When pediatrician Carden Johnston was in medical school, it was practically unheard of to find a child with type II diabetes, also known as adult-onset diabetes.
That was a few decades ago. Since then, the number of overweight children has doubled and the number of overweight teens has tripled, according to the Centers for Disease Control and Prevention (CDC). The rise in obesity also has meant a rise in such health problems as high blood pressure, elevated cholesterol levels and type II diabetes — conditions that formerly were limited to adults.
“When I was in medical school, they said you will never see type II diabetes in a child,” says Dr. Johnston, a Birmingham, Ala., physician and president of the American Academy of Pediatrics (AAP). “I recently talked to an associate who diagnosed it in a 2-year-old.”
Dr. William Dietz, director of the Division of Nutrition and Physical Activity at the National Center for Chronic Disease Prevention and Health Promotion at the CDC, says 60 percent of overweight children have at least one cardiovascular disease risk factor, 25 percent have two or more conditions, and hospitalization rates for children and adolescents with complications from being overweight have tripled.
“It is a public health crisis,” Dr. Dietz says. “The existing cost of childhood overweight is about $175 million a year.”
Dr. Johnston says emotional implications also complicate the life and health of an overweight child.
“Obesity is an incredible problem, one that is going to be devastating to the future of our country,” he says. “The mission of the AAP is to make sure that children grow into optimal adults mentally, physically and socially. There is good evidence that obese children are not healthy physically. There are also studies that show an obese child has a self image similar to a child with cancer. They feel socially isolated.”
Who is at risk?
The CDC uses its body-mass index scale to determine who is moderately overweight, overweight or obese. Health care professionals should use those guidelines, along with a family history and a look at lifestyle factors, in monitoring children for obesity-related diseases, says Melinda S. Sothern, director of the child obesity lab and an exercise physiologist at Louisiana State University, and the author of “Trim Kids: The Proven 12-Week Plan That Has Helped Thousands of Children Achieve a Healthier Weight.”
Body-mass index is calculated by figuring height, weight and age. Children are considered underweight if their BMI is below the fifth percentile for their age and gender. At risk of being overweight are children whose BMI falls between the 85th and 95th percentile. Children are considered overweight if their weight is above the 95th percentile for their height and gender.
“If a school-age kid is above the 95th percentile [in weight for his or her age, the child] should be referred for treatment,” Ms. Sothern says. “If there is a family history of diabetes or high blood pressure, they should get tests such as their fasting insulin and glucose tolerance.
“Anyone above 99 percent — or more than 50 pounds overweight — should have their glucose tested and a lipid profile for cholesterol. What many people don’t understand is that when a child is in the upper 5 percent, or more than 30 pounds overweight, he is very sick. When you do their profiles, you will find high cholesterol, high body-fat percentage, high blood pressure, risk for bone and joint disorders” and drastically reduced ability to exercise.
Stopping diabetes
The fastest-growing condition among overweight children is type II diabetes.
Dr. Francine Kaufman, a pediatric endocrinologist in Los Angeles and past president of the American Diabetes Association, says type II diabetes among children and adolescents has increased tenfold over the past decade. About 25 percent of new-onset patients have type II diabetes. It used to be 2 percent to 4 percent, she says.
In the past, type II was called “adult-onset diabetes.” Type I, or “juvenile diabetes,” caused by a defect in the immune system, is what doctors usually saw in pediatric patients.
Most children with type II diabetes are diagnosed at about age 10. The incidences of type II are higher in certain ethnic groups, such as American Indians, Hispanics or blacks, Dr. Kaufman says.
Long-term effects of diabetes can include atherosclerosis — which can lead to circulatory disorders, coronary artery disease, kidney disorders, eye disorders and nerve problems.
The good news is that type II diabetes can be managed and, in some cases, reversed, Dr. Kaufman says.
A study under way at the National Institutes of Health will look at the effects of drugs versus lifestyle changes such as diet, exercise and counseling.
Called the TODAY trial (Treatment of Diabetes in Adolescents and Youth), the study is being conducted at several medical centers around the country. The randomized trial is looking at three protocols: Group 1, intensive lifestyle components (diet, motivational counseling, exercise); Group 2, one drug; and Group 3, two drugs. About 150 children are in the study, but NIH is looking for more candidates.
Children and adolescents can be treated with diabetes drugs, Dr. Kaufman says. Most drugs have not been approved specifically for pediatric use, she says.
“We don’t know the best treatment because we don’t have that much experience with children and type II,” Dr. Kaufman says. “There is no reason to think the number of children with type II will not go up, as it is mirroring the rise in childhood obesity. We obviously have to get a handle on the number of children who are at risk for being overweight.”
Controlling heart disease
A study presented to the American Heart Association in 2003 estimated that 1 in 8 schoolchildren have three or more risk factors for cardiovascular disease.
Those risk factors include high blood pressure, elevated triglycerides, low levels of HDL or “good” cholesterol, elevated body weight and elevated insulin levels. Clustered together, these factors are known as metabolic syndrome.
Researchers looked at 3,203 children ages 8 to 17 who lived in rural North Carolina. The test group was 47.9 percent white, 42.4 percent black and 9.7 percent other races.
The children’s BMI, blood pressure, cholesterol and glucose were tested. Researchers found that more than half (59 percent) of the children had at least one risk factor, 28 percent had two or more, and 14 percent had three or more.
One in four participants had a BMI above the 95th percentile for their age, height and gender. Forty-one percent had low levels of HDL cholesterol. More than 8 percent had high triglycerides. Ten percent had high blood pressure.
