Type 2 diabetes and metabolic syndrome in youth — formative SAQs

SAQ 1 — The fourteen-year-old with dark skin at the neck and irregular periods (20 marks, ~15 minutes)

A previously well fourteen-year-old girl presents to the general practitioner with worsening acne, irregular periods every six to eight weeks, and dark velvety skin at the back of her neck that she cannot wash off. Her body mass index is at the 95th percentile, and her mother has type 2 diabetes. A random point-of-care glucose reads 11.8 millimoles per litre, and a subsequent HbA1c is 7.1 percent. [1]

Questions

1. Give the diagnosis, the biochemical criteria that confirm it, and the investigations that distinguish the type. (5 marks) [1]
2. Describe the metabolic cluster findings on examination and explain the mechanism that links them. (4 marks) [7]
3. Outline the stepwise management, naming the lifestyle prescription, the first-line drug and its target dose, and the comorbidity care. (6 marks) [1]
4. Explain why polycystic ovary syndrome belongs to the same condition and how it is managed alongside the diabetes. (5 marks) [6]

Model answer (must-hit)

1. This is type 2 diabetes. Diabetes is confirmed by the random glucose of 11.8 with the subsequent HbA1c of 7.1 percent meeting the diagnostic thresholds (random at least 11.1 with symptoms or HbA1c at least 6.5 percent). The type is distinguished by the islet autoantibody panel — glutamic acid decarboxylase, insulinoma-associated antigen 2, insulin and zinc transporter 8, expected negative — and a C-peptide with simultaneous glucose, expected measurable or high, against the phenotype of obesity, acanthosis and family history. [1]

2. The metabolic cluster findings are acanthosis nigricans at the neck, central obesity with striae, hirsutism and acne, oligomenorrhoea, and hepatomegaly suggesting fatty liver disease. The linking mechanism is insulin resistance with compensatory hyperinsulinaemia: the shared signalling defect produces acanthosis at the skin, ovarian hyperandrogenism, hepatic fat accumulation, dyslipidaemia and hypertension together. [7]

3. The stepwise management begins with structured family-based lifestyle change — nutrition with family involvement, at least 60 minutes per day of activity, screen-time limits and weight management. Metformin is first-line, started at 500 milligrams once daily and titrated to a target of 1500 to 2000 milligrams per day. Comorbidity care addresses the blood pressure, the lipid profile and the fatty liver, with an ACE inhibitor or angiotensin receptor blocker for hypertension and a statin where indicated from age ten. [1]

4. Polycystic ovary syndrome belongs to the same condition because both arise from insulin resistance and hyperinsulinaemia, which drive ovarian androgen production and disrupt ovulation. It is managed alongside the diabetes with the same lifestyle prescription and metformin, plus hormonal contraception for cycle control and hirsutism where indicated. The metabolic and reproductive consequences are addressed together. [6]