Alarm Over Rise in Diabetes in Children
Once a true medical oddity, children with adult diabetes are becoming commonplace. Doctors blame the twin evils of too much food and too little exercise, and fear a tragic upswing in disastrous complications as this overweight generation reaches adulthood.
Boys and girls who range from chubby to hugely obese are being diagnosed in unprecedented numbers with type 2 diabetes. Most are barely in their teens; some are as young as 6.
This disease used to be called adult-onset diabetes because it rarely occurred before middle age. But over the last decade, it has slowly become clear this is now a disease of the young as well.
Just how frequently is uncertain since nationwide statistics are still being gathered. Nevertheless, doctors are convinced they see the leading edge of a dangerous shift, one that will inevitably lead to kidney failure, blindness, heart attacks and amputations as these young people live another 10 or 20 years with their diabetes.
“There is an epidemic of type 2 diabetes in youth, absolutely,” said Dr. Lori Laffel, head of the pediatric unit at Boston’s Joslin Diabetes Center. “Over the years, we always saw an occasional child with type 2. It was a handful a year.”
But in the early ‘90s, the pattern changed. Large children, usually accompanied by overweight parents, began to show up with type 2 diabetes. During the early ‘90s, Joslin’s totals increased five times. They have doubled since.
Until this shift, almost all diabetes in children was type 1, called juvenile diabetes. In many ways, it is a different disease. Type 1 results from a misguided attack by the immune system on the insulin-making cells in the pancreas. Victims stop making insulin completely, so they cannot convert sugar to energy.
But type 2 has always been a disease of people in their 50sand beyond. Their bodies still make insulin, just not enough. They may go for years without realizing that they have it.
Throughout the country, doctors say Joslin’s 10-fold rise in childhood type 2 over the last decade is typical. Is it because they are looking harder or doing a better job of separating type 2 from type 1? Not likely, they say.
“It’s not because we missed a lot of cases,” said Dr. Phillip Lee, head of pediatric endocrinology at UCLA. “We just didn’t see it. Now referrals of type 2 are almost 50% of our diabetes cases.”
Why? Doctors have little doubt. They blame inactivity and overeating, as well as the hours on end in front of the tube and the 20-ounce sodas in school vending machines.
Virtually all children with type 2 are overweight, although this hardly makes them unique. The Centers for Disease Control and Prevention recently estimated that 15% of all U.S. children and teenagers -- and nearly a quarter of black and Latino youngsters -- weigh too much. Still, those with diabetes tend to be especially big, tall for their age and large all over. Twelve-year-olds weigh 250 pounds. Invariably, their parents are heavy too.
Nearly all of them have a skin condition called acanthosis nigricans, velvety, dirty-looking dark patches around the neck and other skin folds. They are a sign of insulin resistance, an inability to respond efficiently to insulin, which is common in the overweight. In girls, the insulin resistance often triggers hormone upsets that result in facial hair, acne and ovarian cysts.
Young blacks and Latinos have more of this kind of diabetes than do whites. Their extra weight alone may explain some of it, although experts believe that these minorities also may have an extra genetic tendency toward diabetes that is compounded by their weight.
Many who do not have outright diabetes still have abnormalities that put them at high risk. Doctors estimate that for every youngster with type 2, four or five others have what’s called syndrome X or metabolic syndrome, a combination of obesity, insulin resistance, bad cholesterol counts, high triglycerides and high blood pressure.
“Unless we make a significant alteration in their lifestyles, they will likely progress to a deteriorating course of insulin resistance, pre-diabetes and diabetes,” said Dr. Francine Kaufman, endocrinology chief at Childrens Hospital Los Angeles and president of the American Diabetes Assn.
Adults with type 2 diabetes face many complications that shorten or worsen their lives, although these can be reduced or prevented with medicine, weight loss and exercise.
Because the problem is so new, no one knows what will befall those who start the disease in their teens rather than their 50s. But many fear the complications will emerge in early adulthood.
“The horizon is really dark,” said Dr. Jorge Calles-Escandon, a Wake Forest University endocrinologist. “We know what happens to adults with type 2 diabetes who don’t take care of it.... They have heart attacks, strokes, blindness, renal failure. There is no reason to believe this will be different for adolescents.”
One follow-up study suggests he is right. University of Manitoba researchers tracked down 51 people, mostly in their 20s and 30s, who had been diagnosed with type 2 diabetes as children. Two died on kidney dialysis, and three others were still on it. One woman had a toe amputated, while another had gone blind.
To find out how many young Americans actually have the disease, the CDC will count all the cases among 6 million people under age 20 for five years. It expects 6,000 to have it at the start and 800 more to be diagnosed annually, 30% of them type 2.
“Whatever we get will be an underestimate of the true disease,” said the CDC’s Dr. Desmond Williams, because the study will not go looking for youngsters with diabetes, only record those who come to doctors’ attention.
The diabetes association recommends testing children for type 2 diabetes if they are overweight and have two other risk factors, such as a parent with the disease, signs of insulin resistance, or if they are black, Latino or American Indian.
Nevertheless, experts say this kind of testing is rare. Pediatricians and family physicians are not trained to think about adult diabetes in the young and, without obvious symptoms, children will probably be missed.
Doctors understand what they are up against -- a culture of cheap, high-calorie food and sedentary pleasures -- and can think of no easy solutions.
Some wonder if refocusing the exercise and eating habits of the entire society is the only solution. Others think about more focused approaches, such as luring overweight girls into after-school workouts.
Some experts believe that exercise is as crucial as weight control in preventing type 2. Pediatrics professor Bernard Gutin of the Medical College of Georgia notes that physical activity stimulates movement of sugar into cells and improves the body’s response to insulin.
But the first, often biggest hurdle is getting youngsters and their parents to acknowledge that they have a problem. Often they come from families where everyone is overweight, where no one exercises.
One large federally financed study, involving several thousand young people in North Carolina, Texas and California, will see if modest changes at school can make a difference. It will test whether healthier choices in the cafeteria, better access to water and improved physical education programs, among other things, have an effect on youngsters’ risk of type 2 diabetes.
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Warning Signs
Children and teenagers may be at increased risk of type 2 diabetes, the adult form of the disease, if they have:
* Obesity, especially increased fat around the abdomen.
* Acanthosis nigricans, unusually dark, dirty-looking skin around the back of the neck and under the arms.
* A family history of diabetes.
Among symptoms that should prompt immediate evaluation by a doctor:
* Unusual thirst.
* Frequent urination.
* Unexplained weight loss despite obesity.
* Blurry vision.
* Excessive hunger.
* Cuts that do not heal.
* Yeast or fungal infections in girls.
Source: Associated Press
Los Angeles Times
