft drinks and juices with high sugar content&#44; increasing the intake of fruits and vegetables&#44; controlling portion sizes&#44; changing the family eating behaviors and eliminating unhealthy food from the home&#46;<a class="elsevierStyleCrossRef" href="#bib0675"><span class="elsevierStyleSup">56</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Regular exercise&#44; even without caloric restriction and without weight loss&#44; is associated with a reduction in insulin resistance in the young with excess weight or obesity&#44; regardless of whether they previously had DM2&#46;<a class="elsevierStyleCrossRefs" href="#bib0680"><span class="elsevierStyleSup">57&#8211;59</span></a> The current recommendations for children&#39;s physical activity include 60<span class="elsevierStyleHsp" style=""></span>min a day of moderate-vigorous activity&#44; which can be performed all at once or divided into sessions&#46;<a class="elsevierStyleCrossRef" href="#bib0695"><span class="elsevierStyleSup">60</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Despite the efforts&#44; the results achieved with lifestyle changes are very limited&#46; In one study&#44; only 17&#37; of the patients managed to reduce their BMI 1 year after implementing a diet program plus exercise&#44; and only 23&#37; managed to withdraw the medication after more than 2 years&#46;<a class="elsevierStyleCrossRef" href="#bib0700"><span class="elsevierStyleSup">61</span></a> Another study observed that less than 10&#37; of young individuals with DM2 reached their blood glucose objectives exclusively with lifestyle changes&#46;<a class="elsevierStyleCrossRefs" href="#bib0705"><span class="elsevierStyleSup">62&#44;63</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">Although observational studies on young individuals with DM2<a class="elsevierStyleCrossRef" href="#bib0715"><span class="elsevierStyleSup">64</span></a> have suggested that higher activity levels are associated with improved blood glucose control&#44; the only large-scale therapeutic trial to assess the effects of lifestyle changes in 699 young individuals with DM2 did not support this assumption&#46;<a class="elsevierStyleCrossRef" href="#bib0565"><span class="elsevierStyleSup">34</span></a> The study showed that&#44; after 24 months&#44; the intense lifestyle changes &#40;200&#8211;300<span class="elsevierStyleHsp" style=""></span>min of moderate-to-intense exercise per week and a daily intake of 1200&#8211;1500 calories&#41;&#44; compared with metformin in monotherapy did not improve the long-term blood glucose control&#46; Other cardiovascular risk factors&#44; such as dyslipidemia and inflammatory markers&#44; also did not improve with lifestyle changes compared with monotherapy with metformin&#46;<a class="elsevierStyleCrossRef" href="#bib0720"><span class="elsevierStyleSup">65</span></a> These poor results could be related to the follow-up loss rates&#44;<a class="elsevierStyleCrossRefs" href="#bib0725"><span class="elsevierStyleSup">66&#44;67</span></a> factors related to the socioeconomic status and high rates of depression&#46;<a class="elsevierStyleCrossRef" href="#bib0735"><span class="elsevierStyleSup">68</span></a></p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Pharmacotherapy</span><p id="par0150" class="elsevierStylePara elsevierViewall">Pharmacotherapy is indicated if the treatment objective &#40;HbA1c &#60;7&#46;5&#37; and blood glucose under fasting conditions &#60;130<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41; is not achieved through nutritional education and exercise&#46; There are many available drugs for treating diabetes&#44; although only metformin and insulin have been approved by regulatory agencies for use in patients younger than 18 years&#46;<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">24</span></a> Most pediatric diabetologists use oral agents as the first therapeutic approach because they facilitate therapeutic compliance&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Metformin&#44; a biguanide&#44; is unquestionably the most appropriate starting point for the pharmacotherapy of DM2 in children&#44; as it is for adults&#46;<a class="elsevierStyleCrossRef" href="#bib0740"><span class="elsevierStyleSup">69</span></a> The drug reduces hepatic glucose production and increases hepatic and muscle sensitivity to insulin without a direct effect on beta cell function&#46; Metformin has the advantage of slightly reducing weight&#44; improving the lipid profile without increasing the risk of hypoglycemia and is easy to use and inexpensive&#46; The initial dose is 500<span class="elsevierStyleHsp" style=""></span>mg&#47;d and is increased progressively to 1000<span class="elsevierStyleHsp" style=""></span>g&#47;12<span class="elsevierStyleHsp" style=""></span>h within 4 weeks&#44; unless there are adverse gastrointestinal effects&#46; The drug&#39;s most common adverse effects are gastrointestinal abnormalities &#40;bloating and