Wanted: Childhood diabetes specialists

By Terri Coles

TORONTO (Reuters) -- Despite a recommendation from the American Diabetes Association that all children with diabetes see a specialist for care, there are not enough specialists to treat even a fraction of the diabetic and obese children in the United States, a study showed.

Though the number of board-certified pediatric endocrinologists is increasing, their ranks are not growing quickly enough to keep up with the number of children with type-1 or type-2 diabetes -- or obese children at risk of becoming diabetic -- who are referred to them for care, researchers at the University of Michigan's C.S. Mott Children's Hospital found.

"The results of the study beg the question of whether we shouldn't be directing these kids to other health care delivery systems," said Dr. Joyce Lee, a pediatric endocrinologist and lead author of the study, published this month in the Journal of Pediatrics.

There are an estimated 229,249 diabetic children in the United States, according to the study. Most of those children have type-1 diabetes, where the pancreas does not produce insulin to regulate blood sugar. The incidence of type-2 diabetes, where the pancreas produces insulin but not enough, or the body can't properly use the insulin available, is also rising in children.

"In the adult world, there is a lot of diabetes that is managed by a generalist as well as some specialists," Lee said. Diabetic children often are sent to specialists to help manage their disease, she said, because many pediatricians don't feel comfortable with the kind of disease management that diabetic children require.

Type-1 diabetes in particular can be very difficult to control, Lee said: a patient requires daily insulin injections and frequent blood sugar checks, as well as a specialized diet. "It's certainly a skill that you learn that probably most generalists aren't exposed to and don't feel comfortable with," she said.

The rising number of obese children also adds to the patient burden placed on the country's existing pediatric endocrinologists, Lee said.

Obese children face a higher risk of developing high blood pressure, high cholesterol and diabetes -- weight-related conditions usually seen in adults.

"We're seeing more and more kids referred to us who are thought to be at risk for diabetes because of their obesity," she said. Type-2 diabetes is often associated with obesity, but the development of type-1 diabetes can also be accelerated in a child who is overweight.

More American children today are obese than ever before -- 16.5 percent of kids aged 6 to 19, a rate that has more than doubled over the past 20 years. About 9 million U.S. children are considered obese, according to the Institute of Medicine.

The study found that there's only one pediatric endocrinologist for every 290 diabetic children in the United States, and the ratio of obese children to pediatric diabetes specialists is 17,000 to one. The number of medical fellows entering the field of pediatric endocrinology has increased 12 percent annually since 1997, according to the American Board of Pediatrics, but Lee's team calculated the workforce would need to double or triple to meet the needs of diabetic and obese children. "Supply isn't really increasing at a rate that it's able to meet the demand clinically."

The study authors also found regional disparities. The Northeast showed the greatest supply of endocrinologists, and the Midwest the worst. The ratio of diabetic specialists to obese children varied from 5,000 to one in Massachusetts to 99,000 to one in Mississippi. Two states, Montana and Wyoming, don't have any board certified pediatric endocrinologists.

Part of the issue is that specialists tend to flock to urban areas and cities that have universities with large research hospitals, Lee said, but even taking that into account there are still gaps in specialist availability across the country. "Clearly what the numbers show us is that again, the supply isn't necessarily located where the demand is," she said.

Pay is an important factor affecting the lack of available pediatric endocrinologists, Lee said. Providers find that the amount of care they can claim payment for is less than the amount they actually provide.

"There's a huge group of people that contribute to the care and well-being of a child, and across the country I think what's happening is that pediatric endocrinologists are finding that the reimbursement is a difficult issue," she said. "The amount that they receive for giving comprehensive care to these kids is not meeting the actual cost of their program."

Giving primary care providers the tools to help manage or prevent childhood diabetes may be a more efficient way of treating affected children than referring them to pediatric endocrinologists, Lee said.

Because so many medical professionals work with a single diabetic child -- nurses, pediatricians, specialists, dieticians -- the study indicates that if general pediatricians were able to take a more active role in diabetes management, it could reduce the burden on specialists, she said. "I think it raises the question of how we should structure care for these kids."