A claims data review suggests new approaches are needed for prevention, screening, diagnosis, and treatment of obesity and type 2 diabetes in the pediatric population.
Type 2 diabetes (T2D) was once so rare in children that it was often called adult-onset diabetes to distinguish it from type 1 diabetes (juvenile diabetes). A growing body of evidence has shown, however, that the prevalence of T2D is increasing among the nation’s young people and that a major contributor to this increase is the epidemic of obesity in the same population.1,2 Our recent white paper, “Obesity and Type 2 Diabetes as Documented in Private Claims Data: Spotlight on This Growing Issue Among the Nation’s Youth,”3 examines these trends.
Consulting our FAIR Health database, which, at the time, included more than 21 billion privately billed healthcare claims nationwide (and has since grown to over 23 billion), we analyzed data from 2011 to 2015 to look for trends and patterns in obesity, T2D, and other obesity-related conditions in the nation’s pediatric population, which we defined as youth aged 0 to 22 years. As a point of comparison, we also studied adults 22 years or older. Claims data are a useful means of investigating public health issues because they reflect actual healthcare utilization and the information provided on claims indicates the assessments of providers, who are better than laypeople at judging health conditions. What we found suggests that greater attention and new approaches are needed for prevention, screening, diagnosis, and treatment of obesity and T2D in the pediatric population. The age groups studied were 0-2 years, 3-5 years, 6-9 years, 10-13 years, 14-16 years, 17-18 years, 19-22 years, and 22 years or older.
During the study period, claim lines (the individual services or procedures listed on an insurance claim) with an obesity diagnosis increased in all age groups, from infants and toddlers (aged 0-2 years) to people of college age (19-22 years) to adults 22 years and older. The increase varied by age group, but after 5 years of age, it became greater for each successive age group. For example, the increase was 139% in individuals aged 17 to 18 years and 154% in those aged 19 to 22 years.
This finding contrasts with a report from the CDC, which found that the prevalence of obesity remained fairly stable for children and adolescents aged 2 to 19 years from 2011 to 2014.4 The studies differ in that FAIR Health’s results are based on health insurance claims for the privately insured population whereas the CDC results are based on surveys using interviews and physical examinations of a cross-section of the civilian, noninstitutionalized US population.5 Because our study population had private insurance and excluded those with Medicaid, the results show that pediatric obesity is a problem not only for low-income children on Medicaid, who are often the focus of childhood obesity research,6 but also for those with sufficient economic advantages to have private health insurance.
Type 2 Diabetes and Other Obesity-Related Diagnoses
According to our data, claim lines with diagnoses for T2D more than doubled from 2011 to 2015 in the pediatric population, for an average increase of 109% across all age groups. As with obesity, the increase during the study period tended to be greater among older individuals, reaching between 120% and 125% among youth aged 14 to 22 years. However, even among preschoolers (aged 3-5 years), the increase was 90%.
When we examined other obesity-related diagnoses in the pediatric population, we found trends similar to that of T2D. Claim lines with diagnoses of obstructive sleep apnea rose 161% from 2011 to 2015 and those with hypertension diagnoses rose 67%. Curiously, of the pediatric population, children aged 10 to 13 years had the greatest increase of claim lines associated with obstructive sleep apnea (218%) and elementary school students (aged 6 to 9 years) had the greatest increase in claim lines associated with hypertension (103%).
Because our study period spans the years before and after availability of subsidized coverage under the Affordable Care Act, it is possible that some of the increase in claim lines associated with obesity or obesity-related diagnoses can be attributed to the influx of newly insured people. The increased utilization nonetheless highlights a trajectory of growth in those diagnoses.
Gender was found to be a factor in obesity, T2D, obstructive sleep apnea, and hypertension in the pediatric population. Except for those aged 10 to 13 years, claim lines with obesity diagnoses occurred more frequently in females than males. The greatest disparity was in the 19-to-22 years age group, in which the gender distribution of obesity diagnoses was 72% female to 28% male. However, in all but 2 groups (aged 10-13 and 19-22 years), claim lines with T2D diagnoses occurred more frequently in males than females. The greatest disparity was in the group aged 0 to 2 years, in which the gender distribution of T2D diagnoses was 62% male to 38% female. Claim lines with obstructive sleep apnea or hypertension diagnoses also were generally more common in males than females.
The prevalence of pediatric T2D appeared to vary by state. Comparing the percent of claim lines with pediatric T2D diagnoses to that of claim lines for all pediatric medical claims by state, we found pediatric T2D to be most prevalent in Ohio, Pennsylvania, North Dakota, Utah, and South Dakota. It was least prevalent in New Hampshire, Vermont, Delaware, Hawaii, and Rhode Island. Claim lines with nondiabetic, obesity-related, pediatric diagnoses followed a similar pattern. They were most prevalent in Ohio, New Jersey, North Dakota, Pennsylvania, and West Virginia, 3 states of which have the highest prevalence of claim lines with pediatric T2D diagnoses, as previously noted. Claim lines with nondiabetic, obesity-related, pediatric diagnoses were least prevalent in Vermont, New Hampshire, Rhode Island, Delaware, and California, a group that includes 4 of the states with the lowest prevalence of claim lines with pediatric T2D diagnoses.
