KidsMD Health Topics

Type 2 Diabetes

  • Discovering that your child has diabetes can be upsetting and stressful for the whole family. On these pages, we’ll give you the basic information and skills you’ll need to care for your child, including an understanding of the major forms of the disease—especially type 2 diabetes.

    • Type 2 diabetes is a chronic metabolic disorder resulting from the body's inability to properly use or produce enough insulin. It’s a chronic disease with no known cure.

    • Type 2 diabetes accounts for the majority of cases of diabetes in adults but only rarely presents in children and adolescents.  However, cases of type 2 diabetes in children and adolescents are being diagnosed more frequently particularly among American Indians, African Americans, Hispanic/Latino Americans, and Asian/Pacific Islander Americans.

    • Obesity is an important risk factor for type 2 diabetes.

    • About 25.8 million people of all ages in the United States have diabetes; only about 215,000 people younger than 20 years had diabetes—type 1 or type 2—in the United States in 2010.

    • During 2002–2005, 3,600 youth were newly diagnosed with type 2 diabetes annually.

    • Diabetes is the leading cause of kidney failure, nontraumatic lower-limb amputations, and new cases of blindness among adults in the United States.

    • Diabetes is a major cause of heart disease and stroke.

    • Diabetes is the seventh leading cause of death in the United States. 

    How Children’s Hospital Boston approaches type 2 diabetes
     
    Children’s Type 2 Diabetes Program is a specialty program within our Optimal Weight for Life (OWL) Program. The program focuses on the special needs of patients with—or at risk for—type 2 diabetes and other disorders associated with insulin resistance.

    Children’s has been ranked second in the nation in Diabetes by U.S. News & World Report. We provide comprehensive services for infants, children, adolescents and young adults with all types of diabetes.

    Our services include:

    • diagnostic evaluation
    • management of the acute complications of diabetes
    • long-term management and follow-up care

    Our team understands the physical and emotional challenges diabetes presents for both child and family—and we’re here to help every step of the way.

    Type 2 diabetes: Reviewed by Erinn Rhodes, MD, MPH
    © Children’s Hospital Boston, 2012


    Type 2 Diabetes Program


    Boston Children's Hospital
    300 Longwood Avenue
    Hunnewell Building, Ground Floor
    Boston MA 02115

     617-355-5159

  • Because our research informs our treatment, our diabetes team is known for our innovative treatments and science-driven approach. Children’s Hospital Boston is home to the world’s most extensive pediatric hospital research enterprise, and we partner with elite health care and biotech organizations around the globe. But as specialists in family-centered care, our physicians never forget that your child is precious, and not just a patient.

    In dealing with your child’s diabetes, you probably want to know the basics about what diabetes is, and how type 2 diabetes differs from other forms of the disease.
     

    What are the major forms of diabetes?

    Diabetes (diabetes mellitus) is a lifelong condition that occurs when the body doesn’t make enough insulin, or when the body doesn’t respond properly to the insulin it makes. There are many forms of diabetes mellitus, several of which have undergone name changes as the disease has become better understood.

    • type 2 diabetes: Formerly known as “adult onset” or “non-insulin dependent” diabetes, type 2 diabetes typically occurs in people who are overweight, physically inactive and over age 40, although more and more children are developing type 2 diabetes, possibly because of childhood obesity. Some children need insulin; others can control their diabetes with healthful eating and exercise, or oral medicines (hypoglycemic agents).
       
    • type 1 diabetes: Formerly known as “juvenile” or “insulin-dependent” diabetes,type 1 diabetesis caused by the immune system’s failure to recognize the beta cells as belonging to the body, so it attacks and destroys them. This is why type 1 diabetes is considered an autoimmune disease. Children with type 1 diabetes must take insulin injections every day.
    • maturity onset diabetes of youth (MODY): The main feature of MODY is that diabetes has been diagnosed before the age of 35 years in at least three generations of family members. Doctors have identified many specific genetic defects (mutations) in such families. Some people who have MODY need insulin. Others can effectively manage their condition with diet and/or oral medicines. MODY is increasingly being seen in children.
    • secondary diabetes: This is a form of the disease in which the beta cells are destroyed, not by the body’s immune system, but rather by cystic fibrosis(“secondary to cystic fibrosis”), pancreatic surgery or another cause.

    Note: diabetes insipidus is a very different condition from diabetes mellitus.
     

    What is insulin?
     
    Insulin is the hormone that allows glucose to enter the cells of the body to provide fuel in the form of glucose. Without insulin, glucose builds up in the bloodstream, starving the body’s cells of energy. Some children with type 2 diabetes need insulin injections. Others can manage their condition with diet, exercise and medication.

