Prevention and treatment of type 2 diabetes mellitus in children, with special emphasis on American Indian and Alaska Native children. American Academy of Pediatrics Committee on Native American Child Health

Understanding the Procedural Skills Needed in Rural Pediatric Practices: A Survey of Rural Pediatric Providers in the State of New Mexico

OBJECTIVES

There is little data evaluating procedural skills in current rural pediatric practices. In order to prepare a cadre of pediatricians to work in rural settings, we require an understanding of the unique procedural skills needed by rural pediatric providers. Our objective was to determine how often pediatricians performed various procedural skills, determine the importance of these skills to current practice, and how they differ between rural and urban pediatric providers.

METHODS

A survey evaluating pediatrician utilization of the 13 required Accreditation Council Graduate Medical Education procedural skills in current practice was developed and distributed to pediatric providers in New Mexico. Descriptive statistics were used to profile participants and describe survey responses. Chi-square tests were used to evaluate differences by urban setting or IHS. Fisher's exact test was employed to assess differences if cell sizes were less than five. All p-values were two sided with alpha=.05. Benjamini-Hochberg method was used to control for type 1 errors.

RESULTS

Fifty-two of 216 pediatric providers responded. The majority surveyed performed each of the 13 procedures less than monthly but competency in many of these procedures is important. Thirty-two respondents submitted free-text responses recommending competence with tracheostomy changes, gastrostomy-tube changes/cares, and circumcision.

CONCLUSION

Majority of surveyed pediatricians performed the required procedures less than monthly but deemed several procedures to be important. Rural pediatricians recommended specific procedural skills needed in rural practice. All trainees receive procedural skills training. However, trainees interested in rural practice may need additional training in specific skills different than their non-rural counterparts.

Caring for American Indian and Alaska Native Children and Adolescents

American Indian and Alaska Native (AI/AN) populations have substantial health inequities, and most of their disease entities begin in childhood. In addition, AI/AN children and adolescents have excessive disease rates compared with the general pediatric population. Because of this, providers of pediatric care are in a unique position not only to attenuate disease incidence during childhood but also to improve the health status of this special population as a whole. This policy statement examines the inequitable disease burden observed in AI/AN youth, with a focus on toxic stress, mental health, and issues related to suicide and substance use disorder, risk of and exposure to injury and violence in childhood, obesity and obesity-related cardiovascular risk factors and disease, foster care, and the intersection of lesbian, gay, bisexual, transgender, queer, and Two-Spirit and AI/AN youth. Opportunities for advocacy in policy making also are presented.

Usual Dietary Intake and Adherence to Dietary Recommendations among Southwest American-Indian Youths at Risk of Type 2 Diabetes

BACKGROUND

American Indians are disproportionately affected by obesity and diabetes, and American-Indian youths have the highest prevalence of obesity and diabetes among all ethnic groups in the USA.

OBJECTIVES

The purposes of this study were to assess the usual dietary intake in American-Indian youths who attended a wellness camp program; adherence to the Dietary Guidelines for Americans 2015-2020 (DGA) and to the Healthy People 2020 Objectives; and to compare pre- and postcamp reported diets.

METHODS

A total of six 24-h dietary recalls were conducted in person with American-Indian youths (aged 10-15 y; n = 26) from 3 different Southwest tribes. Three recalls were conducted before the wellness camp, and 3 were conducted after the camp. A series of 2-factor ANOVA were conducted, using a mixed model, to compare the nutrition differences before and after the health camp using a statistical program, R.

RESULTS

Adherence to federal dietary recommendations was low, with few of the youths meeting the DGA recommendations for fruits (15%, average serving 0.69 cup/d) and vegetables (35%, average serving 0.59 cup/d). All of the participants exceeded the DGA recommended limit on empty calories. Nutrient analysis of total fat intake showed a significant decrease in intake after the camp, F (1, 52) = 5.68, P = 0.02.

CONCLUSIONS

Diet is a modifiable risk factor for obesity and chronic diseases such as type 2 diabetes and needs to be an integral part of any healthy lifestyle intervention. The camp-based nutrition education had a positive effect on youths, as observed through the total fat intake decreasing after camp. To reinforce nutrition education, future nutrition education should involve parents, be delivered beyond the week at camp, and encompass social determinants of health and access to healthy foods.

Reducing Risk for Gestational Diabetes Mellitus (GDM) Through a Preconception Counseling Program for American Indian/Alaska Native Girls: Perceptions From Women With Type 2 Diabetes or a History of GDM

Purpose

American Indian and Alaska Native (AIAN) women are disproportionately affected by gestational diabetes mellitus (GDM). GDM is a risk factor for subsequent diagnosis of type 2 diabetes (T2D) in both mother and offspring, yet there is minimal research being conducted in this population. The purpose of this portion of a larger 5-year study is to examine AIAN women’s experiences of having GDM or T2D during pregnancy, inform the development of a GDM risk reduction and preconception counseling (PC) program tailored to AIAN girls, and enhance mother-daughter communication and support within the program.

