Childhood Type 2 diabetes is not the same as Adult-onset type 2. If you wait to educate parents about the risk of diabetes in weight-challenged children, it is too late to reverse type 2 in adolescents. I want to talk about childhood diabetes prevention, and to make sure everyone understands it, we’re going to look at this from two different perspectives: the practitioner and the parent.
Disclaimer: The medical community tries to be politically correct. We need patrons to return and support our practice. The truth about childhood obesity is it’s an unhealthy state which can lead to chronic illnesses and sometimes death in early adulthood. This article will help you understand why it is important to teach your children good daily habits and promote healthy living in young adults.
The obesity epidemic
Obesity is at epidemic levels worldwide. (Lascar, 2018) In the USA, one-sixth of adolescents are overweight and another 33% are at risk for weight challenges before they turn 20 years old. (Schwarz, 2010) The prevalence of severe obesity is increasing dramatically in 2-19 yr olds. Severe obesity is identified in the 95-120th percentile weight for age.
In adults, this is recognized as morbid obesity. As of 2017, 9% of girls and 8% of boys are classified as severely obese. (Daniels, 2019) Adolescents with a Body Mass Index (BMI) at or above the 85th percentile are medically classified as overweight. (Schwarz, 2010) Eighty percent of overweight children ages 10-15 years old are prone to becoming obese adults by age 25 years. (Schwarz, 2010) (Daniels, 2019)
The relationship between type 2 diabetes and early-onset obesity is very strong. (Narasimhan, 2015) This health condition affects their ability to study and work productivity. (Lascar, 2018) It has an adverse effect on their quality of life. (Lascar, 2018) (Kao K. S., 2016)
This will affect everyone’s future. For example, one-third of the young men applying for military service are disqualified because of obesity. (Jancin, 2018) Plus up to 71% of military applicants are disqualified based on obesity, poor physical fitness, lack of education, or substance abuse. (Jancin, 2018) This can affect our country’s ability to protect itself. The repercussions ripple down into our healthcare costs as well as our nation’s productivity. Many professionals are predicting a future public health catastrophe. (Lascar, 2018) (Daniels, 2019)
The initial Type 2 diagnosis for children
Excess weight causes multiple health problems, even in young children. Up to 70% of young people diagnosed with type 2 diabetes previously had metabolic syndrome. (Kao K. S., 2016) These five risk facts combine to make metabolic syndrome:
- Elevated blood pressure above 130/85
- Uncontrolled blood sugars or symptoms of insulin resistance
- Increased inflammation
- High triglycerides, high LDL blood fats, or low HDL blood fats
- Abdominal obesity
These conditions place individuals at higher risk for:
- Heart disease
- Fatty liver disease (NAFLD)
- Type 2 diabetes
- Polycystic Ovary Syndrome
- Sleep Apnea
- Multiple forms of cancer
Comorbidities (the simultaneous presence of two chronic diseases or conditions) are often present at diagnosis of type 2 in teens:
- Obesity 85-95%
- High blood pressure 36%
- High fat in blood 85%
- Kidney damage 14-22%
- Vision problems 9.3%
- Fatty Liver disease 22%
- Depression 14.7%
- Eating disorders 26%
(Kao K. S., 2016)
Two years after Type 2 diagnosis
Children, within two years of diagnoses with type 2 diabetes, already have many of the complications from type 2 diabetes.
- Hypertension up to 65%
- Triglycerides 60-65%
- Low HDL 73%
- Retinopathy 7% at 3y, 23.7% were blind by age 32.
