The Diabetes Epidemic in Children: an Integral Approach

Executive Summary

Diabetes Mellitus Type 2 (DMT2) in children is becoming alarmingly frequent providing a myriad of health complications for an unpromising future. In this paper I am presenting the problem, as well as providing guidelines to stop and reverse the increasing rate of

DMT2 and its main modifiable risk factors: obesity and sedentary lifestyles.

I. Diabetes and Chronic Diseases

According to the World Health organization (WHO) (WHO, 2005) chronic diseases are the major cause of death in almost every country, representing 60% of the deaths in 2005, or 35 million people. This is double the number of deaths from all infectious diseases (including HIV/AIDS, tuberculosis, and malaria), maternal and perinatal conditions, and nutritional deficiencies combined. Deaths from chronic diseases are projected to continue growing unless actions are taken. In 2005, the WHO projected that for the following ten years the estimated number of people that will die as a consequence of a chronic disease will increase by 17%. Almost half of those affected are under seventy years of age, and may experience a long debilitating condition as well as the possibility of a premature death. Diabetes represents 2% of all chronic disease deaths, or 1,125,000 people.

Chronic diseases are forming pandemics that affect members of all social economic strata. Currently 80% of all chronic disease deaths occur in low and middle income countries, which also comprise most of the world’s population. These pandemics have serious effects on the quality of life of the affected individuals, their families, communities, and countries. The economic consequences are also enormous.

Fortunately, it is possible to prevent and control most aspects of chronic disease and every country has the potential to work toward this goal. In this paper I will address the growing epidemic of Diabetes Mellitus Type 2 (DMT2) in children and its main risk factors.

Diabetes is a chronic disease that occurs when the pancreas either does not produce enough insulin or the body cannot effectively use the insulin it produces. Insulin is the hormone that regulates blood sugar. Hyperglycemia, or raised blood sugar, is a common effect of uncontrolled diabetes. Over time it leads to serious damage to many of the body’s systems, especially the nerves, blood vessels, heart, eyes and kidneys (WHO, 2006).

There are three different types of diabetes. Type 1 is characterized by a lack of insulin production; Type 2 is characterized by the body’s ineffective use of the insulin it produces; and Gestational Diabetes is a type of diabetes that is first recognized during pregnancy. Diabetes Type 2 in children will be the focus of this paper.

Symptoms of DMT2 include excessive excretion of urine, thirst, constant hunger, weight loss, vision changes and fatigue. The main complications of DMT2 are retinopathy (which can lead to blindness), neuropathy, foot ulcers, kidney failure and stroke. The overall risk of death for people with diabetes is at least double the risk of their peers without the disease (WHO, 2006).

The global prevalence of DMT2 is rising steadily (Alberti et al, 2004) and its pervasiveness in youth is an increasing public health concern (Huang & Goran, 2003). Until recently, DMT2 was seen exclusively in adults, and also known as adult onset diabetes, but now it is a major childhood problem, particularly in obese children. There is also an increasing incidence of DMT2 among adolescents (Pinhas-Hamiel et al, 1996). In light of this evidence, the use of a name that does not lead us to make unrealistic conclusions about the disease should be encouraged. DMT2 is now affecting the young population.

The WHO projects that DMT2 deaths will increase by more than 50% in the next ten years if action is not taken (WHO, 2006). Diabetes is the fourth or fifth leading cause of death in most developed countries, and there is substantial evidence that it is an epidemic in many developing and newly industrialized nations (IOTF, undated).

Diabetes is not only one of the leading causes of death and disability, it is also a major risk factor for several other serious diseases such as hypertension. This further reduces the life expectancy of individuals with DMT2 and raises health care costs to society.

DMT2: Prevention and Control

Diabetes, as other chronic diseases, has modifiable and non-modifiable risk factors. In the latter group we have age and heredity, particularly genetics. Most of the risk factors for all the major chronic diseases are modifiable. The two principal factors include unhealthy diet and physical inactivity.

The importance of the modifiable risk factors in the incidence of diabetes is underscored by the fact that the incidence of the disease has grown considerably in recent years, while the genetic composition of the population has not changed. At the same time, lifestyle changes relating to nutrition and levels of physical activity have changed considerably.

A dramatic example of the influence of the environmental factors and modifiable factors associated with DMT2 can be found among Pima Indian communities. DMT2 is rare in Pima Indian communities inMexicowhere the traditional lifestyle has been preserved. At the other extreme, the Pima Indians of Arizona have a very high prevalence of DMT2, around 59 per 1000, and a clear association between DMT2 and obesity in 95% of the cases (NIH, undated) (Fagot-Campagna et al, 2002).

Addressing lifestyle changes related to nutrition and physical activity is the key to a program for preventing and controlling DMT2 and will be the focus of the next two sections. One important consideration is that interventions targeting lifestyle factors in young individuals are particularly beneficial because of their long term effects (Huang & Goran, 2003).

