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The weight of obesity: Public health ponders future of children with diabetes

Adult-onset diabetes is striking patients who are barely teenagers, raising questions if severe diabetic complications will develop in patients at younger ages as well. Part 2 of a 3-part series.

By Victoria Stagg Elliott, amednews staff. Oct. 13, 2003.

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Physicians and public health officials are issuing dire warnings about what could become of the children now developing type 2 diabetes, previously considered a disease of adulthood. As its incidence rate among young people continues to increase, so do troubling forecasts of the likely complications -- the heart attacks, strokes, kidney failures, amputations and blindness -- that would strike these people just as they reach the prime of life.

"Diabetes wears your body out," said Mary Kay Sones, a spokeswoman for the Centers for Disease Control and Prevention. "The longer you have it, the more likely you are to have complications."

About 10 years ago, physicians began noticing an increase in type 2 among adolescents and children. They linked it to the alarming rate of youth overweight and obesity. And, although exact CDC statistics will not be available until next year, early data and anecdotal evidence suggest that the numbers will be high.

"We've been seeing increases for several years," said Larry Fox, MD, medical director of the Northeast Florida Pediatric Diabetes Center in Jacksonville. "There are more now than last year and more last year than the year before."

Addressing the root cause of this phenomenon -- obesity -- is one critical public health dilemma. But a separate pressing question now has to do with preventing the downstream complications in the young people who already have type 2 diabetes. Most type 2 diabetics do not confront these difficulties until at least 15 years after the disease hits. This leads experts to predict a dire future for this new generation of diabetics.

A paper at last year's American Diabetes Assn. scientific session examined outcomes in a group of 51 Canadian patients between the ages 18 and 33 who had been diagnosed with type 2 before reaching age 17. The findings: Seven were dead by age 30, three were on dialysis, one was blind and another had a toe amputated.

Granted, these figures provide only a snapshot. And specifics on how the age of onset affects the disease's course are extremely limited. This is an area on which both the CDC and the National Institutes of Health are focused. Still, existing data from the Pima Indians, an ethnic group long bedeviled by high rates of early-onset type 2 diabetes, suggest that it is the disease's duration that contributes to the likelihood of complications. Therefore, most experts suspect that someone who has the disease for 20 years is very likely to have a similar health condition whether they develop it at 10 or 50.

The difference is the stage of life during which these problems occur. Health expectations are very different at age 30, when a person may be starting a family or in the middle of a career, than at age 70, when a person is likely to be retired and their children are probably grown.

"I don't see any reason to believe that adolescents who are getting type 2 aren't going to be subject to complications just the same way their adult counterparts are," said Andrew Muir, MD, a pediatric endocrinologist and an associate professor at the Medical College of Georgia in Augusta. "That worries me because now you've got someone in their prime. They've a few young kids and they've got a job, and all of a sudden they're blind or they've got renal failure and they're no longer productive when they're family is depending on them most. This is a very scary proposition."

Research supports this concern.

A study in a February 2002 issue of the CDC's Morbidity and Mortality Weekly Report found that women who were diabetic -- either type 1 or type 2 -- were twice as likely than non-diabetic women to be earning less than $25,000 per year and twice as likely to have not finished high school.

Complicated compliance

But doctors hope that if patients make lifestyle modifications and take medication, most adverse events can be avoided. That likelihood, again, is a scenario complicated by age. Doctors say it's easier to convince a 50-year-old to make changes and take their meds. A 10-year-old, particularly as he or she approaches adolescence, may be a different story.

"We have one young woman whose mother offers to go walk with her, help her with food and make sure she takes her medicine," said Paula Butler, MD, chief of endocrinology at Mount Sinai Hospital in Chicago. "But she sees it as her parents trying to control her or her parents not letting her do what she wants to do. Her mother was sitting in the office in tears. It's very frustrating."

While this mother is trying to aid her daughter, many doctors report that parents can sometimes be more of a hindrance than a help. Families frequently rally around a young patient with type 1, helping with the constant monitoring and insulin shots required to prevent rapid, dire consequences. Type 2 requires lifestyle changes that other family members also might need to make. Symptoms frequently don't show up for years, leading some patients and their families to be more cavalier.

"Parents are often not very good role models, and they themselves could benefit from some lifestyle changes," Dr. Fox said. "Most of them already have type 2 diabetes as well."

The future for these children looks grim, although many experts hold out hope for better medical treatments that may make the future brighter.

"Diabetes care is changing, so you never know," said Jonathan Krakoff, MD, medical director of the NIH research clinic in Sacaton, Ariz. He has researched youth-onset diabetes in American Indians.

"The medications available now weren't available 10 years ago, so I think there's still reason to be hopeful, but for some kids it's still a very concerning outlook," he said.

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