The proportion of childhood DM attributable to type 2 DM is increasing worldwide(17). In USA there is a tenfold increase in the proportion of young diabetes between eighties and nineties(18).Increase in type 2 DM parallels an increase in obesity. Obese have about 40% lower glucose utilization rate. A clinic based study from Connecticut, USA, on 55 unselected obese children and 112 obese adolescents referred to an Obesity clinic revealed silent DM in 4% of adolescents and IGT in 25% of children and 21% of adolescents(19).Data on type 2 DM in Indian children and adolescents has started appearing. Ramachandran et al(20) reported on 18 children (5 boys and 13 girls) with type 2 DM diagnosed below the age of 15 years at their clinic. Family history of DM was present in all.The youngest age at diagnosis was 9 years. These children were asymptomatic and picked up on screening which was performed due to strong family history of DM and / or because of obesity. Report from a North Indian Clinic showed that type 2 DM accounted for all diabetes cases with onset of DM below 18 years of age (21).

Why Pediatricians need to be concerned?
It is a bit ironic that a problem of "plenty" namely childhood obesity has arisen while we are still fighting undernutrition and infectious diseases. Adverse health consequences of positive nutrition transition in children are undermined as these are seemingly "remote" and therefore "relatively invisible". This has resulted in a false sense of complacency leading to inaction in this age group (22).

The treatment of obesity ultimately involves eating less and being more physically active. As simple as this may sound, long-term weight loss has proven difficult to achieve and, overall, there has been a lack of success of treating obesity once it has become established (9,23). The psychological immaturity of children and their greater susceptibility to peer pressure compared to adults present additional difficulties to the successful treatment of childhood obesity. Because of this, there seems to be consensus that prevention is the most realistic and cost effective approach for dealing with the problem of childhood obesity (24). Thus, although interventions to improve individual lifestyles are needed, especially for children already overweight or obese, remedial actions taken from a broader public health and policy perspective will be necessary to have a significant impact on the problem. As primary care physicians of the children, it is actually the pediatricians who will now have to perform a crucial role by looking after children and adolescents more meaningfully. To create awareness among pediatricians of their role in the prevention of these metabolic conditions, and to provide clear guidelines for actions to be taken by them, the Indian Academy of Pediatrics published its recommendations in a series of articles (25-27). The pediatric community now will have to take a lead role to orient their routine clinical practice in the prevention and early recognition of childhood overweight and obesity. This should be done by dietary history, family history of metabolic diseases, assessment and anticipatory guidance about weight and physical activity. These are briefly outlined below:

Early recognition of excessive weight gain relative to linear growth
This should be done by yearly growth assessment by routine collection of weight and height measurements (recumbent length up to 2 years of age and standing height for older children) to enable monitoring weight-for-height and BMI. Interpretation of weight-for-height and BMI indices based on prescriptive reference data. The NCHS/ CDC charts can be used for this purpose (28). These charts can be downloaded from website. Early intervention after an increase in weight-for-height or BMI percentiles has been observed. International definition for overweight and obesity have been provided by WHO (29). However, it is important for pediatricians to recognize the fact that crossing into higher centiles remains early warning sign.

Dietary modifications
Emphasis should be on nutrition rather than 'dieting'. It is important to maintain healthy components of traditional diets (i.e., micronutrient rich food such as fruits, vegetables and whole grain cereals). Recommended dietary allowances for children are given in Table I (31). and guard against heavily marketed energy dense fatty and salty foods (e.g., pre-packaged snacks, ice-creams and chocolates) and the sugary cold drinks. The strategy should be to recognise and eliminate risk features of high calorie intake such as frequent snacking (samosas, potato chips, chiwdas), eating out frequently (burgers, dosas), celebrating with food (cake, chocolates) and drinks (colas, beers) (Table II). Habits attained early have more chance of remaining throughout life.

A simple Indianized message based on recommendations of AHA (30) could be-"think of a day's food composition as a 'Thali' wherein 50% (half) is full of vegetables, salads and fruits. A quarter (25%) should be made up of cereals such as rice and/or chapattis and the remaining quarter should be protein based (dal/milk/egg/animal protein)"(Fig 1.)

Increase physical activity level
The WHO recommends at least 30 minutes of cumulative moderate exercise (equivalent to walking briskly) for all ages; plus for children, an additional 20 minutes of vigorous exercise (equivalent to running), three times a week. In general, moderate to vigorous activities for a period of at least one hour a day may be a more practical recommendation for all school going children. Perhaps even more important is decreasing sedentary behavior like viewing television (should be restricted to no more than 2 hours a day), computers, telephone conversations. Energy expenditure related to various physical activities are shown in Table III.

Other measures
Children overweight and with family history of metabolic diseases need to be checked with blood pressure and lipid profile from the age 3 years and screening of blood glucose after age 10 years. School based programs to enhance physical activity are already in place in many developed countries and should be encouraged. Campaign against substance abuse like smoking, non smoking tobacco use, alcoholism need intensification. Advocacy at all levels notably teachers, government functionaries, professionals, media, academic bodies, food regulatory authorities and so on are urgently needed to stall the ensuing epidemic of metabolic syndrome.