Overweight and obese teenagers with diabetes may be difficult to treat: Study

By Dr. Ananya Mandal, MDApr 30 2012

New research shows that overweight and obese teenagers who get diabetes may have a tough time keeping it under control.

According to a major study released Sunday, several ways to manage blood sugar in teens newly diagnosed with diabetes were tested. The researchers found that nearly half of them failed within a few years and 1 in 5 suffered serious complications. This is concerning since there is an epidemic rise of Type 2 diabetes brought on by obesity.

A third of American children and teens are overweight or obese. They are at higher risk of developing Type 2 diabetes, in which the body can't make enough insulin or use what it does make to process sugar from food. Until the obesity epidemic, doctors rarely saw children with Type 2 diabetes. The more common kind of diabetes in children is Type 1, which used to be called juvenile diabetes.

“It’s frightening how severe this metabolic disease is in children,” said Dr. David M. Nathan, an author of the study and director of the diabetes center at Massachusetts General Hospital. “It’s really got a hold on them, and it’s hard to turn around.”

The federally funded study is the largest look yet at how to treat diabetes in teens. Earlier studies mostly have been in adults, and most diabetes drugs aren't even approved for youths. “Don't get diabetes in the first place,” said Dr. Phil Zeitler of the University of Colorado Denver, one of the study leaders.

For therapy doctors usually start with metformin, a pill to lower blood sugar. If it still can't be controlled, other drugs and daily insulin shots may be needed. The longer blood sugar remains high, the greater the risk of suffering vision loss, nerve damage, kidney failure, limb amputation — even heart attacks and strokes.

The study involved 699 overweight and obese teens recently diagnosed with diabetes. All had their blood sugar normalized with metformin, then were given one of three treatments to try to maintain that control: metformin alone, metformin plus diet and exercise counselling, or metformin plus a second drug, Avandia.

Over the course of 46 months, the researchers found that metformin alone did not adequately control blood sugar levels in 51.7 percent of patients. Among those who received metformin and lifestyle changes, 46.6 percent did not have their blood sugar controlled. However, among those taking metformin and Avandia, blood sugar levels were not well-controlled in only 38.6 percent of patients, the researchers found. In addition, blood sugar control was harder to achieve in black and Hispanic children, they added. Among all the teens in the study, 1 in 5 had a serious complication such as very high blood sugar, usually needing hospitalization.

Zeitler noted that the choice of Avandia as a companion medication was made in 2002, before the cardiac problems with the drug were known. “Given the problems with rosiglitazone, we are not recommending it at this time,” he said. “However, no problems with rosiglitazone have been noted in [the study participants] to date, though the cohort size is too small for a thorough safety analysis.”

“Metformin is probably not as effective as we've assumed, and additional treatment approaches are urgently needed in this population of adolescents with a steadily progressive form of diabetes,” Zeitler said. In terms of lifestyle changes, Zeitler isn't sure why they didn't work better. Part of the reason may be tied to children's reluctance to adopt new diet and exercise habits, he said.

Another study leader from Children's Hospital Los Angeles, Dr. Mitchell Geffner, agreed that Avandia can't be recommended for teens, but said the study makes clear they will need more than metformin to control their disease. “A single pill or single approach is not going to get the job done,” he said.

Dr. Joel Zonszein, director of the clinical diabetes center at Montefiore Medical Center in New York City, said that “type 2 diabetes in children and adolescents is a calamity, because we don't have any good medications.” “It is not surprising that combination is better than mono-therapy,” Zonszein said. “We want to be aggressive in treating type 2 diabetes in children, but we have to balance the risk and benefits of these drugs. But, we really don't have good data and good medications to treat children.”

Another expert, Dr. Spyros Mezitis, an endocrinologist at Lenox Hill Hospital in New York City, added that “we need a whole new set of studies to see how to treat type 2 diabetes in children.”

The results were published online Sunday by the New England Journal of Medicine and presented at a pediatric meeting in Boston. The National Institutes of Health funded the study and drug companies donated the medications.

Dr. David Allen of the University of Wisconsin School of Medicine and Public Health wrote in an accompanying editorial that the discouraging results point to the need to create “a healthier 'eat less, move more'” culture to help avoid obesity that contributes to diabetes.