Obesity is clearlyrecognized as a major risk

factor for diabetes mellitusand cardiovascular disease.

Body weight has been inverselycorrelated with morbidity and

mortality:1,2 the larger we grow, the shorter our lifespan. Prevalence

rates of diabetes3 in the United Statescontinue 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

Childhood obesityand the risk of diabetesin minority populations

Jay H. Shubrook Jr., DO

18 AOA Health Watch DOs AgainstDIABETES January 2011

It is well documented that childhoodobesity increases the risk of adultobesity. One study found that 80% of obese adults had become obese bythe time they reached age 25.5 Evenobese children as young as age 6 havea 50% chance of being an obese adult.6It appears that if obesity starts beforethe age of 8, it is more likely to besevere in adults. In a study of adultcoronary heart disease risk factors, 30% of obese adults reported that their obesity began in childhood.7Childhood obesity also increases the risk of adult mortality.8 It is notsurprising in light of these statistics that the prevalence of diabetes and its complications are rapidly expandingin our population.

In the past 30 years alone, pediatricobesity rates have tripled in the United States.8 Currently, 1 in 3children are overweight, and 1 in 6adolescents are obese.9 This epidemichas affected even our youngest children: 1 in 7 low-income preschoolchildren are obese.10 Previously,treatment of childhood obesity wasfocused on preventing adult obesity and the complications commonly seen in adults. Recent studies, however,report an increase in morbidity and mortality associated with childhood obesity.11

Childhood complications of obesityare significant and can include type 2diabetes and hepatic steatosis orsteatohepatitis. It has been estimatedthat 40% of obese children haveevidence of fatty liver changes atultrasound imaging,12 which may be a more sensitive marker for thediagnosis of steatohepatitis than elevated levels of transaminases.12

Hepatic steatohepatitis is nowrecognized as the leading cause ofcryptogenic cirrhosis in the UnitedStates.12 We have not yet determinedhow many children will be at risk forfatty liver hepatitis or non-alcoholicsteatohepatitis (NASH), but theincidence of hepatic diseases may closely follow the rise in obesity.

Type 2 diabetes was once considered a disease of adults only, but the rates

of childhood type 2 diabetes are nowrapidly increasing. Typically, a personcan have NASH or type 2 diabetes forup to a decade before complicationsarise. Diagnosis of diabetes and itscomplications in childhood, however,may profoundly affect life expectancy.

Childhood body mass index (BMI) is calculated using weight-to-heightcharts by the percentage of weightdivided by height. The Centers forDisease Control and Prevention has a simple calculator for assessing BMI in children and adolescents (see http://apps.nccd.cdc.gov/dnpabmi/)and also provides standardized BMItables that can be used in the officesetting (see Tables 1 and 2). The former ratings for excess weight inchildren were changed from “at risk for overweight” and “overweight” to “overweight” and “obese,”6 moreaccurately reflecting the adverseoutcomes of excess weight in childhood.Overweight is defined as a BMI of >85% and obesity as a BMI of 95%.

Data from the National Health and Nutrition Examination Survey(NHANES) show that children of allages are at risk, but the greatest burdenfalls on those from minority groups.2Nearly 10% of children under the age

of 2 are overweight, and this numberincreases to 12.5% in Hispanic children.Among children 3 to 17 years of age,32% are overweight or obese. InHispanic adolescents, 43% of boys and40% of girls are overweight, and withinthat population, the rates for Mexican-American adolescents are 46% for boysand 42% for girls. Further, the rates fornon-Hispanic black Americans are 33%for adolescent boys and 46% for girls.2

Why is obesity so prevalent?Many issues contribute to childhoodobesity, but essentially they can beboiled down to increased caloric intakeand reduced calorie expenditure. Food intake has changed substantiallyover the past 20 years. Children now get as much as one-third of their caloriesfrom “fast foods,”13 which typically are calorie and fat dense. Furthermore,soda consumption has increased 65%and has been estimated to be as much as 25% of all calories consumed.14

Even small changes in calorieconsumption can equate to significantweight gain. An additional 50 caloriesper day (one-third can of cola) can resultin 5 extra pounds of weight in 1 year and50 pounds in a decade. Further, accessto fresh whole foods is limited due to

January 2011 DOs AgainstDIABETES 19AOA Health Watch

expense and geographical location. In our rural Appalachian town we haveover 50 fast food restaurants, and theyare easier to access for many peoplethan the grocery store. Many familieshave become too busy to sit down forthe family dinner and will now grabsomething on the run.

