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

2. 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

3. Definitions

4. 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

5. 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

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 o 1 million with Type 1 o 16 million with Type 2 o ? MODY o ? 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) 0 3 6 9 12 15 18 21 90919293949596979899 DM-1

12. Incidence of Diabetes in San Antonio (new cases/100,000 children/year) 0 3 6 9 12 15 18 21 90919293949596979899 DM-2

13. Incidence of Diabetes in San Antonio (new cases/100,000 children/year) 0 3 6 9 12 15 18 21 90919293949596979899 DM-1 DM-2 DM-All

14. DM2 at Presentation

15. BMI (kg/m2) at Diagnosis Post-rehydration Child has:Type 2Type 1 <20 2% 86% 20-2520% 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 110 Tanner 2 - 450 Tanner 540

18. 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%

19. Acanthosis Nigricans DM2DM1 Neck93% 2% Axilla77% 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. 24 DM Risk Factors in 12-14 Year Old MA Youth FH-DM BMI(M) HI BMI(F) AN IFG DM2 010203040506070 Percent Affected

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. 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 0102030405060 Percent Affected

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 4 th grade children 91% economically disadvantaged 87% Mexican American All urban

29. 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%

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 Fasting StrategyCasual Strategy FcGFcG R DM Conf CcCFcGDMC onf >10012.20.90.113.30.90.1 >1105.43.20.44.60.60.3

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

51. 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

52. Not in the Definition Acanthosis nigricans OR Hemoglobin A1c OR Capillary (fingerstick) glucose

53. Screening Recommendations Endorsed by American Diabetes Association American Academy of Pediatrics

54. Screening in children Overweight ( CDC, NCHS ) BMI > 85% for age and sex weight / height > 85% weight > 120% of ideal for height AND

55. 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

56. Sign of / association with insulin resistance o Hypertension o Acanthosis nigricans o Hyperlipidemia o PCOS

57. 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?)