"From the vantage point of where we're going with these 20-year-olds, it's going to be a matter of true systemic education, because the drugs don't fix it," said Dr. John S. Steinberg, a foot and ankle specialist who as co-director of the Center for Wound Healing at Georgetown University in Washington, D.C., treats the diabetic food wounds and nerve damage that can result in amputations.
"You can throw all the diabetes drugs you want at them. If they are living the same lifestyle and eating the same foods, it's a never-ending battle," Steinberg said. "We truly have to change the dynamic and the attitude towards what the health care system can do for diabetes. The main player in the disease is the patient, not the doctor. We thrive off treating patients, but these folks really need to be treating themselves."
Steinberg has seen his patient base skew younger since completing his training in 1999.
"It used to be diabetic foot wounds were all in the 50-, 60- and 70-year-old population. Now we're seeing them in the 30-, 40- and 50-year-olds," he said.
Although dangerous wounds remain rare in 20-year-olds, he routinely checks blood flow and nerve function in the feet of diabetics that age, for whom he hopes to limit the tissue erosion and muscle weakening that can occur after more than a decade with the disease.
"We'll use that as a chance to educate the patient on 'here's what you want to do prevent those things from happening,'" he said.
Younger patients often fail to realize that diabetes has silently worn away the tissues of the foot because after it damages the small blood vessels and nerves, they lose sensation.
They easily get caught between dueling medical recommendations, Steinberg said.
The cardiologist tells them to walk two miles a day, but because that damages a weakened, diseased foot, the wound care specialist wants them to get off the foot so it can heal.
Dr. Gianluca Iacobellis, associate professor of endocrinology at the University of Miami Diabetes Research Institute and co-director of its bariatric surgery program, said that among Type 2 diabetes patients in their 20s, "you see early damage, early dysfunction, even high blood pressure and high cholesterol and high triglycerides that need treatment."
Urine tests may reveal small amounts of protein in the urine, a sign of kidney damage, although they're asymptomatic.
Echocardiograms, which produce ultrasound images of the heart in action, can reveal stress in the some of their heart muscle fibers, although they don't yet have diagnosable heart disease.
"Still, they need prevention, treatment, lifestyle changes. That's, of course, because they are more prone to develop all the bad things," Iacobellis said.
Dr. Anne L. Peters, director of clinical diabetes programs at the University of Southern California in Los Angeles, where she leads several diabetes and obesity prevention programs, said she sees troubling medical complications among patients in their 20s "in underserved East L.A., where lack of access to care has led to the complications."
For the most part, however, she said the cumulative toll that leads to blindness, kidney failure and heart attacks hasn't yet shifted down to diabetics in that age group.
"Someday we may be seeing 20-year-olds with heart disease, but that's really, really rare, which is good," she said. "And perhaps we can change the world and stem the epidemic of obesity and Type 2 diabetes. Wouldn't that be nice?"