diarrhea&#41; and&#44; although it has a good safety profile&#44; should not be administered in cases of hypoxemia&#44; severe infection&#44; severe liver or kidney disease or alcohol abuse&#44; due to the risk of lactic acidosis&#46; Metformin should be used with caution and its dosage adjusted if the patient has impaired renal function&#46; If monotherapy with metformin is ineffective after 3&#8211;6 months&#44; combining another drug should be considered&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">The efficacy of metformin in adolescents has been tested in 2 clinical trials&#46;<a class="elsevierStyleCrossRefs" href="#bib0565"><span class="elsevierStyleSup">34&#44;70</span></a> In the Treatment Options for type 2 Diabetes in Adolescents and Youth &#40;TODAY&#41; trial&#44;<a class="elsevierStyleCrossRef" href="#bib0565"><span class="elsevierStyleSup">34</span></a> children and adolescents were distributed to the 3 treatment arms &#40;metformin&#44; metformin plus rosiglitazone and metformin plus lifestyle changes&#41;&#46; The results suggest that in standard clinical practice a large portion of young patients with DM2 could require combined therapy with insulin a few years after the diagnosis&#46; In this study&#44;<a class="elsevierStyleCrossRef" href="#bib0565"><span class="elsevierStyleSup">34</span></a> monotherapy with metformin was associated with adequate blood glucose control in approximately half of the patients with DM2&#46; The marketing of rosiglitazone was restricted by the Food and Drug Administration in 2010 after a slight increase in cardiovascular risk was observed&#46; Another study that compared metformin versus placebo observed a 1&#8211;2&#37; reduction in HbA1c after 4 weeks of therapy&#44; with a similar tolerance to that reported in adults&#46;<a class="elsevierStyleCrossRef" href="#bib0745"><span class="elsevierStyleSup">70</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">The use of insulin is preferred for patients with ketosis or intense hyperglycemia and who have mixed characteristics of DM1 and DM2&#46; The new guidelines recommend insulin therapy when the plasma glucose concentrations are &#8805;250<span class="elsevierStyleHsp" style=""></span>mg&#47;dL or HbA1c levels are &#62;9&#44; with monitoring every 3 months to adjust the dosage or withdraw it if the control is optimal&#46;<a class="elsevierStyleCrossRef" href="#bib0750"><span class="elsevierStyleSup">71</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">There is no specific contraindication for insulin therapy in children&#44; and the most appropriate administration regimen for each patient&#39;s lifestyle should be selected&#46; The most common adverse effects are weight gain and hypoglycemia&#46; NPH insulin once a day or basal insulin &#40;glargine&#44; detemir or degludec&#41; at an initial dose of 0&#46;25&#8211;0&#46;5<span class="elsevierStyleHsp" style=""></span>units&#47;kg is often effective for metabolic control&#46;<a class="elsevierStyleCrossRef" href="#bib0755"><span class="elsevierStyleSup">72</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">Although studies have been conducted on the use of other hypoglycemic agents &#40;thiazolidinediones&#44; sulfonylureas&#44; meglitinides&#44; alpha-glucosidase inhibitors&#44; dipeptidyl peptidase-4 inhibitors&#44; glucagon-like peptide-1 analogs and amylin analogs&#41; in this population group&#44; their use has still not been approved&#46;<a class="elsevierStyleCrossRef" href="#bib0760"><span class="elsevierStyleSup">73</span></a></p><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Surgical treatment</span><p id="par0180" class="elsevierStylePara elsevierViewall">Bariatric surgery can be a useful therapeutic option&#44; although the experience with adolescents with DM2 is very limited&#46; In a retrospective series of 11 postpubertal adolescents with DM2 who underwent gastric bypass with jejunal Roux-en-Y anastomosis&#44; significant improvements were achieved in BMI&#44; blood glucose control&#44; serum lipid concentrations and blood pressure compared with 67 adolescents who underwent medical treatment for 1 year&#46;<a class="elsevierStyleCrossRef" href="#bib0765"><span class="elsevierStyleSup">74</span></a> In particular&#44; 10 of the 11 patients treated surgically had remission of the diabetes without the need for medication&#46; The recommended selection criteria for bariatric surgery in the young are as follows&#58; BMI &#62;35&#44; advanced puberty development &#40;Tanner stage IV or V&#41; and skeletal maturity&#46;<a class="elsevierStyleCrossRef" href="#bib0770"><span class="elsevierStyleSup">75</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">Other techniques such as tubular gastrectomy and gastric band surgery have also been put into practice&#44; but there is little experience with children and adolescents&#44; and more studies are needed to offer concrete recommendations&#46;<a class="elsevierStyleCrossRef" href="#bib0775"><span