It is no surprise that pediatricians and pediatric endocrinologists are seeing children and adolescents developing type 2 diabetes, previously a disease with onset typically during middle age or in the elderly. The increased occurrence of diabetes in youth follows the epidemic of childhood obesity or overweight. In the United States, the past 2 decades have seen a doubling in the numbers of children who are overweight or at risk for overweight.1,2 Currently, one of every seven children has a body mass index at or above the 95th percentile. Furthermore, certain subpopulations of children are experiencing rates of obesity or risk for overweight that approach one of every three to four children.
Indeed, the Centers for Disease Control and Prevention includes physical activity and overweight/ obesity as two of its leading indicators for its Healthy People 2010 campaign. The need for healthy lifestyle appears critical, certainly for both the prevention and treatment of type 2 diabetes in children and adolescents. This is particularly important if we do not want to witness the current generation of youth develop the morbid complications of diabetes as young adults. Certainly, we do not want to raise the first generation of children who will fail to outlive the generations before them.3,4 In this issue of Pediatric Annals, some leading experts address the emerging problem of pediatric type 2 diabetes.
IN THIS ISSUE
In the first article, Drs. Copeland, Chalmers, and Brown from the University of Oklahoma Health Sciences Center outline the emergence of widespread obesity among youth in the United States and the associated increase in the metabolic syndrome, cardiac risk factors, and type 2 diabetes. Dr. Copeland and his team review the malignant lifestyle habits that have lead to the rise in obesity and type 2 diabetes. These multiple factors include changing eating habits with increased consumption of high-fat, high-calorie fast foods; decreased physical activity; and increased sedentary behaviors. This article presents epidemiologic data, noting the predominance of type 2 diabetes among certain racial and ethnic minority groups, and approaches to prevention and treatment. Readers will find that Dr. Copeland and colleagues' comprehensive review and reference list will serve as a continuing resource for pediatric providers.
The second article reviews the nutritional management of the overweight child with diabetes, written by two leading pediatric dietitians, Kattia M. Corrales-Yauckoes and Laurie A. Higgins, at the Joslin Diabetes Center in Boston. This article reminds us that 85% of children with type 2 diabetes are overweight or obese at diagnosis. The management of type 2 diabetes is multifactorial but clearly centers on family education and lifestyle modification for treating the overweight condition. Nutritional management becomes a fundamental component of the management of type 2 diabetes. The article reviews approaches to identifying weight goals for children and combines the assessment of nutrition with that for physical activity. Indeed, with 30% to 40% of children and adolscents each day eating at least one meal at fast food restaurants,5 ongoing nutritional management must focus on ways to limit such unnecessary high-fat and high-calorie intake. The take-home message for successful dietary management of the child with type 2 diabetes focuses on the need for ongoing family support.
The third article, written by Dr. Andrew Norris and Britta Svoren from Joslin and Boston Children's Hospital, confronts us with the complications and comorbidities associated with pediatric type 2 diabetes. Type 2 diabetes in adults brings significant risk for many long-term complications, mainly related to accelerated cardiovascular disease, including amputations, strokes, and premature coronary artery disease. In addition to these macrovascular diseases, diabetes heralds a risk for microvascular complications, typically involving the eyes, kidneys, and nerves. These microvascular complications have always been concerns for families of children with type 1 diabetes, but the occurrence of type 2 diabetes in children raises awareness for accelerated macrovascular complications as well. Indeed, insulin resistance syndrome, also known as metabolic syndrome, in itself conveys many pathophysiologic features predictive of cardiovascular disease. Children with type 2 diabetes, prediabetes, or metabolic syndrome often have hypertension as well as dyslipidemia.
Drs. Norris and Svoren outline the long-term complications of diabetes and highlight particular concern that the comorbidities of type 2 diabetes will occur at younger and younger ages, significantly diminishing quality of life and reducing life expectancy for persons diagnosed with diabetes during childhood or the early teen years. In addition, the authors discuss the entity of nonalcoholic fatty liver disease as a more subacute complication for youth with type 2 diabetes. Thus, the pediatric provider must address not only the need to treat type 2 diabetes in youth but also its associated comorbidities.
