Boston Public Health Commission
VOL. 5 • NO. 2
© November 2010
Type 2 diabetes: More children at risk for “adult” disease
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.” Nahomi Mendez (left) 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.”
The Disparities of Diabetes Incidence rates of type 2 diabetes among youth ages 15 to 19, 2002-2003 49.4 40
The rate of type 2 diabetes in teens of color is three to nine times the rate of whites.
17.0 15 10
5.6 5 0 Whites
Asian/ Pacific Islander
RACE AND ETHNICITY
RATES ARE PER 100,000 PERSON-YEARS SOURCE: JAMA JUNE 27, 2007 VOL 297, NO.4
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. 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- andgender-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. According to Dr. Erinn T. Rhodes, the director of the Type 2 Diabetes Program at Children’s Hospital Boston, the absolute number of children with type 2 diabetes in the U.S. remains relatively small. “But the number of children at risk is growing,” she added. 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 Mendez, continued to page 4
RISING OBESITY RATES PARTLY TO BLAME Type 2 diabetes is a huge burden to bear for an adolescent and parent. Try being both. Or being a child not quite fully understanding the seriousness of this condition. Kiaralix Guillenramos, 17, is not your typical high school junior. She says she likes math and English, but she has more pressing responsibilities. First is her new baby boy. But that birth triggered an unexpected consequence. Seven months into her pregnancy, Guillenramos was diagnosed with gestational diabetes. “I never heard of it,” she readily admits. Gestational diabetes occurs for the first time when a woman is pregnant, meaning that diabetes did not exist before pregnancy and may not exist after birth. However, women who have gestational diabetes are more likely to develop type 2 diabetes as they age. Guillenramos’ gestational diabetes disappeared after birth, but she was not completely out of the woods. She was told that she was borderline or high risk, for type 2 diabetes. Blood glucose levels, an indication of diabetes, don’t always take one leap from normal to a full-blown case. Kiaralix, continued to page 4
Kiaralix Guillenramos, 17, was diagnosed with gestational diabetes while pregnant with her son, Jacobi. After his birth, her pre-diabetes eventually progressed to type 2 diabetes. (Ernesto Arroyo photo)
Type 2 Diabetes in children: It’s a family affair for the whole family. Hundreds of great recipes appear on the American Diabetes Association website (www.diabetes.org). You’ll also find Planet D, a portion of the website aimed at children and teens with diabetes, plus tools for balancing meals and snacks, personalizing recipes, and searching out healthy substitutes. Ask your medical team for recipe suggestions, too.
WHAT IS TYPE 2 DIABETES? Diabetes keeps the body from making, or effectively using, the hormone insulin. Our cells rely on a simple sugar called glucose for fuel. Insulin made by the pancreas unlocks cells so that sugar circulating in the blood can slip inside. Often, insulin resistance is the first step toward type 2 diabetes. Type 2 diabetes affects 90 to 95 percent of people with diabetes. In this disorder the pancreas must crank out increasing amounts of insulin just to make normal deliveries of sugar to the cells. When the pancreas can’t keep up, sugar builds up in the blood. A build-up in sugar can lead to all kinds of short- and long-term medical problems. Once, type 2 diabetes affected mainly inactive, overweight, middle-aged adults. “Now we’re seeing a worrisome rise in this illness in children over age 10,” says Dr. Jan Cook, medical director of Blue Cross Blue Shield of Massachusetts. “We know how to turn that around. Eating well, exercising daily and keeping a normal body weight are important treatments for type 2 diabetes. For children with type 2 diabetes, these healthy choices plus medicine, if needed, can help prevent complications.”
SEASON WITH LOVE Eating well helps keep a child’s blood sugar within a healthy range — that is, not too high or too low. All children need carbohydrates and fats to give them enough energy to zip around all day, plus protein to build strong muscles and bones. These nutrients are broken down inside the body into glucose, which fuels activities or winds up stored as body fat. Not all foods are equally healthy. Most kids love sugary drinks, fried foods and high-calorie sweets and snacks. Encouraging your child to eat a balance of healthy carbohydrates, fats and protein (see below) and substitute water for sweet liquids will help keep blood sugar as close to normal as possible.