class="elsevierStyleSup">76</span></a></p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Comorbidities</span><p id="par0190" class="elsevierStylePara elsevierViewall">The comorbidities that accompany DM2 in the young are very common and need to be properly approached to prevent the development of vascular complications&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">The SEARCH study observed that 92&#37; of the adolescents with DM2 met the criteria of metabolic syndrome by presenting 2 risk factors for cardiovascular disease&#44; as well as DM&#44; compared with 14&#37; of the patients with DM1&#46;<a class="elsevierStyleCrossRef" href="#bib0780"><span class="elsevierStyleSup">77</span></a> In addition to obesity&#44; the presence of other comorbidities such as arterial hypertension&#44; dyslipidemia&#44; retinopathy&#44; nephropathy and depression should be ruled out&#46; The recommendations for their screening and treatment are shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46;<a class="elsevierStyleCrossRef" href="#bib0785"><span class="elsevierStyleSup">78</span></a></p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0200" class="elsevierStylePara elsevierViewall">In a study conducted in the US that included children and adolescents with DM1 or DM2 with a mean disease duration of 7&#46;9 years&#44; the patients with DM2 had a higher prevalence &#40;adjusted for age&#41; of diabetic nephropathy&#44; retinopathy&#44; peripheral neuropathy&#44; arterial stiffness and hypertension than those with DM1&#46;<a class="elsevierStyleCrossRef" href="#bib0790"><span class="elsevierStyleSup">79</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">We therefore need to pay attention to preventing excess weight and obesity in this population group through public education in healthy life habits and early detection in consultations&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Conflicts of interest</span><p id="par0210" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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          "identificador" => "xpalclavsec1031522"
          "titulo" => "Keywords"
        ]
        2 => array:3 [
          "identificador" => "xres1087559"
          "titulo" => "Resumen"
          "secciones" => array:1 [
            0 => array:1 [
              "identificador" => "abst0010"
            ]
          ]
        ]
        3 => array:2 [
          "identificador" => "xpalclavsec1031523"
          "titulo" => "Palabras clave"
        ]
        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Background"
        ]
        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Epidemiology"
        ]
        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Pathophysiology"
        ]
        7 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "Clinical presentation"
        ]
        8 => array:2 [
          "identificador" => "sec0025"
          "titulo" => "Diabetes screening in childhood"
        ]
        9 => array:3 [
          "identificador" => "sec0030"
          "titulo" => "Treatment"
          "secciones" => array:1 [
            0 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "Nondrug therapy&#58; lifestyle changes"
            ]
          ]
        ]
        10 => array:3 [
          "identificador" => "sec0040"
          "titulo" => "Pharmacotherapy"
          "secciones" => array:1 [
            0 => array:2 [
              "identificador" => "sec0045"
              "titulo" => "Surgical treatment"
            ]
          ]
        ]
        11 => array:2 [
          "identificador" => "sec0050"
          "titulo" => "Comorbidities"
        ]
        12 => array:2 [
          "identificador" => "sec0055"
          "titulo" => "Conflicts of interest"
        ]
        13 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2017-12-10"
    "fechaAceptado" => "2018-03-22"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1031522"
          "palabras" => array:6 [
            0 => "Type 2 diabetes mellitus"
            1 => "Obesity"
            2 => "Childhood"
            3 => "Adolescence"
            4 => "Comorbidities"
            5 => "Treatment"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec1031523"
          "palabras" => array:6 [
            0 => "Diabetes mellitus tipo 2"
            1 => "Obesidad"
            2 => "Infancia"
            3 => "Adolescencia"
            4 => "Comorbilidades"
