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Several closely related adult conditions have their origins in childhood. Diabetes, high blood pressure, coronary artery disease, and obesity each place a large health burden on middle-age adults in the United States, yet they start silently decades earlier — often in the teen years or earlier. Should children be tested for adult diseases? Pediatrician and Today show contributor, Mark Widome, says, "yes." He tells viewers what can be done in the pediatrician's office to combat these adult killers.
Two reports this month highlight the serious consequences of adult diseases that often begin in childhood. A report from the Centers for Disease Control warns that obesity alone will soon overtake tobacco use as a major cause of death in the United States. Another study reported this month by researchers at the University of Toronto reveals that diabetes shortens the life span of those with the disease an average of almost 13 years. Given the major burden that these two disease, as well as high blood pressure and coronary artery disease place on our population, there are growing efforts to detect and treat these diseases in their earliest stages: often in childhood and adolescence.
The rationale behind these efforts is a realization that four adult conditions (diabetes, hypertension, coronary artery disease, and obesity) have a number of things in common:
Each has serious health consequencesObesity is rapidly outdistancing tobacco as a killer, and diabetes shortens the human life span by about two years. One in four adults has hypertension, a major contributor to heart disease, stroke, and kidney failure. And, high cholesterol is a major contributor to adult heart disease, the leading cause of death in the United States from the fifth decade on.
Each has a long lag timeThese four conditions have a very long time—usually measured in decades—from their earliest onset to the time when they have major impact on day-to-day health, or until the point where their complications lead to premature death.
Each is detectable earlyFor a disease to be preventable by screening, it needs to have a screening test that is neither too complicated nor too costly that will detect or predict the condition at a silent and remediable stage. This is true for these four conditions.
For each, there are early interventionsFor children at risk for each of these conditions, there are things that parents and physicians can do to affect the onset or the seriousness of future health problems.
Who should be screened for diabetes, high blood pressure, cholesterol, and obesity? What are the best early screening tests? And if a screening test is positive, what should parents and doctors do? Here is a look at the four "adult" conditions, their screening, their treatment, and how they are related one to another:
There are two kinds of diabetes: type 1 and type 2. Type 2 diabetes (formerly called "adult-onset diabetes) is the predominant form of the disease in adults, but now is responsible for up to 40% of the new cases of diabetes diagnosed in teens. While genetics plays a role, so does lifestyle. Increasing rates of children being overweight is largely to blame for the earlier onset of what was once thought to be an exclusively adult disease. In type 2 diabetes, the body becomes progressively resistant to insulin, and blood sugars eventually rise to dangerously high levels. Yet, the disease is insidious; it can remain silent and undetected for many years, as it does damage throughout the body.
Who should be screened?Physicians will screen young people over the age of 10 (or after the onset of puberty) with some combination of risk factors for diabetes. The most important risk factors are marked obesity and type 2 diabetes in immediate family members. The condition is particularly prevalent in African-American, Native American, and Mexican-American youth, though it occurs in every ethnic and racial group. In addition to obesity and family history, the pediatrician will look for certain physical signs of insulin resistance, and note that a pattern of rapid weight gain or developing high blood pressure can also be a signs of a body's resistance to insulin. It is important to discuss with your child's doctor any family history of diabetes, particularly if your child is overweight.
Screening TestsThe usual screening test is a fasting blood test measure blood sugar. A blood insulin level can also be measured, as an elevated level can be an early sign that diabetes is on the horizon.
TreatmentUnlike with type 1 diabetes, young people with type 2 diabetes rarely need insulin injections. The optimal treatment for this condition has yet to be worked out, but losing weight and increasing physical activity are the mainstays of getting kids blood sugar levels back into the normal range. Educating parents and kids about the disease is essential to bringing it under control. The doctor will prescribe diet and exercise, often with the advice of a dietician and a diabetes specialist. Where these approaches alone don't bring the blood sugar back to normal, the same oral diabetes medicines that are used in adults are increasingly being used in teenagers with diabetes.
Blood pressure is carefully controlled in the human body by a variety of hormones that regulate blood flow and cause constriction and relaxation of blood vessels. Under ideal circumstances, there is adequate blood pressure to assure that blood circulates to all parts of the body, but that excess pressure over time does not damage the kidneys, the heart, and other vital organs. Chronic high blood pressure can cause kidney disease, heart failure, and stroke, typically in older adults. Yet a pattern of high blood pressure often begins silently in childhood or adolescence, and is strongly related to a family history of high blood pressure and to obesity.
Who should be screened?The American Academy of Pediatrics recommends that blood pressure be measured in all children at their routine health visits from the age of three years on.
Screening TestBlood pressure measurements must be done with equipment that is appropriate for the size of the child, and abnormal measurements should be repeated on several occasions. Just like height and weight, normal blood pressure ranges vary with age. The normal range of blood pressure range increases with age, and for any given age, taller kids, are allowed to have slightly higher blood pressures and still be normal.
TreatmentIf your child is found to have high blood pressure, based on several repeated measurements (done on separate days), the pediatrician will look for underlying diseases that may be the cause. If none are found, and particularly if there is a family history of adult high blood pressure, your physician may diagnose "essential hypertension" which is the kind of high blood pressure most common in adults and believed to have a strong genetic component.
