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Can you recommend treatment strategies for obesity and overweight in young glucose-tolerant patients who are at high risk for type 2 diabetes mellitus, ie, who have first-degree relatives with the disease?
Treatment strategies for excessive weight gain and obesity in young children must involve the entire family and focus on gradual and permanent changes in lifestyle choices, especially those affecting eating and physical activity behaviors. It is important for children to understand that obesity is not simply a matter of overeating, but rather a result of dietary and physical activity choices that ultimately result in excessive caloric intake relative to their body's caloric needs.
In general, children with excessive weight gain and obesity can be thought of as having a more "efficient" energy system (ie, one that does not require much energy to survive day to day). When the body is more efficient, any increase in energy intake (eating) or decrease in energy utilization (exercise) will ultimately result in weight gain. To lose weight, therefore, caloric intake must decrease and energy expenditure must increase. From a practical standpoint, this means that children need to be encouraged to make good food choices aimed at decreasing caloric intake while avoiding sedentary behaviors and increasing physical activity.
Other key elements of weight control include goal setting, rewards for positive behaviors, and enhancement of parenting skills. In our clinic, we encourage parents to remove televisions from their children's rooms, have children "buy" their television time with exercise time, and provide small but meaningful rewards for their children's positive choices. It is important for parents to target positive behaviors rather than actual weight loss when providing nonfood rewards. Counseling may sometimes be necessary when children have problems with self-esteem or depression associated with weight gain and obesity. In general, an important concept to keep in mind is that children need to be taught about their power of choice in order to avoid the feelings of guilt and "self-hate" that often precipitate or perpetuate poor eating behaviors.
It is likely that interventions aimed at improving childhood obesity will be effective in preventing the development of type 2 diabetes in children. Nevertheless, our understanding of type 2 diabetes in children remains incomplete. It is likely that genetic and/or environmental factors affecting energy utilization, insulin release, and/or insulin receptor signaling may play a role in the pathophysiology of the condition, but the precise mechanisms remain to be worked out. Recent information suggests that enhancement of insulin action may prove effective in preventing the development of type 2 diabetes. Unfortunately, it remains to be established whether this will prove effective or even tenable in children at risk for the condition.
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