Margaret Perry, BSc (Hons), RN, Nurse Practitioner Dip (HE).
Trainee Advanced Nurse Practitioner, Whiteheath Clinic, Oldbury, West MidlandsObesity is a problem that appears to be increasing in prevalence not only in the UK but in several other nations around the world. The National Audit Office has recently issued its report Tackling Obesity in England (NAO, 2001).
The clinical picture for these children differs sharply from that seen in Type 1 diabetes, where presentation is often acute and requires immediate medical intervention to correct dehydration and keto-acidosis.
Maturity-onset diabetes of the young (MODY) is a rare condition, with symptoms having some similarity to those seen in children with Type 2 diabetes, but its development is genetically determined. Five genes have been identified to date that are believed to account for approximately 80% of all cases of MODY in the UK (Hattersley et al, 1998). The clinical features vary according to the gene affected, as does the level of treatment required and the risk of developing the complications of diabetes.
Suspicions are usually raised from glucose detected on urine testing, which lead to further investigation. Fasting blood glucose levels are raised and HbA1c, which represents longer-term diabetic control, is also above the recommended values. The key feature that distinguishes Type 2 diabetes from MODY is that of insulin resistance, which is identified from high plasma insulin levels and/or the presence of acanthosis nigricans (Shaw, 2001).
In adult life, the role of obesity in the pathogenesis of a number of potentially fatal conditions has been widely researched. It is now regarded as an established risk factor for several chronic diseases, and is hence a burden on health and economic resources, and an indicator for morbidity and mortality. The following problems highlight the need to tackle obesity in adolescence.
Initial treatment mimics that offered to adults who develop diabetes, with weight loss, dietary advice and increased activity levels forming the basis of their management. Initial evaluation should also include assessment for associated morbidity, including cardiac risk factors, joint problems and psychiatric disturbances (Williams et al, 1997), which may require separate investigation and treatment.
Referral to a dietitian is required to enable evaluation and alterations to dietary intake that can be made for the whole family. This will reinforce the importance of healthy eating and remove the focus from the child. Food diaries are useful, and can provide information for professionals who can use the content to help the family adapt to a more nutritionally balanced diet.
Increasing the level of physical activity is an integral part of any weight-loss programme and does not need to involve participation in rigorous sports to be effective. A brisk daily walk lasting 20 minutes or longer is generally advocated, but it is sensible to start gradually and increase slowly.
Tackling obesity is a major challenge and there are many problems associated with encouraging children to adopt the behaviour modification recommended to them. Many of these children find it difficult to achieve and maintain the significant degree of weight loss required (Ng and Burren, 2000) and intervention will need to involve parents and other siblings, particularly in those families where other members are also obese. Compliance with lifestyle advice is also seen to be difficult, particularly because the majority of these children do not feel unwell and therefore do not perceive themselves as ill (Ehtisham et al, 2000).
The health implications from earlier onset of diabetes are enormous, with very real concerns for the risk of earlier development of complications and rising levels of morbidity and mortality as these children progress into adulthood.
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