Adult onset diabetes was a fair description of type 2 diabetes, up until two decades ago, but no longer. In the United States, increasing numbers of adolescents are now diagnosed with type 2 diabetes, most of whom are obese. Furthermore, type 2 diabetes is also diagnosed more frequently in young adults who are in their 20s and 30s, as compared to a decade or two ago.
We know that healthier eating and daily exercise and activity can prevent or delay the onset of type 2 diabetes, in adult people who are at high risk of developing type 2 diabetes. Most people diagnosed with type 2 diabetes still have normal or elevated levels of insulin. However, they can no longer produce enough insulin to overcome their body’s resistance to insulin action. Insulin resistance is commonly observed in obesity and is exacerbated by inactivity. There is also a genetic component to it, such that African Americans are usually more insulin resistant than Caucasians of equal size.
Unlike type 1 diabetes, patients diagnosed with type 2 diabetes have a relative deficiency of insulin. If the child is sick at the time of diagnosis and/or has very high blood sugar levels associated with marked symptoms such as weight loss, or excessive urination, insulin therapy will be started first. Another reason to start insulin in such instance is that not every child who is overweight or obese necessarily has type 2 diabetes. Therefore, the doctors may need to run some tests to verify that the child does not have type 1 diabetes.
For a child or adolescent who is not sick and has few symptoms of diabetes, diet and exercise may be the first choice. However, if the symptoms are more pronounced, or if diet and exercise alone fail, treatment with oral drugs that either enhance insulin secretion (sulfonylureas, for example Glyburide, Glucotrol, Amaryl), and/or drugs that reduce insulin resistance (Actos, Avandia) and/or glucose production (Metformin), are very effective.
In children with type 2 diabetes, the most common drug used first is metformin, which is usually not associated with weight gain or low blood sugars and is well tolerated. Sulfonylureas, which can cause low blood sugars, are often used as well, usually if metformin alone is insufficient. However, some patients with type 2 diabetes may gradually progress and have low insulin secretion, and require insulin. For that reason, the name non-insulin dependent diabetes is not always accurate and was replaced with type 2 diabetes.
Who gets type 2 diabetes in childhood?
In families where there are other members with type 2 diabetes or history of gestational (during pregnancy) diabetes, other members are very likely to develop type 2 diabetes, particularly if they become overweight and obese, and are sedentary. Lack of exercise contributes to weight gain, and insulin resistance, and increase the risk for diabetes greatly.
- Ethnicity is an important factor. The risk for type 2 diabetes is higher in Native American, African American, Pacific Islanders, and Hispanics, compared with nonHispanic Caucasians. In some populations, living a Western society lifestyle, the risk of developing type 2 diabetes for an individual who has a first degree relative with diabetes, is 50% or even higher.
- Low Birth Weight under 5 ½ lbs for a full term baby, or Large Birth Weight of 10 lbs or over, or being born to a mother with diabetes during pregnancy, are all associated with higher risk of type 2 diabetes.
- Obesity is a major risk factor for developing type 2 diabetes, even without family history of diabetes. In some populations, even a modest weight gain of 20 lbs can result in type 2 diabetes.
Treatment Goals
Goals of treatment at the Rady Children’s Diabetes Clinic are to:
1. Maintain blood glucose levels (and A1c) as close to normal, while avoiding low blood glucose levels (hypoglycemia). This requires frequent blood sugar checks, at least 4 times daily in patients on insulin, before meals and at bedtime. Better control of blood sugar levels results in less long-term complication and slower progression of complications, should they develop. Hemoglobin A1c is a blood test done from a finger stick every 3 months, which measures the average blood glucose levels over that time, and helps guide therapy and home blood glucose monitoring. Continuous glucose monitoring is now also available,
2. Have diabetes revolve around a child’s life, not visa versa. Towards that goal, a qualified and experienced diabetes team is available to constantly tailor the treatment plan (insulin regimen and diet) to the individual’s needs. These revolve around the daily schedule, meals, and family needs. To address these issues, our team includes certified diabetes educators, nurses, dietitian, social worker and physicians giving 24-7 coverage. Good communication and education are key to good outcomes.
An insulin pump is a useful tool to achieve some goals, but requires responsibility and a dedicated effort in managing diabetes. In addition, certain basic skills need to be learned before a pump can be prescribed. Good preparation is the key to success in the dozens of patients who are doing great with the insulin pump. We use three major brands of insulin pumps, and the ultimate choice of which pump to use is individual.
3. Promote healthy weight and diet. This is important in controlling blood pressures and lipid levels such as cholesterol and triglycerides. Preventing further weight gain or achieving moderate weight loss in obese patients with type 2 diabetes often helps control blood sugars and prevents other complications associated with obesity.
4. Monitor for complications and other conditions associated with diabetes, during each visit to the clinic and through periodic labs.
These include:
- Check height and weight to monitor growth. Growth can be affected by diabetes or conditions associated with diabetes: abnormal thyroid or adrenal glands, or celiac disease.
- Check blood pressure at each visit. Hypertension is particularly harmful in diabetes and advances other complications more rapidly.
- Monitor the thyroid gland on exam and yearly thyroid blood tests.
- Monitor urine for protein leak (urine microalbumin), as a sign of kidney complication due to diabetes. If left untreated, this can lead to kidney failure and dialysis in adulthood.
- Perform dilated eye examination — done yearly after 5 years duration or as needed. This is to monitor for diabetes damage to the small blood vessels at the back of the eye, which can lead to blindness if left untreated.
- Ensure good foot care and sensation. Along with building good habits for adulthood, this helps prevent ingrown toenails and infections.
- Monitor lipid levels (cholesterol, LDL, HDL and triglycerides), especially in type 2 diabetes, and treat as needed. This is crucial since abnormal lipids results in earlier heart disease and infarctions.
Written by Rady Children’s Division of Endocrinology/Diabetes