Our findings indicate that both obesity and T2D appear to have increased in prevalence in the pediatric privately insured population from 2011 to 2015, as did other obesity-related conditions, such as obstructive sleep apnea and hypertension. The implications for researchers, providers, payers, policy makers, and parents are profound. The increase in T2D among young people brings with it the prospect of decades of treatment and its complications for a larger population than previously anticipated, with all of the accompanying economic and social costs. Reversing this trend, and the rise of other pediatric obesity-related conditions, requires reversing the increase in pediatric obesity. That task will require the effort of all healthcare stakeholders.
Childhood obesity researchers Heidi M. Blanck, PhD, and Janet L. Collins, PhD, wrote: “Obesity-related health behaviors, such as nutrition and physical activity, are shaped by multiple sources of influence and environments, including the home, early care and education, school, healthcare, and other community settings. Therefore, a host of … stakeholders who influence these settings, including government, education, the private setting, nonprofit organizations, and families, have a role to play in creating healthier communities.”7
Researchers must investigate the etiology, prevention, and treatment of pediatric obesity. Pediatricians must apply evidence-based means to prevent, screen for, diagnose, and treat this disease. Medical school curricula should prepare pediatricians to be alert to obesity and armed with skills and strategies to treat it. Payers may need to alter their benefit designs and provider networks to ensure that a full range of services, specialties, and treatments are covered that are necessary for prevention, screening, diagnosis, and treatment of pediatric obesity. Policy makers can have an influence on pediatric obesity through their decisions affecting cities, schools, and people’s way of life. For example, good urban planning can ensure that there are enough parks and playgrounds to encourage outdoor exercise and educational policy can encourage healthful physical education curricula and nutritious school meals. Parents can realize that their child’s weight is both a cosmetic and a health issue and do all they can to instill healthy diet and exercise habits in their children.
Similar measures must be taken to address T2D in the pediatric population. Noting the clinical differences between T2D in young people compared with adults and the inadequacy of available treatment options, a recent consensus report of the American Diabetes Association and other organizations stated: “Comprehensive, coordinated, and innovative strategies for the investigation, prevention, and treatment of youth-onset type 2 diabetes are urgently needed.”8
Even as research into T2D in young people continues, pediatricians must be alert for the signs and symptoms of the illness and be prepared to screen for and treat it with available means. Medical schools must prepare pediatricians to take on this challenge, and parents should be made aware of the signs and symptoms that they should bring to the attention of their child’s doctor. Payers need to ensure coverage for services necessary for screening, diagnosis, and treatment of pediatric T2D.
By addressing obesity in the pediatric population, we have an opportunity to avoid much greater burdens in the future. And by addressing T2D in the same population, we have a chance to minimize the complications that can arise from inadequate management of this disease.
Robin Gelburd, JD, is the president of FAIR Health, New York, New York, a national, independent nonprofit with the mission of bringing transparency to healthcare costs and insurance reimbursement. FAIR Health oversees the nation’s largest collection of healthcare claims data, which includes a repository of more than 23 billion billed medical and dental procedures that reflect the claims experiences of 150 million-plus privately insured individuals and separate data representing the experiences of more than 55 million individuals enrolled in Medicare.
Certified by CMS as a Qualified Entity, FAIR Health receives all of Medicare Parts A, B, and D claims data for use in nationwide transparency efforts. Ms. Gelburd has no conflicts of interest to disclose. References
1. American Diabetes Association. Type 2 diabetes in children and adolescents. Diabetes Care. 2000;23(3):381-389.
2. Dabelea D, Mayer-Davis EJ, Saydah S, et al; SEARCH for Diabetes in Youth Study. Prevalence of type 1 and type 2 diabetes among children and adolescents from 2001 to 2009. JAMA. 2014;311(17):1778-1786. doi: 10.1001/jama.2014.3201.
3. FAIR Health. Obesity and type 2 diabetes as documented in private claims data: spotlight on this growing issue among the nation’s youth. A FAIR Health white paper. FAIR Health website. http://www2.fairhealth.org/l/34972/2017-01-05/mxbgnw/34972/236456/FAIR_Health_Obesity_and_Diabetes_White_Paper_Jan_2017.pdf. Published January 2017. Accessed February 3, 2017.
4. Centers for Disease Control and Prevention. Overweight & obesity: childhood obesity facts. CDC website. https://www.cdc.gov/obesity/data/childhood.html. Updated December 22, 2016. Accessed February 3, 2017.
5. Ogden CL, Carroll MD, Fryar CD, Flegal KM. NCHS Data Brief no. 219. Prevalence of obesity among adults and youth: United States, 2011-2014. CDC website. https://www.cdc.gov/nchs/ data/databriefs/db219.pdf. Published November 2015. Accessed February 3, 2017.
6. Center for Health Care Strategies, Inc. Innovations in childhood obesity. CHCS website. http://www.chcs.org/project/innovations-in-childhood-obesity/. Published January 2015. Accessed February 3, 2017.
7. Blanck HM, Collins JL. The Childhood Obesity Research Demonstration Project: linking public health initiatives and primary care interventions community-wide to prevent and reduce childhood obesity. Child Obes. 2015;11(1):1-3. doi: 10.1089/chi.2014.0122.
8. Nadeau KJ, Anderson BJ, Berg EG, et al. Youth-onset type 2 diabetes consensus report: current status, challenges, and priorities. Diabetes Care. 2016;39(9):1635-1642. doi: 10.2337/ dc16-1066.