Type 2 Diabetes: an Adult Disease Striking Children
The bad news is that children and adolescents are experiencing a steep rise in type 2 diabetes. This diabetes used to be referred to as adult-onset because the weight gain and sedentary behavior that contributes to diabetes was more common in middle aged adults.
The worse news is that doctors who treat children with diabetes say that immediate prospects for solving the problem are not bright. Comments Robert Sherwin, MD, president of the American Diabetes Association and director of the Diabetes Endocrinology Research Center at the Yale University School of Medicine, "there's no quick fix."
It's No Small Matter
Diabetes is one of the country's leading causes of blindness, the leading cause of end-stage kidney disease and lower leg amputations, and a major contributor to heart attacks and strokes. People afflicted with the disease have historically suffered from those complications in their 50s, 60s, and 70s. But, children with the condition who are not able to keep it under control via lifestyle changes are much more likely to lose their sight—or a foot—before they hit 40.
Those youths most likely to be afflicted are of African-American, Asian, and Hispanic descent, as well as children of American Indians and Pacific Islanders. Kids of European ancestry are not immune. Doctors who treat people with diabetes are seeing more of them, too. Whatever the race, overweight girls, particularly obese ones, are more likely to get diabetes than overweight boys.
Type 2 Continues to Spread
As recently as 20 years ago, only 2% of all newly diagnosed cases of diabetes among youths aged 9 to 19 were type 2. Today, up to 50% of new cases of diabetes among kids is type 2.
Gerald Bernstein, MD, was a past president of the American Diabetes Association and a senior endocrinologist at Beth Israel Medical Center in New York. Dr. Bernstein says. "Pushed to give a rough estimate," he adds, "one in 400 kids, by the time they're 20, will have type 2." That makes it more prevalent than cystic fibrosis, one of the most common inherited disorders in U.S. children. In type 2 diabetes, the pancreas produces plenty of insulin, but the body does not respond to it – a condition called “insulin resistance.” Insulin is needed to move blood sugar or glucose from the blood to all the cells for fuel. If this process is interrupted, glucose builds up in the blood-the hallmark of diabetes. Excess weight, particularly around the abdomen, as well as too little physical activity, are what make the body's tissues less sensitive to the workings of insulin, thereby keeping sugar "locked up" in the bloodstream.
Most Type 2 diabetes is due to obesity and reduced exercise, but scientists are actively searching for other causes. Some observational studies in India suggest that deficiency of Vitamin B12 and Folate during pregnancy may affect children’s likelihood of developing diabetes. Some experts also think that certain virus infection may increase risks for obesity. This hypothesis remains controversial, but does not reduce the importance of improved nutrition and exercise for all children.
What Can Be Done?
The goal is for children to stop piling on excess pounds and become more physically active. No one's in doubt about that. But if their parents can't do it—55% of adult Americans are overweight—how are kids supposed to make a start?
Children are best raised to approach life confidently and optimistically. Advice for losing weight and getting in shape, by contrast, often comes with restrictions and finger wagging, which can take a heavy toll on a child's self-image.
What can parents do to help their children make the transition to a more healthful lifestyle without psychological consequences?
"That's a very good question," says Susan B. Nunez, MD, "and there is no good answer." Kenneth Lee Jones, MD, feels, "It's going to be a long struggle. It's going to be like educating the public about smoking". Americans are so entrenched in eating too many high-calorie foods and engaging in too little physical activity. As Dr. Bernstein puts it, lifestyle changes are hard with "the seduction of the environment."
Traditional Dieting Doesn't Work
One thing many experts agree on is that parents should not try to put their children on weight-loss diets. "Do not say, `Don't eat this, don't eat that,'" offers Dr. Nunez. "It's not going to work." Instead, she tells kids simply to cut back on foods they enjoy and want to keep in their meal plans. "For instance," she counsels, "if they are used to three slices of pizza, cut back to 2 or 1 1/2. Or if they are eating three pieces of fried chicken, cut back to two, or one big piece. In that way," she says, "you are not restricting" but rather just making "adjustments."
Ann Loranger, RD, CDE, a dietitian who works to help young people with diabetes eat better, sees it the same way. "I don't give calorie-controlled diets," she says, "just healthy eating." By keeping the focus on better, more nutritious choices, the child has a chance of losing some extra pounds, or at least stemming a continuous weight gain, without the profound sense of deprivation that often goes with "dieting." All it takes to start reducing high blood sugar in many people is a weight loss of 10 pounds.
