Am Fam Physician. 2007 Sep 1;76(5):634-637.
Obesity in youth and its attendant complications, including type 2 diabetes, are of tremendous concern. In addition to future complications, youths with diabetes have a high risk of psychiatric disorders such as anxiety and depression.1 The disproportionate effect of obesity and higher prevalence of diabetes in minority youths is especially alarming.2 Prevention and appropriate management are critical to minimize morbidity and mortality related to youth-onset diabetes and to prevent health disparities later in life.
In this issue of American Family Physician, Peterson and colleagues provide a National Diabetes Education Program update on the management of type 2 diabetes in youth.3 This thorough review of current guidelines highlights important aspects of the management of diabetes in youth, including implementing a team approach, setting appropriate limits, and encouraging self-management based on the youth's developmental status and abilities. Family physicians potentially will care for children into adulthood, when the complications of diabetes manifest. Family physicians are also poised to address treatment of diabetes in youth because of physicians' longitudinal care experience and their familiarity with the management of adult diabetes.
Although much of the update by Peterson and colleagues relates to treatment, physicians have an equally important role in the prevention of type 2 diabetes, both as health care professionals and as advocates for healthy change in the environment. Peterson and colleagues convey the controversies surrounding screening for overweight: screening is only useful if an appropriate therapy exists, yet few interventions to treat overweight in youth have been successful. Despite a lack of evidence that screening affects outcomes, it is unlikely that inaction (i.e., no screening) would be beneficial. The American Academy of Pediatrics recommendation that all children be screened using body mass index (BMI) measurements4 is a call for physicians to begin discussions with patients who have a BMI greater than the 85th percentile for age.
Working with patients to prevent diabetes has many parallels to smoking-cessation assistance. Physician assistance can double the odds that a patient will quit smoking,5 and reinforcing messages about healthy living at each office visit may help youths decrease weight gain. However, as with smoking cessation, multiple attempts usually are required.5
In contrast to cigarettes, which are clearly harmful, the “harm” of food is less clear. Perhaps this is why dietary interventions aimed at preventing cardiovascular disease in high-risk children (e.g., DISC [Dietary Intervention Study in Children]) have had little effect on BMI, although DISC found that intervention improves dietary habits and low-density lipoprotein cholesterol levels.6
Targeting patient activity is an important approach to preventing obesity. Most studies of physical activity indicate that it is possible to improve exercise participation, at least in the short term.7 Successful activity interventions have employed self-monitoring; rewards; and, as with smoking-cessation programs, stimulus control.8 The degree to which strategies to encourage physical activity promote weight loss is unclear.9 However, it may be beneficial for physicians to promote autonomy (e.g., provide appropriate choices for goals); talk through strategies to help youths concretely describe their planned approach (e.g., ask the patient, “When would you bike ride?” or “How would you get to the gym?”); and explore potential barriers (e.g., ask the patient, “What might get in the way of your plan?”).
Similar to antitobacco campaigns, a public health approach is critical in decreasing obesity. Because office-based interventions are not highly effective, screening and counseling should be considered adjuncts to the primary goal of creating a healthier environment for youths.
Physicians can support legislation and school wellness policies to improve the availability of healthy foods and physical activity opportunities in the community and in schools. The California Medical Association Foundation provides resources to help physicians become involved in community initiatives; for more information, go to www.calmedfoundation.org/projects/links.aspx.
Disincentives are integral to the success of an antitobacco campaign10 and could be effective for obesity prevention (e.g., instituting soda taxes). Another potential approach is implementing marketing strategies that counter advertising for unhealthy products.
There has been some positive advancement in the effort to decrease obesity. With the help of health care professionals, new legislation aimed at improving food and beverage options at schools has been passed,11 and a federal mandate for local school wellness policies12 is likely to have a positive impact on physical activity. As approaches to obesity prevention are proved effective, guidelines will continue to change. Family physicians, with their established relationship with children, parents, and other adults in the community, will continue to have an important role in preventing and managing diabetes in youth.
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2. Liese AD, D'Agostino RB Jr, Hamman RF, Kilgo PD, Lawrence JM, Liu LL, et al., for the SEARCH for Diabetes in Youth Study Group. The burden of diabetes mellitus among US youth: prevalence estimates from the SEARCH for Diabetes in Youth Study. Pediatrics. 2006;118:1510–8.
3. Peterson K, Silverstein J, Kaufman F, Warren-Boulton E. Management of type 2 diabetes in youth: an update. Am Fam Physician. 2007;76:658–64.
4. Krebs NF, Jacobson MS, for the American Academy of Pediatrics Committee on Nutrition. Prevention of pediatric overweight and obesity. Pediatrics. 2003;112:424–30.
5. Fiore M. Treating tobacco use and dependence. Rockville, Md.: U.S. Department of Health and Human Services, 2000.
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7. Summerbell CD, Waters E, Edmunds LD, Kelly S, Brown T, Campbell KJ. Interventions for preventing obesity in children. Cochrane Database Syst Rev. 2005;(3):CD001871.
8. Epstein LH, Myers MD, Raynor HA, Saelens BE. Treatment of pediatric obesity. Pediatrics. 1998;101(3 pt 2):554–70.
9. Cawley J, Meyerhoefer C, Newhouse D. The impact of state physical education requirements on youth physical activity and overweight. Health Econ [In press].
10. Schroeder SA. Tobacco control in the wake of the 1998 master settlement agreement. N Engl J Med. 2004;350:293–301.
11. California Center for Public Health Advocacy. Legislative Successes. Accessed June 1, 2007, at: http://www.publichealthadvocacy.org/legsuccess.html.
12. Child Nutrition and WIC Reauthorization Act of 2004. 42 USC §1751 (2004).
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