Obesity and Diabetes In Children Our Challenges

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Obesity and Diabetes In Children Our Challenges
Francine Ratner Kaufman, MD Distinguished
Professor of Pediatrics and Communications, The
Keck School of Medicine and the Annenberg School
of Communications of the University of Southern
California Head, Center for Diabetes and
Endocrinology,Childrens Hospital Los
Angeles Chief Medical Officer and VP of Global
Diabetes, Medtronic Diabetes, 5/09
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Outline of Talk

• Rates of Obesity in Youth
• Are We at the Plateau?
• Rates of Diabetes in Youth
• What is Driving the Increase?
• Diabetes in Youth is Serious
• What Are the Outcomes?
• Opportunities for the Future
• What Will Each of Us Do?

1906
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1920 My Grandmother Made Candy in Chicago
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The Scope of Childhood Obesity Problem
JAMA 20062951549-1555 JAMA 20082992401-2405
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Obesity in California Children Los Angeles
County
In 2003 Sodas were Banned in LAUSD In 2005
Healthy Vending Policy
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1970
1980
1990
2000
NOW
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Studies to Treat Or Prevent Pediatric Type 2
Diabetes

• A comprehensive school-based trial to determine
  if changes in the school environment can reduce
  risk factors for type 2 diabetes
• Performed at 7 sites, in 42 middle schools

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HEALTHY Study
The cohort is over 6,367 6th graders, followed to
8th grade
Decrease percent of students with risk factors
for type 2 diabetes compared to control
Social Marketing Change Social Norm
Social Marketing Change Social Norm
Large-scale, population-based prevention study
investigating multiple integrated components -
physical activity, nutrition, and behavior
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The Study Cohort

• 6th Grade Cohort
• 6367 participants (57.6 of students)
• 11.8 1.1 years (range 9-15)
• 47.5 male 52.5 females
• Ethnicity
• 53.1 Hispanic
• 19.8 African American
• 18.8 Non-Hispanic White
• 0.5 Native American
• 7.7 Other, Mixed

• 8th Grade Pilot
• 1740 participants (47 of students)
• 13.6 ? 0.6 years (range 12-16)
• 43 male, 57 female
• Ethnicity
• 53 Hispanic
• 23 African American
• 15 Non-Hispanic White
• 3 Native American
• 6 Other, Mixed

Diabetes Care 292122006
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6th Grade versus 8th GradeRisk Factors
Percent with BMI ? 85th Percentile
8th grade
6th grade
1740 participants
6367 participants
Total 50 Males 52 Females 47
Total 49 Males 51 Females 48
39.1 IFG 47.7 Low HDL
15.9 IFG 24.8 Low HDL
Diabetes Care 292122006
Diabetes
Care accepted 2009
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The Community - Characteristics of 90022
 

• Population Size 68,688
• The population is Latino
• 95 of residents live under 185 of Federal
  Poverty
• Percent of children in grades 5, 7 9 -
• BMI gt 85TH 44.6
• BMI gt85lt95TH 30.0
• BMI gt 95TH 25.4

In 2009, LA City Council Placed a Moratorium on
Further Building of Fast Food Venues
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NDEP Resource
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State by State Efforts to Control Obesity A
Report Card
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Communities Worksites Health Care Schools and
Child Care Home
Government Public Health Health
Care Agriculture Education Media Land Use and
Transportation Communities Foundations Industry Fo
od Beverage Retail Leisure and Recreation Entertai
nment
Demographic Factors (e.g., age, sex, SES,
race/ethnicity) Psychosocial Factors Gene-Environm
ent Interactions Other Factors
Physical Activity
Food Beverage Intake
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A Tale of Two Boys with Diabetes
11 year old, type 2 diabetes, with co-morbidities
Siblings, type 1 diabetes, boy at 3 years
BG 769 mg/dL A1c 9.7
BG 887 mg/dL A1c 9.7
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Diabetes Rates
The SEARCH Study
0-9 years, 0.79 per 1000
10-19 years, 2.80 per 1000
1.82 cases per 1000 youth Total cases 154,369 in
2001
Type 1 increase 3/year 16,000 new type 1 /
year Type 2 increase 10-fold in 10 years 3700
new type 2 / year
Pediatrics 20061181510
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The Development of Type 1 Diabetes
Environmental Triggers What Are They? The TEDDY
Trail
Genetically At-risk
Beta Cell Mass
Genetic Predisposition
Insulitis Beta Cell Injury
Honeymoon
Pre-diabetes
Diabetes
Time
Newly Diagnosed Diabetes
Honeymoon Over
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Trial Net Intervention Studies

• New Onset Diabetes
• Anti-CD3
• Mycophenolate Mofetil /- Anti-CD25
• Anti-CD20
• Anti-thymocyte globulin
• Intense metabolic control
• GAD immunization
• CTLA4
• Prevention in at Risk
• Oral Insulin
• Newborns
• Nutritional Omega-3-Fatty Acids, Vitamin D

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Does Obesity Promote Type 1 Diabetes?

