Playful and bright, 13-year-old Carlos* loves collecting model cars and playing Nintendo for hours at a time. But last summer, Carlos started complaining about feeling tired, and his parents noticed a waning interest in his hobbies. Normally awake by 8 AM, Carlos started wanting to sleep in longer. He wasn’t interested in playing soccer with his brother, and his mother noticed that the skin around his neck looked unusually dark. His parents began to worry that something more than teenage angst was to blame. They took Carlos to his healthcare provider and received an unexpected diagnosis: Type 2 diabetes.

Unless immediate action is taken, the epidemic of Type 2 in youth promises to be costly in terms of early health complications and healthcare expenditures. Before 1990, only 5% of children or adolescents diagnosed with diabetes were classified as having Type 2 diabetes (previously called Type 2 noninsulin-dependent diabetes or adult-onset diabetes).¹ However, the tide has turned, and while exact statistics on the incidence of Type 2 diabetes in youth are not available, it is estimated that up to 50% of all new cases of diabetes in youth were Type 2 diabetes.² This startling statistic coincides with national data that estimate a tripling in the rate of overweight adolescents in the past 20 years. According to the Centers for Disease Control and Prevention, 15.5% of U.S. youth ages 12 to 19 are overweight.³ More than 9 million U.S. children and adolescents ages 6 to 19 are obese — an increase of 45% in the past 15 years.⁴

Diabetes in youth is considered the “first consequence” of the epidemic of obesity in young people.⁵ Many of the children diagnosed with Type 2 diabetes 10 years ago now are presenting with the sequelae of chronic hyperglycemia and cardiovascular, eye, nerve, and kidney disease.

Nurses’ importance in curbing this epidemic can’t be overstated. Nurses play a vital role in teaching prevention strategies to parents of at-risk youth and helping with early identification and aggressive management of Type 2 diabetes in children and adolescents. In addition, nurses as community advocates and educators can support healthy food choices and daily exercise for children as a national health priority.

Who is at Risk?

As in adults, Type 2 diabetes in children is associated with ethnic background, excess weight, a family history of diabetes, and insulin resistance. Insulin resistance is when muscle, fat, and liver cells resist the insulin molecule on the cell membrane, and inside the cell insulin doesn’t initiate the usual chain of enzymatic reactions. Glucose levels gradually rise, causing hyperglycemia and a clustering of symptoms that indicate insulin resistance. It’s estimated that over 2.⁷ million adolescents in the United States have impaired fasting glucose levels.²

Girls have a higher prevalence of diagnosis than boys, and most new cases of Type 2 in youth occur after age 10 and into middle to late puberty.⁴ The onset of diabetes during puberty coincides with the release of pubertal hormones, which increases resistance to insulin and initiates hyperglycemia.⁶ The prevalence varies based on geographic region and occurs disproportionately in American Indian, African American, Mexican-American, and Asian/Pacific Islander youth.⁴

A connection with severe psychological disturbance and Type 2 diabetes has also been established. In one study, 19% of children with Type 2 diabetes had been diagnosed with neuropsychiatric illness before their diabetes diagnoses. The development of Type 2 diabetes among these children is theorized to be a result of a combination of factors including atypical psychotropic drug therapy with associated weight gain and the development of insulin resistance. Inactivity and poor dietary choices compound the risk factors for these children.⁷

Type 1 vs. Type 2

In the past, a child diagnosed with diabetes was assumed to have Type 1 diabetes. Type 1 still accounts for the majority of new diabetes cases in youth, but unlike Type 2 diabetes, the prevalence of Type 1 diabetes in youth has remained stable. Both Type 1 and Type 2 diabetes are considered chronic diseases that result in hyperglycemia secondary to insulin deficiency. Type 1 diabetes is an autoimmune disease that destroys the beta cells in the pancreas, resulting in complete insulin deficiency.

