Type 2 diabetes more difficult to treat in children
While type 2 diabetes was virtually nonexistent in children nearly 30 years ago, about 4,000 new cases are now diagnosed nationally every year in those under age 20, and a study suggests the condition is much tougher to manage in teens than adults.
The nationwide study involved 700 overweight children under 17 who were recently diagnosed with type 2 diabetes, including some from the Boston area. Researchers found that 46 percent of the participants treated with the drug metformin - either alone, with intensive weight-loss counseling, or in combination with another medication, rosiglitazone, or Avandia - failed to maintain healthy blood sugar levels and needed to be put on more potent insulin injections within slightly less than a year, on average.
Results were published online Sunday in the New England Journal of Medicine and presented at the Pediatric Academic Societies meeting the same day in Boston.
“Before now, there wasn’t a good knowledge base as to how to approach type 2 diabetes in children,’’ said Dr. Lori Laffel, chief of pediatrics at the Joslin Clinic, who helped conduct the study, which was funded by the National Institute of Diabetes and Digestive and Kidney Diseases. “We wanted to see whether adding another oral drug or intensive weight loss therapy could extend the duration of time before teens needed to switch to insulin.’’
Unfortunately, the research didn’t yield much success: 52 percent of those on metformin alone had to switch to insulin over the course of the four-year study, as well as 47 percent of those who received the drug along with weekly sessions from a weight-loss counselor, and 39 percent on metformin plus Avandia.
“The worrisome treatment outcomes in the study highlight the need for a greater and truly serious focus on the prevention of type 2 diabetes in children,’’ said Dr. David Allen, a professor of pediatrics at the University of Wisconsin School of Medicine and Public Health who wrote an editorial that accompanied the study. “This is about youth immersed from a young age in a sedentary, calorie-laden environment, getting a condition that could have been prevented or, at least, delayed for decades.’’
David Desroches, 22, said McDonald’s had been “his second childhood home’’ before he was diagnosed with type 2 diabetes at 13. “I had to change my mentality away from eating foods only because they tasted good to eating foods that were good for me.’’
The Boston resident participated in the study at Joslin, which started in 2004, but wasn’t told which treatment group he was in; despite exercising regularly and cutting back on fast food, he’s now taking insulin.
Adding a second drug to the treatment regimen in youngsters with type 2 diabetes, the study found, had a substantial enough benefit for the study researchers to conclude that most in the real world would probably benefit from getting a second drug besides metformin to help maintain their blood sugar levels.
For now, that means doctors are left to prescribe daily insulin injections, the only approved drug, besides metformin, in children with type 2 diabetes.
Avandia is unlikely to get approved for children’s use, given its severely curtailed use in the United States after it was associated with an increase in heart attacks, according to Laffel, and its cousin pioglitazone, or Actos, has been linked to bladder tumors. Other classes of diabetes drugs like sulfonylureas would require safety studies in children before they could be approved for use.
With one-third of children overweight or obese, type 2 diabetes is starting to catch up with type 1 diabetes as a leading cause of diabetes in children - afflicting an estimated 25,000 American preteens and teens who are predominantly Hispanics and blacks.
While the body is unable to produce insulin with type 1, with type 2 it fails to respond to the hormone insulin, needed to move blood sugar into cells for storage as energy, and can lead to heart disease, kidney problems, and early death.
Making matters worse, “type 2 diabetes may be somewhat more aggressive in children,’’ said study coauthor Dr. Barbara Linder, a senior adviser at Institute for childhood diabetes research, due to increased insulin resistance caused by hormonal surges during puberty. Added Laffel: “Where we usually see a progression to insulin therapy in adults over five to 10 years, in kids we saw the progression in 11 months.’’
Perhaps the study’s biggest paradox was the failure of exercise and dietary counseling to lead to substantial weight loss large enough to help manage or even reverse the diabetes. “This group lost more weight than the other groups, but it wasn’t enough to change their glucose control,’’ said Linder. “But we still have a lot of data to analyze to better understand what went on in that group.’’
Certain individuals may have lost a lot more weight than others, she added, and understanding the reasons why could help personalize care.
Janellia Jolley may be able to teach a few lessons. The 17-year-old from Dorchester lost more than 100 pounds while participating in the study and rejected a nutritionist’s advice to give up all candy and fast food.
“It was very unrealistic,’’ she said, “so I had to come up with my own plan to fit my lifestyle, like cutting down on my portion sizes.’’
Since Jolley hates the gym, she decided to walk everywhere she could, even walking indoors on snowy days. During summers spent in Florida, she swims laps in a pool. At the moment, her blood sugar levels are in the healthy range. And the best part?
“I’m not taking any medication,’’ she said.