The perfect storm

Liz

Liz has already lost 30 pounds, has more energy and feels healthier, overall. She wants to focus on her health now, so that she can become a personal trainer and help other kids in the future. Photo by Mark Sobhani.

As her daughter lay in the emergency room on the brink of a diabetic coma, Becky Salazar thought, “It should be me.”

Her daughter, Liz, was only 17. But her sugar level was sky high, three times higher than it should be. Her face was pale, eyes sunken. She was gasping for air. Her body was critically ill from too much sugar and too much acid in the blood.

They hadn’t even known she was diabetic.

“It’s a parent’s worst nightmare to see your child lying there so sick,” Becky Salazar said.

They had seen the signs. Tired all the time. Always thirsty. She couldn’t seem to lose weight. Then, all of a sudden, there was a dramatic weight drop. But the signs were just as easily dismissible. Teens are always tired. And it wasn’t like Liz was terribly overweight. She was tall and big-boned for her age. And she had recently begun exercising, so a drop in weight was to be expected.

Although Type 2 diabetes runs in their family, Becky and her husband, Gabriel Salazar, himself a diabetic, thought the chances of their teenage daughter being diabetic were slim to none. 

A little more than 20 years ago, they would have been right.

Type 2 diabetes used to be known as adult-onset diabetes because, most frequently, it manifests gradually when people are in their 40s or 50s, after years of struggling with being overweight or obese, poor diet and a lack of exercise. But increasingly, physicians are seeing much younger patients affected by the disease.

At the Children’s Center at Texas Diabetes Institute, a partnership between UT Health San Antonio and University Health System, more than 1,000 children have been diagnosed with Type 2 diabetes since 2005. More than 20 were under the age of 10 when they were diagnosed, and the youngest was just 5. In Texas, it is estimated that 30,000 youth under age 20 will be diagnosed with Type 2 diabetes by 2025. 

“We have the perfect storm in San Antonio,” said Jane Lynch, M.D., FAAP, professor of pediatrics and the Greehey Family Foundation Chair in Pediatric Endocrinology. “We are seeing so much more Type 2 diabetes in San Antonio, and we are seeing it in young ages. We’re the epicenter.”

As one of two U.S.-based members of the Global Expert Committee on Type 2 Diabetes in Youth, Dr. Lynch is well-located—on the logistical frontlines of what she calls an urgent public health threat. Because, while San Antonio bears the burden of being the epicenter for diabetes, it is also a hotbed for breakthrough research.

The epicenter for disease

Diabetes is a chronic disease that affects the way the body uses carbohydrates, protein and fat. People with diabetes have abnormally high levels of sugar in the blood.

In the two most common types of diabetes, Type 1 and Type 2, the sugar builds up in the blood, starving the cells of energy. Over time, this can damage the eyes, kidneys, nerves or heart. It can also be fatal.

Type 2 diabetes occurs when the body can’t properly use insulin, a hormone that the pancreas creates to use sugar for energy or store it for future use. It also can occur if the pancreas cannot keep up with the need to produce higher amounts of insulin. It typically develops slowly, and often is linked with obesity. Until the 1990s, it was almost always diagnosed near middle age.

So what makes San Antonio an epicenter for Type 2 diabetes? The Alamo City claims most of the risk factors. Type 2 diabetes disproportionately affects minorities, especially American Indians, blacks and Hispanics. And San Antonio is a majority-minority city, with Hispanics making up more than 63 percent of the population, while 6.9 percent are black.  

The dramatic rise in pediatric Type 2 diabetes also corresponds with the rise in obesity. In the San Antonio region, obesity rates have been steadily ticking upward, hitting between 34.8 and 39 percent of all adults in 2016, according to the Texas Department of State Health Services. 

biking riding

Since being diagnosed with Type 2 diabetes, Liz Salazar has been exercising regularly and eating healthy foods. Now she’s working to help her 7-year-old sister, Leiya, stay diabetes-free by encouraging her to exercise. Photo by Mark Sobhani.

While obesity is the biggest risk factor for the disease, the role of genetics is profound. If a woman has diabetes or gestational diabetes at the time she gives birth, her child likely is predisposed to the disease. Environmental factors, such as a family’s diet and lifestyle, may trigger its onset.

And women with diabetes are giving birth at higher rates because of improved medical treatments, Dr. Lynch said. 

“We’re seeing a pretty steady trickle of new diabetics,” she said. 

While it’s not a bragging point for San Antonio, the high rate of diabetes makes the city the perfect site for research to better understand how the disease behaves in children and discover new treatment options. One such landmark study, called Treatment Options for Type 2 Diabetes in Adolescents and Youth, or TODAY, began in 2005. The ongoing results, while grim, provide valuable insight that researchers are using to shape treatment plans.

The TODAY study was designed as a randomized trial to try treatment options in children of different ethnicities, ages 10 to 17, from around the United States. It followed 699 youth from 16 sites—including San Antonio—for seven years with medical intervention followed by ongoing observation. Dr. Lynch co-led the San Antonio site for the study, treating 44 children from the area.

The study evaluated the effectiveness of metformin, a drug that helps lower sugar levels and one of only two drugs approved by the Food and Drug Administration for pediatric use. It also studied the success of metformin paired with rosiglitazone, a drug that also reduces the amount of sugar in the blood, and metformin taken in combination with diet and exercise. 

The results were disturbing. Lifestyle intervention had minimal effect on diabetes health outcomes. And although the children on the combined drugs did the best of the three study groups, all did poorly. 

“Half of our enrolled youth failed metformin therapy rapidly,” Dr. Lynch said. “It lost its effect.” 

