Diabetes gets her best shot

DURING her sophomore year at Roosevelt High School, Angie Ramos had a 4.0 grade-point average and a calendar crammed with student council meetings, leadership club and school dances. She had more friends than many people make in a lifetime. “Lazy” was not part of her vocabulary.

But in the summer before her junior year, that’s exactly how Angie described herself. She just wanted to go home and sleep.

Eva Jimenez, who keeps tabs on her granddaughter and grandson when their parents are at work, noticed Angie’s lethargy but it didn’t concern her. Young people these days just seem to lie around and watch television, right?

In hindsight, there were other hints of trouble. Angie was always thirsty, and a shadowy ring on the skin around her neck wouldn’t come off no matter how many times her mother told her to scrub.

But the clues were too subtle to alarm the 16-year-old and her family.

It wasn’t until her annual physical last September that the mystery was solved.

After Angie and her brother, Gabriel, who is 11 months younger, had been poked and measured at the neighborhood clinic, the doctor made a matter-of-fact pronouncement. It was so unexpected that it brought Angie to tears.

Jimenez asked Angie in Spanish to translate. Whatever it was, Jimenez fumed to herself, the doctor should have made an effort to tell the responsible adult first.

“She said I have diabetes,” Angie said.

“No es verdad!” Jimenez said. It’s not true!

Jimenez has diabetes, as did her mother. So do Angie’s paternal grandmother and her father’s older brother.

But a teenager? Angie?

The doctor referred the girl to Childrens Hospital Los Angeles the following day for additional blood tests to confirm the diagnosis, but Angie didn’t need another test to confirm her dismay. Even her brother was crying; in the Ramos family, tears are contagious.

Back at her family’s stucco home in East Los Angeles, Angie took out a journal that she had been keeping since breaking up with her boyfriend. She wrote a single sentence in letters so large that three words took up the entire page: I HAVE DIABETES.

“I felt so sad and angry at myself,” she recalled several months later. “It hurt me to know I’m not perfect.”

ANGIE and her family were stunned for good reason. Her diagnosis, Type 2 diabetes, is the most common form of the disease, but until 1997, it had been so unusual in someone under the age of 40 that doctors called it adult-onset diabetes. Diabetic children were few in number and almost certain to have the much rarer Type 1 form.

With either version of the disease, the body is unable to produce or properly use insulin, a hormone vital for converting food into energy.

Type 1 diabetes is an autoimmune disorder -- the body’s disease-fighting system mistakenly attacks the body, in this case destroying the cells in the pancreas that make insulin. For unknown reasons, Type 1 is more common in whites, especially those from Northern Europe. Of the estimated 20.8 million Americans with diabetes, 5% to 10%, or fewer than 2 million, have Type 1.

The vast majority, as many as 19 million Americans, have Type 2, in which the pancreas makes insulin but the body doesn’t use it properly. The dark ring around Angie’s neck, called acanthosis nigricans, was a sign that insulin was building up, unused.

Because of a complex interplay of genes, culture and socioeconomics, Type 2 is twice as likely to afflict African Americans and Latinos -- especially Mexican Americans -- as whites. Indeed, Type 2 often develops in immigrants or in subsequent generations who eat a high-fat, sugar-laden, super-sized American diet and have a more sedentary lifestyle. Being overweight increases the risk of developing diabetes because it interferes with the body’s ability to use insulin.

Dr. Daina Dreimane understands this better than most. Eight years ago, she saw her first child with Type 2 diabetes when she was a resident in Texas, a state with a large population of minorities and immigrants and a tradition of frying everything from chicken to taquitos. Today she runs a weekly clinic for Type 2 diabetes at Childrens Hospital Los Angeles. Angie is one of her patients.

As someone diagnosed with diabetes at 16, Angie is part of a generation whose members could become the first in recent history to have a shorter lifespan than their parents.

GABRIEL and Alejandra Ramos, Angie’s parents, were high-school sweethearts who became teenage parents, dashing their immigrant parents’ dreams of college.

Their photograph-lined living room is a shrine to the life they worked hard to create, and Angie is its star. There she is as a baby, at her first communion, celebrating her 15th birthday in her white quinceanera dress.

Angie had come to shoulder her extended family’s expectations of being the first to go to college. And no one expected more of Angie than she did of herself. A cousin her age was already pregnant, but Angie had her eye on Columbia University in New York.

