By Jill A. Goldfarb, MD
Until recently, it was thought that Type 2 diabetes was a disease of adults. During the 1990’s, however, pediatric endocrinologists began to recognize and diagnose it in children. There has been an increasing number of children diagnosed with Type 2 diabetes ever since that time, forcing more and more parents to learn about this disease and its treatments.
While many parents may find the thought of a pill a lot easier to swallow than the thought of insulin injections, treatment for Type 2 diabetes varies from child to child. Your child’s health-care team may recommend treatments ranging from a change in diet and more exercise to insulin injections to an oral medicine to a combination of insulin and an oral medicine. To understand why your child is being treated the way he is and why his treatment may change over time, it is important to understand Type 2 diabetes.
People with diabetes have difficulty regulating the level of glucose in their blood. The two major forms of diabetes are Type 1 and Type 2. A person with Type 1 diabetes does not make enough insulin because a misfiring immune system has destroyed insulin-producing beta cells in his pancreas. Insulin is a hormone that has a number of functions, including telling cells to take up glucose from the blood. In Type 2 diabetes, insulin is made initially in normal or increased amounts. The problem, however, is that the person’s cells are “insulin resistant” (not as sensitive to insulin), which means glucose is not able to enter the cells as easily. The body tries to compensate for insulin resistance by producing more insulin, but eventually this is thought to cause insulin-producing cells to “burn out.”
When glucose is not removed from the blood, it can cause a number of problems. High blood glucose (hyperglycemia) can, over time, lead to complications such as eye disease (retinopathy), kidney disease (nephropathy), and nerve damage (neuropathy). Acute hyperglycemia can also cause serious problems such as ketoacidosis (when by-products from fat breakdown build up and cause vomiting and possibly death) and hyperglycemic hyperosmolar syndrome (which can cause coma and death).
Children in the United States today, along with the rest of the population, have an increasing rate of obesity. The increasing rate of Type 2 diabetes mirrors the increasing rate of obesity. This trend is not limited to the United States; it is also seen in countries such as Japan, Libya, Bangladesh, Australia, and Canada. The link between overweight and diabetes is insulin resistance; overweight contributes to insulin resistance.
Because Type 2 diabetes usually develops over a period of years, children often do not have symptoms during the early stages of the disease. If symptoms of diabetes do appear, they can take a variety of forms. Children with uncontrolled diabetes may be more tired, thirstier, or hungrier than usual. Some children may make more trips to the bathroom than usual or wet the bed at night. They may also have frequent infections, complain of blurry vision, or experience weight loss despite an increased appetite. Some children may become extremely sick because of ketoacidosis.
The standard test for diagnosing diabetes, especially in children, is a fasting plasma glucose test, which requires a person to fast for at least eight hours, then have blood drawn. However, many children diagnosed with Type 2 diabetes are given a fasting plasma glucose test only after glucose is found in their urine during a routine physical examination, alerting their doctor to perform a blood test for diabetes.
Physicians do not test all children for diabetes. Unless symptoms are present, physicians usually only choose to screen children at high risk for diabetes. Testing in high-risk children is usually done every two years starting at age 10 or when puberty starts (whichever is sooner). To be considered at high risk, a child must be overweight and have at least two of the following characteristics: family history of Type 2 diabetes; Hispanic, African-American, Native American, Pacific Islander, or Asian American background; or signs of insulin resistance.
One sign of insulin resistance is acanthosis nigricans, areas of darkened skin and velvety thickening that may be seen on a child’s neck, armpits, groin, or other areas where there are skin folds. Acanthosis nigricans is found in up to 90% of children with Type 2 diabetes. Its presence varies with race: It is seen most often in African-American children, then Hispanics, and, although present, is least obvious in Caucasian children.
As mentioned earlier, there are certain genetic risk factors that may place your child at a higher risk for Type 2 diabetes, such as having a relative who has Type 2 diabetes or being of a certain ethnicity. In addition, children of mothers who have had diabetes during a pregnancy are also considered to have a greater risk for developing Type 2 diabetes.
Although a person cannot change his genetic makeup, there are also certain risk factors that can be changed such as high-fat, low-fiber diets; sedentary lifestyles; and overweight or obesity. Other risk factors for Type 2 diabetes include high blood pressure and blood lipid (cholesterol and triglyceride) disorders.