Methods

AIAN women with TD2 or a history of GDM (N = 5) were interviewed to understand their unique perspectives on diabetes and pregnancy, behaviors to reduce risk, and content for a PC education program for AIAN girls. Interviews were digitally recorded, transcribed verbatim, and analyzed using the constant comparison method to construct themes across the interviews.

Results

Four primary themes were constructed: lack of knowledge on GDM and GDM risk factors, importance of AIAN culture for health and wellness, suggestions for communication with AIAN girls to reduce risk of GDM, and the emotional impact of GDM diagnosis.

Conclusions

Participants wished they had known about risk factors for GDM and how to reduce their own risk of developing GDM. Findings from this study have been used to adapt an existing PC program, originally developed for non-AIAN girls with diabetes, for AIAN girls who do not have diabetes but have risk factors for developing GDM in future pregnancies.

Differentially expressed haptoglobin as a potential biomarker for type 2 diabetic mellitus in Hispanic population

Glycosylated hemoglobin (HbA1c) measurement is currently a primary tool for diagnosis of type 2 diabetes mellitus (T2DM), especially for the assessment of chronic hyperglycemia. However, many studies reported the limitation of using HbA1c for T2DM diagnosis/prognosis, such as poor sensitivities, difficult standardization, and variable cut points across ethnic groups. Therefore, the aim of this study was to discover novel biomarkers associated with elevated HbA1c levels as complementary T2DM diagnostic tools. Two-dimensional difference gel electrophoresis combined with mass spectrometry were applied for protein profile analyses of two pooled serum samples collected from Hispanic T2DM subjects (n = 74) with HbA1c ≥7 and HbA1c< 7, respectively. Isoforms of haptoglobin (Hp) α1/α2 chains were significantly altered in pooled serum samples from T2DM subjects with HbA1c ≥7 compared to those with HbA1c< 7. Hp genotypes of 262 Hispanic subjects, including 109 T2DM and 153 nondiabetic controls, were further determined by PCRs and western blotting analysis. Meanwhile, a new droplet digital PCR method for Hp genotyping was also established. The distribution of Hp2 allele was higher in T2DM subjects compared to nondiabetic controls and the HbA1c levels of T2DM subjects carrying at least one Hp2 allele tended to be higher than T2DM subjects with Hp 1-1. In summary, our results indicate that differentially expressed serum Hp protein isoforms could be associated with HbA1c levels and subjects with Hp2 allele have a higher risk for the occurrence of T2DM in Hispanic population. © 2016 BioFactors, 43(3):424-433, 2017.

Utilizing Talking Circles as a Means of Gathering American Indian Stories for Developing a Nutrition and Physical Activity Curriculum

This qualitative study used a focus group approach (talking circles) to elicit tribal elder insight on important concepts for the purpose of creating a curriculum to teach tribal youth in South Dakota about nutrition and physical activity in culturally appropriate ways. The focus groups were part of a larger project that is exploring mechanisms for creating culturally relevant nutrition and physical activity education for American Indian youth. A series of "Eat Smart, Play Hard" posters, created by South Dakota State University Extension, served as the starting point for talking circle conversations with tribal elders about teaching nutrition and physical activity to children. Data from the talking circles were analyzed using qualitative content analysis for themes in elder dialogs. In open-ended conversations, elders discussed barriers and success in achieving good nutrition and physical activity, important aspects of the Siouan food culture, and historical relationships with food. They shared insights on food ingredients and methods of obtaining and preparing food that were and are currently important to their communities. These data were used to better understand the Native cultural perspectives on nutrition and physical activity and to create effective educational material for Native youth that could be used to teach them in culturally relevant ways.

The Impact of a Home-Based Diabetes Prevention and Management Program on High-Risk American Indian Youth

PURPOSE

The purpose of this study was to examine the impact of a home-based diabetes prevention and management program on high-risk American Indian youth.

METHODS

Together on Diabetes (TOD) was designed via a participatory approach with 4 tribal communities in the southwestern United States. A multisite pre- and postevaluation design was used to evaluate the efficacy of the TOD intervention on improving youth's psychosocial, knowledge, behavioral, and physiological outcomes at 4 time points from baseline to 12 months postenrollment.

RESULTS

A total of 256 youth and 225 support persons were enrolled in the TOD program. At 12 months postenrollment, improvements were observed in youth's quality of life (P < .001), depressive symptoms (P < .001), knowledge related to TOD content (P < .001), standardized body mass index scores (P = .004), and hypertension (P = .026). Improvements in mean A1C were observed among diabetic youth with baseline A1C >6.5% (P = .036).