Carbohydrates High-fiber carbs slow the release of glucose. Eating sweets, refined grains (white flour, white bread), or too many carbs at once causes blood sugar spikes. Healthy choices: • Whole grains (oatmeal, brown rice, whole wheat pasta, bread, crackers or whole grain cereals) • Lentils and dried peas or beans (black-eyed pea, split green peas, black, white or navy beans) • Fresh or frozen vegetables and fruits in rainbow colors
STICK WITH IT It’s hard to be different. Teens, particularly, want to fit in. Try these tips to help your child stick with the plan: • Make it a family effort. Children with diabetes do best when the entire family gets involved. Stock up on healthy foods and downplay chips, sweets, soda and fast foods. Launch weekly family taste tests to try a new vegetable, whole grain or fruit. Cooking simple recipes together can help, too, since children enjoy eating food they’ve prepared.
Protein Satisfies hunger without causing blood sugar spikes. Healthy choices: • Beans or tofu • Fish • Poultry (preferably with skin removed) or lean meat • Peanut butter
Fats Won’t make blood sugar rise, but can prompt weight gain. Healthy choices: • Small portions of liquid oils (olive oil, canola oil) • Small amounts of nuts • Omega-3 fatty acids (in oily fish like salmon, walnuts, flaxseed) • Limit saturated fat (butter, red meat), choose low-fat dairy, avoid fried foods and trans fats (hydrogenated oils)
CREATE A FAMILY PLAN Children with type 2 diabetes have different medical needs and food preferences, so a one-size meal plan doesn’t fit all. Work with your child’s medical team or care management program to decide on the right plan. Fortunately, healthy meals and snacks for children with diabetes are good
• Identify hurdles. Sit down with your child nightly for a week to write down healthy eating hurdles that made it hard for each of you to stick to the plan. Obvious culprits are birthday parties, pizza nights, school lunches, sleepovers, sideline snacks at sports events, fast food cravings and lack of time to shop for or cook healthy foods. • Tackle easy problems first. Brainstorm solutions together. Go slow: Pick one easy problem for each of you to tackle so you won’t feel overwhelmed. Success builds confidence. Next week, tackle another. Example: Decide on a snack your child could take to a sleepover. • Reward success. Let your child choose non-food rewards for sticking to the plan. Extra points for active rewards! Examples: Challenge you to a game of basketball or Wii Sports? Read together? Pass on a detested chore? Extra gaming time? • Try, try again. Don’t let discouragement derail your child. Make a pact to try, try again. Every day offers another chance to succeed.
Inactivity contributes to weight problems and insulin resistance, according to the American Diabetes Association. Both start the ball rolling toward type 2 diabetes. Reverse these unhealthy trends by encouraging children to be active 60 minutes a day: • Walking, running • Skipping rope • Dancing, jumping • Skateboarding, biking • Playing basketball, soccer and other active games
IMPORTANT NOTE: Be aware that exercise can cause dips in blood sugar. If your child has diabetes, talk to your medical team about how to be active safely by checking blood sugar and carefully balancing food, medication and exercise. Adults need to reinforce healthy lifestyles for type 2 diabetic children. Eating right and exercising are vital to managing diabetes and staying healthy. Contact your doctor if you have any questions about your child’s diet or exercise routine.
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Questions & Answers 1. What’s the difference between the more common type 1 diabetes and type 2 diabetes? The pancreas is an organ in the body that produces insulin, which is required by the body to keep blood sugars normal. In type 1 diabetes (what used to be called Shari Nethersole, M.D. juvenile-onset diabetes), Medical Director of Community Health the cells in the pancreas Children’s Hospital Boston that make insulin are damaged by the body’s immune system and are no longer able to make insulin. Therefore people with type 1 diabetes need to take insulin every day. In type 2 diabetes (previously called adult-onset diabetes), the pancreas still produces some insulin but the body does not respond to it normally. This is called “insulin resistance.” The pancreas tries to compensate, but over time, the amount of insulin it is able to produce also decreases. Being overweight is one important cause of insulin resistance. People with type 2 diabetes typically manage their diabetes with diet and lifestyle changes, oral medication and sometimes insulin. 2. If a parent has type 2 diabetes, does that mean that a child will get it at a young age? No. While the risk is definitely higher for someone whose parent has type 2 diabetes, maintaining a healthy weight and good nutrition and exercise habits may reduce the risk of developing the disease. 3. Does eating too much sugar cause type 2 diabetes? Not directly. The problem is that people who eat lots of sugar generally eat too many calories, which can contribute to overweight and obesity — significant risk factors for type 2 diabetes 4. Why does exercise reduce the risk of type 2 diabetes? Exercise does several things. First, it burns calories and reduces body fat, so if you exercise you are less likely to become overweight. Additionally, exercise can improve the body’s sensitivity to insulin, allowing muscles to effectively use sugar as energy. It also enhances the fitness of the body’s cardiovascular and respiratory systems.