The fourth article in this issue addresses the important area of the fomily and pediatric type 2 diabetes. Drs. Anderson, Cullen, and McKay from Texas Children's Hospital and Baylor College of Medicine review quality of life, diabetes-specific family behaviors, and health outcomes in pediatric patients with type 2 diabetes. These authors underscore the need to identify and attend to the unique requirements of the pediatric patient with type 2 diabetes, rather than accepting blindly the experience from children with type 1 diabetes, because the social and demographic characteristics differ between the two groups of patients. The rise of obesity and type 2 diabetes, particularly among minorities, focuses attention on the need to devise innovative interventions tailored specifically to this group of patients and families. Quality of life and diabetes-specific family behaviors are both important in the study of health outcomes. This article reviews the few empirical studies of quality of life and the role of the family in diabetes management of children and adolescents with type 2 diabetes. The preliminary studies, along with attention to comorbid obesity, depression, and other mental health needs,6 may help lay the groundwork for future interventional research and effective clinical care for the pediatric population with type 2 diabetes.
The final article in this issue addresses the commonly associated problem of polycystic ovarian syndrome (PCOS), insulin resistance, and diabetes. Many young adolescent women with type 2 diabetes have PCOS, and many young teens with PCOS and features of insulin resistance may be destined to develop type 2 diabetes. Drs. Mansfield and Fleischman, also from the Joslin and Boston Children's Hospital, discuss PCOS and hyperandrogenism in young women, a problem affecting as many as 1 in 10 adolescent females. PCOS is significantly associated with obesity, as well as type 2 diabetes, hyperhpidemia, hypertension, and cardiovascular disease. Insulin resistance, a common feature of PCOS in women who are either lean or obese, may be a causal factor in the generation of increased androgen levels and menstrual irregularity.
Drs. Mansfield and Fleischman outline the approach to diagnosis and treatment, the latter involving a combination of lifestyle interventions and medications directed at reducing the ovarian hyperandrogenism and insulin resistance. Indeed, some of the treatments for PCOS are identical to treatments for type 2 diabetes. While type 2 diabetes may remain undiagnosed, the occurrence of PCOS in the adolescent female frequently invites clinical attention due to the female adolescent's unhappiness with increasing hirsuitism, acne, and menstrual irregularities. Thus, the opportunity to intervene early in the course of PCOS provides the pediatric provider with a chance to address the problem of insulin resistance and potentially prevent progression to type 2 diabetes.
The authors and I hope that you find this issue of Pediatric Annals useful as the pediatric community confronts the burgeoning epidemic of childhood overweight and type 2 diabetes.7,8 Like so many chronic conditions of childhood, the care of the overweight child with type 2 diabetes, or the adolescent female with PCOS, warrants a multidisciplinary, individualized approach. While this epidemic may bode poorly for the future health of the current generation, the pediatric community can play an important role in helping to identify and implement the best approaches to prevention and treatment of type 2 diabetes in childhood through early identification of risk. Fortunately, there are ongoing initiatives at the local, state, and federal levels to try to mitigate the burden of childhood overweight and its progression to type 2 diabetes.9
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2. Hedley AA, Ogden CL, Johnson CL, et al. Prevalence of overweight and obesity among US children, adolescents, and adults, 1999-2002. JAMA. 2004; 291(23):2847-2850.
3. 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.
4. 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.
5. Bowman SA, Gortmaker SL, Ebbeling CB, Pereira MA, Ludwig DS. Effects of fast-food consumption on energy intake and diet quality among children in a national household survey. Pediatrics. 2004;113(1 Pt 1):112-118.
6. Levitt Katz LE, Swami S, Abraham M, et al. Neuropsychiatric disorders at the presentation of type 2 diabetes mellitus in children. Pediatr Diabetes. 2005; 6(2):84-89.
7. Pinhas-Hamiel O, Dolan LML Daniels SR, Standiford D, Khoury PR, Zeitler P. Increased incidence of non-insulin-dependent diabetes mellitus among adolescents. J Pediatr. 1996;128(5 Pt 1):608-615.
8. Pinhas-Hamiel O, Zeitler P. The global spread of type 2 diabetes mellitus in children and adolescents. J Pediatr. 2005; 146(5):693-700.
9. Studies to Treat or Prevent Pediatric Type 2 Diabetes (STOPP-T2D). American Diabetes Assocation. Available at: http://www.diabetes.org/diabetes-research/clinical-trials/news.jsp. Accessed August 12, 2005.