Type 2 diabetes now accounts for up to 45% of the new cases of diabetes in children within the U.S. depending on geographical region and ethnicity of study subjects (ADA, 2000). Being overweight or obese plays a major role in the development of type 2 diabetes. Obesity in children is a growing concern placing more children at risk for the development of type 2 diabetes. Early identification of at-risk youth may assist in the development of intervention strategies targeted at reducing modifiable risk factors associated with type 2 diabetes in children. Twenty-three percent of the students screened were obese, and nearly 40% had a BMI greater than the 85th percentile for age and gender. At the time data were collected, these findings exceeded national statistics on overweight and obesity in children. Due to the rise in rates of obesity in children over the past decade, these rates coincide with national estimates that 19.6% of children 6 to 12 years of age are obese (Ogden, Carroll, Curtain, Lamb, & Flegal, 2010). Thirty-two percent of children 6 to 19 years of age have a BMI greater than 85th percentile for age and gender (Ogden et al., 2010).
Students 10 years of age or older were more likely to be obese compared to children younger than 10 years of age (27.9%, 20.6% respectively). This finding demonstrates the importance of early detection of young overweight students, as well as identifies a target population in which intervention strategies should particularly focus on the prevention of obesity.
Within the overall group of students, grades 1 through 5, African-American students were more obese compared to non-Hispanic Caucasian students (25%, 10.9% respectively). However, by 10 years of age, there was no difference in BMI related to ethnicity. The lack of ethnic differences in BMI percentiles by 10 years of age may be attributed to the geographically close proximity of the study participants to the Appalachia region and the known high rates of obesity in non-Hispanic Caucasian adults within in the region (CDC, 2009). Further studies are needed to determine if these findings are only representative of the region or an emerging trend in the U.S.
Acanthosis nigricans was identified in 23.4% of the students screened. Nationally, prevalence rates among children range from 17% to 55% of children 7 to 19 years of age (Hirschler, Aranda, Oneto, Gonzalez, & Jadzinsky, 2002; Kong et al., 2007). Similar to current research, significantly more African-American students had acanthosis nigricans as compared with their non-Hispanic Caucasian peers. Given that the presence of acanthosis nigricans is a known clinical surrogate for laboratory-deter mined hyperinsulinemia, find ings indicate a number of students have evidence of insulin resistance and are at risk for future development of type 2 diabetes (Litonjua, Pinero-Pilona, Aviles-Santa, & Raskin, 2004).
Nearly one-half of the students screened identified a family history of diabetes. No ethnic differences existed within the group relating to a family history of diabetes. These findings vary from national norms most likely due to the close proximity of the research area to the Appalachian region and the known higher incidence of diabetes in Appalachia (CDC, 2009). No data exist in the literature reporting the prevalence of a positive family history of diabetes within the general population, particularly in children. Further epidemiologic studies are indicated to better determine the prevalence of a positive family history of type 2 diabetes within the general population.
According to AAP and ADA guidelines (ADA, 2000), nearly 40% of the students were eligible for further screening for type 2 diabetes. Similar to the literature, high-risk ethnic groups were likely to have multiple risk factors for the development of type 2 diabetes. Further research is needed to evaluate current screening practices of high-risk children and to better understand acanthosis nigricans as it occurs in children, particularly to determine if regional differences in its occurrence exist. Additional studies focusing on prevention and intervention strategies targeting controllable risk factors are needed and should be directed toward these high-risk students.
Limitations of the Study
Limitations of this study include possible measurement errors of height, weight, and acanthosis nigricans screening due to multiple examiners collecting data. Another limitation was the completeness of the health history form. The form re quired self-reported information. Various forms had areas that were left blank. These errors may have been due to the ambiguity of the questions or the family's inability to read, write, or comprehend English. Additional limitations include the lack of further biological data, such as blood pressure and blood lipid levels collected on the participants. Hypertension and hyper lipidemia are both indicators of in sulin resistance. Seventy percent of obese youth have at least one risk factor for cardiovascular disease, such as high cholesterol or hypertension (Freedman, Zuguon, Srinivasan, Berenson, & Deitz, 2007). Students eligible for further type 2 diabetes screening may have been missed because they could have had evidence of insulin resistance other than acanthosis nigricans, such as hypertension or hyperlipidemia. Screen ing for hypertension and hyperlipidemia are not presently part of required, schoolbased health screenings in Kentucky schools.
The lack of known pubertal status is an additional limitation. Children younger than 10 years of age in puberty may have been excluded from the screening results, yet qualify for further screening due to their pubertal status. Screening for pubertal status is an invasive technique currently not included during routine, school-based health screenings in Kentucky schools.
A final limitation addresses the generalizability of the study findings. Although a cross-sectional design was used for the study, the ethnic makeup of the study population exceeds national percentages for African-American and Hispanic/Other populations (U.S. Census Bureau, 2011). More African-American and Hispanic/Other students were included in the study than representative of the U.S. population. However, ethnic differences in BMI did not exist beyond 9 years of age within the study findings. Acanthosis nigricans rates were much higher in African-American students as compared to non-Hispanic Caucasian and Hispanic/Other students. These findings are similar to previous studies and further support the AAP/ADA screening criteria for identifying at-risk youth.
Implications for School Nurses
School nurses are in a unique position to assist in screening for risk factors associated with type 2 diabetes in children. As an integral part of health maintenance and assessment, annual height/weight, and acanthosis nigricans screenings can easily assist the school nurse with early identification of at-risk children. Through early identification, strategies can be implemented to further screen at-risk youth. The school nurse can also target efforts to possibly reduce modifiable risk-factor development in those atrisk youth through health education and lifestyle modification strategies.
School nurses can collaborate between school personnel, students, their family, and health care providers/professionals. Through this collaborative role, school nurses have the skill and ability to assist high-risk students and their families to institute behavior change strategies that focus on the reduction of controllable risk factors associated with the development of type 2 diabetes. Their knowledge of health and wellness strategies and their understanding of child development also place them in a key position to help guide school leaders and community leaders into making key changes in school dietary and activity offerings.
Due to the potential economic impact and insidious onset of type 2 diabetes, conducting early screening of at-risk youth is important. Study findings support the need to identify target groups/populations. Schoolbased health screenings can provide an opportunity to identify these atrisk youth and initiate early implementation of modifiable risk-reduction strategies.
Pediatr Nurs. 2013;39(4):190-196. © 2013 Jannetti Publications, Inc.