Diabetes at the age of 3! You can't imagine a child's obesity crisis

Difficulty in weight loss in children and adolescents

China News Weekly reporter / Yang Zhijie

Published in the 2023th issue of China News Weekly magazine on November 11, 6

In recent years, the youngest diabetic patient has seen is only 3 years old.

Mu Yiming is the director of the endocrinology department of the First Medical Center of the General Hospital of the Chinese People's Liberation Army. He recalls that the child's grandparents noticed that the child was always thirsty, kept drinking carbonated drinks and urinated frequently. During the physical examination, the child's blood sugar level exceeded 11 mmol/L. In general, the normal fasting blood glucose level in children does not exceed 6.1 mmol/L.

Obesity in children and adolescents is becoming a global epidemic. In April this year, Ma Jun, former director of the Institute of Child and Adolescent Health of Peking University, and others published a study showing that from 4~1985, the total detection rate of overweight and obesity among children and adolescents in China increased by 2019.18 times, and the detection rate of obesity alone increased by 1.75 times. Based on the total number of about 6 million children and adolescents in China, it is estimated that the number of overweight and obese children and adolescents in China will reach about 3 million by 2030.

Obesity is not just a growth in numbers on the scale. More studies and examples have confirmed that obese children and adolescents are suffering from chronic diseases that are thought to be common to adults. Combined with the growth and development period, the health problems of obesity in adolescents are more diverse and complex, but they have not received due attention.

"The child's health is on the 'edge of the cliff'"

Every winter and summer vacation, it is the peak period for many hospitals to receive obese children in the nutrition department and endocrinology department. Yan Jie, director of the clinical nutrition department and chief physician of the endocrinology, genetics and metabolism department at Beijing Children's Hospital, told China News Weekly that in July this year, the daily number of patients in the hospital's endocrinology, genetics and metabolism department increased by one-third, and the number of obese children also increased. At most, at six or seven o'clock in the evening, there are still parents with their children queuing up outside the outpatient clinic. Yan Jie mentioned that the endocrinology, clinical nutrition, child health care, and traditional Chinese medicine departments of Beijing Children's Hospital will all look at the problem of childhood obesity.

Since the 90s of the last century, the overweight and obesity rate of children and adolescents in China has begun to increase, and is currently in a period of rapid increase, and the prevalence of childhood obesity in some large cities has approached the level of developed countries. According to the Blue Book of Children: Report on China's Child Development (2021) released by the China Children's Center in December 12, the overweight and obesity rate of primary and secondary school students in China reached 2021.2019% in 24, an increase of 2.10% from 8 years ago. Overweight and obese rates are rising across all age groups, boys and girls, and students in both urban and rural areas. Among them, the younger the child, the more overweight and obese children are, and about one in four elementary school students is overweight or obese, and this proportion is about 7/4 of high school students. In addition, the prevalence of overweight and obesity among boys is higher than that of girls, and higher in urban areas than in rural areas.

Many studies and data show that the pandemic since 2020 is exacerbating the trend of childhood obesity. According to data from the Hong Kong Department of Health, the proportion of overweight and obese (obese and sluggish) 8-year-olds in Hong Kong increased to 2020% in 4, according to data from the Hong Kong Department of Health, according to the team of Yip Pak-keung, clinical associate professor of the Department of Paediatrics and Adolescent Medicine of the University of Hong Kong. In the 2/8 school year, the prevalence of overweight and obesity among primary school students in the first and second grades reached 5.2020%, an increase of 2021% over the previous school year, and the proportion of overweight and obese students in the first year of secondary school was 20.9%, an increase of 7% year-on-year.

In 2021, a study by the British Medical Journal showed that increased sedentary time in children and adolescents, reduced physical activity, increased household reliance on calorie-dense and processed, low-cost foods, and reliance on digital platforms during the pandemic have all exacerbated the prevalence of childhood obesity. Although there are no relevant authoritative epidemiological studies in Chinese mainland, since 2020, many doctors interviewed have also clearly felt that the number of obese children visiting outpatient clinics is increasing.

