Should children with type 2 diabetes be offered a gastric op?
As a side-effect of the rise in childhood obesity, an increasing number of children are being diagnosed with type 2 diabetes - particularly, in some UK cities, in the Asian community. Will the NHS consider an approach now being tried in the US, and offer these children bariatric surgery, asks the BBC's Sue Mitchell.
Type 2 diabetes was once known as "adult-onset diabetes" but two weeks ago Zaira was diagnosed with it at the age of 14. She is still trying to process the news.
"It was shocking because I didn't know I had diabetes. I just felt like I had stomach ache," she says.
Zaira knew she was overweight, and for a while she had tried to lose weight - but her efforts seemed to have no effect, so she gave up.
She was planning on trying again another time, and hadn't realised diabetes could strike so soon.
"I do feel ashamed. In school we've been told about diabetes and how it's something people get later in life if they're overweight," she says.
"I've got relatives who have it but they're much older. I didn't think I'd get it."
Zaira lives in Bradford and is being treated at St Luke's Hospital, where children with type 2 diabetes were unheard of 11 years ago when consultant paediatrician Dr Mathew Mathai started work in the paediatric diabetes clinic. Back then he only saw type 1 diabetes, which has nothing to do with diet or lifestyle. But now there are at least 18 children with type 2 diabetes at any one time - and the disease is turning out to develop much more quickly in the young than it does in adults.
"The complications are quite significant and they start quite early," Mathai says.
"They include damage to the small blood vessels of the eye, the kidneys and to other organs, and this occurs much earlier on. And therefore we really need to try and see how we can reduce that risk, but the treatment options at the moment aren't there."
A range of medication has been licensed for adults but there is only one oral medication for children - metformin, which lowers the amount of sugar in the blood.
What is type 2 diabetes?
- Type 2 diabetes is a common condition that causes the level of sugar in the blood to become too high
- It's caused by problems with a chemical in the body called insulin, which allows the sugar in our blood to enter our cells and fuel our bodies - if you have type 2 diabetes either the insulin you make can't work effectively or you can't produce enough
- It can cause symptoms like excessive thirst, needing to pee a lot and tiredness
- In the long term it can lead to heart disease and stroke, nerve damage, foot sores that can necessitate amputation, vision loss, miscarriage and kidney problems
One of Mathai's patients, Maryam, was diagnosed when she was just 10 years old. She's now 14 and has struggled to control her diabetes for the last four years. Initially she was given metformin in tablet form, which she had difficulty swallowing. A cousin then tried putting the tablets in chapatis for her, but it didn't work, so she tried the syrup form - but hated the taste. She now injects insulin and before summer she was missing more than half of her weekly treatments.
That all changed in July when Maryam went to stay with relatives in Pakistan. She swapped the junk food in her freezer and endless visits to takeaways near her Bradford home, for her gran's home-cooked meals and a never-ending supply of fresh fruit. At home she rarely exercised and was driven to and from school, but in Pakistan she had to walk everywhere. After two months she had lost 5kg and could feel her clothes becoming looser.
"In the UK we don't do anything, there's nothing to do. We just wash dishes and sit in front of the TV and go to a drawer and get something to eat," she says.
"We're always eating. We're not making ourselves more active as we should be. In Pakistan I saw how thin the girls were and I was really thinking about it and I thought I need to lose my weight.
"I was looking at them and thinking about my health as well."
At her latest appointment with doctors at the paediatric diabetic clinic, Maryam weighed 115kg. She is still considered clinically obese, with a body mass index of 45.7 but staff think she may have turned a corner.
"I think this is the first time I've seen Maryam be successful in losing weight, but also she seems confident that she can continue to lose weight and I think that's a real achievement," says paediatric dietitian Alison Woodhead.
"So we will keep seeing her and supporting her and her family. I think maybe the environment in Pakistan helped her to lose weight and she's realised she can do it."
Sadly, many other patients find it very hard to change.
Just before Ahmed (not his real name) sat his GCSE exams he was warned that he was in danger of developing type 2 diabetes, and three months later the diagnosis has been confirmed. He says he regularly eats burgers and pizzas and does little exercise. His body mass index is 37.5 - less than Maryam's but still obese. At the age of 16, he already has high blood pressure.
Ahmed has seen his dad and other relatives develop type 2 diabetes in later life, and although his dad has recently had a heart attack he'd already had the disease for some years. It may be that Ahmed thinks the disease will progress slowly in his case too.
"It is a lot of shock and grief when they are diagnosed. I think sometimes we might think, 'Well, that shock would be enough to motivate someone to do something about it.' But it doesn't work like that," says Vicki Lee, a psychologist who works alongside paediatricians and dietitians in the Bradford Children's Diabetes Service.
"The brain is very much still under construction until 25 and the last bit to develop is being able to think about long-term consequences, and so that's why with adolescents we often see behaviour that's more about the kind of short-term gain and what's important for me right now.
"I've had people say to me they only really think about diabetes on the way to clinic and then maybe for that night. Unfortunately that's reflected in their behaviour, in terms of not taking medication or not adhering to the advice that they've been given."
