May 2010 Issue

Diabesity in Children — Epic Proportions of Disease Necessitate Major Action
By Janice H. Dada, MPH, RD, CSSD, CDE, CHES
Today’s Dietitian
Vol. 12 No. 5 P. 14

Francine Kaufman, MD, an internationally recognized pediatric endocrinologist, describes her first pediatric case of type 2 diabetes mellitus (DM) in her best-selling book Diabesity: The Obesity-Diabetes Epidemic That Threatens America — and What We Must Do to Stop It. It was 1995 and the patient was a 13-year-old girl weighing 267 lbs with a blood glucose level of 427 mg/dL.

Kaufman details her encounter with this girl and her initial confusion and surprise regarding the case. In the mid-1990s, it was not routine to find children and teens with type 2 DM since it was supposed to be a disease of aging. Unfortunately, times have changed and the number of type 2 DM cases among school-age children has mirrored the rapid increases in obesity rates among this group.

Youths at Risk
DM is one of the most common chronic diseases in childhood. According to the Centers for Disease Control and Prevention (CDC), about 151,000 people under the age of 20 have it. Experts previously assumed a DM diagnosis during childhood to be type 1, formerly known as juvenile-onset DM, and referred to type 2 DM as adult-onset DM. The latter term is no longer accurate because of the staggering number of children and adolescents with this condition. The obesity epidemic and the low level of physical activity among young people, as well as exposure to DM in utero, may be major contributors to the increase in type 2 DM during childhood. Type 2 DM affects all ethnic groups, but per CDC data, it is disproportionately seen in ethnic minorities, with American Indian youths having the highest prevalence.

For children and adolescents aged 2 to 19, the body mass index (BMI) value is plotted on the CDC growth charts to determine the corresponding BMI-for-age percentile. Overweight is defined as a BMI at or above the 85th percentile but lower than the 95th percentile, and obesity is defined as a BMI at or above the 95th percentile. Rates of overweight children have increased over time. In the 1960s, 5% of 6- to 19-year-olds were overweight.1 By the year 2000, this percentage had increased threefold to 15%. For black and Hispanic children, the rate of overweight is 30%.1

A Kaiser Permanente study of more than 700,000 southern California children and teens recently published in the Journal of Pediatrics reported that just over 7% of boys and 5.5% of girls were classified as extremely obese. Among black teenage girls and Hispanic teenage boys, 11.9% and 11.2% were classified as extremely obese, respectively. Extreme obesity among children is defined as weighing more than 1.2 times the 95th percentile or having a BMI of 35. Although these findings highlight only children living in southern California, the researchers believe they are representative of what is occurring throughout the United States. They suggest that these children will face a 10- to 20-year shorter life span if major lifestyle changes are not soon established. The researchers also believe that the children may develop health problems in their 20s that are typically not seen until the ages of 40 to 60.

Diabesity: Type 2 Diabetes and Obesity
It is well known that obesity predisposes the body to an increased risk of developing type 2 DM because of the insulin resistance associated with excess body fat. Former U.S. Surgeon General C. Everett Koop, MD, ScD, founded Shape Up America! in 1994 to raise awareness of the adverse effects of obesity and trademarked the term diabesity as part of his effort to promote a healthy lifestyle.1

As of 2007 (the most current year of reportable data), 23.6 million children and adults in the United States, or nearly 8% of the population, had DM. In addition, approximately 2 million adolescents (or one in six overweight adolescents) aged 12 to 19 had pre-DM. DM is among the leading causes of death by disease in the United States. According to the American Diabetes Association (ADA), the death rate due to DM has increased by 45% since 1987, while the death rates due to heart disease, stroke, and cancer have declined. The ADA predicts that if current trends in childhood obesity continue, nearly one in three American children born in the year 2000 (and one in two minorities) will develop type 2 DM in their lifetime. Blacks are 1.6 times more likely than whites of a similar age to develop DM. The risk is 1.5 times higher for Hispanic Americans and two times higher for Mexican Americans and Native Americans.1 These differences may be due in part to genetics, lifestyle, and/or access to preventive medical care.