Most high blood pressure in teens is treated with improvement in fitness and weight reduction, if the child is overweight. Frequent monitoring is essential. Depending on the level of blood pressure elevation and response to exercise and weight reduction, medication may be necessary.
Large studies in recent years have pointed toward the relationship between cardiovascular risk factors in young people and eventual development of coronary artery disease. Among those risk factors are elevated cholesterol and abnormal lipid problems in the blood. A person's cholesterol level is influenced by genetics as well as by diet and physical activity.
Who should be screened?While there is difference of opinion about how and when to screen, the American Academy of Pediatrics provides some guidance. Three important categories for screening are: family history of high cholesterol, early heart disease or stroke in family members, and children who have additional risk factors for heart disease. Pediatricians will typically screen children sometime during childhood if either parent has a cholesterol level of 240 or greater. They will also screen children if there is a parent or grandparent who had a heart attack, stroke, sudden death, or other significant cardiovascular disease at age 55 or younger. Finally, physicians will often screen children or teens who have other risk factors: diabetes, overweight, and tobacco use. Parents should ask their pediatrician what their practice is for routine screening.
Screening for cholesterol is a simple blood test. Your child's physician may choose to check a cholesterol alone, or do a full "lipid panel" which looks at several components of blood fats, including the HDL and LDL, the "good" and "bad" cholesterol.
TreatmentTreatment of high cholesterol in children remains fairly conservative. Increasing physical activity and lowering total fat and saturated fat content in the diet are important recommendations. (It is important to recognize, however, that children under the age of two should not have restricted fat diets, as adequate fats are essential for normal brain development in infancy and early childhood.)
For adolescents whose cholesterol cannot be adequately controlled with diet and exercise alone, and particularly those with other risk factors for heart disease (such as diabetes) physicians will often refer patients to a "lipid clinic," where adult cholesterol-lowering medicines may be prescribed.
Obesity rates among U.S. children have doubled in the past two decades. Today, about 15% of U.S. children are considered seriously overweight. The epidemic of obesity is attributed to a combination of an increasingly sedentary life style and diets that are increasing in quantity as they decrease in quality. The long-term consequences of being overweight include a higher incidence of high blood pressure, diabetes, and heart disease. Obesity also contributes to adult health problems as diverse as arthritis, sleep apnea and some forms of cancer.
Who should be screened?In 2003, the American Academy of Pediatrics published a policy statement on prevention of overweight and obesity in children. It emphasized early recognition of the problem, and that all children should be screened at routine health visits once a year.
There are several ways to screen for obesity, including measurement of skin fold thickness and tracking height and weight on standard growth charts. However, several professional groups are now emphasizing a number called the Body Mass Index or BMI. The BMI is a single number that is the ratio of a person's weight to the square of his height. It is easy to calculate, and can be plotted on standard percentile charts. Your child's physician can monitor changes from year to year. A child with rising BMI percentiles is at risk for adult obesity — particularly if their BMI is greater than the 85th percentile for age.
Weight management is most likely to be effective if it is started early. Parents should encourage daily physical exercise and healthy eating patterns. They should offer kids healthy foods from which to choose and help them to self-regulate the amounts they eat. First steps that parents can take include limiting TV time, separate eating from television watching, avoiding sugar-laden drinks, and switching to low fat dairy products. Parents need to be good role models here, as elsewhere.
Related Risks: The Metabolic Syndrome
While diabetes, high blood pressure, high cholesterol and obesity can each occur separately, they frequently occur together in some combination. In adults, the combination of obesity, insulin resistance (the precursor to diabetes), elevated blood pressure and abnormal blood cholesterol has been termed the metabolic syndrome. The relationship between these conditions is incompletely understood, and the metabolic syndrome is not quite a disease, but it puts people at high risk for heart disease, stroke, and diabetes. This combination of conditions points to the fact that the risks of being overweight are due in large part to the resulting changes in metabolism of sugars and fats, as well as to the high blood pressure that often accompanies excess weight. The body's increasing resistance to the effects of insulinappars to be a very important part of metabolic syndrome. As many as one in five adults has this condition, including as many as forty percent of older adults in the U.S. are affected.
What is disturbing, but not surprising, is that the metabolic syndrome (also called "insulin resistance syndrome") is increasingly prevalent in younger people: in children and adolescents. Data from the very large Bogalusa Heart Study reveals that about 4% of children ages 5 to 17 years have the features of the metabolic syndrome. Furthermore, a recent analysis of the National Health and Nutrition Examination Survey showed that nearly a third of overweight teens are not just overweight, but also have the metabolic syndrome, putting them had high risk for heart disease and at very high risk for diabetes.
Although genetics plays a role in the metabolic syndrome, the increasing incidence of excess weight and diabetes, particularly in younger people, points to the role of health-related behaviors — particularly diet and exercise — in both the cause of the metabolic syndrome and in its management.
An important note to parents
The health information in this article is meant to complement, not replace the advice of your child's physician. Every child is different, and parents know their own children best. Seek medical advice when you are concerned about your child's health. Your child's physician is usually in the best position to offer advice that is right for your child.
Mark Widome is professor of pediatrics at The Penn State Children's Hospital in Hershey, Pennsylvania. He is a regular contributor to TODAY.