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What once was called "adult-onset" diabetes is no longer solelya grown-ups' disease. An estimated 40,000 U.S. adolescents have type 2diabetes, and 2.5 million more may have impaired fasting glucose(IFG).1
Healthy children gain 0.9–2.7 kg (2–6 lb) of weight per yearalong with 5.08–10.16 cm (2–4 in) in height. "They usuallyshould go hand in hand. It rises in both areas proportionately," says JoAnn Serota, MSN, CPNP, president of the National Association of PediatricNurse Practitioners and a health care provider near Philadelphia.
So, if a youngster suddenly puts on 9 kg (20 lb), should that raise alarmbells for diabetes? At the very least, such an atypical growth spurt meritscareful evaluation. Although obesity is a hallmark of type 2 diabetes, thisdisease used to be a rare phenomenon in children and adolescents. But inrecent years the number of reported type 2 cases among these age groups hasspiked.
Investigators are working hard to devise reliable methods for use byprimary care providers to identify youth who need intervention, but there maystill be a long way to go.
SCREENING RECOMMENDATIONS
A recent study applied current recommendations for examining children andtested an expanded model of assessment to predict a child's risk for beingoverweight and developing cardiovascular disease (CVD) and type 2 diabetes.The findings appeared in the March/April issue of the Journal of PediatricHealthCare.2
According to guidelines set forth jointly in 2000 by the American DiabetesAssociation (ADA) and the American Academy of Pediatrics, clinicians shouldpay close attention to children at high risk—those whose body mass index(BMI) exceeds the 85th percentile for their age and sex and who have two ormore of the following risk factors: family history of diabetes in a first- orsecond-degree relative, minority ethnicity, and signs of insulinresistance.3 Theresearchers also applied recommendations from the National CholesterolEducation Program, the American Heart Association, the Institute of Medicine,and the National Heart, Lung, and Blood Institute.
In a sample of 118 children, the study showed a very high rate of beingoverweight and at risk for CVD and type 2 diabetes. Nurses should take carefulchild and family histories and measure height, weight, and blood pressure, theresearchers conclude. They also should intervene to suggest dietary changes,exercise, and weight management and perform further testing such as lipidprofiles and fasting plasma glucose in children with high BMI and twoadditional risk factors.
In some children, "type 2 diabetes is a silent disease, at least to acertain point," says lead author Ruth McGillis Bindler, RNC, PhD,associate professor at Washington State University's Intercollegiate Collegeof Nursing in Spokane. "The child may not yet manifest signs andsymptoms that lead either the family or practitioner to believe a diseaseprocess is present."
On the other hand, many children with type 2 present with typical symptomsof polyuria, polydipsia, and polyphagia, says Francine Ratner Kaufman, MD,head of the Center for Diabetes, Endocrinology, and Metabolism at Children'sHospital Los Angeles. "In fact, it appears that children with type 2become symptomatic earlier than adults," Kaufman says. "They aremore hyperglycemic and they more rapidly progress through pre-diabetes todiabetes."
Although youth with type 2 diabetes belong to various ethnic groups, thedisease occurs more commonly in nonwhites, with American Indians showing thehighest prevalence.
ONGOING RESEARCH AND GROWING AWARENESS
In response to the increasing public health concern, the Centers forDisease Control and Prevention and the National Institutes of Health arefunding a 5-year, multicenter study called SEARCH for Diabetes inYouth.4 Itsobjectives are to evaluate the magnitude of diagnosed diabetes and toestablish criteria to differentiate types of diabetes among young people.
"The realization among parents that being overweight puts the kids atrisk is only just now beginning to rise," says Philip Zeitler, MD, PhD,associate director of the Pediatric Clinical Translational Research Center atthe University of Colorado Health Sciences Center in Denver. "Ingeneral, chubby kids have been thought of as cute or, at most, as [having] acosmetic problem."
By the time these kids reach their teenage years, the added pounds pack adouble whammy. Onset of type 2 diabetes much earlier than that is unusual."It's not entirely clear when the peak is, but it seems to be in mid tolate puberty, say [ages] 13 to 15," says Zeitler, principal investigatorof the Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY)study, a multicenter trial of adolescent type 2 diabetes supported by theNational Institute of Diabetes and Digestive and Kidney Diseases. "Kidswho are sort of compensating adequately for their insulin resistance ofobesity hit the wall when the insulin resistance of puberty is added,"he theorizes. The incidence is higher among girls than boys.
Providers shouldn't screen kids only for diabetes; according to someclinicians, the condition occurs less frequently than metabolic syndrome, acluster of symptoms including hypertension, glucose intolerance, dyslipidemia,and a large waist size. "The risk factors travel together,"Zeitler says. "We are looking for long-term cardiovascular risk"("Kids' Cardiology," seepage 8).
