Today at our annual meeting in Boston, the American Academy of Pediatrics doubled the recommended amount of vitamin D that children get each day to 400 IU, in response to mounting evidence of the life-long health benefits of getting plenty of the sunshine vitamin.

I applaud this move, and have felt for some time that the old 200 IU recommendation was too low. Taking the vitamin daily will be important for many kids, because they do not get enough from their sun exposure and diet. Over the summer, research showed an astonishing forty percent of healthy babies and toddlers were not getting enough – and the same was true of American teens.

The more closely we look at vitamin D, the more we learn about how important this sunshine vitamin is to both short and long-term health for children. Exciting research has linked getting abundant vitamin D to helping to prevent asthma, eczema, diabetes, and cancer – among other things.

It’s become more difficult to get enough vitamin D in recent years because kids spend more time indoors, wear more sunscreen (appropriately), eat less tuna (because of mercury concerns), and drink less vitamin D-fortified milk (in favor of sweetened drinks with less nutrition). It would take a quart of milk a day to get the levels now recommended.

A huge study of millions of kids revealed for the first time the true measure of type 2 diabetes in children in the United States. The results appeared in the June 27, 2007 Journal of the American Medical Association. In the recent past, type 2 diabetes was called adult-onset diabetes because this obesity-related condition was a problem of the middle-aged and the elderly. It usually takes years of unhealthy eating to tip someone into this type of diabetes. It was rarely seen before age 30 or even 40. Sadly, today we do see type 2 diabetes in children.

A family I saw yesterday had a 10-year-old who already had it. Pediatricians across the country are having similar experiences. But until this significant study none of us knew exactly how large the problem had become.

Stunningly, 22 percent of all diabetes diagnosed in US children was type 2. And in kids aged 10-19, type 2 diabetes was more common than the autoimmune type 1 (previously called juvenile diabetes) – even though type 1 has also been increasing over the last 2 decades around the world.

The consequences of overfed, undernourished, inactive lifestyles have reached from middle age into childhood. The message is clear: it’s time to feed our kids healthy amounts of healthy foods and to ensure that they get a liberal dose of active play every day.

The Writing Group for the SEARCH for Diabetes in Youth Study Group. “Incidence of Diabetes in Youth in the United States.” JAMA 2007, 297, pp. 2716-2724.

On Tuesday, August 27, 2002, the US Food and Drug Administration (FDA) announced that it had approved the Glucowatch for use in children and teens with diabetes. (It had been approved for adults in 2001).

This noninvasive device, worn like a wristwatch, is able to monitor blood glucose levels without pricking the skin. It is capable of following blood sugar levels 6 times an hour painlessly. The technology is not yet at a level where it should replace finger-stick tests, but already can provide much more information about blood sugar patterns than would be practical to obtain otherwise. And it holds great promise for eventually eliminating these needle sticks for children.

Over 150,000 children in the United States have diabetes. Treatment for the next generation of children with diabetes may look very different indeed.

Star GlucoWatch, a painless glucose monitor for diabetics that is worn like a wristwatch, is FDA-approved. The device measures glucose levels every 20 minutes — without needles — even while the wearer is sleeping.

Even though the device has yet to be approved for kids, it is a landmark step forward toward getting non-invasive, objective measures of kids’ health.

I look forward, for instance, to a device that is being developed that when shone in a child’s ear can diagnose an ear infection and tell you which bacteria is causing it, so you will know whether antibiotics are needed, and if so, which ones are most likely to work.

Dr. Greene’s Answer:

Until June 23, 1997, type 1 diabetes was also called insulin-dependent diabetes mellitus (IDDM). Normally, a hormone called insulin pushes sugar from the blood into the body’s cells where it can be used for fuel. The concentration of sugar in the blood remains within a fairly narrow range. If the body stops making insulin (type 1 diabetes), then adequate sugar doesn’t get into the cells.

Actually, all of us are insulin dependent; it’s just that some of us stop producing our own and need insulin injections. Without insulin, muscle and fat begin to be burned for fuel (evidence of this — ketones — shows up in the urine). The person feels hungry all the time, but loses weight in spite of increased eating. Without replacement insulin, the person would eventually starve to death. Meanwhile, the concentration of sugar in the blood begins to increase. We call it diabetes when the fasting blood sugar is at or above 126 mg/dL. When the level reaches around 180 mg/dL, the sugar begins to spill over into the urine. This causes the person to make more urine and then to get thirstier, creating an accelerating cycle.

The classic symptoms of type 1 diabetes, then, are increased urination (polyuria), increased thirst (polydipsia), increased eating (polyphagia) and weight loss. Anyone with the classic symptoms should have a blood sugar test as well as a urine test. Occasionally people also report fatigue, blurred vision, vomiting, abdominal pain, or frequent skin infections. If the disease remains undiagnosed, symptoms progress to include labored breathing, coma, and death.

People who get type 1 diabetes were born with a genetic predisposition to it. Not everyone born with this predisposition gets diabetes, however. In fact, if an identical twin has diabetes, the other twin gets it only about half the time. Along the way, some of the predisposed individuals are exposed to something in the environment that triggers the diabetes. Scientists believe this is usually a viral infection. The virus misleads the body’s immune system into making antibodies against its own pancreas cells that make insulin. (This is why type 1 diabetes is now also called immune-mediated diabetes.)