Obesity

Obesity has reached epidemic proportions globally, with at least 20 million children under the age of five being overweight (WHO, undated a). The International Obesity Task Force estimates that 155 million school-age children worldwide are overweight or obese, with a prevalence of overweight in a range 10% to 25% (Parvez et al, 2007). We are not just facing a huge number of cases; we are also facing an increasing trend. The prevalence of obesity in adolescents, for example, has nearly tripled in the past twenty years (NIH, 2002).

Obesity in children is associated with multiple diseases such as sleep apnea, hypertension, dislipidemia and DMT2. Obesity and DMT2 are linked; most of the diabetes cases in children are attributable to an excess of weight. According to the International Obesity Task Force, about 58% of diabetes globally could be attributed to body mass index BMI above 21kg/m2.

Since there is a strong link between DMT2 and obesity, some authors describe the occurrence of both conditions as a twin epidemic (Zimmet et al, 2001)94.

Insulin resistance is a consequence of weight gain as the pancreas receives more demand to produce insulin. Research by the National Institute of Health shows that many obese children and adolescents have impaired glucose tolerance; a condition that often appears before the development of DMT2.

One of the causes for the increasing incidence of childhood obesity is the increased consumption of calories, especially from sugars and fats. Some contributing factors are the consumption of fast food, larger food portions, and a decrease in the intake of fruits and vegetables. Television viewing is also associated with obesity, both because kids tend to eat while they are watching TV and also because of the effects of the direct marketing of food products -usually unhealthier products- targeting children.

Contemporary levels of obesity in children are unprecedented and there is little knowledge about what will happen when they become adults.

Inactivity

There is a decline in the level of children’s physical activity, which is explained by a more sedentary lifestyle, less time playing outside and more time on the computer.

As was the case with obesity, television viewing is also a contributing factor to inactivity. A study shows that a typical American youth spends approximately four to five hours a day watching TV, using the computer or playing video games (Wild et al, 2005). Urbanization is another contributing factor to inactivity (Wild, 2004). Globalization and industrialization have also increased the incidence of sedentary lifestyles while high levels of violence impede children from playing outside. We also observe less walking and biking and more time traveling in cars.

An estimated 60% of the world’s population does not do enough physical activity (WHO, undated b). According to the WHO, physical inactivity is estimated to cause about 10-16% of global cases of breast cancer, colon, and rectal cancer and DMT2 is reported to cause about 22% of ischemic heart disease. Overall, 1.9 million deaths are attributable to physical inactivity (WHO, undated, a). Inactivity, as obesity, places more demands on the pancreas.

II. Strategies to Fight Diabetes: Treatment versus Prevention

In spite of the fact that there are numerous programs to fight chronic diseases and DMT2 around the world, the number of cases is not falling. On the contrary, as described above, current trends are very worrisome. So much so that the WHO estimates that a 2% annual reduction in chronic disease death rates over and above existing trends during the next 10 years would save 13 million lives; almost 6 million of those lives saved would be of people under age 70 (WHO, undated c).

The WHO proposes investing in chronic disease prevention (WHO, 2005) through strategies that combine population-wide approaches with interventions for individuals. For the WHO, both comprehensive and integrated action is required. Comprehensive action requires combining population wide approaches aimed at reducing the risk throughout the entire population, with strategies that target individuals at high risk. Integrated prevention and control strategies are most effective. Focusing on the common risk factors of DMT2, deals with a number of related diseases, such as heart disease, stroke and diabetes, at the same time (WHO, 2005).

Most of the current DMT2 strategies are based on treatment. However, given the proportions of the epidemic and its incidence among children, attention needs to be directed towards prevention.

There is a lot of theoretical research on how to prevent chronic diseases, but little practical experience. The immense body of available research can be put to work to develop successful interventions.

III. A public health approach to prevent DMT2 in children

In this section I will provide guidelines for action to stop and reverse the increasing rate of DMT2 in children, and its main modifiable risk factors. I will not present a structured program.

The first underlying principle behind my approach is that it will be better to address the DMT2 problem as a public health issue under the heading of primary care and prevention rather than dealing with the consequences of an entrenched condition and its complications in a young population (Alberti et al, 2004). This is not an original idea, see for example the workshop Diabetes Federation Consensus Workshop (2004), but it is an important principle.

A second principle of my approach is that it is very important to work with the younger population. As mentioned previously, the incidence of DMT2 is rising in children. We know the long term effects that the disease can have on adults, and also that the longer a person has the disease, the more likely he or she is to develop its complications sooner in life. Without treatment, young people with pre-diabetes will develop DMT2 and complications will appear at a younger age (Huang & Goran, 2003).

