Besides Diabetes and CVD, Obese Children Will Have 50% Higher Risk of Colon Cancer

The newest reason for doing everything possible to reduce childhood obesity names certain cancers as risks associated with a high BMI....



Obesity in childhood has a direct link with bladder and urinary tract (urothelial), and colorectal cancers in adulthood, warn Israeli researchers.

Childhood obesity is associated with all sorts of immediate health problems, including high blood pressure, high cholesterol, breathing and joint problems, along with an increased risk of developing diabetes and heart disease. This study set out to examine the relationship between childhood obesity and future diagnoses of urothelial, or bladder, and colorectal cancers.

Researchers at Tel Aviv University gathered the health information of 1.1 million males collected by the Israeli Defense Forces and then linked this medical data to the National Cancer Registry. They looked specifically at the rates of urothelial and colorectal cancer over a follow-up period of 18 years in those who were obese, meaning that they had a body mass index (BMI) in the 85thpercentile and above, at age 17. Adjustments were made for year of birth, level of education, and religiosity.

Those whose BMI placed them in the range of obesity in adolescence had a 1.42% greater chance of developing urothelial or colorectal cancers in adulthood.

While these results only tell us about the incidences of two specific types of cancer, Ari Shamiss, one of the doctors involved in the study, has indicated that he is currently researching connections between childhood obesity and other cancers in the hopes of uncovering other connections. "We still need to learn whether obesity is directly causing the high risk of cancer, and, perhaps most essentially, whether losing weight is effective -- and if so, how much and when -- in lowering it.

In conclusion, childhood obesity is associated with a 50% higher risk of urothelial or colorectal cancers.

"Overweight in Adolescence is Related to Increased Risk of Future Urothelial Cancer," published in the journal Obesity.

A1c of 5.8 Percent in Children a Better Diagnostic Target to Diagnose Diabetes

Utility of A1c of 6.5% for diagnosing pre-diabetes and diabetes in obese, questioned....


Hemoglobin A1c has emerged as a recommended diagnostic tool foridentifying diabetes and subjects at risk for the disease. This recommendation is based on data in adults showing the relationship between A1c with future development of diabetes and microvascular complications. However, studies in the pediatric population are lacking.

Researchers studied a multiethnic cohort of 1,156 obese children and adolescents without a diagnosis of diabetes (male, 40%/female, 60%). All subjects underwent an oral glucose tolerance test (OGTT) and A1c measurement. These tests were repeated after a follow-up time of 2 years in 218 subjects.

At baseline, subjects were stratfied according to A1c categories: 77% with normal glucose tolerance (A1c ,5.7%), 21% at risk for diabetes (A1c 5.7–6.4%), and 1% with diabetes (A1c .6.5%). In the at-risk-for-diabetes category, 47% were classfied with pre-diabetes or diabetes, and in the diabetes category, 62% were classified with Type 2 diabetes by the OGTT. The area under the curve receiver operating characteristic for A1c was 0.81 (95% CI 0.70-0.92).

The threshold for identifying Type 2 diabetes was 5.8%, with 78% specificity and 68% sensitivity. In the subgroup with repeated measures, a multivariate analysis showed that the strongest predictors of 2-h glucose at follow-up were baseline A1c and 2-h glucose, independently of age, ethnicity, sex, fasting glucose, and follow-up time.

In a large clinic based multiethnic cohort of obese children and adolescents, regardless of age and sex, an A1c of 6.5% had relatively low sensitivity and specificity for classifying Type 2diabetes. There was poor agreement between A1c and OGTT criteria in classifying subjects with glucose values suggestive of Type 2 diabetes. The optimal threshold of A1c was 5.8% for identifying Type 2 diabetes, with a specificity of 87.64% and sensitivity of 67.7%, and 5.5% for identifying IGT. The diagnostic utility of A1c was examined according to ADA criteria with OGTT as the reference. Researchers observed that the use of an A1c of 6.5% would largely underestimate the prevalence of pre-diabetes and Type 2 diabetes. They said that theseresults suggest that, although A1c could be used as a clinical tool to identify Type 2 diabetes,along with fasting and 2-h glucose, the use of A1c by itself to pinpoint prediabetes and Type 2 diabetes is not recommended.

