MORE and more children are being diagnosed with diabetes every day and that includes in Malaysia.
In 2008, there were 408 children and teenagers below 18 years of age registered with the national Diabetes in Children and Adolescents Registry.
Just 11 years later, the figure more than doubled to 977, as reported by in the 2019 edition of the International Diabetes Federation Atlas.
Double trouble
The two main types of diabetes in children are Type 1 and Type 2.
Type 1 diabetes is the most common form of diabetes in children, but it can occur at any age.
It is an autoimmune condition where the body’s immune system mistakenly attacks and destroys cells in the pancreas that produce insulin, resulting in diabetes.
Therefore, children with Type 1 diabetes require life-long insulin replacement to survive.
Type 2 diabetes is the most common type of diabetes in adults.
It is caused by insulin resistance, where insulin is not able to work effectively due to excess body fat.
Before the 1990s, Type 2 diabetes was uncommon in adolescents, but with the alarming rise of childhood obesity worldwide, it is now increasingly seen in children as young as eight years old.
Classical symptoms of diabetes are increased thirst, frequent urination, bedwetting in a toilet-trained child, unexplained tiredness and weight loss.
The child may also have an increased appetite and be more prone to oral, skin or vaginal infections.
Any child with the above symptoms should be brought to see a doctor to have their blood glucose checked promptly, which can be as simple as a finger prick measurement.
Heart problems
Children with both Type 1 and Type 2 diabetes are at increased risk of developing cardiovascular (heart) disease.
Parents often have the misconception that Type 2 diabetes is a less severe form of diabetes than Type 1.
However, more cardiovascular complications are actually reported in Type 2 diabetes, compared to Type 1.
Cardiovascular disease includes heart and blood vessel disease, e.g heart attacks and strokes.
Heart and blood vessel disease are related to a process call atherosclerosis.
Atherosclerosis is a condition where there is a buildup of fatty substances on the inner walls of blood vessels that provide oxygen-rich blood to the entire body (arteries).
Atherosclerosis makes the arteries narrower and harder for blood to flow to vital organs such as the heart and brain.
When the fatty substances accumulate to the point of blocking the blood flow to the heart or brain, the result is a heart attack or stroke.
The end results of a heart attack or stroke is usually seen only in adulthood.
However, in children with diabetes, the atherosclerosis process can start in childhood itself without outward signs or symptoms of the condition.
This is known as subclinical atherosclerosis.
Managing the risk
Children with diabetes can lower their risk of cardiovascular disease by keeping their blood glucose in the recommended range, and managing the modifiable risk factors described below:
Glucose control is the cornerstone of management in all types of diabetes and for all ages.
Poor diabetes control with high blood glucose levels and a high HbA1c are associated with increased arterial stiffness, atherosclerosis and risk of heart attacks as adults.
In a landmark study called the Diabetes Control and Complications Trial – Epidemiology of Diabetes Complications (DCCT/EDIC), there was a 57% reduction in cardiovascular disease in Type 1 diabetes patients who had intensive insulin treatment for good diabetes control, compared to those who did not, after 17 years of follow-up.
For Type 2 diabetes, good glucose control together with a healthy lifestyle and weight management is emphasised.
Drug treatment often consists of an oral anti-diabetic medication known as metformin, which helps the body to use insulin more effectively.
Many adolescents with Type 2 diabetes will also eventually need insulin treatment.
Dyslipidaemia in diabetes is defined as elevated levels of LDL-C (low-density lipoprotein cholesterol – a bad component of cholesterol) and/or triglycerides.
Dyslipidaemia is associated with heart attacks and stroke in adults.
There is a higher occurrence of dyslipidaemia in children and adolescents with diabetes, especially those with poor glucose control.
Interventions to improve cholesterol level are improving glucose control, increasing vegetable and fruit intake, reducing oil and fatty food, targeting a normal weight, and exercise.
Treatment with a type of medicine known as a statin to lower cholesterol for heart protection, should be considered in adolescents if there is no improvement with initial measures.
The frequency of hypertension in adolescents with diabetes is higher compared to children without diabetes.
