The Dual Epidemics

November is National Diabetes Awareness Month. Obesity and Type 2 diabetes mellitus, two major causes of morbidity and mortality, are growing public health threats in our communities today. Perhaps even more alarming, obesity and type 2 diabetes are becoming public health threats for our children as well.

The prevalence of diagnosed diabetes mellitus is on the rise and disproportionately affects minority populations. Diabetes, a major cause of morbidity and mortality generated a staggering cost of $ 132 billion for direct medical care and indirect costs due to disability, work loss and premature death in 2002. It is estimated that 20.6 million people (9.6% of the population) in the United States, have diabetes. Closer to home, nearly 1.7 (6.6%) California adults, age 18 and over, have been diagnosed with diabetes, up from 1.5 million (6.2%) in 2001. Six percent (6%) of San Diegans ages 18 and over have been diagnosed with diabetes.

The number of Americans with diabetes more than doubled from 1980 to 2004. Type 2 diabetes mellitus, the most common form of diabetes, a progressive metabolic disease is becoming increasingly prevalent. Although type 2 diabetes still occurs most commonly in adults aged 40 years or older, the disease is increasing in adolescents and young adults; and younger people may especially be at risk for diabetes complications when they acquire the disease at an earlier age. Healthcare providers are seeing more and more younger children with type 2 diabetes, a disease usually diagnosed in adults 40 years or older. The primary defect in type 2 diabetes is insulin resistance and insulin deficiency. To date, no single biochemical defect has been found. But, there is general agreement that type 2 diabetes is closely linked to obesity — about 54.8% of persons with type 2 diabetes are obese, and obesity itself can cause insulin resistance. Alarming is the increasing prevalence of type 2 diabetes that is attributable to a younger population and the increasing rates coincident with the increased rates of obesity.

In 2005, over half (57.9%) of the state’s adults were overweight or obese. In addition to type 2 diabetes, obesity has adverse health outcomes such as premature mortality, cardiovascular disease, osteoarthritis and certain other medical conditions for all age groups. As a pediatrician, it is particularly distressing that obesity has become rampant in the adolescent population especially among minority groups, with its potential impact on the lives of children. The percentage of young people who are overweight has more than tripled in the past 20 years since 1980. In 2004, more than one in four children (27.4%) in fifth grade were overweight in San Diego County. Among ninth graders, 23.4% were overweight. Overweight children become overweight adults. Some declare that if the current trajectory continues, obesity will overtake smoking as the primary preventable cause of death. Based on current trends, it may become fairly routine for emergency physicians to see angina and myocardial infarction in the 20 year-olds, who by then will have had their type 2 diabetes for a decade.

The problem is daunting, there is no quick fix; the war on obesity needs to be fought on many fronts. This year, the County of San Diego Health and Human Services Agency released San Diego’s “Call to Action: San Diego County Childhood Obesity Action Plan.” Guided by a Steering Committee of experts in the field, the “Plan” calls for every person in our community to take part in the fight against obesity through strategies in seven domain areas — county and city government, healthcare system and providers, schools, community-based organizations and youth organizations, media outlets and marketing industry, and business. The foundation of the “Plan” is based on an ecological model that addresses multiple levels of behavioral influence and offers a comprehensive approach to preventing childhood obesity.

As physicians, we are key contributors to solving the childhood obesity problem. But, obesity has not received the attention it deserves from clinicians. It is under-recognized and under-treated by pediatric healthcare providers. Few physicians routinely evaluate patients, by calculating body mass index (BMI), promoting breast feeding, and healthy weight and lifestyle. Among the reasons cited are uncertainty of their role in effectively managing and impacting the long-term management of obesity, time constraints, lack of reimbursement, inadequate availability of community resources, and disagreement about effective management.

Increasing awareness, education and timely identification and management of obesity by pediatric healthcare providers are critical elements in addressing the problem. Effective strategies include: a) promoting breast feeding; b) evaluating all children by calculating BMI and using the Centers for Control and Prevention BMI for age percentile charts; c) educating patients about the serious health risks of obesity because one third of mothers misclassify their overweight children as being lower than their measured weight status; d) involving the family by encouraging them to make incremental changes leading to a healthier diet and increased regular physical activity; and e) developing skills in motivational interviewing to assist children and their families to be physically active and adopt less sedentary lifestyles and healthier diets. We have the power to influence, therefore, we must advocate at the local, state, and federal level to raise awareness and support local efforts that promote healthy nutrition and physical activity. As healthcare professionals, we have to be more committed to making creative practice changes and become more vigorous in our efforts to counteract the increasing obesity and type 2 diabetes.