A third principle of my strategy is that it is necessary to build awareness of both the need for lifestyle changes among the whole population, and of the increasing urgency of the disease and need for prevention among the stakeholders. A comprehensive approach designed to change social norms will be more effective in reducing risk factors than the current approach. Lifestyle modification can be more effective than pharmacotherapy; therefore we need to encourage lifestyle modifications. Some studies (Pinelli et al, 1999)(Pinhas-Hamiel et al, 1999) have shown that the lifestyles of families with members with DMT2 share many risk factors. Therefore our intervention should involve entire families, to help them better understand the disease and its risk factors and complications. It’s important to empower families as well as young people, as they can make a difference. There are things parents can do to keep their children healthy concern (Huang & Goran, 2003). Other studies have shown the importance of family involvement and how this has a positive impact in the management of the disease and the psychological well being of the affected children (Tronja, undated).

Combating DMT2 requires action in a wide range of fronts. It requires creating target messages for people of various socioeconomic, racial, and ethnic backgrounds. In addition to other factors, it’s necessary to create a social support network for the affected children as well as for their families.

A fourth principle of my approach to DMT2 is the need to create an appropriate environment to allow changes to take place. Policies should target the environmental factors that affect children’s behavior (Daniels et al, 2005).

A comprehensive plan of action to reduce the incidence of DMT2 in children will require the involvement of several players. Some of them are:

1. Policymakers.
2. The medical community: doctors, nurses, health promoters, nutritionists.
3. Insurers.
4. Patients and the general community.
5. Schools.
6. Private business.
7. Urban design and public transportation systems.
8. Mass media.

1. Policymakers

The International Obesity Task Force (IOTF) recommends specific courses of action in lobbying governments for investment in prevention programs and strategies. There is a need to create both a social and a political change.

Government has a very important role to play in improving the health and well being of the population, and in providing special protection for vulnerable groups, such as children, who can neither choose the environment in which they live nor their diet. Children also have a limited ability to understand the long-term consequences of their behavior. Poor people also have limited choices about what they eat, their living conditions, and their access to education and health care. Supporting healthy choices, especially for those who could not otherwise afford them, reduces risks and social inequalities (WHO, 2005).

A multi-level governmental approach is also needed. A campaign to prevent DMT2 should include different ministries such as health, finance, education, sports, and agriculture; (Zimmet & Alberti, 2006) and it should operate at the different levels of government: local, national and international.

Government intervention can include mandating a greater emphasis on more exercise and dietary education in schools, banning the advertising of unhealthy products (prohibiting marketing to kids, especially for food related products), and taxing less healthy food to give people incentives to consume less of it (Alberti et al, 2004). It is important to work toward making healthy foods more affordable.

Food labels could be another area to focus on as a means to educate and encourage the public to eat healthier.

2. Medical community: doctors, nurses, health promoters, nutritionists

The major role of the medical community can be to educate patients. It can work with the general population regarding prevention, and with diabetic patients in prevention of the disease’s complications as well as its treatment. It can also encourage patients to have a healthier lifestyle with more physical activity and a more beneficial diet. Doctors should emphasize the education of the patients during medical consultations, for example, by having brochures with basic information directed to patients and also to the general public.

The medical community can also help obese children to lose weight. One way to target the obesity problem is by promoting healthier eating habits, with a focus on the daily diet. A possible strategy is to entice the consumption of fruits and vegetables and other foods high in fiber and low in fat, through promotional incentives. Conversely, measures should be made to dissuade individuals from consuming junk foods, and to decrease meal portions.

Children that have impaired glucose tolerance need special attention to prevent them from developing diabetes; and for DMT2 patients it’s imperative to provide the appropriate care and to screen for the most common complications.

Other measures should involve the screening of pregnant woman during the last part of their pregnancy to prevent low birth weight children and treat gestational diabetes. Promoting breastfeeding could also help decrease the occurrence of DMT2 in children95.

3. Insurance.

Health insurance companies can develop policies to promote healthier lifestyles by using incentives to encourage physical activity. They can subsidize memberships to health clubs, provide nutritional consultations, and distribute information to their customers.

There are several creative alternatives that can be implemented to help reduce the incidence of DMT2 and in turn its main risk factors.

4. Patients and the General Community

A key component of my strategy is to include patients in the intervention against the disease. They should have an active role in reducing the epidemic of DMT2, and we need to encourage them and disseminate the message that they can have a positive impact on their health. Patients need to adhere to a healthy diet and include daily exercise in their routines; they can have access to the information and the resources to generate the necessary changes, but in the end it will depend on their willingness to change to acquire the lifestyle modification.

Parents can influence the behavior of their children. Families can develop the habit of eating at home. Families can also work toward reducing television viewing time, and more particularly, parents can try to limit the time their kids spend in front of the TV. Parents can also incorporate more physical activity into their daily lives and the lives of their children.

