Childhood and the risk of in minority populations

Jay H. Shubrook Jr., DO

besity is clearly recognized as Oa major risk factor for diabetes mellitus and cardiovascular disease. Body weight has been inversely correlated with morbidity and mortality: 1,2 the larger we grow, the shorter our lifespan. Prevalence rates of diabetes 3 in the United States continue to exceed predicted levels and are closely related to the rise in obesity we have seen over the past 30 to 40 years. Obesity rates in adults in particular have doubled in the past generation. 4,5

18 AOA Health Watch DOs Against DIABETES January 2011 It is well documented that childhood obesity increases the risk of adult obesity. One study found that 80% of obese adults had become obese by the time they reached age 25. 5 Even obese children as young as age 6 have a 50% chance of being an obese adult. 6 It appears that if obesity starts before the age of 8, it is more likely to be severe in adults. In a study of adult coronary heart disease risk factors, 30% of obese adults reported that their obesity began in childhood. 7 Childhood obesity also increases the risk of adult mortality. 8 It is not surprising in light of these statistics that the prevalence of diabetes and its complications are rapidly expanding in our population. In the past 30 years alone, pediatric obesity rates have tripled in the United States. 8 Currently, 1 in 3 children are , and 1 in 6 adolescents are obese. 9 This epidemic of childhood are now of 2 are overweight, and this number has affected even our youngest rapidly increasing. Typically, a person increases to 12.5% in Hispanic children. children: 1 in 7 low-income preschool can have NASH or type 2 diabetes for Among children 3 to 17 years of age, children are obese. 10 Previously, up to a decade before complications 32% are overweight or obese. In treatment of childhood obesity was arise. Diagnosis of diabetes and its Hispanic adolescents, 43% of boys and focused on preventing adult obesity complications in childhood, however, 40% of girls are overweight, and within and the complications commonly seen may profoundly affect life expectancy. that population, the rates for Mexican- in adults. Recent studies, however, Childhood body mass index (BMI) American adolescents are 46% for boys report an increase in morbidity is calculated using weight-to-height and 42% for girls. Further, the rates for and mortality associated with charts by the percentage of weight non-Hispanic black Americans are 33% childhood obesity. 11 divided by height. The Centers for for adolescent boys and 46% for girls. 2 Childhood complications of obesity Disease Control and Prevention has are significant and can include type 2 a simple calculator for assessing Why is obesity so prevalent? diabetes and hepatic steatosis or BMI in children and adolescents Many issues contribute to childhood steatohepatitis. It has been estimated (see http://apps.nccd.cdc.gov/dnpabmi/) obesity, but essentially they can be that 40% of obese children have and also provides standardized BMI boiled down to increased caloric intake evidence of fatty liver changes at tables that can be used in the office and reduced calorie expenditure. ultrasound imaging, 12 which may be setting (see Tables 1 and 2). The Food intake has changed substantially a more sensitive marker for the former ratings for excess weight in over the past 20 years. Children now diagnosis of steatohepatitis than children were changed from “at risk get as much as one-third of their calories elevated levels of transaminases. 12 for overweight” and “overweight” from “fast foods,” 13 which typically Hepatic steatohepatitis is now to “overweight” and “obese,” 6 more are calorie and dense. Furthermore, recognized as the leading cause of accurately reflecting the adverse soda consumption has increased 65% cryptogenic cirrhosis in the United outcomes of excess weight in childhood. and has been estimated to be as much States. 12 We have not yet determined Overweight is defined as a BMI of as 25% of all calories consumed. 14 how many children will be at risk for >85% and obesity as a BMI of 95%. Even small changes in calorie fatty liver hepatitis or non-alcoholic Data from the National Health consumption can equate to significant steatohepatitis (NASH), but the and Nutrition Examination Survey weight gain. An additional 50 calories incidence of hepatic diseases may (NHANES) show that children of all per day (one-third can of cola) can result closely follow the rise in obesity. ages are at risk, but the greatest burden in 5 extra pounds of weight in 1 year and Type 2 diabetes was once considered falls on those from minority groups. 2 50 pounds in a decade. Further, access a disease of adults only, but the rates Nearly 10% of children under the age to fresh whole foods is limited due to

January 2011 DOs Against DIABETES AOA Health Watch 19 contribute to obesity by displacing time Table 1 for physical activity, adding unplanned 2 to 20 years: Boys NAME calorie consumption during screen time, Body mass index-for-age percentiles RECORD # and leading to a loss of recognition of

Date Age Weight Stature BMI* Comments normal satiety cues when distracted BMI by passive entertainment. These risk 35 factors provide unique challenges for

34 the management of childhood obesity.