How a child with Type 2 diabetes is treated depends on his diabetes control, any changes in that control, and the results of regular blood glucose monitoring at home and regular checkups by his physician.
Diet and exercise. A healthful diet and exercise are the cornerstones of any diabetes care regimen. A healthful meal plan for a person with diabetes is one that takes into account all his needs. One of the first changes that may need to be made to a child’s eating habits is some form of monitoring or modification of carbohydrate intake to ensure a more even intake of carbohydrate throughout the day. Carbohydrate is the type of nutrient that affects blood glucose levels most. Your child’s diabetes care team may teach you and your child how to do carbohydrate counting or how to use exchange lists to control carbohydrate intake. Carbohydrate counting involves calculating the total grams of carbohydrate in the foods consumed in a meal or snack. The exchange lists system has people calculate and regulate the number of “exchanges” of foods they eat; for example, one exchange serving of a starchy food (such as bread, potatoes, or beans) is the amount of that food that contains 15 grams of carbohydrate (and also 80 calories, 3 grams of protein, and 0 to 1 gram of fat).
However, carbohydrate is not the only part of your child’s diet that may need to be modified. Children also have specific needs for protein, fats, vitamins, and minerals for proper growth and development. An overweight child, though, may also require a certain amount of calorie restriction, while a child with high levels of low-density lipoprotein (LDL or “bad”) cholesterol may require a meal plan lower in saturated fats.
Because of the many factors that can influence a child’s nutrient needs, if possible, include a registered dietitian who is also a certified diabetes educator in your health-care team to help you design an individualized meal plan for your child.
Exercise helps make mus
cles more sensitive to insulin, lowering insulin resistance. To combat problems like diabetes and overweight, the Surgeon General recommends that children engage in an hour of moderate physical activity most days of the week.
If diet and exercise alone are not enough to control your child’s diabetes or if your child is very ill at diagnosis, your health-care team will probably add insulin, an oral diabetes medicine, or both to your child’s regimen.
Insulin and drugs. Children newly diagnosed with Type 2 diabetes after a bout of ketoacidosis or hyperglycemic hyperosmolar syndrome are initially treated with insulin. In children who do not have serious symptoms at diagnosis, diet and exercise may be sufficient initially to control blood glucose levels. Over time, however, a child’s treatment may change. Some children may be given an oral medicine or insulin, some may need an oral medicine in addition to insulin, and some may be able to switch from medicines to diet and exercise alone. Changes in diabetes care may occur as a result of changes in blood glucose control, hormone levels during puberty, or weight, or they may be related to the progressive course of diabetes.
Metformin (brand name Glucophage) is currently the only oral diabetes medicine approved by the Food and Drug Administration for use in children. Metformin works by decreasing the amount of glucose released by the liver and by causing the liver and muscle cells to be more sensitive to the effects of insulin.
Metformin can cause gastrointestinal side effects, including nausea, vomiting, a sense of fullness, constipation, and heartburn. Its use is also associated with weight loss (or at least no weight gain), which may be a welcome result for overweight adults but may not be desirable in a growing child. Parents of children experiencing bothersome side effects when taking metformin should tell the child’s doctor. In some cases, drug side effects diminish over time as the body gets used to the drug.
Although other oral diabetes medicines have not been studied as intensively in children, some physicians are comfortable prescribing them for children with Type 2 diabetes in certain cases.
Blood glucose monitoring. Regular blood glucose monitoring is important to evaluate the effectiveness of a child’s diabetes treatment regimen. Children who use insulin are usually advised to check their blood glucose levels at least before each meal and at bedtime. Children who use insulin (along with their parents and caregivers such as a school nurse) should also learn to recognize and treat the symptoms of low blood glucose (hypoglycemia) and know to check their blood glucose level if they develop symptoms of hypoglycemia. Children who do not use insulin should receive individualized recommendations from their health-care team on when to check their blood glucose levels.
