Until 10 years ago, children who were diagnosed with diabetes nearly always had type 1, once called juvenile-onset, disease.

What a difference a decade makes. A growing number of kids are getting type 2 diabetes, the kind that used to be called adult-onset because it started in middle age.

An index to the series

Although a recent study indicates pediatric type 2 diabetes is still relatively infrequent, experts are concerned about the trend and the impact the condition, particularly its complications, might have on affected children and families.

"It does exist and it's increasing," noted endocrinologist Dr. Silva Arslanian, director of the Weight Management and Wellness Center at Children's Hospital. "It's increasing because more and more children are becoming obese."

Stephanie Wilkerson, of Ross, sought solutions for daughter Umayma Dixon's weight problem for years, but as she put it, diabetes never crossed her mind.

"Until she was diagnosed, I wasn't even aware it was happening in children," Ms. Wilkerson said.

Umayma's doctors checked her for thyroid and other problems that can lead to overweight, but none mentioned diabetes. Her worried mom learned about the importance of screening for it while reading books about childhood obesity.

In a June issue of the Journal of the American Medical Association, researchers from the SEARCH for Diabetes in Youth Study Group estimated that 3,700 youth are diagnosed with type 2 annually in the United States.

Cases are more common among older teens who belong to racial or ethnic minorities, the study group said.

African American, Hispanic, Asian/Pacific Islander and American Indian children are at greater risk, as are those with a family history of diabetes, said Dr. Arslanian, who was a member of a 2000 American Diabetes Association expert panel that developed screening guidelines for doctors.

Girls who have polycystic ovarian syndrome are also more likely to develop the condition, she noted.

Also, "if the mother during her pregnancy had diabetes or gestational diabetes, then the risk for the adolescent to have type 2 diabetes is very high," the doctor said. "The risk for obesity is very high, too."

While not every overweight youngster is or will become diabetic, the association between the two is unavoidable.

If a child has a body mass index, or BMI, that ranks above the 85th percentile in comparison with peers of the same sex and age, along with two additional risk factors, "then one needs to rule out the possibility of type 2 diabetes, which can be a silent disease," Dr. Arslanian recommended.

Despite greater public and professional awareness of the problem, many children don't get diagnosed until they already have symptoms, she added.

Umayma didn't urinate more frequently and wasn't excessively thirsty. But she did have dark, thick skin lesions called acanthosis nigricans, which can be a marker for high insulin levels as well as other conditions.

In type 2 diabetes, the pancreas must increase insulin production because muscle and other cells become less sensitive to the hormone, which is known as insulin resistance. In type 1, the pancreatic cells that make insulin are destroyed by the immune system. In both types, blood sugar rises.

There were other reasons to consider screening Umayma for type 2 diabetes. Her maternal grandmother, one of 14 children, had 10 siblings who were diagnosed with the condition as adults, Ms. Wilkerson said.

But Umayma's size sounded the loudest alarm. Even as a toddler, she was large for her age, her mother noted.

"At [age] 1, she wore a 3T," Ms. Wilkerson said. "By the time she was 3, she wore a size 6. And she just kept getting bigger and bigger."

Now 10, Umayma is 5 feet, 3 inches tall and weighs 190 pounds, and her BMI exceeds the 95th percentile. Soon to be a fifth-grader, "she's as big or bigger than most of her teachers," her mom said.

In 2004, when she was 7, Umayma had blood tests that showed she had type 2 diabetes. Soon, she was taking metformin, an oral medication, to control her blood sugar. The dose was increased a couple of times before the level was in the appropriate range.

Twice daily, the girl pricks her finger to test her blood sugar, and keeps a log of the results to show her doctor. And she's trying hard to lose weight by watching what she eats and exercising.

Sometimes, though, "I pack her a good lunch and she goes to school and trades it," said a rueful Ms. Wilkerson. "It's being a kid."

But, she noted, people who don't know Umayma don't realize she's a kid, and that can be frustrating and hurtful. It's not the fault of diabetes, Ms. Wilkerson knows, but the result of being tall and heavy for her age.

So at the park, other children don't approach her to play (Umayma says they think she's one of the moms) and if she has words with another child, the assumption is she's older and a bully. And at restaurants, she's never offered a kids' menu.

