Abnormal Blood Sugar, Cholesterol Common in Middle School

Tara Haelle

March 15, 2019

More than one third of middle school students who underwent cardiovascular screening at school had abnormal blood sugar levels or high cholesterol, a pilot study of 45 students found. For two of those children, hemoglobin A1c (HbA1C) levels were "solidly in the range that would be concerning for diabetes in children without symptoms or diagnosis of diabetes," the researchers write.

They say the findings demonstrate the importance of cardiovascular screening in this age group and that conducting such screening in middle schools is a feasible alternative to medical visit screenings, particularly for communities with limited access to primary pediatric care.

Robert M. Siegel, MD, director of the Center for Better Health and Nutrition in the Heart Institute at Cincinnati Children's Hospital in Ohio, and colleagues reported their findings in a study published online March 15 in the Journal of Pediatrics.

"What our study demonstrates is that this type of screening is very important. You do pick up a number of kids with lipid abnormalities, and there will be some kids that have borderline hemoglobin A1c levels," Siegel told Medscape Medical News.

"Ideally, these screenings should be done in the medical setting, but if that's not happening, this is a reasonable alternative," he added.

The American Academy of Pediatrics, the American Heart Association, and the American Diabetes Association recommend routine screening of school-age children for hypertension, lipid abnormalities, and diabetes.

However, "that's not happening anywhere as much as it should," Siegel said. He and his colleagues designed their pilot study to see whether it was practical to conduct screenings "in a school setting as a backup for those kids being missed by their medical providers."

Among 290 seventh and eighth grade students at a middle school who were invited to participate, parents returned consent forms for 45 students (16%), who then took part the study. During two 4-hour morning screening sessions, those 45 students reported in small groups to the nurse's office for assessment of height, weight, blood pressure, percent body fat, and nonfasting HbA1C, total cholesterol, high-density lipoprotein, and triglyceride levels. Screening is recommended for persons aged 9 to 11 years; these students were 12 to 14 years old.

Among the 45 children, 26 (57.8%) had a normal or low body mass index (BMI), and 19 (42.2%) had a BMI in the overweight or obese range. High triglyceride levels were identified in 23.2% of all students screened, including 12.5% of the students with a normal or low BMI. Overall, 34.8% of the students — including a quarter of those with normal or low BMI — had elevated lipid or HbA1c levels.

None of the lipid abnormalities were in ranges that indicated a need for medication, Siegel said. "They were all in the lifestyle intervention range," he said.

The researchers found that 42% of the students had a high percentage of body fat (more than 25% for girls and more than 35% for boys), including 8% of those with a normal or low BMI.

In addition, the researchers were surprised to find two children with HbA1C values in the diabetes range, yet neither child had symptoms or had been diagnosed with diabetes. After follow-up at a diabetes clinic, one was diagnosed with type 2 diabetes, and the other with maturity-onset diabetes of youth type 1.

Siegel said he did not expect that the discovery of these two undiagnosed cases means that widespread school screenings would uncover a high percentage of children with unrecognized diabetes. However, these findings do underscore the importance of ensuring that screenings occur, regardless of the setting, he explained.

The screenings cost approximately $20 per student, Siegel said. Although that would be a significant amount with respect to school populations, he noted that "the savings can be large on the back end, especially with some of the results we saw."

He acknowledged that an in-school cardiovascular screening program would likely need a "medical champion," such as a school nurse, because the cost and time investment does not end with initial screenings. "They require follow-up phone calls, tracking kids down, and making sure parents get educated and plugged into the proper care," Siegel told Medscape Medical News.

"Still, there are potential advantages that make screening in the middle school setting attractive, such as the inherent efficiency of having a large number of children clustered in one setting for the testing," the authors write.

The city where the study occurred has a population of 19,207. There are no practicing pediatricians in town, which is 86.6% white, 7.6% black, and 5.1% Latino. The racial/ethnic breakdown of the participating students was similar to the town's (71% white, 16% black, 9% Latino). The researchers did not have adequate data to directly compare demographics or characteristics between the 45 participating students and the students whose parents did not return consent forms for the study.

Siegel acknowledged that selection bias was therefore likely, but it is unclear in what direction that bias might take. It is possible that the parents who returned the consent forms were more concerned about their children, perhaps suggesting that those screened were more vulnerable to cardiovascular risk factors or had a relevant family history. On the other hand, participating students' parents could be more attentive in general, and the students screened could be at lower risk than their peers, he explained. Overall, the BMI of those screened did not substantially differ from the school population's BMI, he added.

The researchers also lacked data on students' previous screenings, health histories, and potential barriers to screening, nor did they have data on screening rates in the city. The researchers "assumed that [the rates] are <30% based on published surveys and screening data and that few if any students had been previously screened for lipid abnormalities and diabetes.

"Barriers previously reported to screening such as concerns over adherence to lifestyle recommendations, inability to pay for testing, and lack of knowledge by physicians and families are very likely to be at play in this community as well," they add.

Identifying potential harms of screening were beyond the scope of the study, but Siegel noted that BMI screenings already occur in many schools and that such screenings may be upsetting to some students with higher BMIs.

"By including BMI in a more comprehensive cardiovascular screen with less emphasis on weight, children with a high BMI may feel less stigmatized," the researchers write.

The research was funded by Ethicon Corporation. The authors have disclosed no relevant financial relationships.

J Pediatr. Published online March 15, 2019. Full text

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