Running Header: Type 2 Diabetes in Children: How to stop the epidemic 1

Type 2 Diabetes in Children: How to stop the epidemic

Kathleen Charteris
Oakland University






















TYPE 2 DIABETES IN CHILDREN: HOW TO STOP THE EPIDEMIC2

Type 2 Diabetes Mellitus, a disease of middle aged to older adults 20 years ago, once
known as adult onset diabetes is now occurring at alarming rates in children in our country and
globally. According to Catherine St. Louis (2014), physicians have warned of an epidemic rising
of diabetes in children for years. A new study consisting of more than three million children
under age 20 confirms an increase of 30% of type 2 diabetes cases during 2001 to 2009 (Saint
Louis, 2014). The research does not include data from the last 5 years. David Ludwig, director
of the New Balance Foundation Obesity Prevention Center at Boston Children's Hospital,
believes that the issue has most likely become worse (Szabo, 2014).
The National Institute of Diabetes and Digestive and Kidney Diseases, part of the
National Institutes of Health, states, diabetes affects 25.8 million people of all ages in the United
States or 8.3% of the population (Szabo, 2014). With these numbers, using the terms epidemic
and skyrocketing are sadly appropriate when talking about cases of diabetes. A sign of our
sedentary, calorie-rich times is the rise in obesity and the startling rise in type 2 diabetes in our
nations children (Hensley, 2012). Is this disease as simple as a sign of the times? As a nation
can we say to these children, eat better, move more, lose weight and you will be fine? Can we
blame this disease on the children and their families? David B. Allen, a pediatrician at the
University of Wisconsin medical school writes,
On lifestyle, it's too easy to blame kids for a lack of willpower and an inability to stick
with better eating habits and a more active lifestyle. Today's children are growing up in an
obesogenic world and that undermines them. "Fifty years ago, children did not avoid obesity by
making healthy choices; they simply lived in an environment that provided fewer calories and
included more physical activity for all," (Hensley, 2012).
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One thing is definite; type 2 diabetes does affect all of us in one way or another. In order to
minimize the occurrence of type 2 diabetes in children we must focus on the social and
biological implications of the disease rather than simply treating the symptoms of the disease. To
study this problem fully we need to look at the bigger picture. What is happening in our
neighborhoods, cities and states that may be the start of the biggest and most costly health
problem of our generation?
In order to address a question of this complexity thoroughly an interdisciplinary approach
is necessary. According to Repko (2012) interdisciplinary research is a process of drawing on
more than one discipline and integrating their insights and theories into research (p. 93).
Traditional disciplines include the natural sciences, social sciences, and the humanities. Under
these broad categories, we find biology, chemistry, earth science, mathematics, physics,
anthropology, economics, political science, psychology, sociology, art and art history, history,
literature, music and music education, philosophy, and religious studies. Each of these is a single
discipline containing a distinct perception. Repko (2012) defines a disciplinary perspective as the
way in which reality is viewed by the discipline including elements of phenomena,
epistemology, assumptions, concepts, theory and methods. When doing interdisciplinary
research the challenge is determining which disciplines contribute significantly to the issue one
wishes to study (Repko, 2012, p. 143). Once the contributing disciplines are established, the
process of integration begins.
Interdisciplinary integration, then, is the cognitive process of critically evaluating
disciplinary insights and creating common ground among them to construct a more
comprehensive understanding. The understanding is the product or result of the integrative
process (Repko, 2012, p.263).
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In order to further understand the type 2 diabetes epidemic in children and develop a plan
to end the national crisis we are facing, an interdisciplinary approach of biology and sociology is
appropriate. Repko (2012) explains the social perspective as viewing the world as a reality that
includes the nature of relationships between people and any given society ( p. 103). The biology
perspective studies the behavior of the living world and when looking at humans it considers
behavior through genes and evolution rather than the mental factors considered by the social
sciences (p. 102). These two disciplines, together will integrate to create the interdisciplinary
answers we seek when we tackle the complex issue of how to minimize the occurrence of the
epidemic number of cases of type 2 diabetes in children.
Sociology
Sociology is a discipline with perspective, which looks at the world as a reality that
includes the nature of the relationships between people and any given society. Sociologists have
particular interest in the voices of various subcultures, the analysis of institutions, and how
bureaucracies and interests shape life (Repko, 2012, p. 103). Repko (2012) suggests a
disciplinary perspective is much more than a general view of reality, but also the individual parts
that makes up its character. These parts include phenomena, epistemology, assumptions, and
research methods.
The phenomena of sociology are the nature of societies and the human interactions within
them. Modernist social theorists share a rationalist epistemology with the other social sciences
but this is opposed by critical social theory, a theory group that includes Marxism, critical theory,
feminist theory, postmodernism, multiculturalism, and cultural studies. Epistemology is united
by the assumption that knowledge is socially constructed and knowledge exists in history, which
can change the course of history if properly applied (Repko, 2012).
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Repko (2012) states the assumptions of sociology vary widely. Empiricists believe a
social reality exists that can be apparent and measured through gathering data. Critics of the
modern views assume our perceptions of reality are filtered through assumptions, cultural
influences and value-laden vocabulary. Behavior is socially constructed, while rationality and
autonomy provide little influence at best. Societies exist, independent of the individuals in them.
Individuals are motivated by the desire of social status. Research mechanisms employed by
sociologists are divided among theorists, methodologists, and researchers. The effect of the
separation results in theorists ignoring the relationship of theory to evidence or method. A
sociologists view of the type 2 diabetes epidemic in children would therefore, lean strongly
towards social and cultural factors.
In the United States, diabetes afflicts more than 20 million and is considered the fastest
growing health problem by many health care experts. Today diabetes is one of the most
common chronic health problems in our children, affecting one in every 400 to 500 individuals
under the age of 20. Even more alarming, is the increased rates in minority children, including
African American, Latino, Asian American and Native American. Here the incidence is two to
seven times the rate of White children (Eriksen & Manke, 2011, p. 549). Eriksen and Manke
(2011) suggest much of the research on type 2 diabetes focuses on the western diet, high in fat
and sugar, obesity and family history. These studies suggest strategies for prevention and
treatment in children based on individual food and exercise change. Their study addresses the
broader social and cultural issues that shape childrens risk of type 2 diabetes (p. 550).
The study by Eriksen and Manke (2011) asked parents and children what constituted
good health and what aspects of their communities either helped or impeded good health in the
children. Type 2 diabetes is under diagnosed in the subject population so both children with the
TYPE 2 DIABETES IN CHILDREN: HOW TO STOP THE EPIDEMIC6