    • Insulin is a protein hormone made by the beta cells of an area of the pancreas (an organ that lies behind the stomach).
       
    • Insulin is needed to help glucose (sugar) enter the cells of the body.
      • When glucose enters the cells, it can be used to produce energy, or it can be stored in the liver and muscles (as glycogen) for later use.
         
    • Fatty tissue increases the body’s resistance to its own insulin—this is why obesity is the major reason for children or teens to develop type 2 diabetes.
       
    • If the body becomes resistant to its natural insulin, the insulin must be injected so the body can function properly.
       
    • Insulin can’t be taken by mouth because the digestive system would destroy it.
       
    • Human insulin is the kind most commonly used today to treat diabetes. It’s made in special bacteria (by genetic engineering) so that it’s identical to the insulin the human body produces.

    What are the risk factors associated with type 2 diabetes?

    The major risk factors for type 2 diabetes include:

    • being overweight (Body Mass Index [BMI] >= 85th percentile)

    • age (incidence increases with age)

    • family history of type 2 diabetes

    • lack of regular exercise

    • being a member of certain racial and ethnic groups, such as African-Americans, Hispanics, and Native Americans, Asians and Pacific Islanders

    • conditions associated with insulin resistance, such as:

      • abnormal cholesterol
      • high blood pressure

    Children considered to be at risk for type 2 diabetes should be tested periodically, regardless of whether they show signs or symptoms. (For details on diagnosing type 2 diabetes, see Tests.)
     

    What is pre-diabetes?

    Pre-diabetes is a condition in which your child’s blood glucose levels are higher than normal, but not high enough for a diagnosis of diabetes. Having pre-diabetes is a significant risk factor for development of diabetes.
     

    Can my child prevent or delay the onset of type 2 diabetes?

    Your child may be able to prevent or delay type 2 diabetes by eliminating or reducing her risk factors—particularly through weight management and increasing exercise. The Type 2 Diabetes Program at Children’s can work with you and your child to develop a plan for this.

    What are some complications associated with diabetes?

    People with type 2 diabetes can also be at risk for:

    • polycystic ovary syndrome (PCOS)
    • high blood pressure
    • high cholesterol and triglycerides (metabolic syndrome)
    • eventual damage to heart, vessels, nerves, feet skin, eyes, kidneys, gums         

    Although type 2 diabetes can cause many different problems, there are several key complications that if uncontrolled, can cause emergencies.

    • (only for patients on insulin) hypoglycemia (low blood sugar)

      • occurs when blood sugar drops too low—so the body doesn’t have the source of energy it needs to function properly

      • if unchecked, can result in a low blood glucose medical emergency with loss of consciousness or seizure

      • can result from:

        • too high an insulin dose
        • a missed meal or snack
        • more physical activity than usual
        • sickness with vomiting and/or diarrhea
    • common signs and symptoms include shakiness, sweating, weakness, blurry vision, rapid heartbeat

    • If your child has signs or symptoms of hypoglycemia, measure her blood glucose level (if possible) and give her 15 grams of a fast-acting carbohydrate such as fruit juice, hard candy or raisins. If the child has lost consciousness, is having a seizure or is unable to take food or fluids by mouth, administer injectable glucagon (a hormone that raises blood sugar) as directed by your diabetes team, or call for medical assistance from your local emergency services (e.g., 911).


       
    • hyperglycemia (high blood sugar):
      • can be a sign that diabetes is not well controlled
      • caused by build-up of glucose in the bloodstream; possible causes:
        • not enough insulin—glucose can’t enter the body’s cells
        • too much food, wrong kinds of food
        • less physical activity than recommended
        • sickness or stressors
           
      • excessive urination, bedwetting, weight loss, thirst, yeast infections, nausea and vomiting
         
      • If your child has signs or symptoms of hyperglycemia
        • measure her blood glucose level
        • check her urine or blood for for ketones
        • if you should administer a “booster shot” of extra insulin
           
      • Speak with your diabetes team to discuss a management plan for hyperglycemia. Untreated hyperglycemia and the presence of ketones in the urine or blood could signal and medical emergency called diabetic ketoacidosis.
      • Ketoacidosis develops when the body doesn't have enough insulin and breaks down fats instead of sugar to use for energy. Ketones are produced as part of this process; the body cannot release all of the ketones, which then build up in the blood. Ketoacidosis can be life-threatening and needs immediate treatment. Symptoms include shortness of breath, breath that smells fruity, nausea, vomiting and dehydration.
         
