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Putting the Brakes on Childhood Obesity

Posted on: Tuesday, 2 November 2004, 03:00 CST

With childhood obesity rates at an all-time high, health experts scramble for successful strategies to address the emerging heatth crisis.

Across the nation, obesity is on the rise in both adults and children, taking a toll on our quality of life (and healthcare budget).

More time in front of television and computer screens and less at play, coupled with increased caloric intake, are packing the pounds on America's youth who are surfacing at doctor's offices and hospital emergency rooms with serious health complications associated with the condition, such as hypertension, elevated cholesterol levels, sleep apnea, and type 2 diabetes.

Parents and pediatricians, guardians and grandparents all play a role in helping children maintain a healthy body weight. Encouraging nutritious eating habits and regular exercise are the twin pillars of any successful strategy to reverse the trend of obesity among American youth.

DR. RAVI SHANKAR

The Post met with pediatrie endocrinologist and diabetes specialist Dr. Ravi Shankar at the James Whitcomb Riley Hospital for Children, Indiana University Medicine Center for Children, to learn what you can do to help children avoid the lifelong consequences of obesity.

Post: Are you witnessing the trend in your clinic?

Shankar: In the last 10 years alone, the number of children and adolescents diagnosed with type 2 diabetes has increased several- fold. A decade ago, we rarely diagnosed type 2 diabetes in children and teens. Now, we are seeing an epidemic increase in the incidence of type 2 diabetes in youth. The jump is phenomenal.

Post: How many of your young patients with type 2 diabetes are obese?

Shankar: In my clinic, 99 percent of the patients I see with type 2 diabetes fit the definition of obese; the remaining are overweight but incredibly insulin resistant, so just being overweight has created problems for these children.

Post: How do you measure obesity in children? What tools, such as BMI or waist circumference, do you use?

Shankar: Waist circumferences are not as yet standardized for children. We are awaiting guidelines from the CDC's National Health and Nutrition Examination Survey (NFIANES) data set, which will help provide guidelines on waist circumference.

In the meantime, we use body mass index (BMI) and compute BMI percentiles based on the CDC curves. For children aged 2-21, a chart shows us into what percentile a particular child falls. Using CDC criteria, if a child's BMI is between the 85th and the 95th percentile, that child is overweight. If greater than the 95th percentile, the child is considered obese.

Post: Are children with type 2 diabetes initially diagnosed by pediatricians or in the clinic?

Shankar: About one-third of our patients are initially diagnosed by their pediatricians, then referred to us for management. We diagnose two-thirds of patients, who typically present to the emergency room with high blood glucose levels that lead to a diagnosis of diabetes.

Post: Many still believe that type 2 diabetes is a disease of aging, so they may miss some important early warning signs of the disease. What risk factors for diabetes should parents be on the lookout for?

Shankar: If parents have a question about whether their child's weight is appropriate for his/her height, they should take their child to their pediatrician, who can make that determination. Obesity is one very important risk factor.

Acanthosis is another. Acanthosis is a skin condition that signals insulin resistance and appears as dark, velvety skin around the neck and armpits of the patient. Acanthosis results from elevated levels of insulin in obese individuals who are insulin resistant. When a person becomes insulin resistant, the body compensates by making more insulin. While this increased insulin production delays the development of diabetes for as long as it can, eventually diabetes develops in many.

A third risk factor for development of diabetes is a positive family history. If one parent has diabetes, there is a higher risk of their children developing the condition. If both parents have type 2 diabetes, the risk of type 2 diabetes in their obese child is very high.

Finally, certain ethnic minorities are at high risk, including African-Americans, Hispanics, Asian Indians, and other Asian populations. Members of these racial and ethnic groups have a higher genetic risk for developing type 2 diabetes compared to Caucasians.

If you belong to one of these ethnic groups, your child is obese, and there is a strong family history of type 2 diabetes, and you see darkened skin around the child's neck or armpits, that child is at an incredibly high risk of already having or developing diabetes soon.

Post: What symptoms most often present in children?