            5 => "Tratamiento"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">In recent years&#44; we have witnessed an increase in the number of cases of type 2 diabetes mellitus &#40;DM2&#41; in children and adolescents&#44; which has paralleled the increase in the worldwide prevalence of obesity&#46; Although screening the general population does not appear to be cost-effective&#44; special attention should be paid to children with excess weight&#44; obesity or other factors that predispose them to a state of insulin resistance&#46; When faced with the diagnosis of childhood DM2&#44; the presence of comorbidities &#40;such as hypertension&#44; dyslipidemia and microalbuminuria&#41; should be assessed&#44; and appropriate treatment and follow-up should be administered to prevent the onset of complications&#44; given that the DM2 in this population group will last longer than that started in adulthood&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">En los &#250;ltimos a&#241;os asistimos a un aumento en el n&#250;mero de casos de diabetes mellitus tipo 2 &#40;DM2&#41; en ni&#241;os y adolescentes&#44; que ocurre de forma paralela al aumento de la prevalencia de obesidad en todo el mundo&#46; A pesar de que un cribado de la poblaci&#243;n general no parece coste-efectivo&#44; deber&#237;a prestarse especial atenci&#243;n a los ni&#241;os con sobrepeso&#44; obesidad u otros factores que predispongan a un estado de resistencia a la insulina&#46; Ante el diagn&#243;stico de DM2 en la infancia debe evaluarse la presencia de comorbilidades&#44; como la hipertensi&#243;n&#44; la dislipidemia y la microalbuminuria&#44; as&#237; como llevar a cabo un adecuado tratamiento y seguimiento para evitar la aparici&#243;n de complicaciones&#44; pues en este grupo de poblaci&#243;n la duraci&#243;n de la DM2 ser&#225; mayor que en la iniciada en el adulto&#46;</p></span>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Please cite this article as&#58; Calero Bernal ML&#44; Varela Aguilar JM&#46; Diabetes tipo 2 infantojuvenil&#46; Rev Clin Esp&#46; 2018&#59;218&#58;372&#8211;381&#46;</p>"
      ]
    ]
    "apendice" => array:1 [
      0 => array:1 [
        "seccion" => array:1 [
          0 => array:4 [
            "apendice" => "<p id="par0220" class="elsevierStylePara elsevierViewall">The following are the supplementary data to this article&#58;<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>"
            "etiqueta" => "Appendix A"
            "titulo" => "Supplementary data"
            "identificador" => "sec0065"
          ]
        ]
      ]
    ]
    "multimedia" => array:5 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Flow diagram for the classification of diabetes mellitus in children and adolescents&#46;</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>&#58; DM1&#58; type 1 diabetes mellitus&#59; DM2&#58; type 2 diabetes mellitus&#59; MODY&#58; maturity onset of diabetes mellitus in youth&#46;</p> <p id="spar0025" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Source</span>&#58; Reinehr&#46;<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">14</span></a></p>"
        ]
      ]
      1 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
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            "identificador" => "at1"
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          "leyenda" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>&#58; anti-GAD&#58; glutamic acid decarboxylase antibodies&#59; DM1&#58; type 1 diabetes mellitus&#59; DM2&#58; type 2 diabetes mellitus&#59; ICA&#58; islet cell autoantigen&#59; MODY&#58; maturity onset of diabetes mellitus in youth&#59; ODD&#58; oral diabetes drugs&#59; PCOS&#58; polycystic ovary syndrome&#46;</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Source</span>&#58; Alberti et al&#46;<a class="elsevierStyleCrossRef" href="#bib0615"><span class="elsevierStyleSup">44</span></a></p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">DM1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">DM2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">MODY&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age at onset&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Preschool-Adolescent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#62;10 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;25 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Female<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Female<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Female<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ethnic group&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">White&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">At-risk ethnic groups&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">All races&#47;ethnicities&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Obesity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Uncommon &#40;20&#8211;25&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Frequent &#40;&#62;80&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Uncommon&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Onset&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Acute-symptomatic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Insidious-asymptomatic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">From asymptomatic hyperglycemia to acute severe presentation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Symptoms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Weight