• The Accelerator Hypothesis
• Age at diagnosis of type 1
• associated with fatness

BMI gt 85th percentile At Diagnosis

• Type 2
• 100 AA
• 95 non-Hispanic
• 91 Hispanic
• Type 1
• 44 BMI gt 85th Percentile
• 30 BMI gt 95th Percentile

Search Data
Wilkens et al, Diabetes Care 262865,2003
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The March to Type 2 Diabetes in Youth
30 BMIgt 85th ile 17.1 obese 16.3 obese
3700 per year 6W, 67 AI
40 IFG 25 IGT
45 A1C lt 7 26 Hypertension 59 Dyslipidemia

• Family History
• Environmental Factors
• Geneticsusceptibility
• Beginning in utero

Insulin sensitivity 75 Impaired glucose
tolerance Beta-cell 50
Insulin sensitivity 50 Diabetes Beta-cell 75
Obesity Insulin sensitivity 75 normal
glucose tolerance Beta-cell function 2Xs

• Metabolic Syndrome Risk Factors

Care 28 638, 2005
JCEM 86 66, 2001
Care 27 547, 2004
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Type 1 versus Type 2 Outcomes in Youth Data from
Australia, Diabetes Care 291300,06
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Prevalence of Cardiovascular Risk Factors in
Youth with Diabetes
MetS gt 2 CVD risk factors

• Prevalence of gt 2 Risk Factors
• 68 AI, 37 Asian, 32 AA, 35 Hispanics, 16
  Whites (plt0.0001)
• Diabetes Type
• 92 of type 2
• 14 of type 1 (plt0.0001)

Rodriguez et al, Diabetes Care, 2006
Diabetes Care 291891,2006
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DKA/Cerebral Edema and Hyperosmolar Coma
Devastating Outcomes at the Presentation of
Diabetes

• Type 1 25-40 at onset with DKA
• 1/200 episodes lead to cerebral edema
• 1/3 die, 1/3 normal, 1/3 neurologic complications
• In Italy, DKA reduced to 12
• Children's Hospital of Philadelphia
• 3.7 (7/190) children with T2DM HHS
• Case fatality rate of 14.3.
• 28 reported cases of adolescents with HHS
• Mortality 43 (12 of these 28 cases)

Fournier, et al Pediatr.Diabetes 20056(3)129-35
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Intensive Management of Diabetes
Evidence from the DCCT and UKPDS Importance of
early and persistent glycemic controls

• Blood glucose monitoring continuous glucose
  monitoring
• Understanding the glucose targets
• Medications
• Oral medications if type 2
• Insulin therapy Multiple injections, pens,
  pumps
• Changing dosages of insulin when indicated
• Healthy weight
• Balancing food - Managing carbohydrates
• Physical activity
• Visits to your health care provider
• Transition to adult care
• Working as a team
• Child, Parents, HCP, School

Diabetes Care 28186-212, 2005
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Childrens Hospital Los Angeles - Type 1
Glycemic Control in Children and Youth
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The TODAY Trial 704 subjects, 10-17 years, 3
Treatment Arms, 15 Sites

• Treatment
• No medication 11
• Insulin only 12
• Metformin only 49
• Metformin Insulin 25
• Other medication 4
• Comorbidities
• Elevated BP 26
• Dyslipidemia 59
• Both 17

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On the Horizon
 

• Pharmacogenomics, genetic analyses
• Target complications
• Novel insulin molecules
• Innovation in reducing insulin resistance
• Bariatric surgery
• Pumps, Sensors, Artificial Pancreas
• Replace ß-cells
• Technological modalities to improve adherence and
  healthy behaviors

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What Are Our Opportunities and What Are Our
Needs?

• We need an ecological approach to obesity and
  diabetes
• Poor public awareness that diabetes occurs in
  children and youth
• An unacceptable rate of DKA at diagnosis
• Understand the transition process
• Health promotion/disease management in schools,
  communities
• Innovation and evidence to reduce short and long
  term complications

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500,000 children with diabetes in the world Half
in developing countries 10-20,000 die a year -
lack of awareness, medication, providers
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Conclusions

• Rates of Obesity in Youth
• We at the Plateau Multi-component
  approach
• Rates of Diabetes in Youth
• There is an Increase Multiple factors
  including obesity
• Diabetes in Youth is Serious
• Outcomes are poor Innovation and evidence to
  improve the future
• Opportunities for the Future
• What Will You Do?

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THE HUNGRY PLANET
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Type 1 - DKA
Quito, Ecuador
Quito, Ecuador
Big Bear, California
Type 2 Sleep Apnea
Big Bear, California
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The School Environment
78 secondary schools have vending machines
 
15 middle schools, 34 high school permit use at
any time
Little Health Education
20 of lunches stay within limits on fat
85 of children driven to school even when they
live lt than two miles away
11 minutes of PA in PE class
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The HEALTHY Intervention Components

• PE COMPONENT
• PE program of lesson plans in units or themes
• Training program for PE teachers focuses on class
  management and motivational techniques
• Increase moderate-to-vigorous physical activity
  (MVPA) in PE
• Goals
• 150 minutes of MVPA per student over 2 weeks.

