Dyslipidemia and Type II Diabetes

CHAPTER 7

Dyslipidemia and Type II Diabetes LORRAINE KATZ, MD  •  BRETT BARRETT, DO, MS

INTRODUCTION As the rate of childhood obesity has risen over the past few decades, so has the incidence of children and adolescents diagnosed with type 2 diabetes. The SEARCH for Diabetes in Youth study, a cross-sectional, population based study conducted across six centers, estimated a prevalence of type 2 diabetes in youth of 0.46 per 1000 in 2009.1 The high prevalence of obesity in youth has also led to an increase in type 2 diabetes and dyslipidemia.2 Recognizing diabetes early in its course is imperative in managing complications that are associated with this disease, including dyslipidemia.

TYPE 2 DIABETES AND DYSLIPIDEMIA IN CHILDREN

Dyslipidemia is defined as a lipoprotein disorder promoting the development of atherosclerosis. The lipid abnormalities included in this definition are increased low-density lipoprotein cholesterol, decreased highdensity lipoprotein cholesterol, and increased serum triglycerides. Lipid abnormalities have been strongly linked to the risk of cardiovascular disease (CVD) in diabetes in adults, but is less understood in youth. Data in adults with diabetes have shown that lipoprotein composition is more atherogenic and is influenced by glycemic control. The majority of research done on the subject of dyslipidemia in diabetes in youth and has been performed in type 1 diabetes. The SEARCH for Diabetes in Youth study revealed that a large proportion of youth aged 10–22 with type 1 diabetes had lipid concentrations greater than the recommended targets3 and that mean lipid levels and presence of dyslipidemia are influenced by glycemic control. Children with poor glycemic control and type 1 diabetes have higher prevalence of dyslipidemia, specifically total cholesterol, LDL cholesterol, and non-HDL cholesterol than nondiabetic youth. SEARCH data showed that regardless of glycemic control, children with type 1 diabetes have significantly elevated apoB levels and have more small dense LDL particles than nondiabetic children.4 

It is known that in both adults and children with type 2 diabetes, the combination of obesity, insulin resistance, and relative insulin deficiency is associated with elevated serum triglycerides, decreased HDL cholesterol, and higher LDL cholesterol. Dyslipidemia is very common in adults with type 2 diabetes, and we now know that a substantial portion of children with type 2 diabetes have dyslipidemia. The SEARCH for Diabetes in Youth study showed that 33% of youth with type 2D had total cholesterol greater than 200 mg/dL; 24% had LDL cholesterol greater than 130 mg/dL; 29% had triglyceride concentration greater than 150 mg/dL; and 44% had HDL cholesterol level less than 40 mg/dL.3 The Treatment Options for type 2 Diabetes in Adolescents and Youth (TODAY) study was designed to assess the effect of diabetes treatment on duration of metabolic control. This study included 699 multiethnic participants aged 10–17 years diagnosed with type 2 diabetes for less than 2 years. The youth were randomized to three possible groups: metformin, metformin plus rosiglitazone, or metformin plus lifestyle changes. Statins were initiated for LDL cholesterol greater than 130 mg/dL or triglycerides greater than or equal to 300 mg/dL. Studies have shown in adults with diabetes that statin therapy has been beneficial to dyslipidemia,5,6 but specific benefit in children with type 2 diabetes has not yet been demonstrated. The TODAY study showed that LDL cholesterol increased with increasing HbA1c. After 36 months of follow-up, the prevalence of elevated LDL cholesterol or those on lipid lowering therapy increased to 10.7%. Elevated triglycerides at baseline were seen in 21% and this increased to 23.3% after the 36 months of follow-up. Treatment assignment had no significant effect on LDL or nonHDL cholesterol. However, triglycerides were lower in the metformin plus lifestyle group than metformin alone. Metformin plus lifestyle also attenuated the negative effect of elevated hemoglobin A1C levels on triglyceride levels in all patients and on HDL cholesterol levels in female patients.7

Pediatric Type II Diabetes. https://doi.org/10.1016/B978-0-323-55138-0.00007-3 Copyright © 2019 Elsevier Inc. All rights reserved.

