Critical Reflection

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8 volume 36 | number 1 January/February 2011

2ndOPINION PRO Writing for the PRO position: Wanda Montalvo, MSN, RN, ANP

I n my opinion, poverty is a major contributing factor to the twin tower epidemic of childhood

obesity and type 2 diabetes mellitus (T2DM). Between 1963 and 1970, the rate of obesity among children and adolescents was 4.0%. By the year 2000, the rate almost quadru- pled to 15.5% (Bloomgarden, 2004). According to the CDC, in the last two decades the United States has experienced increased rates of T2DM in children and adolescents, with obesity being identified as one of the major con- tributors. Although childhood obesity is known to be a major risk for the development of diabetes (along with other contributing factors such as eating high-calorie foods, lack of exercise, and family history), poverty plays a key, but often overlooked, role.

Studies have shown that older non-Hispanic white children in the 8 to 16 age group in families with low incomes were significantly more likely to be overweight than children in families with high in- come (Alaimo, Olson, & Frongillo, 2001). People living in the lowest socioeconomic status (SES) cate- gories with less than a high school diploma had an excess risk (2.4 times that of higher SES catego- ries) of diabetes-related mortality (Saydah & Lochener, 2010). The poorest income groups are the ones most likely to be obese and thus at risk for developing diabetes.

Food insecurity due to uncertain availability of nutritionally ade- quate foods and socioeconomic constraints impact families in the lowest SES. Clearly, there is an im- portant link between a family’s income level and a child’s health

and well-being. Current strategies to reduce childhood obesity and diabetes recommend raising clinical awareness about the disease, developing standard definitions, and assessing and improving the quality of care among children and adolescents diagnosed with T2DM. Unless we focus on poverty, however, this epidemic will not be alleviated. Awareness of the disease is not enough. Recently New York City has taken a strong policy position in increasing the population’s awareness of foods being ordered in all fast food and other restaurants by requiring that use of trans fats be reduced in restaurant food preparation and that calorie counts on menus must be posted in all food estab- lishments. Yet, New York City still shows a variance of diabetes among different socioeconomic groups, especially among ethnic minorities with less than a high school diploma.

It is time to broaden our efforts toward learning how to combat poverty if we are ever going to hope to reduce obesity and diabetes in children. In the 2000 recommendations of the American Academy of Pediatrics, it was sug- gested that social scien- tists be integrated into pediatric research be- cause of the complexity of the combined issues of race/ethnicity, gen- der, and SES on child health status. As the U.S. economic recession pushes more families into unemployment and lower SES, both school lunch programs and emergency food assistance have increased by 18%, highlighting the burden of poverty. Addressing poverty as essential in improving children’s lives and health is crucial. If inequalities in SES cause inequalities in health status, it is our job to change this. As nurses, we need to think beyond the clinical indicators and advocate for changes in socio- economic policies that will reduce income inequality and thus diabetes and obesity in children.

Wanda Montalvo is the Clinical Director of NYS Health Diabetes Campaign, NY State Health Foundation, New York, NY.

References

Alaimo, K., Olson, C. M., & Frongillo, E. A. (2001). Low family income and food insufficiency in rela- tion to overweight in US children: Is there a paradox? Archive Pediatric Adolescent Medicine, 155(10), 1161–1167.

Bloomgarden, Z. T. (April 2004). Type 2 diabetes in the young: The evolving epidemic. Diabetes Care, 27(4), 998–1010. doi 10.2337/diacare.27.4.998

Saydah, S., & Lochener, K. (2010). Socioeconomic status and risk of diabetes-related mortality in the U.S. Public Health Reports, 125(3), 377–388.

Is Poverty the Root Cause of the Epidemic of Type 2 Diabetes Mellitus in Children?

Children in families with low income are signifi cantly more likely to be overweight than children in families with high income, and people living in the lowest SES categories have an excess risk (2.4 times that of higher SES categories) of diabetes-related mortality.