Researchers also said that their data are in agreement with those who reported using the National Health and Nutrition Examination Survey of 14,611 individuals aged <20 years,clearly showing that an A1c of 6.5% has a lower capacity to detect prediabetes and undiagnosed Type 2 diabetes than the OGTT.

Studies in adults have clearly shown the utility of A1c in predicting Type 2 diabetes (12–14) and cardiovascular disease even in nondiabetic adults. Nevertheless, concerns in the use of A1c for diagnosing Type 2 diabetes have been recently raised in view of the poor relationship with fasting glucose, the overall lower diagnostic performance in some groups such as pregnant women and the elderly, and the risk of over diagnosing patients with anemia and those predisposed to rapid glycosylation. In addition, as previously stated, it should be noted that, despite the numerous advantages, the use of A1c as a diagnostic tool would largely affect national surveillance of prediabetes and Type 2 diabetes.

Different cutoff points have been reported when the ROC curve was used to identify the cutoff point for diagnosing Type 2 diabetes or prediabetes. A review on A1c as a screening tool for diabetes showed that three cutoff points (5.9, 6.1, and 6.3%) of A1c were advised as cutoff points for detecting diabetes in at least two different studies, and most studies identified a cutoff point of >6.1% as optimum for the detection of Type 2 diabetes. In addition, researchersconcluded that at equivalent cutoff points, sensitivity was generally lower in detecting IGT for both A1c and fasting plasma glucose in both community- and hospital-based studies. Thus, the cutoff point identified in this study of 5.8% is somewhat lower than oftentimes reported,which might indicate that the population is of especially high risk. Although only a small percentage of subjects had a repeated A1c and OGTT after a follow-up of 2 years, we believethat the data are important, indicating that the best predictors of future diabetes or prediabetes are A1c and the 2-h glucose from the OGTT. Thus, both the cross-sectional and longitudinal data would argue in favor of the utility of performing both tests in obese youth forpredicting future development of diabetes.

A few limitations are worth noting. There is no lean control group, a clinic based cohort was studied, and the follow-up group is small. Strengths include the large group of obese youngsters without known diabetes and the existence of data derived on the same day for both the OGTT and A1c.

The American Diabetes Association suggested that an A1c of 6.5% underestimates the prevalence of prediabetes and diabetes in obese children and adolescents. Given the low sensitivity and specificity, the use of A1c by itself represents a poor diagnostic tool forprediabetes and Type 2 diabetes in obese children and adolescents.

Further investigation on the role of A1c in the diagnosis of prediabetes and diabetes in children and adolescents is needed. Prospective studies are especially important to examine the utility of A1c in pediatric populations in the prediction of diabetes-related comorbidities later in life.

Published online before print April 22, 2011, doi: 10.2337/dc10-1984 Diabetes Care April 22, 2011

Motivating a Teen With Type 1 Diabetes

Q: My 16-year-old son is having difficulty staying motivated to consistently take care of his diabetic needs like checking his blood sugar often and keeping a log book. His doctor hospitalized him at the start of school to establish better control — his first hospitalization since diagnosis with type 1 10 years ago. He is active in sports, likes to stay up late, eats only 15 to 30 carbs for breakfast, and is on a regimen of Lantus twice daily and Humalog for meals and highs (injections, no pump.) His last A1c was 10.3. Do you have suggestions for helping him be motivated to care for himself?
— Janelle

A:
That's a tough situation indeed. Many of my colleagues who care for teenaged patients have similar moments of exasperation. As you know so well, the teen years are filled with layers of complexities for kids themselves and their families. There are many issues that become priorities in any teenager's life, among them the challenges presented by their own growth and development. These issues become even more complicated for a teenager with diabetes.

