Racial And Ethnic Disparities In Type 2 Diabetes Prevalence In Children

Type 2 diabetes (TD2) is a common disease that is becoming increasingly prevalent in children and teenagers. However, racial and ethnic disparities mean some groups of children are more affected than others.

Pediatric type 2 diabetes and its prevalence today

Pediatric TD2 is an important health issue. Its prevalence is increasing in children and adolescents from all racial and ethnic backgrounds.¹ However, the disease is more common in certain groups, including Black, Hispanic, Asian American and Pacific Islander (AAPI), and Native American populations.²

Diabetes is a chronic disease that results in high blood sugar levels. It occurs when your body can’t effectively use insulin — a hormone that controls blood sugar levels by helping glucose move into cells.

It’s essential to understand the differences between type 1 diabetes (TD1), type 2 diabetes, and prediabetes.³

• Type 1 diabetes is associated with reduced insulin levels. It usually occurs due to an autoimmune reaction that destroys the insulin-secreting cells in the pancreas.

• Type 2 diabetes is associated with insulin resistance. Enough insulin is produced, but the body’s cells don’t respond to it properly. Certain lifestyle factors greatly increase the risk of TD2. Addressing these factors may help prevent this condition.

• In a person with prediabetes, blood sugar levels are somewhat higher than normal — but they are still below the levels of someone with diabetes. Having prediabetes significantly increases your risk of developing TD2 later on. Prediabetes can often be reversed before it progresses.

TD1 is more common than TD2 in children and adolescents, but cases are rising.

TD2 now accounts for 20–33% of all diabetes diagnoses in children.⁴ In 2018, 210,000 children and adolescents under the age of 20 in the US had diagnosed diabetes. Of these, 187,000 had TD1.⁵

Research has shown that children with TD2 have a higher risk of complications than those who develop the disease in adulthood.⁶ ⁷ People who have diabetes for longer are more likely to accumulate damage. This damage could result in a serious condition like cardiovascular disease, high blood pressure, eye disease, or kidney disease.

Research also shows that, when compared to adults, TD2 and related complications may be more aggressive and treatment-resistant in children and adolescents.⁸

Potentially manageable risk factors in children and adolescents

Some risk factors for TD2 in children can be modified. These include:

• Weight: People who are overweight or have excess body fat are more likely to develop insulin resistance — a distinguishing characteristic of TD2.⁹

• Sedentary lifestyle: Longer periods spent physically inactive are associated with a greater risk of diabetes. In contrast, physical activity reduces the risk.¹⁰ ¹¹

• Diet: Consuming a nutrient-rich diet low in processed foods, especially highly processed sugar, significantly reduces a child’s risk of TD2.¹² However, poverty and food insecurity may present barriers to accessing nutritious food.¹³

Unmodifiable risk factors in children and adolescents

Some TD2 risk factors cannot be modified. These include the following:

• Race and ethnicity: The overall incidence of TD2 is increasing in children and adolescents. However, this increase is highest in certain racial and ethnic groups, including AAPI (7.7% increase), Hispanic (6.5% increase), Black (6.0% increase), and Native American (3.7% increase).¹⁴

• Early puberty: Adolescents who begin menstruating at an earlier age are more likely to develop impaired glucose tolerance and TD2.¹⁵

• Family history: Children with a parent who has or previously had TD2 or gestational diabetes are at a greater risk of developing TD2 themselves.¹⁶

• Medical conditions: Certain medical conditions, such as polycystic ovary syndrome (PCOS), increase the risk of TD2.¹⁷ PCOS is more common in minority groups, such as AAPI and Hispanic people.¹⁸

Racial and ethnic disparities in TD2 prevalence among children

Racial and ethnic disparities affect the prevalence of type 2 diabetes in children as well as adults.¹⁹

These disparities can be partly explained by the social determinants of health — non-medical factors that positively or negatively influence health outcomes and quality of life.

