Pediatric Research 2014: The Year's Most Interesting Studies

Alan Greene, MD; Laurie Scudder, DNP, PNP


September 08, 2014

In This Article

Diabetes, Obesity, and Kids

Medscape: Whereas virtually every pediatric clinician is aware of the rising incidence of type 2 diabetes in teens and even preteens, there is a less noted but equally concerning rise in type 1 diabetes. A recent study[7] documented a 21% increase from 2001 to 2009 in all sex, age, and race/ethnic subgroups except the youngest children (0-4 years) and American Indians. Two major trials -- the SEARCH for Diabetes in Youth trial and the Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY) study group -- have provided new insights into the presentation and early management of these kids. What do you think are the most important take-home messages from these studies?

Dr. Greene: There are a couple of key take-home messages from recent research. The first is that we are now getting hard data on the why of type 2 diabetes in kids. Most of us have known that this increase -- a 35% increase over just the past 8 years of available data[7] -- is happening. Each new case is a lifetime burden to the medical system and the family. But type 1 diabetes is also increasing over a similar period. Both are very important for us to recognize and deal with.

A recent study[8] found that for approximately one third of kids, the diagnosis of type 1 diabetes is made when the child presents in diabetic ketoacidosis. This is a dangerous way to discover diabetes.

Part of the problem is that type 1 diabetes is increasing across different cultural and genetic groups. It is increasing in Hispanic and African American children, and in low-income children without private health insurance. Children who present in diabetic ketoacidosis are more likely to be members of these groups, and they go underrecognized.

We need to pay attention to the classic symptoms of type 1 diabetes: polydipsia, polyphagia, polyuria, and weight loss. We need to screen early and often if there is any concern, especially in kids younger than 4 years.

The other thing that was really striking to me in these studies is that with both type 2 and type 1 diabetes, the complications can happen early. We've seen a real increase early on in hypertension, which is rising quickly in kids with type 2 diabetes. Retinopathy is showing up in both groups of kids. Kidney damage -- microalbuminuria -- is showing up and is linked to glycemic control. So not only is early diagnosis important, but early treatment can make a big difference.

Medscape: The increase in type 2 diabetes goes hand in hand with the increase in obesity. A recent study[9] called into the question the usefulness of body mass index (BMI) as a measure of adiposity. If not BMI, then what?

Dr. Greene: What this study found was that approximately 25% of obese kids are missed by calculating their BMI. They have a BMI within the normal range, but are actually obese as measured by body fat. So they have excess adipose tissue and altered metabolisms.

The researchers examined a variety of different ways to assess body fat, ranging from something as simple as a triceps skin caliper to sophisticated equipment. The take-home lesson from their study is that we're probably underestimating the obesity epidemic. As bad as the current obesity numbers are, probably 25% of obese kids aren't even identified in those numbers. Yes, we need to be doing the BMI in all kids because it does give valuable information, but it's insufficient for some kids. If we think that a child may have excess body fat, we have to measure and track that as well.

Medscape: Virtually all experts agree that preventing obesity is a much better strategy than trying to treat it. Increasing fruit and vegetable consumption can go a long way toward achieving the goal of prevention, with the added benefit of significant reductions in cancer, cardiovascular disease, and all-cause mortality.[10] Yet every pediatrician has heard parents lament their problems in getting their children to consume these important foods. A recent study examined individual factors that seem to affect a child's willingness to consume a new food.[11] What are the implications of this study for parent education?

Dr. Greene: I think there are 2 key things. First, the analysis of health survey data[9] collected in England showed yet again a link between increased fruit and, even more, vegetable consumption -- with lower mortality rates, better cardiovascular health, and lower incidence of cancer. There was a linear relationship with every additional daily serving of fruit and, more so, veggies. Maximal benefit was seen with 7 or more servings a day, not just 5 a day.

It is great news that we can make a difference in health with the way kids eat, but it's also a concern because in today's environment, it can be really tough to get kids to eat real vegetables and fruit. Parenthetically, this health benefit was not found with the consumption of with canned fruit or fruit juice. That actually went in the opposite direction.

The second important lesson comes from a recent study that looked at how babies and even older kids come to be willing to consume a vegetable or a fruit.[10] The bottom line was: Feed kids fruits and vegetables early and often. The earlier you start, and the more times kids are exposed, the more likely they are to eat these healthy foods. This replicates results from other earlier studies.

The interesting lesson from this particular study was the classification of kids in the study into different groups of eaters. Most kids, about 40%, were classified as "learners" by the researchers. In this largest group of kids, more exposures to these foods -- not high pressure, just encouraging kids to relax, just taste a bite -- meant that the kids were more likely to learn to like it.

The second largest group of kids, about 21%, were deemed "plate cleaners." These kids were even more likely to like what was offered to them. They are more adventurous eaters, and they just go for it. That group is pretty easy.

About 16% of children in this study were classified as "noneaters." These are the ones who, even after trying something as much as 5 times, are unlikely to like it. The take-home lesson with those kids is to not push it, but it's not unusual for it to take 10-15 tries or more early in childhood before they learn to like something later in childhood.

Food preferences are learned. They're not something that's born innately, and that was true for the noneaters more so than for the others.

The rest of the group had a highly variable eating pattern that changed from food to food. They were plate cleaners for some things, but it was really hard for them to like other foods. Their preferences may have a lot to do with what their mother was eating during pregnancy and nursing. For those kids, it will probably be very important to focus on teaching nutritional intelligence --the ability to recognize and enjoy healthy amounts of good food. That's something that we can cultivate in children.

Practically, it's much harder to introduce new foods once kids enter what I call the "food neophobia" stage, which starts in early toddlerhood and peaks around 3 years old and persists through the rest of childhood; it's much harder to learn new flavors after that. The easiest time is early, but there are a number of strategies that will work later on. One of them is repetition.

Another is to involve kids in food preparation. Cooking classes are great. Growing anything is great. If they are involved, even just in helping to chop something up, they're more likely to eat it. If they're involved in going to the farmer's market and picking it out, they're more likely still. If they plant something and see it grow and pick it, then they're actually quite likely to enjoy it. Their brain recognizes it as safer, the more involved they are. So food prep is great.

A really big factor can be a "trusted hero," whether that be a slightly older kid or an adult whom the child admires. Kids tend to eat what the trusted hero does. Finally, parents can be encouraged to use a flavor profile that the child already likes, such as a sauce, dip, or puree that is used now with a different vegetable or fruit, as a way to bring that along.


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