Adolescence is a time of great change, and with physical growth come greater insulin requirements. And with rebellion, experimentation and the need for peer acceptance comes greater non-adherence. In addition, while trying to find and assert their own identity, teens become less reliant on mom and dad. The challenge for parents is equally great and the solutions, unfortunately, are usually time-consuming and labor-intensive.

Your son is doing certain things for which he should be congratulated, including getting involved in sports, carbohydrate counting and injecting his insulin several times a day. These are feats that many of my adult patients do not accomplish. Motivating your son further might require one or more of the following:

1.Understanding his attitude towards frequent glucose checks and his coping and problem-solving skills will help you in identifying specific ways to help him change his behavior.

2.Assessing his knowledge-base about the need to check his sugar levels and his knowledge of glucose and insulin balance during athletic engagements can identify gaps, which can be easily addressed.

3.Understanding his priorities and academic responsibilities and showing empathy to these daily challenges can help you provide a structure that is conducive to checking blood glucose levels and diabetes self-management.

4.Exploring the barriers of checking his sugar level at school, as well as the challenges he might face from his peers about having diabetes, doing frequent glucose checks and injecting insulin, might uncover issues that he finds difficult to discuss. Since you live in a small town, there might not be many other kids living with diabetes. Perhaps your son can connect with other kids with diabetes via the Internet for peer support. A good place to start is the American Diabetes Association.

5.More importantly, understanding your communication pattern with your son and assessing its effectiveness will help you find a happy medium between too much involvement and too little engagement. Empathy is important, but so is leaving him room to make his own decisions. In other words, asking him how he can meet the challenge of good glucose control might also be more effective than telling him to make a specific change in his behavior.

6.When exploring these areas, you should enlist the help of your son's doctor as well as a psychologist or diabetes educator in your area. In addition, if you find that there are barriers at school that prevent your son from checking glucose, you should involve the school and teachers. Some teens like taking leadership roles in teaching others about diabetes, advocating for students with diabetes and organizing groups. This gives them the motivation for also managing their diabetes better. Teachers can be recruited to stage such a forum for your son and perhaps other teens. Other possible venues you might explore include religious organizations, social clubs, and community fitness centers.

Finally, this might be time to consider the insulin pump, which many teens like because it allows them better control. I wish you much luck and hope you will write back with further questions or to tell us how you and your son are doing.

When to Test Children for Diabetes

Q: My husband is a type 1 diabetic, and we didn't know that until he went for a physical and the doctor said his body was in "ketosis" (shutting itself down). We didn't expect that since he looked healthy, and we didn't recognize any symptoms except frequent urination. At what age should we have our three children (ages 13, 15, and 16) checked? Are there more obvious signs in children? Do you recommend any particular diet as a starting point for better eating? Sorry for the many questions, I am just trying to keep my info straight. Thank you very much in advance for your time in answering this. Have a great day.
— Christina, Kansas
A:
These are all great questions. Discovering that you or a loved one has type 1 diabetes can be overwhelming — and troubling to parents who worry that their children are at risk of developing the disease. How wonderful that you are thinking about trying to prevent that from happening!

There isn't a definitive answer to your question regarding early screening. First of all, even though your husband has type 1 diabetes, it does not mean that your children will invariably develop the disease. In fact, very few children of diabetic parents do. The bad news is that we do not have a way to determine who will and who won't. Second, even when we know the specific inherited tendencies for diabetes, there are many factors in the environment that are yet undiscovered triggers. If we knew these factors, we might then be able to work on reducing their influence. Third, we do not know the rate at which a person who carries the genetic risk actually develops diabetes. They may develop the disease early or it may take many years for diabetes to establish a foothold. Fourth, we do not have an effective treatment or preventive measure to stave off type 1 diabetes among those who are at greatest risk of developing it.

