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Growing Up With Us... © A Newsletter For Those Who Care For CHILDREN Volume 17, Issue 10 TYPE 2 DIABETES IN CHILDREN October 2011 Editor-in-Chief: Mary Myers Dunlap, MAEd, RN BEHAVIORAL OBJECTIVES AFTER READING THIS NEWSLETTER THE LEARNER WILL BE ABLE TO: 1. Compare the pathophysiology of type 1 and type 2 diabetes. 2. Describe five clinical manifestations of type 2 diabetes in childhood, as well as two changeable risk factors. Type 2 diabetes is an epidemic in the United States, affecting 20 million adults and children. According to the American Diabetes Association (ADA), of these, an estimated 6 million Americans are undiagnosed. Type 2 diabetes was previously rare in children – it was previously called adult-onset diabetes, but in the last couple of decades, the most rapid increase in the incidence of this disease is in children. For the first time in human history, type 2 diabetes is now more common than type 1 diabetes in children. Because of epidemic rates of obesity and inactivity in children, type 2 diabetes mellitus is occurring at younger and younger ages. It has been diagnosed in children as young as 2 years of age. However, new cases of type 2 diabetes in children are typically diagnosed after age 10. During this time, the bodies of preadolescents are growing and developing rapidly, placing an additional demand on the pancreas to produce additional insulin. This newsletter will compare the pathophysiology of type 1 versus type 2 diabetes. Pediatric risk factors for type 2 diabetes will be described, which are key for healthcare providers to note during patient assessment. GLUCOSE METABOLISM Normally, after eating, the body’s digestive system breaks down the sugars and starches consumed into glucose, which then travels in the bloodstream to cells throughout the body. Any food or drink containing glucose (or the digestible carbohydrates which contain it, such as sucrose, fructose and starch) causes blood glucose levels to increase significantly. In a person with normal metabolism, the elevated blood glucose level causes the pancreas to release insulin into the blood. Insulin then binds with glucose in the bloodstream and to cell receptors, particularly in tissue, muscles and the liver, opening a portal that allows glucose to enter the cell, where it's transformed into energy. As a result, the blood glucose is maintained at approximately 90 mg/dL. If the body does not produce insulin, as with type 1 diabetes, or enough insulin or the cells ignore the insulin, as with type 2, glucose builds up in the blood instead of going into cells, resulting in hyperglycemia. PATHOPHYSIOLOGY – TYPE 1 VS TYPE 2 In children with type 1 diabetes, the beta cells in the Islets of Langerhans in the pancreas are destroyed, rendering them incapable of producing insulin. Type 1 diabetes occurs when the immune system attacks and destroys the cells of the pancreas that produce insulin. Lifelong insulin replacement is necessary for glucose metabolism. Most children with type 1 diabetes are slender, while the overwhelming majority of children with type 2, are overweight/obese. However, in both instances, this is not always the case. Unlike with type 1 diabetes, in type 2 diabetes, the pancreas secretes insulin, but the body is unable to use insulin. Initially, the cells are said to be insulin resistant, meaning additional insulin must be released to overcome the tissue cells’ resistance and to allow glucose to move into the cells. Eventually, the pancreas wears out from working overtime to produce extra insulin. It gradually becomes unable to produce enough insulin to keep blood sugar levels normal. The length of time before the child actually shows signs of type 2 diabetes is unknown, but many authors agree that insulin resistance is present for several years before type 2 diabetes is diagnosed. Insulin resistance exists when fasting blood sugars (FBS) are > 100mg/dL. Type 2 diabetes is diagnosed if the FBS is higher than 126 mg/dL on two occasions. Generally, children with type 2 diabetes have poor glycemic control (A1C = 10% - 12%). The A1C measures a patient’s average blood glucose control for the past 2 to 3 months. It is determined by measuring the percentage of glycated hemoglobin, or HbA1c, in the blood. With proper glucose metabolism, the A1C is normal, between 4% and 6%. Children with type 2 diabetes often present with glycosuria (glucose in the urine), as well as an increased insulin level, hyperinsulinemia. Although beta cells function normally with type 2 diabetes, the cycle of impaired insulin production