November is American Diabetes Month
A closer look 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.
stomach gall bladder
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.
Some children have no symptoms of type 2 diabetes, while others may experience: • Increased thirst • Frequent urination • Increased hunger but loss of weight • Blurred vision • Fatigue • Frequent infections or slow-healing sores • Tingling in hands and feet • High blood pressure or high cholesterol • Areas of darkened skin
pancreas Source: The National Cancer Institute SEER
Is it a dirty neck or a sign of diabetes? One of the signs of type 2 diabetes is increased pigmentation (acanthosis nigricans) in body folds and creases. Common sites are armpits, groin and neck.
5. Do adolescents with type 2 diabetes have to follow a special “diabetes” diet? No. Youth with type 2 diabetes are encouraged to follow a healthful eating plan that will foster a healthy weight, reduce insulin resistance and avoid frequent spikes in blood sugars. Foods that are higher in sugar, such as rich desserts, are not completely off limits, but need to be eaten in small portions and not every day. A “low glycemic load” diet, which includes the “right” carbohydrates, such as whole grains and fruits and vegetables, has been recommended by some as an eating plan that addresses these goals. (For more information on glycemic load, see http://www.mayoclinic.com/health/glycemic-index-diet/MY00770). 6. Can a young person be cured of type 2 diabetes once diagnosed? Unfortunately, there is no cure for type 2 diabetes. However, young people with the disease who improve their diet and exercise habits can see improvements in insulin resistance, and may get to the point where they no longer need to take additional medication to manage their blood sugar. However, they will still need to be careful about their eating and exercise habits for their lifetime. 7. Are high blood pressure and cholesterol more common in youth with type 2 diabetes? Yes. Because virtually all youth with type 2 diabetes are obese, and because we know that people who are overweight and obese have higher rates of high blood pressure and high cholesterol, those problems are definitely more common in type 2 diabetes. 8. Is type 2 diabetes in children and teens preventable? Absolutely yes! It is important to instill good eating and exercise habits in children from the time they are born. If children and adolescents can maintain a healthy weight, eat foods that are high in whole grains and fiber, eat many fruits and vegetables, avoid sodas and other sugar-sweetened beverages, and stay physically active on a daily basis, they can reduce their risk of developing type 2 diabetes. 9. Does insulin resistance — the inability to effectively use insulin — always result in diabetes? No … but insulin resistance is a warning sign. If an obese adolescent with insulin resistance gets his or her weight down to a healthy level through eating a more healthful diet and gradual increase in physical activity, it is possible to reduce the chance for developing type 2 diabetes.
The information presented in BE HEALTHY is for educational purposes only, and is not intended to take the place of consultation with your private physician. We recommend that you take advantage of screenings appropriate to your age, sex, and risk factors and make timely visits to your primary care physician.
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Mendez, continued from page 1 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
Erinn T. Rhodes, M.D., M.P.H. Director, Type 2 Diabetes Program Children’s Hospital Boston
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
NEED MORE INFORMATION? • Take Charge of Your Health! A Teenager’s Guide to Better Health 877-946-4627 • National Diabetes Education Program 888-693-NDEP • MyPyramid.gov • American Diabetes Association Planet D 800-342-2383 www.diabetes.org/planetD 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.
IS YOUR CHILD AT RISK FOR TYPE 2 DIABETES? ASK YOURSELF THESE QUESTIONS 1. Is your child overweight or obese? Go to http://apps.nccd.cdc.gov/dnpabmi to calculate the BMI for age and gender.
2. Is there a family history — parent, sibling, grandparent, aunt or uncle — of type 2 diabetes? 3. Did the mother have gestational diabetes during her pregnancy with the child? 4. Is your child African American, Latino, Asian American, Pacific Islander or Native American? 5. Are there symptoms of insulin resistance, such as dark patches of skin and high blood pressure or cholesterol? If the BMI is at or above the 85th percentile and you answered ”yes” to at least two of questions 2 to 5, your child may be at risk. Talk to the pediatrician about screening for type 2 diabetes. The American Diabetes Association recommends testing for type 2 diabetes in asymptomatic children beginning at age 10 or at puberty if it occurs earlier than 10. Testing should be repeated every three years.