Children with Type 1 diabetes usually present with recent weight loss, polyuria and polydipsia, and usually are thin. However, as the population becomes increasingly overweight, about one-quarter of children with Type 1 diabetes may be overweight at diagnosis.⁸ Because they are nearly or completely insulin deficient at diagnosis, their bodies can no longer effectively use glucose for fuel. As a result, they use alternate fuels for energy, such as amino acids from muscle and energy from fat, which leads to excess ketones in their blood (diabetic ketoacidosis). They lose tremendous amounts of fluids and electrolytes as their kidneys work overtime to clear excess glucose from the blood (glycosuria). The result is dramatic fluid and weight loss, electrolyte imbalances, ketosis, and acidosis, all of which alert the parent and child to seek medical care. Simple blood tests are available to verify that the patient has Type 1 diabetes, including C-peptide and fasting insulin levels to quantify the amount of endogenous insulin produced. Other tests, including glutamic acid decarboxylase (GAD) and islet cell autoantibodies (ICA), identify autoimmunity against the beta cells of the pancreas.⁸

As with Type 2 diabetes, the onset of Type 1 diabetes most commonly occurs around puberty. With a diagnosis of Type 1 diabetes, the child must immediately begin to receive multiple daily insulin injections to replace the insulin secretion of the now nonfunctional pancreas. The patient and family need intensive and ongoing education and support regarding nutrition therapy, exercise, and daily diabetes self-management.

Type 2 diabetes accounts for up to half of all diagnosed cases of diabetes in youth and adolescents. However, unlike Type 1 diabetes, the prevalence has risen dramatically in the past 10 years.⁵ As with Type 1 diabetes, Type 2 diabetes leads to hyperglycemia, but for different reasons. Type 2 diabetes is not caused by an autoimmune disease, and upon diagnosis, about 50% of the beta cells still produce insulin. Instead of complete beta cell destruction, people with Type 2 diabetes experience a combination of insulin resistance and decreased insulin secretion. With Type 2 diabetes, the pancreas is still producing insulin but not enough to overcome the persistent hyperglycemia.

Emerging evidence also suggests that a multitude of other factors contributes to Type 2 diabetes, including the storage of body fat and regulation of appetite and glucose metabolism. These include hormones and peptides, such as ghrelin, amylin, adiponectin, and GLP-1.⁹

Unlike those with Type 1 diabetes, patients with Type 2 do not usually present urgently with dramatic fluid and weight loss. Instead, they may complain of fatigue, blurry vision, frequent urination, or yeast infections. The patient may have other signs of insulin resistance and Type 2 diabetes, including hypertension, elevated LDL and triglycerides, polycystic ovary syndrome, and acanthosis nigricans. Polycystic ovary syndrome www.nurse.com/CE/CE301-60 (PCOS) causes irregular or absent menses and is associated with increased acne and facial hair (hirsutism) or hair loss. Because acanthosis nigricans www.emedicine.com/derm/topic1.htm occurs in up to 90% of youth with Type 2 diabetes, it is a vital clue in its detection and diagnosis.⁴ Acanthosis nigricans appears as dark, velvety patches of skin (sometimes confused with poor hygiene) that most often occur where the skin bends or rubs together. The most common areas are the neck, axilla, inguinal folds, elbows, and knees. The patient also may have neck skin tags. To verify that the patient has Type 2 diabetes, additional lab tests can verify that beta cell destruction is a not result of an autoimmune process.

It is, however, sometimes difficult to make a definitive clinical diagnosis because Type 2 diabetes in children and adolescents can also have a presentation similar to Type 1 diabetes with ketoacidosis and glucose toxicity.⁴

With Type 2 diabetes, it’s not critical to immediately initiate insulin injections because the pancreas is still producing insulin. The focus of therapy is to decrease insulin resistance through increased physical activity and healthier eating. If these strategies do not lower blood glucose levels, medications, insulin therapy, or both may be needed. As in Type 1 diabetes, young adults with Type 2 and their families need ongoing education and support with an intensive focus on nutrition therapy and increased physical activity.

Diagnosing Diabetes

The glucose threshold to make a diagnosis is the same in Type 1 and Type 2 diabetes. To diagnose diabetes, there must be a confirmed fasting glucose of 126 mg/dL or greater or a random glucose of 200 mg/dL or greater along with the typical symptoms of diabetes.¹⁰ Prediabetes is the diagnosis for patients with fasting glucose levels higher than normal (100 mg/dL to 125 mg/dL) yet lower than the glucose threshold for diabetes.¹⁰ Patients with prediabetes (previously called impaired fasting glucose) are insulin resistant and have a greater risk of developing Type 2 diabetes and heart disease. Patients with prediabetes may prevent diabetes by immediately starting a program of lifestyle changes that includes healthy eating and increased activity.¹¹ Youth with prediabetes need a yearly glucose evaluation to identify conversion to Type 2 diabetes.¹⁰ Parents need detailed instructions to contact their healthcare provider immediately if their child shows signs of Type 2 diabetes. If there is any doubt based on the fasting glucose level that the patient may have Type 2 diabetes, a 75-gm oral glucose tolerance is performed to evaluate two-hour postglucose level. If it is 200 mg/dL or greater, a diagnosis of Type 2 can be made.¹⁰