The day after the initial diagnosis, the family drove to Childrens Hospital. Gabriel, 35, took time off from his job at a meat shop. Alejandra, 36, took a day off from her work as a tax preparer. Angie skipped school.

They met Dreimane, who prescribed pills to help Angie’s body use insulin and three shots of insulin a day to help her overtaxed pancreas.

Nurses, counselors and nutritionists gave the Ramos family a crash course on managing the lifelong disease. Angie and her parents learned how to fill a hypodermic needle with insulin and plunge it into a pad that looked like human skin.

Gabriel was the first to try giving Angie a shot. His eyes registered fear. This was his princess, his baby girl.

Alejandra, who once passed out when a nurse drew a blood sample, couldn’t bear to watch.

Angie said nothing but thought to herself: “Just do it and let’s get this over with.”

She practiced until she could pinch a fold of skin in her abdomen and stick the 1 1/2 -inch needle all the way in.

It was a ritual she followed three times a day: First thing in the morning, immediately after school and before she went to bed. In addition, five times a day, she pricked her finger, squeezed a drop of blood onto a strip of test tape and popped it into a device the size of an iPod that measured her blood-glucose level and told her how much insulin to take.

She wrote in her journal: “I hate this. It makes me mad. The shots hurt.”

The knowledge that she was different hurt as well.

Angie had always been the life of the party, the one who picked everyone else up when they were down. She was fun. She was loud. She had an attitude.

Except now, she didn’t.

Jimenez noticed that her pretty granddaughter, who had been known to spend an hour on her hair alone, had stopped applying lip gloss or fussing with her clothes before she went out.

“What’s the point?” Angie would say. “I’m going to die anyway.”

Angie kept her diabetes private, except for telling her two close friends, Maria Orozco and Lupe Pena, and her teachers. She wrote about it in her journal but never on her MySpace page.

“I don’t want to live the rest of my life saying I’m diabetic,” she said. “I just want to be, like, ‘I’m a regular person and my name is Angie and I’m fine.’ ”

DIABETES clearly runs in Angie’s family. But her uncle, grandmothers and great-grandmother weren’t diagnosed until middle age.

Angie, however, is growing up in a different world than her relatives. Today, 17% of children under age 19 -- about 12.5 million children -- are seriously overweight, triple the number in 1980. Another 12.5 million are at least mildly overweight. This means that one in three children under age 19 is seriously overweight or on the brink of becoming so. The appearance of Type 2 diabetes in children and teenagers follows that trend.

Angie resolved to lose 20 to 30 pounds. But someone unlucky enough to have a genetic predisposition to diabetes or weight gain, or both, has to work harder at eating a healthy diet and exercising. And it doesn’t help that Angie’s generation is considered the most inactive in history.

Angie’s parents took physical education classes all through high school. Angie had PE for only her first two years, and those periods were truncated because of the school’s year-round schedule; she and her classmates spent most of the time changing in and out of gym clothes.

The Ramos’ tidy home is on a well-kept block, but Angie’s parents, like many these days, don’t feel it’s safe for her to walk by herself. They put a basketball hoop in the courtyard, but Angie prefers cruising for boys on MySpace and her brother plays Nintendo.

Angie’s doctor prods her young patients to exercise or walk at least 30 minutes each day. She reminds them to read food labels, watch portion sizes, avoid fats and eat fruits and veggies.

Once every three months they come into the clinic to weigh in, show her their glucose readings and get a pep talk. Dreimane asks them what they hate the most.

They answer: I hate giving myself shots. I hate always having to think about what I eat. I hate having this.

WHAT Angie hated most was pricking her finger to check her blood.

She hated having to do it every day. She hated having to always remember to take her glucose meter with her. She hated how it left her fingers too sore to strum her guitar.

Most of all, she hated it because she knew that her mom would ask (because she asked every single day) about her glucose reading. If it was high, her mom would say, “I told you not to eat that!”

Once, for a week, maybe longer, Angie stopped checking her blood-sugar levels. She confessed the lapse to her doctor during a checkup.

Dreimane wasn’t surprised.

“You’ll do everything right,” she tells her patients. “Test blood. Take insulin. Take pills. Then you’ll want to see what happens when you stop....

“Don’t do it!”

