When I was doing my doctorate research on diabetes in Oxford during the late 80s and early 90s, to all intents and purposes, children and adolescents who developed diabetes did so because their pancreatic islets, which produce insulin, were destroyed by an autoimmune process. The type of diabetes in these young people is called type I diabetes. It was very unusual to find type II diabetes in this young population because type II diabetes occurs as a result of insulin resistance. Simplistically, this means your body tissues are less sensitive to the action of insulin and the pancreas needs to produce more insulin than normal thus leading to an inadequate amount of circulating insulin to control the blood sugar level. Traditionally, type II diabetes is commonly seen in the older adult population.

Only 15 years ago, type II diabetes accounted for < 3% of all cases of new onset diabetes in adolescents. Now it accounts for 45% of adolescent diabetes - a 15 fold increase!! Why? The most likely explanation is the rapid increase in the number of overweight and obese children and adolescents. This phenomenon is not confined to the rich, developed Western countries. It is a global problem. In the United States, the prevalence of overweight 6 -11 year old children and 12 - 17 year old children doubled and tripled, respectively, between 1980 and 2000. Approximately 15% of all 15 year old children in the United States are obese. In another study of adolescents in 13 European countries, Israel and the United States, the highest prevalence of overweight adolescents was found in the United States, Ireland, Greece and Portugal. In a study of school children aged 6.5 – 11.5 years in Shiraz, southern Iran, 7% of boys and 4% of girls were found to be overweight / obese (Obes Rev 2007; 8: 289 – 291). More significantly, the median body mass index (BMI) of these children lies almost on the 38th centile of the Center for Disease Control and Prevention reference data while the median BMI of similar cohorts born just over 10 years ago previously lay on the 20th centile. This implies a rapid increase in overweight / obese Iranian children over the last 10 – 15 years.

What are the known risks associated with obesity in children / adolescents? Type II diabetes in overweight / obese youngsters has reached such a proportion that the American Academy of Pediatrics and the American Diabetes Association recommend that all youngsters who are overweight and have at least 2 other risk factors should be tested for type II diabetes beginning at age 10 years or at the onset of puberty and every 2 years thereafter. [The risk factors are family history of type II diabetes in 1st or 2nd degree relatives, belonging to certain ethnic groups such as native American, African-American, Hispanic, Japanese, Asian / Pacific Islander, or having signs associated with insulin resistance (hypertension, dyslipidaemia, acanthosis nigricans or polycystic ovarian syndrome).] Other health risks associated with being overweight / obese include metabolic syndrome, hyperandrogenism causing menstrual disorders, heart disease, hypertension (high blood pressure), asthma, obstructive sleep apnoea, nonalcoholic fatty liver disease, gallstone disease, skin problems and joint problems. (To read the article about the consensus statement for childhood obesity, go here.)

When I read a review article (Lancet 2007; 369: 1823 – 1831) on acute and chronic complications of type II diabetes in children and adolescents recently, the hair on the back of my neck stood up immediately! The association of type II diabetes and hypertension in adults is well established and research findings suggest a similar relationship in adolescents. Hypertension at diagnosis is 8 times more frequent in type II diabetic adolescents than in type I diabetic adolescents. Kidney damage (called nephropathy) in type II diabetic adolescents appears to worsen at a much faster rate when compared to type I diabetic adolescents. In a study of young Maori type II diabetic patients, the frequency of microalbuminuria rose from 14% to 62% over 10 years. On the other hand, the rate of progression of microalbuminuria in type I diabetic adolescents was only 18% over 10 years. (Rapid progression of nephropathy can lead to end stage renal disease requiring dialysis or kidney transplantation.) Diabetes damages the retina of the eye (called retinopathy) and when severe can lead to blindness. In a study of type I and II diabetic adolescents, retinopathy was found to be more common in type I (10%) than type II (4%) diabetic adolescents. However, the diabetes duration was much shorter in type II patients before retinopathy appeared. The disease duration was 3 years for type II diabetic adolescents compared with 10 years in those with type I diabetes. [Could obesity in the young lead to accelerated aging in the organ system? I wonder.]

