Alarming increases of Type 2 diabetes in children are no closer to being managed successfully, according to a study in The New England Journal of Medicine showing common diabetes-control medications failed to work in children.

The study also found that because children now develop Type 2 diabetes at younger ages, there is an increased lifetime risk for serious complications such as heart attack and stroke. Terri H. Lipman, of the University of Pennsylvania School of Nursing, was a co-investigator in this multicenter study. Lipman, the Miriam Stirl endowed term professor of nutrition and professor of nursing of children, is an expert in pediatric diabetes.

"Increases in childhood obesity have yielded an increased incidence of Type 2 diabetes in children," says Lipman, who has a clinical practice at The Children's Hospital of Philadelphia. "It is important to understand that the epidemic of Type 2 diabetes in youth is secondary to high caloric intake and low activity. Both of these causes are a result of a multitude of socioeconomic factors that include food desserts and lack of safe places for activity."

Researchers analyzed 699 overweight children, ages 10 to 17, who recently were diagnosed with Type 2 diabetes, and found that 46 percent of those treated with the drug metformin, commonly used for diabetes control in adults, weren't able to maintain healthy blood sugar levels. They needed to begin more powerful insulin injections within slightly less than a year. Among all the study participants, one in five had a serious complication such as very high blood sugar, typically leading to hospitalization. The study also suggested that a healthy lifestyle has little bearing on the effectiveness of treatment.

Health care providers began noticing a significant increase in cases of Type 2 diabetes in children in the 1990s, especially among African-Americans and Hispanics from low-income families. The problem started even earlier in American Indians. Data from the Philadelphia Pediatric Diabetes Registry show that Type 2 diabetes is six times more common in African-American children than in Caucasian children. The Philadelphia registry, developed and maintained by Lipman, claims to be the only such registry in the U.S. operating since 1990.

The purpose of this latest study was to identify the best treatment for youth with Type 2 diabetes. All participants were overweight, some very obese. All received diabetes education, with the support of a parent or guardian. They then were assigned at random to one of three groups. One group took only metformin, a standard diabetes medication also called Glucophage. Another took metformin and a second medication, rosiglitazone, also called Avandia. A third group took metformin and went through an intensive diet, exercise, and weight-loss program, which has been successful in adults. Participants were followed for an average of four years.

All three regimens yielded high failure rates and were unable to control blood sugar levels. Metformin alone failed in 52 percent of participants; metformin plus rosiglitazone failed in 39 percent of participants; and metformin plus the diet program failed in 47 percent of participants. Metformin alone was least effective in African-American participants, and metformin combined with rosiglitazone worked better in girls than in boys. The failure rates were high even in the participants who adhered most strictly to their treatment programs.

"There is disappointment that the lifestyle intervention was not more effective, particularly because this intensive intervention included both a personal activity-nutrition leader (a study member acting as a lifestyle coach) and a family member designated for support throughout the intervention," Lipman says. "What we have learned is that the effect of the obesity-prone environment of these youths is even more difficult to overcome than we had predicted."

While better treatments are needed to manage Type 2 diabetes in children, Lipman says prevention is key.

"If we are ever to arrest the rise of Type 2 diabetes in youth, we must intervene with those at risk for this preventable disease," Lipman says. "This major public health problem must be addressed through collaboration among researchers, clinicians, and community partners."