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DIABETES AND DYSLIPIDEMIA

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SECTION III Complications

Further analysis from the TODAY study attempted to determine the impact of insulin therapy on lipid and inflammatory markers in youth who had reached primary outcome. This study subgroup included the 285 participants who failed to sustain glycemic control on randomized treatment (primary outcome: HbA1c >8%) and 363 who were compared with those who maintained glycemic control. Upon failing to maintain control, insulin therapy was started. Of note, in those patients who had LDL cholesterol >130 mg/dL, statin therapy was initiated. Changes in lipids and inflammatory markers were then measured over time. The results revealed again that progression of dyslipidemia was related to glycemic control. In the primary outcome group, insulin therapy had a modest impact of HbA1c, and decreased the rise in total cholesterol, LDL cholesterol, and total apolipoprotein B. Statin use in this group also increased from 8.6% to 22% one year after reaching primary outcome. The increase in triglycerides and nonesterified free fatty acids stabilized after initiation of insulin, independent of HbA1c. The analysis showed that insulin therapy without improvement of glycemic control showed little benefit.8 As expected, glycemic control among adolescents with type 2 diabetes is often poor. Studies have reported that less than half of adolescents with type 2 diabetes regularly attend follow-up visits.9 A study in Canadian patients reported an average hemoglobin A1C concentration of 12%, even among patients who are actively following up in clinic.10 As it has been established that diabetes is a major risk factor for cardiovascular disease,11 given the poor control and follow-up for T2D in this age group, it is important to take preventative measures for dyslipidemia and related comorbidities. It is well known that obese children can have type 2 diabetes along with metabolic, syndrome, and liver disease. Clinical effects of obesity can be seen as early as infancy.12 There is significant overlap with T2 diabetes and metabolic syndrome, as well as with fatty liver disease given the role insulin may play in both diseases. Nonalcoholic fatty liver disease NAFLD is more common in children with metabolic syndrome. A recent study of 254 children aged 6–17 years with nonalcoholic fatty liver disease showed that 26% met criteria for metabolic syndrome.13 As lipogenesis and lipolysis in the liver are influenced by insulin, it is likely that the hyperinsulinemia due to insulin resistance is etiologic.14 The potential of NAFLD comorbidity with metabolic syndrome is common. The most widely accepted theory of nonalcoholic steatohepatitis (NASH) pathogenesis is that of the two-hit hypothesis in which the primary abnormality, accumulation of triglyceride within hepatocytes, occurs due to insulin resistance. Insulin resistance leads to hyperinsulinemia, which in turn promotes de novo hepatic lipogenesis through upregulation of transcription

factors, and an influx of free fatty acids to the liver due to loss of insulin-mediated suppression of lipolysis. Hepatic export of triglycerides as very low-density lipoprotein is also impaired. Following this hepatocellular triglyceride accumulation, the steatotic liver is then vulnerable to a second hit. Proposed sources of this secondary injury include oxidative stress and adipocytokines.13 Children with NAFLD have increased prevalence of risk factors for CVD including elevated low-density lipoprotein, increased total cholesterol, and decreased high-density lipoprotein, when compared to matched controls.15 The severity of NASH, as assessed by the NAFLD activity score is associated with increased triglyceride/HDL, total cholesterol/HDL, and LDL/HDL ratios.16 Children with NAFLD also have greater carotid arterial intima-media thickness, when compared to obese children without NAFLD.17 In a study by Corey et al., the resolution of NASH in children was associated with a significant decrease in total cholesterol levels from baseline compared to those who did not experience a resolution of NASH (mean change −10.0 mg/ dL vs. −0.9 mg/dL). In addition, in those whose NASH had resolved, there was a significant decrease in non-HDL cholesterol levels compared to subjects without resolution of NASH (mean change −7.3 mg/dL vs. 1.1).1.8 

SCREENING FOR DYSLIPIDEMIA Children with low A1C levels and type 1 diabetes have lipid profiles that are similar to or even less atherogenic than those observed in nondiabetic youth. Based upon observations from adult trials, the American Diabetes Association in combination with the American Academy of Pediatrics developed guidelines for dyslipidemia screening and treatment in children with both type 1 and type 2 diabetes.19 The ADA 2017 recommendations in patients with type 1 diabetes above age 10 is for a fasting lipid panel to be obtained shortly after diagnosis, but after glycemic control is established. This should include total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides. Goal levels of LDL cholesterol are less than 100 mg/dL; for HDL cholesterol, goals are greater than 35 mg/dL; and for triglycerides, goals are less than 150 mg/dL. If levels are abnormal, annual monitoring is recommended. If LDL cholesterol level is less than 100 mg/dL, repeating every 3–5 years is reasonable. In those with type 2 diabetes, pediatric patients should be screened after glycemic control is achieved regardless of age. After screening, the same goals as for type 1 diabetic patients are followed (Fig. 7.1).20 

TREATMENT OF DYSLIPIDEMIA Initial treatment for dyslipidemia in youth consists of optimizing glucose control and medical nutrition

CHAPTER 7  Dyslipidemia and Type II Diabetes

Type 1

Type 2

>Age 10

Any age

Establish Glycemic Control

Fasting Lipid Panel Screen Including Total Cholesterol, LDL, HDL, Triglycerides

Goals: LDL <100 mg/dL, HDL>35 mg/dL, Triglycerides <150 mg/dL

If dyslipidemia is present, repeat annually.

