Type 2 diabetes alarming in kids
SAN ANTONIO — Since he was 9 years old, Joseph Leal has dealt with the steady progression of his Type 2 diabetes.
Once or twice a year, Leal, now 21, is hospitalized for infected skin abscesses. An eye exam last year revealed diabetic retinopathy, an eye disease caused by damaged blood vessels in the retina. In March, doctors amputated a portion of his ring finger, after a boil turned gangrenous.
Within the last few weeks, Leal has also watched as his mother, who is blind in one eye from diabetes, started dialysis and suffered a heart attack.
“It is terrible,” Leal said. “I see what my mom goes through, and I can’t imagine going through the same thing.”
Leal is part of a study that looked not only at treatment options for children with Type 2 diabetes but also the effects of the disease over the years as they reached adulthood.
The long-term damage was alarming, researchers found.
Type 2 diabetes develops when a person’s body becomes resistant to insulin, hampering its ability to control sugar in the bloodstream. That type of diabetes is usually associated with adults,
but it emerged in children several decades ago. The causes aren’t entirely known, but the risk factors include a poor diet, inactivity and other lifestyle choices. Type 1 diabetes is different — the immune disorder is usually inherited.
Starting in 2004, researchers began to track hundreds of children with Type 2 diabetes across the country, hoping to learn how to best treat them. Soon after his diagnosis, Leal was among several dozen San Antonians who enrolled in the long-term study, which measured how well the children responded to different combinations of medication, diabetes education programs and lifestyle modifications.
After the first phase of the study ended in 2011, researchers continued to follow about three-quarters of the participants, including Leal, observing them as they became adults
Of the 517 people in the observational follow-up research, which will conclude this year, five have died from complications related to their diabetes. One, a 20-something participant on dialysis, died this month of heart failure, sepsis and kidney failure.
The patients, now 25 on average, have suffered from earlier and more advanced complications than expected, including kidney and eye disease, high blood pressure, heart problems and early signs of nerve damage. As a group, they had worse outcomes compared to children with Type 1 diabetes and adults with Type 2 who had lived with the disease for the same amount of time.
And young women who began to have children experienced high rates of complications with their pregnancies. Nearly half of the women whose pregnancy outcomes were known had a miscarriage, stillbirth or pre-term birth.
Taken together, the results indicate that for a significant portion of children with Type 2 diabetes, the existing treatments are woefully inadequate, said Dr. Jane Lynch, a pediatric diabetes specialist with UT Health San Antonio who has worked on the study for almost its entire duration. The full results of the research will be published later this year.
“I would argue standard of care sucks,” said Lynch, a study co-author who presented the findings earlier this month at an annual conference hosted by the American Diabetes Association. “We’re publishing a study to say, wow, this is a super scary disease and we’ve got to figure out a way to be more aggressive in our therapy early on to prevent what we’re seeing in this cohort.”
Disease advances
The results have particular resonance in San Antonio, where more than 14 percent of adults have been diagnosed with diabetes. Diabetes jumped 44 percent among Texans over the course of a decade, according to a 2017 report by the Texas Diabetes Council.
During the first phase of the study, nearly 700 Type 2 diabetic children under 15 were randomly assigned to three groups, which determined the type of treatment they would receive. Some participants were prescribed the diabetes medication metformin. Others received metformin and rosiglitazone, which boosts the effectiveness of a person’s insulin, along with education about managing the disease. The last group was given metformin and undertook an intensive lifestyle
modification program.
During that period, the transportation and health care costs associated with the children’s diabetes and related conditions were paid for by researchers. The participants also had support from at least one family member and had proven their ability to be compliant with the program.
“These were the kids who had every advantage to do well with their Type 2 diabetes,” Lynch said.
Yet the metformin therapy alone, a standard treatment for diabetes and the only drug approved for Type 2 diabetic children, failed to control blood glucose in half of the participants. Adults typically take that medication for around a decade, with slower disease progression.
Ultimately, the research found that the group that took metformin with rosiglitazone was most successful in controlling their blood sugar, but the results were not clinically significant, Lynch said.
As the study moved into the observational phase, many patients continued to fare poorly.
Even with so many resources at their disposal, many participants continued to gain weight or needed insulin. Half tested for abnormal cholesterol levels, and close to two-thirds developed high blood pressure. A third showed early signs of nerve disease, and about 40 percent had started developing kidney disease. During more recent visits, eye disease was observed in close to half of participants.
In San Antonio, 45 children enrolled in the initial study and 26 participated in the observational phase. They were treated at the Texas Diabetes Institute, which operates as a partnership between UT Health San Antonio and University Health System.
Alexis Franklin, who enrolled in the study in San Antonio when she was 11 and was in the dual drug group, said she “freaked out” when she was first diagnosed — so much so that for a period she was afraid to eat, lest she make things worse.
As a child, the 23-yearold would occasionally miss a dose because of school, but it wasn’t until a year or two ago that she grew sick after she stopped taking her medicine. She was sent to the hospital with high blood sugar, after which she recommitted to taking her medicine for diabetes, high blood pressure and cholesterol.
Leal has learned the same lesson about managing his diabetes.
“You just got to stay on top of it, make that your No. 1 priority,” he said.
‘Very ugly perfect storm’
Even participants who have avoided major complications have faced other hurdles.
Richard Zarate, 24, said the research “kind of saved my life.” He used to drink large amounts of soda but said he adopted healthier habits after enrolling in the study at age 13.
But once the medication portion of the study ended, Zarate found himself uninsured. Unable to afford the cost to purchase his medicine and supplies out of pocket, he went a year and a half without taking any medication. Eventually, his family started crossing the border into Mexico to purchase insulin, needles and metformin at a lower cost.
Zarate is now insured through CareLink, a UHS program that provides financial assistance to uninsured Bexar County residents.
Many of the people who participated in the research were born to mothers who had gestational diabetes during their pregnancies, which can cause changes in the kidneys, gastrointestinal tract and even the DNA of a fetus, Lynch said. Factors such as socioeconomic status may combine with genetic factors that predispose them to diabetes to create “a perfect storm,” she said — “a very ugly perfect storm.”
The problems have the potential to carry over into yet another generation. Many women in the study who conceived experienced “disturbing” problems with their pregnancies, Lynch said, including late-term stillbirths and congenital abnormalities. The complications were “disproportionate to any comparable group of young women,” she added.
When presented with the pregnancy data, the National Institutes of Health, which funded the study, grew concerned. Its safety board convened a meeting to determine whether it was safe to continue the research, Lynch said. Ultimately, the work was allowed to move forward after researchers argued they weren’t causing the outcomes and were “the messengers on this,” she said.
When participant Amelia Quiroga, 30, became pregnant with her first child almost a decade ago, her doctors treated the pregnancy as high risk due to her diabetes. Quiroga, who has been diabetic for 15 years, came in for more frequent visits and was instructed to be strict about her blood sugar and glucose levels.
Both of Quiroga’s children were born at largerthan-average weights due to her diabetes — her second child was 10 pounds, 11 ounces at birth. Both were also delivered preterm by Caesarean section, although her son was delivered early due to other complications, she said.
The eating habits of Quiroga’s children, now 2 and 8, are closely watched by their mother. She has already lost both sets of grandparents to the disease, and three of her five siblings are also diabetics.
“I don’t want what happened to me to happen to them,” Quiroga said.