- Nephropathy 14-22%
- Depression 7-26%
- Sleep Apnea up to 60%
(Kao K. S., 2016) (Narasimhan, 2015) (Associates, 2014)
Genetics and ethnicity
The TODAY study (Treatment Options for Diabetes in Adolescents and Youth) identified a strong familial relationship between type 2 in children and their families. Of these children, 89.4% had a family history of diabetes with 60% of these children had a first-degree relative (mother, father, sibling) that had type 2. One-third of them were a product of a pregnancy with the complication of uncontrolled blood sugars. (Narasimhan, 2015)
But genetics is only one factor. This is a polygenic disorder. (Kao K. S., 2016) Family customs and cultural traditions can greatly contribute to weight problems in children. (Schwarz, 2010) Of children on public insurance, 43.2% are reported as weight challenged. (Schwarz, 2010) Unfortunately, when these children turn 18 years old, optimal care for all health screening to prevent many complications tends to fall off when they go off of their parent’s insurance plans. (Associates, 2014)
Ethnicity plays a key role in glycemic control and complications of diabetes. Twenty-seven percent of youth-onset diabetics had HbA1c equal to or greater than 9.5%. (Associates, 2014) Minority youth, particularly Native American and Asian Pacific Islanders, had poor glycemic controls. (Associates, 2014) Hispanics and African Americans were also not well controlled. (Associates, 2014) This places them at high rise for heart attacks, blindness, and kidney disease. (Associates, 2014) SEARCH research suggests many youths diagnosed with diabetes will suffer debilitating complications early in life. This not only affects their quality of life but also their ability to work and their cost of health insurance. (Associates, 2014)
Early diagnoses and proper treatment is key
Many of the medications that are approved for type 2 diabetes are not approved for children. We don’t have a lot of Rx options. Many children are placed on insulin at diagnoses.
The Rise Study (Restoring Insulin Secretion Pediatric Medication Study) identified that within 12-15 months from diagnoses, beta cell function was significantly reduced. (Edelstein, 2018) Although they may first present with DKA, they will test negative for diabetes autoantibodies (GAD65 and IA2). (Associates, 2014)
Many youths are started on insulin but can go through a honeymoon phase of up to two years. This can be very challenging for parents. They may believe the child has been misdiagnosed. According to the RISE study, beta cell function can drop off significantly within 12 -15 months. (Edelstein, 2018) The TODAY study shows a decline in beta cell function from 20-35% per year. (Narasimhan, 2015) These youth need to be monitor closely for their changing medication needs. Poor glycemic control also contributes to their risk of heart problems.
Cardiovascular disease develops – even in children
The rapid development of cardiovascular disease is also significant within this group. In youth, with every 1% increase in HbA1c above the normal range, the risk for carotid stiffness increased by 30%. (Narasimhan, 2015) Plus, for each year after diagnoses of type 2 in youth, the risk for carotid stiffness increased 30%. (Narasimhan, 2015)
In addition to atherosclerosis, being overweight causes an enlarged heart placing them at risk for additional heart complications. (Daniels, 2019) “If the time course of cardiovascular disease relates to diabetes (type 2) is the same for adolescents as for adults, it is anticipated that adolescents with diabetes will begin having substantial cardiovascular disease morbidity and mortality in their 30’s and 40’s.” Stephen R. Daniels, MD Ph.D. (Daniels, 2019)
Uncontrolled Blood Sugar causes birth defects
Many overweight teens could have elevated blood sugars and never know it. It is unfortunate that many teenage girls get pregnant. Many of them want to keep the baby no matter what. Uncontrolled blood sugars cause birth defects. We can foresee special needs infants being born to teenage mothers. Pediatricians need to monitor overweight girls for prediabetes and provide counseling for pregnancy prevention. Do not rely on the school systems to teach birth control. Whatever the school systems are teaching is not effective in controlling teen pregnancies.
Ways to predict early onset problems in children
Concerning pediatric care, body mass index (BMI) coupled with waist circumference is important in predicting early onset heart problems. (Daniels, 2019) Ninety-five percent of type 2 youths had a waist circumference greater than the 90th percentile for age, sex, and height. (Associates, 2014) To avoid heart problems, prevention of obesity is a far superior treatment in children. (Daniels, 2019) Dr. Daniels stresses the need for exercise with improved nutrition to prevent obesity. (Daniels, 2019)
Cardio-respiratory fitness could be used to identify kids at risk for type 2 diabetes and cardiovascular disease. (Cimino, 2018) Dr. Agbaje suggests using Cardio-Respiratory-Function (CRF) thresholds, using CRF to identify children at risk for cardio-metabolic complications. (Cimino, 2018)
Fatty liver disease – even in children
Fatty liver disease is a significant problem with these children. (Brunk, 2018) Non-alcoholic fatty liver disease is two times higher in teens with weight problems and insulin resistance. (Lascar, 2018) Non-alcoholic steatohepatitis (NASH) is up to 43% higher in young adults with type 2 and 34% higher in youth with prediabetes. (Lascar, 2018) Alcohol plays an important factor to consider with this age group. It is important to teach these young people the real problems with alcohol use and the risks from peer pressure.
Just get moving!