loss<br>Polyuria<br>Polydipsia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Variable<br>Family history of DM2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Family history of diabetes in more than 2 generations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ketosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Frequent &#40;30&#8211;40&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Typically absent &#40;Hispanics and African Americans&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Low risk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Peptide C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8595; &#8595;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Normal or &#8593;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Antibodies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ICA&#43;<br>Anti-GAD&#43;<br>ICA 512&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ICA&#8722;<br>Anti-GAD&#8722;<br>ICA 512&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Absent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Insulin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ODD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Depending on the genetic defect&#58; diet&#44; sulfonylureas or insulin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Associated diseases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Autoimmune &#40;thyroid&#44; adrenal&#44; vitiligo&#41;&#44; celiac disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">PCOS&#44; acanthosis nigricans&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Low birth weight&#44; agenesis or severe pancreatic hypoplasia&#44; nephropathy&#44; acanthosis nigricans&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Differential characteristics of type 1 and type 2 diabetes mellitus in adolescence&#46;</p>"
        ]
      ]
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        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "detalles" => array:1 [
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            "identificador" => "at2"
            "detalle" => "Table "
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        "tabla" => array:2 [
          "tablatextoimagen" => array:1 [
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Criteria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Excess weight defined as</span> &#8230;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>BMI<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>85 percentile for sex and age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Weight<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>120&#37; of ideal for height&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Weight&#47;height<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>85 percentile 85&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Two or more of the following risk factors&#58;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Family history of DM2 in first or second-degree relatives&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>At-risk ethnic group &#40;Native American&#44; African&#44; Latino&#44; Asian&#44; Pacific Islander&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Signs of insulin resistance or conditions associated with insulin resistance &#40;acanthosis nigricans&#44; AHT&#44; dyslipidemia&#44; polycystic ovaries or low birth weight&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Maternal history of diabetes or gestational diabetes during child&#39;s gestation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Age of onset&#58; at 10 years or at the onset of puberty&#44; whichever comes first</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Frequency&#58; every 3 years</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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          "notaPie" => array:1 [
            0 => array:3 [
              "identificador" => "tblfn0005"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Individuals<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>18<span class="elsevierStyleHsp" style=""></span>years of age&#46;</p> <p class="elsevierStyleNotepara" id="npar0010"><span class="elsevierStyleItalic">Abbreviations</span>&#58; AHT&#58; arterial hypertension&#59; BMI&#58; body mass index&#59; DM2&#58; type 2 diabetes mellitus&#46;</p> <p class="elsevierStyleNotepara" id="npar0015"><span class="elsevierStyleItalic">Source</span>&#58; Standards of Medical Care in diabetes 2017&#46;<a class="elsevierStyleCrossRef" href="#bib0640"><span class="elsevierStyleSup">49</span></a></p>"
            ]
          ]
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Screening for type 2 diabetes mellitus and prediabetes in asymptomatic children&#46;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a></p>"