The American Diabetes Association recommends screening children every two years, starting at age 10 or at onset of puberty if they are overweight (above the 95th percentile for their age and sex) and have two or more high-risk criteria. These high-risk criteria include —

• Family history of Type 2 diabetes in a first- or second-degree relative
• High risk ethnicity: African American, American Indian, Hispanic, Asian/Pacific Islander
• Indicators of insulin resistance: hypertension, dyslipidemia, PCOS, acanthrosis nigricans8

Comorbidities

In addition to being hyperglycemic, most children and adolescents with Type 2 diabetes have other chronic conditions associated with insulin resistance, including hypertension, dyslipidemia, and sleep apnea.^{12(LEVEL C)}

Hyperglycemia: For children with Type 2 diabetes, the goal is to return glucose levels to as near normal as possible. More specific goals are negotiated with the patient and family. Lifestyle changes are tried first, and if unsuccessful, medication therapy is started. The only diabetes medication FDA-approved for children 10 and older is metformin (Glucophage). Sulfonylureas such as glipizide (Glucotrol), glyburide (Micronase, Diabeta, Glynase), and other oral agents also are used although they haven’t been approved. If monotherapy does not bring down glucose levels, combination therapy, insulin therapy, or both may needed.⁶

Hypertension: The goal for systolic and diastolic blood pressure in children with diabetes is less than the 95th percentile for age, sex, and height, according to the American Heart Association.¹³ The first treatment strategies for blood pressure control include weight management, reduced sodium intake, and increased consumption of fruits and vegetables. If this is unsuccessful, blood pressure medications are initiated. Recommended medications include ACE inhibitors, beta-blockers, calcium antagonists, and low-dose diuretics.¹³ If blood pressure control is not achieved on monotherapy, combination therapy is indicated. Blood pressure control is critical because it not only protects the cardiovascular system, but also prevents eye and kidney disease.

Dyslipidemia: All children with elevated glucose levels also require a lipid screening on diagnosis and every two years thereafter. For these children, the goal for the atherogenic LDL cholesterol is less than 100 mg/dL, the protective HDL greater than 35 mg/dL, and triglycerides less than 150 mg/dL.^{14(LEVEL C)} First strategies used to reach this goal include exercise, a lower-fat diet, and weight management. If lifestyle changes do not lower LDL sufficiently within six months, drug therapy including resins (bile acid sequestrants) and statin drugs may be initiated.

Dyslipidemia is an especially troublesome comorbidity among immigrants and minority young people with Type 2 diabetes. One recent study of Mexican-American teenagers revealed that 55.8% had total cholesterol levels above 200 mg/dL, 39.4% had LDL levels greater than 130 mg/dL, 40% had HDL levels below 35 mg/dL, and 65.1% had triglyceride levels above 150 mg/dL. Even when diabetes is well controlled, the lipid profiles do not fall within therapeutic recommendations and often necessitate aggressive drug therapy to reduce future cardiovascular risks.^{15(LEVEL B)}

In another study of 1,366 Mexican adolescents, 66% of 10- to 14-year-olds classified as overweight were positive for the metabolic syndrome. A shocking 85.4% had low HDL levels.^{16(LEVEL B)}

Obstructive sleep apnea: A small percent of children with hyperglycemia also have obstructive sleep apnea,¹⁷ pauses in breathing during sleep that can cause low oxygen levels in the brain and partially awaken the child, causing poor sleep. Signs to look for include loud breathing or snoring at night, daytime sleepiness, headaches upon awakening, need for multiple pillows to raise head during sleep, increased bedwetting, hyperactivity, and poor school performance. If obstructive sleep apnea is suspected, the child would most likely be referred to a pediatric sleep specialist for evaluation and treatment.^{12(LEVEL C)}

Depression

The diagnosis of diabetes can cause grief, anger, and depression for both parent and child. Parents often feel responsible for the diabetes and may grieve for the loss of their “healthy child.” Depression and anger may occur as a result of the changes they will need to make in eating and exercise and the additional chore of self-monitoring blood sugar levels. Social stress can hinder metabolic control, and the anxiety children may have about how friends view them can compound this stress and lead to noncompliance.¹⁸