A Family Affair
Parents also have to engage in that delicate dance of knowing when to step in and take control and when to recognize a child's right to make her own decisions. That can be particularly difficult since most teens and near-teens, when they learn of their diabetes, are extremely impatient to exercise their independence. "Adolescents have so much autonomy, deservedly or not," says William Dietz, MD, PhD at the Centers for Disease Control and Prevention. Parents have much more control over what their younger children eat.
But he and others believe that parents still hold a lot of dietary cards and that it's up to mothers and fathers, in fact, to involve the whole family in more healthful eating rather than single out the child with diabetes. "Adolescents still live in families," says Dr. Dietz. "Focusing on the adolescent alone is only going to make the problem worse. It's not up to the adolescent to modify the home environment, but to the family. And it's the parents who have to get everybody else in line" by serving appropriate meals with vegetables and fruits and low-fat cuts of meat and not keeping too many high-calorie, high-fat snacks on hand.
Dietitian Loranger agrees, saying that a child's ego is more likely to remain intact if the whole family is involved. She notes that some parents come in and say the whole family can't be fed the same way because one kid is thin and one is overweight. But, she comments, "everybody should be eating the same" healthful meals. It's not as if a thin child who doesn't have diabetes shouldn't be having plenty of produce, low-fat dairy products, and other nutritious fare.
Ms. Loranger and others make it clear that eating healthfully does include letting ice cream and chips cross the threshold so that everyone, including the child with diabetes, can have a favorite snack sometimes. But such items shouldn't be dietary mainstays. They do not always have to be available. (Such a dietary approach is likely to help more than one person in the household control diabetes progression. Anywhere from 45% to 80% of people with diabetes has a parent with the disease as well.)
Educating Kids at the Supermarket and in the Classroom
Children's hospital's Dr. Nunez says that "what I usually suggest to the families is bringing the adolescent along [to the supermarket] and allowing him to participate in choosing the items that will be brought home." That "helps them take responsibility" as they "learn about food and nutrition."
The experts generally agree that schools should play a bigger role in educating children about healthful eating, too. "Kids need to learn in their health classes not just about the birds and the bees," says American Diabetes Association president Dr. Sherwin, "but about living a healthy lifestyle."
School cafeteria choices should also reflect health concerns. "If the school serves McDonald's or Kentucky Fried Chicken," Dr. Sherwin says, "then the child is going to eat that" instead of less fatty fare. In addition, notes Dr. Jones, we "need to have non-caloric drinks in school cafeterias so that kids are not slaking their thirst" with sugary beverages. Even "if kids drink enormous amounts of milk and juice without drinking soda," he notes, they could be downing too many calories from fluids.
Dr. Jones and others feel, too, that schools can do a much better job of encouraging kids to keep active. "One of the first things that [gets cut in schools] is physical education," Dr. Jones says. It's unfortunate, he reasons, because schools can play a big part in "getting kids to the point where physical activity is seen as fun. Schools should help kids not be embarrassed," he comments. "You shouldn't have to be a full-court jock to participate."
Of course, every child is different, and adults need to keep that in mind as they encourage children with diabetes to live more healthfully. For instance, Dr. Nunez says that some obese teens are too embarrassed to move their bodies in front of others no matter what, and for them she recommends exercise videos. And whereas some children might benefit from participating in physically active outings with their families on weekends, others might do well with encouragement to take walks on their own or with peers, while still others might simply need to have their television and computer time limited. Many "kids, if they don't have something [sedentary] to keep them occupied, will get up and move," says Dr. Jones.
The point is to keep treating the child respectfully even as you educate her or him that some significant lifestyle changes are necessary in order to stave off the ravages of the disease. The one-size-fits-all approach or the drill-sergeant tack, no matter how well-meaning, will probably only backfire
Which Kids Should Be Tested for Diabetes?
Diabetes is most prevalent in overweight, particularly obese, children. Overweight for a 5-foot, 2-inch 12-year-old is more than 136 pounds, according to the American Diabetes Association; obese is more than 164. The association recommends that overweight children with at least two other risk factors for the disease get tested.
Other risk factors include:
American Diabetes Association
Joslin Diabetes Center
National Institute of Diabetes & Digestive & Kidney Diseases
Canadian Diabetes Association
Atkinson RL. Viruses as an etiology of obesity. Mayo Clin Proc. 2007 Oct;82(10):1192-8.
Yajnik CS, Deshpande SS, Jackson AA, et al. Vitamin B(12) and folate concentrations during pregnancy and insulin resistancein the offspring: the Pune Maternal Nutrition Study. Diabetologia. 2008 Jan;51(1):29-38.
Last reviewed March 2008 by Lawrence Frisch, MD, MPH
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