Presence of Type 2 Diabetes Risk Factors in Children

Leslie K. Scott, PhD, PNP-BC, CDE

Disclosures

Pediatr Nurs. 2013;39(4):190-196. 

In This Article

Review of the Literature

As early as 1916, diabetologists recognized that some children with diabetes had an unusually mild and slowly progressive form of the disease that did not require insulin for survival (Ludwig & Ebbeling, 2001). Until the last decade, little attention was paid to this form of diabetes that closely resembled type 2 diabetes, typically diagnosed in adults.

Before 1990, fewer than 4% of children diagnosed with diabetes had type 2 diabetes (Pinhas-Hamil & Zeitler, 2005). Although type 2 diabetes remains rare in youth under 10 years of age, rates have increased among individuals 10 to 19 years of age, particularly those in high-risk ethnic groups. Prior to 1994, most epidemiologic studies focused on small, high-risk ethnic groups of adolescents, such as Pima Indians, American-Indians, First Nations, Mexican-Americans, and African-Americans (Nadeau & Dabelea, 2008). More recent studies have identified that up to 45% of African-American and Caucasian children diagnosed with diabetes in the U.S. have type 2 diabetes (CDC, 2008a; Soltesz, 2006).

Based on 2002–2003 data, 3,700 youth are diagnosed with type 2 diabetes annually (CDC, 2008b). The incidence rate of type 2 diabetes is 5.3 per 100,000 youth under 19 years of age (Zeitler & Pinhas-Hamil, 2008). Symptoms associated with hyperglycemia are insidious; adults with type 2 diabetes are thought to have hyperglycemia or impaired glucose tolerance for 7 to 10 years prior to diagnosis (Zeitler & Pinhas-Hamil, 2008). Current literature now indicates the insidious onset of type 2 diabetes in children mirrors the disease onset of adults (Bloomgarten, 2004). The longer a person has diabetes, the greater the chance of developing complications associated with diabetes (National Institutes of Health [NIH], 2010). Because complications associated with diabetes occur due to prolonged hyperglycemia, mounting evidence suggests that children and adolescents diagnosed with type 2 diabetes are at tremendous risk for developing early/premature complications (Pinhas-Hamil & Zeitler, 2007). Due to the risk for the onset of these diabetes-related complications, finding youth with unknown diabetes has been the impetuous of youth diabetes screening programs.

Four primary risk factors as identified by the American Diabetes Association (ADA) and the American Academy of Pediatrics (AAP) place children at risk for the development of type 2 diabetes: obesity, ethnicity, family history of diabetes, and the presence of insulin resistance (see Figure 1) (ADA, 2010). Although the ADA and the AAP do not recognize gender as an independent risk factor for the development of type 2 diabetes in children, being female can provide additional risk. In the U.S., the adult prevalence of type 2 diabetes is slightly higher in women than men. Similarly in children, females are 1.63 times more likely to develop type 2 diabetes than males (Dabelea et al., 2007).

Figure 1.

Screening Criteria for Type 2 Diabetes in Children
Source: ADA, 2010.

Approximately 17% (or 12.5 million) children and adolescents 2 to 19 years of age in the U.S. are obese (CDC, 2011b). Since 1980, obesity prevalence rates among children and adolescents have almost tripled. Obesity is the most important, yet modifiable risk factor for the development of type 2 diabetes. High-risk ethnic groups (i.e., Native-American, African-American, Mexican-American, Asian-American, Pacific Island ers) are particularly susceptible to the onset of type 2 diabetes, especially if they are overweight. Obese children produce too much insulin as a result of excess adipose tissue, which leads to insulin resistance and compensatory hyperinsulinemia (Copeland, Becker, Gottschalk, & Hale, 2005). Acanthosis nigricans has been well documented as a clinical indicator of hyperinsulinemia and demonstrates evidence of insulin resistance. Typically, the greater the severity of acanthosis nigricans, the more significant is the degree of insulin resistance and hyperinsulinemia. Other clinical indicators associated with insulin resistance include hyperlipidemia and hypertension (Hu & Stampfer, 2005).

According to the ADA and AAP, all obese children and those whose body mass index (BMI) is greater than the 85th percentile for age and gender, with any two risk factors – highrisk ethnicity, family history of diabetes, or evidence of insulin resistance – should be screened beginning at 10 years of age or at the onset of puberty if that develops earlier (see Figure 1) (ADA, 2010). Many studies report these screening guidelines are inconsistently applied (Zeitler & Pinhas-Hamil, 2008). In the primary care setting, as few as 45% of children who qualify for type 2 diabetes screening are actually screened with further ancillary testing (Anand, Mehta, & Adams, 2006).

Children meeting criteria for type 2 diabetes screening should have further ancillary tests to assess their glucose response to carbohydrate metabolism. Children should also be further screened for additional evidence of insulin resistance and common comorbidities associated with type 2 diabetes. Common ancillary tests for screening for type 2 diabetes in children and its complications include fasting plasma glucose, 2-hour oral glucose tolerance test, hemoglobin A1c, blood pressure, lipid profile, and thyroid-stimulating hormone (TSH) (ADA, 2000).

Most studies investigating the increased incidence of type 2 diabetes in children and screening at-risk youth have focused on very small populations of high-risk children (ADA, 2000; CDC, 2008a). Texas screens children in grades 3, 5, and 8 for the presence of acanthosis nigricans (Texas Department of Health, 2002). Although youth are identified for the presence of acanthosis nigricans, no statistics have been reported indicating the incidence of type 2 diabetes or the prevalence of additional risk factors in the students screened (Hardin, 2006). Children were screened for acanthosis nigricans; however, quantitative information regard ing acanthosis nigricans was not reported.

Burke, Hale, Hazuda, and Stern (1999) developed a quantitative acanthosis nigricans screening tool. The tool was tested on Mexican-American adults and included a description of each degree of acanthosis nigricans severity at various anatomic locations. The neck was found to be the only reliable location for accurate detection of acanthosis nigricans (Burke et al., 1999).

No current studies have specifically focused on identifying high-risk children as described by the AAP/ADA screening guidelines within the general population, particularly those under 13 years of age. Therefore, the purpose of this study was to determine the prevalence of type 2 diabetes risk factors among elementary school-age children in grades 1 through 5 and identify the number of youth eligible for further screening as described by AAP/ADA screening guidelines.

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