49

Establish Glycemic Control

Fasting Lipid Panel Screen Including Total Cholesterol, LDL, HDL, Triglycerides

Goals: LDL <100 mg/dL, HDL>35 mg/dL, Triglycerides <150 mg/dL

If dyslipidemia is present, repeat annually.

If lab work is normal, repeat in 3-5 years.

FIG. 7.1  Screening for dyslipidemia in children with diabetes.20

therapy to decrease the amount of saturated fat in the diet. Specifically the American Heart Association step 2 diet is suggested. This diet recommends daily dietary cholesterol intake of less than 200 mg per day and saturated fat of less than 7% of all total calories (Fig. 7.2). Follow-up of fasting lipids should be obtained at 3 months and again at 6 months after diet and lifestyle changes have been implemented. After age 10 years, the addition of a statin is suggested in patients who despite lifestyle and nutritional changes, continue to have LDL-cholesterol level greater than 160 mg/dL or LDL cholesterol greater than 130 mg/ dL plus one or more cardiovascular risk factor. Of note, studies in youth have shown short-term safety equivalent to that seen in adults and efficacy in lowering LDL cholesterol levels.21 However, published data are lacking in long-term efficacy in youth with type 2 diabetes. The goal of medical therapy is an LDL cholesterol value less than 100 mg/dL.20 It is important to consider the risks of starting any medication, including statins. In randomized trials, statin therapy seems to cause only slight increase in risk of side effects compared with placebo, and

no increased risk of discontinuation of therapy compared with placebo.22,23 Hepatic dysfunction is one of the more common side effects noted during statin therapy. Clinical studies of statins have demonstrated a 0.5%–3.0% occurrence of persistent elevation in aminotransferases in those receiving statins. This primarily occurred during the first three months of therapy and was dose-dependent. However, several randomized trials have also reported no significant difference in the incidence of persistently elevated aminotransferases between statin and placebo therapy.24,25 In 2012, the US Food and Drug Administration (FDA) revised its recommendations on statins to only check liver function testing prior to initiation of statin therapy and to only repeat testing for clinical indications.26 Statin muscle-related adverse events are fairly uncommon. Myalgias and myopathy occur with the highest frequency at 2%–10% based on the literature.27-29 However, severe myonecrosis and clinical rhabdomyolysis are much rarer (0.5% and less than 0.1%, respectively). Increased susceptibility to statinassociated myopathy occurs in patients with hypothyroidism, acute or chronic renal failure, and obstructive

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SECTION III Complications Recommended Intake as Percent of Total Calories Step I Diet

Step II Diet

Total Fat

Nutrient*

30% or less

30% or less

Saturated

7 - 10%

less than 7%

Polyunsaturated

Up to 10%

Up to 10%

Monounsaturated

Up to 15%

Up to 15%

55% or more

55% or more

Carbohydrate Protein Cholesterol Total Calories

Approximately 15%

Approximately 15%

Less than 300 mg per day

Less than 200 mg per day

To achieve and maintain desired weight

To achieve and maintain desired weight

FIG. 7.2  American Heart Association step I and step II diets.20

liver disease. Hypothyroidism is also known to be a cause of dyslipidemia and therefore would be a consideration for screening prior to statin therapy initiation.30 There has been concern of renal dysfunction with statin use; however, the significance of renal injury and the statin being the cause of injury have been questioned. Statins appear to be able to cause proteinuria through tubular inhibition of active transport of small molecular weight proteins.31 There have been reports to the FDA about proteinuria with statin use as well. However, the FDA has stated that this is benign finding.32 Elevated triglycerides with levels between 150 and 699 mg/dL should be managed by maximizing glucose control and weight loss. In those patients with triglyceride levels greater than 1000 mg/dL, treatment should be considered with fibric acid or niacin due to the risk for pancreatitis.33 Fibric acid derivatives are most commonly used for treating severe hypertriglyceridemia in children due to side effects of niacin such as flushing, abdominal pain, vomiting, headache, or elevated serum aminotransferase levels.34 Fibric acid agents raise high-density lipoprotein cholesterol (HDL-C) and lower TG levels.35 Again, there is not sufficient data in pediatric patients with type 2 diabetes for clear recommendations. Omega-3 fatty acids have long been known to lower plasma triglycerides.36 Although the triglyceride lowering due to fish oils are not evident at intakes in the normal Western diet37 they manifest at pharmacologic doses (i.e., >3 g/day of EPA  +  DHA).38 The pharmaceutical grade product of omega-3 acid fatty acids provides EPA and DHA as acid ethyl esters, and the approved dose is 4, 1-g capsules per day that provides 1860 mg of EPA and 1500 mg of DHA for a total of 3.4 g omega-3 fatty acids per day. The triglyceride lowering effect of