33 Link between childhood 32 obesity and diabetes 31 The direct link between type 2 diabetes 30 95 and obesity in children has become 29 increasingly evident. This was confirmed BMI 28 when a recent study showed that 90 27 27 89.8% of children diagnosed with type 2 18 26 85 26 diabetes were overweight or obese.

25 25 Children born in the year 2000 in the 75 United States have a 1 in 3 chance of 24 24 developing diabetes. This rate increases 23 23 50 for people of color and is as high as 50% 22 22 among Hispanic children. 19 Obesity and 21 21 its related complications are largely 25 20 20 responsible for the increased prevalence 10 19 19 of this disease and have contributed to 5 18 18 the fact that this is the first generation of Americans expected to have a shorter 17 17 life expectancy than their parents. 20 16 16 15 15 Diabetes in 14 14 minority populations 13 13 Studies report that 20% of pediatric 12 12 patients with newly diagnosed diabetes have type 2 diabetes. 21 There appears kg/m2 AGE (YEARS) kg/m2 to be a disproportionately higher 253678910111213141516171819204 incidence of type 2 diabetes in minority

Published May 30, 2000 (modified 10/16/00). SOURCE: Developed bytheNationalCenterforHealthStatisticsincollaborationwith children, as shown by ranges from the National Center for Chronic Disease Prevention and Health Promotion (2000). http://www.cdc.gov/growthcharts 3.7/100,000 in non-Hispanic whites to 38.42/100,000 in Navajo Indian females. 22 This difference seems to coincide with a higher incidence expense and geographical location. isolated from public play spaces. 15,16 of obesity in pediatric minority In our rural Appalachian town we have Families may also live at greater populations. Gender also influences over 50 fast food restaurants, and they distances from health-related resources incidence: females in the pediatric are easier to access for many people and have inadequate access to public population have a 60% higher incidence than the grocery store. Many families transportation. 16 During harder of type 2 diabetes than of their have become too busy to sit down for financial times, fewer children male counterparts. 23 the family dinner and will now grab participate in school gym programs, Our understanding of diabetes something on the run. clubs, and team sports. in American youth has been greatly Children also spend less time in Further, American youth are improved with the publication of physical activity. Fewer schools offer affected by increased television results from the SEARCH trial, a large daily gym classes, and many athletic viewing and screen time. 16 Television population-based study examining programs have been cut. There are watching and other “screen-time” physician-diagnosed diabetes in people fewer safe outdoor places for play, activities (video games, video under age 20 in the United States. 21 and many children are geographically phones, smart phones, and texting) This large epidemiologic trial set out

20 AOA Health Watch DOs Against DIABETES January 2011 to gain a better understanding of the prevalence of type 1 and type 2 diabetes Table 2 in children, the level of control, and 2 to 20 years: Girls NAME their experience with this disease. 21 Body mass index-for-age percentiles RECORD #

The SEARCH trial found that many Date Age Weight Stature BMI* Comments children who have developed type 2 BMI diabetes have poor control. 35

Black and Hispanic children, however, 34 97 were more likely to develop diabetes 33 and to have worse control. 23 32 In a trial of glucose tolerance 31 status in obese youth, good control 95 was observed in 71% of non-Hispanic 30 white children, 59% of African 29 American children, 50% of Hispanic BMI 28 90 children, 47% of Asian/Pacific 27 27 Island children, and only 34% of 26 85 26 American Indian children. 23 Among 25 25 Hispanic children, those of Mexican heritage had the greatest risk. Lower 24 75 24 income status among this group was 23 23 seen to further increase risk, with 22 22 50 the peak incidence of diabetes seen 21 21 24,25 in girls aged 10-14 years old. 20 20 25 It is clearly recognized that type 2 19 19 diabetes is a progressive, incurable, 10 18 18 but treatable disease, and the duration 3 17 of the disease predicts complications 17 and mortality. As such, it is reasonable 16 16 to conclude that children with 15 15 type 2 diabetes may be facing a grim 14 14 future unless they seek comprehensive 13 13 treatment for diabetes and obesity. 12 12 Preventing our youth from getting diabetes and treating it aggressively kg/m2 AGE (YEARS) kg/m2 once diagnosed should be a public 253678910111213141516171819204 health priority. Published May 30, 2000 (modified 10/16/00). SOURCE: Developed bytheNationalCenterforHealthStatisticsincollaborationwith the National Center for Chronic Disease Prevention and Health Promotion (2000). Screening children http://www.cdc.gov/growthcharts for diabetes The American Diabetes Association has developed screening guidelines for children who are at high risk Ⅲ physical signs of Final notes of developing diabetes. 26 The such as acanthosis nigricans. As a clinician, I often think the burden recommendations endorse screening Ⅲ conditions related to insulin resistance of obesity is too great to manage from children who are overweight (BMI . such as , dyslipidemia, the perspective of a single practice. 85th percentile for age and gender), or polycystic ovarian syndrome. 24 I have learned, however, that physicians those who have a body weight greater can be trusted resources, and many than 120% of the ideal for height, Testing should begin at age 10 or lifestyle changes are more likely to occur and anyone who meets at least 2 at the onset of puberty, whichever if addressed by a physician. We need of the following criteria: comes first. Screening should occur to remember that changing even one every other year, and the test of choice child’s life may affect many more Ⅲ family history of type 2 diabetes. is a fasting blood glucose test. One indirectly. The first phase of this Ⅲ high-risk race/ethnicity, including study found that obese children who treatment occurs in our office. American Indian, African-American, had impaired fasting glucose developed For those who need additional help, Hispanic, or Asian/Pacific Islander. type 2 diabetes within 2 years. 25 there are comprehensive programs