The insulin-producing cells of the pancreas are gradually destroyed over time. When 90% of them have been destroyed, the person suddenly begins to develop symptoms. Thus, insulin-dependent diabetes generally brews for years, but appears abruptly. It rarely goes undiagnosed for more than a few weeks.

Immune-mediated or type 1 diabetes most often strikes young people, especially between the ages of 5 and 7 (when viruses run through the schools), or at the time of puberty (when so many hormones change). For this reason, it used to be called juvenile-onset diabetes. This term has now been eliminated, since we now know that it can appear at any age. Currently, over a million people in the United States have type 1 diabetes. It is estimated that one in every 400-600 children and adolescents has type 1 diabetes. About 30,000 people develop it each year, and their lives will never be the same.

Dr. Greene’s Answer:

Timbo, I’m so glad you have raised this issue. There are indeed early ways to detect diabetes, but most children with type 1 diabetes are not diagnosed until the situation has become desperate. The diabetes symptoms that most people are familiar with (increased thirst and increased urination) are very late warning signs. By then, the child is dangerously close to the end, unless she receives prompt treatment.

Diabetes is a slow process that may have begun as long as nine years earlier – with no one suspecting.

In healthy children a hormone called insulin pushes sugar from the blood into the body’s cells, where it can be used for fuel. This insulin is produced in the pancreas. Diabetes is an attack on the pancreas.

People who get type 1 diabetes were born with a genetic predisposition to it. Not everyone born with this predisposition gets diabetes, however. In fact, if an identical twin has diabetes, the other twin only gets diabetes about half the time. Some predisposed individuals are exposed to something in the environment that triggers the diabetes. This is usually a viral infection. The virus misleads the body’s immune system into making antibodies that attack its own pancreas cells. Type 1 diabetes is what we call an autoimmune disease.

When diabetes first begins, the insulin-producing cells of the pancreas are destroyed gradually over months or years. The remaining cells are able to compensate for this by increasing their insulin production. The body can still make enough insulin to keep the concentration of sugar in the blood within a fairly narrow range.

Not until 90% of the insulin-producing cells are destroyed is the sugar no longer pushed effectively from the blood into the cells. The blood sugar level begins to rise. Without sugar in the cells, muscle and fat begin to be burned for fuel (evidence of this — ketones — shows up in the urine). The person feels hungry all the time, but loses weight in spite of increased eating.The person is literally starving.

Meanwhile, the concentration of sugar in the blood begins to increase. We call it diabetes when the fasting blood sugar is higher than 126 mg/dL. When the level reaches around 180 mg/dL, the sugar begins to spill over into the urine. This causes the person to make more urine and then to get thirstier, creating an accelerating cycle.

Thus, insulin-dependent diabetes generally brews for years, but appears abruptly. Then it rarely goes undiagnosed for more than a few weeks. The classic symptoms at diagnosis are increased urination (polyuria), increased thirst (polydipsia), increased eating (polyphagia) and weight loss. Anyone with the classic symptoms should have a blood sugar test as well as a urine test. Occasionally people also report fatigue, blurred vision, vomiting, or abdominal pain. If the disease remains undiagnosed, symptoms progress to include labored breathing, coma, and death.

How much better it would be to diagnose diabetes long before everything is out of control! As you have pointed out, Timbo, chronic yeast infections (or other skin infections) can be an early warning sign. Healthy kids in diapers commonly get yeast diaper rashes. But if these infections are very frequent, or not easy to clear up with appropriate treatment, I get concerned. If a child who is out of diapers develops even one yeast infection, the child should be checked for diabetes. In the pediatrician’s office, a blood sugar test can be performed to check for diabetes. Checking for diabetes is especially important if there is a family history of diabetes.

Other tests are available for even earlier detection of the diabetes process. People with type 1 diabetes have measurable antibodies in their blood that reveal their autoimmune condition. One autoantibody found in people with type 1 diabetes is the islet cell antibody. This antibody is often detectable months or years before symptoms appear. Other antibodies include the ICA 512 antibody and the GAD (or 64-K) antibody. The presence of these antibodies is a sign that the body is attacking its own insulin-producing cells. I expect that testing for autoantibodies will get less expensive and more common over the next several years.

An intriguing study released in October 1999 ¹ showed that by measuring the number of autoantibodies in siblings of children with diabetes, they were able to predict the risk each of these siblings had for going on to develop diabetes. They were even able to predict how long it would be likely to take.

Clearly this is useful information. It will become especially powerful when we find ways to prevent the autoantibodies from completing their destructive actions.

My hope is that in this next century, most diseases from cancer to diabetes to the common cold will no longer be thought of as beginning when we first notice the symptoms. As we are able to detect the true beginnings of these processes, we will be far more able to prevent and treat diseases before they wreak mayhem and destruction in our bodies.