Upon diagnosis and on an ongoing basis, healthcare providers should include all family members in diabetes self-management education. Nurses and educators can help the child and family set realistic behavior-change goals so they are set up for success. The child and family may benefit from a referral to a support group or a social worker or other counselor to help them adjust. Ongoing assessment of the child and family’s adaptation is important and should include instruction on problem-solving and coping skills.¹³

Lifestyle interventions

The Diabetes Prevention Program, although focused on an adult population, revealed that lifestyle interventions can reduce the risk Type 2 diabetes by 31% to 58%.^{19(LEVEL A)} Two pediatric studies, the STOPP-T2D Prevention Trial and the Treatment Options for Type 2 Diabetes in Adolescents and Youth trial, are under way to determine whether lifestyle interventions can prevent, or at least delay, Type 2 diabetes among children and adolescents.⁴

To increase the chances that a child will change daily habits, family members must act as role models and participate in the new lifestyle plan. Physical activity recommendations include participating at least 60 minutes a day in a moderate to vigorous physical activity that the child enjoys and limiting sedentary time and television viewing to no more than two hours a day.¹²

Two serious barriers to adequate physical activity include the inability of many children to exercise outdoors because of safety concerns and the lack of traditional physical education classes each day.^{20(LEVEL B)} While in many schools academic needs are a higher priority than physical education, one study indicates that even a few minutes of walking built into the school day can have a significantly positive impact for children who are overweight. One pilot program had children walking a mile each day with their teacher. At the end of two school years, the children who walked had decreased their body fat percentages, increased their lean body mass, and when questioned, expressed a preference for physical activity over sedentary activities.²¹

One of the most challenging aspects of diabetes education is changing family eating habits that rely on children home alone choosing their own food or parents selecting unhealthy fast food options because of time constraints. Registered dietitians can help the family develop a realistic meal plan focusing on healthy eating and reduction of high-calorie, high-fat food, with a special focus on eliminating or greatly reducing soft drink consumption.²²

One pilot program to prevent Type 2 diabetes in adolescents showed success in motivating tennagers make positive dietary changes through the use of a Web-based nutrition education program.²³

Successful treatment with diet and exercise is defined as stopping excessive weight gain, maintaining the expected weight gain consistent with a child’s growth curve for sex and height, and achieving near-normal blood glucose levels.⁸ In addition to improving eating habits in the home, there is increased public pressure to improve the quality of food offered in schools and fast-food restaurants.

To evaluate the success of these changes, the parent and child must monitor blood glucose levels regularly. The frequency of testing is based on blood glucose goals and the child and family’s willingness and ability to monitor. When Type 2 diabetes is diagnosed, nurses often have close relationships with the child and their family and can serve as the first-point-of-contact person for reviewing blood sugar control logs.²⁴

Involving school personnel

Providers, nurses, and families need to know that children with diabetes have rights as far as diabetes self-care at school. Children with diabetes are protected against discrimination by the Individuals with Disabilities Education Act of 1991 and the American with Disabilities Act. Federal law requires an individual assessment of the child and accommodations to manage his or her diabetes at school. More specifically, children with diabetes now can keep and carry their diabetes supplies instead of going to the nurse’s office. Trained nurses and school personnel can administer glucagon in an emergency. Parents need to meet with the school nurse to set up a care plan.

Preventing Type 2 in youth

Diabetes is incurable, but it can be managed to reduce complications and promote the healthiest life possible. Studies conducted on adults provide hope that children diagnosed with prediabetes may be able to delay or prevent the diagnosis of diabetes.¹³ The Diabetes Prevention Program, conducted over three years with final results reported in 2001, demonstrated that people with prediabetes can reduce their risk of getting diabetes by 58% through 30 minutes of daily activity, a low-fat diet, and a 5% to 7% body weight loss.¹⁹ To get the message out about preventing diabetes, the government has launched the first-ever national diabetes prevention campaign, “Small Steps, Big Rewards: Prevent Type 2 Diabetes.” (See www.ndep.nih.gov/campaigns/SmallSteps/SmallSteps_overview.htm.)

Nurses have a critical role in the early identification of Type 2 diabetes in children and adolescents. Teaching aimed at parents of at-risk youth can promote prevention. In addition, nurses as advocates and educators can support legislation and social change to improve the quality of food in schools and restaurants and encourage daily physical education in schools.

*Not an actual patient.