Why the youngest type 2 diabetic patients are the sickest

Dressed in a brown sweatshirt with "San Leandro Rebels" on the front, Gail Punongbayan, 17, did not flinch when the assistant d & rsquo; A doctor took blood.

"One, two, three, four, show!" Jonathan Ramos, a doctor assistant at UCSF Benioff Hospital, shouted when he pricked Gail's finger to spread a drop of blood on a small card to check his blood sugar.

The high school student knows the routine. For the past four years, she has been visiting the Children's Clinic of UCSF Benioff Children's Hospital in Oakland, CA, every three months for medical examinations.

In this one, Ramos first checks his height, then his weight and blood sugar. The routine may seem normal, but Gail's condition is actually extremely abnormal for children or teenagers of her age.

Or it was the usual.

Today, Gail is part of a growing number of children and adolescents with type 2 diabetes. Despite their young age, many of them have complications and progression of the disease four times faster than adults with the same disease, which triggers alarms for diabetes specialists who treat them.

From 0 to 5,300 cases per year

Stories like those of Gail are no longer rare. The Centers for Disease Control and Prevention (CDC) estimated in 2012 that there were 5,300 new pediatric type 2 cases diagnosed this year in the United States.

This number is significantly lower than the 17,900 children diagnosed with type 1 diabetes, but it is a substantial increase from zero, which was the case in 1990.

This increase reflects the trend of type 2 diabetes cases in the United States. Currently, nearly one third of the country, or 100 million people, have diabetes or prediabetes, says the CDC.

There are two main types of diabetes: type 1 and type 2. In type 1 diabetes, the immune system attacks the pancreas, rendering it unable to produce insulin.

In type 2 diabetes, the pancreas still makes insulin, but the body has become more resistant. This can happen for a variety of factors, such as diet, obesity or genetic predisposition. The pancreas will continue to make more and more insulin, but eventually the body can use it. In some cases, it stops producing insulin.

Experts have linked the growth rate of childhood obesity as a factor accounting for the sudden spike in pediatric type 2 diabetes cases. The CDC estimates that one out of every five school-aged children is obese. That's triple the number of the 1970s.

But obesity is not the only factor in the increase of type 2 diabetes cases in children. After all, there were children with obesity before 1990. But virtually none of them developed this disease.

Jane Lynch, FAAP, chair of the section on endocrinology at the American Academy of Pediatrics and professor of pediatrics at the University of Texas at San Antonio, said that several factors have put children in danger for decades.

These factors include an increase in gestational diabetes, changes in food processing and less activity time for children.

"We also know that there was a much higher rate of gestational diabetes and that diabetic mothers had children," she said. "And we know that there is a genetic predisposition to type 2 diabetes."

In addition, Lynch says that changes in the American diet – including processed foods high in fat and sugar – have put children at risk. A diet high in fat and sugar reduces the body's sensitivity to insulin, which acts on blood sugar, resulting in pressure on the pancreas.

"We know that the diet has really changed in those years, we are making a lot more processed foods, glucose and servings," she said.

Another less obvious factor is air pollution: A study published this year in The Lancet: Planetary Health estimates that 150,000 cases of diabetes each year in the United States could be related to air pollution

The danger to adolescents [19659010] Many of these young people are diagnosed with puberty diabetes, when a stream of human growth hormone is released, which makes the body less sensitive to insulin.

Gail was diagnosed at 14.

"The growth hormones you make to grow quickly in adolescence thwart insulin," explained Lynch. "So, the mix of hormones during the first half of the year," says Lynch. adolescence, pubertal hormones and hormones s, is unique and different from adults. "

Getting a diagnosis at 13 or 14 also means teens are struggling with a potentially dangerous chronic disease, just when they might want to assert more independence from their parents.

Mark Heyman, Ph.D., a diabetes psychologist and certified diabetes educator with Beyond Type 1, says that working with teens who have type 1 or 2 diabetes can be a challenge due in part to their age. Teenage rebellion can mean ignoring parents or even their medications, so that they do not feel so different.

"Parents have trouble getting their hands off their hands and are not actively involved," Heyman said. "That makes [teens] more rebels, they say," I'm mad ".

As teens begin to assert their independence, they can also turn to online sources to not feel lonely. Sarah Bacon posts on YouTube her experience with diabetes to reduce the stigma of the disease.

"I would say it's the group of teenagers that I hear the most," Bacon told Healthline. "When I was diagnosed, I was given a lot of diabetes pamphlets, but one of the first things I did when I got home was to watch on YouTube. I sometimes have the impression that "clinical" answers are not enough, so I'm going to ask people on social networks that I'm going through the same things as me. "

Only 17 years old, Gail says she's at an age she's trying to be more independent in managing her illness.