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          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>&#58; ACEI&#58; angiotensin-converting enzyme inhibitors&#59; ARB-II&#58; angiotensin-receptor blockers&#59; BP&#58; blood pressure&#59; HDL&#58; high density lipoprotein&#59; LDL&#58; low density lipoprotein&#46;</p><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Source</span>&#58; Kao and Sabin&#46;<a class="elsevierStyleCrossRef" href="#bib0785"><span class="elsevierStyleSup">78</span></a></p>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Comorbidity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Prevalence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Screening&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Therapeutic recommendation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hypertension&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Affects up to 36&#37; of the young within 1&#46;3 years of the diagnosis&#59; up to 66&#37; in a number of cross-sectional studies&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">At the time of the diagnosis and at every subsequent visit&#46; Use the appropriate cuff size and adjust the readings according to age&#44; sex and height&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lifestyle modifications&#58; Treatment with ACEI if the lifestyle modification is not successful after 6 months&#46;<br>ARB-II if ACEI is not tolerated&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Dyslipidemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hypertriglyceridemia in 60&#8211;65&#37;&#46;<br>Reduction in HDL-cholesterol in 73&#37;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">At the time of diagnosis&#46; If monitoring every 2 years is normal&#46;<br>If more frequent follow-up is abnormal&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Evaluation and change in diet&#46; If failure after 6 months&#44; consider&#8230;<br>Treatment with statins if LDL<span class="elsevierStyleHsp" style=""></span>&#62;130<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#46;<br>Therapy with fibrates if triglycerides<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>800&#8211;1000<span class="elsevierStyleHsp" style=""></span>mg&#47;dL and if patient is &#62;10 years of age due to risk of acute pancreatitis&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Retinopathy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&#46;3&#37; at the time of diagnosis&#46;<br>12&#46;7&#37; have proliferative retinopathy at 35 years&#46;<br>23&#46;7&#37; go blind at a mean age of 32 years&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Examination with pupil dilation by ophthalmologist at the time of the diagnosis&#46; Annual examination if the examination results are normal and more often if abnormal&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Consult an ophthalmologist if there is evidence of retinopathy&#46; Laser therapy might be required if there is proliferative retinopathy&#44; clinically significant macular edema or severe nonproliferative retinopathy&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Kidney disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Frequently present in the diagnosis&#46;<br>14&#8211;22&#37; in cross-sectional studies&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Microalbuminuria in urine sample&#58; 30&#8211;299<span class="elsevierStyleHsp" style=""></span>mg&#47;g&#46;<br>Proteinuria in 24-h urine&#58; 20&#8211;199<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;min&#46;<br>Can be increased by tobacco use&#44; exercise and menstruation&#46;<br>Rule out orthostatic proteinuria&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">If condition persists &#40;&#62;2 samples&#41;&#44; start with ACEI&#44; even with normal BP&#46;<br>The objective is to normalize proteinuria&#46;<br>Treat the hypertension&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Depression&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Up to 14&#46;7&#37;&#59; more common in women&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Detect symptoms of depression at the time of the diagnosis and periodically&#44; especially in those with deficient blood glucose control and&#47;or frequent visits to the emergency department&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Consult with a mental health specialist&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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Article information
ISSN: 22548874
Original language: English
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2023 March 13 5 18
2023 February 6 0 6
2023 January 11 0 11
2022 December 14 0 14
2022 November 13 0 13
2022 October 16 2 18
2022 September 10 0 10
2022 August 11 2 13
2022 July 15 2 17
2022 June 10 0 10
2022 May 13 2 15
2022 April 17 3 20
2022 March 20 2 22
2022 February 15 2 17
2022 January 19 0 19
2021 December 11 0 11
2021 November 4 0 4
2020 September 0 1 1
2018 June 0 1 1
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¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?