3–4 g per day of omega-3 fatty acids has been shown to decrease plasma triglycerides by about 30%.39 

TYPE 2 DIABETES AND CARDIOVASCULAR RISK For nearly 70 years, there has been a postulated link between impaired glucose metabolism and atherosclerotic cardiovascular disease. The clustering of risk factors (obesity, insulin resistance, hypertension, and dyslipidemia) now known as metabolic syndrome has been shown to predict higher cardiovascular morbidity, mortality, and risk for diabetes in adults.40 Features of metabolic syndrome are present in children as well. However, the precise definition has been a matter of debate. In 2007, the International Diabetes Federation attempted a definition of pediatric metabolic syndrome using age-specific diagnostic criteria and proposed that metabolic syndrome to be considered in children aged 6–10 years who are obese (defined as waist circumference (WC) ≥90th percentile) and have other relevant risk factors (such as family history of cardiometabolic disease, which includes myocardial infarction or stroke < age 55) and in children aged 10–16 years who are obese (defined as WC ≥ 90th percentile) and meet the adult metabolic syndrome criteria for triglycerides, HDL-cholesterol, blood pressure, and glucose concentrations.41 In terms of glucose metabolism, a study has shown that in patients aged 6–16 years, those with fasting blood glucose greater than 100 mg/dL, there was a higher risk of aggregation of hypertension, hypercholesterolemia, and abnormal glycemia.42 Central adiposity is an important factor in metabolic syndrome. Weiss et al. showed that obese children

CHAPTER 7  Dyslipidemia and Type II Diabetes with impaired glucose tolerance had different fat distribution than equally obese children who had normal glucose tolerance. The impaired glucose tolerance group had more visceral and intramyocellular fat as opposed to subcutaneous fat.43 It has been shown that when lipid accumulates in the liver and muscle, the lipid metabolites can cause defects in insulin signaling.44 Visceral fat has also been shown to secrete higher amounts of inflammatory adipokines, which may be a part of the underlying pathogenesis and morbidity of metabolic syndrome.45 Previous studies in adults with type 2 diabetes have established that diabetes is an independent risk factor for cardiovascular disease. The Framingham cardiovascular risk assessment states that type 2 diabetes is equivalent to an increase in age of 10 years in adults. When combined with other risk factors, such as dyslipidemia, type 2 diabetes increases the risk of cardiovascular disease by an additional three- to fourfold greater than that predicted for each risk factor independently.46 Children and adolescents with type 2 diabetes are also at increased risk for associated comorbidities including hypertension, dyslipidemia, and nonalcoholic fatty liver disease. Type 2 diabetes, smoking, hypertension, and dyslipidemia are also risks for macrovascular complications. This has been established in adults, but accumulating data suggest that it is also the case for children and adolescents with T2DM.47 Indicators of atherosclerosis are already present in youth populations with type 2 diabetes and dyslipidemia.48 Both elevated HbA1c and dyslipidemia can worsen markers of subclinical atherosclerosis in youth with type 2 diabetes, including carotid intima media thickness and arterial stiffness.49-52 In youth without diabetes, dyslipidemia similar to that of type 2 diabetes is associated with increased indicators of subclinical atherosclerosis over time.53 As a secondary aim, TODAY study looked at arterial stiffness in young adults with youth onset type 2 diabetes by measuring femoral, radial, and pedal pulse wave velocity, augmentation index, and brachial distensibility. These measures were compared to published data for obese and lean controls. The report showed that patients with type 2 diabetes had significantly higher arterial stiffness compared with lean and obese controls.54 

CONCLUSIONS The epidemic of type 2 diabetes now involves youth. Worsening dyslipidemia over time raises concern for premature development of atherosclerosis in youth

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with type 2 diabetes. The challenges in achieving optimal control in adolescents with type 2 diabetes highlight the critical need to promote a healthy lifestyle to prevent or postpone the development of type 2 diabetes as well as its comorbidities. For individuals already found to have early-onset type 2 diabetes, glycemic control must be carefully monitored and treated, adding insulin when necessary. With regards to type 2 diabetes in the youth, worsening dyslipidemia over time raises concern for premature development of atherosclerosis. In the absence of glycemic control, insulin therapy in the TODAY trial did not improve dyslipidemia. This highlights the importance of optimizing glycemic control to limit comorbidities and improve long-term outcomes of dyslipidemia in youth with T2D. Ongoing monitoring and treatment for diabetes comorbidities, cardiovascular risk factors, and complications are essential to prevent early morbidity and mortality.

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