CONCLUSIONS

The TOD program was feasible, acceptable, and effective in lowering diabetes risk among reservation-based American Indian youth. It is the first efficacious youth-focused diabetes prevention and management program developed and implemented in partnership with tribal communities.

Community-identified strategies to increase physical activity during elementary school recess on an American Indian reservation: A pilot study

The aim of this study was to determine the effect of an 8-week recess intervention on physical activity levels in children attending elementary school on an American Indian reservation during fall 2013. Physical activity was measured with direct observation in three zones on the playground. Lines were painted on existing pavement in zone 1. Zone 2 had permanent playground equipment and was unchanged. Zone 3 contained fields where bi-weekly facilitators led activities and provided equipment. Pre- to post-changes during recess in sedentary, moderate physical activity, moderate-to-vigorous, and vigorous physical activities were compared within zones. Females physical activity increased in Zone 1 (moderate: 100% increase; moderate-to-vigorous: 83%; vigorous: 74%, p < 0.01 for all) and Zone 3 (moderate: 54% increase, p < 0.01; moderate-to-vigorous: 48%, p < 0.01; vigorous: 40%, p < 0.05). Male sedentary activity decreased in Zone 2 (161%, p < 0.01). Physical activity changes in Zone 3 were not dependent upon the presence of a facilitator. Simple and low-cost strategies were effective at increasing recess physical activity in females. The findings also suggest that providing children games that are led by a facilitator is not necessary to increase physical activity as long as proper equipment is provided.

Clinicians' Implicit and Explicit Attitudes about Weight and Race and Treatment Approaches to Overweight for American Indian Children

PURPOSE

Obesity is one of the most serious health problems among American Indian/Alaska Native (AI/AN) children. We investigated Indian Health Service (IHS) primary care providers' implicit and explicit attitudes about weight and race and their association with treatment approaches to overweight in children.

METHODS

We conducted an online survey of long-term primary care clinicians in two western regions of the IHS. We used the existing Weight Attitude Implicit Association Test (IAT) and developed a new Native American Attitude IAT to measure implicit attitudes. Explicit attitudes about weight and race were assessed through self-report. We assessed self-rated treatment approaches to childhood overweight. We used linear regression models to evaluate the association of attitudes about weight and race with treatment approaches.

RESULTS

Our sample included 75 clinicians (56% response rate) who, on average, saw 74 patients per week. Fifty-five percent of clinicians reported that 30-60% of their child and adolescent patients were overweight or obese, and 25% of clinicians reported that 60-100% of their patients were overweight or obese. We found strong implicit bias favoring thin people (Cohen's d=1.44) and weak implicit bias favoring whites (Cohen's d=0.35). We found no association between implicit or explicit bias scores and self-reported treatment of childhood overweight. Continuing education on obesity was associated with self-rated success and competence in weight management.

CONCLUSIONS

Weight and race bias exists among long-term IHS clinicians, but may not influence treatment approaches for overweight AI/AN children. Further research should assess the effect of clinicians' attitudes on real-world weight management.

The Role of the Pediatrician in Primary Prevention of Obesity

The adoption of healthful lifestyles by individuals and families can result in a reduction in many chronic diseases and conditions of which obesity is the most prevalent. Obesity prevention, in addition to treatment, is an important public health priority. This clinical report describes the rationale for pediatricians to be an integral part of the obesity-prevention effort. In addition, the 2012 Institute of Medicine report "Accelerating Progress in Obesity Prevention" includes health care providers as a crucial component of successful weight control. Research on obesity prevention in the pediatric care setting as well as evidence-informed practical approaches and targets for prevention are reviewed. Pediatricians should use a longitudinal, developmentally appropriate life-course approach to help identify children early on the path to obesity and base prevention efforts on family dynamics and reduction in high-risk dietary and activity behaviors. They should promote a diet free of sugar-sweetened beverages, of fewer foods with high caloric density, and of increased intake of fruits and vegetables. It is also important to promote a lifestyle with reduced sedentary behavior and with 60 minutes of daily moderate to vigorous physical activity. This report also identifies important gaps in evidence that need to be filled by future research.

Fasting Blood Glucose Profile among Secondary School Adolescents in Ado-Ekiti, Nigeria

Background. Over the past two decades there has been an increase in type 2 diabetes mellitus (T2DM) in children. Baseline data is needed to assess the impact of changing lifestyles on Ado-Ekiti, a previously semiurban community in Southwest Nigeria. This study was therefore conducted to assess the fasting blood glucose (FBG) of adolescents in Ado-Ekiti, Nigeria. Methodology. This was a cross-sectional study involving 628 adolescents from three different secondary schools in Ado-Ekiti, Nigeria. With parental consent, volunteers completed a structured questionnaire, and an overnight FBG was measured. Results. There were 346 males and 282 females (male : female ratio = 1.2 : 1). Their ages ranged from 10 to 19 years (mean age: 14.2 ± 1.7 years). Four hundred and forty-four (70.7%) had normal FBG, while 180 (28.7%) and 4 (0.6%) had FBG in the prediabetic and diabetic range, respectively. Female gender, age group 10–14 years, and family history of obesity were significantly associated with impaired FBG (P value <0.001, <0.001, and 0.045, resp.). Conclusion. Impaired FBG is common among secondary school adolescents and it is more prevalent among younger female adolescents (10–14 years) with positive family history of obesity.

