As a pediatrician, I applaud my colleagues in the American Academy of Pediatrics (AAP) for releasing a set of clinical guidelines for the Management of Newly Diagnosed Type 2 Diabetes Mellitus in Children and Adolescents last week. It is time that we, as health care providers, acknowledge and begin to give the best evidence-based tools for the treatment of chronic disease to our primary care workforce. The problem is, as the guidelines point out, that we have very little evidence for effective strategies in treating obesity and Type II Diabetes in children. As pediatric providers, we are all familiar with Type I diabetes, but Type II was relatively rare among children until recent years—so much so that it used to be called “adult onset diabetes”. Now, sadly, we are forced to confront this issue with guidelines for its treatment. I am pleased to see that even with limited evidence, the recommendations still include physical activity, family-centered care, lifestyle modifications, and nutrition education. However, there are a few issues of concern.
In June 2012, the Bipartisan Policy Center’s (BPC) Nutrition and Physical Activity Initiative (NPAI) released a report, Lots to Lose: How Americas Health and Obesity Crisis Threatens Our Economic Future, which highlights prevention strategies to mitigate the expanding obesity and chronic disease crisis at a population level. The report focuses on a national strategy for communities, families, workplaces, and schools to improved health and reduced cost. NPAI is co-chaired by four former cabinet secretaries, two from the Department of Health and Human services (HHS) and two from U.S. Department of Agriculture (USDA), two from Republican administrations and two from Democratic ones — Dan Glickman, Ann Veneman, Donna Shalala, and Mike Leavitt.
While I realize that these AAP guidelines are intended for the medical care of individual patients, I would suggest that the committee consider expanding its guidelines to include public health intervention strategies as a part of the solution. In our schools, we can provide smaller portion sizes with healthier options and mandatory physical activity. In our communities, we can create safer places for families to exercise and promote breastfeeding inside and outside the hospitals. And, in our medical educational system, we can better balance the curriculum between treatment and prevention. These clinical guidelines focus on what the provider must do with the child who is already diagnosed, but there is little emphasis on techniques the provider could use to prevent at-risk patients from developing diabetes. For example, our report recognized the need for improved training of our medical professionals in effective patient-physician communication and recommended behavior change strategies such as motivational interviewing. Furthermore, the guidelines devote little discussion to the assessment of the social determinants of health in the context of this disease.
The authors of these guidelines have done an outstanding job outlining clinical treatment paths with limited data; however they missed an opportunity to incorporate a more comprehensive, public health perspective in this discussion. While it is critical to appropriately treat the rapidly rising tide of children with Type II diabetes, it is also crucial to intervene on a broader scale to prevent or slow the number of children who develop this disease. I support the authors in their assertion that we need to push for more research on effective strategies to treat and reverse this trend before these diabetic children become diabetic adults, but we also need to focus resources on prevention. This must be a multipronged approach and we cannot afford to wait.
Matt Levy is an advisor to BPC’s Nutrition & Physical Activity Initiative. He is the Division Chief of Community Pediatrics at Georgetown University Hospital, a practicing physician, and an associate professor of clinical pediatrics at the Georgetown University School of Medicine.