Umayma understands the only way to find out if dropping the extra pounds will make the diabetes go away is to do it and see what happens, said her mom, who also wants the girl to be aware of the complications of the disease.

Ms. Wilkerson has a relative who lost toes to type 2 diabetes, so as she put it, Umayma knows "there are consequences in not taking care of this properly."

"You're the person responsible to avoid it," she tells her. "I can help you, but I can't do it."

Dr. Arslanian noted that when young patients are first admitted to the hospital after diagnosis and their calorie intake is reduced, glucose levels quickly decline.

"Instead of six cans of pop, we give them water, so the sugar load is less, the calories are less and the blood sugars go from 300 to being 140," she said. "If you just change the way you're eating and drinking -- before there is even weight loss -- your blood sugar starts becoming normal."

But, Dr. Arslanian cautioned, "It's not that the diabetes disappears. It gets better. The problem is that most lifestyle changes don't sustain themselves."

And because type 2 diabetes has been rare in children, experts can only speculate about the impact it might have on growth and the development of complications.

Typically, the insulin-producing cells of the pancreas eventually fail and the type 2 patient requires insulin treatment to control blood sugar, Dr. Arslanian explained. A newly diagnosed 15-year-old might be OK with oral medications for a few years and become dependent on insulin by the time he or she is in the early 20s.

In adults, type 2 diabetes is associated with increased risk of blindness, kidney failure, nerve damage that can lead to limb amputations, and heart attacks. The longer a person has the condition, the greater the likelihood of serious complications.

But there is little information on whether children run the same risks. Anecdotes and a small study in Canadian First Nations (native Canadian) kids hint that after 10 years, some are already on dialysis and have had amputations, Dr. Arslanian said.

Still, "they are a unique population, so I'm not sure one can generalize from that," she said. "At least it's a warning sign we have to be careful."

A small study led by Dr. Arslanian showed in May 2005 that adolescents with type 2 diabetes had arteries as stiff as 50- to 60-year-old men, and the artery stiffness of those who were obese but did not have diabetes were comparable to 40- to 45-year-old men.

Dr. Arslanian is the principal investigator of the local arm of TODAY, which stands for Treatment Options for Type 2 Diabetes in Adolescents and Youth. The five-year trial is sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases.

The multicenter study aims to get a handle on what the future might hold for youngsters with type 2, and to find out how best to treat them.

In the trial, 750 children, ages 10 to 17, will be randomly assigned to be treated either with metformin alone, metformin and rosiglitazone, or metformin plus intensive lifestyle change to reduce weight and increase physical activity.

Due to recent concerns that rosiglitazone, better known as Avandia, increases the risk for heart attack, an independent expert panel reviewed available study data and concluded that TODAY could safely continue, NIDDK officials said in June.

So far, 23 of 30 children needed for the local arm of the study have been enrolled, Dr. Arslanian said.

Umayma is one of them. She is in the group that is being treated with metformin and lifestyle interventions, so she meets weekly with a "personal activity liaison" or PAL. She also counts calories, logs what she eats and keeps track of her medicine.

"She's currently wearing a pedometer trying to reach 10,000 steps a day," her mom said. "We've only gotten there twice, but we get close."

Dealing with Umayma's diabetes has also opened Ms. Wilkerson's eyes. She's 33 and gets checked for it every year.

"I talked with my doctor and, so far, there's nothing," she said. "He said it could come rapidly or never at all."

More adults are developing type 2 diabetes, too. And, to the experts' surprise, since 1980 in the United States and elsewhere, more children are diagnosed with type 1.

Why?

"We have no idea," Dr. Arslanian acknowledged. "It has to be environmental. It can't be genetic, because the change is happening too fast. It is very disturbing."

Find links to BMI percentile calculators for adults as well as children and teens online at apps.nccd.cdc.gov/dnpabmi/Calculator.aspx

One in an ongoing series appearing Sundays and Wednesdays through October on the causes, complications and costs of type 2 diabetes, its impact on Western Pennsylvania and what might be done to stop the epidemic.

Go online Aug. 29, from noon to 1 p.m., for a chat with Dr. Silva Arslanian, endocrinologist and director of the Weight Management and Wellness Center at Children's Hospital. She'll answer questions about childhood obesity and childhood diabetes at www.post-gazette.com/chat