In light of all these factors, the best way to move forward is to do the following:

Make sure your children get regular checkups and talk to your pediatrician about new developments in early diagnosis and prevention efforts. There are ongoing studies, the results of which will teach us more about how to proceed. There might also be research projects that your children might participate in that may give them access to genetic and immunology tests not available to the general public. These tests can give you a better idea of your children's specific odds of developing diabetes.Have your children undergo blood glucose tests starting now, biannually or annually, to prevent severe symptoms such as ketosis from being the stimulus for a diagnosis.
Watch out for the following signs and symptoms: excessive thirst, frequent urination, weight loss, fatigue, or blurred vision; and much less common signs of ketosis, including nausea and vomiting, abdominal pain, lethargy, and decreased alertness and rapid breathing. These are the same signs and symptoms as in adults.While there are no specific dietary supplements or diet recommendations, a healthy lifestyle and maintaining a healthy weight will help in general. Specific recommendations depend on your children's caloric needs, activity level, and preferences. I frequently tell my patients that their first loyalty is to nutrition — making sure they have adequate nutrients (i.e., vitamins, minerals, and protein intake) necessary for survival. In the children's case, it is important to take their growth and developmental needs into account. You might consult a dietitian for specific suggestions.

Finally, coping with a diabetic parent can be a frightening experience for children. I would advise that you and your husband normalize the daily routines of his care, which include home blood glucose testing, doctor's visits, diet and exercise regimens, insulin injections, and discussing the symptoms of high and low sugar levels. This way, you can avoid crises and show your children that diabetes is a condition that can be managed as long as you take care of yourself. This knowledge will help them a great deal in the event that they are someday diagnosed with diabetes, however small the odds may be. Best wishes to you and your husband and children. I hope all goes well.

Diabetes Differences, Demystified

Understanding the Types of Diabetes
Diabetes management varies, depending on what type of diabetes you have. This guide will help you understand the many different types of diabetes.
By Krisha McCoy, MS

Medically reviewed by Pat F. Bass III, MD, MPH Print Email If you have diabetes, your body has problems producing or effectively using insulin, which can cause your blood glucose levels to be out of control. There are several different causes of insulin problems, and your treatment plan will depend on which type of diabetes you have.

Type 1 Diabetes: An Autoimmune Disease

With type 1 diabetes, which used to be called juvenile diabetes, your body does not produce insulin or produces very little. Type 1 diabetes is known as an autoimmune disease because it occurs when your immune system mistakenly attacks the insulin-producing cells in your pancreas.

Type 1 diabetes usually develops in children and young adults and accounts for 5 to 10 percent of diabetes cases in the United States. Symptoms may include thirst, frequent urination, increased hunger, unexplained weight loss, blurry vision, and fatigue.

People who have type 1 diabetes need to take insulin injections daily to make up for what their pancreas can’t produce.

Type 2 Diabetes: The Lifestyle Connection

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Type 2 diabetes, which used to be called adult-onset diabetes, is the most common form of diabetes, accounting for 90 to 95 percent of diabetes cases. While most people who develop type 2 diabetes are older, the prevalence of type 2 diabetes in children is on the rise.

The exact cause of type 2 diabetes is largely unknown, but the disease tends to develop in people who are obese and physically inactive. People who have a family history of diabetes or a personal history of gestational diabetes are also at increased risk of developing type 2 diabetes.

Symptoms of type 2 diabetes usually develop gradually, and are similar to symptoms of type 1 diabetes.

Treatment for type 2 diabetes usually includes dietary changes, regular physical activity, and oral diabetes medications to help control blood glucose. If left untreated, serious health conditions such as heart disease or stroke can develop.

Gestational Diabetes: A Pregnancy Concern

Gestational diabetes is a condition that occurs in 3 to 8 percent of pregnant women during late pregnancy. Its cause is thought to be pregnancy-related hormonal fluctuations and a shortage of insulin that often occurs during pregnancy.

Many women with gestational diabetes have no symptoms, so it is important to get screened for this condition during pregnancy. Gestational diabetes can lead to problems such as high-birth-weight babies, breathing problems in the baby, and high blood pressure in the mother during pregnancy. Gestational diabetes is usually treated with dietary changes and exercise, and sometimes insulin injections.

Women who have had gestational diabetes have a 40 to 60 percent chance of developing type 2 diabetes within 5 to 10 years after their pregnancy.

