Obesity Projects: Lessons Learned and Relearned

Daniel E. Hale, M.DProfessor of Pediatrics, UTHSCSA

Overview

o Definitions of DM typeso Epidemiology of DM1 and DM2 o DM2 as a major pediatric health risko The environment for obesity

Definitions

Type 1 Diabetes (DM1)

o Insulin dependento Juvenile (onset)o Autoimmune B-cell destructiono Positive antibodieso No insulin resistanceo Rapid clinical onset

Type 2 Diabetes (DM2)

o Non-insulin dependento Adult (onset) diabeteso Insulin resistance is major

componento B-cell dysfunction occurs lateo 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 DMo 1 million with Type 1o 16 million with Type 2o ? MODYo ? Atypical

How common is Type 1 diabetes in pediatrics?

Prevalence U.S. 2.5/1,000

IncidenceU.S. 12-16/100,000/yrMexico City 1San Antonio 9Pittsburgh 15

How common is Type 2 diabetes in pediatrics?

Prevalence U.S. ???

IncidenceU.S. ???Mexico City ??? Pittsburgh ???

Incidence of Diabetes in San Antonio (new cases/100,000 children/year)

0

3

6

9

12

15

18

21

90 91 92 93 94 95 96 97 98 99

DM-1

Incidence of Diabetes in San Antonio (new cases/100,000 children/year)

0

3

6

9

12

15

18

21

90 91 92 93 94 95 96 97 98 99

DM-2

Incidence of Diabetes in San Antonio (new cases/100,000 children/year)

0

3

6

9

12

15

18

21

90 91 92 93 94 95 96 97 98 99

DM-1

DM-2

DM-All

DM2at Presentation

BMI (kg/m2) at Diagnosis

Post-rehydrationChild has: Type 2 Type 1<20 2% 86%20-25 20% 11%>25 78% 3%

For 13 yr old female: 50% BMI =18.785% BMI = 2295% BMI = 26

Age at Diagnosis of DM2

No DM2 <5 yrs of age (yet)5% of new DM diagnoses 5-9 yrs35% of new DM diagnosed 9-14 yrs75% of new DM diagnosed >15 yrs

Mean age at DX with DM2 = 13.4 years

Tanner Stage at Diagnosis

Pubertal Status PercentTanner 1 10Tanner 2 - 4 50Tanner 5 40

Family History of Diabetes

Child has: DM2 DM1

0 Parent with DM 30% 88%1 Parent with DM 66% 12%2 Parents with DM 4% 0%

Estimated prevalence of DM2 in adults in 25-40 age range in SA varies from 4-12%

Acanthosis Nigricans

DM2DM1

Neck 93% 2%Axilla 77% 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

24

DM Risk Factors in 12-14 Year Old MA Youth

FH-DM

BMI(M)

HI

BMI(F)

AN

IFG

DM2

0 10 20 30 40 50 60 70Percent Affected

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 follow-up is bad public health policy.

26

CAD Risk Factors in 12-14 Year Old MA Youth

TC

BMI(M)

FH- Lipid

BMI(F)

Trigly

BP(M)

FH-MI<50

FH-SD

LDL-C

BP(F)

HDL-C

0 10 20 30 40 50 60Percent Affected

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) 12.2%FcG (>110) 5.4%

Repeated IFcG 3.2%

All with FcG>110 on repeat to OGTTIGT (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

10

12

14

16

18

20

22

24

26

28

4 5 6 7 8 9 10 11

AGE (years)

BO

DY

MA

SS

IN

DE

X

95

%

50%

BMI in RGC Girls

10

12

14

16

18

20

22

24

26

28

30

4 5 6 7 8 9 10 11

AGE (years)

BO

DY

MA

SS

IN

DE

X

90%

50%

0

10

20

30

40

50

60

Age 4 Age 5 Age 6 Age 7 Age 8 Age 9 Age 10 Age 11

Pe

rce

nt

of

Bo

ys A

ffe

cte

d

>85

>99

Boys BMI Risk Categories

0

10

20

30

40

50

60

Age 4 Age 5 Age 6 Age 7 Age 8 Age 9 Age 10 Age 11

Pe

rce

nt

of

Po

pu

lati

on

Aff

ec

ted

>85

>99

Girls BMI Risk Categories

Lessons Learned

Overweight and Obesity are Common

Overweight and Obesity are Common at 4 years of age

0

5

10

15

20

25

Age 4 Age 5 Age 6 Age 7 Age 8 Age 9 Age 10 Age 11

Pe

rce

nt

Aff

ec

ted

Prevalence of Acanthosis Nigricans

Lessons Learned

Acanthosis in common The prevalence of AN increases

with increasing age

Hyperglycemia Screening Protocol

Two stage screenRandom (nonfasting)If cG ≥ 100 then

Rescreen on fastingIf cG ≥ 100 on fasting rescreen refer for OGTT

Strategy Comparison

Fasting Strategy Casual Strategy

FcG FcGR DMConf

CcC FcG DMConf

>100 12.2 0.9 0.1 13.3 0.9 0.1

>110 5.4 3.2 0.4 4.6 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 ActivitiesPhysical EducationCafeteria ChangesAfterschool ProgramParent Component

Bienestar Laredo

Curriculum/Classroom ActivitiesPhysical EducationCafeteria ChangesAfterschool ProgramParent 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-to-face 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 nigricansOR Hemoglobin A1cOR Capillary (fingerstick) glucose

Screening RecommendationsEndorsed byAmerican Diabetes AssociationAmerican 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 groupo Sign of insulin resistance or conditions

associated with insulin resistance

Sign of / association with insulin resistance

o Hypertensiono Acanthosis nigricanso Hyperlipidemiao 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?)