In the first half of 2022, Su Qin found that his 10-year-old son Zheng Zheng had a cold and cough with "constant minor illnesses", and there was an inflammation and suppuration on his arm. Dermatologists say that treating inflammation alone is useless, and that obesity is also a problem. She took the child to the Department of Endocrinology, Genetics and Metabolism of Beijing Children's Hospital for examination, "The doctor told me that because of obesity, the child's health has reached the 'edge of the cliff'."

Zheng Zheng, who was 1.55 meters tall, weighed 156 pounds at the time, had a waist circumference of more than 100 centimeters, and a body mass index (BMI) of 32.5. He had black marks on his neck, armpits, and the base of his thighs, and the doctors at the Children's Hospital could tell at a glance that it was acanthosis nigricans. This is an outward manifestation of insulin resistance caused by excessive fat accumulation in the body, which is common in obese people and is a precursor to diabetes. For people with diabetes or those at high risk, the ability of the wound to heal naturally and the ability to fight off infection are reduced. In addition, the examination also showed that Zheng Zheng had fatty liver, which made it difficult for Su Qin to accept, "I can understand that I have fatty liver myself, but he is a 10-year-old child."

"Childhood obesity is more complex than adults"

The clinical diagnosis of overweight and obesity in children is also based on BMI. However, unlike adults, who have a fixed standard, minors are in the period of growth and development, and different ages and genders have a separate standard line for obesity. A 10-year-old boy with a BMI of more than 21.9 is considered obese. Chen Wei, chief physician of the Department of Clinical Nutrition of Peking Union Medical College Hospital and chairman of the Clinical Nutrition Branch of the Chinese Nutrition Society, has a more intuitive judgment experience: children with a BMI of more than 28 are generally diagnosed as severe obesity. "The child is not tall, the BMI number is high, and he must be very fat", this kind of "big fat dun" has increased at a rate visible to the naked eye in recent years.

"Parents should not think that old age is very far away from children." Chen Wei found that this is a cognitive misunderstanding of most parents. Children who are overweight or obese are a major risk factor for cardiovascular disease and type 2 diabetes. In addition, these children are at increased risk of developing high blood pressure, metabolic syndromes such as non-alcoholic fatty liver disease, sleep-disordered breathing, and asthma. Chen Wei clinically noticed that the proportion of severely obese children suffering from hypertension is very large, "not one or two people, the minor patients I see may account for 10%~15%", if not intervened in time, there will also be cerebral hemorrhage, cerebral infarction and other problems.

Yan Jie also mentioned that many people don't believe that children can get type 2 diabetes. In the past ten years, the children with type 2 diabetes caused by obesity have been admitted to the ward of Beijing Children's Hospital, and "it used to feel not so much, but now it is very common".

In addition, as children and adolescents grow and develop, obesity poses more complex health problems than adults. This summer, a foreign doctor shared a case with Yan Jie: a 13-year-old boy with a height of 1.7 meters and a weight of 87 kilograms, and the parents suddenly found that the child was no longer tall. The father of the boy is 1.85 meters and the mother is 1.62 meters, and the parents are worried about the future development of the child. After Yan Jie looked at the relevant examination results, she found that the child's bone age was seriously beyond the age, and he had reached sixteen or seventeen years old, and the epiphyseal line was closed, which meant that the height stopped growing. She preliminarily judged that the child's bone age was advanced and was caused by obesity.

Yan Jie's team has also done related research projects, and went to some primary schools to measure bone age, and found that most obese children have advanced bone age. She pointed out that obese children are more likely to have abnormal secretion of sex hormones, which can lead to problems such as precocious puberty, in addition to advanced bone age. In recent years, she has noticed that there has been an increase in the number of girls with precocious puberty, the youngest being as young as 6 years old, who have early breast development, early menarche or sudden growth. According to the latest expert consensus on the diagnosis and treatment of precocious puberty released by the Pediatric Branch of the Chinese Medical Association, a number of epidemiological surveys have confirmed that obesity is positively correlated with the prevalence of precocious puberty, and the age of puberty initiation and menarche in girls are related to BMI.