Which tests and what do they mean? The doctor may order one or more of the following: Test
Fasting blood glucose (mg/dl)
Less than 100
100 to 125
126 or greater
Oral glucose tolerance (mg/dl)
Less than 140
140 to 199
200 or greater
Less than 5.7
5.7 to 6.4
6.5 or greater
Source: American Diabetes Association
Typically, diagnosis is confirmed if test results indicate diabetes on two different days.
NOT A NATURAL PROGRESSION Pre-diabetes is not the initial phase of diabetes. It is a warning. A 3-pronged approach to prevent or delay type 2 diabetes — at any age
WATCH YOUR WEIGHT
Kiaralix, continued from page 1
Sometimes there’s a warning — an intermediate stage called pre-diabetes or impaired glucose tolerance. That means that the level of sugar in the blood is higher than normal — but not high enough to be labeled diabetes. If the blood sugar levels continue to rise, then the diagnosis may progress to diabetes. The aim of any intervention is to prevent the progression of borderline cases. Such is the case with Deidre Dyette and her 12-year-old daughter. Diabetes runs in the family, and race and weight are contributing factors. Her daughter has gained as much as 30 pounds a year, raising her BMI to the 95th percentile. A blood test during her last physical diagnosed the prediabetes. And a blood pressure test found pre-hypertension, meaning a blood pressure also at the border between normal and abnormally high. The seriousness of the situation hasn’t sunk in yet for Dyette’s daughter. For her part, Dyette is taking an honest look at herself as well. The apple does not fall far from the tree, she reasons. She too also has borderline hypertension and diabetes and carries a bit more weight than she should. She knows it’s time to do something. She and her daughter are in this together, but she admits it’s a struggle. They both see a nutritionist. She acknowledges that she has to change some of her habits that affect her daughter. “I fry a lot,” she said. “But I try to bake or roast more now.” Her schedule and finances add to the problem. “We do
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fast foods a lot,” she admitted. “You can get a burger for a dollar. It’s sort of my fault. I need to reinforce good habits.” Dyette is right about one thing — it’s extremely difficult to change habits. Guillenramos agrees. Her period of pre-diabetes was short-lived. She was soon diagnosed with type 2 diabetes, which did not completely surprise her. Diabetes runs in her family, and her weight added another risk. She readily admits living with the disease — especially at such a young age — is hard. She takes medicine twice a day — after breakfast and after dinner. She knows she’s supposed to watch what she eats, and has visited a nutritionist. “They tell you what to do,” she says. “But I’m not used to it [food recommendations].” She says she likes her soda and juice — both sources of sugar. She has managed to switch to diet soda, but has not yet tackled her penchant for juice. “I drink it three times a day,” she said. And 2 percent milk? “I don’t think so,” she quips. “I’ve tried it, but it just doesn’t taste right.” She admits needing a little more work on whole grains as well. “I like white rice,” she explains. She has made progress on portion sizes. She says she loves meat and beans — lots of it. Fortunately, she can still eat both — just in smaller amounts. She also has managed to incorporate some exercise into her routine. She walks her baby in a stroller for about 20
minutes three times a week. The pin pricks to check her glucose levels are another story. She checks three times a day. “You wouldn’t want to do it,” she said. I’m still scared of it.” The most difficult part for Guillenramos is taking care of her diabetes and taking care of her baby at the same time. She gets up before 6 a.m. to be in class at 7:30. In that short span of time, she needs to check her glucose, eat, take her medicine, get her baby ready for day care and get herself ready for school. She cannot skip one step. “You have to do things different from when you were not sick,” she said. But Guillenramos still has her eye on her future. “I want to be a medical assistant,” she said. Dyette says she too has made progress. She makes more salads and eats more yogurt. She buys fresh fruits and vegetables, substituted sweetened cereal with unsweetened and has even acquired a taste for light mayonnaise. Her daughter is not as gung-ho. “She doesn’t think she has a weight problem,” said Dyette. “She does not understand why we have to keep going to the nutritionist.” But Dyette is not backing down. She is enrolling her daughter in a fitness center and hopes her desire for pretty new clothes will be an incentive. “She’s a pre-teen now,” said Dyette. She sees clothes that she likes, but her mother warns “you can’t fit into that.”
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