diabetes, is also prevalent among adolescents. A recent study estimates that approximately one in five adolescents in the U.S. have prediabetes (Andes et al., 2020). Male adolescents are near- Pathophysiology In T2DM, pancreatic ß -cell function declines in a progressive fash- ion, which is unrelated to an autoimmune process (Arslanian et al., 2018). The cause of ß -cell dysfunction is less defined in T2DM and may be multifactorial. Dysfunction of ß cells results in inad- equate insulin secretion, which leads to disordered metabolism of glucose. Without proper insulin function, the body is unable to utilize glucose effectively for energy, and blood glucose levels rise above normal values in the bloodstream. Most patients with T2DM are overweight, are obese, or carry a large percentage of body fat in the abdominal area. These characteristics may contrib- ute to insulin resistance, which occurs when insulin levels appear to be elevated but are insufficient to control blood glucose lev - els (ADA et al., 2022a). When insulin resistance develops, insulin secretion must continuously increase to balance the circulating blood glucose levels. Eventually, the pancreas cannot produce Risk factors Several genetic and environmental factors contribute to the de- velopment of T2DM (ADA et al., 2022a). Risk factors for the de- velopment of T2DM include older age, higher body mass index (BMI), and a sedentary lifestyle. Most pediatric patients are not diagnosed with T2DM until after puberty or at least 10 years of age (ADA et al., 2022g). There is also a strong genetic link to the development of T2DM, especially if noted in first-degree rel - atives. Additional risk factors include female sex, adiposity, and low socioeconomic status (ADA et al., 2022g). High-risk races and ethnicities include Native Americans, African Americans, Asian Americans, Latinos, and Pacific Islanders. In adult patients, history of cardiovascular disease, hypertension, and increased high-den- sity lipoprotein cholesterol or triglyceride levels are additional risk factors for the development of prediabetes or diabetes. While many risk factors are nonmodifiable, including genetic predisposition, there are several modifiable risk factors, which are the focus of intervention. These include low physical activity and a surplus of caloric intake, along with stress, depression, and sleep-related disorders (Arslanian et al., 2018). Healthcare Consideration: During the COVID-19 pandemic, children and adolescents experienced significant social, emo - tional, and physical disruptions to their normal lives. A longitu - dinal study found that the pandemic decreased physical activity and increased sedentary behavior in young adults (Zheng et al., 2020). These lifestyle changes may contribute to the develop - ment of diabetes and should be intervened upon in the post- pandemic era. For those that continue to participate in remote education and/or work, incorporating home-based exercises may decrease sedentary time. Despite known risk factors and concomitant interventions, rates of childhood obesity and T2DM are on the rise (CDC, 2022a). It is vital to examine alternative risk factors, which may elucidate novel areas of intervention and prevention. The gut microbiome is undergoing study, as its composition may be related to obesi- ty, allergies, and other chronic diseases (Kumbhare et al., 2019). The microbiome is especially vulnerable to alteration in the first 2 years of life, which may have lifelong consequences. A study ex- plored the association of antibiotic or acid suppressant exposure during the first 2 years of life with the development of childhood obesity (Stark et al., 2019). An association was found with both Presentation Many children with T2DM will not present with classic symptoms of diabetes because the development is much more gradual than is seen with T1DM (Arslanian et al., 2018). Children with T1DM may experience dehydration, unintentional weight loss, polydip- sia, and polyuria, but children with T2DM may be initially asymp-
ly twice as likely to have prediabetes compared to their female counterparts.
enough insulin to compensate for this resistance, and glucose ho- meostasis is compromised (Arslanian et al., 2018). In pediatric patients, decline in ß -cell function is noted to be more rapid, and associated complications arise earlier in the disease course as compared with their adult-onset counterparts (ADA et al., 2022g). In fact, many individuals with childhood-onset T2DM present with microvascular complications, including nephropathy, retinopathy, and neuropathy in young adulthood. An unhealthy lifestyle, which is common in individuals with complicated so- cial and financial situations, may contribute to the prevalence of T2DM in certain communities. Youth with T2DM are also more likely to present with concomitant metabolic syndrome, including elevated liver enzymes and systolic blood pressure, than are chil- dren with T1DM (Arslanian et al., 2018). types of medications, and stronger associations were noted with prolonged courses or exposure to multiple classes of antibiot- ics. Since obesity is strongly associated with the development of T2DM, antimicrobial stewardship and reduction of inappropriate acid suppression are important areas of study for prevention. Healthcare Consideration: Data from a national registry in Finland was recently analyzed to determine if prior antibiotic exposure was associated with subsequent diagnosis of type 2 diabetes (Nuotio et al., 2022). More than 25,000 participants were included for analysis. Information regarding early life pa- rental smoking, physical activity, socioeconomic status, and di- etary habits were collected to aid in adjustment for potential confounders. Study authors determined that individuals with >5 courses of antibiotics were twice as likely to be subsequently di- agnosed with type 2 diabetes compared to those who received ≤1 antibiotic course. This value remained unchanged after ad - justment for age, sex, and additional confounders. Antibiotic exposure was also associated with increased risk of being over- weight or obese. These findings are meaningful, but of course correlation does not equate causation in studies with an obser- vational design. Prospective, randomized trials are required to confirm causation. While the scientific community awaits these studies, healthcare professionals can work together to minimize inappropriate antibiotic use to reduce impact on the microbi- ome. Another study specifically examined gut microbial diversity and its association with insulin resistance and T2DM (Chen et al., 2021). Conducting a review of more than 2,000 participants, greater mi- crobial diversity was associated with less T2DM and lower insulin resistance. Along with this diversity, more butyrate-producing gut bacteria was associated with less T2DM. Butyrate, which is pro- duced by certain bacteria from fermentation of dietary fiber, may have beneficial metabolic effects throughout the body. Although this was theorized to contribute to the study’s findings, butyrate concentrations in the blood and stool were not measured. Future studies may elucidate clearer risk factors for T2DM related to the microbiome, which may uncover new methods of prevention and treatment. The production of butyrate can be modulated via di- etary intake of fermentable fiber, so confirmation of this theory may help guide nutritional management in the future. tomatic (Arslanian et al., 2018). Diagnosis is typically made based on screening laboratory values. An objective finding in children with T2DM is acanthosis nigricans, which is a darkening and thick- ening of skin folds, most commonly in the neck, armpits, or groin (ADA et al., 2022g). Another objective finding is vulvovaginal can -
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