    • diabetic ketoacidosis (more common in type 1 diabetes, but can occur in type 2):
      • lack of sugar to the cells of the body cause the body to break down fats, releasing toxins (ketones) into the bloodstream faster than the kidneys can get rid of them
      • Diabetic ketoacidosis is a serious condition that requires immediate medical attention; children become very sick; call your doctor if your child has ketones in her blood or urine.
  • At Boston Children’s Hospital, we know that the first step in treating your child is forming an accurate and complete diagnosis.

    Often, clues are when a child is very thirsty and needs to urinate frequently. Your child’s doctor may also order blood and urine tests including:

    • hemoglobin (A1C) test: indicates average blood sugar level for the past two to three months

    • random blood sugar test

    • fasting blood sugar test: taken after an overnight (eight-hour) fast

    • oral glucose tolerance test: a two-hour test that includes checking blood sugar after your child drinks a prescribed sugar drink

    • check for autoantibodies in the blood less common in type 2 diabetes (vs. type 1)

    • check for the presence of ketones (byproducts from the breakdown of fat in children without enough insulin) in the urine or blood

    Test results may need to be confirmed with a second test on a different day, so it’s possible that your child will have blood drawn more than once. Distinguishing between type 1 and type 2 diabetes in children can sometimes be difficult, and your child's doctor may need to do additional testing or monitor your child for some time before the type of diabetes can be confirmed.

    Is it diabetes?

    Your child will be diagnosed with diabetes if her:

    • blood glucose is 126 mg/dL or higher first thing in the morning before eating or drinking (fast for at least eight hours)
      -or-
    • blood glucose is 200 mg/dL or higher at any time if symptoms of high blood sugar are also present
      -or-
    • blood glucose is 200 mg/dl or higher at two hours during a standard oral glucose tolerance test
      -or-
    • hemoglobin (A1C) test is 6.5 percent or higher 

    Children who are considered to be at risk for type 2 diabetes should be tested periodically, regardless of whether they show signs or symptoms. (For details on risk factors, see Who’s at risk tab.)
     


  • Treating your child's type 2 diabetes

    Treating type 2 diabetes is an ongoing process of management and education that involves not only the child with diabetes, but also family members, and often the condition can be controlled through losing weight, improved nutrition and increased exercise and activity levels.

    Through education, dietary consultation and behavior modification therapy, our team can empower you and your child to successfully manage your child's diabetes. Our registered nutritionists and dietitians will work with you to develop a meal plan based on your child's specific needs. And our diabetes nurse-educators will work with you and your family to increase your knowledge and confidence, so you can best care for your child.

    After stabilizing your child, the goal of treating her for type 2 diabetes will be to keep blood-sugar levels as close to normal as possible. Your child's diabetes team will help you control her blood sugar (glucose) through:

    • meal planning
      • healthful food choices
      • portion control
      • meals at regular intervals
      • reduced snacking
         
    • increased and regular physical activity, which improves the body's insulin acceptance
       
    • weight management
       
    • routine health care, including frequent monitoring of blood-sugar levels

    But sometimes even these steps these aren't enough—and your child's doctor will need to prescribe oral medications and/or insulin.
     

    What’s a healthful diet for kids with type 2 diabetes?

    Proper meal-planning is very important if your child has diabetes, since the type and amount of food your child eats affects her blood sugar levels. If she eats too much, her blood sugar may go up too high. If she skips meals, her blood sugar may go too low. Good blood sugar control requires a balance of food, exercise and medication. Healthy meals include foods that contain the right amounts of carbohydrates, protein and fat. 

    Understanding your child's feelings and condition

    Regardless of your child's age, a diagnosis of diabetes can be devastating. Your child may resist all the lifestyle changes that must come with a diagnosis of type 2 diabetes. She may experience feelings of:

    • vulnerability
    • anger
    • difference from peers (“Why me?”)

    If your child is a teen with diabetes, the normal challenges of the teenage years can even more intense. Teens want to belong, and being different in any way from one's peers can be emotionally stressful. She may:

    • become rebellious and refuse to comply
    • experience denial of the disease
    • become aggressive in reaction to the stress of managing diabetes

    Blood sugar control is especially hard during adolescence. Researchers believe the growth hormone produced during adolescence that stimulates bone and muscle growth may also act as an anti-insulin agent. Blood sugar levels become harder to control—resulting in blood sugar levels that swing from too low to too high. This lack of control over blood sugar levels can be very frustrating for your teen.
     

    Family interdependence is the key

    Although a child who's diagnosed with type 2 diabetes needs supervised medical care, the ideal relationship between parents and child is one of interdependence—with family members working together as a team—especially with a healthful diet—to help the child live normally and happily. With your encouragement and our diabetes team's guidance, your child will learn how to take care of her diabetes—and her increasing independence will improve her self-esteem.
     