Shankar: Children can present with the classic symptoms of diabetes-constant thirst, constant urination, and perhaps weight loss. Despite the weight loss, however, these children are still obese. Unlike adults, children with type 2 diabetes can present explosively with severe dehydration, abdominal pain, and alterations in consciousness called diabetic ketoacidosis-the hallmark of type 1 diabetes. While extremely rare in adults with type 2 diabetes, diabetic ketoacidosis is reasonably common in children with type 2 diabetes and is one big difference between children and adults with type 2 diabetes. But for the majority of patients with type 2 diabetes, symptoms of diabetes are very subtle, which is why it is very important to screen everybody at high risk.

Post: How often should a child at high risk undergo screening?

Shankar: It is very important to screen children at high risk at least every two years as recommended by the American Diabetes Association. Fasting plasma glucose (sampled after a 10-12 hour fast) is the recommended screening test. I screen children at high risk every year.

Post: Recently, a concerned mother told me about her son, who is overweight and depressed. She took him to a pediatrician about his weight problem, and the pediatrician sent her home, telling her not to worry about it because "he's going through a phase . . . he'll grow out of it."

Shankar: That is a dangerous statement. We need to diagnose obesity in its early stages. While it was once thought that obese children did not have the same health risks as obese adults, we now know that is not true. This is not puppy fat that will go away. Obesity is not benign. It is dangerous. Besides the social issues and problems with depression, obese children are at immediate risk of serious health problems that include high blood pressure, lipid abnormalities, metabolic syndrome, and sleep apnea.

It is also important to note that the majority of obese adolescents become obese adults. From all perspectives, we know that obesity is not benign.

Post: How does insulin resistance develop?

Shankar: In normal physiology, carbohydrates are digested and broken down into glucose that the body uses for energy. Glucose is absorbed into the blood, then proceeds to the pancreas, which secretes an appropriate amount of insulin. The cells utilize the insulin by opening cell membrane gates that allow glucose to enter.

In some people, the cells of the body cannot open the membrane gates to allow the sugar to enter, so sugar builds up in the bloodstream, causing a tendency for blood sugars to rise-a condition called insulin resistance, meaning the body is not able to utilize the insulin being secreted.

An insulin-resistant person needs much more insulin than an insulin-sensitive person needs to move glucose from the blood into the cell. That is the key defect in obese patients who develop type 2 diabetes.

At some point, the persistent weight gain will raise insulin resistance to such a level that even very high levels of circulating insulin will be unable to compensate for the degree of insulin resistance, and the pancreas is unable to secrete more insulin, which is when diabetes develops.

Post: Is it possible to intervene early and reduce the risk of type 2 diabetes?

Shankar: Follow a child's height and weight, calculate the BMI, and plot it on the BMI chart in the medical record, then follow its progression. If your child's BMI reaches the 85th percentile for the child's age, it is time to start intervening aggressively.

The bottom line is that based on all available epidemiological data, prevention should begin in preschool and early infancy. Parents should be educated about appropriate food choices and the importance of physical activity to prevent obesity.

Post: Are physicians adequately monitoring BMI and screening for diabetes in obese pediatric patients?

Shankar: Recently, the CDC published data stating that in 2000, 40 percent of obese adult patients-known to be obese by their primary care doctors-were not asked to lose weight. Even though the doctor knew that they were obese, at no point were the patients asked to lose weight or anything done to address the obesity issue. Even in the remaining 60, the advice was not very appropriate.

I don't think that 100 percent of obese and overweight teenagers are being identified. Pediatricians should begin to be concerned when the BMI starts to inch towards the 85 percentile.

Second, we must educate pediatricians and family practitioners to discourage pat\ients from gaining inappropriate weight. When patients gain weight, they should focus on the family to change lifestyle and promote healthier living.

As a nation, we focus so much on obesity, which poses major health problems. But people should understand very clearly that this focus on weight relates only to health issues. We are not trying to make all girls into supermodels or all boys into Ken dolls. The idea is to maintain a healthy individual weight. Some people are lucky enough to maintain a BMI of 21, while others will go through life slightly overweight but healthy-that is what counts.

Post: What types of medications are you using in obese children with type 2 diabetes who also have elevated cholesterol levels, hypertension, or other ailments?