• NUTRITION COMPONENT
• Work with food service to modify foods and
  beverages in school
• Conducts activities to promote healthy nutrition.
  
• Goals
• Increase consumption of fruits, vegetables, whole
  grain foods, fiber, water
• Decrease consumption of high calorie, low
  nutrient foods
• Decrease beverages with added sugar

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The BEHAVIOR Intervention ComponentParent and
family outreach newslettersFun Learning
Activities for Student Health (FLASH)Student
Peer Communicators

• FLASH
• Gain knowledge and target specific behaviors
• Learn from students via peer led and group
  activities
• Set goals and monitor their own progress towards
  targeted behaviors
• Bring what they learn to the rest of the school -
  creative products such as posters and PSAs

• Ten brief (less than 30 minutes) scripted
  activities that aim to
• Improve knowledge
• Increase social influence
• Overcome barriers and assist in healthy decisions
• Module 1 Water and You
• Module 2 Lets Be Active
• Module 3 Quality Matters
• Module 4 Energy Ins and Outs
• Module 5 Maintaining a Healthy Lifestyle

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Kids N Fitness? ProgramA Program for Weight
Maintenance

• A family-centered program (Kids N Fitness?) to
  ameliorate weight and weight-related pediatric
  health factors in overweight 7-17 year-old
  children.
• Clinic, Community and School based programs

Monzavi, R. et al. Pediatrics 2006117e1111-e1118
Dreimane, D. et al. Diabetes Research and
Clinical Practice, 2006
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Significant Weight and Health Benefits
Monzavi, R. et al. Pediatrics 2006117e1111-e1118
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KIDS N FITNESS Megan Lipton, MA Roshanak
Monzavi, MD Sharon Braun, MS, RD, CDE Katie
Klier RD, CDE Blanca Sanchez, BA Mary Helen
Black, MS, Adam Kaufman, BS Francine Kaufman,
MD Childrens Hospital Los Angeles, Center for
Endocrinology, Diabetes, and Metabolism
 
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Take Charge Website
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Influence of Race, Ethnicity Culture on
Childhood ObesityConvened by Shaping American
Health

• What are the prevalence, severity and
  consequences of childhood obesity across
  race/ethnicity in the US?
• How might socio-economic factors influence
  racial/ethnic differences in childhood obesity?
• What are the biological and cultural factors
  associated with racial/ethnic differences in
  childhood obesity?
• What are the implications of race/ethnicity on
  the prevention of childhood obesity?
• What are the implications of race/ethnicity on
  the treatment of childhood obesity?

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How might socio-economic factors influence
racial/ethnic differences in childhood obesity?

• Area-base SES measures, poverty levels, property
  taxes, house values, more objective ways to
  assess wealth or deprivation of neighborhood
• Living in high-poverty areas associated with
  higher obesity and diabetes - after controlling
  for individual education, occupation, income
• Harvards Geocoding Study census tract poverty
  more powerful predictor of health outcomes than
  race/ethnicity
• In LA youth obesity associated with economic
  hardship level and park area per capita

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What are the biological factors associated with
racial/ethnic differences in childhood obesity?

• Relationships between stress and illness differ
  by race/ethnicity, in part due to differences in
• The genes or gene variants that would support
  this hypothesis have not been identified
• Exposure to social/environmental stressors
• Degree to which environment, SES and
  discrimination appraised as stressful
• Culturally appropriate strategies for coping
• Biological vulnerability to stress
• A thrifty genotype may confer an advantage in
  an energy-poor environment, and a disadvantage in
  an energy dense environment

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What are the cultural factors associated with
racial/ethnic differences in childhood obesity?

• Culture, unlike instinct, is learned
• Cultural variation impacted by
• Migration of new groups
• Residential segregation of groups defined by
  culture, race and ethnicity
• Maintenance of original language
• Second generation of immigrants
• Formal social organizations (religious
  institutions, clubs, community or family-based
  associations)
• Globalization
• Acculturation
• First generation Asian and Latino adolescents
  consume higher amounts of fruits and vegetables
  and lower amounts of soda compared to whites
• Succeeding generations of Asians continue this
  pattern
• By the third generation, Latinos nutrition is
  poorer than whites

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What are the Implications of Race/Ethnicity in
the Prevention of Childhood Obesity?
Public Policy
Government
Laws
Community
Parks Recreation
Neighborhood
Regulations
Organizational
Health Care
Media
Faith Organizations
Culture
Schools
Interpersonal
Community Organizations
Food Industry
Values
Family
INDIVIDUAL
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Conclusions

• Rates of diabetes in children and youth
• Increasing
• Diabetes in youth is serious particularly type
  2
• Accumulation of CVD risk factors
• The development of type 2 diabetes related to
  childhood obesity
• Childhood obesity rates
• ? stabilized
• School and community based strategies for
  prevention
• Comprehensive strategies
• Understanding the influence of race, ethnicity,
  SES, and culture
• Socio-ecological model