Adolescents' views and experiences of treatments for Type 2 diabetes: a qualitative study

AIM

To explore adolescents' views and experiences of different treatments for Type 2 diabetes, in order to improve treatment concordance and consider how the current treatment pathway for adolescent Type 2 diabetes could be improved.

METHODS

In-depth interviews were held with 12 adolescents who had been diagnosed with Type 2 diabetes. Adolescents were sampled from a UK cohort study. Data were analysed thematically.

RESULTS

Interviewees struggled to maintain lifestyle changes. Insulin, metformin and liraglutide were described as effective but, in some cases, as resulting in side effects. Injected treatments were viewed less favourably than oral medications. Weight loss surgery was considered an acceptable treatment for obese adolescents who had tried other treatments for their diabetes. It was apparent that some adolescents had not been surprised by their diagnosis and did not fully appreciate the implications of having diabetes. It was also evident that some individuals had not told peers about their diagnosis due to fearing how they would react. Factors identified as improving treatment concordance included reminders and viewing treatment as effective and easy to take.

CONCLUSIONS

Adolescents want treatments that are effective, discrete, easy to take and do not make them different from their peers. As liraglutide was described as effective, and surgery viewed as acceptable in certain circumstances, greater consideration should be given to their potential role in treating adolescent Type 2 diabetes. Practitioners need to ensure that adolescents appreciate the implications of having diabetes and may want to address adolescents' concerns regarding how others view this condition.

Phlorotannins from Alaskan seaweed inhibit carbolytic enzyme activity

Global incidence of type 2 diabetes has escalated over the past few decades, necessitating a continued search for natural sources of enzyme inhibitors to offset postprandial hyperglycemia. The objective of this study was to evaluate coastal Alaskan seaweed inhibition of α-glucosidase and α-amylase, two carbolytic enzymes involved in serum glucose regulation. Of the six species initially screened, the brown seaweeds Fucus distichus and Alaria marginata possessed the strongest inhibitory effects. F. distichus fractions were potent mixed-mode inhibitors of α-glucosidase and α-amylase, with IC50 values of 0.89 and 13.9 μg/mL, respectively; significantly more efficacious than the pharmaceutical acarbose (IC50 of 112.0 and 137.8 μg/mL, respectively). The activity of F. distichus fractions was associated with phlorotannin oligomers. Normal-phase liquid chromatography-mass spectrometry (NPLC-MS) was employed to characterize individual oligomers. Accurate masses and fragmentation patterns confirmed the presence of fucophloroethol structures with degrees of polymerization from 3 to 18 monomer units. These findings suggest that coastal Alaskan seaweeds are sources of α-glucosidase and α-amylase inhibitory phlorotannins, and thus have potential to limit the release of sugar from carbohydrates and thus alleviate postprandial hyperglycemia.

Addressing prediabetes in childhood obesity treatment programs: support from research and current practice

BACKGROUND

Type 2 diabetes mellitus (T2DM) and prediabetes have increased in prevalence among overweight and obese children, with significant implications for long-term health. There is little published evidence on the best approaches to care of prediabetes among overweight youth or the current practices used across pediatric weight management programs.

METHODS

This article reviews the literature and summarizes current practices for screening, diagnosis, and treatment of prediabetes at childhood obesity treatment centers. Findings regarding current practice were based on responses to an online survey from 28 pediatric weight management programs at 25 children's hospitals in 2012. Based on the literature reviewed, and empiric data, consensus support statements on prediabetes care and T2DM prevention were developed among representatives of these 25 children's hospitals' obesity clinics.

RESULTS

The evidence reviewed demonstrates that current T2DM and prediabetes diagnostic parameters are derived from adult-based studies with little understanding of clinical outcomes among youth. Very limited evidence exists on preventing progression of prediabetes. Some evidence suggests that a significant proportion of obese youth with prediabetes will revert to normoglycemia without pharmacological management. Evidence supports lifestyle modification for children with prediabetes, but further study of specific lifestyle changes and pharmacological treatments is needed.

CONCLUSION

Evidence to guide management of prediabetes in children is limited. Current practice patterns of pediatric weight management programs show areas of variability in practice, reflecting the limited evidence base. More research is needed to guide clinical care for overweight youth with prediabetes.