Similar to adults, high blood pressure predisposes children to the development of cardiovascular, kidney (microalbuminuria and nephropathy) and eye disease (diabetic retinopathy).
Hypertension in children is treated by dietary adjustment, reduced salt intake, targeting a healthy weight and optimising glucose control.
Some children will need oral medications (anti-hypertensives) to lower their blood pressure.
Diabetic nephropathy or kidney disease is a strong risk factor for cardiovascular disease.
It is diagnosed when there is a persistent amount of a protein known as albumin excreted in the urine, and is associated with high blood pressure and kidney failure.
Good glucose, blood pressure and cholesterol control are important to avoid diabetic nephropathy.
Avoidance of smoking is also essential.
Medical treatment is indicated if there is persistent presence of albumin in the urine or hypertension.
This is important to prevent development or progression of diabetic nephropathy.
Childhood obesity is related to cardiovascular complications in young adulthood.
Obese adolescents are more likely to also have hypertension and high cholesterol levels.
Healthy lifestyle habits must be instilled early in children with diabetes, including healthy dietary and eating habits, avoidance of excess calories, sufficient sleep and regular physical activity.
For children who are on insulin, excessive unnecessary doses should be avoided.
In children, motivation, behavioural modifications and involvement of the whole family are crucial for success.
It is well known that both active and passive smoking causes many health problems, including cancers, heart and lung disease.
Adolescents must be educated on the dangers of smoking from an early age as prevention is best.
Parents should also stop smoking to set a good example.
Vaping or ecigarettes should also be avoided in adolescents.
Nicotine, which is present in both conventional cigarettes and ecigarettes, raises blood glucose levels and causes addiction.
Food intake is strongly linked to Type 2 diabetes.
Eating food high in saturated fats, trans fat and cholesterol has been linked to heart disease and atherosclerosis.
Too much salt in the diet can raise blood pressure.
Overeating, excessive calorie intake and too many sweet drinks increase obesity and diabetes risk.
Tips for parents to encourage healthy eating habits include:
- Avoiding sugary drinks and opting for plain water.
- Not skipping meals as it can lead to overeating at the next meal or snacking. Instead, reduce portion sizes.
- Increasing intake of fibre through eating vegetables and fruits.
- Choosing healthy carbohydrates, e.g. brown rice, whole wheat bread, oats, and pairing them with a protein.
- Reducing fried, oily and salty food.
Exercising and being active improve glucose levels, weight, blood pressure, cholesterol and general wellbeing.
Children should exercise 30 to 60 minutes on most days of the week.
Insulin doses should be adjusted with prolonged exercise.
Limiting the amount of screen time can help a child to be more active.
Parents can enrol their child in sports lessons or gym activities that suit the child’s interest.
For children who are overweight and not used to exercise, it should be done in a gradual manner.
For children who do not like sports, focus on “active play” instead of exercise.
Most importantly, parents should spend time with their child and create family outings that involve moving, e.g. biking, walking and hiking.
Lack of sleep or poor quality of sleep may lead to higher blood glucose levels.
It also increases the risk of obesity and depression.
Psychosocial stress and depression in adolescents with diabetes lead to poorer diabetes control because of poor self-care.
Acceptance and support from family, teachers and friends are important to cultivate a positive mindset and good self-esteem.
Parents also often affect their children's emotions, hence parents must practice good self-care themselves.
Professional help should be considered in severe depression or to assist in developing coping abilities if needed.
You can do it!
Most cardiovascular risk factors that affect children with diabetes can be prevented or controlled with early identification and interventions.
Measures include improving glucose control, maintaining a healthy weight, eating healthy, exercising, getting sufficient sleep and thinking positively.
Adherence to treatment and regular follow-up with a paediatrician or paediatric endocrinologist are also essential.
Dr Jeanne Wong Sze Lyn is a consultant paediatrician and paediatric endocrinologist. This is the 11th article in a monthly series called Hormones and Kids. For more information, email starhealth@thestar.com.my. The information provided is for educational purposes only and should not be considered as medical advice. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.
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