January/February 2011 MCN 9

Writing for the CON position: Xxx

Second Opinion columns are coordinated by Kathleen Leask Capitulo and Heidi VonKoss Krowchuk. Dr. Capitulo can be reached via e-mail at: DrKatieRN@ hotmail.com. Dr. Krowchuk can be reached via e-mail at: [email protected]

CON Coordinated by Kathleen Leask Capitulo, DNSc, RN, FAAN Writing for the CON position: Melissa Capitulo, BSN, RN

W hy is pediatric type 2 dia- betes (T2DM) an epi- demic? In my opinion,

the root causes are not just poverty, but rather multifactorial: poor nu- tritional education, changing di- etary patterns, increased sedentary lifestyles, obesity, genetics, family histories of diabetes, poor socio- economic status (SES), high body mass index (BMI), and insulin re- sistance syndrome. This global epidemic is evidenced by the tri- pling of people with diabetes since 1985 (Bloomgarden, 2004).

A major contributing factor to this public health problem is nutri- tion: what children eat. The Ameri- can diet has changed over the past 25 years. For many families, fast foods and high-calorie drinks have replaced home cooking and milk. In the current economic recession many families find it cheaper to buy fast food or junk food, rather than prepare healthy and organic foods. Increased amounts of simple car- bohydrates have contributed to higher insulin resistance and obesi- ty, resulting in increased T2DM in children.

Exercise plays an important role in the prevention and treatment of T2DM by decreasing weight, and lowering BMI and insulin resis- tance. As schools so often cut phys- ical education and extracurricular activities to make more time prepar- ing for testing, children are less active. The increased use of video games and computers has contrib- uted to a sedentary lifestyle for chil- dren. Exercise, alone, however, has not been found to decrease T2DM, but when combined with diet and a healthy lifestyle, it is effective (Hayes & Kriska, 2008).

Obesity in children has tripled in the last 47 years leading to increased inci- dence of T2DM, hypertension, behavioral and musculoskeletal, and behavior diseases. Obesity in children leads to obesity in adulthood with the concomitant risks of cardiovascular disease, hypertension, hyperinsulinemia, hypercholester- olemia, and colon cancer. Some interventions have been successful in altering these patterns. Sepulveda, Tait, Zimmerman, and Edington (2010) have shown that web-based, voluntary intervention program giving parents incentives to promote healthy lifestyles, including food management, increased physical activ- ity, family dinners, and decreased children’s screen time (time on the computer or video games). Results of the intervention program included increases in healthy behaviors such as increased physical activity, increased consumption of fruit and vegetables, and family dinners.

Genetics also plays a role in the development of T2DM in children. The inci- dence of T2DM is significantly higher in Native American children, particularly in the Pima Indians of Arizona where the incidence is 50.9 per 1,000. Overall, Native American populations in the United States have a rate of 4.5 per 1,000. In some populations, however, diabetes has a low incidence such as in Italy, where a study of 710 obese children in Italy showed that only 0.2% developed T2DM (Bloomgarden, 2004).

T2DM is a growing epidemic and health concern, but not just because of poverty. Increased con- sumption of simple carbohydrates and fast food, decreased physical activity and a sedentary lifestyle, obesity, and genetics all play a role. Healthcare providers should focus on prevention through education of children, families, and schools about healthy lifestyle behaviors, and on early detection, particularly in high-risk populations such as children with obesity and a family history of T2DM. With- out early detection and treatment, future generations will be challenged by the health and economic costs of increasing numbers of adults with T2DM. ✜

Melissa Capitulo is a Staff Nurse, Pediatrics, Winthrop University Hospital, Mineola, NY. DOI:10.1097/NMC.0b013e3181fbaf1f

References Bloomgarden, Z. (April 2004). Type 2 diabetes in the young: The evolving epidemic. Diabetes Care,

27(4), 998–1010. doi 10.2337/diacare.27.4.998 Hayes, C., & Kriska, A. (2008). Role of physical activity in diabetes management and prevention.

Journal of the American Dietetic Association, 108(4 Suppl. 1), S19–S23. doi: 10.1016/j. jada.2008.01.016

Sepulveda, M. J., Tait, F., Zimmerman, E., & Edington, D. (2010). Impact of childhood obesity on employers. Health Affairs, 29(3), 513–521. doi: 10.1377/hlthaff.2009.0737

T2DM is a growing epidemic and health concern, but not just because of poverty. Increased consumption of simple carbohydrates and fast food, decreased physical activity and a sedentary lifestyle, obesity, and genetics all play a role.