The pancreas, a tapered seven-inch long gland situated beneath the stomach, secretes a hormone called insulin, which plays a major role in the absorption of glucose into the cells of the body.
Glucose is a simple sugar that is released into the bloodstream after we eat and digest certain foods, particularly carbohydrates. Glucose provides fuel for the body. Just as cars run on gas, our bodies run on glucose. We are able to walk and run because glucose fuels our muscles. However, glucose cannot enter the cells without the assistance of insulin.
In type 2 diabetes, the body either does not make enough insulin or does not effectively use the insulin it produces. Sugar builds up in the blood, starving the cells of their much-needed energy, and causing potentially serious health complications.
Type 2 diabetes:
More children at risk for “adult” disease
Nahomi Mendez (right) and Caroline Reyes, both 16, work out together at the Roxbury YMCA. Nahomi, who was diagnosed with type 2 diabetes three years ago, is followed by a nutritionist at Uphams Corner Health Center. (Ernesto Arroyo photo)
Nahomi Mendez loves to sing and dance and at one time participated on her school’s swim team.
But three years ago her life changed.
She recognized that she was heavy for her height, but “I had a lot of energy,” she recalled, “Everything seemed fine, when all of a sudden I kept itching.”
The itch was not the only sign that something was wrong. Always thirsty, Nahomi said that she drank more than her usual share of water. Most telling was that she lost 40 pounds in three months — without even trying.
For most, losing weight is a good thing. But Nahomi’s mother, Ylsia Mendez, a psychologist at an after-care program, was a bit suspicious. During her daughter’s annual physical, she asked the doctor to run a blood test for diabetes.
Surprisingly, the reluctant doctor said, “You shouldn’t worry.”
Fortunately, Mendez, who has type 2 diabetes, didn’t listen — she knew better. “No, no,” she told the doctor. “Please listen to me.”
Mendez offered a carrot. “Look, you do what I want,” she told the doctor. “After that I’ll do whatever you say.”
Mendez persevered and she was glad she did. A normal blood glucose reading after eating should typically not exceed 140; the test showed that Nahomi’s was over 700. She was immediately taken to the hospital. She stayed for a week. “I thought my daughter was going to die,” Mendez said.
It wasn’t fun and games for Nahomi either. “I was crying,” she remembered. “... I didn’t know if I was ready for it.”
It was type 2 diabetes, and Nahomi was just 13 years old.
The hardest part of living with diabetes, Nahomi explains, is knowing that you’re not like other teenagers. “Your life has to be measured … and everything has to be accurate.”
It wasn’t that long ago when the two most common types of diabetes were more clearly delineated. Type 1 occurred in the young, and type 2 in adults.
But those days have changed — and unfortunately, not for the better. Though still generally rare in children, type 2 diabetes is now on the rise in pre-adolescents and teens.
One of the reasons for the rise is the nation’s weight problem. The National Diabetes Education Program, a partnership of the Centers for Disease Control and Prevention and the National Institutes of Health, warns that the increased incidence of type 2 diabetes in children is a “first consequence” of the obesity epidemic among young people.
And this is not good news for children of color.
The SEARCH for Diabetes in Youth Study Group, a population-based study to assess the prevalence of diabetes in youth under the age of 20, found that type 2 diabetes is more common in blacks, Hispanics, American Indians and Asian-American kids. American Indians are particularly hard hit. Gender is also a factor. According to SEARCH, rates are approximately 60 percent higher in females.
One risk factor stands out — a child’s weight. Body mass index (BMI) is a measure of weight in relation to height. The BMI for children is plotted on growth charts and is age- and- gender-specific. “Overweight” is defined as a BMI between the 85th and 94th percentile while “obesity” is a BMI at or above the 95th percentile.
A recent study highlights the high prevalence of children at risk for type 2 diabetes. Funded by the National Institute of Diabetes and Digestive and Kidney Diseases, the HEALTHY study showed that almost half of the participating sixth grade students had a BMI at the 85th percentile or higher. Sixteen percent had abnormally high fasting blood sugars and almost 7 percent had abnormally high insulin levels, both risk factors for progression to type 2 diabetes.