January 2011 DOs Against DIABETES AOA Health Watch 21 Important links Ⅲ Centers for Disease Control and Prevention (CDC): The Health Consequences of Obesity http://www.cdc.gov/obesity/causes/ health.html

Ⅲ CDC: The Economic Consequences of Obesity http://www.cdc.gov/obesity/causes/ economics.html

Ⅲ American Academy of Pediatrics: Preventing Pediatric Overweight and Obesity: American Academy of Pediatrics Policy Statement http://aappolicy.aappublications.org/ cgi/content/full/pediatrics;112/2/424

Ⅲ CDC: Tips for Parents http://www.cdc.gov/healthyweight/ children/index.html

Ⅲ US Department of Health and Human Services: Report on Childhood Obesity http://aspe.hhs.gov/health/reports/ child_obesity/ HW Steps to confront childhood obesity References Ⅲ Address obesity in children in your practice. 1. Lee IM, Manson JE, Hennekens CH, Paffenbarger RS Jr. Body weight and mortalitya; 27-year Ⅲ Make BMI measurement one of the vital signs at every visit. follow-up of middle-aged men. JAMA. 1993;270(23):2823-2828. Ⅲ Instruct patients not to “drink their calories.” 2. Manson JE, Willett WC, Stampfer MJ, et al. Body weight and mortality: among women. N Engl J Med. 1995;333(11):677-685. Ⅲ Suggest the recommended 60 minutes of physical 3. New cases of diagnosed diabetes on the rise. activity per day—encourage families to do it together. Centers for Disease Control and Preveniton Web site. http://www.cdc.gov/media/pressrel/ Ⅲ Teach children to grow into their weight. 2008/r081030.htm?s_cid=mediarel_r081030. Accessed September 3, 2010. Ⅲ Screen high-risk children for diabetes. 4. Flegal KM, Carroll MD, Ogden CL, Johnson CL. Prevalence and trends in obesity among US adults, Ⅲ Try to link those who need help 1999-2000. JAMA. 2002;288(14):1723-1727. to established weight-loss centers. 5. Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of overweight and obesity in the United States, 1999-2004. JAMA. 2006;295(13):1549-1555. that can supplement our efforts. nearly 40% of children in the United 6. Whitaker RC, Wright JA, Pepe MS, Seidel KD, Previous studies have shown that States are from minority backgrounds Dietz WH. Predicting obesity in young family-based programs that include and many of these children may develop adulthood from childhood and parental obesity. both nutritional and physical activity diabetes at a young age, which may N Engl J Med. 1997;337(13):869-873. interventions are the most successful. 27-30 substantially shorten their lives. As 7. Freedman DS, Khan LK, Dietz WH, Srinivasan SR, The health and economy of our Berenson GS. Relationship of childhood obesity to we acknowledge the increased risk, coronary heart disease risk factors in adulthood: country are directly affected by the we need to address this issue swiftly the Bogalusa Heart Study. Pediatrics. obesity epidemic. It is estimated that and universally. 2001;108(3):712-718.

