Children and Diabetes

Diabetes is one of the most common chronic diseases among children in the United States.

When diabetes strikes during childhood, it is routinely assumed to be type 1, or juvenile-onset, diabetes. Type 1 diabetes develops when the body's immune system destroys pancreatic cells that make the hormone insulin that regulates blood sugar. It normally strikes children and young adults. People with type 1 diabetes must have daily insulin injections to survive.

In the last two decades, type 2 diabetes, formerly known as adult-onset diabetes, has been reported among U.S. children and adolescents with increasing frequency. Type 2 diabetes begins when the body develops a resistance to insulin and no longer uses the insulin properly. As the need for insulin rises, the pancreas gradually loses its ability to produce sufficient amounts of insulin to regulate blood sugar.

Overview

• Epidemiology of Type 1 and Type 2 Diabetes Mellitus Among North American Children and Adolescents

Diabetes is one of the most common chronic diseases in children and adolescents; about 151,000 people below the age of 20 years have diabetes.

When diabetes strikes during childhood, it is routinely assumed to be type 1, or juvenile-onset diabetes. However, in the last 2 decades, type 2 diabetes (formerly known as adult-onset diabetes) has been reported among U.S. children and adolescents with increasing frequency. Also, studies conducted in Europe showed an increase in the frequency of type 1 diabetes, especially in young children. It is unclear whether the frequency of type 1 diabetes is also increasing among U.S. youth.

Statistics

• Each year, more than 13,000 young people are diagnosed with type 1 diabetes.
• Type 2 diabetes begins when the body develops a resistance to insulin and no longer uses the insulin properly. As the need for insulin rises, the pancreas gradually loses its ability to produce sufficient amounts of insulin to regulate blood sugar.
• Health care providers are finding more and more children with type 2 diabetes, a disease usually diagnosed in adults aged 40 years or older.
• A statistically significant increase in the prevalence of type 2 diabetes among children and adolescents was found only for American Indians.
• The epidemics of obesity and the low level of physical activity among young people, as well as exposure to diabetes in utero, may be major contributors to the increase in type 2 diabetes during childhood and adolescence.
• Type 2 diabetes in children and adolescents already appears to be a sizable and growing problem among U.S. children and adolescents. Better physician awareness and monitoring of the disease’s magnitude will be necessary.
• Standard case definition(s), guidelines for treatment, and approval of oral hypoglycemic agents (to lower blood sugar) are urgently required for children and adolescents.

Children and adolescents diagnosed with type 2 diabetes are generally between 10 and 19 years old, obese, have a strong family history for type 2 diabetes, and have insulin resistance. Generally, children and adolescents with type 2 diabetes have poor glycemic control (A1C = 10% - 12%).

Those affected with type 2 diabetes belong to all ethnic groups, but it is more commonly seen in non-white groups. American Indian youths have the highest prevalence of type 2 diabetes. In the 15-to-19-year age group, the current prevalences were

• 50.9 per 1000 for Pima Indians from Arizona;
• 4.5 per 1000 for all U.S. American Indian populations (reported cases from the U.S. Indian Health Service outpatient clinics);
• 2.3 per 1000 for Canadian First Nation people from Manitoba (reported cases from outpatient clinics).

In comparison, the prevalence per 1000 of type 1 diabetes for U.S. residents aged 0-19 years is 1.7 per 1000.

Population-based prevalence estimates for other ethnic groups were not available. In a retrospective study of such reports, a referral center in Cincinnati, Ohio, found an incidence for type 2 diabetes of 7.2 per 100,000 for African Americans and whites aged 10-19 years in 1994. By comparison, the national incidence of type 1 diabetes among those aged 10-19 years is 19 per 100,000. In most of the U.S. case reports, type 2 diabetes accounted for 8% to 46% of all new cases of diabetes (type 1 and type 2) referred to pediatric centers. The magnitude of type 2 diabetes is probably underestimated.

Why is it hard to detect the prevalence of type 2 diabetes in children?

It is hard to detect type 2 diabetes in children because it can go undiagnosed for a long time; because children may have no symptoms or mild symptoms; and because blood tests are needed for diagnosis. It is difficult to be sure it is type 2, because criteria for differentiating between types of diabetes in children are confusing; that is, children with type 2 can develop ketoacidosis (acid build-up in the blood); children with type 1 can be overweight; and because the overall prevalence of the disease may still be low. This means that scientists will have to sample a very large population of children in order to find a stable estimate of prevalence.

