In a single generation's time, type 2 diabetes has become so prevalent in children it's no longer known by its traditional label of "adult-onset" diabetes.

With the link between diabetes and obesity firmly established, worries about weight gain and finding time to exercise that used to solely nag at adults are now a concern for kids and their parents.

The stakes are much higher for children with type 2 diabetes because they will have to live with the disease and its devastating effects for a much larger part of their lives.

"In the past, type 2 diabetes was considered to be the diabetes of adults," said Dr. Beatriz Rodriguez, a diabetes researcher and professor at the University of Hawai'i John A. Burns School of Medicine.

"The reason why it's very alarming is that we know there are many complications for diabetes including blindness, renal disease, cardio diseases and amputations, and the longer the duration the more likely these complications start to show up.

"When you have someone who is 16 instead of somebody who is 60, we're talking about having these complications very early in life."

The U.S. Centers for Disease Control and Prevention estimates that one in three American children born in 2000 will develop diabetes in their lifetime if current trends continue. In Hawai'i, it's closer to one in two because of the state's ethnic mix.

The recent alarm over childhood diabetes is only "the tip of the iceberg," said nurse practitioner Lisa Zick-Mariteragi, who works with the chronically ill at the Waianae Coast Comprehensive Health Center.

The communities served by the health center have the highest rates of diabetes and obesity in the state.

Zick-Mariteragi said many children are living the same sedentary lifestyles as their elders and face the same health challenges.

"You look at them and they're drinking soda on the way to school. When you have diabetes you're tired and you don't want to move," she said.

"You're fatigued and the sugar in the soda sucks the fluid from your body and you pee it off and drink more soda because you're thirsty, and that increases sugar further and causes more dehydration, and you pee more and get more thirsty and then you're drinking Big Gulps all day long. It's a downhill spiral."

A FAMILY MATTER

When a young patient registers a BMI — body mass index — indicating weight trouble, the health center invites parents to enroll the child in its Kid-Fit exercise program.

"The whole family has to be engaged in the change of behavior, otherwise it's not going to have an impact," Zick-Mariteragi said.

Type 2 diabetes is still rare in children under 10 years old, but in the 10 to 19 age group, the incidence of type 2 diabetes is increasing significantly, especially in Asians and Pacific Islanders, according to a national study.

The 10-year SEARCH for Diabetes in Youth study, funded by the CDC and the National Institutes of Health, has been gathering diabetes data since 2001 from six sites around the country. Rodriguez is the principal investigator for the Hawai'i part of the study, conducted in partnership with the University of Hawai'i, the Pacific Health Research Institute and Kaiser Permanente.

The data indicate that approximately 15,000 new cases of type 1 diabetes and 3,700 cases of type 2 occur each year among the nation's youths under age 20.

Rodriguez said the numbers may seem small when spread across the country until you consider the compounding effect of each year's newly diagnosed cases and the related medical costs.

"It's a really big number when you think about the costs associated with the disease, especially for someone who is diagnosed at a young age," she said.

According to the study, kids with diabetes demonstrated a higher prevalence of metabolic syndrome, a collection of conditions that occur together and increase the risk for heart disease, stroke and diabetes. The conditions include high blood pressure, elevated insulin levels, abnormal cholesterol levels and excess body fat around the waist.

Rodriguez said more than 90 percent of the children in the study with type 2 diabetes have metabolic syndrome and that 35 percent show signs of early renal disease.

"This is very serious when you're already beginning to see all of these complications in people who are so young," she said.

Estimates for the number of children in Hawai'i with diabetes are hard to come by, but Rodriguez has been able to identify 500 cases of both types by working with Kaiser Permanente, HMSA and the state's Med-Quest program, which together provide health insurance to 80 percent of the state's population.

Type 1 diabetes is usually first diagnosed in children, teenagers, or young adults. In this form of the disease, the pancreas is unable to produce insulin. Those with type 1 require daily doses of insulin in order to survive.

Type 2 diabetes, the most common form of the disease, can develop at any age. It usually begins with insulin resistance, a condition in which muscle, liver and fat cells do not use insulin properly. Eventually, the pancreas loses the ability to secrete adequate insulin.

Obesity is seen as a trigger for insulin resistance.

"You cannot overemphasize the link between body weight and obesity and type 2 diabetes and insulin resistance," said Dr. Wilfred Fujimoto, a retired endocrinologist and diabetes researcher. "And obesity is appearing at a younger and younger age."

PHYSICAL ACTIVITY CRUCIAL

According to the SEARCH study, children under age 10 with diabetes almost exclusively have type 1, regardless of race or ethnicity. In youngsters ages 10 to 19, Caucasians have a higher incidence of type 1 diabetes, with type 2 more prevalent in Asians and Pacific Islanders, including Native Hawaiians.

In fact, for every single case of type 1 diabetes newly diagnosed in Asian and Pacific Islander children ages 10 to 19, there are two new diagnoses of type 2, Rodriguez said.

"This is very different from what is seen in the other studies on the mainland where most of the participants are Caucasians and type 1 diabetes is more common than type 2," she said.

"That would indicate a strong genetic component. Somehow the white children have a lower risk of type 2 diabetes compared to ethnic minorities. The opposite is true for type 1, which is more common among white children."

The study also found that 100 percent of the Pacific Island children with type 2 diabetes were obese. For Asians, 70 percent.

A likely reason is that less than 10 percent of children with both forms of the disease met national dietary recommendations, according to the study.

"They are not eating very well," Rodriguez said.

Another reason could be lack of exercise. The Department of Health's 2007 Hawai'i Youth Risk Behavior Survey indicates two-thirds of high school students don't meet recommended levels of physical activity, and that a third spend at least three hours each school day watching television, playing video or computer games or using a computer for purposes other than school work.

"It is really clear that it is very important that we look at these lifestyles and address these issues very early in life. We need to be putting a lot more effort into educating children and working in schools and with the media to try to change some of these things that are happening in society," Rodriguez said.

CHANGING EATING HABITS

To address concerns about obesity, type 2 diabetes and other health issues, the state Department of Education last year adopted mandatory Wellness Guidelines to be implemented at public schools over a four-year period.

The policy bans the on-campus sale of food containing trans fats and also prohibits food and beverages that list sugar in any form as the first ingredient.

There also are limits on fat and sugar content in snacks and beverages that are sold on campus, provided in classrooms, or served in the federal After School Snack Program.

Changes already have been served up on the 100,000 breakfast and lunch trays provided daily by public school cafeterias.

French toast, pancakes and waffles are now of the whole-wheat variety, and baked goods must be made from at least 50 percent whole grains. Cafeteria managers also are mixing salads with at least 50 percent Romaine lettuce, which is more nutritious than iceberg lettuce.

And that scoop of rice is now split 50-50 between brown and white rice. The change was introduced gradually and seems to have been accepted by students, said Glenna Owens, director of DOE's School Food Services Branch.

"There's a whole new generation of kids who are familiar with brown rice," she said.

DOE officials said it's too early to judge the effectiveness of the Wellness Guidelines. But there is widespread support among administrators and school staff for the mandate, which isn't expected to tax school budgets, according to Dave Randall, education specialist for health and physical education.

"They know it's the right thing to do for kids. We think it's a win-win situation because there's a growing body of evidence that healthy kids not only learn better and but do better on standardized tests," he said.

Ultimately, parents are responsible for their kids' health habits, and Rodriguez said the best way to change their behavior is to walk the walk.

"We are the role models for our children. We have to set an example by following a healthy diet and getting some exercise," she said.