Erinn T. Rhodes, M.D., M.P.H.
Director, Type 2 Diabetes Program
Children’s Hospital Boston
Excessive weight is just one red flag. Genetics also play a significant role. “Children with type 2 diabetes usually have some degree of excess weight,” said Rhodes. “But a family history of type 2 diabetes is a common risk factor as well.”
Distinguishing between type 1 and type 2 diabetes can sometimes be difficult. The distinguishing factor between the two types of diabetes is how the body makes and responds to insulin, which is needed in order to allow cells in the body to use sugar as a source of energy. In type 1 diabetes, the most common form of diabetes found in children, the body is unable to produce insulin. In type 2 diabetes, the body makes an insufficient amount of insulin and becomes resistant to its impact. As a result, too much sugar builds up in the blood, and the cells and organs are deprived of their fuel to function.
Both consequences are potentially dangerous. Over time, too much sugar, for instance, can result in damage to the heart, nerves, eyes and kidneys.
In Nahomi’s case, she needed more insulin to manage her blood sugar and was given three doses a day during her time at the hospital. When she returned home, Nahomi remained on insulin for a year before switching to oral medication twice a day.
“When possible, we try to wean patients off insulin,” said Rhodes.
The hardest part of living with diabetes, Nahomi explains, is knowing that you’re not like other teenagers. “Your life has to be measured,” she said, “and everything has to be accurate.”
It’s hard for her mother as well. “Sometimes she listens to me, sometimes she doesn’t,” Mendez said.
In spite of it all, Nahomi credits her strength and discipline to her mother. “She’s the one who pushes me every day,” she said. “She keeps me on point.”
Parents have to maintain a watchful eye. Often diabetes has no symptoms. But children may notice increased thirst as well as frequent urination and unintended weight loss. Excessive fatigue, blurred vision and frequent infections may result.
Some children may notice areas of darkened skin, that are associated with high levels of insulin, especially in the neck and armpits. High levels of insulin can also be seen in girls with polycystic ovarian syndrome, a hormonal disorder, which may cause infrequent or absent periods, acne and an excessive amount of body hair.
Testing for diabetes among those at risk is important. The American Diabetes Association (ADA) recently updated its criteria for screening for type 2 diabetes in children. A BMI at the 85th percentile or higher and two of the following risk factors — family history of type 2 diabetes in a first or second degree relative, minority race, maternal history of gestational diabetes or signs of insulin resistance — should indicate the need for a screening test.
The ADA recommends that testing should begin at age 10 — or the onset of puberty if earlier than 10 — and should be repeated every three years. If a child is identified to be at risk based on these criteria but does not have diabetes, healthy lifestyle changes may lower the risk for future progression to diabetes.
The disease poses more than just medical problems. Emotional and behavioral issues come with the territory, according to Dr. Julie M. Cappella, a psychologist for the Type 2 Diabetes Program at Children’s Hospital Boston. “It can be very difficult to accept that you are different from other kids your age,” she said.
There’s a wide range of emotional responses including denial, depression and anxiety. Cappella admits that children are often teased about their weight, which adds to the stress. Although compliance with their treatment plan is important to prevent complications, often children fail to check insulin levels, take medication, or exercise and eat right as required. “Motivation is a major factor,” said Cappella. “You have to find out what works for the child and use that as an incentive to get them to take care of themselves.”
Rhodes agrees. “This is a disease that’s often asymptomatic,” she said. “It’s hard to demonstrate consequences.”
Young people often consider themselves invincible. The thought of complications linked to diabetes, like amputation or blindness, flies below the radar. It’s hard for them to imagine that such a fate could befall them.
But Rhodes points out that when kids can actually “see” the impact of food on blood sugar, it is a great learning experience. “It can be powerful,” she said.