Social determinants of health include economic stability, access to and quality of education, neighborhood, access to healthcare, and social community. Approximately 80% of young people with TD2 come from racial and ethnic minority groups.²⁰

Compared with adults, children and adolescents are at an increased risk of death from diabetes.²¹ However, there are also racial disparities in the death rate. Evidence collected from 2000 to 2014 shows Black children are more than twice as likely to die from diabetes than White children.²²

Other diabetes outcomes are also affected by racial and ethnic disparities.

On average, Black and Hispanic children and adolescents have significantly worse blood sugar control. These populations are also more likely to develop diabetes complications, like kidney disease and diabetic ketoacidosis (a potentially fatal condition caused by very high blood sugar).²³

Barriers to reducing type 2 diabetes and complications in children

Research has consistently found clear racial and ethnic disparities in TD2 prevalence in adulthood. Similar disparities appear to exist in children and adolescents, but more research is needed to fully understand how social determinants of health generate these racial and ethnic disparities.²⁴

Negative social determinants of health, such as low family income, low parental education, and high stress, have been linked to childhood TD2, but it’s less clear how race and ethnicity influence the risk.²⁵

Here are some of the barriers to reducing TD2 in children and preventing complications:

Being undiagnosed

Many children and adolescents with TD2 are undiagnosed.²⁶

Children with diabetes frequently have mild or no symptoms, meaning cases can be missed easily without adequate screening.

Disparities in treatment

Notably, White children living in the wealthiest areas are more likely to use both insulin pump therapy and continuous glucose monitoring.²⁷ The use of these technologies helps improve diabetes control and outcomes. Unfortunately, both economic deprivation and ethnicity are associated with less use of these technologies. 

Under-utilizing the healthcare system

Research shows adolescents with TD2 have a high dropout rate from the healthcare system, which involves not attending recommended medical visits.²⁸

Various factors are thought to cause this, including a lack of psychosocial support for the child and their family and poor support for the parents to make good choices. Other factors may include a lack of motivation to make lifestyle changes and barriers to accessing treatment. Financial constraints, difficulty taking time off work, and limited transportation options are just some of the things that make it challenging for people to access treatment.

It’s important to consider how structural racism has affected and continues to affect how minority populations use the healthcare system.²⁹

Perceived racial discrimination can negatively impact diabetes care and outcomes. Additionally, because of the history of systemic abuse within the healthcare system, many people from racial minority groups don’t fully trust it. They may minimize or avoid contact with it because of this.

Low medication adherence

The Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY) clinical trial found that, after two years, only 56% of patients were still taking their medications as prescribed.³⁰ Those who stopped taking their medications were more likely to report having symptoms of depression.

Race and ethnicity did not appear to influence outcomes in this study. Notably, the participants were primarily minority youth with low levels of parental education and household income. The impact of race on diabetes care may be mediated mostly through social determinants of health. As such, when nearly everyone in the study is affected in similar ways, it makes sense that race would not have an obvious separate impact.

Early-life socioeconomic factors

A study found that socioeconomic factors in early life have long-lasting health effects. This is because they set children down unequal life-course pathways.³¹

Low socioeconomic status is a risk factor for TD2. A study on youth with diabetes found that 40% of patients came from families with an annual income of less than $25,000.³²

Strategies to reduce the prevalence of type 2 diabetes in children

Implementing and prioritizing the following strategies could help reduce the prevalence of TD2 in children:

Increase access to high-quality medical care

Limited use of healthcare is associated with poor blood glucose control.³³ This means it’s vital to ensure everyone can access the care they need by removing as many barriers as possible. 

For example, many people with lower socioeconomic status have difficulty traveling to medical appointments. Financial and time constraints are just two possible reasons.