and elevated blood glucose is thought to gradually contribute to their destruction, as occurs in type 1 diabetes. This is why many patients with type 2 diabetes, nearly 50%, will require insulin to control their blood sugar levels at some point in the course of their illness. Copyright © 2011 Growing Up With Us, Inc. All rights reserved. Page 1 of 4 CLINICAL MANIFESTATIONS Type 2 diabetes usually develops gradually, often over a period of years, whereas type 1 diabetes typically occurs rapidly, in a matter of weeks. Some children who have type 2 diabetes have no signs or symptoms, while others will have the following manifestations: Polydipsia and polyuria increased thirst and urination may occur. As excess glucose builds up in the child's bloodstream, fluid is pulled from the tissues. This may cause excessive thirst, causing the child to drink, as well as urinate, more than usual. Often nighttime bedwetting, in a previously trained child, is an initial sign of a problem in children, as well as adults. Polyphagia, increased hunger may be evident. Without enough insulin to move glucose into the child's cells, the child's muscles and organs become depleted of energy. This triggers hunger. Weight loss - Despite eating more than usual to relieve hunger, the child may lose weight. Significant weight loss is not a presenting symptom in most children with type 2 diabetes\ Fatigue. When the child's cells are deprived of glucose, he or she may become tired and irritable. Blurred vision. With hyperglycemia, fluid may be pulled from the lenses of the eyes, affecting the child's ability to focus clearly. Slow-healing cuts or frequent infections. Type 2 diabetes affects the child's ability to heal and resist infections. Yeast infections are common. Areas of darkened skin. Areas of darkened skin (acanthosis nigricans) may be a sign of insulin resistance. These dark patches often occur in the armpits or neck. RISK FACTORS Not all factors associated with an increased risk for developing type 2 diabetes can be changed. However, obesity and physical inactivity, which place children at highest risk for developing type 2 diabetes, can be corrected. ETHNICITY: Certain ethnic groups are at increased risk for type 2 diabetes. Compared with a 6% prevalence in Caucasians, the prevalence in African Americans and Asian Americans is estimated to be 10%. Additionally, type 2 diabetes is more common in Hispanic/Latinos and Hawaiian natives and other Pacific Islanders. FAMILY HISTORY: Unlike in Type 1 diabetes, approximately 25-33% of all children with type 2 diabetes patients have family members with type 2 diabetes. However, because families share many lifestyle features, such as eating and exercise habits, it’s unclear whether genetics or environment play the major role. When clusters of diabetes appear within families, genetic factors should be strongly suspected. MATERNAL FACTORS: Maternal obesity during pregnancy is a proven risk factor for offspring to develop obesity and type 2 diabetes later in life. Latest research suggests babies of obese mothers begin to develop insulin resistance in utero. Women with a history of gestational diabetes, as well as their children, are also at greater risk for progressing to type 2 diabetes mellitus later in life. OBESITY, regardless of age, is the greatest risk factor for type 2 diabetes. Fat cells secrete chemicals that directly sabotage the cells' ability to use insulin. Insulin resistance and type 2 diabetes not only stimulate the pancreas to produce excessive insulin, but also stimulate the fat cells to absorb glucose (fat cells are not insulin resistant). The result is an outpouring of free fatty acids (FFA) from the fat cells. The FFA’s get quickly converted into triglycerides in the liver. Triglycerides are simply fats that circulate in the bloodstream. The child’s triglyceride level may also be elevated at the time of diagnosis. Overweight and obesity in children are significant public health problems in the United States. According to the Centers for Disease Control and Prevention (CDC), childhood obesity has more than tripled in the past 30 years. There is a direct correlation between this statistic and the rise in type 2 diabetes in children. In our country, approximately 17% (or 12.5 million) of children and adolescents aged 2 - 19 years are obese. It is estimated that one-third of children born in 2000 will develop obesity-related diabetes. Children's dietary habits have shifted away from healthy foods, such as fruits, vegetables, and whole grains, to fast foods, processed and snack foods, as well as sugary drinks. These foods