By Bethanne Bradshaw and Marcy Snyder

The Rise of Type 2 Diabetes in Youth

By Bethanne Bradshaw and Marcy Snyder

In 2015, a patient presented to an endocrinology clinic in Houston, Texas with excessive urination, thirst and tested for a high fasting plasma glucose and HbA1c. However, the patient tested negative for type 1 diabetes mellitus. While this may sound like your “bread-and-butter” presentation for type 2 diabetes, here’s the kicker: the patient was only three years old6 with an extensive history of poor family nutritional behaviors and lack of calorie counting contributed. Her weight, height and Boby Mass Index (BMI) were all in the top 5% for her age. As of today, she is the youngest recorded patient in history to be diagnosed with this disease. Unfortunately, children are not immune to the diabetes and obesity epidemics we are seeing in adults today. The medical community knows there are numerous factors contributing to the increasing number of diagnoses: diet, exercise and genetics, but are there socioeconomic factors that we are not addressing? Is there more we can do to protect the most innocent from the harmful and lasting effects of obesity and poor nutrition that plague our nation’s adults? If so, why have we not already started?

Food has always played an essential role in our world. In certain cultures, a fat baby is considered a healthy baby as opposed to the emaciated children that parents may think of when children starve to death or succumb to illness. Most holidays have traditions centered around calorie-rich sweets and treats, and we often reward desired behaviors with a cookie from the cookie jar. In contrast, physical activity is typically not viewed as a gift. Parents praise a calm, sleeping baby and hyperactive children in the classroom are reprimanded. Movement and exercise are only encouraged at very specific times of the day such as re-

cess and physical education class (PE), but even these opportunities are taken away as kids move up through the school system. In fact, poor behavior in PE often results in extra laps around the track as punishment or a certain number of pushups. In less affluent environments, exercise is often unattainable and even unsafe. A child coming home after school in a wealthy neighborhood can safely spend hours biking with friends and walking to a nearby park, while others may come home and have to immediately lock the door.

It is hard to know exactly how many children are living with type 2 diabetes in Texas. The CDC’s only data available concerning type 2 diabetes in children for those ages 10-19 and came from a study that had too few participants extrapolations to be accurate. This is concerning because anecdotally, pediatric endocrinologists in Texas are reporting more and more children younger than age 10 who present with type 2 diabetes.5

What we do know about children in Texas who are diagnosed with type 2 diabetes is they tend to experience more complications from the disease than adults and they experience these complications much earlier in the disease course.4 The TODAY study, led by Dr. Jane Lynch, a pediatric endocrinologist at UT Health San Antonio, showed that 60% of patients diagnosed with type 2 diabetes as children have a diabetes related complication 15 years after diagnosis and just under a third have two or more complications. This study highlighted the need for more research on treatment options of pediatric type 2 diabetes given the severity of the disease. Children under the age of 10 have only two drug options – metformin and insulin, and children over the age of 10 have four drug options – metformin, insulin, liraglutide and exenatide. This pales in comparison to the over 30 drugs that adults have access to.4 While the data on pediatric type 2 diabetes is far from comprehensive, what it shows is that much like adults living with type 2 diabetes, children with the disease are more likely to be from minority racial and ethnic groups. The highest rates of pediatric type 2 diabetes are in Hispanic children and non-Hispanic black children.3

It’s easy to get overwhelmed looking at the magnitude of the problem; however, there are opportunities for our communities to get involved in tackling it. To begin, we cannot fight an enemy we do not know and tracking of pediatric type 2 diabetes is incredibly sparse. We have no estimates of the incidence and prevalence of the disease that are based on Texas populations and we have no data at all on children younger than the age of 10 in any state. Historically, type 2 diabetes in children was a case study and not a statistic, but it seems that this no longer applies. Tracking pediatric patients with type 2 diabetes and reporting that data to a centralized location for analysis would be an excellent first step. Research on treatment options needs to be increased so current and future patients have more medical therapies available for use. Furthermore, many children diagnosed with type 2 diabetes are in their teens and likely have their own opinions about how they could best be supported. “Texas Public Radio” interviewed 14-year-old Abram Estrada in June of 2022 and he described how the Covid pandemic led to him exercising less and eating more.1 Better understanding how these patients want to be supported and what they see holding them back is critical to both preventing and treating this disease effectively. As mentioned previously, type 2 diabetes has social and biological components, so a multifactorial approach that takes into account these parameters is quintessential in preventing further damage caused by a disease no child should ever be diagnosed with.

References 1. Family matters in childhood type 2 diabetes. Texas Standard. https://www.texasstandard.org/stories/family-history-matterschildhood-type-2-diabetes/. Accessed September 19, 2022. 2. Group* TODAYS, Author AffiliationsAddress reprint requests to

Dr. Hirst at the George Washington University Biostatistics Center,

Allen DB, et al. A clinical trial to maintain glycemic control in youth with type 2 diabetes: Nejm. New England Journal of Medicine. https://www.nejm.org/doi/full/10.1056/nejmoa1109333. Published June 14, 2012. Accessed September 19, 2022. 3. National Diabetes Statistics Report. Centers for Disease Control and Prevention. https://www.cdc.gov/diabetes/data/statistics-report/index.html?ACSTrackingID=DM72996&ACSTrackingLabel=New+Report+Shares+Latest+Diabetes+Stats+&deliver yName=DM72996. Published January 18, 2022. Accessed September 16, 2022. 4. Sansom W. Young adults show serious complications from type 2 diabetes. UT Health San Antonio. https://news.uthscsa.edu/ young-adults-show-serious-complications-from-type-2-diabetes/.

Published August 2, 2021. Accessed September 16, 2022. 5. Warren BC. City issues: Health. San Antonio Magazine. https://www.sanantoniomag.com/city-issues-health/. Published

May 1, 2017. Accessed September 16, 2022. 6. Yafi M et al. Abstract 303: A toddler with type 2 diabetes. Presented at: EASD 2015; Sept. 14-18, 2015; Stockholm.

Bethanne Bradshaw and Marcy Snyder are medical students at the Long School of Medicine and are the CoPresidents of the Pediatrics Interest Group.