CDC Initiatives

SEARCH for Diabetes in Youth Study

Reports of increasing frequency of both type 1 and type 2 diabetes in youth has been among the most concerning aspects of the evolving diabetes epidemic. Unfortunately, reliable data on changes over time in the U.S., or even how many children in the U.S. had type 1 or type 2 diabetes, were lacking. In response to this growing public health concern, the Centers for Disease Control and Prevention (CDC) and the National Institutes of Health (NIH) in 2000 funded the SEARCH for Diabetes in Youth Study www.searchfordiabetes.org. SEARCH is a multicenter, epidemiological study, conducted in six geographically dispersed populations that encompass the racial/ethnic diversity of the U.S. It is designed to characterize the burden of both type 1 and type 2 diabetes, along with the associated complications, the levels of care, and impact on the daily lives of children and youth in the U.S.

SEARCH Facts

In the year 2001, approximately 3.5 million children less than 20 years of age were under surveillance at the six SEARCH centers to estimate how many children or young people had DM (prevalent cases);

• SEARCH provides estimates of 2001 DM prevalence (1.8 per 1,000) (Link to directly to PUB MED; Pediatrics, 2006 118(4):1510-8).
• SEARCH prevalence data indicate that in the U.S., at least 154,000 children/youth have Diabetes Mellitus (DM). DM prevalence varies across major racial/ethnic groups:

• In children 0–9 years of age non-Hispanic whites have the highest prevalence (about 1/1,000). In this age group across all race/ethnic groups, type 1 DM is the most common form of diabetes. The study found that type 2 DM is extremely rare in children of all races younger than 10 years of age.
• Among adolescents and young adults (age 10–19 years), African American and non-Hispanic white youth have the highest burden of DM (about 1 of 315) and Asian/Pacific Islanders have the lowest (about 1 of 746).Type 1 DM prevalence is 2.3/1,000 and it is the most common form of DM in all racial/ethnic groups except in American Indian youth. Type 2 prevalence is 0.4/1,000 and it represented 6% of the cases of diabetes in Non-Hispanic White, 33% in African American, 40% in Asian/Pacific Islander, and 76% among American Indian youth.

Since 2002, approximately 5.5 million children less than 20 years of age (approximately 6 percent), each year have been under surveillance at the SEARCH research centers to estimate how many children/youth develop diabetes (incidence cases) per year;

• Based on 2002 and 2003 data, the overall incidence is estimated to be 24.3 per 100,000 per year. Annually, an estimated 15,000 youth are diagnosed with type 1diabetes, and about 3,700 youth are diagnosed with type 2.

• Among youth aged <10 years, most diabetes cases are type 1, regardless of race/ethnicity. In this age group the highest incidence of type 1 diabetes is observed in non-Hispanic whites (19/100,000 for 0– to 4– years-old and 28/100,000 for 5– to 9– years-old)
• Among older youth (ages 10–14 and 15–19 years), the highest incidence of type 1 diabetes is in non-Hispanic white youth (33/100,000 per year for 10– to 14– years-old and 15/100,000 for 15– to 19– year olds), followed by African American (19.2 and 11.1) and Hispanic (17.6 and 12.1), and lowest among American Indian (7.1 and 4.8) and Asian/Pacific Islanders (8.3 and 6.8).
• The incidence of type 2 DM is the highest among American Indians (25.3 and 49.4 for ages 10–14 and 15–19 years, respectively), followed by African Americans (22.3 and 19.4), Asian/Pacific Islanders (11.8 and 22.7) and Hispanics (8.9 and 17.0), and is low (3.0 and 5.6) among non-Hispanic whites.

SEARCH has shown that nutritional intake in adolescents with DM is poor and does not follow current recommendations. Recommendations for total dietary fat intake are met by only 10 percent of youth with DM and recommendations for saturated fat intake by only 7 percent.

SEARCH found that about 9 percent of adolescents with DM have moderate or severely depressed mood symptoms, with more girls than boys being affected. Depressed mood is associated with poor glycemic control and a higher likelihood of emergency room visits. (Pediatrics, 2006; 117:1348–58);

About half of the SEARCH participants had an LDL-C concentration above the optimal level of 100 mg/dL. In older youth (≥ 10 yrs of age), the prevalence of abnormal lipids was higher in those with type 2 (33%) than in those with type 1 diabetes (19%). (J Pediatr, 2006; 149(3); 314-9). Moreover, worse glycemic control was associated with a worse lipid profile, regardless of diabetes type (Arch Pediat Adoles Med 2007;161:159–165)

The prevalence of multiple cardiovascular disease (CVD) risk factors is high in children and adolescents with DM. CVD risk factors are present in both youth with T1 or T2 DM, but were more common in adolescents with T2 DM (Diab Care 2006; 29:1891-1896). Higher Body Mass Index (BMI) is associated with younger age at diagnosis of T1 DM but, only in children with reduced beta cell function. These data suggest that, only among individuals with already compromised beta-cell function or high rate of beta cell loss, obesity accelerates T1 DM onset. In addition, low birth weight may be a factor in accelerating the onset of T1 DM. These data suggest that the intrauterine environment may be an important determinant of age of onset for T1 DM (Diabetes Care, 2006; 29: 290–4).

