At 20, Erika Rodriguez struggles to do the adult thing and manage the Type 2 diabetes that's remained stubbornly uncontrolled since she was diagnosed in junior high.
She frequently forgets to test her blood sugar and take her medications. Down from 260 pounds to 213 pounds on a 5-foot-3 frame, she's no longer morbidly obese, but a BMI of 38 puts her solidly among obese Americans.
Although she doesn't feel sick, she takes medication to protect her from the silent indications of early kidney disease and remains at risk of the heart attacks, strokes, blindness and eventual amputations that make diabetes one of the most brutal maladies.
Her struggle has become the new face of the nation's intertwined epidemics of obesity and Type 2 diabetes, as ever-widening waistlines in tender years have shifted to children and young adults the burdens of a chronic illness once called "adult onset" diabetes because it struck at 40 or later.
Unlike Type 1 diabetics, whose bodies stop making the insulin needed to break down sugar to fuel the muscles and brain, Type 2 diabetics cannot properly process the insulin they do make.
Because the disorder can go undetected for years, it's difficult to quantify the numbers of young Type 2 diabetics, although worried clinicians and federal health agencies increasingly encounter Type 2 diabetes among those who spend their days in junior high, high school and college corridors.
They're scrambling to keep them out of hospital corridors.
At a time when Rodriguez should be choosing fall courses at Bunker Hill Community College in Charlestown, Mass., 11 train stops from the house she shares in Dorchester with her non-diabetic parents and two younger brothers, she's recuperating from recent surgery for painful underarm abscesses, a diabetic complication she cannot ignore.
Like many younger patients with diabetes, she's had a tough time making lifestyle changes for a diagnosis that blindsided her.
"When they first told me about it, I was in shock," she told ABC News Friday. "I didn't know what I was going to do. I thought, 'oh, my God.' I thought I was going to die."
She was hospitalized soon afterward at Children's Hospital in Boston to lower dangerously elevated blood sugar levels.
More recently, she joined a clinical trial at Harvard's Joslin Diabetes Center in Boston, where doctors, nurses and nutritionists regularly implore her to exercise, test her blood sugar and take metformin pills and insulin injections.
Nevertheless, she admits she's largely noncompliant.
"I'm worried. I try to do one thing at a time to be able to change the way my health is now," she said. Perhaps this fall, "in between classes or after classes I could go to the gym and work out."
That youthful denial of potential death and disability down the road troubles diabetes specialists, who say that halting Type 2 diabetes' menacing march into youth requires the discipline and focus to make lasting changes.
Stubborn resistance to change, even among those participating in innovative programs for the disorder, is among topics under discussion at the American Diabetes Association's 71st Scientific Sessions in San Diego, where more than 13,500 people, including Rodriguez' doctor, Lori Laffel, a pediatric endocrinologist at Joslin, are gathered through Tuesday.
"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?"