tend to be high in fat and/or calories and low in many other nutrients. Portion sizes have increased in the American diet. Patterns commonly associated with obesity are eating when not hungry and eating while watching TV. BEING PHYSICALLY INACTIVE: Physical inactivity is directly related to weight gain, as well as the body’s ability to utilize insulin. Exercise and weight loss go hand in hand. If a person is inactive, calories consumed aren’t burned effectively - each 3500 calories consumed above the body’s needs results in one pound of weight gain. Exercise also improves the sensitivity of the insulin receptors. It stimulates the release of growth factors, one of which is insulin-like growth factor 1 (IGF-1), that helps insulin attach to the insulin receptors and that stimulate the production of even more insulin receptors. Many American children live sedentary lifestyles. Children and adolescents, 8 -18 years old, spend an average of 7.5 hours a day using entertainment media, including TV, computers, video games, and cell phones. Eighty-three percent of children from 6 months to 8 years of age view TV or videos an average of 2 hours a day. In type 2 diabetes, either the body does not produce enough insulin or the cells ignore the insulin. Type 2 diabetes predisposes the child to serious health problems, including heart and blood vessel disease, as well as eye, nerve, and kidney damage. An upcoming newsletter will discuss implications for the healthcare provider related to prevention of type 2 diabetes in children, including assessment of risk factors and teaching. Growing Up With Us, Inc. PO Box 481810 • Charlotte, NC • 28269 GUWU Testing Center www.growingupwithus.com/quiztaker/ Phone: (919) 489-1238 Fax: (919) 321-0789 Editor-in-Chief: Mary M. Dunlap MAEd, RN E-mail: [email protected] Website: www.growingupwithus.com Copyright © 2011 Growing Up With Us, Inc. All rights reserved. Page 2 of 4 Name:_____________________________________________________ Date:___________________________________ Employee ID#:____________________________________________ Unit:____________________________________ POPULATION/AGE-SPECIFIC EDUCATION POST TEST GROW ING UP WITH US... A Newsletter for Those Who Care for Children October 2011 Competency: Demonstrates Age-Specific Competency by correctly answering 9 out of 10 questions related to Type 2 Diabetes in Children. TYPE 2 DIABETES IN CHILDREN 1. Today, type 1 diabetes is more common in children than type 2 diabetes. a. True b. False 2. A difference between type 1 and type 2 diabetes is that: a. b. c. d. only type 1 involves the pancreas. with type 2, symptoms occur abruptly. too many beta cells are produced with type 1. insulin resistance occurs in type 2. 3. As opposed to type 1 diabetes, with type 2 diabetes: a. b. c. d. the beta cells in the pancreas are destroyed. the body is unable to use insulin. lifelong insulin replacement is necessary. the pancreas is unable to produce glucose. 4. Which of the following does NOT contribute to type 2 diabetes in children? A/an: a. b. c. d. immune attack destroying all pancreatic beta cells. obesity. increase in insulin resistance. reduced physical activity. 5. Which of the following is least likely to be evident in a newly diagnosed 11 year old with type 2 diabetes? a. b. c. d. Excessive thirst Nightime bed-wetting Fatigue Significant weight loss Copyright © 2011 Growing Up With Us, Inc. All rights reserved. Page 3 of 4 Name:_____________________________________________________ Date:___________________________________ Employee ID#:____________________________________________ Unit:____________________________________ POPULATION/AGE-SPECIFIC EDUCATION POST TEST GROWING UP WITH US... Caring For Children TYPE 2 DIABETES IN CHILDREN 6. A fasting glucose greater than which of the following values would suggest insulin resistance in a child? a. b. c. d. 60 mg/dL 86 mg/dL 100 mg/dL 156 mg/dL 7. With type 2 diabetes and insulin resistance, hyperinsulemia may be present. a. True b. False 8. Which of the following laboratory findings is NOT consistent with a child suspected of having type 2 diabetes in children? a. b. c. d. Glucose in the urine A1C of 4% FBS >126 mg/dL Increased insulin levels 9. Which of the following maternal factors does NOT predispose a child to type 2 diabetes? His or her mother: a. b. c. d. had gestational diabetes while pregnant with the child. was obese when pregnant with the child. has type 2 diabetes. is Caucasian. 10. Fat cells interfere with the body’s ability to use insulin. a. True b. False Copyright © 2011 Growing Up With Us, Inc. All rights reserved. Page 4 of 4