"My mood is changing. I must take responsibility. I have to do all this, "she told Healthline.

But like any teenager, she can become irritable to her father's instinct to watch her diet.

"He always screams and gets angry at me if my sugar does not go," she says. "It controls what I eat, it's hard to eat what I want and be satisfied … because you can not keep eating salad every day for the rest of your life."

The fight to control the blood sugar

endocrinologist, Dr. Sonali Belapurkar, during her last exam, she confided to her father that she was worried about a blood glucose measurement called A1c. The last time she was at the clinic, this measure – an average of her blood glucose over several months – was so high that Belapurkar wanted to see her in just one month, as opposed to the usual three.

"It's probably high," Gail told his father. "My A1c is probably high, I can say."

Volatile blood glucose is common in these young diabetics.

The TODAY study, a major multi-year study funded by the National Institutes of Health, found that young patients had four times the deterioration of beta cells compared to adults. These pancreatic cells are what makes insulin. When they stop working, it becomes incredibly difficult to control blood sugar.

Lynch says that about half of the children have failed the beta cell, which exposes them to a high risk of complications.

"These children are much more likely to need insulin within two years, and they are at a much higher risk of developing diabetes complications in a few years, unlike adults who may to be fairly asymptomatic for 10 to 12. The future of the diabetes generation

Over time, type 2 diabetes means an increased risk of kidney failure, heart disease, nerve damage, lesions Eyes and a host of other ailments. [19789004] Nancy Chang, PhD, creator of the Type 2 Diabetes Program at the Los Angeles Children's Hospital (CHLA), has been working on the TODAY study and said that some of these young patients were already suffering from serious complications, including blindness and renal failure.

"They develop diabetes at the age of 10 years and s & # 39; 39: they do not take good care of their diabetes … at the moment Where they are 20 years old, they are going to dialysis or be blind, and unfortunately, that's what we're seeing already, "Chang said.

In the TODAY study, researchers found that high blood pressure had increased from 11% in these patients at the time of diagnosis to 34% less than four years later.

Microalbuminuria – or protein in the urine – increased from 6% at the time of diagnosis to 17% less than four years later. Microalbuminuria is an early sign of vascular injury and indicates an increased risk of heart and kidney disease.

About 14% of these young patients developed retinopathy or ocular lesions less than five years after diagnosis.

Lynch says studies have found that children often do well on drugs for about five months. But then they come back to the hospital at one year with extremely high blood sugar and complications.

"They disappear five months later," she says. "They got sick and that was bad news."

In addition, living with diabetes from childhood to adulthood may mean that the next generation is at greater risk. Lynch says that early data showed that when these patients become pregnant, they are at high risk for serious complications, including miscarriages, stillbirths, and birth defects.

"We are seeing – we are afraid – dialysis and heart attacks in our late twenties in these children, and we continue to be really scared of pregnancy outcomes," Lynch said.

"They should be in the really productive years of their lives, and instead they are really sick."

What treatments are there?

Although there are dozens of drugs for adults with type 2 diabetes, the Food and Drug Administration (FDA) has approved only two drugs to treat type 2 diabetes in people under the age of 18 years old: metformin and injectable insulin itself.

Lynch says medical experts across the country have come together to lobby pharmaceutical companies and the FDA to do more studies to see if some of the dozen diabetes medications readily available to them adults could be given to adolescents.

And while adults may benefit from an intense lifestyle intervention, this has been found to be ineffective in most cases of type 2 diabetes in children, according to researchers today. 39; hui.

Chang said the team was surprised when an intense lifestyle intervention for patients during the study TODAY's HUI did not improve their health or their illness. As a result, they reconsidered how to treat these patients.

"We thought the lifestyle change was going to be better, but we could not show it in the study," she said. "I think the reason is all the challenges we have to work in this population, to help them eat healthier and help them do more exercise."

A new study published last month in Diabetes Care a type of insulin and metformin or only metformin alone did not prevent the progression of the disease in many of these younger patients.

Horizon Treatments

In the hope of helping these children, some experts have turned to surgical options to help them lose weight.

Shinault's Travion of Denver, Colorado, underwent bariatric surgery earlier this year to help treat her diabetes. Diagnosed at the age of 15, Shinault struggled to keep her blood sugar stable. He explains that he was not always paying attention to his diet and that he sometimes ate food that added his blood sugar.