Why are children and adolescents getting overweight / obese in the last 10 – 15 years? Most would likely put the blame on genetic causes or some unseen infective agents perhaps. Unfortunately that is not the case. While numerous genetic markers have been linked with obesity and its metabolic consequences, presently, identifiable hormonal, syndromic or molecular genetic abnormalities can only account for < 5% of obese individuals! It is easier to blame the obesity problem on genetic or hormonal problems because it lets one off the hook for being fat. When the dust finally settles, we are likely to find that the most likely culprits are a lack of regular physical activity, consumption of the wrong types of food and eating way beyond your daily nutritional requirements!

The majority of children do not get overweight / obese just like that. We, as parents, can do something about it. We can keep an eye on what they eat. We can make them take regular exercise and we can make sure that they do not over eat. It takes a lot more effort to watch over what the children eat and what they do or do not do, but is that not what a good parent supposed to do?

With the rising incidence of childhood and adolescent obesity, the sight of enthusiastic children who want to go out and take up sports of any kind is a welcome relief to all parents. In USA, it is estimated that 30 – 45 million 6 – 18 year old youths take part in some form of athletics. The form of sport participation ranges from recreational play and school activities, to highly organized and competitive traveling teams, to pre-Olympic training opportunities. Just to name a few, the sporting varieties include soccer, tennis, rugby, field hockey, running, lacrosse, baseball, American football, cheerleading and dance. For some children, the weekly sports schedule can be grueling. The drive behind the intense year round training, weekend tournaments and participation in endurance events is partly a desire to be successful in sports but also success in sport may be a ticket to university, fame and perhaps riches for some! However, are present day parents and athletics instructors pushing the kids too far, too much and too young? After a sporting injury on the field, it is not unusual to hear an adult say “Oh, he is young and fit. Just needs a day or two of rest and he will recover from it.” Well, is it that easy?

When an athlete does not have enough rest in between training and competitions, he gets tired. When your body is tired you have an increased risk of injury. Overusing your muscles and joints can lead to minute injuries to a bone, a muscle or a tendon. When there is insufficient time given to these repetitive stress injuries to heal, you develop overuse injuries. In USA, up to 50% of all injuries seen in paediatric sports medicine are related to overuse. The incidence of overuse injuries in young athletes mirrors the growth in youth participation in sports. Why is the risk of overuse more of a problem in paediatric or adolescent athletes? The answer is both simple and logical - growing bones cannot handle as much stress as mature bones.

For example, a young baseball pitcher who has not yet learned proper throwing mechanics is at risk of traction apophysitis at the elbow. (The apophysis is the growing end of the young bone. When there is inflammation in it, called apopysitis, the growth can be affected.) After a while, a young swimmer may start to complain of fatigue and experience a drop in performance. Usually this is put down to ‘an off day’ or ‘the kid is losing focus’. What the coach and the young swimmer may not realise is that the vague symptoms are a sign of rotator cuff tendonitis (inflammation of the tendons around the shoulder). A consequence of overusage with inadequate time for healing and recovery! Recognising the fact that there are 4 stages of overuse injuries would be a start. The 4 stages are (1) pain in the affected area after physical activity; (2) pain during the activity, without restricting performance; (3) pain during the activity that restricts performance; and (4) chronic, unremitting pain even at rest. It is not uncommon to see an adolescent athlete soldier on with pain during a match because he or she doesn’t want to let the team down or to hear the coach saying ‘Hang in there, we really need you to win this match for us’.

When a young athlete starts to show a lack of enthusiasm about practice or competition or develops difficulty in completing usual routines that is a sign of burnout. It is crucial that we do not let a young athlete get to this stage. It is possible to prevent overtraining and burnout. Keep the practice fun by having age-appropriate games and training. Every 2 to 3 months, have a longer scheduled break from training and competition and institute some cross-training activities to prevent loss of skill or level of conditioning. For 1 – 2 days a week, take time off from organized or structured sports participation to allow the body to rest. Encourage and teach the young athletes to be in tune with their bodies, ‘listen’ to their bodies so that they may know when to slow down or alter training methods.