disease and those at risk for the disease were included. The study found that participants, both
children and adults measured health with food and activity. They were hard pressed to come up
with other factors of health even when prompted. Participants felt that children whom ate
vegetables, were thin, and exercised were healthy. Food was the central factor to both health and
illness. Subjects were fixated on food, believing it rendered the body vulnerable to illness, and
becoming diabetic is the punishment for being bad, placing the responsibility directly on the
child. Placing blame on a child or the family does not solve the problem and may lead to
feelings of hopelessness and an inability to change behaviors.
Most individuals will not argue the direct link between type 2 diabetes, and the obesity
epidemic along with more sedentary lifestyles. However, this issue is not just one of individual
choice, but of changes in food and the physical landscape of society (Erickson & Manke, 2011).
Calorie dense, nutrient poor foods are less costly and more readily available then they were 30
years ago. Fast food and poor quality food is much easier to obtain and afford than high quality
foods, especially in areas with low standards of living. Erickson and Manke (2011) found
socioeconomic areas that have poor food choices often are unsafe for children to play.
Children that live in urban areas frequently live in apartments and areas with few parks
and green space. The schools in these areas do not always offer physical education classes.
Parents may not want their children outside if they are working and unfortunately, community
recreation centers are not abundant (Erickson & Manke, 2011). While pointing out the struggles
of high risk children this study also points to the factors, we need to improve as a culture.
Erickson and Manke (2011) state the current media stance on type 2 diabetes is the
individual factors, in this way the focus ignores the cultural issues and is placed on the child. Part
of the epidemic is embedded in the broader phenomenon of food access; therefore, a broader
TYPE 2 DIABETES IN CHILDREN: HOW TO STOP THE EPIDEMIC7