Implications

SEARCH provides the foundation for childhood diabetes surveillance efforts in public health, clinic, and research settings. SEARCH data is important to ultimately design and implement public health efforts to prevent type 1, once prevention strategies are identified, and type 2 diabetes in youth.

The data that are acquired by SEARCH regarding the natural history, risk factors of diabetes complications, quality of care and quality of life will also help design and implement interventions that can reduce the risk for both acute and chronic diabetes complications.

SEARCH Research Centers

Kaiser Permanente Southern California, Pasadena CA

University of Colorado Health Sciences Center, Denver CO

Pacific Health Research Institute, Honolulu HI

Children’s Hospital Medical Center, Cincinnati OH

University of South Carolina School of Public Health, Columbia SC

Children’s Hospital and Regional Medical Center, Seattle WA

Coordinating Center: Wake Forest University School of Medicine, Winston-Salem NC

Central Laboratory: Northwest Lipid Research Laboratories, University of Washington, Seattle, WA

SEARCH Publications

The SEARCH Writing Group. SEARCH for Diabetes in Youth: a Multi-Center Study of the Prevalence, Incidence and Classification of Diabetes Mellitus in Youth. Controlled Clinical Trials 2004;25:458–471.

Dabelea D, D'Agostino RB Jr, Mayer-Davis EJ, Pettitt DJ, Imperatore G, Dolan LM, Pihoker C, Hillier TA, Marcovina SM, Linder B, Ruggiero AM, Hamman RF. Testing the accelerator Hypothesis: Body size, beta-cell function, and age at onset of T1 (autoimmune) diabetes. Diabetes Care 2006;29:290–294.

Lawrence JM, Standiford DA, Loots B, Klingensmith GJ, Williams DE, Ruggiero A, Liese AD, Bell RA, Waitzfelder BE, McKeown RE, the SEARCH for Diabetes in Youth Study. Prevalence and correlates of depressed mood among youth with diabetes: The SEARCH for Diabetes in Youth Study. Pediatrics 2006;117:1348–1358.

Mayer-Davis EJ, Nichols M, Liese A, Bell R, Dabelea D, Johansen J, Pihoker C, Rodriguez B, Thomas J, Williams DE For the SEARCH for Diabetes in Youth Study Group. Dietary intake among youth with diabetes: the SEARCH for Diabetes in Youth Study. Journal of the American Dietetic Association 2006;106:689–697.

Rodriguez BL, Mayer-Davis EJ, Imperatore G, Williams DE, Bell RA, Pihoker C, Wadwa RP, Palla SL, Liese AD, Liu LL, Kershnar A, Daniels SR, Linder B, FujimotoWY the SEARCH for Diabetes in Youth Study. Prevalence of cardiovascular disease risk factors in U.S. children and adolescents with Diabetes: The SEARCH for Diabetes in Youth Study. Diabetes Care 2006; 29:1891–1896.

Kershnar AK, Daniels SR, Imperatore G, Palla SL, Petitti DB, Pettitt DJ, Marcovina S, Dolan LM, Hamman RF, Liese AD, Pihoker C, Rodriguez BL. Lipid abnormalities are prevalent in youth with T1 and T2 diabetes: the SEARCH for Diabetes in Youth Study. Journal of Pediatrics 2006;149:314–319.

The SEARCH for Diabetes in Youth Study Group. The burden of diabetes among U.S. youth: prevalence estimates from the SEARCH for Diabetes in Youth Study. Pediatrics 2006;118:1510–1518.

Petitti DB, Imperatore G, Palla SL, Daniels SR, Dolan LM, Kershnar AK, Marcovina S, Pettitt DJ, Pihoker C the SEARCH for Diabetes in Youth Study Group. Serum lipids and glucose control: the SEARCH for Diabetes in Youth Study. Archives of Pediatrics and Adolescent Medicine 2007;161:159–165

The SEARCH for Diabetes in Youth Study Group. Incidence on diabetes in youth in the United States: the SEARCH for Diabetes in Youth Study. JAMA 2007; 297:2716–24).

In response to this growing public health concern, the Centers for Disease Control and Prevention (CDC) and the National Institutes of Health (NIH) are funding a 5-year, multicenter study, SEARCH for Diabetes in Youth, to examine the current status of diabetes among children and adolescents in the United States.