5. Schools

Schools are in a perfect position to prevent obesity and diabetes because they have daily contact with the whole target population. Schools are an important environment for young kids and can help create healthy lifestyle habits. School based intervention has already shown to be effective in theUSand Singapore96.

Schools could have a great impact on promoting physical activities; including physical education as a daily part of the schools activities. There are successful physical education interventions that can focus on replacing the standard physical education curriculum with one of greater intensity or with more motivation activities such as popular dance (Flores, 1995). Children will not exercise solely to lose weight; recommended activities must be enjoyable and congruent with the child’s and family’s lifestyle, as well as rewarding, independent of the health benefits (Daniels et al, 2005).

School meal programs could also have a key role in encouraging the adoption of healthier foods. School kitchens could incorporate healthier food into lunch and breakfast programs. Classroom instruction about healthy eating, and about diabetes, and its main risk factors could also be done.

6. Private business

Private players should also play a role in this strategy, and adopt the common goal of raising healthier children. They can be included in several different ways. The food industry could be educated and encouraged to develop an awareness of their part in contributing to the increased number of overweight and diabetic children. They could take measures to prevent this, such as reducing portion sizes, incorporating healthier snack options in vending machines, and reducing the amount of sugar in soft drink beverages.

Restaurants and fast food chains could promote healthier options of foods, as well as include the nutritional information of the foods they offer in their menus.

The entertainment and marketing industries could also disseminate the message by choosing role models that opt for healthier food options and a more active lifestyle.

7. Urban design and public transportation system

The importance of an appropriate environment for the changes to take place has already been mentioned. To target sedentary lifestyles, creating environments conducive to physical activities will help produce a change in social norms around exercise. The urban planning department can be involved by working on urban development, so as to encourage an environment that makes exercise easier. This could be done with an increase in the number of parks or places to exercise, and by making them more accessible and in some cases safer. The public transportation system can also play a role by facilitating families to incorporate walks in their daily routines.

8. Media

A media campaign could also be used to disseminate the messages about health, diet, and exercise. Another strategy is to endorse opinion leaders that promote our message. An educational campaign could increase awareness about DMT2 in the different sectors of society, and increase diabetes related knowledge, such as its complications, and how to prevent it.

Programs should be directed to the general population as well as to diabetic patients. The general public will benefit from the program in two ways: not only the increased prevention of DMT2 but, also, the increased prevention of other chronic diseases that share the same risk factors.

IV. Obstacles and challenges

Several obstacles are likely to appear during the implementation phase of this strategy to reduce the incidence of DMT2 in children. I expect to find some sort of resistance to change from every one of the players involved. It is impossible to exactly anticipate the sources and types of obstacles that the plan will face. This section describes some possible obstacles and challenges that the DMT2 prevention program might encounter from the different players as an example of the importance of being aware of the plausible resistance to change.

A first example is that it may not be easy to achieve consensus among policy makers to establish prevention of DMT2 and its main risk factors as a public health priority. Even after the strategy is adopted, it might be very hard for the patients and the general community to accept their responsibility for the problem and to take a step toward action to protect their own health.

The medical community is already overwhelmed with short visits and an increasing number of patients, and even this intervention that has the long term benefit of healthier patients, will require more time dedicated to prevention during daily visits.

Insurance companies will be happy to have a healthier group of patients, but will also need to adjust to create the necessary changes.

One of the greatest sources of resistance could come from private business, the food industry in particular. It will resist the restrictions on advertising I propose, the call for more disclosure of the nutritional content of food. As the food industry did not always assume a responsible role in the health care of the population in the past, making them participants in the initiative will be important.

Schools will also have extra responsibilities in educating children in the areas of nutrition and physical activity. The DMT2 prevention program can help them to achieve an understanding of why it is important to make these changes in the areas of physical activity and nutrition. If they do not know why they are doing something, most likely they will not do it. It is also important to help schools through partnerships with other players such as the private sector and the medical community.

The public transportation system and urban designers will need to take into consideration the new demands of the society, and adapt the environment to make it easier to have a healthier lifestyle. For the mass media campaign, it will be a challenge to target the population with clear messages.

V. Summary

The next table summarizes my principal points:

VI. Conclusion

This paper explored the problem of DMT2 in children and its possible solutions. It shows that the problem is increasing and that there are things that can be done to change that trend. A central aspect of the fight against DMT2 is to attack its two main risk factors: obesity and inactivity. The paper advocates the creation of an integral solution to the DMT2 epidemic and to prioritize DMT2 in children as an important public health problem.

The integral solution proposed in the paper includes the participation of several players with an important role in fighting this disease: policy makers, the medical community, insurers, patients and the general community, schools, private business, urban design and public transportation planners, and the media. The response to the DMT2 epidemic should be of the same magnitude as the problem, which accounts for over 1% of all deaths. It is necessary to start working toward curbing the DMT2 epidemic in children NOW!

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