approach is required to stop the epidemic. Social workers are one of the groups that understand
the epidemic proportions of type 2 diabetes and are addressing the issue broadly.
Once a child is diagnosed with the disease, it becomes a lifelong factor of daily living.
Preventing or delaying onset is well worth the effort or resources. When a child is diagnosed,
the entire family should be thought of as the patient. Social workers use an approach that
addresses healthy changes that benefit the entire family, regardless of weight or current health
(Ciporen, 2012). A social worker has the unique ability to address both the psychosocial and
pragmatic issues of care compliance states Ciporen (2012). Practitioners realize that the
socioeconomic status, ethnicity, family dynamics, and neighborhood status are all factors in the
treatment of a child with type 2 diabetes. Gaining compliance from the individual with only
lifestyle modification is difficult at best. It is clear that more than diet and exercise modification
should be addressed.
Wiseman and Capehart (2010) propose that the obesity epidemic and resulting type 2
diabetes and other health complications result from a society in which high stress and insecurity
are a constant. Poor diet and lack of exercise alone are not to blame. Humans, like other
mammals, possess the fight or flight response to stressors. This flight or fight response leads to
increased cortisol levels in the blood. These increased levels of cortisol may cause obesity when
they are prolonged or chronic (p. 941). Studies have shown that under stress, individuals show a
preference for calorie dense food.
Multiple studies have shown an increase in stress and insecurity during the last 40 years
in the United States. This insecurity comes from an increase in concern about job security,
employee responsibility for their own retirement, changes in health care benefits, and income
insecurity of both educated and uneducated workers. A consequence of the unstable work
TYPE 2 DIABETES IN CHILDREN: HOW TO STOP THE EPIDEMIC8

environment is over half of American children will experience one year of poverty before they
turn 18 (Wiseman & Capehart, 2010 p. 947). While the stress of job insecurity is not a primary
threat to our children, the insecurity parents worry about does add to the household environment
and the obesity and type 2 diabetic epidemic in our children.
The social perspective on type 2 diabetes is broad, bringing in several sociological and
environmental possibilities to explain it. The biological perspective addresses the issue
somewhat differently.
Biology
Biology is a discipline that falls under the social sciences. It studies the behavior of the
living physical world, looking for physical deterministic explanations of behavior rather than
mental ones on which social sciences derive their bases. Repko (2012) explains the phenomena
of biology as the interrelationships, and evolution of living organisms, health, nutrition, disease,
and fertility (p. 106). When speaking of epistemology, biology values classification and
experimental control. Experimental methods are privileged over all other methods of gathering
information (p. 114). Biologists, according to Repko (2012), use deductive reasoning to derive
explanations or predictions from laws or theories. When proof is logically impossible, theories
are disproved. Research methods occur in lab or field, both taking into consideration the
scientific method and ethical limits (p. 131).
A biological perspective ties the global epidemic of type 2 diabetes in both adults and
youth to the increase of overweight and obesity as well as a genetic factor. Chen, Magliano and
Zimmet (2012) believe the disparity in risk over different ethnicities with other factors controlled
points to a genetic component, or predisposition to the disease (p. 232). They further state that
TYPE 2 DIABETES IN CHILDREN: HOW TO STOP THE EPIDEMIC9

the complex combination of genetic predisposition interacting with complex societal issues that
determine behavior and environmental risk work together to create this problem (p. 235).
The American Diabetes Association states that nearly 85% of children diagnosed with
type 2 diabetes are overweight or obese (Must, Holl er, & Economos, 2006). There is evidence
from a longitudinal study that children born large for gestational age or born to a mother with
obesity or gestational diabetes are more likely to develop type 2 diabetes, suggesting that the
uterine environment may play a role.
Childhood obesity is the product of both nonmodifiable factors (genetics, gender,
family history and socioeconomic status) and modifiable factors (diet, activity and maternal
behavior) (Must, et all, 2006, p.233). The current changes in BMI charts for children suggest
that the rapid change is environmental rather than genetic. Interventions that address a childs
home, school and community encouraging healthier eating, and decreased sedentary behaviors
offer the greatest potential. The design of built environment, for example, communities with
safe walking environments, fresh produce, and opportunity for other forms of physical activity
encourage healthier behaviors.
It is imperative we find every opportunity to change these modifiable risk factors. The
Center for Disease Control and Prevention state that 1 in 3 children born in the United States in
the year 2000 will develop type 2 diabetes and the number for African American and Hispanic
children are even higher at 50% (Urutia-Rojas & Menchaca, 2006). The goal is to find
interventions that prevent type 2 diabetes especially targeting at risk populations. Prevention of
overweight and obesity at all levels seems to be the most promising as close to one-half of type 2
diabetes cases may be prevented by decreasing sedentary practices.

