Download Type 2 Diabetes Mellitus in Children

Obesity Projects: Lessons
Learned and Relearned
Daniel E. Hale, M.D
Professor of Pediatrics, UTHSCSA
Overview
o
o
o
o
Definitions of DM types
Epidemiology of DM1 and DM2
DM2 as a major pediatric health risk
The environment for obesity
Definitions
Type 1 Diabetes (DM1)
o
o
o
o
o
o
Insulin dependent
Juvenile (onset)
Autoimmune B-cell destruction
Positive antibodies
No insulin resistance
Rapid clinical onset
Type 2 Diabetes (DM2)
o
o
o
o
o
Non-insulin dependent
Adult (onset) diabetes
Insulin resistance is major
component
B-cell dysfunction occurs late
Indolent clinical onset
MODY and Atypical DM

Maturity Onset Diabetes of Youth



Autosomal dominant with variable
penetrance
Single gene defect involving insulin
production or signaling
Atypical



Ketosis prone (during illness)
Flatbush, African American
Late teen/early adult
Epidemiology
How common is diabetes?
17 million people in the U.S.
with DM
o 1 million with Type 1
o 16 million with Type 2
o ? MODY
o ? Atypical
How common is Type 1
diabetes in pediatrics?
Prevalence
U.S.
Incidence
U.S.
Mexico City
San Antonio
Pittsburgh
2.5/1,000
12-16/100,000/yr
1
9
15
How common is Type 2
diabetes in pediatrics?
Prevalence
U.S.
Incidence
U.S.
Mexico City
Pittsburgh
???
???
???
???
Incidence of Diabetes in San Antonio
(new cases/100,000 children/year)
21
18
15
DM-1
12
9
6
3
0
90
91
92
93
94
95
96
97
98
99
Incidence of Diabetes in San Antonio
(new cases/100,000 children/year)
21
18
15
DM-2
12
9
6
3
0
90
91
92
93
94
95
96
97
98
99
Incidence of Diabetes in San Antonio
(new cases/100,000 children/year)
21
DM-1
18
DM-2
15
DM-All
12
9
6
3
0
90
91
92
93
94
95
96
97
98
99
DM2
at Presentation
BMI (kg/m2) at Diagnosis
Child has:
<20
20-25
>25
Post-rehydration
Type 2
2%
20%
78%
Type 1
86%
11%
3%
For 13 yr old female: 50% BMI =18.7
85% BMI = 22
95% BMI = 26
Age at Diagnosis of DM2
No DM2 <5 yrs of age (yet)
5% of new DM diagnoses 5-9 yrs
35% of new DM diagnosed 9-14 yrs
75% of new DM diagnosed >15 yrs
Mean age at DX with DM2 = 13.4 years
Tanner Stage at Diagnosis
Pubertal Status
Tanner 1
Tanner 2 - 4
Tanner 5
Percent
10
50
40
Family History of Diabetes
Child has:
0 Parent with DM
1 Parent with DM
2 Parents with DM
DM2
30%
66%
4%
DM1
88%
12%
0%
Estimated prevalence of DM2 in adults in 25-40
age range in SA varies from 4-12%
Acanthosis Nigricans
Neck
Axilla
DM2
DM1
93%
77%
2%
0%
Acanthosis is a sign of insulin resistance, not
diabetes
Other features
Hospitalization


20% at Dx (most not ill)
Insurance Status



20% self pay
55% Medicaid/Chip
25% Private
Lesson Learned

If the BMI>95%, the child is over
age 10 and/or pubertal and the
child has one close family
member with DM, seriously
consider the possibility of DM2
Going to Middle School




1492 middle school children
89% economically disadvantaged
92% Mexican American
All urban
Going to Middle School





Questionnaires
Blood pressure
Acanthosis screening
Height and weight
Fasting blood sample for glucose,
insulin and lipids
DM Risk Factors
in 12-14 Year Old MA Youth
DM2
IFG
AN
BMI(F)
HI
BMI(M)
FH-DM
0
10
20
30
40
Percent Affected
50
60
70
24
Lesson Learned



As many as 20% of students may
have acanthosis.
About 0.5% or less will have DM2
Acanthosis screening without
resources and personnel for
adequate and appropriate followup is bad public health policy.
CAD Risk Factors
in 12-14 Year Old MA Youth
BP(F)
LDL-C
HDL-C
FH-SD
FH-MI<50
BP(M)
Trigly
BMI(F)
FH- Lipid
BMI(M)
TC
0
10
20
30
40
50
60
Percent Affected
26
Lesson Learned

If you are thinking about
screening for diabetes,
you should also screen
for cardiovascular risk
(lipid profile, blood
pressure)
Going to Elementary
School