Children with Type 2 diabetes experienced a very different, much more aggressive form of the disease than their adult counterparts.

“Deterioration in diabetes control was reported, and these youth with Type 2 diabetes were different from adult Type 2 diabetes patients for their very concerning rapid loss of the ability of the pancreas to continue to produce adequate insulin,” she said. “These youth could no longer be treated with the two oral study medications alone and required the addition of insulin therapy to control their blood sugars.” 

Because diabetes is a progressive disease that damages the cells in the pancreas that make insulin, many people with Type 2 eventually need insulin therapy. Insulin therapy uses a syringe, insulin pen or insulin pump to inject insulin into the fat under the skin to help maintain blood sugar levels.

But with the youth, the rate of deterioration of the insulin-producing pancreatic cells, called beta cells, was almost four times higher than in adults. And the kids kept getting sicker. By the time the treatment phase of the study was complete in 2011, many of the children had developed early kidney disease, and teenage boys were 81 percent more likely to develop hypertension. They also developed fatty liver disease, which can lead to liver failure.

“This is devastating,” Dr. Lynch said. 

Nearly a decade after the study began, participants were transitioned to routine medical care with their own physicians, with researchers continuing to monitor their progress. This second phase of the TODAY study, funded by the National Institutes of Health, began in 2011 and allows the researchers to record the long-term effects of Type 2 diabetes and the timing and prevalence of complications to the kidneys, heart, eyes and nerves, and overall health issues. The study has been extended twice, with the current funding slated to end in spring 2020.

Dr. Lynch has been following the same children for 15 years. Study participants are now in their mid-20s. While some have done well, others have struggled to maintain control of their diabetes. 

“It was pretty scary and it keeps getting more worrisome as results become available,” Dr. Lynch said. “This is the first generation that will not live to be as old as their parents—in history.”

Still, she said, there’s hope. 

“I feel like we missed a generation or two and now we’re trying to catch up,” Dr. Lynch said. “And we’re trying to figure out what is going to be most effective approach to turn the tide.”

While there are 34 drugs available to treat Type 2 diabetes in adults, there are only two approved by the FDA for use in children—metformin and insulin.

This is where Dr. Lynch and other researchers see a gaping window of opportunity. They have joined more than 55 other leading diabetes centers from around the country to form the Pediatric Diabetes Consortium. The group is helping redesign clinical drug studies to make them more accessible to pediatric participants. Whereas trials of the past required children to meet strict criteria in order to participate, the consortium is working to modify the trials to meet the children where they are in their disease. Already, the group has helped oversee and guide pharmaceutical and investigator-initiated clinical trials in nearly 50 sites throughout the U.S. Three of them are being led at UT Health San Antonio. 

“In the past year we have seen significant changes in study designs, which continue to improve,” Dr. Lynch said. “Each protocol has gotten a little better. We have now reached a point where these companies are willing to work with us to do these very kid-friendly studies, which is important to be successful.”

And while there are no new treatments yet, she believes new medications are on the horizon. Until then, she said, education and outreach are important tools to correctly diagnose and fight back against both Type 1 and Type 2 diabetes. Just one example, Camp Independence of San Antonio, provides a summer camp for children with diabetes and offers physical education, arts and crafts and diabetes-related educational games. UT Health San Antonio staff and endocrinology fellows volunteer each year to provide medical counseling and gain experience in the management of diabetes in children of all ages.

“I think we need to accept that Type 2 diabetes is a real threat to our youth and that we need to aggressively treat it, and we need to aggressively attempt to prevent it,” Dr. Lynch said. 

Fighting for health

family dinner

It took a crisis to get the Salazar family to change their eating habits. Now, parents Becky and Gabriel Salazar guide the family toward healthy meals. Photo by Mark Sobahni.

Before Liz Salazar was rushed to the emergency room on the brink of a diabetic coma Nov. 4, 2018, the Salazar family approached their health lackadaisically. 

“As young parents, our priority was to always accomplish as much as we could and not worry about the consequences of what we ate or how we ate,” said Gabriel Salazar, who was diagnosed with Type 2 diabetes at age 29. “It took a crisis like this to really change how we eat as a family.” 

Now, instead of eating out every day, they make their meals at home. “We’re disgusted by eating out now,” Becky Salazar said. 

Trips to the grocery store can take hours as they read nutrition labels to make sure they keep track of all the carbohydrates and sugars in each item. It takes a lot of work, time and money.

“It’s insane how much education you really need to have in order to maintain your healthy lifestyle,” Gabriel Salazar said. “You have to be aggressive and you have to really want to be healthy to maintain it. It takes a lot of work.”

But it’s worth it, they said. Not just for Liz, but also for her 7-year-old sister Leiya, who already struggles with weight and doesn’t much like eating healthy foods. They want to permanently change their lifestyle before it’s too late and affects her too.

“I think about my little sister and I try to play with her outside. Take more walks. Make sure she’s as healthy as we can get her,” Liz said. “I try to encourage her to do more so she doesn’t end up where I’m at now.”

It’s an uphill battle. The odds are statistically against Liz, but she doesn’t dwell on that. She has already lost nearly 30 pounds and has more energy. She feels better, overall. 

“I don’t worry about my health down the road,” she said, but she does think about her future. “I want to get certified to do personal training so I can use this experience to help others. I see myself teaching others—kids—because it could happen to them. It could happen to my little sister. I want to help others so they don’t get to the point I was in.

“Diabetes changes your life completely. I hurt my body for so long. I don’t want to do that anymore.”

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