Type 2 diabetes in young people: be careful!

The author is a full professor at the School of Optometry at the University of Montreal.

16-year-old Carl recently became my patient. When we met, he was referred to me because of a change in his vision. On examination, I found signs of diabetes that could explain his fluctuating vision problem. After the family doctor confirmed the diagnosis of this disease, this suspicion became a reality. Carl’s world had just changed.

As an optometrist, I invite you to dive into this reality that concerns us all.

Diabetes, what is it?

Diabetes is an insidious disease. Its symptoms (thirst, frequent urination, fatigue, weight loss, dark areas of the skin on the neck and armpits) are often not noticeable, at least in the early stages of the disease.

Diabetes affects the lives of one in 14 people (7%) in Canada and one in 10 (10%) in North America.

Two types of diabetes can be diagnosed:

  • Type 1, called insulin-dependent, occurs when the body is unable to produce the insulin needed to metabolize the sugars we ingest and nourish our tissues;
  • Type 2 occurs when insulin is produced well, but not in sufficient quantities. It happens that the produced insulin cannot fulfill its role.

Type 1 diabetes is usually associated with the onset of the disease during childhood and adolescence. Type 2, the most common, usually appears later, often after the age of 50.

A counter-intuitive diagnosis, but not that uncommon

According to this definition, it would be reasonable to assume that Karl has type 1 diabetes, whose course and treatment are well managed by doctors. However, in his case and after the necessary examinations, the doctor identified type 2. This counterintuitive diagnosis poses significant problems. The rate of onset, initial severity of attack, and mechanisms of resistance or decreased insulin secretion may be different in younger patients with disease.

In addition, due to the longer duration of this type of disease, which begins at a young age, the treatments considered are more complicated by trial and error. Small and major changes affecting the blood vessels of a patient with type 2 diabetes can lead to serious consequences that are difficult to predict if we consider an evolution over 40-60 years.

However, Carl’s situation is not exceptional. More and more young people and teenagers are affected by type 2, especially those who are overweight, obese and lead a highly sedentary lifestyle. About 75% of them have parents or siblings with diabetes.

If at first glance this confirms genetics as a risk factor, it is actually, in this particular case, the result of poor lifestyle habits, including poor nutrition and lack of physical activity, which are often shared by the whole family.

Results related to vision

Carl’s early onset of type 2 diabetes puts him at higher risk for eye complications. A recent post challenged me in this regard. This study examined the records of 1,362 people with diabetes living in the state of Minnesota, North America. The data is compiled from 1970 to 2019, which allows to measure the evolution of the situation in recent decades.

The results are surprising: young type 2 diabetics (compared to age-matched type 1 diabetics) are 88 times more likely to suffer from retinopathy (abnormal blood vessels and/or hemorrhages in the retina). In addition, the risk of the latter becoming “proliferative” and therefore a threat to vision increases 230 times. There is also a 49-fold increase in the risk of fluid accumulation in the retina (macular edema) and a 243-fold increase in the risk of developing adult cataracts at a young age. The latter requires riskier surgery in young people compared to age-related senile cataracts.

Vascular and metabolic complications of diabetes (hemorrhages, exudates) appearing in the back of the eye. (Photo by Langis Michaud)

What to remember? Major problems, often requiring surgery to preserve vision, occur sooner in young type 2 diabetics than in type 1 diabetics. Therefore, these patients should be monitored more closely. In fact, approximately one in two patients with type 2 diabetes will develop some form of retinopathy within one to eight years of diagnosis. In comparison, one in three patients with type 1 diabetes will experience retinopathy 6-10 years after diagnosis.

Significant effects

Although there has already been an increase in the past 10 years, the prevalence (number of cases) of type 2 diabetes among young people is estimated to quadruple by 2050. This forecast is the most frightening for health professionals. as well as for decision makers and managers of public health agencies. In 2013, the lifetime cost of direct medical care for a single person with diabetes between the ages of 25 and 44 was $125,000. This cost has since increased; and many dollars must be added to cover the period from 15 to 25 years, which is not accounted for. If 20% of the child population has diabetes in 2050, that’s millions (billions?) of dollars our governments will have to spend on health care.

In the long term, the quality of life of people with diabetes also decreases. Another study, this time among young type 1 diabetics, reveals that they show great dissatisfaction with their disease. They have to spend a lot of time on their care. And the burden of the illness of those around them is very heavy on their shoulders. They are also affected by the fear of hypoglycemia (a lack of sugar that can lead to coma) or serious complications from the disease. Autonomy is more difficult for these teenagers to achieve, and their quality of life is proportional to the freedom they may or may not exercise.

Eat well, exercise and see your optometrist!

It is difficult to prevent type 1 diabetes because we do not know all the causes of its appearance. However, the situation is different for type 2, which is strongly associated with lifestyle among young people. A healthy diet, regular exercise, and combating a sedentary lifestyle, especially by limiting screen time (less than two hours a day), are good ways to prevent or delay the onset of diabetes in young adults. Screen time has also been linked to insulin resistance and obesity. In other words, healthy lifestyle habits should be encouraged and shared, especially within the family unit.

At the ocular level, a regular visit to an optometrist or ophthalmologist allows you to detect early signs of diabetic attacks (these signs appear shortly after diagnosis in about 30% of patients). These health care providers may also detect other problems caused by the disease, such as loss of ability to focus up close (accommodation), partial paralysis of some eye muscles resulting in double vision, delayed healing of changes in the surface of the cornea, dry eye, or glaucoma. Testing should be done at the time of medical diagnosis of diabetes or in anyone presenting a risk profile (heredity, obesity, sedentary lifestyle).

Because healthy lifestyle habits are an integral part of treating the disease, it’s not too late for Carl to have a happy future. But don’t forget regular checkups with your doctor and frequent visits to your family optometrist!

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