Learning TODAY for a healthy tomorrow

National study brings Type 2 diabetes discoveries to light, gives patients healthy options

At 5 years old, Richard Zarate’s skin began to change. Dark, rough patches began to appear along his neckline. When he turned 10 and entered the fifth grade, Richard experienced more unusual changes in his health. He was constantly thirsty and made more frequent trips to the bathroom to urinate. His mother, Christine, who is a nurse, was alarmed by the changes. Using her own blood-glucose monitoring device, she checked her son’s sugar levels. They were very high, so Christine rushed him to the emergency room. Richard was diagnosed with Type 2 diabetes.

Researchers at the UT Health Science Center San Antonio led a national study that has revealed a frightening fact – Type 2 diabetes is becoming more prevalent in children aged 10 to 17 and is more aggressive and deadly in children than in adults.

Richard and his mom were quickly referred to the Texas Diabetes Institute, one of the nation’s largest and comprehensive diabetes and endocrinology centers operated by University Health System, which is the teaching hospital for the UT Health Science Center. There they learned of the TODAY study, a national collaborative clinical trial for children and adolescents with Type 2 diabetes. TODAY stands for Treatment Options for Type 2 Diabetes in Adolescents and Youth. The UT Health Science Center is one of 16 sites throughout the country and one of only two in Texas funded by the National Institute of Diabetes and Digestive and Kidney Diseases to enroll patients. The goal of the study is to improve treatment and outcomes for children with Type 2 diabetes.

Christine was, at first, skeptical of the study and thought she could handle her son’s health situation. “Both of my parents have Type 2 diabetes, and I was diagnosed when I was 40 years old,” she said.

But Richard had an instinct about the program.

“Mom, maybe they can help me,” he suggested. “Maybe something good can come from this.” A year later, Richard convinced his mom, and in 2006 he became a part of TODAY. Richard is one of 699 children and adolescents with Type 2 diabetes nationwide who were enrolled in the study from 2004 to 2009.

The TODAY study team in San Antonio includes: (standing left to right) Daniel Hale, M.D., Elisa Morales, Rose Ann Barajas, Aimee Wauters, M.S., RD, LD, CDE, (sitting left to right) Nancy Amodei, Ph.D., and Guadalupe Rupert, RN, CDE.

According to the U.S. Centers for Disease Control and Prevention (CDC), diabetes is becoming one of the most common chronic, preventable diseases among children in the United States. Family history, obesity and the low level of physical activity among young people may be major contributors to the increase in Type 2 diabetes during childhood and adolescence.

Daniel Hale, M.D., professor and chief of the Division of Pediatric Endocrinology, and Jane Lynch, M.D., professor of pediatric endocrinology at the UT Health Science Center, are the lead investigators of the San Antonio study and they and their staff are authors of an article revealing their findings published in an April 2012 issue of the New England Journal of Medicine.

Patients aged 10 to 17 whose body mass index (BMI) indicated that they were overweight or obese received a minimum of six weeks to a maximum of six months of comprehensive, standardized diabetes education, including diet and exercise counseling from diabetes educators and were then randomly assigned to one of three groups: 1.) treatment with metformin alone; 2.) treatment with the drugs metformin and rosiglitazone (rosiglitazone is currently FDA-approved for therapy for adults only with Type 2 diabetes); or 3.) treatment with metformin and lifestyle intervention, which included diet and exercise counseling. Metformin and insulin are currently the only FDA-approved forms of therapy for children with Type 2 diabetes.

“Standard education was provided at the beginning to give the participants a good knowledge base,” said Aimee D. Wauters, M.S., RD, LD, CDE, a senior dietitian and diabetes educator with the TODAY study. “At every visit throughout the study, all of the participants had access to a diabetes educator, and everyone had tailored, customized education and health care based on what was happening to them,” she said.

Researchers found that children who were given the combined therapy of metformin plus rosiglitazone did not have significantly better outcomes compared to children who were administered the metformin alone or who took metformin and had lifestyle intervention. Fifty two percent of children on metformin alone, nearly 40 percent of patients on metformin plus rosiglitazone, and 47 percent of children on metformin plus lifestyle intervention lost their ability to produce insulin and had to be placed on insulin therapy. The children in the combined therapy group of metformin plus rosiglitazone lost their ability to produce insulin later than the children in the group taking metformin alone and those taking metformin with a lifestyle intervention.

Richard responded well to the metformin. “I wish I would have enrolled him right away because we could have gotten it under control a lot better sooner,” Christine said. “I could have kicked myself.” But mom and son are optimistic and moving forward. Among the many new approaches they’ve taken to adopt a healthier lifestyle – making their own sodas and vegetable chips.

Today, Richard is a bright 17-year-old who dreams of becoming a chef or a physician – career opportunities influenced by his experience with Type 2 diabetes. He also serves as a “big brother” to fellow youths and encourages them to see their doctors if they describe symptoms similar to what he experienced. He enjoys offering them positive advice on how to maintain a healthy lifestyle.

Researchers said unfortunately, most patients are not as compliant as Richard and consequentially experience serious, irreversible long-term damage, including neuropathy (nerve damage), or develop kidney or cardiovascular disease. Twenty two percent of the children in the study developed secondary complications, including high blood pressure and high cholesterol.

“This study showed us that Type 2 diabetes in children is more aggressive, progressive and different than Type 2 diabetes in adults,” said Rose Ann Barajas, study coordinator. “If this frightening trend continues, this generation of children will be the first who will not outlive their parents. Parents will have to bury their children.”

The study also revealed insight on how rapidly the disease progresses in children and adolescents. “This is really contrary to what we know about pediatric illnesses,” Dr. Lynch said. “This disease is more aggressive than previously thought, with many more complications.”

Dr. Hale added, “Typically children are more resilient across all chronic and acute illnesses compared to adults. This disease is ravaging kids at a faster rate.”

Researchers said these findings will be published in the future. A continuation of the study, called TODAY 2 Phase I, is under way, and will follow the cohort of participants to track how Type 2 diabetes progresses.

Dr. Hale’s healthy lifestyle tips

1. Turn off the television, computers and video games. Have no more than two hours of screen time a day for children older than 2. Read a book, play a game or talk instead.
2. Have at least one hour of vigorous physical activity every day for children and adults.
3. Put aside sodas, sports drinks and juices. Make water and low-fat milk the only beverages available at home.
4. Treat fast food as a treat by consuming it once per week or less. Beware of any meal greater than 500 calories.
5. Make healthy snacks from fruits and vegetables. Beware of all other foods labeled “snacks.”

Obesity may contribute to Type 2 diabetes

• Type 2 diabetes costs as much as one-third of the U.S. military budget.
• More than one in three children in Texas is overweight.
• Over the past three decades, the childhood obesity rate has more than doubled for preschool children aged 2 to 5 years and adolescents aged 12 to 19 years and has more than tripled for children aged 6 to 11 years.

Sources: U.S. Centers for Disease Control and the Texas Department of State Health Services

Natalie Gutierrez contributed to this story.

Zarate Family Fruit Soda recipe

4 cups water
1 cup fruit (except citrus)
1/4 cup sugar substitute
Carbonated water

Mash fruit and add to water in a sauce pan; bring to a boil. As soon as the mixture boils, bring down to a simmer and let simmer for 20 to 30 minutes to reduce mixture. Strain mixture to remove pulp and sweeten with sugar substitute. Place from 1 tablespoon to 1/4 cup of mixture in a large glass with ice and fill with carbonated water. Enjoy!