Diabesity and Our Children

It is hard to pick up a newspaper or magazine or turn on the TV today andnot be barraged by some story about the life-altering childhooddiabesity—obesity and diabetes—epidemic. The story told in themedical literature is not much better.

The latest National Health and Nutrition Examination Survey (NHANES) showedyet another increase in the obesity rate for children, which is now up to17.1%.¹ Elevenpercent of teens have impaired glucose tolerance (IGT), which brings us to anestimated 2,769,736 youth with this problem. In addition, 0.5% of kids12–19 years of age have diabetes, with 29% estimated to have type 2disease.² That meansabout 39,000 teens in this country have what used to be almost exclusively anadult disorder.

This leaves clinicians and researchers caring for children with a host ofadult-type problems. There is now a need to research how to decrease thesoaring numbers of children developing obesity, cardiovascular disease (CVD)risk, metabolic syndrome (a cluster of symptoms including hypertension,glucose intolerance, dyslipidemia, and large waist size), pre-diabetes, anddiabetes.

In a recent article in Diabetes Care, the STOPP-T2D (Studies toTreat or Prevent Pediatric Type 2 Diabetes) study group reported on 1,740eighth-grade students and found 49% had a body mass index (BMI) greater thanor equal to the 85th percentile for sex and age, 40.5% had a fasting glucosevalue ≥100 mg/dl (impaired fasting glucose), and 36.2% had fasting insulinlevels ≥30μU/ml.³ Notsurprisingly, fasting and 2-hour glucose and insulin values increased acrossBMI percentiles, and fasting glucose was highest in Hispanic and AmericanIndian students.

Data presented at the American Diabetes Association (ADA) ScientificSessions in 2004 showed that 47.7% of the subjects had low HDL cholesterol(<40 mg/dl for girls and <50 mg/dl for boys), 7.3% had elevatedtriglycerides (>150 mg/dl), and 18.4% of boys and 10.6% of girls had bloodpressure elevation greater than the 95th percentile for sex andage.⁴ The good newswas that very few of the children studied were found to have unrecognizeddiabetes or IGT; 0.4% had a fasting glucose concentration ≥126 mg/dl, 2%had a 2-hour glucose value ≥140 mg/dl, and 0.1% had a glucose level ≥200mg/dl. The full trial (the HEALTHY study) will be under way soon and will helpus determine if a school-based strategy that increases physical activity andimproves school-based nutrition can reduce risk factors for diabetes.

Clinic-based data on overweight and obese children show that more childrenin this context have either multiple risk factors associated with themetabolic syndrome orIGT.^5–7

WHAT TO DO WITH THE DATA

What do these population- and clinic-based studies suggest? Three things:1) Children should be evaluated for adiposity; 2) depending on degree ofadiposity, they should be further evaluated for risk factors for CVD,components of the metabolic syndrome, pre-diabetes, and diabetes(“`Adult-Onset' Diabetes Finding Way to Kids,” seepage 1, and “Kids'Cardiology,” see page8); and 3) strategies need to be developed and critically evaluatedfor prevention of childhood overweight and obesity, pre-diabetes, anddiabetes.

Although we do not have all the answers, a number of guidelines have beendeveloped to identify and address these problems in youth. The AmericanAcademy of Pediatrics (AAP) has promulgated BMI as a vital sign. In itsPrevention of Pediatric Overweight and Obesity in 2003 policy statement, AAPcharged the health care team to recognize excessive weight or increase inweight gain relative to linear growth in pediatric ambulatory caresettings.⁸ Aconsensus panel convened by ADA and AAP in 2000 recommended testing for type 2diabetes during a health care visit if the child has a BMI greater than the85th percentile plus any two of the following: family history of type 2diabetes in first- or second-degree relatives, certain race or ethnicity(American Indian, African American, Hispanic, Asian/Pacific Islander), orsigns of insulin resistance or conditions associated with insulin resistancesuch as acanthosis nigricans, hypertension, dyslipidemia, or polycystic ovarysyndrome.⁹ Screeningshould start at age 10 years or at the onset of puberty and should take placeevery 2 years.

In addition to primary prevention and early detection, managementstrategies are also critical to addressing the childhood diabesity problem.The Treatment Options for type 2 Diabetes in Adolescents and Youth (TODAY)trial is under way to determine treatment strategies that will help improvethe outcome of type 2 diabetes in youth. The ADA released its Management ofDyslipidemia in Children and Adolescents with Diabetesstatement¹⁰ withrecommendations to help pediatric providers focus on reducing CVD risk.Children with type 2 diabetes have a lipid pattern similar to that of adultswith this disease: elevated triglycerides, decreased HDL cholesterol, andnormal to slightly elevated LDL with increased small, dense particles. Thesechildren should have a screening lipid examination at diagnosis. If valuesfall within the accepted risk levels, this screening should be repeated every2 years.

Treatment should be based on fasting lipid levels (mainly LDL) obtainedafter glucose control is established. Initial therapy should consist ofoptimizing glucose control and medical nutrition therapy aimed at decreasingthe amount of total and saturated fat in the diet, as well as encouraginglifestyle changes to control weight, increase exercise, and, if applicable,discontinue tobacco use. The addition of pharmacological lipid-lowering agentsis recommended for patients with LDL >160 mg/dl or with 130–159 mg/dlafter nutrition therapy and lifestyle changes have failed.

MORE THAN MEDICAL TREATMENT

As research and clinical experience continue to define best practices andintervention and treatment guidelines, we must work on all fronts to addressthe childhood diabesity epidemic head-on. We must not just follow theguidelines listed above, but we should step out of our traditional roles ashealth care providers and work with others to devise effective approaches tocurtail the diabesity epidemic in children.

There are lots of interested parties and potential partners. Just look atwhat has been done already. President Clinton persuaded the soda industry toagree to stop selling sugar-added sodas in schools across the country.Governor Schwarzenegger banned the vending of junk food in all Californiaschools, and almost all states are dealing with legislation about schoolphysical education, health education, and food policies. The ADA, AAP,American Association of Family Physicians, and other professional groups areasking us to expand our roles and become advocates. The National Institutes ofHealth and the Centers for Disease Control and Prevention are providing grantsto programs and research endeavors to define best practices and accumulateevidence as to what is effective and translatable.

The childhood diabesity epidemic is not just being reported on TV and inthe newspapers; it is on our nation's—in fact mostnations'—political agenda. Each of us should place it high on ourpriority list and take an active role in trying to understand how to give ourchildren a life in which risk reduction is possible. ▪