In contrast, Yan Jie saw overweight or obese boys in clinical practice, most of whom were stunted in sexual development, with symptoms such as large mammary gland development and small genital development. However, many parents do not care about obesity and do not know the association between obesity and these diseases, so they often take their children to the urology department first, and are referred to Yan Jie's outpatient clinic by doctors. Even so, Yan Jie repeatedly emphasized that the core of the problem lies in obesity and weight loss, but parents are most concerned about the development of their genitals in the future.

Yan Jie told China News Weekly that a child will go through four "dangerous stages" when he is growing up, namely in the last trimester of pregnancy, within one year after birth, 4~6 years old, and puberty, which are the most active periods for fat development, and parents need to pay attention to and prevent their children's obesity.

Taking adolescence as an example, children at this stage have a rapid increase in height and weight, increased eating, and are mostly in the upper grades of primary school and junior high school, with high academic pressure, unguaranteed exercise, and a higher risk of obesity and metabolic syndrome. Mu Yiming added to China News Weekly that adolescence is the most important stage for the development of all organs and cells in the human body, and the number of fat cells will increase in obese children, "which is equivalent to laying the groundwork in the process of body stereotyping", and it is also very difficult to lose weight after obesity. Even if you lose weight later, the number of fat cells will not decrease, and it is easy to regain weight as an adult.

Families need to change

Unlike in the past, when the public was more concerned about weight and body shape, experts in the medical and public health fields called for a reconfiguration of the perception of childhood obesity from a health perspective.

In January this year, the American Academy of Pediatrics updated its guidelines for the treatment of childhood obesity for the first time in 1 years. Childhood obesity is a disease with genetic, social and environmental factors, rather than individual choice, according to the society. In 15, obesity was not yet considered a disease in the United States, and treatment focused on diet, nutrition and exercise, and the general view of society on the treatment of childhood obesity was "wait and see". The new guidelines emphasise the need for "aggressive treatment" of childhood obesity at an early stage, and the introduction of medical and surgical treatments into treatment options. Despite the controversy surrounding the release of the new guidelines, there are concerns that the use of medical and surgical treatments in minors is too aggressive, and there is no consensus on treatment options.

However, for severely obese children, most doctors recommend timely medication or hospitalization intervention if the physical indicators have shown a red light. For example, Yan Jie said that if some obese children have a blood sugar ≥ 11.1 mmol/L after an oral glucose tolerance test, they can be diagnosed with diabetes and ask the other party to be hospitalized immediately. For children with mild to moderate obesity, the key challenge in weight loss is outside the hospital, i.e. improving diet and lifestyle.

In Su Qin's past cognition, losing weight is nothing more than "keeping your mouth shut and opening your legs". But Zheng Zheng is a lover of fried food, eats burgers and pizza at least once a week, usually eats two bowls of rice at a meal, has unlimited meat, eats few green leafy vegetables, and has difficult to change his eating habits. After the pandemic, the diet has become even more unhealthy. In order to lose weight, Su Qin thinks that it is necessary to reduce the child's meals, but he is worried that the child is still developing, "If I reduce his meals, the nutrition is not enough, resulting in not growing up, the loss will be too great."

In terms of sports, before the epidemic, Zheng Zheng took physical education classes every week and occasionally went skiing. After staying at home, in addition to online classes, he mostly eats snacks, catches up on dramas, and watches variety shows. In June 2022, Su Qin suggested that Zheng Zheng exercise to check in, but every time he was called out, he would make trouble until "mother and son broke up", and he gave up after a few times.

Not being able to find a safe and effective way to lose weight is a problem for most parents. Chen Wei stressed to China News Weekly that some parents may strictly control their children's diet during the winter and summer vacations, and at the same time let them exercise at high intensity, but this is difficult to achieve the goal of weight loss. Even if you lose a few pounds, once your child returns to daily life, the weight will quickly regain weight. For children with mild to moderate obesity, Chen Wei suggested that the change for the purpose of "how many pounds to lose weight" can have a better effect. For example, not eating things that shouldn't be eaten and not drinking drinks may improve your weight.