    Work together towards prevention

    Your child may be able to prevent or delay type 2 diabetes by eliminating or reducing her risk factors—particularly by losing weight and increasing exercise. The Type 2 Diabetes Program at Children's can work with you and your child to develop a plan for this. Your child's diabetes team is committed to helping you control and manage her type 2 diabetes—so your whole family can thrive.

  • Normalizing blood sugar in type 2 diabetes

    It’s well known that obesity contributes to type 2 diabetes. In previous work with mice, researcher Umut Ozcan, MD, in Children’s Division of Endocrinology, discovered a key link between the two conditions, showing that obesity overloads a structure in the cell that assembles and folds proteins, known as the endoplasmic reticulum (ER). This so-called “ER stress” sparks a chain of events that reduce the body's response to insulin.

    Until now, however, researchers haven't known precisely why this happens. Reporting online in Nature Medicine on March 28, Ozcan and first author Sang Won Park, PhD, of Endocrinology, identify a specific cellular pathway that fails when people become obese. That discovery also suggests an approach to treating diabetes.

    Normally, when stimulated by insulin, a protein fragment called p85 attaches to a protein in the cell called XBP-1. This enables XBP-1 to travel to the cell nucleus, where it turns on genes that help relieve ER stress. But obesity impairs the insulin signaling that normally frees up p85 to interact with XBP-1. Without p85, the researchers showed, XBP-1 becomes stranded and never gets to the nucleus. The result is more ER stress and even less response to insulin, a vicious cycle.

    The good news is that Ozcan’s team was able to break the destructive sequence. “When we increase levels of free p85 in the liver of obese, severely diabetic mice, we see a significant increase in XBP1 activity and, consequently, improved glucose tolerance and reduced blood glucose levels,” says Ozcan. “Our results indicate that a high-fat diet and consequent obesity weaken the ER’s capacity and reduce its normal functioning ability.”

    Ozcan’s group is now looking for practical ways to activate XBP-1 artificially, which could translate into a promising treatment strategy for type 2 diabetes.
     

    Does air pollution contribute to diabetes?

    A link between air quality and diabetes may not seem intuitive, but a national population-based study from the Boston Children’s Hospital Informatics Program finds a strong, consistent correlation—even after adjustment for variables like obesity.

    Researchers led by John Pearson and John Brownstein, PhD, focused on fine particulates 0.1 to 2.5 nanometers in size (known as PM2.5), amain component of haze, smoke and car exhaust. They obtained county-by-county data on PM2.5 pollution from the Environmental Protection Agency (EPA), and crunched it against health data from the Centers for Disease Control and the U.S. Census.

    After adjustment for known diabetes risk factors, including obesity, exercise, geographic latitude, ethnicity and population density, the level of PM2.5 pollution was strongly predictive of diabetes prevalence. Even at concentrations below the EPA safety limit, counties with highest PM2.5 levels had 20 percent more diabetes than counties with the lowest.

    The findings jive with prior laboratory studies. Obese mice exposed to PM2.5 show an increase in insulin resistance, a precursor to diabetes. They also have increased blood markers of inflammation, which may contribute to insulin resistance.“We didn’t have data on individual exposure, so we can’t prove causality, and we can’t know exactly the mechanism of these peoples’ diabetes,” acknowledges Brownstein. “But pollution came across as a significant predictor in all our models.” (Diabetes Care, October.)

    The Type 2 Diabetes Program, part of the Optimal Weight for Life (OWL) Program at Children’s Hospital Boston, is actively involved in developing novel dietary approaches and progressive clinical protocols to treat childhood obesity and type 2 diabetes. We’re also engaged in a variety of studies to improve the treatment and ongoing management of overweight children and adolescents, including those with type 2 diabetes.
     

    Diabetes research initiatives

    Because diabetes requires lifelong management, researchers at Children’s are investigating the earliest stages of the disease in order to understand how it develops and how it can be treated. Areas of research include:

    • how to keep insulin-secreting beta cells alive as a method for treating and preventing type 1 diabetes
    • tempering autoimmune activity in type 1 diabetes
    • genetic factors for obesity, which can lead to type 2 diabetes
    • predictors related to glycemic control
    • the utility of using continuous glucose monitoring in non-diabetic patients in the ICU setting
    • long-term follow-up of diabetic patients
  • Children's patient featured on PBS series about type 2 diabetes

    Minnie Ortiz, a patient of Children’s Hospital Boston’s Optimal Weight for Life Program, was featured on a new PBS Web video series called Living with My Type 2. Here’s her introductory video, where she talks about not even knowing what type 2 diabetes was before she was diagnosed with it and how, after the death of her mother left her without someone to talk with, she writes in her journal to express the concerns she has about her health.

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