We are in a hurry all the time, overcome stress, struggle with physical inactivity, eat quickly … And what followed? The number of patients has increased, for example, diabetes mellitus (DM), obesity, hypertension. Unfortunately, children and adolescents are not spared many diseases.
Diabetes “grew up” and “younger”
The total number of patients with diabetes (both the first and second type) in the world has exceeded 150 million people; Russia has officially registered 2.5 million patients among adults. Approximately the same person is at the stage of pre-diabetes. But in fact, the number of patients is two to three times higher than the official figures … Each year the number of patients increases by 5-7%, and every 12-15 years doubles. Children’s statistics are still sad – until the 90s there was an increase in the incidence of not more than 4%. After 2000 – up to 46% of new cases per year. In the last decade, the increase in diabetes from 0.7 to 7.2 cases of diabetes per 100,000 adolescents.
Diabetes, translated from Greek means “outflow” and, therefore, diabetes mellitus literally means “losing sugar”, was known in ancient Egypt. In the 17th century, the sweet taste of urine in a patient with diabetes was first described; this later became the main symptom for diagnosing the disease. In 1889, Mr .. Langergans under microscopy of the pancreas found specific clusters of cells, later named after him, but the scientist could not explain their significance for the body. In the same 1889, Mehring and Minkowski caused diabetes mellitus in animals, removing the pancreas. In 1921, for the first time, Banting and Best in Toronto received insulin, which in a dog with diabetes eliminated the symptoms of the disease, and in 1922 the first patient with diabetes began to receive insulin injections. In 1960, the chemical structure of human insulin was established. In 1976, human insulin was synthesized from pig insulin, and in 1979, a complete genetic engineering synthesis of human insulin was carried out.
What and why
Diabetes mellitus, as defined by WHO, is a disease of the endocrine system, in which there is a state of chronic elevated blood glucose (hyperglycemia), which can develop as a result of many genetic, exogenous and other factors. Hyperglycemia may be due to either a lack of insulin, a pancreatic hormone, or an excess of factors that counteract its activity. The disease is accompanied by deep disorders of carbohydrate, fat and protein metabolism and the development of insufficiency of various organs and systems, especially the eyes, kidneys, nerves, heart and blood vessels.
According to modern concepts, insulin-dependent diabetes mellitus (IDDM) type 1, which develops in childhood and adolescence (mostly up to 30 years old), is a disease that develops against a background of genetic (hereditary) susceptibility when exposed to environmental factors. The causes of type 1 diabetes are that insulin production decreases or stops altogether due to the death of beta cells (Langerhans cells) of the pancreas under the influence of, for example, a viral infection, the presence of toxic agents in food, such as nitrosoamine, stress and other factors.
Diabetes mellitus type 2, which mainly affects the elderly, is four times more common than type 1 diabetes. In this case, the beta cells first produce insulin in normal and even large quantities. However, its activity is reduced (as a rule, due to the redundancy of adipose tissue, the receptors of which have a reduced insulin sensitivity). In the future, there may be a decrease in the formation of insulin. The causes of type 2 diabetes are genetic predisposition, obesity, often associated with overeating, as well as diseases of the endocrine system (pathology of the pituitary, thyroid gland (hypo- and hyperfunction), adrenal cortex). In more rare cases, type 2 diabetes can also occur as a complication of viral diseases (influenza, viral hepatitis, herpes virus, etc.), gallstone and hypertension, pancreatitis, pancreatic tumors.
Classification of diabetes mellitus (DM) and impaired glucose tolerance
Type 1 – insulin-dependent diabetes mellitus (IDDM);
Type 2 – non-insulin dependent diabetes mellitus (NIDDM);
Type 3 diabetes with other syndromes or other causes;
Type 4 – impaired glucose tolerance (the so-called prediabetes stage):
no obesity
with obesity
Type 5 – diabetes of pregnant women.