HbA1c test. Another important blood test for every person with diabetes is the glycosylated hemoglobin (HbA1c) test, which gives an indication of longer-term blood glucose control. Some doctors order this lab test every three months, and some less often, especially if a person’s diabetes is in good control. While the American Diabetes Association (ADA) recommends an HbA1c goal below 7% for most people with diabetes, children are often given higher goals to prevent hypoglycemia. In any event, each child should have an individualized HbA1c goal.
Blood pressure control. Blood pressure goals for children and adolescents are different from those for adults. Children are considered to have high blood pressure (hypertension) when their systolic (the upper number) and/or diastolic (the lower number) blood pressures are above the 95th percentile for children of that sex, age, and height on several occasions.
If your child has high blood pressure along with Type 2 diabetes, it is important to treat his blood pressure through dietary changes, exercise, and possibly through medicines. Angiotensin-converting enzyme (ACE) inhibitors are often a good choice for people with diabetes because, in addition to lowering blood pressure, they also act to prevent diabetic nephropathy (kidney disease). Other medicines may include alpha-blockers, calcium antagonists, and diuretics (“water pills”). Beta-blockers, while useful, are sometimes not used in children with diabetes because of reports they may worsen hypoglycemia or conceal symptoms of hypoglycemia.
Blood lipid control. Some children with Type 2 diabetes also have high blood lipid levels. Your child can control his blood lipid levels primarily through weight loss, increased activity, and improvement in blood glucose control. Medicines may also be necessary in some cases.
Regular checkups. Also important are regular visits to your physician and other members of your child’s diabetes team for routine health exams. These exams should include an annual dilated eye exam, foot exams at every medical visit, and annual urine tests for albuminuria (albumin in the urine, a sign of diabetic kidney disease).
When it comes to making lifestyle changes, it’s often helpful to have the entire family involved in making those changes together. This might include stocking the kitchen and preparing meals with more healthful foods for everyone, not just for the child with diabetes. It could include incorporating more physical activity—such as outdoor games, bike rides, hikes, or even yardwork—into family time and setting limits on TV watching and computer use for everyone in the home, adults and children alike. Having family support is also important for kids who participate in team sports or wish to pursue active interests such as dance or in-line skating.
Although lifestyle and dietary changes may seem burdensome at first, family members may grow to appreciate their benefits over time. Eating a more healthful diet and becoming more aware of the amounts of carbohydrate, fat, and protein one eats often contributes to weight loss for a person who is overweight. It can also lower blood pressure and blood lipid levels. For a person with diabetes who is overweight, weight loss can reduce insulin or other medicine needs—sometimes to the point where insulin or drug therapy can be discontinued altogether.
Getting more physical activity can also lead to improved fitness levels and weight loss, but more important, it can be fun if it is approached with a positive attitude. Both parents and children may discover new interests and skills as they explore new activities.
Your child may express feelings of being different from other kids because of his diabetes. Just like many other kids with chronic diseases, children who have Type 2 diabetes may have feelings of anger, depression, isolation, or denial. Feelings like these can cause a child to not take care of his diabetes as well as he otherwise would.
How you and other adults in your child’s life respond to his diagnosis and treatment can have a big effect on how he feels and behaves. A child can pick up on parental anxiety, anger, and grief over his illness, but he also responds to a parent’s ability to stay calm and use problem-solving techniques when things don’t go exactly as planned. For this reason, finding support for parents and other family members is often as important as finding support for the child who has diabetes. Visit the ADA’s Web site at www.diabetes.org (click on “Community Programs & Local Events” then “What’s Happening Locally”) or check with your diabetes team to find a support group for families in your area. If you are unable to find local support groups, online support groups can also provide answers and a sense of community when you need it.
Summer camps for kids with diabetes are often a great way to expose your child to others who share the same challenges and to lessen his feelings of isolation. For a list of camps, visit the ADA’s Web site at www.diabetes.org (click on “Community Programs & Local Events” then “Diabetes Camps”).
If your child remains angry, depressed, or in denial about his diabetes in spite of your best efforts, it may be necessary to seek professional mental health counseling.
You are not alone in the treatment of your child with Type 2 diabetes. There are many resources available to help you and your family, including your diabetes team and community and national resources. Accessing these resources and making lifestyle modifications are important and can decrease the amount of medical care that your child may need.
Children with Type 2 diabetes have a bright future ahead of them, and with education and support, they can also live a normal kid’s life.
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