Find out more
People of Asian origin, like Zaira, Maryam and Ahmed are particularly susceptible to diabetes because of their body type. Fourteen thousand babies born in Bradford between 2007 and 2009 are being tracked from birth by health researchers in one of the largest longitudinal health studies of its kind, the Born in Bradford study. It has demonstrated how from birth the children of Pakistani families are carrying more fat around the waist than white children. They are five times more likely to develop diabetes and seven times more likely to have type 2 diabetes when they're young.
According to Dr John Wright, who leads the research, there are important cultural differences in terms of lifestyle and exercise.
"We know that our South Asian children in the first year of life have pretty similar physical activity to white children, but by three or four they're more sedentary," he says.
"By five or six they're really considerably less physically active and by 10 and 11 that's really starting to pull away - and particularly in South Asian girls. So we're seeing those trajectories of physical activity really at an early stage, and that divergence between ethnic groups."
The US has a more deeply entrenched problem with child diabetes and doctors in the UK have been following their efforts to tackle it. Some British paediatric diabetes clinics have adopted the US model for their type 2 teenagers, ensuring that a dietitian and a psychologist work with each family.
One of the first doctors in the world to report on the alarming increase in child diabetes, was Dr Philip Zeitler, who spotted a sevenfold increase in the number of cases in the Children's Hospital, Colorado, in the late 1980s and early 1990s.
He now oversees the Today study, which started in 2004 and has been tracking 699 teenagers, all of whom have been given one of three alternative treatments: metformin; metformin plus another drug, rosiglitazone (not licensed for children in the UK); or metformin plus lifestyle changes affecting diet and exercise.
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Zeitler says the research has led US doctors to favour a more aggressive approach.
"What we saw was that the ability of the pancreas to make insulin is deteriorating much more rapidly than it is in adults in these kids. Nobody knows why," he says.
The bodies of children with type 2 diabetes become less sensitive to insulin, and the pancreas initially responds by producing "massive" amounts, Zeitler says. But then the amount of insulin produced begins to decrease fast.
"The speculation is that this incredible demand that's being placed on the pancreas to make insulin during puberty is one of the reasons why this deterioration happens so quickly. And probably the biggest recommendation changes are much more aggressive treatment of kids," he says.
"The default position has been, 'Well, you know, they're kids, we shouldn't be exposing them to lots of medications and we should take our time.' And I think what we've learned is that that's the exact opposite of what we should be doing."
Today in the US some youngsters with a body mass index of 35 or over are offered the option of gastric bypass operations, and the early results appear promising.
Megan Kelsey, a paediatric endocrinologist who is the medical director for the bariatric surgery programme at the Children's Hospital, Colorado, says an operation called a sleeve gastrectomy - in which 80% of the stomach is removed, leaving a tube-shaped stomach the size of a banana - appears to have a positive effect.
"That makes your stomach smaller but it also changes your metabolism, and for some reason we don't really understand it makes your pancreas work better," she says.
"And so many patients who have this surgery can come off all of their medications, and many others can come off their insulin and just be on pills."
One of those earmarked for gastric surgery is 16-year-old Arleth Avila, who is currently struggling to control her blood sugar levels, despite having largely given up junk food and following portion control at home. As with all surgery, there can be complications, but she has no hesitations about wanting to try it, if it offers the possibility of coming off insulin.
"It would be a chance for my health and to be better - I'd definitely take that chance," she says.
Doctors in this country are reluctant to turn to surgery for the growing number of youngsters they're seeing with type 2 diabetes.
In Bradford, Dr John Wright believes that solutions have to come through partnerships between medical staff and communities who know the problems they face.
"One of the most effective treatments for obesity, any type of obesity, is gastric stapling and that's OK when you've got extreme cases but given that 60% of our adult population are overweight or obese, we can't set up massive hospital centres just for gastric stapling to deal with this," he says.
"For individual children like the children with diabetes that you've been talking to, I think it's a quick fix and I think that investment of funding is easy because it's immediate. But the harder issue is to tackle the complex causes and, if we're braver, we should be doing that."
Zaira, the 14-year-old recently diagnosed with type 2 diabetes is getting strong support from her family, particularly her mum, Zahida, who was diagnosed with diabetes herself during pregnancy and began a weight-loss programme after the last of her children was born. Through a combination of a healthier diet and more regular exercise she was able to lose around 36kg. She now thinks Zaira will definitely be able to turn things around.
With regular visits from dietitian Alison Woodhead, and input from others in the Bradford paediatric diabetes team, they've introduced several changes, including more regular family walks with the dog, a switch to healthy packed lunches, fewer fizzy drinks and care over portion sizes, especially at big gatherings and celebrations. Zaira says she already feels better and is hopeful that if she keeps up the improvements she might eventually be able to come off her metformin medication.
"My blood sugar levels are improving and I'm keeping to all the changes. Now I try to do at least an hour of exercise a day," she says.
"Before I used to just have chocolates or sweets when I was hungry and doing my homework, but now that I'm more active, I don't feel hungry. If I do then I just get an apple. I think I can do it."
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