In Yan Jie's opinion, some parents think that losing weight means skipping dinner and only eating fruits and vegetables, which is wrong. Children are in the period of growth and development, to ensure three meals a day, it is important to formulate the intake of each meal according to the calories consumed by the child, and do a good job of nutritional matching. Each child has a different degree of obesity, and the choice and combination of food is also different, but there are some general standards, "such as choosing one-third of the coarse grains in the staple food, choosing less fat in meat, choosing more dietary fiber in vegetables, how many grams of oil and salt are limited, and how many types of food are maintained in a day."

But unlike adults, a child's weight loss requires a change from a family. The challenge, Chen Wei said, is that some children can understand the doctor's words, but they often can't hold on. Adults are anxious, but they are unwilling to help children do the work of landing. "I often say to some parents that you can't just let your child go out for a run, you husband and wife are lying at home and playing with your mobile phone, and your child must feel unfair." Chen Wei said.

Yan Jie once treated a 13-year-old boy with a BMI as high as 34 and severe obesity. He participated in the weight-loss summer camp held by Beijing Children's Hospital every summer, learned the popular science knowledge of nutrition and exercise, and returned to his grandmother's house, who cooked three meals a day in strict accordance with the doctor's requirements, and many of the child's physical indicators improved. But later, the child returned to his parents' house, and the indicator quickly rebounded. Every time she was checked, Yan Jie found that the boy's and his father's bellies would be bigger. Parents often blame their children for their lack of self-control, but Yan Jie believes that the more important thing is the importance and involvement of parents.

Many doctors have mentioned that it is common for families to disagree when it comes to weight loss in clinical medicine. In China, many families have grandparents taking care of their children. Older people often think that it is good for children to eat more. In July 2022, Su Qin signed Zheng Zheng up for the summer weight loss summer camp of Beijing Children's Hospital, and during the two-week closed training, Zheng Zheng learned nutrition and exercise-related knowledge, exercised three times a day, and lost a total of 7 pounds. The doctor told you that the first three months after returning home are crucial. But before she lasted a few days, Su Qin found out that her mother-in-law secretly bought ice cream for Zheng Zheng to eat. Some parents often complain to doctors about similar situations. Yan Jie generally recommends that the elderly in the family be brought over for the next follow-up visit. She will patiently explain the dangers of obesity to the elderly, "mention the risks of fatty liver and diabetes to them, and the elderly can accept them."

When Zheng Zheng left the weight-loss summer camp, the doctor asked him to take away the four-square dinner plate and suggested that parents should mix and match their diet every day to let their children consume 25 nutrients a week. Summer camps have nutritionists who specialize in formulating recipes, but this is not realistic for the average family. Su Qin began to be anxious from the first day of formulating the recipe, "feeling that he was writing exam papers every day". Tried it for a week and had some unused vegetables left in the fridge. "When you feel like it's a burden, you can't hold on." Su Qin said. She resigned to the next best thing, no longer writing recipes, but according to the plan of three dishes and one soup, adding coarse grains to the staple food, eating more than 20 kinds of ingredients in the refrigerator every week, first ensuring balanced nutrition for the child, and finally persevering. Today, Zheng Zheng's weight is still 156 pounds, but his height has grown to 1.69 meters, his BMI is 27.3, and his muscle mass and metabolism are also rising.

In daily life, many parents have the wrong way to reward their children, and they are also contributing to their children's unhealthy eating habits. When communicating with Zheng Zheng, Su Qin found that in the past, she often unconsciously said that if you do well in the exam, she will buy you candy or eat pizza, which conveys a concept to the child, "Think that some unhealthy food is good food". Since then, Su Qin has gradually changed her "reward strategy", she agreed with Zheng Zheng that if she wants to eat ice cream, she needs to go to the park three times; If you can lose a few pounds, take him to an amusement park or go on a trip, this will be more conducive to weight loss.

Schools are a key part of this

The intervention and prevention of obesity in adolescents is not only in the family, but also requires the cooperation of the family, the school and the society. Pan An suggested that the government should increase investment in the prevention and management of obesity in children and adolescents, "because this is a group of people who have a good effect after intervention". Among them, the school is a key part, the child is in the stage of receiving knowledge, the school can increase health knowledge education, improve the sports environment and food environment, and can also more directly and effectively popularize relevant knowledge to parents.

