Few docs to care for kids with diabetes

The rate of childhood obesity in the United States has more than doubled in the past 20 years, bringing with it more children at risk for developing type 1 and even type 2 diabetes.

Despite this growing trend, the number of board-certified pediatric endocrinologists - those physicians who specialize in caring for children with diabetes and obese children at risk for the disease - is not keeping pace with demand for their specialized care, say researchers at the University of Michigan C.S. Mott Children's Hospital.

Results from a new study published in the March issue of The Journal of Pediatrics show that at the national level, for every 290 children with diabetes, there is only one board-certified pediatric endocrinologist available to care for them. It also finds that the ratio of obese children to board-certified pediatric endocrinologists is about 17,000 to one.

"Although the American Diabetes Association recommends that all children with diabetes be cared for by a pediatric endocrinologist as part of a diabetes team, there is a current shortage of pediatric endocrinologists in this country," says study lead author Joyce Lee, M.D., MPH, a pediatric endocrinologist and member of the Child Health Evaluation and Research (CHEAR) Unit in the U-M Division of General Pediatrics. "This problem will likely only worsen due to the recent epidemic of childhood obesity."

Currently, 16.5 percent of American children ages 6 to 19 are obese. These children are at an increased risk for developing diseases previously thought to be limited to adults, including type 2 diabetes, high blood pressure and high cholesterol. As a result, more children than ever before are being referred to pediatric specialists, such as pediatric endocrinologists who can screen, evaluate and manage children at risk for developing diabetes.

"Even if just a small fraction of obese children are referred to a pediatric endocrinologist for evaluation, the overall ratio of one pediatric endocrinologist to 17,000 obese children makes providing the necessary care extremely challenging," says Lee, assistant professor in the Department of Pediatrics and Communicable Diseases at the U-M Medical School.

The bottom line: pediatric endocrinologists currently do not have the capabilities to see even a fraction of the large number of children with diabetes or at risk for diabetes. "The epidemic of childhood obesity has undoubtedly created new challenges for our health care, and we need to reassess the current system to ensure children with diabetes or at risk for diabetes receive appropriate care," Lee notes.

Using data from the American Board of Pediatrics and the National Survey of Children's Health, Lee and her colleagues compared the number of board certified pediatric endocrinologists by region to obese children and children with diabetes in those same areas.

Their research revealed that there are an estimated 229,249 children with diabetes, and only 790 board-certified pediatric endocrinologists in the country. And, in two states - Montana and Wyoming - there are no board-certified pediatric endocrinologists.

Further complicating matters, Lee and her colleagues found that the geographic distribution of children with diabetes and obesity does not match the geographic distribution of board-certified pediatric endocrinologists.

According to study results, the area with the greatest supply of pediatric endocrinologists was in the Northeast. In comparison, the Midwest fared the worst with regard to the supply of pediatric endocrinologists. The geographic disparity was even greater for ratios of children with obesity to board-certified pediatric endocrinologists by state, ranging from about 5,000 to one in Massachusetts to about 99,000 to one in Mississippi.

While the American Board of Pediatrics reports that the number of medical fellows entering the field of pediatric endocrinology since 1997 has increased annually by 12 percent - with about 76 pediatricians entering the field from 2005 to 2006 - Lee cautions that it is still not enough of an increase to meet growing demand for care.

"The increases in the endocrinology workforce are incremental. Ultimately, the pediatric endocrine workforce shortage raises the question of how health care delivery for U.S. children with diabetes and children at risk for diabetes should ideally be organized," says Lee.

She notes that a critical reassessment of the current system of health care delivery for obese children is needed, along with the creation of sustainable models of care to effectively improve health outcomes for obese children who are at risk for developing chronic diseases in childhood.

To learn more about childhood obesity and diabetes care offered at C.S. Mott Children's Hospital, visit these Web sites:

• Pediatric endocrinology, diabetes and metabolism services: www2.med.umich.edu/departments/mott/clinics/dsp_cliniclist.cfm?group_id=ENDO
• Pediatric Comprehensive Weight Management Center: www.med.umich.edu/MPOWER/index.shtml

In addition to Lee, U-M C.S. Mott Children's Hospital co-authors are: Matthew M. Davis, M.D., M.A.P.P., associate professor of general pediatrics and internal medicine, and associate professor of public policy at the Gerald R. Ford School of Public Policy; Ram K. Menon, M.D., professor, Department of Pediatrics and Communicable Diseases, and director of Pediatric Endocrinology; and Gary L. Freed, M.D., MPH, Percy and Mary Murphy Professor of Pediatrics and Child Health Delivery, and chief of the Division of General Pediatrics.

Lee's work on this study was supported by the Clinical Sciences Scholars Program at the University of Michigan.

Reference: The Journal of Pediatrics, March 2008, Vol. 152, No. 3.