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Type 2 Diabetes in Children and Adolescents

Type 2 diabetes mellitus, formerly called adult onset diabetes or non-insulin dependent diabetes mellitus (NIDDM), accounts for 90% of all the diabetic cases diagnosed. Until recently, it was believed that children could not develop this type of diabetes. However, in the early 1990s, pediatric endocrinologists across the country began recognizing a type of diabetes in children similar to the type 2 diabetes found in adults. Since that time, the incidence or recognition of this condition has risen significantly. In some diabetes centers it now accounts for about one-third to one-half of all new cases of diabetes in individuals younger than 18 years of age.

Most people diagnosed with type 2 diabetes are obese. African Americans and Latinos are commonly affected, although obese adolescents of any ethnic background may be predisposed to this condition.

What is Type 2 Diabetes?

Type 2 diabetes is a disease in which the body has difficulty regulating the level of glucose (sugar) in the blood. As compared to type 1 diabetes in which the pancreas has no ability to secrete insulin, type 2 diabetes results from a combination of insulin resistance (an inability of cells to respond to insulin) and an insulin secretory defect (a defect in the ability of the pancreas to secrete insulin).

How does Type 2 diabetes occur?
Insulin is produced by the islet beta cell located within the pancreas. It is insulin's job to help carry the glucose (sugar) from the blood into the cells in your body. Glucose provides the best form of energy for the cells, so that they can fulfill their cellular functions.

High insulin levels indicate that the body is resisting the insulin that is being produced. The body of a person with type 2 diabetes resists insulin so the pancreas produces more insulin than is needed to try to compensate. In time, the pancreas may "burn out" and stop producing enough insulin to take the glucose into the cells of the body. This causes hyperglycemia (elevated blood sugar).

The diagnosis of diabetes is made when there is either a random blood sugar level greater than 200 mg/dl or a fasting blood sugar level more than 125 mg/dl. Normal blood sugar levels in people without diabetes are between 60-120 mg/dl.

Signs and symptoms of diabetes
The signs and symptoms of diabetes include:

• Frequent urination
• Excessive thirst
• Excessive appetite and weight loss or lack of weight gain despite increased food intake.

What Causes Type 2 Diabetes?

The cause of this type of diabetes is not precisely known but it appears to be related to increased weight gain rather than to the autoimmune pancreatic islet cell damage that causes type 1 diabetes. Most individuals diagnosed with type 2 diabetes are significantly overweight with a body mass index (BMI, refer to definition below) greater than the 85th percentile. Insulin resistance occurs after a person is already significantly overweight.

Sedentary lifestyle and poor dietary habits, combined with the genetic predisposition of certain ethnic groups, are the most likely reasons we are seeing an epidemic in type 2 diabetes.

Obesity: A growing problem
The increasing incidence of obesity in young children and adolescents has reached epidemic proportions. According to the National Health and Nutrition Examination Surveys (NHANES) the prevalence of obesity increased from 15 to 22% in adolescents just in the last decade. Obesity is associated with many negative health consequences. In children, the greatest immediate consequence of obesity is psychological distress and the potential for childhood obesity to persist into adulthood. Reports suggest that about a third of obese preschool children and about half of obese school-age children will be obese as adults, especially if their parents are overweight. By the time they are adolescents, the risk of remaining overweight is up to 80%. Many of the health consequences of obesity in adults occur much less in children, but they are on the rise. Conditions such as type 2 diabetes, hypertension, hyperlipidemia, sleep apnea, orthopedic disorders and liver enzyme abnormalities are now being found in children.

What Are the Clinical Characteristics of Type 2 Diabetes?

Young people with type 2 diabetes come to me with symptoms ranging from severe insulin deficiency to mild incidental hyperglycemia. Some patients have ketoses (a side effect usually of uncontrolled type 1 diabetes in which there is a buildup in the blood of glucose and certain substrates called ketones causing dehydration, nausea, and abdominal pain) and it may be difficult to distinguish them from type 1 diabetics, until specialized blood tests such as C-peptide and insulin levels come back from the lab. These levels are normal to high in type 2 diabetes, but not in type 1 diabetes. As many as one-third of my patients are diagnosed with type 2 diabetes by routine urinalysis demonstrating high levels of glucose in the urine.

More girls are affected than boys, and the average age when type 2 diabetes becomes apparent is 13.5 years old, with the majority of the patients in mid-puberty. There are studies that indicate that certain minority populations have a higher prevalence of type 2 diabetes than the national norm, such as African American, Pima Indian and Mexican American children. In my practice, I see a group of patients with more diverse ethnic backgrounds than those most commonly reported, such as Jewish, Italian, Puerto Rican, Dominican, Chinese, African American, and Caribbean West Indian children. The majority of these children were obese, and ancanthosis nigricans (defined below) was present in 60-100% of patients. 80-100% of these patients had a strong family history of type 2 diabetes.

What is Acanthosis Nigricans?
Acanthosis Nigricans is a skin condition that is symptomatic of high insulin levels in the body and it is frequently associated with obesity. It is a darkening and thickening of the skin, found most often at the posterior base of the neck, in the axillae (underarms), the antecubital areas (the part of the arms opposite of the elbows), and at the beltline (waist). It is important to take note of this condition because these markings can help identify people who run the risk of developing diabetes and other associated conditions in the future. Once children and adolescents who are at risk are identified, the necessary measures to lower the insulin levels and reduce the risk of developing type 2 diabetes can be taken. Exercise and proper nutrition will help the body become more sensitive to insulin and lower insulin levels. Similarly, the acanthosis nigricans markers can begin to fade.