Ethics and Community Involvement in Syntheses Concerning American Indian, Alaska Native, or Native Hawaiian Health: A Systematic Review

BACKGROUND

The objective of the research was to review reporting of ethical concerns and community involvement in peer-reviewed systematic reviews or meta-analyses concerning American Indian, Alaska Native, or Native Hawaiian (AI/AN/NH) health.

METHODS

Text words and indexed vocabulary terms were used to query PubMed, Embase, Cochrane Library, and the Native Health Database for systematic reviews or meta-analyses concerning AI/AN/NH health published in peer-reviewed journals, followed by a search through reference lists. Each article was abstracted by two independent reviewers; results were discussed until consensus was reached.

RESULTS

We identified 107 papers published from 1986-2012 that were primarily about AI/AN/NH health or presented findings separately for AI/AN/NH communities. Two reported seeking indigenous reviewer feedback; none reported seeking input from tribes and communities. Approximately 7% reported on institutional review board (IRB) approval of included studies, 5% reported on tribal approval, and 4% referenced the sovereignty of AI/AN tribes. Approximately 63% used evidence from more than one AI/AN/NH population study, and 28% discussed potential benefits to communities from the synthesis research.

CONCLUSIONS

Reporting of ethics and community involvement are not prominent. Systematic reviews and meta-analyses making community-level inferences may pose risks to communities. Future systematic reviews and meta-analyses should consider ethical and participatory dimensions of research.

Adolescent and young adult male health: a review

Adolescent and young adult male health receives little attention, despite the potential for positive effects on adult quality and length of life and reduction of health disparities and social inequalities. Pediatric providers, as the medical home for adolescents, are well positioned to address young men's health needs. This review has 2 primary objectives. The first is to review the literature on young men's health, focusing on morbidity and mortality in key areas of health and well-being. The second is to provide a clinically relevant review of the best practices in young men's health. This review covers male health issues related to health care access and the Centers for Disease Control and Prevention's Healthy 2020 objectives for adolescents and young adults, focusing on the objectives for chronic illness, mortality, unintentional injury and violence, mental health and substance use, and reproductive and sexual health. We focus, in particular, on gender-specific issues, particularly in reproductive and sexual health. The review provides recommendations for the overall care of adolescent and young adult males.

Healthy gardens/healthy lives: Navajo perceptions of growing food locally to prevent diabetes and cancer

Poor access to nutritious foods, departure from traditional diets, and reduced physical activity are associated with a rise in type 2 diabetes and certain types of cancers among the Navajo. Diabetes in particular is of concern because of its increased prevalence among Navajo youth. Gardening can successfully address issues of poor availability of fruits and vegetables and offer many other social and health benefits. Our assessment aimed to determine Navajo attitudes about gardening and health in San Juan County, New Mexico. We conducted seven focus groups (including 31 people) to assess knowledge and attitudes related to gardening and uncover barriers and facilitators to participation in a garden project. Each group session was moderated by two Navajo students. Transcripts revealed that many Navajo are aware of adverse health issues that occur on the reservation, predominantly obesity and diabetes. Participants expressed a preference for educational approaches that incorporated cultural traditions, respect for elders, use of visual aids, and experiential learning. Several social and agronomic barriers to gardening were also mentioned. Results suggested a broad interest in promoting gardening especially to reduce the risk of diabetes with the added value of enhancing social capital in Navajo communities.

Management of newly diagnosed type 2 Diabetes Mellitus (T2DM) in children and adolescents

Over the past 3 decades, the prevalence of childhood obesity has increased dramatically in North America, ushering in a variety of health problems, including type 2 diabetes mellitus (T2DM), which previously was not typically seen until much later in life. The rapid emergence of childhood T2DM poses challenges to many physicians who find themselves generally ill-equipped to treat adult diseases encountered in children. This clinical practice guideline was developed to provide evidence-based recommendations on managing 10- to 18-year-old patients in whom T2DM has been diagnosed. The American Academy of Pediatrics (AAP) convened a Subcommittee on Management of T2DM in Children and Adolescents with the support of the American Diabetes Association, the Pediatric Endocrine Society, the American Academy of Family Physicians, and the Academy of Nutrition and Dietetics (formerly the American Dietetic Association). These groups collaborated to develop an evidence report that served as a major source of information for these practice guideline recommendations. The guideline emphasizes the use of management modalities that have been shown to affect clinical outcomes in this pediatric population. Recommendations are made for situations in which either insulin or metformin is the preferred first-line treatment of children and adolescents with T2DM. The recommendations suggest integrating lifestyle modifications (ie, diet and exercise) in concert with medication rather than as an isolated initial treatment approach. Guidelines for frequency of monitoring hemoglobin A1c (HbA1c) and finger-stick blood glucose (BG) concentrations are presented. Decisions were made on the basis of a systematic grading of the quality of evidence and strength of recommendation. The clinical practice guideline underwent peer review before it was approved by the AAP. This clinical practice guideline is not intended to replace clinical judgment or establish a protocol for the care of all children with T2DM, and its recommendations may not provide the only appropriate approach to the management of children with T2DM. Providers should consult experts trained in the care of children and adolescents with T2DM when treatment goals are not met or when therapy with insulin is initiated. The AAP acknowledges that some primary care clinicians may not be confident of their ability to successfully treat T2DM in a child because of the child's age, coexisting conditions, and/or other concerns. At any point at which a clinician feels he or she is not adequately trained or is uncertain about treatment, a referral to a pediatric medical subspecialist should be made. If a diagnosis of T2DM is made by a pediatric medical subspecialist, the primary care clinician should develop a comanagement strategy with the subspecialist to ensure that the child continues to receive appropriate care consistent with a medical home model in which the pediatrician partners with parents to ensure that all health needs are met.

