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Editorial Indian Pediatrics 2001; 38: 701-704 |
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Type 2 Diabetes in Children: A Problem Lurking for India? |
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What about type 2 diabetes in children in India, a country with a billion people in a state of dynamic economic and health transforma-tion? India is poised to be among the world’s top four economies by 2020(4), and is undergoing a rapid epidemiological transition: the burden of chronic diseases is overtaking the burden of infectious diseases(5,6). India already has the highest number of adult diabetes cases (20 million) worldwide and this number is expected to rise to 57 million by 2020(7,8). Although, there are few data on T2DM in children and adolescents in India, there are five reasons to believe that this type of diabetes is a phenomenon waiting to declare itself in large measure. First, rapid urbanization and economic growth creates social dynamics that promote diabetes risk factors. These include over-weight, decrease in physical activity, increase in sedentary activities such as television viewing, and high fat and high-energy diet among adults and children. Other factors may also make India’s children and young adults more vulnerable to diabetes. These include prenatal factors (e.g., low birth weight, maternal under-nutrition), biological propen-sity to central obesity and insulin resistance, low lean mass, diabetes during pregnancy, impaired glucose tolerance, and urban stress (5,9-13). Overweight (body mass index greater than 25 kg/m2) among middle-class adults in India is already a major problem and has a socioeconomic gradient (prevalence among high-, middle-, low-income middle-class groups, respectively: men: 32%, 16%, 7%; women: 50%, 30%, 28%)(14). The prevalence of abdominal obesity (waist to hip ratio ³1.0 for men, ³0.85 for women) is 29% overall among middle-class men and 46% among women(14). Second, T2DM in children is being increasingly reported from other Asian countries (e.g., Japan, Singapore, and Hong Kong) which are ahead of India in terms of economic developments(1,15). In Japan the incidence of T2DM in children increased over a 20-year period (6-12 years: 0.2/100,000/year in 1976 and 2.0/100,000/year in 1995; 12-15 years: 7.3/100,000/year in 1976 and 13.9/100,000/year in 1995)(15). This increase in incidence correlated with increased reported intake of animal protein and fat(15). Third, T2DM is being reported in children of Indian origin living in countries such as the United Kingdom(16) and Singapore (Personal Communication, Warren Lee). There is an urban-rural gradient in adult diabetes risk in India, and when the data are standardized for age and sex differences, the prevalence of diabetes in urban Indians is similar to that of Indians abroad(11). This finding suggests that T2DM in children of Indian origin living abroad may be an early indication of things to come in India. Fourth, there have been recent isolated unpublished reports of T2DM in children in India. For example, among 93 cases of diabetes in children and adolescents younger than 18 years seen at a specialist center, 3 were classified as T2DM (based on obesity or strong family history, absence of ketonuria, and negative islet cell antibodies) (Personal communication, Vijaylakshmi Bhatia). A population-based study of 3515 children aged 5-19 years in the mid-1990s assessed with oral glucose tolerance tests, however, did not find any cases of diabetes(17). On the other hand, in a series of 545 cases of diabetes in those under 30 years in south India in the mid-1980s, 314 were classified as T2DM and a small number of these cases were in those younger than 20 years(18). Fifth, T2DM in children is probably under-diagnosed because it can exist without symptoms (1,2,19). It may also be under-reported and part of the reason for this may be misclassification(1,2,19). The prevalence of childhood diabetes among those younger than 15 years in the early 1990s in an urban population in south India was 0.26/1000(20) and the incidence was 10.5/100,000/year(21). These studies used the Eurodiab criteria to classify diabetes (type 1 if age of diagnosis <15 years and treatment with insulin) and some of these cases may have been type 2 misclassified as type 1. Some of the cases considered as malnutrition-related, fibrocalculous pancreatic, or protein-deficient diabetes may be T2DM(18). Based on the revised criteria of Tattersall, 4.8% of 4560 consecutive patients in Madras were considered as Maturity-Onset-Diabetes-of-Young (MODY)(22). The mode of inheritance of these ‘MODY’ cases were known in only 27% of cases and a proportion of the remaining cases may be T2DM. There are two important implications of the potential emergence of T2DM in children in India. First, obesity and T2DM in children may be at the epicentre of a much larger diabetes epidemic in India than currently predicted(7). Second, we are now more compelled to act against the potential diabetes epidemic in an organized and systematic manner. What action is needed and from whom? Primary care workers need to be aware of the emergence of this disease and be appropriately vigilant for T2DM. Data from the United States indicates that the disease affects girls more than boys and is associated with obesity, physical inactivity, a family history of T2DM, exposure to diabetes in utero, and signs of insulin resistance (such as acanthosis nigricans and polycystic ovarian disease)(1,2,19). T2DM may present with weight loss, ketosis, and acidosis(1,2,19). Insulin and C-peptide levels are often raised and antibodies are absent. Primary care workers will need to think of prevention of T2DM among children by emphasizing more physical activity, less sedentary activity such as television viewing, and a healthy diet. Once diabetes is diagnosed, paying close attention to all cardiovascular risk factors as well as prevention of microvascular complications become important(19). Public health professionals and epidemio-logists should establish standardized surveil-lance systems for chronic diseases (including diabetes) and their risk factors (overweight, low physical activity, sedentary behavior such as television watching, dietary factors) starting in youth. These surveillance activities should be used to plan and motivate appro-priate public health action. Researchers in India need to join international efforts using standardized methods to: (a) classify diabetes in children; (b) assess prevalence, incidence, and risk factors for childhood diabetes and its associated complications; and (c) test preven tion and treatment strategies for childhood diabetes(1). The emergence of obesity and T2DM in children is a feature of the growing tide of chronic diseases and can be viewed as a symptom of the changing social norms and lifestyle resulting from urbanization and economic development(1,8,23). Is T2DM an inevitable consequence of industrialization, urbanization, and economic development, or is it a consequence of mal-adaptation to these factors? We suggest the latter. Diabetes is a serious and costly health problem, and there is much that can be done to reduce its impact(8). The earliest description of diabetes came from India over 2500 years ago and the roles of obesity, sedentary behavior, and dietary factors were known in those ancient times(24). What is now needed is concerted public health action against these risk factors for diabetes. Will the potential threat of diabetes to India’s children motivate and energize public health action to prevent diabetes and other chronic diseases? K.M. Venkat Narayan,
Funding: None. | ||
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