Shankar: Metformin and insulin are the only medications approved for use in the treatment of type 2 diabetes in adolescents. We follow the patient's renal and liver functions carefully to make sure that no serious side effects occur.

To treat hypertension, we primarily use ACE inhibitors, because they reduce blood pressure and protect the kidneys in patients with diabetes.

For lipid-lowering therapy, statins can be used, but I am not very experienced in their use because they are not approved for most of the patients in the age group that I work with. I have been using a new medication called Zetia that is FDA-approved for children 10 and older.

The most important issue in the management of diabetes is dealing with insulin resistance-by losing weight or increasing physical activity. Exercise has a very good effect on insulin sensitivity, blood pressure, and cholesterol, even without changes in weight. If people lose weight as a result of exercise, these effects are amplified.

Post: Do you actually write a prescription for exercise?

Shankar: I actually write "exercise" on a prescription pad, telling them that they have to work out for 45-60 minutes every day of the week. Exercise has an excellent effect on insulin sensitivity, blood pressure, and cholesterol levels-even without major changes in weight. If a person actually loses weight by exercising, it would amplify the effect of exercise. It doesn't have to be an organized activity or anything fancy. They can simply put on a CD and dance at home for 45-60 minutes every day.

Post: In your busy clinic, what is the parents' reaction to their child's condition?

Shankar: Most parents don't see their role clearly. Studies support my view that diabetes is a family affair that an adult must manage and involve the whole family.

The family's practices and beliefs play a major role in leading to obesity in the first place, and therefore, changes in the family practices and beliefs can make a significant difference.

Post: In Arkansas, educators started sending home health report cards, broaching the subject of obesity in children. The schools calculated a child's BMI and sent the results to parents in the form of a health report card, along with educational materials about health risks. Although controversial, do awareness programs like this help?

Shankar: It can be an important element. Studies suggest that if the mother is lean, the chances of bringing an overweight child to medical attention are much higher than if the mother is obese. In single-family homes where the mother is obese regardless of the father's size, the child may not appear obese to her. Giving her a report card could bring the problem to her attention.

Post: Of the patients involved in your program, what percentage of parents are also overweight?

Shankar: Almost 100 percent of the parents I have seen are overweight.

Post: What hurdles do you face in the battle against childhood obesity at your clinic?

Shankar: One major issue is funding. Unfortunately, insurance companies do not think that nonpharmacologic therapy for obesity and weight loss should be funded, so not many insurance companies pay for weight loss programs. We provide care for a very underserved, poor population that does not have resources for gyms and other activities. These children come home from school to unsafe neighborhoods where they do not have outside activities, so they end up sitting at home watching television and eating-a highly conducive situation for weight gain. We would dearly love to provide an after- school center where we can educate children about appropriate food choices and physical activity.

Weight gain results from a combination of increased caloric intake and decreased activity. Today, kids watch television and sit in front of a computer. Some also get hours of homework. Kids barely expend energy, so it becomes easy to gain weight, compared to decades ago when kids cycled or walked to school because neighborhoods were safe. In school, they had daily PE. Then, they would return from school and go out to play with their friends. Look at the physical acUvily elimiiiaLetl over Llic course of the last several decades. Under these circumstances, weight gain and obesity are easy to explain.

Post: Would re-instating PE classes help?

Shankar: Such a move might help. I am unsure if any one move will be better than another. I think a concerted effort to improve food choices in school, along with increasing physical activity, is likely to help. As a first step, schools could make PE compulsory throughout the school years, including high school. PE has been one of the biggest cuts in school budgets. If schools mandated PE classes every day from elementary through high school, that would ensure at least five days of physical activity a week. By investing in a PE program with 40-45 minutes every day of physical activity, we can make a serious investment in the health of our nation's youth.

"While it was once thought that obese children did not have the same health risks as obese adults, we now know that is not true. . . . Obesity is not benign. It is dangerous."

"Diabetes is a family affair that an adult must manage and involve the whole family."

Copyright Benjamin Franklin Literary and Medical Society Nov/Dec 2004

Source: Saturday Evening Post, The

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