Can You Recognize Insulin Resistance in Children? Do You Need To?

Interviewer: Laurie Scudder, DNP, PNP; Interviewee: Diva D. De León-Crutchlow, MD, MSCE

Disclosures

April 12, 2019

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The International Pediatric Association biennial meeting has long focused on the terrifying list of threats to child health: poverty, malnutrition, vaccine-preventable disease, toxic stress. But this year's meeting, held in Panama City, Panama, March 17-21, added a new agenda item: the paradoxical twin burden of undernutrition and obesity. A range of experts described the rising incidence of obesity, particularly as more countries have turned away, for myriad reasons, from locally sourced traditional foods to mass-produced, cheap, nutritionally poor yet calorically dense foods to feed their populations.

This rise in overweight and obesity is underpinning a rise in insulin resistance. While historically a problem that does not manifest until adulthood, insulin resistance—and the resultant cascade effects of hyperglycemia, prediabetes, and, if unchecked, diabetes—heralds a lifetime of health risks for the affected child.

Diva De León-Crutchlow, MD

Diva De León-Crutchlow, MD, chief of the division of endocrinology and diabetes, and director of the Congenital Hyperinsulinism Center at Children's Hospital of Philadelphia, presented the latest research on this topic at the conference and joined Medscape after her talk to summarize key messages.

What is the incidence of insulin resistance in both the United States and internationally? While obesity is well recognized as a risk factor, what other factors increase risk? Can you "tell by looking" which children may have insulin resistance?

We don't have a specific test to measure insulin resistance, so it's difficult to pin down hard-and-fast incidence numbers. But the studies that have followed obese or overweight children longitudinally indicate that a large percentage of those children will develop insulin resistance, particularly those with unfavorable fat distribution. The reality is that if you start with fat distribution in subcutaneous tissue, it is going to move to other tissues that impact insulin sensitivity, such as the liver. Normally this is a problem that occurs in adults, but increasingly it also occurs in children, and that is very highly associated with obesity.

A rise in obesity is accompanied by a parallel rise in insulin resistance. One study[1] that followed healthy 6-year-olds found a prevalence in insulin resistance of over 25% in the children who were overweight or obese. However, I'm hesitant to cite some of those studies because there is not agreement on which measures should be used to assess insulin resistance in children.

There are several specific risk factors that clinicians may not recognize. Infants born small for gestational age, especially those who then gain weight very rapidly early in childhood, are at particular risk, even if they are not obese during adolescence and later.

Another group at risk are girls with polycystic ovarian syndrome and menstrual irregularities. The general practitioner, while addressing the menstrual irregularity, may not put that into the context of the whole metabolic profile. These girls often have insulin resistance and are at risk for type 2 diabetes.

There is a genetic component that increases insulin resistance independent of weight. I don't think we completely understand what these genetic predispositions are, but it is important to ask about the frequency of type 2 diabetes in the child's family. The child of a mother with gestational diabetes is at higher risk for obesity and insulin resistance.

You mentioned that there is not agreement on measures to assess insulin resistance. How can clinicians best identify these children?

Rapid weight gain during the first year of life has been shown to be particularly important in predicting later adiposity, which correlates with insulin resistance.

We're all so frustrated with the difficulty in successfully addressing overweight and obesity—particularly for children living in poverty, with more limited food options and environments that may not support vigorous outdoor play. Your practice is in an urban environment. Could you talk about some practical strategies that you have used?

We tell parents to provide a high-fiber, low-sugar diet, but many people really don't know what that means. So in our one-to-one or group educational sessions, which are conducted by a nutritionist, we explain the different food groups and how to implement them in the diet. We teach people how to cook foods that are healthy and edible, too. Not all clinicians may have the ability to refer their kids to these kinds of educational interventions.

In terms of physical activity, you're absolutely right that there are so many factors that are outside the control of the families and the medical community that affect a child's opportunity for physical activity.

Schools are key. There are a lot of things that can be done inside the school that can be impactful, from the foods served to the opportunity to play. I frequently ask children if they like to dance. Most people like to dance, and that may be a perfect way of exercising inside the house or school, as well as doing it with friends.

Are diet and exercise enough? Should pharmacotherapy be part of the strategy? If so, for which kids?

The reality is that even in adult populations, there's no good evidence that metformin is indicated just for insulin resistance.

I think that the approach to pharmacotherapy may change in the future as we realize that the results of nonpharmacologic interventions are not enough. But right now, with the evidence we have, there is not, in my opinion, a role for using pharmacotherapy in a child who doesn't have some comorbidity.

What about surgery?

We've been resistant to thinking about surgical intervention for obesity. But that's changing. We are realizing that surgery for an adolescent that is done by a multidisciplinary team that addresses all of the potential consequences and helps that family to support the needed lifestyle changes is an effective intervention.

We're going to need more data outside the context of a research environment before we recommend this intervention for younger children. But for adolescents, it's becoming more and more of an option.

Can surgery get teens off the insulin resistance slope? Can a child return to normal insulin sensitivity?

The studies that have been done demonstrate that one can. The question is sustainability of the interventions that support a child in staying off that ramp. If the initial interventions that support a healthy lifestyle are sustained, that can permanently get that child off the track to insulin resistance and diabetes.

We know that type 2 diabetes is a more severe disease in a young person than in a 60-year-old. Do you think the message that type 2 diabetes is a life-threatening condition in kids is getting out there?

I have to say, probably not. I don't think it is recognized that it is a severe disease. There is a whole risk profile that accompanies type 2 diabetes in kids, including a very high risk for cardiovascular disease and complications we're used to seeing in adults that are now seen even at presentation in children. That is out of proportion to adult presentation of type 2 diabetes. I don't know that we understand why that is.

Is the lack of recognition that diabetes is present—the long delay until diagnosis—the reason there is so much comorbidity at presentation? Or is the comorbidity a result of the severity of the disease itself?

I think it's probably a combination. It is a more severe disease, and not only because it affects individuals for a longer time when it starts early, but because the disease itself is different, even within the same family. The parent may have developed diabetes at age 40 or 50 years of age, but the child develops diabetes at a younger age. It is likely a combination of genetic predisposition and environmental factors that determines the severity of the condition in children and adolescents. And while we're all learning to screen children earlier, not all kids see a healthcare provider annually. The lack of access to medical care, especially for vulnerable populations, affects how early the condition is recognized in a child and therefore how early intervention is sought.

If we're going to effectively prevent this disease cascade, we really have to be looking at the whole cluster of risk factors in the children we are seeing for well-child visits.

Thinking about how the child and family are eating, the opportunities for play, the family genetics, are all necessary. Early recognition of this profile and early intervention before the child even becomes overweight and insulin resistant are critical. As of now, we're not doing enough.

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