What’s the link?

Without question, the prevalence of diabetes and obesity is on the rise. This is occurring not only in adults but children as well. Many experts are very concerned about this change. The impacts it’s having now and will continue to have are significant. What are these? Can anything be done to change the trajectory?

Diabetes Obesity ChildrenBoth obesity and diabetes have increased in prevalence in recent years and are now epidemic health problems. Every year, at least 2.6 million people die due to being overweight or obese, and approximately 90% of people with diabetes are overweight. Adults aren’t the only ones affected by the surge. Both conditions have increased among children, regardless of age, sex, and race. According to the Centers for Disease Control and Prevention (CDC), obesity in American children and adolescents has more than tripled since the 1970s, with close to 14 million children and teens currently being obese. Another 8.6 million children are at risk for it. The Endocrine Society’s Endocrine Facts and Figures report shows that between 2002 and 2005, over 3,600 U.S. children and teens were diagnosed with type 2 diabetes each year. The numbers have steadily risen since then. The link between obesity and diabetes is strong. Obesity is a risk factor for four of the ten leading causes of death in the U.S.: coronary heart disease, type II diabetes, stroke, and cancer.

Childhood obesity is a complex health issue but occurs when a child is well above the normal or healthy weight for their age and height. It’s important to note that being overweight is not the same as being obese. An individual can be overweight because they have heavy bones or muscle mass, or even high body water content, but not necessarily fat. Obesity is having too much adipose (fat) tissue in the body. However, both types refer to having more weight than what is considered healthy for a person’s height. Body mass index (BMI) is one tool used by doctors to measure whether someone is overweight/obese. Those who fall at or above the 95th percentile are considered “obese” or “overweight.” Those who are between the 85th and 95th percentiles are “at risk for obesity or overweight.” Individuals with a BMI above 30 are 80 times more likely to develop Type 2 diabetes than people with a BMI under 22. The CDC has developed BMI charts adjusted for age and gender for children ages 2 to 20. A study published in the Journal of the Endocrine Society in 2017 found that obese children had four times the risk of developing type 2 diabetes than children with a BMI in the normal range. The study examined electronic health records from one of the largest primary care databases worldwide, the U.K. Clinical Practice Research Datalink. It looked at data from 369,362 children between the ages of 2 and 15. The study found no association between obesity and increased incidence of type 1 diabetes, an autoimmune disorder. Type 2 diabetes is a chronic condition that affects how the body metabolizes sugar (glucose). It was previously reported to account for 2%-3% of all diabetes in children, which is why it was called adult-onset diabetes.

The reason overweight individuals have an increased likelihood of diabetes is due to insulin resistance. Understanding how these elements interact is fundamental to figuring out the obesity-diabetes link. Insulin, which the pancreas produces, helps the food we eat become fuel for cells to use for energy by assisting them in absorbing glucose. Insulin resistance reduces this ability. This is more likely to occur in overweight or obese people because excess fat makes the cells less responsive to insulin. When glucose isn’t absorbed, it stays in the bloodstream resulting in high blood sugar levels, which harms the body in many ways. Besides obesity, there are several contributing factors to insulin resistance. Some can be controlled, while others cannot. Genetics, age, and ethnicity are examples of those that can’t be changed. Lifestyle factors, such as alcohol intake, smoking, exercise level, and stress, are those within your power to change. Individuals with cardiovascular problems, like high blood pressure and high cholesterol, are more prone to diabetes as well. However, obesity is the single best predictor of whether a person will develop insulin resistance.

The other issue is where the extra weight is stored in the body, which is how body fat is classified. Visceral fat is stored inside the stomach area and wraps around the walls of internal organs. It can’t easily be removed by diet or exercise. Subcutaneous fat is found right beneath the skin and is physically measured when taking your waist circumference. Visceral fat is the type that elevates the risk of developing severe health problems. While subcutaneous fat isn’t as dangerous in general, it’s often present if visceral fat is.

Another problem is the type of fat being stored. There are two kinds of adipose tissue. Brown adipose tissues are dark brown and are linked with many blood vessels, and associated with calorie burning, heat production, and energy balance. White adipose is responsible for storing energy and accumulates excessively in obesity. In a healthy body, muscles, fat tissue, and the liver absorb glucose from the bloodstream, a process with which white adipose normally assists. However, when it becomes excessively thick, its ability to do this is disrupted.