Other Types of Diabetes

Latent autoimmune diabetes in adults, or LADA, is a less common form of diabetes that usually affects people over the age of 30. In LADA, what looks like type 2 diabetes at first eventually develops into a condition more closely resembling type 1 diabetes.

People with LADA make enough insulin at first, but their immune system later begins making antibodies against insulin-producing cells of the pancreas. Patients will usually require insulin injections as part of their treatment. It is estimated that up to 10 percent of people with type 2 diabetes have LADA.

"Double diabetes" occurs when someone with type 1 diabetes develops resistance to the insulin they are taking, a hallmark of type 2 diabetes. This condition is more and more frequently seen in children, especially those who are overweight or obese.

All types of diabetes require attention to keep blood glucose in check, but the medical plan differs by diabetes type. Getting the right diagnosis is the first step.

You Can Help Children Avoid Type 2 Diabetes

Type 2 diabetes is affecting kids in a big way, but diet and exercise can help children avoid or reverse this condition.
By Madeline Vann, MPH
Medically reviewed by Pat F. Bass III, MD, MPH

Once upon a time, type 2 diabetes was called “adult-onset diabetes.” If children had diabetes, 99 times out of 100 it was type 1 diabetes; type 2 diabetes didn’t appear until midlife. Now, studies suggest that up to 45 percent of childhood diabetes cases are type 2 diabetes.

Type 2 Diabetes: Why the Increase?
“No one is certain why, but most experts believe that it is related in part to the obesity epidemic,” explains Frank Diamond, MD, clinical director for the University of South Florida Diabetes Center and professor of pediatrics at the University of South Florida in Tampa. “We now have approximately 17 percent of the pediatric population that is overweight. Genetically at-risk children may be acquiring the disease earlier because of the increased insulin resistance associated with their early obesity. We are seeing many children with adult weights in our pediatric clinics today.”

Dr. Diamond also notes that the increase may be due to a rise in the proportion of children with ethnic minority heritage that puts them at increased risk for type 2 diabetes.

Basically, says Paul Robertson, MD, president of medicine and science at the American Diabetes Association, and professor of medicine and pharmacology at the University of Washington in Seattle, the causes of childhood type 2 diabetes boil down to genetic risk mixed with physical inactivity and poor eating habits.
“We know if the diets are corrected and they lose the weight, the diabetes becomes undetectable,” says Dr. Robertson.
The first step to preventing type 2 diabetes in childhood is to face the fact that it can happen to children, says Diamond. Then be on guard for symptoms and ask for diabetes screening.

“Symptoms include tiring easily, thirst, and increased urination. A darkening of the skin (acanthosis nigricans) on the back of the neck, under the arms, and in the groin area is associated with obesity and [is] a common finding with newly diagnosed type 2 diabetes children,” he says.

Also, bear in mind that if you had gestational diabetes during your pregnancy, your children are at increased risk of type 2 diabetes.

“Especially in families with a positive family history of type 2 diabetes, avoidance of excessive weight gain and encouragement of an active lifestyle are extremely important and the best tools to avoid the development of type 2 diabetes,” says Diamond. Some children may be candidates for a drug called metformin.

Type 2 Diabetes: Testing
Parents who are concerned that their child might have diabetes should ask for a fasting glucose screening test. That test determines how much sugar is in the blood before a person has eaten.

“A value over 99 mg/dL is abnormal and suggests ‘impending’ diabetes or glucose intolerance. A value equal to or greater than 126 mg/dL is diagnostic of diabetes,” says Diamond.

Any results above the normal range should be red flags for you and your family to:
• Eat a healthy diet rich in whole grains, lean proteins, fruits, and veggies. You can get help changing your family’s diet from a dietitian, if necessary.
• Get at least 30 minutes of exercise a day.
• Help your child lose at least 5 percent of his body weight if he is overweight.

Remember, childhood type 2 diabetes is within your family’s control.
“Lose weight, be active, eat the right foods,” says Robertson. “Lifestyle modifications can do a great deal in terms of staving off type 2 diabetes.”