Type 2 diabetes in the young has a multitude of detrimental effects in the long term
The good old rhyme that goes 'chubby cheeks, dimple chin......recounts a cute, cuddly and an adorable child. A chubby child is considered an 'Apple of the eye' to everyone. But interrogating the fact whether being chubby is an acceptable healthy norm or a cause for concern is something that has to be given a momentous thought as it is important for the long term health of the child.
In reality, while looking at the possible link between 'baby fat' and 'childhood obesity', a healthy norm means that a baby is within the normal weight range for their length despite a plump appearance. Babies do normally store fat under the skin as it is a major source of energy for their growth and development. The transition from infancy to toddler stage signifies an overall change in appearance and weight. In this regard the expected outcome would be achieving a weight for height balance. But if the baby's weight gain is rapid, rather than contradicting this as 'just baby fat', the realization of a future health risk is critical.
Childhood obesity has reached the status of a significant public health issue globally. With the prevalence showing an increasingly slim disparity with respect to the economical status of the country and population, the development of obesity in children is related to the intermingling of genetic, environmental and lifestyle factors. So the shift in the disease trend leading to metabolic, hormonal and psychological disruptions begins in childhood with obesity as a key contributing factor.
The conventional link between the types of diabetes to the 'phases of life' is a long established notion. On the contrary, type 2 diabetes which was once tagged as an adult metabolic disorder, is now increasingly seen in children. Though yet to climb the epidemic ladder, data reveals that there has been a three to four fold increase in the overall incidence of type 2 diabetes among children and adolescents in the last three decades. With India contributing significantly to the global health burden of diabetes among adults, it is not far behind with respect to pediatric population.
The metabolic derangement seen in type 2 diabetes comprises of peripheral insulin resistance and hyperglycemia. Insulin is the key hormone produced by the beta cells of pancreas that helps to balance the blood sugar levels by aiding the entry of glucose into the muscle, fat and liver cells for storage and energy expenditure. These are called peripheral tissues as they are near to the body surface. In insulin resistance these tissues are inefficient in absorbing glucose from the blood stream. So the term 'peripheral insulin resistance'. As a result the pancreas produces more insulin thus resulting in elevated insulin levels called as hyperinsulinemia. With worsening of insulin resistance and exhaustion of beta cells, hyperglycemia or elevated blood sugar results. The combination of obesity especially belly fat, raised blood sugar, blood pressure, cholesterol and triglycerides is called metabolic syndrome. In children these values are based on the percentile charts. On the other hand, in type 1 diabetes the immune system attacks the insulin producing cells resulting in insulin deficiency.
Type 2 diabetes in children is usually detected in the adolescence period. Besides factors such as overweight/obesity, genetics, maternal gestational diabetes, sedentary lifestyle and unhealthy eating, exacerbation of insulin resistance coinciding with hormonal changes contribute to the risk. The discrepancy in clinical presentation ranges from an asymptomatic state to symptoms such as increased thirst, urination and hunger, fungal infections of the skin and genital area as well as dark velvety skin patches involving the creases and folds. This is called acanthosis nigricans and is indicative of insulin resistance. A small proportion of children present with diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HSS) which manifests as highly elevated blood sugar, dehydration, labored breathing and altered sensorium.
Notable differences
Even though type 2 diabetes shows similarity with respect to the metabolic disruption, symptoms and complications irrespective of the age, children show some variation. In contrast to adults, the disease severity, premature complications pertaining to the heart, eyes, kidneys and blood vessels and rates of treatment failure is more in children. They have a higher possibility for DKA although HSS is infrequent. Children are more likely to face the psychological impact manifesting as depression, anxiety, low self esteem and behavioral issues. The diagnosis of diabetes poses difficulties as there is an overlap between type 1 and type 2 diabetes. Specific tests that measure fasting insulin and auto antibodies aid the diagnosis.
Multi strategic approach
Ideally the ' plan of action' to walk into a healthy adulthood should begin in the early childhood itself. The 'school of thought' should begin at the home level wherein the child should be encouraged healthy habits. Like the saying 'old habits die hard', it gets more challenging as the child reaches adolescent stage. The American Diabetes Association proposes screening of children who are overweight/obese as defined by age specific 85th and 95th percentile criterion with the presence of at least two risk factors.
Once the diagnosis is made, patient centered approach with a strong team work involving healthcare professionals, family and the child is important. The continuing education should focus on target HbA1c (less than 6.5%), home glucose monitoring, averting complications, healthy diet, physical activity (one hour every day), and screen time (less than 2 hours). The importance of regular medication which is usually metformin /insulin should be stressed upon, at the same time addressing issues such as hypoglycemia. Periodic dental and eye checkups along with yearly watch on blood pressure, cholesterol and kidney functions need to be emphasized. Psychological and emotional support to combat social issues such as smoking and substance abuse should not be ignored. The point is to achieve a normal and happy childhood.
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