22 AOA Health Watch DOs Against DIABETES January 2011 8. Hoffmans MD, Kromhout D, Coulander CD. Body mass index at the age of 18 and its effects on 32-year-mortality from coronary heart disease and cancer: a nested case-control study among the entire 1932 Dutch male birth cohort. J Clin Epidemiol. 1989;42(6):513-520. 9. Ogden CL, Carroll MD, Curtin LR, Lamb MM, Flegal KM. Prevalence of high body mass index in US children and adolescents, 2007-2008. JAMA. 2010;303(3):242-249. 10. Centers for Disease Control and Prevention. Overweight and obesity. Obesity prevalence among low-income, preschool-aged children 1998-2008. http://www.cdc.gov/obesity/childhood/ lowincome.html. Accessed August 30, 2010. 11. Krebs NF, Himes JH, Jacobson D et al. Assessment of child and adolescent overweight and obesity. Pediatrics. 2007;120(suppl 4):S193-S228. 12. Guzzaloni G, Grugni G, Minocci A, Moro D, Morabito F. Liver steatosis in juvenile obesity: correlation with profile, hepatic biochemical parameters and glycemic and insulinemic responses to an oral glucose tolerance test. Int J Obes Relat Metab Disord. 2000;24(6):772-776. 13. Massachusetts Medical Society Committee on Nutrition. Fast-food fare: consumer guidelines. N Engl J Med. 1989;321(11):752-756. 14. Ludwig DS, Peterson KE, Gortmaker SL. Relation between consumption of sugar-sweetened drinks and childhood obesity: a prospective, observational analysis. Lancet. 2001;357(9255):505-508. 15. Centers for Disease Control and Prevention. National diabetes fact sheet, United States, 2005. General information and national estimates on diabetes in the United States, 2005. Atlanta, GA: US Department of Health and Human Services; 2005. http://www.cdc.gov/diabetes/pubs/pdf/ ndfs_2005.pdf Accessed August 30, 2010. 22. The HEALTHY Study Group. Risk factors for type 2 28. Epstein LH, Wing RR, Penner B, Kress MJ. 16. Cherry DC, Huggins B, Gilmore K. Children’s health diabetes in a sixth-grade multiracial cohort: the Effect of diet and controlled exercise in the rural environment. Pediatr Clin North Am. HEALTHY study. Diabetes Care. 2009;32(5):953-955. on in obese children. 2007;54(1):121-133. 23. Weiss R, Taksali SE, Tamborlane WW, Burgert TS, J Pediatr. 1985;107(3):358-361. 17. Tessaro I, Smith S, Rye S. Knowledge and Savoye M, Caprio S. Predictors of change 29. Epstein LH, Wing RR, Steranchak L, Dickson B, perceptions of diabetes in an Appalachian in glucose tolerance status in obese youth. Michelson J. Comparison of family-based population. Prev Chronic Dis. 2005;2(2):A13. Diabetes Care. 2005;28(4):902-909. behavior modification and nutrition education http://www.cdc.gov/pcd/issues/2005/ 24. Lawrence JM, Mayer-Davis EJ, Reynolds K, for childhood obesity. J Pediatr Psychol. apr/04_0098.htm. et al; for SEARCH for Diabetes in Youth Study 1980;5(1):25-36. 18. Liu LL, Lawrence JM, Davis C, et al; for the Group. Diabetes in Hispanic American youth: 30. Epstein LH, Wing RR, Koeske R, Valoski A. SEARCH for Diabetes in Youth Study Group. prevalence, incidence, demographics, and A comparison of lifestyle exercise, aerobic Prevalence of overweight and obesity in youth clinical characteristics: the SEARCH for exercise, and calisthenics on weight loss with diabetes in USA: the SEARCH for Diabetes Diabetes in Youth Study. Diabetes Care. in children. Behav Ther. 1985;16(4):345-356. in Youth Study. Pediatr Diabetes. 2009;11(1):4-11. 2009;32(suppl 2):S123-S132. 19. Narayan KM, Boyle JP, Thompson TJ, 25. Petitti DB, Klingensmith GJ, Bell RA, et al; Sorensen SW, Williamson DF. Lifetime risk for the SEARCH for Diabetes in Youth Study for diabetes mellitus in the United States. Group. Glycemic control in youth with diabetes: Jay H. Shubrook Jr., DO, is an associate JAMA. 2003;290(14):1884-1890. the SEARCH for Diabetes in Youth Study. professor of family medicine and a 20. Olshansky SJ, Passaro DJ, Hershow RC, et al. J Pediatr. 2009;155(5):668-672. diabetologist. He serves as the director A potential decline in life expectancy in the 26. American Diabetes Association. of clinical research and director of the United States in the 21st century. N Engl J Med. Type 2 diabetes in children and adolescents. Diabetes Fellowship at Ohio University 2005;352(11):1138-1145. Diabetes Care. 2000;23(3):381-389. College of Osteopathic Medicine. He 21. The Writing Group for the SEARCH for Diabetes 27. Epstein LH, Valoski A, Wing RR, McCurley J. is a Fellow of the American College of in Youth Study Group. Incidence of diabetes Ten-year outcomes of behavioral family-based Osteopathic Family Physicians. He can be in youth in the United States. JAMA. treatment for childhood obesity. Health Psychol. reached at [email protected]. 2007;297(24):2716-2724. 1994;13(5):373-383.

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