Children also spend less time inphysical activity. Fewer schools offerdaily gym classes, and many athleticprograms have been cut. There are fewer safe outdoor places for play, and many children are geographically

isolated from public play spaces.15,16Families may also live at greaterdistances from health-related resourcesand have inadequate access to publictransportation.16 During harder financial times, fewer childrenparticipate in school gym programs,clubs, and team sports.

Further, American youth are affected by increased television viewing and screen time.16 Televisionwatching and other “screen-time”activities (video games, video phones, smart phones, and texting)

contribute to obesity by displacing timefor physical activity, adding unplannedcalorie consumption during screen time, and leading to a loss of recognition ofnormal satiety cues when distracted by passive entertainment. These riskfactors provide unique challenges for the management of childhood obesity.

Link between childhood obesity and diabetes The direct link between type 2 diabetesand obesity in children has becomeincreasingly evident. This was confirmedwhen a recent study showed that 89.8% of children diagnosed with type 2diabetes were overweight or obese.18Children born in the year 2000 in theUnited States have a 1 in 3 chance ofdeveloping diabetes. This rate increasesfor people of color and is as high as 50%among Hispanic children.19 Obesity andits related complications are largelyresponsible for the increased prevalenceof this disease and have contributed tothe fact that this is the first generationof Americans expected to have a shorterlife expectancy than their parents.20

Diabetes in minority populationsStudies report that 20% of pediatricpatients with newly diagnosed diabeteshave type 2 diabetes.21 There appears to be a disproportionately higherincidence of type 2 diabetes in minoritychildren, as shown by ranges from3.7/100,000 in non-Hispanic whites to 38.42/100,000 in Navajo Indianfemales.22 This difference seems tocoincide with a higher incidence of obesity in pediatric minoritypopulations. Gender also influencesincidence: females in the pediatricpopulation have a 60% higher incidenceof type 2 diabetes than of their male counterparts.23

Our understanding of diabetes in American youth has been greatlyimproved with the publication of results from the SEARCH trial, a largepopulation-based study examiningphysician-diagnosed diabetes in peopleunder age 20 in the United States.21This large epidemiologic trial set out

20 AOA Health Watch DOs AgainstDIABETES January 2011

2 543 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

26

24

22

20

18

16

14

12

kg/m2

28

26

24

22

20

18

16

14

12

kg/m2

30

32

34

BMI

BMI

AGE (YEARS)

13

15

17

19

21

23

25

27

13

15

17

19

21

23

25

27

29

31

33

35

95

90

75

50

25

10

5

85

2 to 20 years: Boys

Body mass index-for-age percentilesNAME

RECORD #

SOURCE: Developed b

(2000).

y the National Center for Health Statistics in collaboration with

the National Center for Chronic Disease Prevention and Health Promotion

http://www.cdc.gov/growthcharts

Date Age Weight Stature BMI* Comments

Published May 30, 2000 (modified 10/16/00).

Table 1

to gain a better understanding of theprevalence of type 1 and type 2 diabetesin children, the level of control, and their experience with this disease.21

The SEARCH trial found that manychildren who have developed type 2diabetes have poor glucose control.Black and Hispanic children, however,were more likely to develop diabetesand to have worse control.23

In a trial of glucose tolerance status in obese youth, good control was observed in 71% of non-Hispanic white children, 59% of African American children, 50% of Hispanicchildren, 47% of Asian/Pacific Island children, and only 34% ofAmerican Indian children.23 AmongHispanic children, those of Mexicanheritage had the greatest risk. Lowerincome status among this group wasseen to further increase risk, with the peak incidence of diabetes seen in girls aged 10-14 years old.24,25

It is clearly recognized that type 2diabetes is a progressive, incurable, but treatable disease, and the durationof the disease predicts complications and mortality. As such, it is reasonable to conclude that children with type 2 diabetes may be facing a grimfuture unless they seek comprehensivetreatment for diabetes and obesity.Preventing our youth from gettingdiabetes and treating it aggressively once diagnosed should be a publichealth priority. Screening children for diabetesThe American Diabetes Association has developed screening guidelines for children who are at high risk of developing diabetes.26 Therecommendations endorse screeningchildren who are overweight (BMI .85th percentile for age and gender),those who have a body weight greaterthan 120% of the ideal for height, and anyone who meets at least 2 of the following criteria:

� family history of type 2 diabetes.� high-risk race/ethnicity, includingAmerican Indian, African-American,Hispanic, or Asian/Pacific Islander.