Who Should Be Screened for Type 2 Diabetes?

Recent studies have shown an increasing incidence of type 2 diabetes among young people, accompanying the national rise in child and adolescent obesity. So children who are obese (BMI > 85th percentile), have strong family histories of type 2 diabetes or have acanthosis nigricans should be screened regardless of their ethnic background.

Treatment

Despite the large number of children and adolescents diagnosed with type 2 diabetes, treatment of this condition remains less than ideal. Lifestyle changes, such as good diet and weight control, are essential for a healthy prognosis.

Insulin
Insulin is the only FDA approved medication in the treatment of type 2 diabetes in young people. It can help stabilize diabetes patients, especially those who have extremely high blood sugars, but long-term insulin therapy is not very effective for the following reasons:

• Insulin raises the risk of hypoglycemia or low blood sugar
• Because insulin is injected under the skin, people are sometimes reluctant to take it
• Patients can gain weight as a result of the therapy

Oral Agents
The oral agents used as the gold standard of treatment in adults with type 2 diabetes appear to be effective in pediatric type 2 diabetes, but only one drug (metformin or glucophage) is currently being studied in children. More research will need to be done to determine the long-term efficacy of oral agents. In the meantime, greater efforts need to be made in preventing this condition.

Is Type 2 Diabetes Preventable?

This number of people being diagnosed with type 2 diabetes is growing exponentially, and efforts are being made to understand exactly how and why this is happening. From my personal experience it is clear that the prevention of type 2 diabetes is directly related to the treatment and prevention of obesity.

Weight control is a lifelong commitment
The aim of losing weight and maintaining a healthy weight is not about cosmetic standards. It's about health. Overweight individuals should be encouraged to set reasonable goals. They must recognize that increasing levels of exercise and decreasing caloric intake needs to be a life-long commitment if lower body weight is to be maintained. The treatment plan, which should address both behavioral and lifestyle modifications, should be individualized for the patient and family, with their health care provider. Nutritional counseling is often very helpful in devising a diet plan.

Solving the weight problem early
Because children are still growing, maintaining the same weight for 1 to 2 years can effectively allow overweight children to grow into their excess of body weight. Catching a weight problem early will save problems in the long-run.

A family affair
Maintaining and losing weight should be a family affair. In treating obese children, it is often helpful to treat the parents as well. When adolescents are treated, better outcomes are seen when the intervention is directed at both the patient and the patient's parents. Parents and adult caregivers need to understand how important a role they play in the development of proper eating habits in their young children. The quantities and variety of foods in the home, the parents' eating behaviors and physical activity patterns all work in concert to establish an environment in which obesity may or may not occur in the household.

Dietary Changes
The goal is to create a diet low in saturated fat that contains at least the minimal recommended amounts of protein, essential fatty acids, vitamins and minerals. Decreasing the number of calorie-rich foods on the menu, such as fried foods and chips, and adding more fruits and vegetables to the daily diet is essential. Drinking water instead of non-nutritious highly caloric "sugar-drinks", like sugary juices, iced tea and soda, may be very effective as well. In fact, reductions in calorie-rich foods and "sugar-drinks" through substitution and/or elimination alone can decrease calories and weight without changing the general eating pattern in the family.

It's best to avoid eating out, as families eating at restaurants and fast food places have less control over food choices than they do at home.

Avoid fad diets
It is also very helpful to work on a diet plan with your health care provider and avoid restrictive calorie deficient diets you find in popular magazines and books. They may be unhealthy or even harmful in many instances.

Changing sedentary lifestyle
Changing sedentary lifestyle is extremely important in helping children avoid obesity. Television watching, reading, driving, all these activities are sedentary. Television viewing appears to be directly associated with the incidence of obesity, and inversely associated with the remission of obesity. Not only is watching television a sedentary activity, but food is the most heavily advertised product on children's television in the United States. Children and adolescents should be encouraged to watch as little television as possible, preferably no more than 2 hours per day.

Exercise
Exercise alone is not sufficient to lose weight, but the combination of dietary changes and exercise is an effective formula for long-term weight management. Any form of exercise is beneficial and it decreases insulin resistance.

Programs should be designed to increase the interaction between parents and children (family walks, bike riding, and museums) or between friends (basketball, karate). Children and adolescents must want to participate so that they will continue to exercise.

Summary

It is upsetting that childhood type 2 diabetes and its possible future complications are most likely a direct result of our society's disregard for adequate nutrition, exercise and the problem of childhood obesity.

The adult experience with type 2 diabetes and its medical, social and economic impact consumes a large percentage of our national medical expenditure. Children are now developing this disease and it will only get worse if we do not begin to address our national problem with obesity. It is time that local, state and national public health efforts are directed at preventing obesity and thus preventing type 2 diabetes.

Definitions

Body Mass Index
Weight and stature are the most common measurements in clinical settings and in health-related surveys. The ratio most widely used to assess whether a person is overweight is called  the Body Mass Index (BMI).

Body Mass Index (BMI) =

(Weight in kilograms)
(Height in meters) 2

OR

(Weight in pounds) x704
(Height in inches) 2

This index adjusts weight for stature and larger values are associated with increased mortality rates in adulthood. Values for this index can be compared with the national reference data from NHANES II. The 85th percentile for BMI in these data during young adulthood has been recommended as the upper limit of normal for adults. This corresponds to 27.8 for males and 27.3 for females or 20% above ideal body weight.