Obesity Projects Lessons Learned and Relearned Daniel E
Obesity Projects: Lessons Learned and Relearned Daniel E. Hale, M. D Professor of Pediatrics, UTHSCSA
Overview o o Definitions of DM types Epidemiology of DM 1 and DM 2 as a major pediatric health risk The environment for obesity
Definitions
Type 1 Diabetes (DM 1) o o o Insulin dependent Juvenile (onset) Autoimmune B-cell destruction Positive antibodies No insulin resistance Rapid clinical onset
Type 2 Diabetes (DM 2) 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 n Maturity Onset Diabetes of Youth n n n Autosomal dominant with variable penetrance Single gene defect involving insulin production or signaling Atypical n n n 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
DM 2 at Presentation
BMI (kg/m 2) 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 DM 2 No DM 2 <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 DM 2 = 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 DM 2 30% 66% 4% DM 1 88% 12% 0% Estimated prevalence of DM 2 in adults in 25 -40 age range in SA varies from 4 -12%
Acanthosis Nigricans Neck Axilla DM 2 DM 1 93% 77% 2% 0% Acanthosis is a sign of insulin resistance, not diabetes
Other features Hospitalization n n 20% at Dx (most not ill) Insurance Status n n n 20% self pay 55% Medicaid/Chip 25% Private
Lesson Learned n 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 DM 2
Going to Middle School n n 1492 middle school children 89% economically disadvantaged 92% Mexican American All urban
Going to Middle School n n n 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 DM 2 IFG AN BMI(F) HI BMI(M) FH-DM 0 10 20 30 40 Percent Affected 50 60 70 24
Lesson Learned n n n As many as 20% of students may have acanthosis. About 0. 5% or less will have DM 2 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 Percent Affected 40 50 60 26
Lesson Learned n If you are thinking about screening for diabetes, you should also screen for cardiovascular risk (lipid profile, blood pressure)
Going to Elementary School n n 2672 4 th grade children 91% economically disadvantaged 87% Mexican American All urban
Hyperglycemia in 4 th Grade Students Fasting Samples Only Fc. G(>100) Fc. G (>110) 12. 2% 5. 4% Repeated IFc. G 3. 2% All with Fc. G>110 on repeat to OGTT IGT (2 hr>140, <200) 1. 3% DM 2 (2 hr>200) 0. 4%
Lessons Learned n 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 n n 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
BMI in RGC Girls
Boys BMI Risk Categories
Girls BMI Risk Categories
Lessons Learned n n Overweight and Obesity are Common at 4 years of age
Prevalence of Acanthosis Nigricans
Lessons Learned n n Acanthosis in common The prevalence of AN increases with increasing age
Hyperglycemia Screening Protocol Two stage screen Random (nonfasting) If c. G ≥ 100 then Rescreen on fasting If c. G ≥ 100 on fasting rescreen refer for OGTT
Strategy Comparison Fasting Strategy Fc. G R >100 12. 2 0. 9 >110 5. 4 3. 2 Casual Strategy DM Cc. C Conf 0. 1 13. 3 0. 4 4. 6 Fc. G DMC onf 0. 9 0. 1 0. 6 0. 3
Lesson Learned n n 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 n n n Bienestar Laredo Healthy Di. RRe. CT Starr County Di. RRe. CT 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 n n 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 n n n 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) n n n Classroom Activities (FLASH) Revamped PE Cafeteria Changes and Events Social Marketing Parent Program
Lessons (Re)Learned n n n Every school system is different Every school is different PE can be done “better” Students can be “engaged” Parent involvement in very, very difficult
Di. RRe. CT n Behavioral Weight Management Program delivered afterschool on school property by face-toface contact or by telelink
Lessons Learned n 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 n n 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 n Hemoglobin A 1 c OR n Capillary (fingerstick) glucose n
Screening Recommendations Endorsed by American Diabetes Association American Academy of Pediatrics
Screening in children Overweight (CDC, NCHS) BMI > 85% for age and sex n weight / height > 85% n weight > 120% of ideal for height n 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 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? )
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