Dr. Greene’s Answer:

Irina, just last week on Monday morning, I picked up the top chart from my inbox and began walking to Exam Room 1 (the Safari Room). Before opening the door, I paused to open the chart and glance at the nurse’s notes. I was about to meet a 7-year-old boy whose mother had brought him in because he had been drinking much more than usual for about 2 weeks — especially over the preceding weekend.

I stepped in the room and greeted the mother and son. They confirmed what had been written in the chart, adding that he had also been urinating much more than usual, and perhaps had lost some weight. As they spoke I could tell that the mom felt a little guilty about bringing him in unnecessarily, but at the same time she was worried that something might be seriously wrong. Parents often experience this dilemma. Whenever you are battling inside about whether to contact your doctor, do it.

The boy’s clothes were indeed loose fitting, but he otherwise appeared healthy. We did a simple urine test in the office, and two minutes later found that he had a huge amount of sugar and ketones in his urine. He had diabetes.

Even though the mom suspected the diagnosis, she was totally stunned. She couldn’t believe it was true. I sent them across the parking lot to the hospital lab for some bloodwork. His blood sugar level was 645 mg/dL! A fasting blood sugar over 126 mg/dL or a random blood sugar over 200 mg/dL is diagnostic of diabetes, according to the official American Diabetes Association definition as of June 23, 1997.

I admitted the surprised boy to the Packard Children’s Hospital at Stanford for the whole family to learn a new way of life with type 1 diabetes mellitus.

Now, Irina, I must reassure you that the first part of the above scenario is played out in my office about every two weeks. A child is brought in for nothing more than drinking or urinating more than usual. The weight and physical exam are normal, and I run a urine test. Thankfully, the test is almost always normal, and everyone can take a deep breath and relax.

About once a year, though, I diagnose someone with diabetes mellitus. The name comes from the Greek words for “to flow through” and “sweet.” The Greek physicians used to diagnose the condition by actually tasting the urine. (That’s dedication!).

Normally, a hormone called insulin pushes sugar from the blood into the body’s cells where it can be used for fuel. The concentration of sugar in the blood remains within a fairly narrow range. If the body stops making insulin (type 1 diabetes), then adequate sugar doesn’t get into the cells. Until June 23, 1997, type 1 diabetes was also called insulin-dependent diabetes mellitus (IDDM).

Actually, all of us are insulin dependent; it’s just that some of us stop producing our own. Without insulin, muscle and fat begin to be burned for fuel (evidence of this — ketones — shows up in the urine). The person feels hungry all the time, but loses weight in spite of increased eating. Without replacement insulin, the person would eventually starve to death. Meanwhile, the concentration of sugar in the blood begins to increase. When the level reaches 180 mg/dL, the sugar begins to spill over into the urine. This causes the person to make more urine and then to get thirstier, creating an accelerating cycle.

The classic symptoms of type 1 diabetes, then, are increased urination (polyuria), increased thirst (polydipsia), increased eating (polyphagia) and weight loss. Anyone with the classic symptoms should have a blood sugar test as well as a urine test. Occasionally people also report fatigue, blurred vision, vomiting, abdominal pain, or frequent skin infections. If the disease remains undiagnosed, symptoms progress to include labored breathing, coma, and death.

People who get type 1 diabetes were born with a genetic predisposition to it. Not everyone born with this predisposition gets diabetes, however. In fact, if an identical twin has diabetes, the other twin gets it only about half the time. Along the way, some of the predisposed individuals are exposed to something in the environment that triggers the diabetes. This is usually a viral infection. The virus misleads the body’s immune system into making antibodies against its own pancreas cells that make insulin. (This is why type 1 diabetes is now also called immune-mediated diabetes).

The insulin-producing cells of the pancreas are gradually destroyed over time. When 90% of them have been destroyed, the person suddenly begins to develop symptoms. Thus, insulin-dependent diabetes generally brews for years, but appears abruptly. It rarely goes undiagnosed for more than a few weeks.

Immune-mediated or type 1 diabetes most often strikes young people, especially between the ages of 5 and 7 (when viruses run through the schools), or at the time of puberty (when so many hormones change). For this reason, it used to be called juvenile-onset diabetes. This term has now been eliminated, since we now know that it can appear at any age. About 0.1-0.2% of the general public (or 1-2 out of 1000) has type 1 diabetes. About 500,000 people in the United States now have type 1 diabetes. About 30,000 people develop it each year, and their lives will never be the same.

Type 2 diabetes is caused, not by the absence of insulin, but by insulin’s not working properly. It is much more frequent in overweight adults over the age of 45, but can occur at any age and weight. There are often no symptoms. Thus, it is often picked up on routine screening tests. The National Institutes of Health estimates that more than 7 million adults in the United States have undiagnosed type 2 diabetes.

So, Irina, given your concern about your daughter, I would recommend bringing her in. Since her hefty thirst appears to be her normal pattern rather than a recent increase, I expect you will be happy with the results.

In the unlikely event that you are not, I strongly recommend a website called children with DIABETES. Anyone who has type 1 diabetes, or anyone who has a child with type 1 diabetes, will be hooked on this site. It is loaded with excellent information and has real-time chat rooms. They call themselves “The on-line community for kids, families and adults with type 1 diabetes,” and they live up to their claim!