Type 2 diabetes runs in overweight families
Victims are becoming younger and younger
Treating an overweight adolescent for Type 2 diabetes has become dauntingly common in the clinical setting. Now researchers recommend that the entire family needs to be treated and major lifestyle changes implemented to prevent the spread of what is now often called an "epidemic."
Researchers at Children’s Hospital Medical Center in Cincinnati wrote in the October issue of the Archives of Pediatrics and Adolescent Medicine that they found a disturbing pattern of obesity, and what they termed a "striking" rate of diagnosed and undiagnosed Type 2 diabetes and insulin resistance in the families of adolescents diagnosed with the disease.
In what the authors say is the first report of lifestyle characteristics of Type 2 diabetic adolescents and their families, the team found another common thread among these Type 2 families: a high-fat, low-fiber diet; central obesity; minimal physical activity; and a high incidence of binge eating.
"I think we are looking at a combination of lifestyle and genetics," says lead researcher Philip Zeitler, MD, PhD, a pediatric endocrinologist, now assistant professor of pediatrics at Children’s Hospital in Denver. "It’s not only the sedentary lifestyle. Some people have led sedentary lifestyles and been obese and not developed diabetes and vice versa."
Zeitler and many other clinicians are alarmed about the dramatic upswing in Type 2 diabetes among adolescents. Cincinnati’s rate of adolescent Type 2 rose 10-fold over the past decade.
"We’ve always known that diabetes runs in families," says Zeitler. "But what we’re seeing now is a family where maybe a grandmother got diabetes at the age of 60, the mother was diagnosed at the age of 35, and now the kid has it at the age of 15. The risk of complications for these teenagers is staggering," he says, recalling an 18-year old patient who already has hypertension and nephropathy.
Zeitler’s study involved 42 subjects from 11 African-American families with an adolescent family member in whom Type 2 diabetes had been diagnosed. Five of the 11 mothers and four of the 11 fathers had already been diagnosed with Type 2 diabetes at the beginning of the study and three of the remaining seven fathers were diagnosed during the study. Six mothers and two fathers had fasting insulin levels greater than 179 pmo/L.
Zeitler and his team subscribe to the thought that because of certain risk factors, including obesity and family history, certain individuals may be almost predestined to develop diabetes sometime in their life. "These kids are getting their diabetes early because they are so remarkably obese."
The subjects were all obese and sedentary, with diabetic teenagers and fathers in the 95th percentile in body mass index and mothers and siblings in the 85th percentile. None of the diabetic teenagers participated in structured or routine exercise, and nine reported no physical activity at all. They reported an average of five hours a day of watching television or playing computer or video games.
Three of the teens met the criteria for binge-eating disorder, where the patient experiences out of control eating several times a week. Although the young patients know it is a problem, they don’t feel capable of controlling it and they feel guilty afterward. Zeitler says no one knows if the binge eating existed before the diagnosis of diabetes or if it is in rebellion against the strict dietary regimen required to manage diabetes.
The mothers with Type 2 diabetes had markedly elevated HbA1c levels, indicating poor control, and all but one of the siblings had evidence of insulin resistance.
The Cincinnati study authors suggest screening all family members when a teenager is diagnosed with Type 2 diabetes.
"[Clinicians should] take into account the lifestyle and health habits of the entire family when they are designing treatment programs," Zeitler says. Then they should target family members not yet diagnosed with aggressive intervention programs. "Yes, it’s sensitive when you’ve got a 400-pound mother sitting in front of you, but you’ve got to be very proactive about childhood obesity."
He challenges primary care physicians and their diabetes team members to talk about lifestyle and diet and urge family physical activities and healthier diet choices to make the transition easier. A scheduled family exercise time each day, such as a walk in the early morning or after dinner, can become a valuable first step to lifestyle changes, Zeitler says.
An educator or nurse might be able to help the parents figure out affordable ways for kids to get exercise, which is in itself a daunting task in these days of dwindling school physical education programs and a dearth of community-based sports facilities.
Making a commitment to physical education
Zeitler says he thinks the answer lies in schools and in parents committed enough to reverse the trend against physical education in schools. "There will be a lot of resistance because of the cost, so parents need to be advocates for their kids about this."
"Schools and communities need to decide this is an important thing to do," he says, citing a recent article about a new school built without a playground, "because the school officials said kids had no time to have recess anyway."
Zeitler says he is perplexed at this attitude since dozens of studies show how a mixture of mental and physical activity enhance learning. Gone are the days when kids went outside to play after school and only came home for dinner reluctantly, he recalls. "Now they come home from school and sit down in front of the TV or computer and eat potato chips and drink soft drinks."
He says another way of addressing the problem of overeating has been found on the Pima Indian reservation in Arizona, where 30% of all residents have diabetes — the highest incidence in the world. Children diagnosed with diabetes (virtually all of them Type 2) are fed breakfast and lunch at school and enrolled in a school exercise program. Changing lifestyle is an enormous challenge for a family, Zeitler says. "Families won’t be able to change without quite a bit of support."
"Not everybody wants to be helped," says Joe Solowiejczyk, MSW, RN, CDE, associate director of family services at Naomi Berrie Diabetes Center in New York City.
"It’s a bell curve," he says. "Ten percent aren’t going to make any change at all, 80% will make some attempt, and 10% are really pro-living and will make the changes they need. To think you can change that curve is naive."
It’s time to expand the definition of the word "patient" to include the entire family, he says.
"The most influencing variable in a child’s behavior is how the family functions," says Solowiejczyk as he suggests that Type 2 families are often functioning poorly and will not do what they need to do to deal with diabetes. His recommendation to clinicians: Be available to everybody, but don’t spend all your time with the ones who won’t do what they need to do.
This straight-shooting clinician admits this may sounds harsh, and acknowledges that clinicians believe they have to "fix" people. Instead, he challenges health care professionals to "help people who want to work on their problems."
The assessment of who falls in the upper 10% — who are ready and willing to make needed lifestyle changes — is not difficult if a clinician follows a specific diagnostic pathway assuming basic education has already been done.
Solowiejczyk offers these tips:
• Look at the family dynamics. See how the parents relate to each other and to the children. What are their parenting skills? What are the common patterns? As a family, how do they organize family life around illness?
• Look at family behavioral patterns. Is it OK to eat a lot? Is it OK to eat a lot if you are stressed or anxious? What are the rules about food? What are the boundaries and the rules within the family?
Once these assessments have been made, Solowiejczyk suggests, a pattern of dysfunctionality is likely to emerge. "In families where obesity runs, there is a lot of pathology ranging from low self-esteem to abuse to alcohol and drug problems, which almost invariably lead to the kid acting out," he says.
The optimal treatment plan involves the entire family. "I talk to the parents alone and remind them they are a behavioral model for their children, and they need to be very clear about the messages they are giving to them," Solowiejczyk says.
Help the family make boundaries, he says, and make it clear who are the adults and who are the kids. "The bottom line is that this disease is non-negotiable," he tells the parents and kids complaining about monitoring and medications. "It’s like taking out the garbage or doing your homework. You don’t have to like it. It’s a pain in the a**, but you have to do it." In dysfunctional families where parents are not willing to make the changes to save their kids from serious complications, some kids have to act more grown up than their parents, Solowiejczyk says. And he tells them so.
A young teen who is not getting support from his family may require intervention. "We always hope it doesn’t come to this, but think about whether it’s really abuse, and if you feel the kid’s life is in danger, you have no choice but to file a report," he says.
[Contact Philip Zeitler at (303) 861-6128 and Joe Solowiejczyk at (212) 304-5492.]
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