The goal of encouraging children and adolescents to play sports is to teach them about healthy competition, to learn about the joy of lifelong physical activity and the skills of being a team member. The goal and motivation should not be skewed toward the goals of the parent or the coach. The parent may have the hope that the child will become a professional athlete but the reality may not be as rosy as one thinks. Depending on the sport, only 0.2% to 0.5% of high school athletes ever make it to the professional level! (National Collegiate Athletic Association Fact Sheet)

Whenever I go to watch my children’s basketball or baseball games in school, I am constantly amazed by how some parents get so uptight about their young son’s or daughter’s performance in the intra-school game. Sometimes, I just can’t help wonder if the parents are there to live through their children the sporting opportunities they never had or are they there because they want to encourage their children to enjoy the sport for what it is? Remember, young athletes who participate in a variety of sports have fewer injuries and play sports longer than those who specialize before puberty! (Pediatrics 2000; 106: 154 – 157)

Every year, the American Society of Clinical Oncologists (ASCO) holds its annual meeting around the end of May and beginning of June. It is the biggest meeting for clinical oncologists and cancer researchers to present their research findings and to hear ground breaking research information on topics related to cancer. This year 30,000 delegates have been attending the meeting in Chicago which runs from 1st to 5th June. Every year, not only the oncologists, researchers and pharmaceutical companies get excited about the gathering; investors, speculators and fund managers get excited as well. Why? A chance to make money, that’s why!

The cancer medicine market is huge. The market researcher IMS Health has predicted that worldwide cancer drug sales will rise by 17 – 20% a year through 2010. By then the cancer medicine market will have reached a staggering US $62 - $70 billion. To a small biotechnology drug company, the results of a single drug trial can make or break the company. An example of what positive trial results can do for the fortune of a biotechnology company is Onyx Pharmaceutical Inc. Onyx Pharmaceutical developed a new molecular drug, called Nexavar (the generic name is sorafenib) which has been approved for treating kidney cancer. The drug was then subsequently used in a trial for patients with incurable liver cancer (also called hepatocellular carcinoma or hepatoma). In February this year, the trial was stopped prematurely by the investigators because patients treated with sorafenib survived significantly longer than those who received placebo. When the news about the premature termination of the trial due to positive results was announced, the stock price of Onyx Pharmaceutical went from $12.26 to $24.15 overnight! By 1st June the share price had reached $30.88. At the weekend of 3rd June, the formal trial results on the use of sorafenib in patients with liver cancer were presented at ASCO. On Monday, 5th June, Onyx stock opened at $34.00, a 10.1% increase!

Before you rush out to speculate on pharmaceutical and biotechnology companies, you should also realize that you could lose a lot of money if you get it wrong. An example is Dendreon Corp. who developed a cancer vaccine called Provenge to be used in treating patients with prostate cancer. On 29th March the stock closed at $5.22. On the following day, the US Food and Drug Administration (FDA) advisory panel voted to recommend to FDA that Provenge should be approved. On 30th March the stock ended the day at $12.93, a 147.7% increase overnight!! The speculators and investors piled in and the stock reached an all time closing high of $23.58 on 9th April. Over the next month, the stock traded between a low of $15.03 and $19.39. On the morning of 9th May the FDA informed Dendreon Corp. that it required more data before it could make a decision on its approval. The stock price fell precipitously from the overnight level of $17.74 to close at $6.33 on that day! On 1st June, the stock closed at $8.10. At the ASCO meeting, no one spoke about Provenge.

These speculators and investors are merely betting on the potential outcome of a drug trial in order to make a financial gain. The patients on whom the new drugs are being tested on are also making a bet. However, these patients are betting with their life. They are hoping that the new drug just might buy them some extra time. Indeed, these patients are making the ultimate bet! Without them medical science cannot advance as we will not know if our theory about the function of the new drug is correct or wrong. The medical community and future patients owe much to these patients who take part in drug trials.