2672 4th grade children
91% economically disadvantaged
87% Mexican American
All urban
Hyperglycemia in
4th Grade Students
Fasting Samples Only
FcG(>100)
FcG (>110)
12.2%
5.4%
Repeated IFcG
3.2%
All with FcG>110 on repeat to OGTT
IGT
(2hr>140, <200) 1.3%
DM2 (2hr>200)
0.4%
Lessons Learned

If one is interested in diabetes
identification, a fasting capillary
glucose is of value, especially if
repeated on a second day.
(More Later)
On to Kindergarten and
Prekindergarten




Rio Grande City Independent
School District
Poorest county in the US
8 elementary schools
62% participation in screening
program (total of 2927 children)
BMI in RGC Boys
RGC Boys BMI
28
BODY MASS INDEX
26
95
24
%
22
20
18
16
14
12
50%
10
4
5
6
7
8
AGE (years)
9
10
11
BMI in RGC Girls
RGC Girls BMI
30
BODY MASS INDEX
28
26
90%
24
22
20
18
16
14
12
50%
10
4
5
6
7
8
AGE (years)
9
10
11
Boys BMI Risk Categories
Boys BMI stratified by Prevalence
60
Percent of Boys Affected
50
40
>85
30
>99
20
10
0
Age 4
Age 5
Age 6
Age 7
Age 8
Age 9
Age 10 Age 11
Girls BMI Risk Categories
Girls BMI Prevalence by Age
60
Percent of Population Affected
50
40
>85
30
>99
20
10
0
Age 4
Age 5
Age 6
Age 7
Age 8
Age 9
Age 10 Age 11
Lessons Learned


Overweight and Obesity are
Common
Overweight and Obesity are
Common at 4 years of age
Prevalence of
Acanthosis Nigricans
Prevalence of AN by Age
25
Percent Affected
20
15
10
5
0
Age 4
Age 5
Age 6
Age 7
Age 8
Age 9
Age 10 Age 11
Lessons Learned


Acanthosis in common
The prevalence of AN increases
with increasing age
Hyperglycemia
Screening Protocol
Two stage screen
Random (nonfasting)
If cG ≥ 100 then
Rescreen on fasting
If cG ≥ 100 on fasting rescreen
refer for OGTT
Strategy Comparison
Fasting Strategy
FcG
FcG
R
>100
12.2
0.9
>110
5.4
3.2
Casual Strategy
DM CcC
Conf
0.1 13.3
0.4
4.6
FcG
DMC
onf
0.9
0.1
0.6
0.3
Lesson Learned


A casual glucose level is a
reasonable initial screen. It
gives no more false positives
than a “fasting” screen
For the follow-up, you can focus
your efforts on being certain
that people are fasting
Interventions





Bienestar
Bienestar Laredo
Healthy
DiRReCT Starr County
DiRReCT Harlandale
Bienestar
Curriculum/Classroom Activities
Physical Education
Cafeteria Changes
Afterschool Program
Parent Component
Bienestar Laredo
Curriculum/Classroom Activities
Physical Education
Cafeteria Changes
Afterschool Program
Parent Component
Differences




Program Staff vs School and
Public Health Staff
One School System vs 2 School
Systems
Long-established Relationships
vs New Relationships
Local vs Distance
Lessons (Re)Learned



Translational research is
difficult
Compromises have to be made
to sustain project
School policy and
administrative changes can
have major effects on
implementation
HEALTHY (multisite)





Classroom Activities (FLASH)
Revamped PE
Cafeteria Changes and Events
Social Marketing
Parent Program
Lessons (Re)Learned





Every school system is different
Every school is different
PE can be done “better”
Students can be “engaged”
Parent involvement in very, very
difficult
DiRReCT

Behavioral Weight Management
Program delivered afterschool
on school property by face-toface contact or by telelink
Lessons Learned

Increased physical activity,
improved eating habits and weight
loss can be achieved by children
and adults by a 10 week program
BUT effects are not sustained after
the program stops
Lessons Learned




There is much interest in nutrition
and weight control
Telelink connections are very
acceptable to parents and children
Participation after school is
preferable to office-based activities
Minimal, if any stigma
Not in the Definition
Acanthosis nigricans
OR
 Hemoglobin A1c
OR
 Capillary (fingerstick) glucose

Screening
Recommendations
Endorsed by
American Diabetes
Association
American Academy of
Pediatrics
Screening in children
Overweight (CDC, NCHS)
BMI > 85% for age and sex
 weight / height > 85%
 weight > 120% of ideal for
height

AND
Screening in children
Any two of the following:
o Family history of Type 2 diabetes in
first or second degree relative
o High risk group
o Sign of insulin resistance or
conditions associated with insulin
resistance
Sign of / association with
insulin resistance
o
o
o
o
Hypertension
Acanthosis nigricans
Hyperlipidemia
PCOS
Screening in children
o
Start at age 10
onset of puberty if onset< 10
o
Every 2 years
unless symptoms/signs
o
Fasting plasma glucose
preferred (OGTT?)