Youth-onset type 2 diabetes among american indians and alaska natives

Youth-onset type 2 diabetes has emerged as a significant public health concern for American Indians and Alaska Natives. Data from the National Institutes of Health longitudinal epidemiological study among the Pima Indians of southern Arizona and the Indian Health Service continue to document a rising incidence and prevalence of type 2 diabetes among American Indian and Alaska Native youth. Although national trends related to lack of physical activity and to unhealthy nutrition behaviors have contributed to the epidemic, the adverse conditions created by poverty, social injustice, trauma, and cultural disruption are also important in understanding the underlying causes for this public health crisis. This adverse environment is likely to provide little support for healthy nutrition and physical activity behaviors as well as other diabetes self-care behaviors. Known risk factors from the Pima Indian studies, such as intrauterine exposure to diabetes, bottle-feeding, and obesity, provide a basis for worthwhile intervention strategies. In this article, the author will review the current literature on the epidemiology of youth-onset type 2 diabetes among American Indians and Alaska Natives, discuss causes for the diabetes epidemic among American Indians and Alaska Natives, review risk factors for youth-onset type 2 diabetes in this population, and share promising youth physical activity promotion programs created and implemented specifically for American Indian and Alaska Native youth. However, more research on interventions to address the Native communities' psychosocial issues and concerns around youth-onset type 2 diabetes is urgently needed.

Trends of overweight and obesity among white and American Indian school children in South Dakota, 1998-2010

OBJECTIVE

To investigate the prevalence of overweight and obesity among white and American Indian children in a predominantly rural state.

DESIGN AND METHODS

Using a repeated, cross-sectional design of school children's height and weight, the study sample included 361,352 measures of children who were 5.0-19.9 years, attending school across 13 academic calendar years. Trained staff measured height, weight, and recorded gender, age, and race. Data were voluntarily reported to the State Department of Health.

RESULTS

American Indian children consistently had higher rates of overweight and obesity compared to white children. Across the years, 16.3% of white students were overweight, whereas 19.3% of American Indian students were overweight. In addition, 14.5% of white children were obese and 25.9% of American Indian children were obese. Examining by rural versus urban schools, prevalence of overweight had been increasing among white male and female students and American Indian female students living in rural areas. Obesity is also increasing among rural white females and male and female American Indian children.

CONCLUSIONS

The findings here suggest that although American Indian children are at higher risk, in general, compared to white children, rural populations in general are experiencing increases in childhood overweight and obesity. Targeted rural interventions beginning at an early age are necessary to improve the health of rural children, especially in American Indian communities.

Diabetes, pre-diabetes and insulin resistance screening in Native American children and youth

OBJECTIVES

Early identification of pre-diabetes and insulin resistance (IR) provides an important window of opportunity for diabetes prevention. Little is known about the prevalence of pre-diabetes and IR in Native American (NA) youth. We designed a cross-sectional, community-based study of NA children to estimate the prevalence of diabetes, pre-diabetes and IR and their association with other diabetes risk factors.

STUDY DESIGN

NA children (5-18 years) were screened with body mass index (BMI), blood pressure, oral glucose tolerance test (OGTT), lipids, insulin and highly sensitive C-reactive protein (hsCRP), and calculated homeostatic model assessment of IR (HOMA-IR).

RESULTS

Mean age of the cohort (n=201) was 10.8 ± 3.8 years (± s.d.; 94/107 M/F). BMI percentile for age and sex (BMI%) was elevated (≥ 85 th percentile) in 58.6% of 5-11 years and 51.1% of 12-18 years, and positively correlated with HOMA-IR, blood pressure, triglycerides and hsCRP (P<0.05). The prevalence rate for pre-diabetes and diabetes were 6.5% (3.5-10.8%) and 1.0% (0.1-3.6%), respectively. Mean HOMA-IR was greater in the older than younger age group while prevalence of pre-diabetes was the same. Those with pre-diabetes and diabetes had a greater HOMA-IR, abdominal circumference and BMI% than normal youth.