Cooperative agreements were awarded to six sites to establish a multi-center registry system that will cover over 6 % of the children and adolescents in the United States. The main objectives of the study are to assess the magnitude and burden of diagnosed diabetes and to develop criteria to differentiate between the types of diabetes among young people in the United States.

The study includes a data coordinating center and a central laboratory and has these two phases:

• to develop a uniform protocol to identify children and adolescents with diabetes
• to implement the uniform protocol to identify cases of diabetes in children in the areas covered by the six study sites.

CDC Workshops

To respond to a potential emergence of type 2 diabetes among North American children and adolescents as a public health problem, CDC’s Division of Diabetes Translation invited a group of health care providers, epidemiologists, and public health professionals to review the current knowledge of the disease in North America; see Fagot-Campagna A, Ríos Burrows N, Williamson DF. The Public health epidemiology of type 2 diabetes in children and adolescents: a case study of American Indian adolescents in the southwest United StatesExternal Web Site Icon. Clin Chim Acta 1999;286:81-95.

The first workshop in October 1998 focused on the prevalence, incidence, and secular trend of the disease among different ethnic groups. A second workshop in January 1999 focused on the characteristics, complications, treatment, and follow-up of children diagnosed with the disease.

CDC's Division of Diabetes Translation defined these four objectives, which will require strong collaborations with other agencies and organizations:

1. Raise physicians' awareness about the disease. 2. Develop a standard case definition(s). 3. Determine the magnitude of the problem. 4. Assess and improve the quality of care among children and adolescents diagnosed with type 2 diabetes.

External Resources

• Appendix: Guidelines for School Health Programs to Promote Lifelong Healthy Eating Among Young People MMWR June 14, 1996 / 45(RR-9);34-41.
• Bloomgarden ZT. Type 2 diabetes in the young: the evolving epidemic External Web Site Icon. Diabetes Care 2004 Apr;27(4):998–1010.
• Body Mass Index-for-Age — CDC's Nutrition and Physical Activity.
• CDC Growth Charts: United States
• CDC National Center for Chronic Disease Prevention and Health Promotion. Diabetes Threat on the Rise Among U.S. Children, Specialists Say. Chronic Disease Notes & Reports 1999 spring/summer 12(2):1,10–12. (Select Spring/Summer 1999.)
• CDC's Global Health Spotlight: Children's Health
• CDC School Health Index for Physical Activity and Healthy Eating
• Diabetes Among Young American Indians — Montana and Wyoming, 2000-2002. MMWR November 21, 2003 / 52(46);1127–1129
• Fact sheet: Trends in Diabetes Prevalence Among American Indian and Alaska Native Children, Adolescents, and Young Adult — 1990-1998
• Fagot-Campagna A, Pettitt DJ, Engelgau MM, Burrows NR, Geiss LS, Valdez R, Beckles GL, Saaddine J, Gregg EW, Williamson DF, Narayan KM. Type 2 diabetes among North American children and adolescents: An epidemiologic review and a public health perspective External Web Site Icon. J Pediatr 2000;136(5):664–72.
• Kaufman F, Schatz D, Silverstein J; American Diabetes Association. Diabetes care at diabetes camps. External Web Site Icon Diabetes Care 2004 Jan;27 Suppl 1:S129–31.
• Klingensmith G, Kaufman F, Schatz D, Clarke W; American Diabetes Association. <http://care.diabetesjournals.org/cgi/content/full/27/suppl_1/s122?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=Care+of+children+with+diabetes+in+the+school+and+day+care+setting&searchid=1083784737653_5732&stored_search=&FIRSTINDEX=0&sortsp Diabetes care in the school and day care setting External Web Site Icon. Diabetes Care. 2004 Jan;27 Suppl 1:S122–8.
• Komulainen J, Julmala P, Savola K, et al. Clinical, Autoimmune, and Genetic Characteristics of Very Young Children with Type 1 Diabetes External Web Site Icon. Diabetes Care 22(12):1950
• National Diabetes Education Program Resources on Diabetes in Children and AdolescentsExternal Web Site Icon
• Nutrition — CDC's Division of Adolescent and School Health (DASH)
• Physical Activity — CDC's Division of Adolescent and School Health (DASH)
• Physical Activity Levels Among Children Aged 9-13 Years — United States, 2002 MMWR August 22, 2003 / 52(33);785-788.
• Update: Prevalence of Overweight Among Children, Adolescents, and Adults — United States, 1988-1994 MMWR March 07, 1997;46(09):199-202.
• 2001 Information and Results on Youth Risk Behavior Surveillance System (YRBSS) — CDC's Adolescent and School Health