DM is a leading cause of heart attack, stroke, blindness, amputation, kidney disease, and death, costing the nation more than $174 billion per year, according to the ADA. However, once the additional costs of undiagnosed DM, pre-DM, and gestational DM are factored in, the total expense in the United States is closer to $218 billion. Average medical expenditures for those with diagnosed DM are about 2.3 times higher than expenditures would be in the absence of the disease.

Let’s Move!
On February 9, First Lady Michelle Obama announced an ambitious national goal of solving the problem of childhood obesity within a generation. According to the White House Web site, the Let’s Move campaign will combat the childhood obesity epidemic through a comprehensive approach that builds on effective strategies and mobilizes public and private sector resources. It will engage every sector impacting children’s health to achieve the national goal and will provide schools, families, and communities with simple tools to help kids be more active, eat better, and get healthy. Let’s Move claims to be a comprehensive, collaborative, and community-oriented plan that will include strategies to address the various factors that lead to childhood obesity. It aims to foster collaboration among the leaders in government, medicine, science, business, education, athletics, community organizations, and more. It plans to encourage, support, and pursue solutions tailored to children and families facing a wide range of challenges and life circumstances.

The ADA released a statement applauding the first lady’s childhood obesity campaign as a step toward fighting type 2 DM in children. Similarly, the American Dietetic Association, the American Public Health Association, the American Academy of Pediatrics (AAP), and other organizations have given full support to the plan. However, some RDs fear the plan will foster too much attention on the problem of childhood obesity, resulting in negative psychosocial implications for the children.

Helping Without Harming
Ellyn Satter, MS, RD, LCSW, BCD, an internationally recognized child feeding/nutrition expert, suggests in a 2003 position statement that the two major causes of child overweight are misinterpreting a child’s normal size and shape and labeling it overweight and imposing food restrictions. Satter recently sent a letter to the first lady with her major points regarding the best way to tackle the obesity epidemic. She included the following points in her letter:

• Don’t talk about child obesity. Research shows labeling children as overweight or obese makes them feel flawed. She suggests child obesity can be prevented and/or treated from birth by maintaining a division of responsibility in feeding: “Parents do the what, where, when of feeding and children do the how much and whether of eating.”

• Provide, don’t deprive. Satter suggests children who are given regular, reliable, and rewarding meals and snacks will eat to mirror their needs and grow appropriately. On the other hand, children who are restricted fear going hungry and eat as much as they can whenever they can as a result, causing them to grow larger than nature intended.

• Optimize feeding and parenting and let children be children. Satter states that adults must trust children to learn to eat the foods they desire, eat as much as they need, and grow in a way that is genetically appropriate for them.

What Does the Future Hold?
The AAP suggests the enormity of the childhood obesity and diabesity epidemics necessitate action. Preventing childhood obesity will prevent type 2 DM in children since the disease is so strongly related to weight. Pediatricians, along with RDs, need to proactively discuss and promote healthy eating behaviors to children at an early age and empower parents to promote children’s ability to self-regulate energy intake while providing appropriate structure and boundaries around eating. Significant changes in growth patterns can and should be recognized and addressed before children become severely overweight. Foster dietary practices that encourage healthy choices and moderation rather than restrictive eating patterns, and promote regular physical activity to families, schools, and communities.

RDs can advocate for change as parents or a community members by participating in committees, conducting assessments, and making recommendations. They can also provide leadership for nutrition and wellness policy development and implementation, provide nutrition expertise in healthy product selection, and facilitate regular monitoring of school nutrition policies.

— Janice H. Dada, MPH, RD, CSSD, CDE, CHES, is a dietitian in private practice, college nutrition instructor, and freelance writer based in southern California.

Reference
1. Kaufman FR. Diabesity: The Obesity-Diabetes Epidemic That Threatens America—And What We Must Do to Stop It. New York: Bantam Books; 2005.