Assess the risks of diabetes
Specialists endocrinologists believe that the risk of diabetes increases, if someone in your family is sick or has diabetes. However, different sources cite different figures that determine the likelihood of the disease. There are observations that type 1 diabetes is inherited with a probability of 3-7% through the mother and with a probability of 10% through the father. If both parents are sick, the risk of the disease increases several times – up to 70%. Diabetes of the second type is inherited with a probability of 80% both on the maternal and paternal lines, and if type 2 diabetes is sick of both parents, the probability of its manifestation in children approaches 100%.
Therefore, a family where blood relatives have cases of diabetes should be remembered that the child is in the “risk group”, and therefore it is necessary to minimize the risk of developing this serious disease (prevention of infection, healthy lifestyle and nutrition, etc.).
The second most important cause of diabetes is overweight or obesity, this symptom is important in both adults and children. For a long time of their practice and observations, endocrinologists have found that almost 90% of patients with type 2 diabetes are obese, and pronounced obesity can increase the likelihood of diabetes in almost 100% of people. Every 5–10 extra pounds increases the risk of developing various diseases by a factor of 5–10: incl. cardiovascular, such as myocardial infarction and cerebral stroke, diseases of the joints and, of course, diabetes.
The third reason that plays a role in the development of diabetes, especially in childhood, is viral infections (rubella, chicken pox, epidemic hepatitis and other diseases, including flu). These infections play the role of a mechanism that triggers an autoimmune process in children with immunological disorders (often not previously diagnosed). Of course, for most people, the flu or chickenpox will not be the beginning of diabetes. But if a child is obese from a family where his father or mother has diabetes, then for him and the flu poses some threat.
Another reason for the development of diabetes are diseases of the pancreas, in which there is a defeat of beta cells, such as pancreatitis (inflammation of the pancreas), pancreatic cancer, organ trauma, as well as poisoning with medicines or chemicals. These diseases develop mainly in older age. Also, in adults, an important role in the onset of diabetes is played by chronic stress and emotional overstrain, especially if the person is overweight and sick in the family.
I want to note that in adolescents the risk factors for the development of type 2 diabetes are:
- obesity
- decrease in physical activity
- burdened heredity
- puberty
- polycystic ovary syndrome in girls
Currently, pediatricians and children’s endocrinologists are concerned about the development of the so-called “metabolic syndrome” in adolescents: obesity + insulin resistance (a condition in which there is a decrease in glucose consumption by the tissues at normal insulin concentrations). Insufficient consumption of glucose by the tissues leads to the stimulation of Langerhans cells, the production of new insulin portions and the development of hyperinsulinemia), plus dyslipidemia (elevated / altered blood lipid levels), plus arterial hypertension.
In the United States, metabolic syndrome was detected in 4.2% of adolescents among the entire adolescent population (studies from 1988–1994), and boys are more susceptible to this syndrome than girls. It was also found that impaired glucose tolerance is observed in 21% of adolescents with obesity. In Russia, there is no full-fledged statistics, but in 1994, the Register of diabetes patients with children living in Moscow was created within the framework of the State Register of Diabetes. It was established that the incidence of IDDM in children in 1994 was 11.7 people. per 100 thousand child population, and in 1995 – 12.1 per 100 thousand. This is a sad dynamic.
Time to recognize
Diabetes mellitus refers to the number of diseases with many “masks”. If the disease (type 1 diabetes) develops in children, especially at an early age, then the latent (hidden) period is often short – while parents can pay attention only to the fact that the child suddenly began to drink and urinate a lot, including at night, may occur enuresis. The child may change his appetite: either there is a constant desire to eat or, conversely, a complete rejection of food. The baby quickly loses weight, becomes sluggish, does not want to play and walk. Both parents and pediatricians may not notice these symptoms, because there are no clear manifestations of the disease (fever, cough and rhinitis, etc.). In some children, in the early stages of diabetes mellitus, skin diseases can appear: eczema, boils, fungal diseases, periodontal disease develops.