TYPE 2 DIABETES IN CHILDREN: HOW TO STOP THE EPIDEMIC10

Integration
The disciplines of sociology and biology look at the human condition. Biologists tend to
focus on the physical deterministic explanations of behavior and sociologists look at the
relationships between individuals and society. In other words, biologist look at genes and
evolution and sociologists look at the range and nature of the relationships that exist between
individuals (Repko, 2012).
When speaking of the issue of type 2 diabetes in children, the biologists tend to
incorporate more of the genetic component of the disease. They point out factors such as
conditions in utero, family history and genetic predisposition. On the other hand, sociologists
tend to be more focused on environmental factors and issues of the human condition such as
neighborhoods, socioeconomic factors, stress and feelings of insecurity. Biologists do agree
with sociologists in believing, it is likely that in the case of diabetes, there must be more than just
genetic factors at play.
In order to integrate biology and sociology to discover interdisciplinary common ground
we must understand how to create it. Common ground uses one or more assumptions in which
conflicts between theories can be reconciled and integrated enabling communication between
disciplines. It is the interdisciplinarians responsibility to create common ground by using
intuition and unconventional thinking (Repko, 2012).
When speaking of type 2 diabetes in children and the biological and sociological
approaches one may establish common ground by using the technique of extension. Repko
(2012) explains the focus of extension as conceptual, addressing the difference in disciplinary
concepts by extending their meaning beyond the domain of the discipline (p.340). As stated
earlier both sociology and biology look at the human condition, one focusing on the physical the
TYPE 2 DIABETES IN CHILDREN: HOW TO STOP THE EPIDEMIC11

other on relationships. In order to establish common ground between the two we could extend
the focus of each to include all factors that affect the human condition as it relates to type 2
diabetes; including genetics, relationships, society, evolution and nature. Focusing on the
problem in an interdisciplinary fashion is simplified when common ground is established.
Solution
Multiple factors that affect the human condition play an extensive role in the rise of type
2 diabetes in children. The focus must take all of the human condition into consideration. We
cannot look at one without addressing all. Much of media has placed the blame of this epidemic
on the individual. If one eats less and moves more type 2 diabetes would not be an epidemic.
While there is some truth to this, there is much more taking place. If it were this simple, all type
2 diabetic children would be overweight and all overweight children would be type 2 diabetics.
We also know that type 2 diabetes affects different ethnicities and socioeconomic groups at
differing levels. These factors tell us the disease has a genetic component as well as the social
component. The solution to ending the epidemic lies in considering all these factors.
Focus of an interdisciplinary approach must center on risk, prevention and care of
children already affected by the disease. Education is the key. The first group that needs to be
educated is the media and society as a whole. In the United States, many of the government
subsidies go towards foods that are calorie dense but nutrient lacking. Programs are starting to
encourage the consumption of fresh fruits and vegetables by offering things like double food
stamp benefits when purchased but this is not enough. As a country, we need to encourage the
production of whole foods at a cost that is more reasonable than processed foods. Schools need
to get the junk foods out of the cafeterias and vending machines so making the right choice is the
only choice. Our cities need more areas to allow children to play and schools need to realize the
TYPE 2 DIABETES IN CHILDREN: HOW TO STOP THE EPIDEMIC12

importance of recess and physical education that appeals to all children, regardless of athletic
ability. When society is less obesogenic healthier children will follow.
The biggest organization to address type 2 diabetes in children in the United States is the
American Diabetes Association. The ADA supports individuals and families in multiple
capacities. Information about treatment, awareness programs, camps, prediabetes, medications,
diet regimens, and activity are available through the organization. The ADA also advocates at
the local, state and federal level. Unfortunately, in most cases, individuals are not aware of the
ADA until they already have diabetes.
In order to stop the epidemic individuals need to know if they are at risk and need to
understand how to take steps at prevention. Medical professionals are in the best position to help
at this level. The various genetic components and socioeconomic components may be addressed
as early as birth. Physicians can educate new mothers on proper nutrition of newborns, toddlers,
preschoolers and beyond. Starting early is the best way to prevent the disease.
One-step at a time we must change our attitudes and our neighborhoods. We need to go
back to a society that encourages activity by design, has access to healthy affordable foods and
that discourages junk foods by increasing their costs while subsidizing nutritious foods. Our
goal is to create a society that is no longer obesogenic, seeking out at risk individuals and
populations and working together in order to educate and thereby eliminate type 2 diabetes in
children.




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