At age 19, Shinault took a cocktail of medications to help manage her diabetes and subsequent complications. Eventually, his doctors came to him and asked him if he wanted to examine the surgical options – although they are still experimental as a diabetes treatment for a teenager.

"I was fit enough for that," he told Healthline. "The members of my family … they were much more nervous.They [constantly] asked a lot of questions about it."

Shinault had to take a semester off Colorado Mesa University for recover from bariatric surgery. But now, a few months after surgery, Shinault has lost weight and is only taking metformin to help control her blood sugar.

"Now that I'm able to eat more, I can make more vegetables and make more healthy foods," he told Healthline.

Dr. Phil Zeitler, chief of section of endocrinology at the Children's Hospital of Colorado, treated Shinault and was co-author of a study published earlier this year in JAMA Pediatrics that examined the effects of surgery bariatric on 93 adolescents with type 2 diabetes.

"In children who have very aggressive type 2 diabetes, doing so early can help maintain metabolism," he said. "Either we take diabetes for a long period of time or at least put it off."

Zeitler and his team found that young people with type 2 diabetes who had surgery had better glycemic control, improved kidney function, and decreased risk of cardiovascular disease compared to those who were treated only with drugs.

But Zeitler says this surgery does not "cure" their diabetes. He can buy them time, however, so that they can live longer and healthier before their diabetes progresses again.

He also points out that this surgery comes with its own set of risks and complications.

"I share the concerns of people about the extreme need to do surgery on children to deal with diabetes," he told Healthline.

Trying to treat children without a safe place to play

At ABSC, Chang created the new Type 2 Diabetes Program in 2017 after noting the inefficacy of treating diabetes at home. these younger patients

. We also have programs to help them try to change their behavior, so we do not just treat them at the clinic. Right now, we are going into the community to try to help them, "she said.

Part of the treatment involves a therapist to help children overcome stigma and accept the disease.

"Most of these children also have parents with type 2 diabetes," Chang said. "There are several problems that we have to work with these children to help them accept the diagnosis."

For 12-year-old Megan Perez and her mother, Ilda Gomez, the center was a useful source of information. education and support. . The mother and daughter are living with type 2 diabetes.

Gomez says she was horrified to discover that her daughter had type 2 diabetes last year.

"It was the worst day of my life, because being a diabetic myself, I know what it's like when your sugar is high, when you have stockings," she says. "There are some days when you feel really sick."

After Megan's diagnosis, Gomez jumped into action to make sure that her daughter would not develop complications of the disease. She took her daughter to CHLA, where they registered her at their diabetes clinic.

Gomez says that as a family, they went to the clinic to learn how to cook healthier foods, avoid hidden sugar and find better ways to stay active. But it is always difficult.

At Megan's school, there are no more gym classes. The nurse must help count her carbohydrate meal at her school so that she does not sting her blood sugar from the cafeteria pizza.

"We get a tiny little tray, really tiny, and there's a little salad in it," Megan said of her lunch.

Megan is also interested in cycling and maybe running, but the park is a 10-minute drive, and the family only goes on weekends.

"The thing is, we live in South Central LA, our neighborhood is really bad," said Gomez. "I will not let her go outside."

The Chang team also faces a deadline to help many of these children. Most of them are in the Californian version of Medicaid, called Medi-Cal. Once they are 21 years old and they stay at Medi-Cal, they will not have access to specialists who help monitor and control their diabetes.

"[They might] has a primary care provider who generally does not know how to handle drugs that are not the basic drugs for type 2," explained Chang. "They should always see a dietician, they should always have psychological support, and they can not have that [on Medi-Cal]."

Chang points out that without this help and support, "the future of these children is very, very dark. "

Growing up with diabetes

For Gail, there are good and bad signs about the state of his diabetes

During his health check, Belapurkar was concerned that Gail sometimes had blurred vision and irregular liver enzymes, but she also gave him a high five for weight loss in recent months and reported that his A1C levels were back

But the teenager is also struggling to stay u current of his medication. In between getting ready for school and needing to prepare a healthy breakfast before taking her medications, Gail says she often forgets her morning insulin pill.

At that time, Gail became a little calmer when Belapurkar asked a question about the school, asking if it was stressful.

"Yes," says Gail.

Belapurkar has found a new type of insulin for Gail that she can take at night with food, so she does not have to worry about her morning routine. But Belapurkar insists that the teenager must be aware of her diet and treatment schedule to stay healthy.

While also surviving his last year of high school.

"I'm trying to get back to what I usually do, but I'm lazy," she said softly to Belapurkar. "Life is hard."

Belapurkar paused before answering.

"I know it's hard, but it's feasible, no?"