obesity projects: lessons learned and relearned daniel e. hale, m.d professor of pediatrics, uthscsa
TRANSCRIPT
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?)