“Everyone can dramatically improve their health just by moving: anytime, anywhere, and by any means that gets you moving.” Dr. Brett Giroir (Jancin, 2018) Only 20% of American teens get the recommended physical activity. (Jancin, 2018) The weekly recommendations for physical activity for teens include:
- 150-300 minutes of moderate aerobic exercise
- 75-100 minutes of vigorous aerobic exercise
- 2 days of muscle strengthening exercise
The best way for a teen to accomplish these physical goals is to participate in sports. (Jancin, 2018) There are new guidelines for younger children. It is recommended that 3-5-year-olds get 3 hours of activity every day. Recommendations for 6-17-year-olds include:
- One hour each day of moderate to vigorous exercise every day
- Three days each week with heart building (vigorous) exercise
- Three days each week with muscle-strengthening activities.
Physical activity helps your brain too
Regular activities can benefit brain health too. It can improve memory and thinking in preschool children. (Jancin, 2018) In children with ADHD, regular physical activity can help with cognition as measured on Academic Achievement Tests. (Jancin, 2018)
Exercise needs to become a part of their daily lives. The potential benefits of cardiovascular exercises can be lost within 3-6 months of being discontinued. (Lascar, 2018) To protect from heart attacks, aerobic exercise needs to be incorporated into their daily lives. Also, exercise does not cancel poor nutrition in teens. The benefits of aerobic exercise must be coupled with proper nutrition. (Lascar, 2018)
Childhood Type 2 diabetes in presents a major health crisis today and in the near future. (Rowley, 2017) Youth-onset diabetes is very different from adult-onset diabetes. It is unfortunate that many of the medications available for adults are not available for children. The TODAY study and the RISE study reveals type 2 diabetes is children progresses much faster than in adults over 40 years. (Narasimhan, 2015) (Edelstein, 2018) They often initially present with DKA, so it is important to properly diagnose. (Kao K. S., 2016)
Prediabetes progresses much quicker
There is an unusually rapid progression through prediabetes of 12-21 months. (Kao K. S., 2016) Adults can have prediabetes over 10 years. Prediabetes is rarely diagnosed in children because it is without noticeable symptoms. (Kao K. S., 2016) The only way to diagnose prediabetes is with an A1c test. Unfortunately, this test is not approved for diagnosing children. Many risk factors for comorbidities are present at diagnoses, (Kao K. S., 2016) and they will need insulin therapy much earlier than adult-onset type 2.
Moderate to late puberty
It is important to remember biological differences within this age group. Typically youth on-set diabetes presents in moderate to late puberty. (Edelstein, 2018) Human growth hormone could significantly affect blood sugar levels. (Edelstein, 2018) Also, many of these young women will experience pregnancy with uncontrolled blood sugars resulting in birth defects. It is important to teach about planned pregnancy and encourage birth control pills when necessary. Never underestimate the power of peer pressure. Plus, they feel as if they have little control over their own socioeconomic status due to their dependence on their parents. (Edelstein, 2018) The medical community must address these issues with family caregivers.
The TODAY study
Non-compliance with medications is high. Participants in the TODAY study had 57% compliance in medication after 5 years. (Narasimhan, 2015) We can only speculate teen medication compliance based on their HbA1c scores. We need to motivate these teens toward better self-care to avoid complications like heart disease in their 20’s and 30’s.
The TODAY study’s Intensive Lifestyle Program focused on healthy eating, increased activities with a personal exercise therapist and moderate weight loss. Adherence to the program dropped to 54%. (Narasimhan, 2015) Small support groups for families struggling with uncontrolled weight in children is recommended. (Hartzler, 2018) When we motivate the parents to take better care of their children, the whole family’s health will improve. Teens also need support groups that include their peers. (Lascar, 2018) These groups are often set-up within their schools. Teens need to be encouraged to join. Mutual respect will help reach their hearts and help motivate them to better health.
Childhood diabetes prevention – it’s the key!
The prevention of weight problems through lifestyle interventions is key. (Rowley, 2017) (Lascar, 2018) (Edelstein, 2018) (Kao K. S., 2016) If things stay the same, it is predicted that the diagnoses of type 2 diabetes will quadruple by 2050, (Associates, 2014) which is why we all need to work together to provide consistent messages. (Hartzler, 2018) If we don’t, the sad truth is that obesity in children will result in early deaths. (Narasimhan, 2015) (Daniels, 2019) (Brunk, 2018)
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