It was 1990 in New York when Dr. Ileana Vargas saw her first child with Type 2 diabetes. The condition, usually seen in middle-aged or older adults after a lifetime of too much food and too little exercise, was unmistakable. The 12-year-old Hispanic girl was frequently tired and thirsty, and at the same time, urinating more frequently, often getting up several times a night to go to the bathroom. Despite being seriously obese, weighing more than 160 pounds, the youngster had recently shed pounds for no apparent reason.
As the decade wore on, the trickle of similar patients had become a steady stream, says Vargas, a pediatric endocrinologist at the Naomi Berrie Diabetes Center of Columbia Presbyterian Medical Center in New York.
“Instead of seeing it in the occasional 16- or 17-year-old who weighed 300 pounds, we started seeing children who were 10, 12 or 13 who weighed 200 pounds,” Vargas says.
And she was not alone. Across the United States and in other parts of the world, specialists who treat diabetes began to see more children with Type 2, a disease once referred to as “adult-onset” diabetes that can result in blindness, limb amputations and kidney failure as well as dramatically boost the risk of heart disease and stroke. Type 2 results when the body fails to properly use or make enough insulin, the hormone that moves blood sugar into cells, where it is converted to energy.
The exact number of American children with Type 2 diabetes is still unclear. But experts agree that cases are on the rise, almost surely related to the boom in obesity that picked up speed in the 1990s.
Prior to 1994, only 2 to 4 percent of children newly diagnosed with diabetes had the Type 2 form of the disease, says Dr. Francine Kaufman, past president of the American Diabetes Association. By 1999, anywhere from 8 to 45 percent of new diabetes cases in children, depending on the center, were Type 2.
In the past, diabetic children almost always had Type 1, a much less common condition that occurs when the immune system attacks and destroys the insulin-producing beta cells in the pancreas.
“Before it used to be 96 percent were Type 1, now in some places only 65 percent are Type 1,” says Kaufman, head of pediatric endocrinology at Childrens Hospital Los Angeles.
Certain groups at greater risk
Some overweight children are at higher risk for developing Type 2 than others. The disease is more likely in kids who have a close relative, such as a parent or grandparent, with the disease, as well as in youngsters in certain ethnic groups, such as American Indians, African-Americans, Hispanics and Asian/Pacific Islanders.
It’s not entirely clear why certain ethnic groups are at higher risk than others. But social factors certainly play a role. In the gritty corner of Manhattan where Vargas treats patients, exercise facilities are few and far between, budget cuts have whittled down school-based exercise and scary streets prompt parents to keep kids parked safely at home — usually in front of the TV or video games. And the quickest and cheapest meals are almost always those highest in fat and calories.
Doctors also know that Type 2 diabetes is more likely to strike at puberty, showing up in girls first and boys a bit later. Its signs can be subtle, including difficult-to-heal sores, yeast infections in girls or bed-wetting in children who have never had such problems before. Another indicator is acanthosis nigricans, a condition in which the skin becomes darker and thicker in the folds, usually in the neck and armpits.
In 2000, the American Academy of Pediatrics and the American Diabetes Association recommended that starting at age 10, obese children with two or more risk factors be tested for Type 2 diabetes every two years.
Disease hits kids harder
When Type 2 diabetes does strike children, it hits harder. About half of children with Type 2 diabetes immediately require insulin to get their blood sugar under control.
“Many are quite sick and some have diabetic ketoacidosis, and we give them insulin right away,” said Vargas. Diabetic ketoacidosis is a potentially life-threatening condition characterized by fatigue, nausea, vomiting and confusion, which can lead to coma or death if untreated.
Some kids can be weaned off insulin, but most require oral drugs that help increase their body’s sensitivity to insulin.
“Over 90 percent need medication and only under 10 percent can actually be treated with what we call lifestyle mainly because so few can actually invigorate such a difficult lifestyle change,” Kaufman said.
In contrast, 17 percent of adults control their disease with diet and exercise alone.
And kids are at risk for the same problems seen in adult diabetics. A third of such children already have high blood pressure and a third have elevated cholesterol, two major risk factors for heart disease, notes Vargas.
One study found that 9 percent of children needed kidney dialysis within 10 to 15 years of diagnosis. Such children can also go on to have a high rate of pregnancy loss, elevated mortality and signs of diabetic retinopathy, a sight-robbing condition.
‘Double diabetes'
What’s more, obesity may not only boost the risk of Type 2, it may also speed up the appearance of Type 1 in susceptible children. New evidence published in the journal Diabetes Care seems to support the theory, known as the accelerator hypothesis. And some children may have “double diabetes” — or elements of both Type 1 and Type 2 diabetes.
Dr. Ingrid Libman, a pediatric endocrinologist at Children’s Hospital of Pittsburgh, found that one in four black children with diabetes had signs of both Type 1 and Type 2. And a second study by Libman and her colleagues, also published in Diabetes Care, found that the percentage of children with Type 1 who were overweight increased dramatically from the 1980s to the 1990s from 13 percent to 37 percent.
This bolsters the accelerator hypothesis, which says that obesity stresses the insulin-producing cells of those genetically vulnerable to Type 1, says Libman.
Family effort
Although it may seem difficult, at least initially, overweight children can make lifestyle changes to counter obesity and, if they have diabetes, to reduce their risk of complications. But they’ll need some help.
Kids tend to be successful because “parents get really, really involved,” Vargas says. “The whole family has to change.”
She encourages her patients to eat a healthy breakfast, steer clear of junk-food-laden vending machines at school and skip the fast food meal that precedes dinner for many teens.
Until trends in obesity turn around, cases of diabetes will continue to rise, she says. In the U.S., the prevalence of Type 2 diabetes in children is expected to outstrip Type 1 within the next 10 years.
“It’s going to accelerate and it’s going to accelerate potentially to the point of breaking the healthcare budget of our nation and the developing world,” says Kaufman.
Theresa Tamkins is a freelance health writer based in New Jersey.