Several other factors can exacerbate the link between diabetes and obesity. Sleep is one of them because it’s vital to many core body functions, including insulin regulation. Abdominal fat and overall obesity are the two most significant risk factors for developing sleep apnea because the excess fat in the pharynx (the part of the throat behind the mouth and nasal cavity) is more likely to block a person’s airway. Sleep apnea leads to poor sleep, which increases the risk for further obesity, increasing the risk for insulin resistance and Type 2 diabetes. Essentially, a repeating cascade effect occurs. Poor sleep negatively affects blood sugar levels, which disrupt many other bodily processes, like cholesterol and blood pressure, which is why these problems are much worse in obese individuals. Both the quality of sleep as well as the quantity matter. People who get less than six hours or more than nine hours are more prone to type 2 diabetes.

There’s another theory that obesity leads to prediabetes, a condition where blood glucose levels are elevated but not high enough to make a diabetes diagnosis. As of 2015, at least 84 million people in the U.S. had this condition. Most people with prediabetes end up developing type 2 diabetes within ten years. Metabolic syndrome (Syndrome X or obesity syndrome) is a related condition. It’s a complex set of risk factors, such as excess abdominal fat, high blood pressure, elevated triglycerides, low HDL (“good” cholesterol), and high blood sugar levels. Many obese people suffer from this condition. It’s hereditary, and the older you get, the risk higher the risk.

One study highlights how much of an issue diabetes and obesity have become in children. It was conducted from 2011 to 2015 and used the FAIR Health database, which includes more than 23 billion privately billed healthcare claims nationwide. Researchers found that claims data is a valuable means of investigating public health issues because they reflect actual healthcare utilization. Besides, the information provided on claims indicates the assessments of providers, who are better at judging health conditions than nonmedical professionals. The researchers analyzed the data looking for trends and patterns in obesity, type 2 diabetes, and other obesity-related conditions in the pediatric population (0 to 22 years). To have a comparison, the group also studied adults 22 years or older. The groups were broken down to 0-2 years, 3-5 years, 6-9 years, 10-13 years, 14-16 years, 17-18 years, 19-22 years, and 22 years or older. During the study period, obesity diagnosis increased in all age groups. The increase varied by age group, but after 5 years of age, it became greater for each successive age group. Since the study population had private insurance and excluded those with Medicaid, the results show that pediatric obesity is a problem regardless of economic status. When it comes to type 2 diabetes, the average increase was 109% across all age groups. As with obesity, the growth tended to be greater among older individuals. Other obesity-related diagnoses, such as obstructive sleep apnea and hypertension, had similar trends. Gender was found to be a factor. In most groups, obesity diagnoses occurred more frequently in females than males. However, in all but two groups (aged 10-13 and 19-22 years), type 2 diabetes diagnoses occurred more frequently in males than females. Obstructive sleep apnea and hypertension diagnoses were also more common in males than females. Since the study period spans the years before and after the availability of subsidized coverage under the Affordable Care Act, researchers did theorize that some of the growth in claims might be attributed to the influx of newly insured people. Without question, the amplified utilization highlights a trajectory of change in these diagnoses.

Not surprisingly, children who are obese are more likely to become adults with obesity. This is often the result of physical activity, and dietary habits learned in childhood being carried into adulthood. More than half of obese children over age 6 become obese adults, and between 70 – 80% of obese adolescents remain obese in adulthood. The onset of obesity and type 2 diabetes during childhood can harm the body in various ways, making children with these conditions at greater risk for serious health problems as they grow older. These children will be more likely to have high blood pressure, high cholesterol, asthma, sleep apnea, joint problems, musculoskeletal discomfort, fatty liver disease, gallstones, gastroesophageal reflux (heartburn), and certain types of cancer (endometrial, breast, and colon). In addition, they will likely experience psychological problems, like anxiety, depression, low self-esteem, and lower self-reported quality of life. These children are more likely to endure bullying and stigmas.

These chronic conditions often require acute and long-term care. Many also are limited in daily activities, including paid work. Along with increased healthcare costs, these individuals are disproportionately impacted financially. In some cases, this is spread to others because nearly one-third of obese children are covered under Medicaid. This is because about 34% of children from lower-income households are obese, whereas 19% of children from higher-income homes are obese. Some healthcare services, such as weight management programs or supportive services, aren’t covered by health insurance and must be paid out-of-pocket. As a result, low-income families are more likely to have restricted access to these types of services. Diabetes is similar in the heavy burden it imposes on society.

