Type II diabetes is no longer an adult disease

Minority kids bear a disproportionate burden

Clinicians are deeply concerned about the growing number of children and adolescents being diagnosed with Type II diabetes. In fact, some researchers suggest the Type II diagnosis in children under the age of 18 has increased tenfold in the past five years.

The average Type II diabetic is diagnosed around the age of 50; the thought of children ages 12, 14, and 16 with the disease once called "adult onset diabetes" presents a mind-boggling array of future problems for the young patients and for the health care system.

"When we began to look closely at this, we found it was almost certainly the result of an unbelievable epidemic of obesity in this country," says Kenneth Lee Jones, MD. The pediatric endocrinologist also is professor of pediatrics and chief of the division of pediatric diabetes and endocrinology at the University of California School of Medicine at San Diego (UCSD).

Arlan Rosenbloom, MD, a pediatric endocrinologist and professor emeritus at the University of Florida in Gainesville, echoes Lee’s concern for the increasing numbers of minority children being treated in his clinic.

"It’s probably true for people in their 20s and 30s, too, even though we don’t see them here," he says. "There’s not a sudden peak and a drop off. The average age of onset of Type II diabetes is shifting downward with increasing obesity."

Jones estimates that 10% of all pediatric diabetes is Type II, and he estimates the percentage is far higher in minority populations.

What’s more, he says 21% of the Mexican American children in his UCSD pediatric diabetes clinic have Type II, as compared with only 3% of the non-Hispanic diabetic children. His clinic has seen a tenfold increase in the number of children diagnosed as Type II diabetics in the past five years.

Jones notes that Type II seems to be skyrocketing, not only in Mexican American and Hispanic children, but among Native American, Pacific Islander, Asian Indian, and Japanese children. He says the incidence of Type II diabetes in Japanese children is more than double those diagnosed as Type I (2.80 to 4.61 per 100,000 per year, compared to only 1.2 to 2.1 per 100,000 per year), the form of diabetes more commonly found in children in most societies.

Jones is the first to concede his experience with Mexican American children is due, at least in part, to the large Mexican American population in San Diego.

But the story is much the same in New York, except African American children are bearing the burden.

Children’s obesity is the key

While the Naomi Berrie Diabetes Center of Columbia-Presbyterian Medical Center in New York City sees its share of Hispanic and Native-American children with Type II, the preponderance of the disease is in black children, perhaps simply because of the population distribution in New York, says Robin Goland, MD, co-director of the center.

She says Type II diabetes is being diagnosed in 10% to 20% of the center’s new pediatric patients. But there is a disturbing commonality between what Lee and Goland are seeing. "Virtually every one of the children we have diagnosed as a Type II diabetic is obese," says Goland.

"There’s an interplay between obesity, their environment, and a genetic predisposition to diabetes," she adds.

Those who are watching the progression of this outbreak add it can be traced to poor diet, little or no exercise, a family history of diabetes, and a racial predisposition toward the disease.

The latest data from the National Health and Nutrition Examination Surveys show one in five American children is overweight and the number of obese children has doubled in the past 20 years.

The greatest risk is for poor minority children whose working parents often leave them to eat high-fat meals at fast-food restaurants and who have little access to recreation programs or gyms.

Trend in ethnic groups repeated for children

When the predisposition toward diabetes in blacks, Mexican Americans, and Native Americans is factored in, it’s no surprise that the rise in Type II among children is being seen so much more frequently in those communities.

Diagnosis can be tricky, since Type II diabetes often mimics other diseases in children and distinguishing between Type I and Type II is sometimes difficult, says Jones.

He offers clinicians the following indicators that a child may be suffering from Type II diabetes:

- obesity;

- family history of diabetes;

- acanthosis nigricans (a darkening of the skin at the back of the neck, armpits, and waist — also a sign of colon cancer);

- females with hyperandrogenism, including hirsutism and irregular menses, frequently with polycystic ovaries.

Treatment can be equally difficult because oral agents have not yet been formally approved by the Food and Drug Administration for pediatric use, although they are often prescribed. Clinical trials of metformin for pediatric use are just getting under way.

And compliance and control are difficult to achieve in children, particularly in those who spend a great deal of their time unsupervised, says Goland.

"We do everything we can. We send nutritionists into their homes to look at what’s on the shelves; we even go shopping with them. We involve the families, friends, even the community to help them understand the seriousness of the problem."

The age of onset is not suddenly dipping downward, says Jones. "These are kids who have a predisposition because of family history, genetics, whatever. They might still have developed diabetes, but maybe not until their 40s or even later if they weren’t obese," he explains.

Rosenbloom echoes those concerns and raises yet another fearsome aspect of the disease that may be just around the corner — a wild swing in the number of diabetic complications among young people. "We may be facing an enormous epidemic of complications in the coming years," he says.

Is the age to start dialysis dropping?

Japan is already seeing a "tremendous increase" in end-stage renal disease, or ESRD, among diabetics whose onset was between the ages of 30 and 35. This trend, Rosenbloom says, causes him to speculate that the age at which young diabetic adults may need dialysis may drop to the early 30s or even into the 20s if the current trend in the United States continues.

He notes that under the old model in which a Type II diabetic might be diagnosed at 40 or 50, it might take 20 years or more to get to ESRD, and the patient "might have died of something else before that."

But a person diagnosed with Type II at age 15, 20, or even 30 could reach ESRD at a far younger age.

"This is only the tip of the iceberg in terms of diabetic complications," says Rosenbloom. "It’s just easier to monitor nephropathy because of the need for dialysis." He also predicts that retinopathy, neuropathy, and cardiac complications so commonly associated with diabetes are likely to follow suit.

[Kenneth Lee Jones can be reached at (619) 543-5238, Arlan Rosenbloom can be reached at (352) 334-1393, and Robin Goland can be reached at (212) 304-5492.]