Approximately 12.5 million children and adolescents in the United States are classified as obese. That’s 17 percent of people aged 2 to 19, according to the Center for Disease Control and Prevention (CDC). The number of children who are obese has almost tripled since 1980. Not only is the prevalence of obesity apparent in the general population of children and adolescents, but the pervasiveness of overweight and obesity is also evident within the pediatric diabetes population both in the U.S. and here at Joslin Diabetes Center.
SEARCH, a national multi-center study of diabetes in youth, found that 22.1 percent of pediatric patients with type 1 diabetes are overweight and 12.6 percent are obese. Within the general pediatric population, 15 percent of children and adolescents are overweight and 17 percent are obese, according to a 2010 National Health and Nutrition Examination Survey (NHANES).
Current childhood obesity rates make it more common for a patient with type 1 diabetes to present at diagnosis as overweight or obese, but for many years this was not the case. Before the rise of the obesity epidemic, people with type 1 diabetes were generally distinguished as being lean and thin, whereas people with type 2 diabetes were identified as commonly being overweight or obese.
“Traditionally, it used to be the case that children at diagnosis were often underweight since they had lost weight substantial weight by the time they were diagnosed with type 1 diabetes,” said Charumathi Baskaran, M.D., Pediatric Research fellow at Joslin. “This was because as children develop diabetes, they do not produce enough insulin to use the carbohydrates in foods for energy. As a result, they start using up their fat stores for energy.”
She continued, “despite the weight loss before diagnosis, a recent study demonstrated that the body mass index (BMI) at disease onset has been gradually increasing, which could be a reflection of what is happening in the general pediatrics population regarding the increased occurrence of childhood overweight and obesity.”
This increase in the number of pediatric patients with type 1 diabetes who are also overweight or obese has led to the phenomenon called “double diabetes,” which is when patients have type 1 diabetes, but may also present with characteristics of type 2 diabetes, such as insulin resistance.
In patients with type 1 diabetes, their immune system attacks the pancreatic beta cells that produce insulin, causing patients to become insulin dependent. On the other hand in type 2 diabetes, people are insulin resistant, typically from being overweight or obese and inactive, which prevents their bodies from using insulin properly.
“With the current increase in the obesity rate, children with type 1 diabetes are showing some degree of insulin resistance from being overweight or obese, in addition to having insulin deficiency,” explained Dr. Baskaran. In fact, there are a number of ongoing studies in pediatric patients with type 1 diabetes to add an oral medication to the insulin regimen on order to help manage the insulin resistance.
Increased weight gain in the presence of insulin deficiency can lead to double diabetes. Regardless of the cause, double diabetes can be challenging with respect to management for both clinicians and patients. Additionally, it is important to correctly diagnose diabetes in the setting of a child who may also be overweight or obese.
“If a child is overweight or obese at presentation, the diagnosis of the type of diabetes requires special testing,” commented Dr. Baskaran.
“We test for antibodies against the insulin producing beta cells, which, when positive, confirm the diagnosis of type 1 diabetes,” adds Lori Laffel, M.D. MPH, Chief of the Pediatric, Adolescent and Young Adult Section at Joslin. “We can always begin treatment of the child while we are awaiting confirmation of the type of diabetes.”
Dr. Baskaran said that after type 1 diabetes is diagnosed, there could be an extra psychological burden on the patient and family if the child is obese.
There is some encouraging news – the increase in obesity rates in adults has slowed down in recent years, with data from the CDC demonstrating that from 2003 to 2010 the prevalence of obesity, meaning someone who has a BMI of 30 or higher, decreased slightly from 15.21 percent to 14.94 percent. Similarly, the prevalence of extreme obesity, or a BMI of 40 or higher, decreased from 2.22 percent to 2.07 percent.
The rates of childhood overweight and obesity have also remained stable for the past decade. Nonetheless, about one out of three American youth remain overweight or obese and half of American adults are either overweight or obese.
Dr. Baskaran credits the stabilization of the obesity epidemic to a greater awareness of the importance of lifestyle changes for weight management and the prevention and treatment of diabetes and its complications.
Despite this, there is still the challenge of how to properly treat double diabetes. This conundrum prompted Dr. Baskaran and other Joslin pediatric physicians to participate in a clinical trial that will better inform care for overweight and obese pediatric patients with type 1 diabetes.
“We are conducting these studies to understand the best way to treat this subset of children with type 1 diabetes who are also overweight or obese, ” said Dr. Baskaran.
The pediatric program at Joslin is also launching a new program aimed at helping youth and their families to manage childhood overweight and obesity for any child or teen with or without diabetes. This program is called the Joslin Unites for Metabolic disease Prevention (JUMP) Program. This program includes pediatric endocrinologists, nurse practitioners, dietitians, exercise physiologists and pediatric psychologists all working together to help families manage weight and lifestyle changes.
Elvira Isganaitis, M.D., M.P.H., will help to direct this new program. For questions and to make an appointment, please call the pediatric office at 617-732-2603.