Telehealth appointments are one way to solve this problem. A study found that telehealth appointments are associated with lower dropout rates and higher satisfaction levels among children and their families.³⁴

Employing strategies to make community health workers and pharmacists more available and accessible to these disadvantaged communities could also be beneficial.³⁵

Lifestyle interventions

Early lifestyle interventions can effectively reduce weight in children with obesity when parents are involved.³⁶

A review of studies found that programs designed to help children and their parents adopt a healthy lifestyle can help reduce body mass index in children with obesity. This is a major risk factor for diabetes.³⁷ This suggests the best results are achieved when the whole family commits to healthy choices together. 

Lifestyle changes you can make as a family include:³⁸

• Physical activity: At least one hour of physical activity daily is recommended for children.

• Diet: Eat more fruits and vegetables, reduce your intake of sugary treats and drinks, and make your favorite recipes healthier.

• Dietary habits: Choose to eat slowly and mindfully at the table together as a family. This encourages you to consume the amount of food your body needs instead of mindlessly eating while distracted by another activity (such as watching TV). It also tends to reduce the consumption of highly processed snacks.

The Supplemental Nutrition Assistance Program (SNAP) provides food benefits to low-income families, making nutritious food more affordable and accessible.³⁹ Increasing funding for SNAP and similar programs could help more struggling families purchase food that helps protect them and their children from diabetes and other diseases.

Access to treatment drugs

Studying medications to determine their efficacy in children and adolescents could help reduce the prevalence of TD2 and improve outcomes for those who are diagnosed. Currently, only a few medications are approved to treat or prevent diabetes in this population.

Glucagon-like peptide-1 receptor agonists (GLP-1RAs)

These drugs improve glycemic control and lead to weight reduction by stimulating insulin secretion, reducing glucagon secretion, delaying gastric emptying, and reducing appetite.⁴⁰

Only two GLP-1RAs are approved for use in people with diabetes aged ten or above, but they are not yet approved for younger patients.

Empagliflozin (Jardiance)

This medication causes the kidneys to increase glucose excretion through the urine.⁴¹

It can also be combined with a common diabetes drug known as metformin (Glucophage, Glumetza, Fortamet, Riomet, and others) to reduce the amount of glucose made in the liver.

The US Food and Drug Administration (FDA) recently approved empagliflozin for diabetes patients aged ten and below, while metformin has been approved for pediatric use for years.⁴²

The lowdown

The rise of type 2 diabetes in children presents a serious health challenge. Disparities in the social determinants of health are well documented in adult populations, but less so in youth. Exploring these issues is important as they increase obesity rates, restrict access to high-quality healthcare, and enable systemic racism within the healthcare system.

Moving forward, research should focus on racial and ethnic disparities in the prevalence, treatment, and outcomes of TD2 in children and adolescents.

A multifaceted approach is needed to encourage family-based lifestyle changes in children at risk for or living with TD2. This can help break the growing prevalence of the disease in youth and improve diabetes statistics.

Frequently asked questions

What is the youngest age a child can develop type 2 diabetes?

Type 2 diabetes is more common in adolescents than in younger children. However, research has discovered that in rare cases, children as young as five can develop TD2.⁴³

What are pediatric diabetes levels?

The diagnostic criteria for pediatric type 2 diabetes are:⁴⁴

• Random blood glucose level greater than 200mg/dL with symptoms of polyuria (excessive urination), polydipsia (excessive thirst), or weight loss

• Fasting blood glucose levels greater than 126mg/dL (in a patient with no symptoms)

• Blood glucose level greater than 200mg/dL two hours after drinking a glucose solution during an oral glucose tolerance test (OGTT)

• Hemoglobin A1c (HbA1c) levels greater than 6.5% — indicates high average blood glucose levels

At what age should you screen your child for type 2 diabetes markers?

The American Diabetes Association recommends screening children every three years, starting from the age of ten or the onset of puberty, if they have:⁴⁵

• Obesity (above the 95th percentile) or overweight (above the 85th percentile)

• At least two other risk factors for diabetes