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Obesity Projects: Lessons Learned and Relearned. Daniel E. Hale, M.D Professor of Pediatrics, UTHSCSA. Overview. 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). Insulin dependent

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obesity projects lessons learned and relearned
Obesity Projects: Lessons Learned and Relearned

Daniel E. Hale, M.D

Professor of Pediatrics, UTHSCSA

overview
Overview
  • Definitions of DM types
  • Epidemiology of DM1 and DM2
  • DM2 as a major pediatric health risk
  • The environment for obesity
type 1 diabetes dm1
Type 1 Diabetes (DM1)
  • Insulin dependent
  • Juvenile (onset)
  • Autoimmune B-cell destruction
  • Positive antibodies
  • No insulin resistance
  • Rapid clinical onset
type 2 diabetes dm2
Type 2 Diabetes (DM2)
  • Non-insulin dependent
  • Adult (onset) diabetes
  • Insulin resistance is major component
  • B-cell dysfunction occurs late
  • Indolent clinical onset
mody and atypical dm
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
how common is diabetes
How common is diabetes?

17 million people in the U.S.

with DM

  • 1 million with Type 1
  • 16 million with Type 2
  • ? MODY
  • ? Atypical
how common is type 1 diabetes in pediatrics
How common is Type 1 diabetes in pediatrics?

Prevalence

U.S. 2.5/1,000

Incidence

U.S. 12-16/100,000/yr

Mexico City 1

San Antonio 9

Pittsburgh 15

how common is type 2 diabetes in pediatrics
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
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 year1
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 year2
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

bmi kg m2 at diagnosis
BMI (kg/m2) at Diagnosis

Post-rehydration

Child has: Type 2Type 1

<20 2% 86%

20-25 20% 11%

>25 78% 3%

For 13 yr old female: 50% BMI =18.7

85% BMI = 22

95% BMI = 26

age at diagnosis of dm2
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
Tanner Stage at Diagnosis

Pubertal Status Percent

Tanner 1 10

Tanner 2 - 4 50

Tanner 5 40

family history of diabetes
Family History of Diabetes

Child has:DM2DM1

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
Acanthosis Nigricans

DM2DM1

Neck 93% 2%

Axilla 77% 0%

Acanthosis is a sign of insulin resistance, not diabetes

other features
Other features

Hospitalization

    • 20% at Dx (most not ill)
  • Insurance Status
    • 20% self pay
    • 55% Medicaid/Chip
    • 25% Private
lesson learned
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
Going to Middle School
  • 1492 middle school children
  • 89% economically disadvantaged
  • 92% Mexican American
  • All urban
going to middle school1
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

50

60

70

Percent Affected

DM Risk Factors in 12-14 Year Old MA Youth
lesson learned1
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.
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

CAD Risk Factors in 12-14 Year Old MA Youth
lesson learned2
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
Going to Elementary School
  • 2672 4th grade children
  • 91% economically disadvantaged
  • 87% Mexican American
  • All urban
hyperglycemia in 4 th grade students fasting samples only
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 OGTT

IGT (2hr>140, <200) 1.3%

DM2 (2hr>200) 0.4%

lessons learned
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
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)
lessons learned1
Lessons Learned
  • Overweight and Obesity are Common
  • Overweight and Obesity are Common at 4 years of age
lessons learned2
Lessons Learned
  • Acanthosis in common
  • The prevalence of AN increases with increasing age
hyperglycemia screening protocol
Hyperglycemia Screening Protocol

Two stage screen

Random (nonfasting)

If cG ≥ 100 then

Rescreen on fasting

If cG ≥ 100 on fasting rescreen refer for OGTT

lesson learned3
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
Interventions
  • Bienestar
  • Bienestar Laredo
  • Healthy
  • DiRReCT Starr County
  • DiRReCT Harlandale
bienestar
Bienestar

Curriculum/Classroom Activities

Physical Education

Cafeteria Changes

Afterschool Program

Parent Component

bienestar laredo
Bienestar Laredo

Curriculum/Classroom Activities

Physical Education

Cafeteria Changes

Afterschool Program

Parent Component

differences
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
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
HEALTHY (multisite)
  • Classroom Activities (FLASH)
  • Revamped PE
  • Cafeteria Changes and Events
  • Social Marketing
  • Parent Program
lessons re learned1
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
DiRReCT
  • Behavioral Weight Management Program delivered afterschool on school property by face-to-face contact or by telelink
lessons learned3
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 learned4
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
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 RecommendationsEndorsed byAmerican Diabetes AssociationAmerican Academy of Pediatrics
screening in children
Screening in children

Overweight (CDC, NCHS)

  • BMI > 85% for age and sex
  • weight / height > 85%
  • weight > 120% of ideal for height

AND

screening in children1
Screening in children

Any two of the following:

  • Family history of Type 2 diabetes in first or second degree relative
  • High risk group
  • Sign of insulin resistance or conditions associated with insulin resistance
sign of association with insulin resistance
Sign of / association with insulin resistance
  • Hypertension
  • Acanthosis nigricans
  • Hyperlipidemia
  • PCOS
screening in children2
Screening in children
  • Start at age 10

onset of puberty if onset< 10

  • Every 2 years

unless symptoms/signs

  • Fasting plasma glucose preferred (OGTT?)