Experts attribute diabetes and obesity to unhealthy diets and lack of physical activity. Most people’s diets include high-calorie, low-nutrient foods and beverages. We spend a significant amount of time sitting using electronic devices compared to the past. Over 25% of children ages 8 to 16 watch four or more hours of television per day, and 43% of high school students watch more than two hours of television on school days. Also, a child may have an increased risk for type 2 diabetes if they have a sibling/other close relatives with the disease; they’re of Asian, Pacific Islander, Native American, Latino, or African descent; they show symptoms of insulin resistance; or they’re overweight/obese. In March 2000, the American Diabetes Association (ADA) developed a consensus position with screening children for type 2 diabetes in children if they were overweight and had two additional risk factors for diabetes. Patients who meet these criteria testing should begin at age 10 (or at the onset of puberty if earlier) and should be tested every two years. When it comes to spotting symptoms of type 2 diabetes, it isn’t always easy. In most cases, they develop gradually. Six things to keep an eye out for are excessive fatigue, frequent urination, excessive thirst, increased hunger, slow-healing sores, and darkened skin (most commonly in the armpits and neck).

Greater attention is needed to prevent, screen, diagnose, and treat obesity and type 2 diabetes in children because early intervention is essential to minimize the risk of complications. The goal of managing diabetes is to achieve a normal blood sugar level (normoglycemia) and reduce the chances of hypoglycemia (low blood sugar), hyperglycemia (high blood sugar), and complications. To reach these goals, individuals should follow the 2015-2020 Dietary Guidelines for Americans, emphasizing eating a variety of vegetables and fruits, whole grains, a variety of lean protein foods, and low-fat and fat-free dairy products. It also recommends limiting foods and beverages with added sugars, solid fats, or sodium. Many different factors influence foods, like cooking methods used, processing methods, the form of the food, the particle size of the food, water content, temperature, or foods in a mixed meal. It’s essential to learn about and understand these to make the best choices. According to the Physical Activity Guidelines for Americans, children aged 6 – 17 should do at least 60 minutes of moderate to vigorous physical activity every day. Children 3 – 5 years should be physically active during the day. For most individuals, losing as little as 5 – 10% of their weight would drastically improve their overall health. Even making minor adjustments to diet and exercise can have numerous beneficial outcomes.

Reversing the current trend of obesity and diabetes will require an enormous effort from all healthcare stakeholders. As a consensus report from the American Diabetes Association and other organizations put it, “Comprehensive, coordinated, and innovative strategies for the investigation, prevention, and treatment of youth-onset type 2 diabetes are urgently needed.” This is also true for obesity. Since multiple factors and our environments, including our home situation, early care/education, school, healthcare, and other community settings, influence us, all of them will need to be tackled. Those that have input on these settings include government, the education system, nonprofit organizations, and families. Pediatricians must apply evidence-based techniques to prevent, screen for, diagnose, and treat these diseases, which means medical school curricula should prepare pediatricians for this. Policymakers can influence outcomes through their decisions affecting cities, schools, and people’s way of life. Public health initiatives should be implemented to help increase activity and improve young people’s nutritional habits. There need to be school-based programs that enhance physical education in schools and improve meal/snack options available. We should see better results by targeting total populations rather than attempting to screen and treat high-risk individuals. Parents must realize that their child’s weight is not just a cosmetic issue but also a health one. Their actions can significantly impact their children, so they need to do all they can to instill healthy diet and exercise habits. One way to do this is to set a good example by following the same things they’re teaching. However, this can be difficult due to the affordability of healthy food options, peer/social supports, and marketing/promotion children are exposed to. It’s also key to know there’s a difference between a healthy weight and an ideal weight; they aren’t the same thing. A healthy weight is based on your height, weight, and other factors. An ideal weight is a personal preference and how an individual wants their physique to appear. The goal should always be to aim for a healthy weight.

Lowering diabetes and obesity across all populations, particularly in children, is vital. The health of our nation depends on it. If we don’t address these concerns, it’ll lead to more long-term, costly health complications and shorter life spans in the future. It’s up to all of us to do our part to bring these epidemics under control. The good news is that it’s achievable if we all work together.