CONCLUSION

In the first prospective, community-based screening for pre-diabetes, IR and diabetes in United States NA youth using OGTT, while the number of diabetes cases was low, pre-diabetes was found in a significant number of youth, particularly in those with BMI ≥ 95 th%. As proportions of pre-diabetes were similar in 5-11 and 12-18 year olds, diabetes risk begins early in NA youth.

The Native Comic Book Project: native youth making comics and healthy decisions

BACKGROUND

American Indians and Alaska Natives have traditionally used stories and drawings to positively influence the well-being of their communities.

OBJECTIVES

The objective of this study was to describe the development of a curriculum that trains Native youth leaders to plan, write, and design original comic books to enhance healthy decision making.

METHODS

Project staff developed the Native Comic Book Project by adapting Dr. Michael Bitz's Comic Book Project to incorporate Native comic book art, Native storytelling, and decision-making skills. After conducting five train-the-trainer sessions for Native youth, staff were invited by youth participants to implement the full curriculum as a pilot test at one tribal community site in the Pacific Northwest. Implementation was accompanied by surveys and weekly participant observations and was followed by an interactive meeting to assess youth engagement, determine project acceptability, and solicit suggestions for curriculum changes.

RESULTS

Six youths aged 12 to 15 (average age = 14) participated in the Native Comic Book Project. Youth participants stated that they liked the project and gained knowledge of the harmful effects of commercial tobacco use but wanted better integration of comic book creation, decision making, and Native storytelling themes.

CONCLUSION

Previous health-related comic book projects did not recruit youth as active producers of content. This curriculum shows promise as a culturally appropriate intervention to help Native youth adopt healthy decision-making skills and healthy behaviors by creating their own comic books.

Estimated morbidity and mortality in adolescents and young adults diagnosed with Type 2 diabetes mellitus

AIMS

To estimate remaining life expectancy (RLE), quality-adjusted life expectancy (QALE), causes of death and lifetime cumulative incidence of microvascular/macrovascular complications of diabetes for youths diagnosed with Type 2 diabetes.

METHODS

A Markov-like computer model simulated the life course for a hypothetical cohort of adolescents/young adults in the USA, aged 15-24 years, newly diagnosed with Type 2 diabetes following either conventional or intensive treatment based on the UK Prospective Diabetes Study. Outcomes included RLE, discounted QALE in quality-adjusted life years (QALYs), cumulative incidence of microvascular/macrovascular complications and causes of death.

RESULTS

Compared with a mean RLE of 58.6 years for a 20-year-old in the USA without diabetes, conventional treatment produced an average RLE of 43.09 years and 22.44 discounted QALYs. Intensive treatment afforded an incremental 0.98 years and 0.44 discounted QALYs. Intensive treatment led to lower lifetime cumulative incidence of all microvascular complications and lower mortality from microvascular complications (e.g. end-stage renal disease (ESRD) death 19.4% vs. 25.2%). Approximately 5% with both treatments had ESRD within 25 years. Lifetime cumulative incidence of coronary heart disease (CHD) increased with longer RLE and greater severity of CHD risk factors. Incorporating disutility (loss in health-related quality of life) of intensive treatment resulted in net loss of QALYs.

CONCLUSIONS

Adolescents/young adults with Type 2 diabetes lose approximately 15 years from average RLE and may experience severe, chronic complications of Type 2 diabetes by their 40s. The net clinical benefit of intensive treatment may be sensitive to preferences for treatment. A comprehensive management plan that includes early and aggressive control of cardiovascular risk factors is likely needed to reduce lifetime risk of CHD.

Type 2 diabetes mellitus in young need for early screening

Type 2 diabetes mellitus (T2DM) has increased dramatically throughout the world in recent years. This increase has also affected the young, such that over the last decade, the rise in the number of children and youth with T2DM has been labeled an epidemic. The main reason for this epidemic is the spurt in childhood obesity worldwide. This is linked to the global economic growth and changes in lifestyle and dietery habits. It is important that we recognize this epidemic of T2DM early, and institute national and global measures to contain it. T2DM in childhood can be controlled to a large extent through lifestyle modification measures. It is important that we screen this disease condition, and identify the at-risk cases.

Preferences for type 2 diabetes health states among adolescents with or at risk of type 2 diabetes mellitus

OBJECTIVE

We evaluated how adolescents with or at risk of type 2 diabetes (T2DM) and their parent/guardians (parents) value health states associated with T2DM.

METHODS

We interviewed overweight/obese [Body Mass Index (BMI) ≥ 85th percentile], 12-18-yr old adolescents with T2DM, prediabetes, or insulin resistance (IR) and a parent. The standard gamble (SG) method elicited preferences (utilities) for seven hypothetical T2DM health states reported on a scale from 0 (dead) to 1 (perfect health). Adolescent's current health was evaluated with the SG and Health Utilities Index (HUI).