� physical signs of insulin resistancesuch as acanthosis nigricans.� conditions related to insulin resistancesuch as hypertension, dyslipidemia, or polycystic ovarian syndrome.24

Testing should begin at age 10 or at the onset of puberty, whichevercomes first. Screening should occurevery other year, and the test of choiceis a fasting blood glucose test. One study found that obese children who had impaired fasting glucose developedtype 2 diabetes within 2 years.25

Final notesAs a clinician, I often think the burdenof obesity is too great to manage fromthe perspective of a single practice. I have learned, however, that physicianscan be trusted resources, and manylifestyle changes are more likely to occurif addressed by a physician. We need to remember that changing even onechild’s life may affect many moreindirectly. The first phase of thistreatment occurs in our office. For those who need additional help,there are comprehensive programs

January 2011 DOs AgainstDIABETES 21AOA Health Watch

2 to 20 years: Girls

Body mass index-for-age percentilesNAME

RECORD #

2 543 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

26

24

22

20

18

16

14

12

kg/m2

28

26

24

22

20

18

16

14

12

kg/m2

30

32

34

BMI

BMI

AGE (YEARS)

13

15

17

19

21

23

25

27

13

15

17

19

21

23

25

27

29

31

33

35

Date Age Weight Stature BMI* Comments

90

85

75

50

10

25

97

3

95

SOURCE: Developed b

(2000).

y the National Center for Health Statistics in collaboration with

the National Center for Chronic Disease Prevention and Health Promotion

http://www.cdc.gov/growthcharts

Published May 30, 2000 (modified 10/16/00).

Table 2

that can supplement our efforts.Previous studies have shown that family-based programs that include both nutritional and physical activityinterventions are the most successful.27-30

The health and economy of ourcountry are directly affected by theobesity epidemic. It is estimated that

nearly 40% of children in the UnitedStates are from minority backgroundsand many of these children may developdiabetes at a young age, which maysubstantially shorten their lives. As we acknowledge the increased risk, we need to address this issue swiftly and universally.

Important links � Centers for Disease Control and Prevention (CDC): The Health Consequences of Obesityhttp://www.cdc.gov/obesity/causes/health.html

� CDC: The EconomicConsequences of Obesityhttp://www.cdc.gov/obesity/causes/economics.html

� American Academy of Pediatrics:Preventing Pediatric Overweightand Obesity: American Academy of Pediatrics Policy Statementhttp://aappolicy.aappublications.org/cgi/content/full/pediatrics;112/2/424

� CDC: Tips for Parentshttp://www.cdc.gov/healthyweight/children/index.html

� US Department of Health and Human Services: Report on Childhood Obesityhttp://aspe.hhs.gov/health/reports/child_obesity/

References1. Lee IM, Manson JE, Hennekens CH, Paffenbarger

RS Jr. Body weight and mortalitya; 27-year follow-up of middle-aged men. JAMA.1993;270(23):2823-2828.

2. Manson JE, Willett WC, Stampfer MJ, et al. Body weight and mortality: among women. N Engl J Med. 1995;333(11):677-685.

3. New cases of diagnosed diabetes on the rise.Centers for Disease Control and Preveniton Web site. http://www.cdc.gov/media/pressrel/2008/r081030.htm?s_cid=mediarel_r081030.Accessed September 3, 2010.

4. Flegal KM, Carroll MD, Ogden CL, Johnson CL.Prevalence and trends in obesity among US adults,1999-2000. JAMA. 2002;288(14):1723-1727.

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.

6. Whitaker RC, Wright JA, Pepe MS, Seidel KD,Dietz WH. Predicting obesity in young adulthood from childhood and parental obesity. N Engl J Med. 1997;337(13):869-873.

7. Freedman DS, Khan LK, Dietz WH, Srinivasan SR,Berenson GS. Relationship of childhood obesity tocoronary heart disease risk factors in adulthood:the Bogalusa Heart Study. Pediatrics.2001;108(3):712-718.

22 AOA Health Watch DOs AgainstDIABETES January 2011

Steps to confront childhood obesity

� Address obesity in children in your practice.

� Make BMI measurement one of the vital signs at every visit.

� Instruct patients not to “drink their calories.”

� Suggest the recommended 60 minutes of physical activity per day—encourage families to do it together.