And if the diagnosis is not made in time, the child’s condition worsens dramatically – diabetic ketoacidosis develops: thirst, dryness of mucous membranes and skin develop, children complain of weakness, headache, drowsiness. Nausea and vomiting appear, which soon becomes more frequent. As ketoacidosis increases, breathing becomes frequent, noisy and deep, the child smells like acetone. There may be a disorder of consciousness up to a coma, and if the emergency care is not provided to the little patient, he may die.
In adolescents with the development of type 2 diabetes, the clinical picture is growing slowly. The first symptoms of the disease may be increased thirst (polydipsia), an increase in the volume and frequency of urination (polyuria), the appearance of nocturnal enuresis, itching of the skin and genitals, fatigue.
Find and neutralize diabetes
- The easiest way to detect a disease or impaired glucose tolerance is to determine the blood glucose level. Normal fasting blood glucose ranges in healthy people in the range of 3.5-5.5 mmol / l.
- If the study of morning urine revealed glucosuria (presence of glucose in the urine), aceturia (presence of acetone bodies in the urine), ketonuria (presence of ketone bodies in the urine) or an increased level of blood glucose, you should contact a specialist and conduct a special examination – glucose tolerance test .
- Glucose Tolerance Test (sugar curve).
- Before the test, it is necessary to give the child a regular diet without restriction of carbohydrates for three days. The test is carried out in the morning on an empty stomach. The child is given a drink of glucose syrup (glucose is prescribed at the rate of 1.75 g / kg of ideal weight, but not more than 75 g). The study of sugar is carried out on an empty stomach 60 and 120 minutes after administration of glucose.
- Normally, after 1 hour the level of glucose in the blood should rise no higher than 8.8 mmol / l, after 2 hours be no more than 7.8 mmol / l or return to the normal fasting value.
- If the glucose level in the plasma of venous blood or in whole blood on an empty stomach exceeds 15 mmol / l (or several times on an empty stomach exceeds the level of 7.8 mmol / l), a glucose tolerance test is not required to make a diagnosis of diabetes mellitus.
- Obese children who have 2 more risk factors – burdened heredity on type 2 diabetes and signs of insulin resistance – should be examined for blood glucose at least every 2 years, starting at 10 years of age.
- Consultation with an endocrinologist, an ophthalmologist, a neurologist, a nephrologist, an orthopedist is obligatory.
- Additional special examination methods are possible: determination of the level of glycated hemoglobin in the blood (HbA1c), concentrations of proinsulin, C-peptide, glucagon, ultrasound of the internal organs and kidneys, fundus examination, determination of the level of microalbuminuria, etc., which specialists will assign to the child.
- If there are repeated cases of diabetes in the family, especially with the parents of the child, a genetic study can be performed to diagnose the disease early or predispose to it.
- There are various ways of treating diabetes. The most important goals in the treatment of diabetes are the elimination of symptoms, optimal metabolic control, the prevention of acute and chronic complications, and the achievement of a higher quality of life for patients.
The basic principles of treatment are diabetic diet, exercise dose, self-control of blood glucose levels, etc. taught in diabetes schools. Now there are many such schools. Around the world, children with diabetes and their parents have the opportunity to gain knowledge about their disease, and this helps them to be full members of society.
The first diabetes school has been operating in Moscow since 1989. After the initial training, if necessary, after 1-2 years, adolescents or relatives of sick children can undergo a repeated course of study to consolidate and update knowledge about diabetes.
Non-pharmacological treatment of diabetes
Diet therapy in diabetes should meet the following requirements: the exclusion of easily digestible carbohydrates (sugar, chocolate, honey, jam, etc.) and a low intake of saturated fat. All carbohydrates should provide 50-60% of the daily caloric intake, proteins not more than 15%, and the total fat content should not exceed 30-35% of the daily energy requirement. For young children under 1 year old, the calculation of food and the number of meals, including feeding, is carried out by type of feeding (artificial, mixed, natural). It should be noted that ideally up to 1.5 years to maintain breastfeeding.
