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february 99

In December, another in a growing list of newspaper and journal articles appeared in the New York Times. The article titled, ‘Adult-onset diabetes cases up in children, small scale studies find a tripling of cases of a disease, once thought to occur later in life,’ was written by Ginger Thompson. The problem is worrisome enough for the Centers for Disease Control and Prevention to convene a meeting to discuss the problem and for the ADA to appoint a task force. At the Naomi Beatrice Diabetes Center at Columbia University’s College of Physicians and Surgeons, type 2 diabetes was diagnosed in 10% to 20% of the center’s new pediatric patients, compared to less than 4% five years ago. This article links the rise in type 2 diabetes to the doubling in the number of obese children in the U.S. in the last twenty years. One in five children in this country is overweight. Physicians credit the rise in reported cases to an increased incidence of the disease and increased awareness of it by the primary care physician. What does this adolescent type 2 diabetic look like? Drs. Pinhas-Hamieln and Zeitler in Diabetes Spectrum, state that in the past type 2 diabetes was rare in teens. In cities like Cincinnati they report that there is a ten-fold increase in the incidence of type 2 diabetes in adolescents over the last decade. Type 2 now accounts for 40% of new-onset adolescent diabetes cases in some cities. This has been noted in major US cities and around the world. About one-third of these new diabetic are non-Hispanic whites, a percentage which is growing, while the remainders of the patients are African-American and Hispanics. The female -to -male- ratio is 17 to 1 with a preponderance of females irrespective of race. The common denominator in these adolescent diabetic patients is morbid obesity. Known risk factors in their environment include overweight, high caloric intake, and low physical activity. At the Cincinnati clinic, even after education, 85% did not begin a physical activity program, nor did they change their high fat, low fiber diet. Of the adolescents with type 2 diabetes, females are diagnosed on the average one year earlier than males. One reason for this may be their earlier maturation and the hypothesis that relative insulin resistance which is characteristic of puberty, may be an etiological factor or contributing factor in the appearance of overt type 2 diabetes in these adolescents. Furthermore, since the age of onset of puberty in obese children is younger than their peers, the relationship between body mass and puberty may further contribute to the early onset on type 2 diabetes in some adolescents. Presenting complaints are polyuria, polydipsia, and weight loss. Most patients are diagnosed during a regular physical exam, even though the teens were aware of their symptoms. This points out the importance of screening for teens with obesity, acanthosis nigricans (present in 60 % of cases), hypertension, other signs of insulin resistance, and/or a family history of type 2 diabetes. Noted is the 25% of females that had a vaginal monilial infection before being diagnosed. One confounding problem is that although the patients were aware of their symptoms, they did not seek medical intervention because they were happy with their weight loss. Adolescents diagnosed with type 2 diabetes may present in DKA. The presentation with DKA or some degree of ketosis may confuse the initial diagnosis. Thus in young obese adolescents who develop DKA, the presence of type 1 diabetes cannot be assumed and the diagnosis of type 2 should be considered. In fact many of these patients are initially diagnosed with type 1 diabetes. Early-onset of type 2 diabetes among adolescents may have particularly devastating effects on long term health because these patients will have the disease for many more years than adults who develop the disease much later in life. It is, therefore, mandatory to combat this disease and to treat the underlying causes of the disorder, namely obesity, poor diet, and sedentary lifestyle. Education for these patients with dietitians needs to be different from their peers with type 1 diabetes. Because of their ingrained behavior, failure follows when the education discontinues. Therefore, education with a professional who has interest in treating this special population needs to be specific and repeated. It should include all family members. This is very important in this population as many family members are also overweight and may have diagnosed or undiagnosed type 2 diabetes, or be at high risk for developing the disease. Further, maintenance of a high fat, high calorie, low fiber diet by other family members makes its virtually impossible for the teen with type 2 diabetes to comply with dietary recommendations. Once the diagnosis has been made, education about the disease must begin for the patients and family. Often patients mistakenly think that because they have type 2 diabetes and don’t take insulin, that they are not really ill so they have time to begin to take care of themselves. An emphasis on good treatment adherence to avoid early complications is important for all family members to understand. Adolescents with type 2 diabetes should be followed closely after the initial education