The participants will be followed for three to four years, says Joanne Harrell, professor of nursing at the University of North Carolina at Chapel Hill and the lead author of the study.
Metabolic syndrome is also something doctors were used to seeing in patients closer to midlife, says Dr. Robert DiBianco, a cardiologist and chairman of medicine at Washington Adventist Hospital in Takoma Park.
A child or adolescent is considered to be at risk if total cholesterol is more than 170 or the LDL cholesterol level is more than 130. Resting blood pressure should be no higher than 120 over 80, Dr. DiBianco says.
Family history and BMI are good starting points before having a child tested for metabolic disorder, he says.
This is another area in which doctors recommend lifestyle changes before medications to control high cholesterol or high blood pressure.
“Medications are primarily for individuals at high risk,” Dr. DiBianco says, “but we shouldn’t be using medications unless lifestyle changes have failed or if levels are exceedingly high, such as cholesterol above 190 with a high level of bad cholesterol.”
Dr. DiBianco encourages lifestyle changes such as keeping weight at a BMI of 25 or below; exercising four times a week for at least 20 to 30 minutes; and eating sensibly, with a reduced intake of saturated fat.
Ms. Sothern says lifestyle changes can mean long-term improvement.
“We have 35 studies that show that exercise, diet and behavior counseling show dramatic reductions in LDL,” she says. “Five years later, they are still there.”
Conditions to watch
Childhood obesity also can lead to osteoporosis and other joint conditions, gall bladder disease and sleep apnea.
Dr. Johnston says children who go through a growth spurt with excess weight and an accompanying decrease in calcium absorption are at risk for osteoporosis, the bone-thinning disease more commonly found in post-menopausal women.
Dr. Dietz of the CDC says there recently has been a threefold increase in obstructive sleep apnea and gall bladder conditions.
Sleep apnea is a condition in which a person’s airway is constricted by fatty tissue, causing stoppages in breathing while sleeping. Sleep apnea can lead to a reduction in oxygen to the brain and also can trigger heartbeat irregularities. Losing weight usually will reverse the problem, Dr. Dietz says.
Gall bladder problems are more of a mystery, he says.
“This is an odd problem,” Dr. Dietz says. “Overweight people have an increase in cholesterol in their bile. If you lose a lot of weight, you are sometimes at risk for gall bladder problems, although no one is quite sure why.”
Again, keeping weight down in the first place can go a long way toward prevention, he says.
“If you can control weight, you can control medical conditions,” Dr. Dietz says. “The challenge, though, is controlling weight.”
MORE INFO:
BOOKS —
• “TRIM KIDS: THE PROVEN 12-WEEK PLAN THAT HAS HELPED THOUSANDS OF CHILDREN ACHIEVE A HEALTHIER WEIGHT,” BY MELINDA S. SOTHERN, T. KRISTIAN VON ALMEN AND HEIDI SCHUMACHER, HARPERRESOURCE, 2003. THIS BOOK EXPLAINS BEHAVIOR MODIFICATION, EXERCISE AND HEALTHIER EATING TO CONTROL WEIGHT.
• “HELPING YOUR CHILD LOSE WEIGHT THE HEALTHY WAY: A FAMILY APPROACH TO WEIGHT CONTROL,” BY JUDITH A. LEVINE AND LINDA BINE, CITADEL TRADE, 2001. THIS BOOK GIVES TIPS FOR PARENTS TO GET CHILDREN TO EAT HEALTHIER MEALS WHILE TAKING INTO CONSIDERATION THE EMOTIONAL STATE OF AN OVERWEIGHT CHILD.
• “HELPING YOUR OVERWEIGHT CHILD: A FAMILY GUIDE,” BY DR. CAROLINE J. CEDERQUIST, ADVANCE MEDICAL PRESS, 2002. THIS BOOK, WRITTEN BY A PHYSICIAN, HELPS CHILDREN UNDERSTAND WHAT A HEALTHIER FOOD CHOICE IS, HOW TO MAKE BETTER FOOD DECISIONS AND HOW TO SET GOALS.
ASSOCIATIONS —
• AMERICAN DIETETIC ASSOCIATION, 120 S. RIVERSIDE PLAZA, SUITE 2000, CHICAGO, IL 60606. PHONE: 800/877-1600. WEB SITE: WWW.EATRIGHT.ORG. THIS PROFESSIONAL ASSOCIATION HAS RESEARCH INFORMATION, FACT SHEETS, HEALTHY EATING GUIDELINES, WEIGHT MANAGEMENT TIPS AND REGISTERED DIETITIAN REFERRALS.
ONLINE —
• THE CENTERS FOR DISEASE CONTROL AND PREVENTION (WWW.CDC.GOV) HAS CHRONIC DISEASE INFORMATION AND BMI — BODY MASS INDEX — CALCULATORS ON ITS WEB SITE.
• THE AMERICAN HEART ASSOCIATION (WWW.AMERICANHEART.ORG) HAS INFORMATION ABOUT CHILDREN, CHOLESTEROL, HEART DISEASE AND WEIGHT ON ITS WEB SITE.
• AT SHAPE UP AMERICA (WWW.SHAPEUP.ORG), A NONPROFIT GROUP DEDICATED TO WEIGHT LOSS AND FITNESS, VISITORS CAN FIND TIPS ON HEALTHY EATING AND EXERCISE. SHAPE UP SPONSORS THE 10,000 STEPS PROGRAM, WHICH ENCOURAGES CHILDREN AND ADULTS TO WEAR A PEDOMETER TO MEET A GOAL OF TAKING 10,000 STEPS A DAY TO STAY IN SHAPE.
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