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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. 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

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  1. Obesity Projects: Lessons Learned and Relearned Daniel E. Hale, M.D Professor of Pediatrics, UTHSCSA

  2. Overview • Definitions of DM types • Epidemiology of DM1 and DM2 • DM2 as a major pediatric health risk • The environment for obesity

  3. Definitions

  4. Type 1 Diabetes (DM1) • Insulin dependent • Juvenile (onset) • Autoimmune B-cell destruction • Positive antibodies • No insulin resistance • Rapid clinical onset

  5. Type 2 Diabetes (DM2) • Non-insulin dependent • Adult (onset) diabetes • Insulin resistance is major component • B-cell dysfunction occurs late • Indolent clinical onset

  6. 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

  7. Epidemiology

  8. 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

  9. 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

  10. How common is Type 2 diabetes in pediatrics? Prevalence U.S. ??? Incidence U.S. ??? Mexico City ??? Pittsburgh ???

  11. 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

  12. 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

  13. 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

  14. DM2at Presentation

  15. 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

  16. 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

  17. Tanner Stage at Diagnosis Pubertal Status Percent Tanner 1 10 Tanner 2 - 4 50 Tanner 5 40

  18. 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%

  19. Acanthosis Nigricans DM2DM1 Neck 93% 2% Axilla 77% 0% Acanthosis is a sign of insulin resistance, not diabetes

  20. Other features Hospitalization • 20% at Dx (most not ill) • Insurance Status • 20% self pay • 55% Medicaid/Chip • 25% Private

  21. 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

  22. Going to Middle School • 1492 middle school children • 89% economically disadvantaged • 92% Mexican American • All urban

  23. Going to Middle School • Questionnaires • Blood pressure • Acanthosis screening • Height and weight • Fasting blood sample for glucose, insulin and lipids

  24. 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

  25. 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. 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

  27. Lesson Learned • If you are thinking about screening for diabetes, you should also screen for cardiovascular risk (lipid profile, blood pressure)

  28. Going to Elementary School • 2672 4th grade children • 91% economically disadvantaged • 87% Mexican American • All urban

  29. 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%

  30. 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)

  31. 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)

  32. BMI in RGC Boys

  33. BMI in RGC Girls

  34. Boys BMI Risk Categories

  35. Girls BMI Risk Categories

  36. Lessons Learned • Overweight and Obesity are Common • Overweight and Obesity are Common at 4 years of age

  37. Prevalence of Acanthosis Nigricans

  38. Lessons Learned • Acanthosis in common • The prevalence of AN increases with increasing age

  39. Hyperglycemia Screening Protocol Two stage screen Random (nonfasting) If cG ≥ 100 then Rescreen on fasting If cG ≥ 100 on fasting rescreen refer for OGTT

  40. Strategy Comparison

  41. 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

  42. Interventions • Bienestar • Bienestar Laredo • Healthy • DiRReCT Starr County • DiRReCT Harlandale

  43. Bienestar Curriculum/Classroom Activities Physical Education Cafeteria Changes Afterschool Program Parent Component

  44. Bienestar Laredo Curriculum/Classroom Activities Physical Education Cafeteria Changes Afterschool Program Parent Component

  45. 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

  46. 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

  47. HEALTHY (multisite) • Classroom Activities (FLASH) • Revamped PE • Cafeteria Changes and Events • Social Marketing • Parent Program

  48. 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

  49. DiRReCT • Behavioral Weight Management Program delivered afterschool on school property by face-to-face contact or by telelink

  50. 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

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