What you need to know about Type 2 Diabetes
There has been growing concern about the recent sharp increase in reported cases of type 2 diabetes in children and adolescents. Several studies have documented this epidemic. In light of this and the fact that little is known about type 2 diabetes in children, the American Diabetes Association (ADA) developed a panel of experts to review current trends and to develop consensus about the prevention, diagnosis, and treatment of type 2 diabetes in young people. The consensus statement, Type 2 Diabetes in Children and Adolescents, was published in the March, 2000 issue of Diabetes Care. We present here a simplified summary of that consensus statement for the lay public.
Types of Diabetes in Children
Type 1 diabetes (diabetes caused by a defect in the immune system which leads to destruction of the insulin-producing beta cells) has classically always been considered the only type of diabetes in children except in rare instances. Indeed, type 1 diabetes was called "juvenile diabetes" in the past. However, some recent findings suggest that somewhere between 8 - 45% of newly diagnosed children with diabetes, may indeed have type 2 (insulin deficiency due to other factors). At the time of diagnosis, it may not be possible for the classification to be correctly determined, because symptoms and findings often are similar.
Types of Diabetes in Children
Type 1 (immune-mediated) Diabetes
Type 2 (insulin resistant) Diabetes
It is sometimes difficult for clinicians to properly classify children with diabetes. Current practice suggests that treatment for children with diabetes be based on their initial presentation and clinical course. In the event that specific classification is warranted, additional testing is necessary. Some these of these tests include: fasting insulin or C-peptide levels; antibody measurements; and genetic testing. Most of these especially those for antibodies and genotypes should be performed only in highly qualified research laboratories.
Type 2 Diabetes In Children -- What Is It?
Type 2 diabetes is extremely complex. There is an underlying genetic susceptibility that, when exposed to a variety of social, behavioral and environmental factors, unmasks diabetes. While this genetic background is important, the alarming increase in new cases of children with type 2 diabetes underscores the role of environmental factors. Maintaining blood sugars in the normal range requires a delicate balance between the amount of available insulin and is action at the cellular level. Experts do not agree as to whether diminished insulin secretion or insulin resistance is the primary problem in the population of adults with type 2 diabetes. From what has been observed in children the abnormality appears to be that of inappropriate insulin action progressing to later failure of the insulin-producing cells.
Puberty has been identified as important in the development of type 2 diabetes in children. Changes in hormone levels during this period cause insulin resistance and decreased insulin action. Therefore it is quite understandable that type 2 diabetes in children most often occurs during mid-puberty although cases as young as 4 years of age have been reported.
Obesity is another significant factor. It is well understood that obese children produce too much insulin so that when the need for more insulin arises, they are likely to be unable to produce enough more. In addition, the presence of too much fatty tissue (adipose cells) leads to insulin resistance.
Screening For Type 2 Diabetes in Children
Only children who have risk factors for the development of type 2 diabetes need to be screened. The American Diabetes Association consensus panel suggests the following:
Which children should be screened for Type 2 diabetes?
When should you screen?
Every 2 years
How should you screen?
Fasting blood sugar
Treatment of Type 2 Diabetes In Children
The treatment goals for children with Type 2 diabetes are:
- Blood sugar levels as close to normal as possible
- Glycosylated hemoglobin levels as close to normal as possible
- Prevention of complications
Since type 2 diabetes in children has traditionally been a rare occurrence, little is know about treatment. The panel of experts can draw conclusions and make recommendations based on experience in adults. It is a well-known fact that optimal diabetes control without the use of medications (oral agents or insulin) is obtainable in less than 10% of adults with type 2 diabetes over the long term. Studies indicate that this form of diabetes is progressive. That is, over time, control of blood sugar will diminish requiring the addition of oral medication(s) and/or insulin therapy. This is despite rigorous attention to meal plans and exercise programs.
Children with type 2 diabetes and their significant others should participate in a diabetes self-management education. Ideally, the program selected should have a team of educators (physician, dietitian, nurse, social worker, exercise specialist, etc) who are well-versed in education of children. Standards to look for are pediatric centers with Certified Diabetes Educators on staff and whose programs have met the National Standards for Diabetes Self-Management Education as identified by the American Diabetes Association. Education should include but should not be limited to: self-monitoring of blood glucose, medications and their use, exercise and meal planning.