process to monitor their compliance, provide support for their successes, and to work with their families to modify multiple aspects of behavior. Experts who deal with this population of type 2 diabetics suggest that the role of nutrition should be gradual, sustained weight loss. Realistic goals should be set, not a return to normal weight as the later is discouraging to these adolescents. It is known that even a modest weight loss can result in marked improvement in glycemic control and plasma lipoprotein in adult patients with type 2 diabetes, and it is hoped that the same will be true for these teens. It is also known that reduction in total body fat and improvement in tolerance to exercise is the most effective way to improve insulin resistance in type 2 diabetics. This also lowers blood pressure and improves hypertriglyceridemia. Besides weight loss, nutritional goals are also based on metabolic control of blood glucose levels and decreasing lipids and lipoproteins. Nutritional interventions need to be based on lifestyle and individual management goals as outlined by the ADA guidelines. This is especially important for this group of patients who may have been initially diagnosed as type 1 diabetics, and who are used to eating snacks and because they as adolescents have fewer skills to cope with what they see as losses in their lives. Special attention must also be paid to the development or presence of binge-eating disorders in this high-risk group. Daily exercise for type 2 type diabetics is important in the prevention and treatment of the disease. Yet we are dealing here with a population of obese adolescents who do not exercise. Therefore, compliance with an exercise regime may be difficult both physically and emotionally. Other problems that arise are the logistics of getting to a facility as many of these children live in neighborhoods where outdoor activity is not feasible, and they may be spending hours after school at home without supervision. Another problem is that exercise facilities may be beyond the family’s financial means. Any suggested program therefore, must fit the family and its circumstances. Above all, it should be suggested that even moderate exercise can be of benefit and that includes daily walks. An exercise plan that includes family members may be helpful to promote family lifestyle changes and act as a support for the adolescent. Support is very important for this age-group which is trying to cope with a chronic disease -- a disease whose implications for long term complications are daunting. The development of depression and adolescent adjustment disorder can significantly complicate the ability of the teen to comply with the changes necessary to maintain normal blood glucose levels while losing weight. In the best of all possible worlds a team approach with mental health professionals present would be important to make an initial evaluation and continuing re-evaluations. If this is not possible, other professionals and family need to be aware of changes in behavior and mood. Medication for this group will depend on the needs of the adolescent. Certainly oral agents to help control insulin resistance or to decrease glucose production in the liver may be tried. Weight loss medications should be aimed toward solving the underlying problem of obesity. These issues are individual and need expert individualized interventions based on the needs of each patient. Physician and patient and family conferences are in order. The physicians are the Cincinnati Clinic do not recommend the use of insulin for this population, if at all possible, because it may lead to increased weight gain; insulin increases the burden on the family; and it increases diabetic complications such as hypoglycemia. They suggest that if weight loss, exercise, and oral agents do not control the disease, nighttime NPH insulin with oral agents may be the preferred initial approach to insulin therapy. So here we are at the brink of a new millennium looking into the face of a possible new epidemic. Our teens are eating too much and exercising less. School may be the most sedentary time of their day. Physical education programs are being exorcised from our schools, and if they exist, they are geared to the best athletes, not the overly obese. Latch key children binge on high-fat, low fiber foods, and we know that these type 2 adolescents are at high risk for all of the long term complications of this chronic disease. Type 2 diabetes is an insidious disease. Children with type 2 diabetes often have little incentive to care for themselves as they do not feel ill, as opposed to type 1 diabetics who know they have to take their insulin in order to feel well. They may wake up three times a night to urinate, but then so might other adults in their families, so they don’t worry. No longer can pediatricians and primary care physicians look the other way thinking that diabetes and hypertension are diseases of adults. We now have 12 year-old type 2 diabetics and the numbers are growing. We need to all be advocates for all of our children. In our first magazine more than a year ago we asked that everyone get involved and now we ask again. We cannot allow diabetes and diabetics to be forgotten in our society. Please help by getting involved at the local level or national as you can. Thanks.