Dr Kuben Pilay is a paediatric endocrinologist in private practice at Westville Hospital, Durban.
In the last 20-30 years there have been changes in the world of diabetes.
Firstly, there has been a rapid increase in the number of people with diabetes. It is recognized that more adults are developing type 2 diabetes across the world. It has also become clear that the number of children who are developing diabetes is increasing.
Twenty years ago, there was a clear distinction between the types of diabetes. Type 1 diabetes developed early in life, affected people required insulin from diagnosis, they were usually thin and often had ketones when diagnosed.
Type 2 diabetes occurred after 45 years of age, usually in overweight/obese adults, people were usually asymptomatic and they could be treated with life style change, weight control and tablets.
In the last 20 years, the types of diabetes in child, adolescents and young adults have changed. Now, we can recognize more types of diabetes in these young people. While the majority of young people in South Africa still have type 1 diabetes, we now recognize that they may also get type 2 diabetes, neonatal diabetes (in children younger than 6 months), cystic-fibrosis related diabetes and range of rare types of diabetes. It is also becoming more difficult to determine what type of diabetes children have.
Youth with type 1 diabetes are more often overweight and those who may have type 2 diabetes may be unwell with ketones and are occasionally not very overweight. Many affected youth now have features of both type 1 and type 2 diabetes. This inability to differentiate the types of diabetes has created ‘new terminology including ‘type 1.5 diabetes’, ‘double diabetes’ and ‘even triple diabetes’.
The increase in type 2 diabetes in both youth and adults is closely associated with the increase in the rates of obesity around the world. Increasing weight is a huge risk factor for the development of type 2 diabetes at all ages. The main reason for the increase in obesity is a change in life styles to increased intake of (often high carbohydrate and high fat) foods and decreased physical activity. Only in rare circumstances is obesity due to hormonal disorders or medical conditions. Certain other features increase the chances of a young person having type 2 diabetes including:
- Family history of diabetes
- Certain ethnic groups e.g youth from African and Asian ethnicities (also Hispanic, American Indian and Pacific island ethnicities)
- The onset of puberty is often a time when youth are diagnosed with type 2 diabetes as the hormonal changes that occur with puberty increases insulin resistance.
- People of all ages often have no symptoms of type 2 diabetes. When they do occur, symptoms develop slowly and may include:
- Unexplained weight loss
- Increased hunger or thirst
- Dry mouth
- Increased urination (including at night)
- Tiredness and lethargy
- Blurred vision
- Slow healing of sores or cuts
The diagnosis of diabetes is made by checking blood glucose values. In recent years, and HbA1c has been used for making a diagnosis of diabetes. Unfortunately, in youth, this is a less reliable way of making the diagnosis (particularly in obese children and adolescents). In certain countries where children have type 2 more commonly than type 1, screening for diabetes in carried out in schools!
While the treatment options for type 2 diabetes are well known, less is known about how to treat this condition in children and adolescents. The safety and effectiveness of medications have not been tested in this group of people.
As more youth with type diabetes are cared for around the world, it have become more obvious that this is a more aggressive form of diabetes than type 2 diabetes in adults. Complications appear more rapidly and therapy needs to be more aggressive than in adults. The additional changes in growth, puberty and the emotional changes of puberty increases the challenge of having type 2 diabetes at a young age.
These changes and the emergence of type 2 diabetes in youth means that these young people need medical attention from practitioners that have the necessary knowledge and skills to give them appropriate care.