It is essential that meal plans be developed by a dietitian with experience in the pediatric population. The dietitian needs to stress the importance of healthy eating patterns for the entire family while taking into account financial and other family resources, lifestyles, and cultural preferences.
Changing sedimentary lifestyles is essential to weight loss and control of type 2 diabetes in children. Exercise speeds up calorie expenditure promoting weight loss. It also increases insulin sensitivity at the cellular level. A pediatric exercise counselor should work with the child and family to develop an appropriate program.
Currently, there are five classes of oral medications approved by the FDA for treatment of type 2 diabetes. It is important to note that few safety and effectiveness studies have been conducted in the pediatric population. None of these drugs have FDA approval for use in children. However, the consensus panel believes that since children with type 2 diabetes have the same defects as adults, their use should not be excluded and the panel does make recommendations.
Oral medications for diabetes
Names: Amaryl (glimepiride); DiaBeta, Micronase, Glynase (glyburide); Glucotrol, Glucotrol XL (glipizide), and others.
Actions: Sulfonylureas stimulate the beta cells in the pancreas to make more insulin. Some of them appear to also make body cells more sensitive to insulin.
Name: Prandin (repaglinide)
Actions: Meglitinides stimulate the beta cells in the pancreas to make more insulin. In contrast to the sulfonylureas, it has a short duration and no known effect on insulin sensitivity.
Name: Glucophage (metformin)
Actions: Biguanides decrease the amount of sugar produced by the liver and increase insulin sensitivity both in the liver and muscle cells. They do not have a direct effect on insulin-producing cells.
Names: Precose (acarbose), Glyset (miglitol)
Actions: Glucosidase inhibitors work in the intestines to slow down the conversion of ingested carbohydrates to sugar.
Names: Avandia (rosiglitazone), Actos (pioglitazone)
Actions: Thiazolidinediones increase insulin sensitivity at the cellular level and improve glucose usage by the cells.
The consensus panel recommends the use of oral agents when blood glucose and other treatment goals are not met. Glucophage should be the first oral agent used because it works as well as the sulfonylureas in controlling blood sugar levels and carries little risk of low blood sugar reactions. It also causes weight to decrease or remain the same unlike the sulfonylureas, which have a tendency to cause weight gain. Another benefit is metformin's advantageous effect on blood lipid levels. Glucophage may have also control PCOS. However, Glucophage should not be used in children with known liver and kidney disease, low oxygen problems, or severe infections. Other oral agents such as a sulfonylurea or meglitinide can be added if control does not improve after three to six months. The thiazolidinediones probably should not be used in children. Rezulin has been on the market long enough to show rare adverse liver reactions, while safety information about the other thiazolidinediones is not yet available.
The most effective way to quickly normalize blood sugar levels is with the use of insulin. Insulin therapy should be started in children with severely elevated blood sugar levels or children with intense thirst and frequent urination. There are a wide variety of insulin regimens that can be employed. The regimens range anywhere from bedtime alone to multiple daily injections. Once blood sugars are under control, Glucophage can be added while decreasing insulin dosage. It is important to monitor for ketones during this time to rule out type 1 diabetes in a honeymoon period.
Periodic Monitoring of Control and Complications
Monitoring of control and complications should include:
To look at control over a 3 month period
Every 3 months
Blood sugar testing
To see treatment effects
At least twice a day
Dilated eye exam
To screen for eye problems
Screening for the presence of small protein bodies in the urine (microalbuminuria)
To detect early kidney problems
In addition, children with hypertension and blood lipid disorders need to closely monitored for these problems and treated appropriately.
Prevention of Type 2 Diabetes in Children
Prevention of type 2 diabetes in children is based upon:
- Identification of high risk children (by glucose testing or genetic markers) and
- early intervention.
Primary prevention should involve a public health approach, that involves school and community-based programs, directed at improving overall nutrition and physical activity (see above table).
The population of children with type 2 diabetes is growing perhaps to epidemic proportions. To date experience in dealing with this problem has been limited. Ongoing research is need to further define the scope of type 2 diabetes in children, to clearly delineate its characteristics in terms of children at risk and its clinical course, and to develop a well-defined efficacious treatment plan.