� Teach children to grow into their weight.

� Screen high-risk children for diabetes.

� Try to link those who need helpto established weight-loss centers.

HW

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 diseaseand 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. Assessmentof 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 lipid profile, hepatic biochemicalparameters and glycemic and insulinemicresponses to an oral glucose tolerance test. Int J Obes Relat Metab Disord. 2000;24(6):772-776.

13. Massachusetts Medical Society Committee onNutrition. Fast-food fare: consumer guidelines. N Engl J Med. 1989;321(11):752-756.

14. Ludwig DS, Peterson KE, Gortmaker SL. Relationbetween consumption of sugar-sweetened drinksand childhood obesity: a prospective, observationalanalysis. Lancet. 2001;357(9255):505-508.

15. Centers for Disease Control and Prevention.National diabetes fact sheet, United States, 2005. General information and national estimateson 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.

16. Cherry DC, Huggins B, Gilmore K. Children’s healthin the rural environment. Pediatr Clin North Am.2007;54(1):121-133.

17. Tessaro I, Smith S, Rye S. Knowledge andperceptions of diabetes in an Appalachianpopulation. Prev Chronic Dis. 2005;2(2):A13.http://www.cdc.gov/pcd/issues/2005/apr/04_0098.htm.

18. Liu LL, Lawrence JM, Davis C, et al; for theSEARCH for Diabetes in Youth Study Group.Prevalence of overweight and obesity in youth with diabetes in USA: the SEARCH for Diabetes in Youth Study. Pediatr Diabetes. 2009;11(1):4-11.

19. Narayan KM, Boyle JP, Thompson TJ, Sorensen SW, Williamson DF. Lifetime risk for diabetes mellitus in the United States. JAMA. 2003;290(14):1884-1890.

20. Olshansky SJ, Passaro DJ, Hershow RC, et al. A potential decline in life expectancy in the United States in the 21st century. N Engl J Med.2005;352(11):1138-1145.

21. The Writing Group for the SEARCH for Diabetes in Youth Study Group. Incidence of diabetes in youth in the United States. JAMA.2007;297(24):2716-2724.

22. The HEALTHY Study Group. Risk factors for type 2diabetes in a sixth-grade multiracial cohort: theHEALTHY study. Diabetes Care. 2009;32(5):953-955.

23. Weiss R, Taksali SE, Tamborlane WW, Burgert TS,Savoye M, Caprio S. Predictors of change in glucose tolerance status in obese youth.Diabetes Care. 2005;28(4):902-909.

24. Lawrence JM, Mayer-Davis EJ, Reynolds K, et al; for SEARCH for Diabetes in Youth StudyGroup. Diabetes in Hispanic American youth:prevalence, incidence, demographics, and clinical characteristics: the SEARCH for Diabetes in Youth Study. Diabetes Care.2009;32(suppl 2):S123-S132.

25. Petitti DB, Klingensmith GJ, Bell RA, et al; for the SEARCH for Diabetes in Youth Study Group. Glycemic control in youth with diabetes: the SEARCH for Diabetes in Youth Study. J Pediatr. 2009;155(5):668-672.

26. American Diabetes Association. Type 2 diabetes in children and adolescents.Diabetes Care. 2000;23(3):381-389.

27. Epstein LH, Valoski A, Wing RR, McCurley J. Ten-year outcomes of behavioral family-basedtreatment for childhood obesity. Health Psychol.1994;13(5):373-383.

28. Epstein LH, Wing RR, Penner B, Kress MJ. Effect of diet and controlled exercise on weight loss in obese children. J Pediatr. 1985;107(3):358-361.

29. Epstein LH, Wing RR, Steranchak L, Dickson B,Michelson J. Comparison of family-based behavior modification and nutrition education for childhood obesity. J Pediatr Psychol.1980;5(1):25-36.

30. Epstein LH, Wing RR, Koeske R, Valoski A. A comparison of lifestyle exercise, aerobicexercise, and calisthenics on weight loss in children. Behav Ther. 1985;16(4):345-356.

January 2011 DOs AgainstDIABETES 23AOA Health Watch

Jay H. Shubrook Jr., DO, is an associateprofessor of family medicine and adiabetologist. He serves as the director of clinical research and director of theDiabetes Fellowship at Ohio UniversityCollege of Osteopathic Medicine. He is a Fellow of the American College ofOsteopathic Family Physicians. He can bereached at SHUBROOK@oucom.ohiou.edu.