Diabetes used to be the illness of our parents and grandparents. Currently, however, the number of children, adolescents and young adults getting diagnosed with diabetes is increasing. As in older adults, there are several types of diabetes in young people. These consist of type 1 and type 2 diabetes mellitus plus a third type defined by single gene mutations-monogenic diabetes.

Type 1 Diabetes
Type 1 diabetes mellitus is the more common type of diabetes in children. It was previously called juvenile diabetes because of the young age of onset. It is an autoimmune disease – meaning the body’s immune system “attacks” the pancreas and the pancreas is thus unable to produce insulin. Most of these children do not have a family history of diabetes. The diagnosis is usually made when symptoms of weight loss, thirst, frequent urination, and fatigue develop over several weeks and high blood sugar is detected on testing.

Sometimes abdominal pain, nausea and vomiting occur in a condition called diabeticketoacidosis (DKA). The treatment of type 1 diabetes is insulin replacement as these children cannot produce any or enough insulin to lower their blood sugar levels. Insulin may be given by frequent multiple-dose injections daily or by continuous insulin pumps. The type and dosage of insulin will be determined by a diabetic specialist working closely with the child’s parents as well as with the guidance of a dietitian and diabetes nurse educator. Balancing the meals with the amount of insulin given will require practice and lots of patience especially in the very young.

Type 2 Diabetes
Type 2 diabetes mellitus is getting increasingly common in adolescents and young adults. Although this is due to both genetic and environmental factors, the latter has been identified as the main cause for this growing prevalence. Both the proliferation of high-density, low-nutrient fast food and drink globally, as well as the increasing sedentary lifestyle that industrialization and computerization has brought about, have resulted in the risingobesity epidemic that parallels the rise in diabetes.

This type of diabetes is either due to one or both of the following: (1) a relative lack of insulin secretion by the pancreas; or (2) insulin resistance – the inability of the body to use insulin properly. Insulin resistance is commonly due to excess weight and fat together with physical inactivity.

The diagnosis of type 2 diabetes in the young may be done by early blood sugar testing of those at risk, such as the overweight or obese child or those children of diabetic parents. Physical signs such as acanthosis nigricans – the darkening or thickening of the skin in the neck/nape or axillary areas—may indicate insulin resistance. Waiting for the classic signs and symptoms of fatigue, polyuria and polydipsia (increased thirst and urination) may delay the diagnosis and treatment of these young patients. Furthermore, prevention may be initiated if the blood sugar levels are still in the prediabetic or borderline stage.

Most children will be treated with a sulfonylurea and/or metformin to lower their blood sugar levels. These have to be coupled with proper diet and exercise. Some may need insulin therapy if the blood sugars are very high or if the diabetes is complicated by an infection. Although most of these type 2 children may not need lifelong insulin treatment (unlike their type 1 counterparts), the possible side effects of chronic intake of oral anti-diabetic medications have to be taken into consideration.

The newer medications have not been approved for use in people below 18 years of age. Hence, the importance of lifestyle modification, dietary changes, and a physically active daily routine cannot be overemphasized. These changes need to be instigated at the earliest age possible. Because of the premature onset, type 2 diabetes in the young should be considered a serious disease in children and adolescents. These young diabetics will be living longer with diabetes and its potential complications –complications that may involve the eyes, nerves, kidneys, heart and brain.

Monogenic diabetes
Types 1 and 2 diabetes are polygenic, meaning multiple gene changes may be involved in increasing the risk of developing diabetes. There is another form of diabetes which results from a single gene mutation (where a transformation or alteration in only 1 gene results in the development of diabetes). This is classified as monogenic diabetes.

Monogenic diabetes accounts for only 1-2% of all diabetes in the young, and this may be inherited or may develop even in the absence of a family history. Types of monogenic diabetes include Permanent or Transient Neonatal Diabetes (where the diabetes is diagnosed before 6 months of age); or Maturity-Onset Diabetes of the Young (MODY). Diagnosis and presentation may be very similar to type 1 or type 2.

Certain tests like antibody testing or C-peptide levels may help differentiate type 1 from monogenic diabetes. But in most cases, genetic testing is the key to specific diagnosis. Because genetic testing is not easily available and affordable, your doctor will only consider doing additional tests if suspicion is high. Some of these features are: (1) Diabetes diagnosed in the very young ( < 6 months of age), (2) Familial diabetes with an affected parent, (3) Mild elevations in the fasting blood sugar levels and (4) other features as part of a genetic syndrome (such as blindness, deafness and certain movement disorders)

Some forms of monogenic diabetes may not require insulin, or even milder forms may not require medication. A correct diagnosis with the proper management should lead to better glucose control and lesser complications, as well as to further testing of other family members at risk.

Approach to All Young Patients with Diabetes
Although the specific type of diabetes is important for the proper medical management of all patients, certain key features apply to the treatment of all young people with diabetes. These include proper diet, exercise and prevention of hypoglycemia. Frequent blood sugar monitoring with a glucose meter will greatly aid in better glycemic control and lessen complications and hospital admissions.

Children should be eating three main meals with 2 or 3 snacks depending on their insulin regimen and their activity levels. It is recommended that the whole family eats the same meals since a healthy diet is the same for everyone, whether or not they have diabetes. Sweets, in moderation and when accompanied by appropriate insulin doses, are not anymore taboo in these children. Exercise is important in all growing children. Since physical activity lowers the blood sugar, an extra snack of bread, juice or carbohydrates may be given before engaging in any sports activity.

Good glucose control is important in order to avoid the complications that may develop as the length of time of diabetes increases. Hypoglycemia or low blood sugar levels also need to be avoided as these episodes can impact on the quality of life of the child. Having a child with diabetes at a young age can cause considerable strain on the parents as well as on the child himself.

Access to a multidisciplinary diabetes team can help in terms of proper diet and appropriate activity levels. Compliance with medications or insulin regimens and appropriate response to both the highs and lows (hyperglycemia and hypoglycemia) will require practice and patience. Monitoring blood sugar levels with a glucose meter and injecting insulin may need to be taught to the child himself as soon as he is at the appropriate age of understanding. Support from both the family, other caregivers, teachers and other staff in school and the diabetes medical team is essential for these children.

Related terms:

• the young

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