What is Type 2 Diabetes? Is it here? Now?

by Dr. Ann L. Engelland

(October 10, 2005) I head to my office, driving down the Boston Post Road around noon. It’s hot out and the road is congested with cars, police vehicles and students. When I stop for pedestrians near McDonald’s, I notice the crowd of high school kids. The weather and the current clothing styles lend themselves to a study of body types. Those on the south side of the street, headed for a Big Mac and fries, seem significantly heftier than the leaner types on the north side of the street. Before me is a snapshot of the current epidemic of overweight and obese adolescents.

Later, I am ready to see my first patient of the afternoon, a fourteen-year-old new to my practice, coming to discuss “unexplained weight gain.” As soon as she and her mother walk in, I am struck by their resemblance. Both Mom and Daughter are round, overweight by anyone’s standard, and have large middles shaped like apples, not pears. Daughter has acne and Mom has residual scars of what must have once been severe acne. Daughter has some dark, fuzzy sideburns, noticeable to a trained eye (and no doubt to her). From across the desk I note skin discoloration on her neck. I suspect her diagnosis from just a glimpse.

I want to ask: ”Where did you have lunch today?”

So, what is it?

I am thinking she has Metabolic Syndrome, otherwise known as Insulin Resistance Syndrome (IRS) or Syndrome X. Other names for this constellation of symptoms are “ prediabetes” or dysmetabolic syndrome. Eventually IRS can lead to Type 2 Diabetes if not treated and managed in time. Such a mumbo jumbo---difficult for anyone to understand—even for trained professionals. These are sophisticated terms and they reflect complicated processes in the body.

Putting it bluntly and simply, this girl is obese. Why can’t we leave it at that?

 Metabolic syndrome is defined as three of the following five characteristics in the same patient:

  • Elevated blood pressure
  • Low HDL (the “good” cholesterol)
  • High Triglyceride
  • High fasting blood glucose (FBG)
  • Abdominal obesity (that round quality)

This type of obesity – while exacerbated by overeating – has more complicated metabolic causes. We now understand, regardless of what we call them, that all of these syndromes are essentially nutritionally related, often genetically programmed, disorders that result in abnormal metabolism of glucose (sugar), lipids(fats) and hormones. Fortunately we are also more aware of ways to manage this kind of obesity and its consequences.

Patients with Metabolic Syndrome usually have some degree of insulin resistance, which in its more serious form is the hallmark of Type 2 Diabetes. Insulin is a pancreatic hormone produced in response to glucose in the blood. When a person is insulin resistant, the body’s insulin is less effective - so more of it needs to be produced in response to a given amount of sugar. One effect of the excess insulin is to lower blood sugar, but it also kicks into gear a number of other negative effects.

Effects of Excess Insulin

  • Multiple changes in the composition of body lipids, including increased triglycerides
  • Elevation of blood pressure
  • “stickier” platelets, possibly increasing risks of heart attacks and strokes
  • Increased tissue growth in the throat area (sometimes leading to sleep apnea)
  • Increased deposition of fat in the abdominal cavity and around the waist, leading to the apple shape
  • Hyperpigmentation of the skin in creases and on the neck.
  • Abnormal hormone levels in women and girls leading to acne, increased hair in unusual places, and irregular or absent periods

Although Type 2 Diabetes was formerly called “Adult Onset Diabetes” it has become clear in the last few decades that the problem is prevalent even among kids and teens and that the chronic, long-term consequences (heart attacks, strokes, kidney disease) may take root at a very young age. As with many diseases and disorders, genetics, ethnicity, gender and family history play a large part. Children and teens with Type II diabetes belong to all ethnic groups but in many studies, Latino and African-American kids seem to predominate. Girls outnumber boys with this disorder by almost two to one.

The “Nature versus Nurture” argument is alive and well in circles where this public health threat is discussed. Do the kids on the south side of the Boston Post Road look the way they do because of where they eat lunch or do they eat lunch there because it’s cheaper and faster?

What to do?

So what do we do with a teen like this? First and foremost a doctor takes a good history paying attention to the family, its cardiovascular history and importantly to the growth patterns, puberty and weight issues of the patient. A history, physical exam and some blood work would be in order. If we determine that she has metabolic syndrome we would try to help her understand what it means and what her responsibilities are. Many kids respond to the notion that their “unexplained” weight gain now has an explanation that does not include “their fault.” That does not mean there is a magic solution to the problem. Far from it. The treatment plan would involve a number of dimensions:

Diet: we try to engage the whole family in understanding Metabolic Syndrome and encourage affected siblings and parents to get checked. Then we stress the importance of fundamental diet changes (like moving toward whole grains and “Complex Carbs”) for the whole family.

Exercise: regular aerobic exercise is prescribed. We know this is easier said than done so again we try to enlist the family in a program that will work for the kid. One of my patients introduced me to the “Dance Dance Revolution” DVD as her method of managing her weight.

Support: All family members may require support to understand the causes and consequences of the diagnosis and to best learn how to help the patient.

Medication: Sometimes , but usually not before a fair trial of diet and increased activity, specific medications are prescribed which help increase the sensitivity of insulin and lower the blood sugar.

Education: Often habits, developed over years and part of family culture, are hard to break and education is one part of the program. Good websites to explore include: www.diabetes.org; www.mendosa.org; and www.glycemicindex.com

So, it’s complicated and it’s not simply about whether you eat fries or salads. But you will notice that more and more people at Stop and Shop just “look” like they’ve tipped over into the dangerous zone of Metabolic Syndrome and Type 2 Diabetes. Fortunately, however, there is a road back and the sooner we get kids to cross to the other side of the street the better for our public health.

Dr. Engelland has a practice in Mamaroneck devoted to Adolescent Primary Care. She can be reached at 698-5544.

Have a teen health question? Use the form below to send it to Dr. Engelland. Please note: Dr Engelland cannot respond privately to individual queries online. Comments are welcome and anonymous questions may be answered in future columns. Serious medical problems should be referred to your own physician.

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