Symposium on Adult Diseases in Children - February 2009
Tex Med. 2009;105(2):21-22.
By Surendra K. Varma, MD, Guest Editor
Two decades back, practicing primary care providers for children did not encounter type 2 diabetes, lipid disorders, and obstructive sleep apnea with any frequency. Occasionally, hypertension and obesity were diagnosed during children's health care visits.
In the early 1990s, childhood obesity became very common to the extent of an epidemic. Health care professionals worked with legislative personnel to mandate physical activity in schools. The increased incidence of childhood obesity led to higher incidence of type 2 diabetes mellitus and the associated metabolic syndrome. Metabolic syndrome in this age group includes polycystic ovary syndrome, lipid disorders, hypertension, and acanthosis nigricans. The physicians taking care of these children were not prepared to manage these diseases effectively. Literally, these diseases occurred most commonly in adults and were infrequently seen in children. These diseases occur because of a combination of environmental factors, genetic factors, and factors such as physical inactivity and indulgence of fast foods with increased frequency.
In this symposium, Soumya Adhikari, MD, provides insight for our understanding of childhood obesity . He discusses national as well as Texas initiatives. Of great concern is the fact that 32 percent of Texas high school students were either overweight or obese in 2007. This figure is much higher than those reported nationwide in the National Health and Nutrition Examination Survey (NHANES). Dr. Adhikari further provides alarming evidence that an overweight 12-year-old has a 75-percent chance of being overweight as an adult. From a financial point-of-view, the increasing prevalence of childhood obesity threatens to increase the burden on public health care systems.
Carmen Mikhail, PhD, and her group reveal psychological predictors of success in a pediatric cognitive-behavioral weight-control program . They provide a good analysis, which helps in managing childhood obesity more comprehensively. Managing obesity in these children is a struggle; diet and physical activity are major factors in obesity management in children. Family awareness and cooperation are critical to its success. Dr. Mikhail's group addresses the outcome, as well as predictors of weight loss in a pediatric cognitive-behavioral weight-control program. They conclude that any success in a pediatric weight-control program should emphasize cognitive-behavioral techniques. This relates to several factors, such as self-esteem, family structure, and number of sessions completed in counseling.
Steven Ponder, MD, reviews type 2 diabetes mellitus in children in great depth. He appropriately states that due to high penetration within the family, type 2 diabetes is a family disease of the 21st century. He addresses the criteria for making the diagnosis of type 2 diabetes in children. He cautions that an overweight or obese child discovered to have diabetes should not be assumed to have type 2 diabetes simply on the basis of size, ethnicity, presence of acanthosis nigricans, or even family history. He recommends close follow-up of children who have developed type 2 diabetes. With limited oral antidiabetic medications approved by the U.S. Food and Drug Administration for use in the pediatric age group, managing type 2 diabetes can be difficult. Along with diet modifications and increased physical activity, metformin is the only drug that can be used in the pediatric age group. The failure of these treatments ultimately leads to insulin therapy.
Until recently, we were at a loss with how to manage lipid disorders in childhood , except to manage with diet and exercise. Recently, the use of statins has been recommended in children, which may give us some hope in managing lipid disorders with more efficacy. Vandana S. Raman, MD, and Rubina A Heptulla, MD, address lipid disorders very effectively. They address the much-needed help regarding management of lipid disorders in children with familial hyperlipidemias and disorders with elevated cholesterol and triglycerides. The authors discuss evaluations and management of these patients. They caution that untreated dyslipidemias are associated with premature cardiovascular disease and may lead to atherosclerosis process much earlier.
Tammy Camp, MD, and Deogracias Pena, MD, discuss hypertension in children , which in the past has not been well addressed. We now have the norms for blood pressure values in different childhood age groups. Drs. Camp and Pena strongly counsel for measuring blood pressures in children during office visits and during the hospitalization of every child and adolescent.
Obstructive sleep apnea was not a well-known entity in children until recently. Now it has been well identified. Daina Dreimane, MD, addresses this very important condition in great detail. Dr. Dreimane states that the effect of obstructive sleep apnea is pervasive, including decreased cognitive function, cardiovascular complications such as cor pulmonale, and occasionally overt congestive heart failure. She cautions that infants younger than 1 year with obstructive sleep apnea may be at increased risk of sudden infant death syndrome. In addition, up to 20 to 30 percent of children with this disorder suffer from hyperactivity and attention deficit disorders and have problems with working memory, self-regulation, motivation, and effect.
Overall, these symposium articles provide current understanding in the field of adult diseases that have been encountered in the pediatric age group. We are optimistic that these discussions will provide much-needed help to primary care providers for children.
I sincerely hope that these articles help my fellow physicians in effectively diagnosing and managing these disorders in children and adolescents. I further hope that our awareness of these diseases in children continues to be more global and we become more effective in managing them.
Dr. Varma is the associate dean for graduate medical education, Ted Hartman endowed chair in medical education, university distinguished professor and vice-chair, residency program director in the Department of Pediatrics, and professor of physiology and health services management at the Texas Tech University Health Sciences Center School of Medicine in Lubbock. He also is a member of the Texas Medicine Editorial Board.
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