Dreimane has learned to give this lecture early on. But sooner or later most of her young patients try to game the system.

After one boy and his mother left her office, Dreimane said, “He lies to her about his glucose readings.”

All of her patients eventually learn how to trick the meter -- and their mothers -- by replacing the drop of blood with a glucose solution used to test the meter’s accuracy.

“If they can show the mom it’s OK, then everybody can be happy,” Dreimane said. “I don’t blame them. But I tell them, ‘It’s not a report card. It’s to know how to treat you.’ ”

And that is sometimes difficult. Children with Type 2 typically don’t feel sick. They don’t have a fever. It’s hard to persuade them to check their blood sugar day in and day out.

The costs of not managing Type 2 come later, years after high blood-glucose levels begin their silent assault on kidneys, eyes, nerves and blood vessels.

Uncontrolled, the illness that starts out with few or no symptoms can leave its victims on dialysis from kidney failure. It can cause blindness, lead to foot and leg amputations and put young mothers at risk for miscarriage. Nationwide, diabetes is the sixth leading cause of death, but the toll is probably higher given its role in heart disease and stroke.

But how do you explain the stakes when teenagers famously see themselves as immortal?

AFTER the first wave of shock and angst, Angie was finding it surprisingly hard to remain a martyr. For one thing, her family and friends wouldn’t let her. For another, she wouldn’t let herself.

She would retreat to her room, worrying over whether diabetes would dash her college dreams, and her dad would say, “Let’s go for a walk.” Off they’d go for a turn around the nearby cemetery, and soon he’d have her laughing instead of brooding.

On Sunday evenings her mom would fire up the grill for carne asada, and cousins and friends would spill out of the house. Maria and Lupe stuck by her no matter how many times she said they didn’t understand.

After about two months, Angie had walked off five pounds. Her grades, which had dipped a bit, crept back in the stratosphere. She started to believe her life might not be over. The control freak was beginning to feel back in control.

She started hounding Maria and Lupe about what they ate (when she didn’t break down and join them). At one point she realized, “Oh my God, I’m starting to sound like my mom!”

By Christmas, Angie was down to two insulin shots a day, three finger-prick tests and a pill.

Her journal filled again with gossip and plans for a school dance. She went to a weekend leadership camp in Malibu, and the other teenagers didn’t freak out when she gave herself shots. She told friends about her diabetes. She even agreed to talk with a reporter. “Maybe it will help other kids,” she said.

By February, she’d lost another five pounds and dropped two clothing sizes. Dreimane cut her back to just one insulin shot a day, plus the pill. By the next visit, she hoped Angie would be able to get off insulin altogether.

“I can’t promise that you’ll never need it,” the doctor warned, reminding Angie that she’d always have to watch her diet and exercise, take her pills and yes, test her glucose levels.

But adult caution was no match for teenage exuberance. Before she reached the elevator, Angie was on her cellphone to give Maria the good news.

“I’m going to cry,” she said.

For her 17th birthday that month, her parents hired a DJ for a party in the courtyard. A hundred people -- aunts, uncles, cousins, family friends, classmates and a new boyfriend -- came.

Angie spent an hour on her hair.

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mary.engel@latimes.com

Times staff writer Francisco Vara-Orta contributed to this report.

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Diabetes risks

The American Diabetes Assn. recommends that mildly overweight youths 10 and older with any two of the risk factors listed below be screened for Type 2 diabetes:

* Have a family history of Type 2 diabetes

* Belong to a certain race/ethnic group (Native Americans, African Americans, Latinos, Asian/Pacific Islanders)

* Have signs of insulin resistance or conditions associated with insulin resistance (acanthosis nigricans, hypertension, elevated blood lipids).

Mildly overweight for children and teenagers is defined as having a body mass index (BMI) at or above the 85th percentile for age and sex. For a BMI calculator, see the Centers for Disease Control and Prevention website (https://apps.nccd.cdc.gov/dnpabmi/Calculator.aspx).

Information about Type 2 diabetes in children can be found at the website www.childrenwithdiabetes.com or by calling Childrens Hospital Los Angeles at (323) 361-2185. Other pediatric diabetes centers in Southern California include Children’s Hospital of Orange County, Loma Linda University and UCLA Mattel Children’s Hospital.

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Source: Mary Engel, Times staff writer