San Diego Dr. Kenneth Jones, a pediatric endocrinologist with UCSD, is concerned about the rise in Type II or "adult" diabetes in young people. "The age limit is moving down. Initially, it was thought to be a disease of the older population, and it still is, in large part. But it's now moving down in age groups. The youngest patient who we've seen in our particular practice is five. When I was in basic pediatric training a couple of decades ago, we were told that this particular disease didn't exist in children. In the past decade, we've found it more and more frequently."
Once thought to exist in only two forms, diabetes is now recognized as a more diverse disease. "Traditionally, the lay public talks about 'juvenile' diabetes and 'adult' diabetes. Those were considered the only two forms. Now, we know there are probably pretty close to 40 or 50 forms of diabetes, all of which have subtle differences, in terms of their causes. They break down primarily into three categories: one is a deficiency of insulin, the biggest chunk of that is represented by what used to be called 'juvenile' or 'childhood onset' or 'insulin dependent' diabetes. That now is categorized as Type I diabetes. It's a destruction of the insulin-producing cells in the pancreas by an autoimmune process. The immune system, which usually protects us from foreign pathogens, like bacteria, viruses, et cetera, is short-circuited in a way, and we begin to attack tissues in our own body. In diabetes, it destroys insulin-producing cells. That form of diabetes attacks primarily the young, though it hits some adults as well, and it needs to be treated with insulin therapy. The only way we treat it now is with injections, although there are forms of inhaled insulin which are now being tested
"Type II diabetes characterizes the other forms of diabetes I mentioned. It begins as a resistance to insulin rather than as a deficiency. Point of fact, most people, when they begin to get symptoms of Type II diabetes, present clinically in very similar ways [to Type I], but this is because their bodies are very resistant to insulin and they actually make it in excess. So if we were to measure insulin in the blood of someone with Type II diabetes, it would actually be higher than it would be in a normal individual. Then Type II diabetes actually progresses into this third form, where there is not only insulin resistance, but an increasing deficiency of insulin as well. The three large categories are insulin deficiency, insulin resistance and a combination thereof. Most forms of diabetes, for different reasons, fit into those categories in terms of physiology.
"Insulin is critically important in getting glucose from the food we eat into the cells so it can be utilized. If there is no insulin, glucose cannot get out of the blood into the cells and be utilized. What happens as a result of that is we starve. The glucose that accumulates is excreted in urine, carries water, and we get into the thirst and excessive urination that characterizes diabetes."
While the rise in Type II diabetes is a worldwide phenomenon, Jones says it is particularly bad in the U.S. The five pediatric endocrinologists in his group have 500 patients, of which 50 to 75 are Type II patients.
"Type II diabetes...is worse in the U.S. than it is in most of the world. Probably a major contributor to this is our increasing obesity. Obesity makes us even more resistant to insulin. This varies with ethnic groups and different races and sometimes individuals. Some of those populations where the disease tends to be more prevalent are people of Mexican origin, Native Americans, and Americans of African heritage. It can account for up to 30 or more percent of the new diagnoses of diabetes in those particular populations in adolescents. But our increasing obesity is enough to push us over the edge. It is certainly increasing in the adult population, but it's also increasing enormously in the child and adolescent population. One of the reasons that this has gotten so much publicity is not because it is enormously important to children, but because it had been previously thought that it didn't occur in children.
"We are a much more sedentary population than we were in the past. Kids spend much more time not only watching television, but sitting at computers; homework takes longer. Many schools have had to eliminate physical education programs. We don't walk anyplace anymore, we ride. And we don't ride bicycles, we ride in cars. In addition, our general caloric intake is up; not only in terms of the amounts we eat, but also in terms of the fat content, which has more than twice as many calories per equivalent weight as carbohydrates or protein."
If the marketing is responsible for the prevalence of the Big Gulp culture, its effects are particularly felt by poorer populations. "If you see food or drinks advertised on television, the message isn't about how good it is, but about how big it is. The kind of food available to young people at school has come under lots of criticism, not only from the medical community, but the nutrition community too. I've spoken at a number of conferences, and the nurses and health-care providers on these reservations and in the school systems have trouble getting diet soft drinks and water into the soft-drink machines. There are objections and resistance from a number of sources. If you look at some of the attempts to get some of the fast-food purveyors out of the school system, the schools will say, 'We've come to rely on them as sources of revenue.' It's insinuated itself into our lives in an overwhelming fashion."
Another local family practice physician, who spoke on condition of anonymity, said that treating diabetes in teenage girls can be especially problematic, as they often use it the same way they use eating disorders: as a weight-loss tool. "They think that being out of control will help them lose weight, and it actually does. One of the out-of-control symptoms is that the blood sugar doesn't go into the cells, and it gets urinated out -- they'll pee night and day. They end up actually losing weight, but their sugar gets out of control, and they get very sick and end up in the hospital. It's extremely dangerous."
Helen, now 22, was 16 years old when she was diagnosed with diabetes. The diagnosis was accidental. "I broke my arm, and they had to operate on me to set my arm with pins. In my pre-op workups, they took blood and urine samples that showed I was diabetic. I didn't find out until about two weeks after the surgery. My blood sugar was over 400 after I hadn't eaten anything for a while." (A normal blood-sugar level is between 80 and 120.)
As is the case with many teenagers, Helen's physicians found mixed indications that made them unsure whether she had Type I or Type II diabetes. Overweight at the time of her diagnosis, her family doctor originally prescribed an oral medication. "The orthopedic doctor told me to see my primary-care doctor about it. He put me on pills -- I don't remember the name of it, but after a couple of months they couldn't control it, so he sent me to a specialist. He kept me on the pills for a while, until I ended up in the hospital again. I've been on insulin ever since."
Living with diabetes is a burden for anyone, but for Helen, learning that she was diabetic at 16 was a big letdown. "I wasn't too happy about it. It scared me and overwhelmed me, to think I was going to have this for the rest of my life. I have to test my blood four times a day. Now I'm used to it. It's like a part of my life now. When I was on the pills, it was out of whack, but now I'm doing a bit better. I don't eat as much as I used to, and there's no more sweets. Sometimes it's tough to watch my friends eat junk food, because I'm the only diabetic. I wasn't really much of an ice cream person before, so it's not too hard."