Mandatory weight loss is the first step to the prevention and treatment of diabetes.
It is also necessary to explain to the sick child the need for self-control and to train him at home with the help of test strips (determination of the level of glucose in the blood and urine).
With the duration of diabetes over 5 years, careful monitoring of blood pressure, urine for albuminuria, annual consultation of patients in the office of vascular diagnosis of an eye clinic for the detection of retinopathy are necessary. Twice a year, the child should be examined by a dentist and ENT doctor.
Young patients need psychological help and support from adults, not the gift of the motto of many diabetes schools – “Diabetes is a way of life.” But parents need to remember that the constant fear for their child and the desire to protect him from everything can lead to the fact that the child will also begin to perceive the world around us as a world that is dangerous and dangerous at every step.
Drug treatment of diabetes
- Treatment of type 2 diabetes begins with the appointment of sugar-reducing drugs in the form of tablets.
- Insulin therapy.
Insulin regulates the sugar content in the blood, contributing to the conversion of excess sugar entering the body into glycogen. Insulin receptors act as a kind of “locks”, and insulin can be likened to a key that opens locks and allows glucose to enter the cell, therefore during IDDM, treatment begins with insulin therapy.
In adult patients with a long-term course of the disease, addiction to sugar-reducing drugs in the form of tablets often develops, and after 10–15 years from the onset of the disease, an average of 10–15% of patients with type 2 diabetes switch to insulin treatment.
In case of diabetes mellitus, insulin is injected subcutaneously. Insulin cannot be taken inside, as the digestive juices destroy it. To facilitate the implementation of injections using semi-automatic injectors – syringes, pens.
Over time, the need for insulin increases, appetite may change, in children it decreases more often. Therefore, it is necessary to carefully monitor blood glucose, as well as urine glucose and acetone.
Features of the disease
In most children with IDDM, within 2–4 weeks from the moment of diagnosis and correct therapy, regression of the disease begins, even a temporary remission is possible, when the need for insulin sharply decreases. This phase can last up to several months. Unfortunately, the need for insulin rises again and reaches in 3-5 years from the onset of the disease 0.8-1 U / kg of body weight. During puberty, when there is a jump in growth and an increase in body weight, the course of diabetes is labile and requires very careful monitoring. After the end of adolescence, diabetes becomes stable again.
Often, diabetes is the first manifestation of the pathology of the entire endocrine system. Subsequently, children may develop autoimmune diseases of other endocrine glands, primarily the thyroid gland. Poor compensation for diabetes leads to disruption of all types of metabolism and especially protein, which in turn is accompanied by a decrease in nonspecific protection and immunity. As a result, the frequency of developing infectious lesions of the skin and mucous membranes in the form of pyoderma and fungal infections, complicates the process of wound healing.
Acute complications of diabetes mellitus in childhood include: keto-acetosis, keto-acidosis coma, hypoxlemic states and hypoxlemic coma, hyperosmolar coma.
The remaining complications in children develop slowly. They are based on vascular complications – microangiopathy, the development of which depends on the genetic characteristics of the child and the compensation of carbohydrate metabolism. Usually microangiopathy develops in 5-7 years from the onset of the disease. Complications can manifest as:
- kidney damage (diabetic nephropathy);
- lesions of the nervous system (diabetic neuropathy, encephalopathy);
- eye damage (diabetic retinopathy);
Often, patients are detected infectious complications, including tuberculosis.
Disease child diabetes is certainly stressful for the whole family. But with a strong alliance between the family and the doctor, we will be able to provide the child with proper physical and mental development, as well as adequate social orientation. Children suffering from this disease can actively participate in the life of the school, with a sufficient level of preparedness, they can go on trips, go hiking, drive a car, etc. with their parents. Having matured, they can have high-grade families. And correct and during diabetes therapy will ensure the development of complications as late as possible.