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

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

Definitions

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

Type 2 Diabetes (DM2) o Non-insulin dependent o Adult (onset) diabetes o Insulin resistance is major component o B-cell dysfunction occurs late o 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 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.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? Prevalence U.S.??? Incidence U.S.??? Mexico City ??? Pittsburgh ???

Incidence of Diabetes in San Antonio (new cases/100,000 children/year) DM-1

Incidence of Diabetes in San Antonio (new cases/100,000 children/year) DM-2

Incidence of Diabetes in San Antonio (new cases/100,000 children/year) DM-1 DM-2 DM-All

DM2 at Presentation

BMI (kg/m2) at Diagnosis Post-rehydration Child has:Type 2Type 1 <20 2% 86% % 11% >25 78% 3% For 13 yr old female:50% BMI = % BMI = 22 95% BMI = 26

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 Pubertal Status Percent Tanner 110 Tanner Tanner 540

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 age range in SA varies from 4-12%

Acanthosis Nigricans DM2DM1 Neck93% 2% Axilla77% 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 Year Old MA Youth FH-DM BMI(M) HI BMI(F) AN IFG DM Percent 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 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 Percent 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 th grade children 91% economically disadvantaged 87% Mexican American All urban

Hyperglycemia in 4 th Grade Students Fasting Samples Only FcG(>100)12.2% FcG (>110) 5.4% Repeated IFcG3.2% All with FcG>110 on repeat to OGTT IGT (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

BMI in RGC Girls

Boys BMI Risk Categories

Girls BMI Risk Categories

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

Prevalence of Acanthosis Nigricans

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

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

Strategy Comparison Fasting StrategyCasual Strategy FcGFcG R DM Conf CcCFcGDMC onf > >

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 Activities Physical Education Cafeteria Changes Afterschool Program Parent Component

Bienestar Laredo Curriculum/Classroom Activities Physical Education Cafeteria Changes Afterschool Program Parent 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 nigricans OR Hemoglobin A1c OR Capillary (fingerstick) glucose

Screening Recommendations Endorsed by American Diabetes Association American 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 group o Sign of insulin resistance or conditions associated with insulin resistance

Sign of / association with insulin resistance o Hypertension o Acanthosis nigricans o Hyperlipidemia o 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?)