When the interviewed doctors suggested that their children should strengthen exercise, some parents reluctantly said that their daily physical education classes were often occupied by other main classes, and their children had a heavy homework load, and it was difficult to have time to ensure exercise. In many primary and secondary schools, even the ten minutes between classes have "disappeared".

Ma Jun is the former director of the Institute of Child and Adolescent Health at Peking University and the deputy editor-in-chief of the China Childhood Obesity Report. He told China Newsweek that primary and secondary schools still face challenges in strengthening physical activity. On the one hand, in recent years, the Ministry of Education has successively introduced policies to reduce the burden on students, hoping to give children more time to exercise. But the problem is that the mainstream social perception still believes that good grades are the only criterion for judging whether a child is good or not. As a result, even if the school reduces the burden, parents will still put a lot of pressure on their children to learn.

On the other hand, students will inevitably bump and bump in school, and parents and public opinion will hold the school responsible, "the pressure on the school is too great, in order to protect the children, reduce their activities as much as possible". Ma Jun believes that families, schools and society still need to explore a new consensus, that is, it is inevitable that children will be injured at school, and on the premise of giving better compensation to injured students and their families, more tolerance and understanding of school will help more children release their nature in the growth stage.

At the end of 2020, six departments, including the National Health Commission, the Ministry of Education, and the General Office of the State Administration for Market Regulation, jointly issued the "Implementation Plan for the Prevention and Control of Obesity in Children and Adolescents" (hereinafter referred to as the "Plan"), which clearly pointed out that heavy homework burden, unbalanced nutrition of children and adolescents, and insufficient physical activity are one of the reasons for the rapid increase in the rate of overweight and obesity. The notice mentioned that schools should ensure that physical activity time in school should be guaranteed, and all schools in all localities should strictly implement the national physical education and health curriculum standards, and include physical education results in the assessment of the high school entrance examination in accordance with relevant regulations, and primary and secondary school students should spend more than 1 hour of moderate and above intensity physical activity in school every day, and ensure at least 3 hours of high-intensity physical activity per week.

In September this year, the "Beijing Compulsory Education Physical Education and Health Process Assessment Management Measures" was released, requiring all districts in the new semester to carry out the national student physical fitness test for students in grades 9, 15 and 9, and the results will be included in the total score of the high school entrance examination. Among them, the body mass index (BMI) of students accounts for <>% of the physical test score. In late September, a doctor interviewed clearly found in the outpatient clinic that many obese children went to the hospital at the recommendation of the school, "children from Dongcheng, Xicheng, Fengtai and Tongzhou". Some children also mentioned that the school also requires some overweight or obese students to supplement their exercise on the playground after school every day from this semester. The doctor believes that the participation of schools is of great help in the prevention and control of childhood obesity.

In Ma Jun's view, from the perspective of finding ways to let children exercise, the original intention of this measure is good. But he reminded that there is a disadvantage of BMI indicators, some children exercise a lot, their muscles are strong, and the BMI value will be relatively high, "The ideal way is that the school can judge the BMI and body fat percentage when assessing, and it will be more scientific."

Chen Wei also pointed out to China News Weekly that the increase in the availability of highly processed foods and various beverages for children is also an important reason for the obesity of children and adolescents, but it is easy to be ignored. According to the Report on Childhood Obesity in China (2018), the diet of school-age children in China is not reasonable, and the diet of fried and creamy products, candies and sugary drinks has increased. Each additional 350 ml serving of sugar-sweetened beverages per day for one year increased a child's BMI by 0.06%.

The Plan also requires that the State Administration for Market Regulation should strengthen the management of food marketing, further strengthen the management of the sale of breastmilk substitutes, and formulate and improve departmental rules and regulations to strengthen the management of food labels for high-sugar, high-fat and high-salt foods, and discourage the use of pictures, descriptions and designs that appeal to children in marketing and food packaging.

(Su Qin and Zheng Zheng are pseudonyms)

China News Weekly, Issue 2023, 41

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