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 Yale-New Haven Hospital, New Haven, Connecticut, USA HealthLINK: Pediatrics
May 8, 2000

News this month
Diabetes on the rise among children

Recent research is showing a dramatic rise in Type 2 diabetes among children in the U.S. and other countries, a trend that could have major health implications, according to an expert panel convened by the American Diabetes Association.

Type 2 (diabetes) is most common in children age 12 to 19 and those who are obese.

As recently as 1990, less than 4 percent of childhood diabetes cases were Type 2, most often associated with lifestyle and obesity. Now that number has reached about 20 percent, and ranges from 8 to 45 percent. The variation is caused by the age of the group studied, as well as the racial or ethnic mix of the children. Type 2 is most common in children age 12 to 19 and those who are obese.

The Questions
Last fall, the panel of diabetes experts met with representatives from the Centers for Disease Control and Prevention and the American Academy of Pediatrics. Their report, released in February, consists of six questions and answers that will help practitioners diagnose and treat this chronic disease and help families understand it. Some of the questions posed by the panelists were:

  • What is the classification of diabetes in children and adolescents? (Type 1 or Type 2)
  • Who should be tested for diabetes?
  • How should children and adolescents with Type 2 diabetes be treated?
  • Can Type 2 diabetes in children and adolescents be prevented?

The answers

Type 1 or Type 2?
Diabetes occurs when the body does not produce or properly use insulin. Insulin is a hormone produced by specialized cells in the pancreas. Insulin helps convert starches, sugars and other foods into energy the body needs. Type 1 diabetes was once called insulin-dependent diabetes and happens because the body produces little or no insulin. Type 2 is caused by resistance to insulin or the inability of the pancreas to keep up with increased demand for insulin. In the past, children with Type 1 diabetes were often underweight at time of diagnosis. But as obesity became more common, it has become harder to use weight to tell what type of diabetes these children have.

Risk factors for Type 2 diabetes in children include decreased exercise and increased fat and calorie intake.

The panel’s findings also showed that:

  • Children with Type 2 diabetes are often obese. Sometimes, the obesity may be masked by significant weight loss in the months or year before diagnosis.
  • Risk factors for Type 2 diabetes in children include decreased exercise and increased fat and calorie intake–the same as in adults.
  • A family history of diabetes is usually present.
  • Diabetes in the parent or other relative may not be recognized until the child is diagnosed.

Who’s at risk?
Not much is known about how Type 2 diabetes is distributed among children because the trend is so new. Historically, certain populations, such as some Native American tribes and African Americans have shown higher incidence of the disease. Childhood diagnosis in all ethnic groups often peaks around the time of puberty, although this may be pushed to an earlier age by obesity. And although genetics clearly plays a factor in the trend, environmental factors, particularly lack of exercise and obesity, are playing a role.

Who to test?
The report suggests testing be done every two years, starting at age 10 or at onset of puberty, on children who are overweight with a body mass index greater than the 85th percentile or weight greater than 120 percent of the ideal, OR if a child has the following characteristics:

  • Having a family history of Type 2 diabetes in first- and second-degree relatives
  • Belonging to a certain race/ethnic group (American Indians, African-Americans, Hispanic Americans, Asians/South Pacific Islanders)
  • Have signs of insulin resistance or conditions associated with insulin resistance (acanthosis nigricans, hypertension, dyslipidemia, PCOS).

Children found to be diabetic and their families should receive counseling and close follow-up to make sure they can comply with the somewhat difficult methods of controlling this disease. Preventing the disease will require accurately identifying children at risk, and providing them the services they need, the panelists noted.

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Sonia Caprio, M.D.

Type 2 diabetes in children: The silent epidemic

The report by the American Diabetes Association brings to the forefront something that has greatly concerned those of us who treat diabetes in children. At Yale-New Haven Children's Hospital we are clearly seeing more children with Type 2 diabetes now than 10 years ago. Many of these children are very overweight, which unmasks whatever genetic predisposition they may have had for diabetes. As a result of being overweight, they become very inactive and when they are asked to do exercise, they are unable to do it. It’s a vicious cycle. Most often these children are from 12 to 16 years old, with equal numbers of girls and boys.

“…at puberty, something is happening that triggers the diabetes.&#!48;

This agrees with the panels’ findings that at puberty, something is happening that triggers the diabetes. Puberty is a time of natural insulin resistance, when the pancreas is overworking to help growth occur. In addition to puberty, these children have the proper genetic background that includes a family history of this disease.

Testing children at risk
We are currently running a study that shows about a quarter of obese children who are not diabetic may be heading toward the disease. They undergo oral glucose tolerance tests, the same type of tests used during pregnancy. If the results come back higher than 140, that child has impaired glucose tolerance. Those readings, along with other tests, are a red flag that says this child will very likely become diabetic if major changes in lifestyle and diet are not made. With weight loss and increased exercise, these numbers can normalize. If not, the child will likely be diabetic in 10 years.

“Key issues in the increase…are that children are eating more and exercising less.”

Tipping the scales in favor of diabetes
So the key issues in the increase in diabetes are that children are eating more and exercising less. It’s not clear whether poverty is an underlying cause as well. Computers, television, concern about crime and being home alone all contribute to children sitting and eating more and exercising less. Even the number of hours children spend in gym in schools has been reduced in recent years.

That so many children are being diagnosed says something about our overall genetic make-up as humans. We were probably not meant to live in an environment so rich in foods requiring so little physical exertion.

Getting started on treatment
When a child is diagnosed in our clinic, we know that his or her future health depends on properly controlling the disease. Typically, the child with Type 1 diabetes is underweight, feels thirsty all the time, is tired and is urinating frequently. In these children, an autoimmune disease attacks the beta cells in the pancreas, killing them and stopping insulin production.

In Type 2 diabetes, there is still insulin produced, but it does not work properly. The hard part is that children with Type 2 diabetes often don't feel sick. It's hard for them to understand they are at risk for heart disease, circulatory problems, eye problems, kidney failure and other conditions if they do not control their diabetes. So it’s critical we help the families understand these risks and carefully explain options for medications, food, weight loss, exercise and the like. These children often receive oral medications rather than insulin because they are easier for the children to take and we therefore get better compliance. And we see them regularly for follow-up.

“I would urge parents who have a strong history of diabetes to notify their pediatrician…”

The need for research and awareness
Because this is such a totally new area, we’ve been relying on what we know about Type 2 diabetes in adults to guide how we treat it in children. It’s not easy to learn what is happening in children with Type 2 diabetes because they are reluctant to be studied and the parents are hesitant as well. At the very least, I would urge parents who have a strong history of diabetes to notify their pediatrician, if they have not done so already.

Dr. Caprio is a pediatric endocrinologist affiliated with Yale-New Haven Children’s Hospital and an associate professor at Yale University School of Medicine.

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