Primary care providers play a pivotal role in the early detection ofdiabetes. There is some evidence that these children develop complicationssimilarly to the adult population, says Ingrid Libman, MD, PhD, a pediatricendocrinologist at Children's Hospital of Pittsburgh. "So the earlierthey are identified, the better their prognosis in the long run," Libmansays.
Some experts contend that the ADA guidelines don't go far enough. Forinstance, the current recommended screening for high-risk children is afasting glucose test every 2 years, but Libman advises more in-depthscrutiny.
"Some limited evidence suggests that a 2-hour oral glucose tolerancetest [OGTT] may be more useful in identifying diabetes in the high-riskpopulation," she says. "If your index of suspicion is high, youshould do an OGTT."
Zeitler says he would order an OGTT for kids with fasting glucose >100mg/dl and a lipid profile for those with triglycerides >150 mg/dl. Theevaluation also should include liver enzymes aspartate aminotransferase andalanine aminotransferase.
"There is a very high incidence of nonalcoholic fatty liver diseaseamong obese adolescents," Zeitler says, "and although not perfect,this is a reasonable screening approach." 
Classic Disease Definitions Blur With `Double' Diabetes
In most cases, clinicians can readily determine whether a child has type 1or type 2 diabetes. But sometimes elements of both appear, and thisdistinction isn't clear. That's when so-called double diabetes comes intoplay.
"Some people have called it hybrid diabetes," says IngridLibman, MD, PhD, a pediatric endocrinologist at Children's Hospital ofPittsburgh. "In our experience, this phenomenon is present more commonlyin African-American children."
Youngsters with double diabetes may exhibit signs associated with insulinresistance. These include obesity and acanthosis nigricans—a darkeningof the skin common in children with hyperinsulinemia; it is most often seenaround the neckline or in the armpit. But these same children also could haveantibodies that fight the beta-cells in the pancreas, a classic calling cardfor type 1 diabetes.
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"The hallmark of type 1 is the presence of antibodies, and thehallmark of type 2 is the preservation of insulin secretion," saysFrancine Ratner Kaufman, MD, head of the Center for Diabetes, Endocrinology,and Metabolism at Children's Hospital Los Angeles.
But even type 1 diabetes in children, particularly children <5 years, isincreasing, Kaufman points out. The 3% increase per year, and nearly 6%increase in youngchildren,1 is feltto be due in part to the "accelerator hypothesis," which statesthat increased weight gain in children leads to insulin resistance thatimpairs beta-cells when there is the genetic predilection forautoimmunity.2
Since the diagnosis in youth and young adults may be murky, Kaufmansuggests obtaining samples of antibodies and ordering a C-peptide test tomeasure insulin secretion to help guide treatment.
People with type 1 diabetes require insulin. Children with type 2 may needinsulin if their blood glucose levels are very high or if ketoacidosis ispresent. For the most part, though, they should be started on lifestylechanges involving proper nutrition and activity, as well as oralglucose-lowering agents.
More studies are necessary to ascertain the best protocol for youth withdouble diabetes, experts say. "The area of double diabetes is just nowbeing recognized, and we need to learn a lot more," Libman says."Obesity seems to play a role, not just in type 2 diabetes, but maybealso in double diabetes. Efforts to prevent obesity in children should be thefocus for now."
Footnotes
The National Association of Pediatric Nurse Practitioners has produced apreventive model of care to address the rapidly growing incidence ofoverweight and obese youth. The Healthy Eating and Activity Together (HEAT)initiative is designed for nurse practitioners, doctors, and physicianassistants. More information about HEAT's "Identifying and PreventingOverweight in Childhood Clinical Practice Guideline and Resource Kit" isavailable atwww.napnap.org/index.cfm?page=198&sec=220&ssec=486.
The National Institute for Healthcare Management recently published a briefcalled "Tackling Childhood Obesity Through Public-PrivateCollaboration" that is available atwww.nihcm.org/finalweb/NIHCMObesityBrief.pdf.
Connect for Kids offers numerous online resources about children'snutrition and physical activity needs compiled by the Council for Excellencein Government Youth Obesity Results team. The resources can be found atwww.connectforkids.org/obesity_resource.
References
2. Bindler RM, Bruya MA: Evidence for identifying children at risk forbeing overweight, cardiovascular disease, and type 2 diabetes in primary care.J Pediatr Health Care 20:82–87, 2006.[Medline]
3. American Diabetes Association: Type 2 diabetes in children andadolescents (Consensus Statement). Diabetes Care 23: 381–389, 2000.[Medline]
4. The SEARCH for Diabetes in Youth Study Group: SEARCH for diabetesin youth: A multicenter study of the prevalence, incidence, and classificationof diabetes mellitus in youth. Control Clin Trials 25: 458–471, 2004.[Medline]
2. Kibirige M, Metcalfe B, Renuka R, et al.: Testing the acceleratorhypothesis: The relationship between body mass and age at diagnosis of type 1diabetes. Diabetes Care 26:2865–2870, 2003.
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