RESULTS

There were 70 adolescents and 69 parents. Adolescents were 67.1% female and 15.5 ± 2.2 yr old; 30% had T2DM, 30% prediabetes, and 40% IR. Almost half (48.6%) had a BMI > 99th percentile. Parents (83% mothers) were 45.1 ± 7.3 yr old and 75% had at least some college/technical school education. Adolescents and parents rated T2DM with no complications treated with diet as most desirable [median (IQR); adolescent 0.72 (0.54, 0.98); parent 1.0 (0.88, 1.0)] and end-stage renal disease as least desirable [adolescent 0.51 (0.31, 0.70); parent 0.80 (0.65, 0.94)]. However, adolescents' utilities were significantly lower (p ≤ 0.001) than parents for all health states assessed. Adolescents' assessments of their current health with the SG and HUI were not correlated.

CONCLUSIONS

Adolescents with or at risk of T2DM rated treatments and sequelae of diabetes as significantly worse than their parents. These adolescent utilities should be considered in the evaluation of treatment strategies for youth with T2DM. Family-based programs for T2DM must also be prepared to address conflicting preferences in order to promote shared decision-making.

Promoting wellness in Alaskan villages: integrating traditional knowledge and science of wild berries

People draw upon multiple forms of environmental knowledge, from scientific to highly contextual local or traditional forms of knowledge, to interpret problems and gauge risks in complex socio-ecological systems. In collaboration with three remote Alaska Native communities, and using an interdisciplinary, participatory, and mixed methods research approach, we explored traditional ecological knowledge and scientific aspects of wild berries and the broader context of community health and environmental change. Combining site visits, key informant interviews, focus groups, survey questionnaires, portable field bioassays, and laboratory follow-up analyses, our research revealed the importance of local subsistence resources for community wellness. Multiple berry species were found to have powerful bioactive health properties for ameliorating metabolic syndrome as well as importance for community wellness. Communities differed in the degree to which they characterized berries as healthy foods and perceived environmental risks including climate change. Findings suggest the importance of incorporating locally available foods and socio-cultural traditions into community wellness programming. This article also discusses challenges and opportunities associated with transdisciplinary, participatory research with indigenous communities.

Analysis of pathogenesis of juvenile new-onset diabetes

BACKGROUND

Measurement of anti-islet autoantibodies at the time of disease onset contributes greatly to the differentiation of Type 1A diabetes with HLA Class II subtyping also contributing.

METHODS

Blood samples were obtained from 900 patients with age from 1 month to 25 years (median age 11.1 years) within 2 weeks of diabetes onset to test anti-islet autoantibodies to insulin (IAA), glutamic acid decarboxylase (GADA), insulinoma antigen (IA-2AA), the zinc transporter-8 (ZnT8AA), and islet-cell antibodies (ICA). Polymorphisms of the HLA Class II gene were typed in 547 randomly selected patients.

RESULTS

Of the 900 subjects analyzed, 145 (16.1%) were negative for all five anti-islet autoantibodies, and autoantibody negativity significantly increased with age: 10.2% (38/372) among children <10 years of age, 14.2% (46/325) in those 10-14 years of age, and 30.1% (61/203) in those >14 years of age (P < 0.001). The prevalence of IA-2AA was the highest among young children. The prevalence of GADA increased with age while the prevalence of IAA was inversely correlated with age. At diagnosis, the subjects with negative antibodies had a higher body mass index (P < 0.001) and less high risk HLA genotype DR3-DQ2/DR4-DQ8 (P < 0.01).

CONCLUSION

A large percentage of children and youths negative for all anti-islet autoantibodies at the onset of diabetes are likely to have the non-immune form, especially those without DR3/DR4 and obese patients. Among autoantibody-positive Type 1A patients, IAA and GADA showed a reciprocal prevalence, suggesting differential disease pathogenesis.

Body mass index percentile more sensitive than acanthosis nigricans for screening Native American children for diabetes risk

BACKGROUND

Many Native American tribes use acanthosis nigricans to screen for type 2 diabetes risk. We hypothesized that acanthosis nigricans misses many children at risk for type 2 diabetes.

METHODS

We evaluated 5- to 18-year-old Native American children and youth to assess the sensitivity and specificity of acanthosis nigricans as a marker for insulin resistance.

RESULTS

In a cohort of 161 youth (72 males/89 females), mean age was 10.7 years + 3.9. Mean body mass index (BMI) percentile was 76.8 +/- 23.3, and 54% had a BMI at or above the 85th percentile. Acanthosis nigricans was present in 21.7% of the participants and was more common in 12-to 18-year-olds than in 5 to 11-year-olds (p = .02). Of those with acanthosis nigricans, 82.4% had insulin resistance (homeostatic model assessment of insulin resistance >4), but only 48.3% of those with insulin resistance had acanthosis nigricans. In contrast, BMI at or above the 85th percentile had a high sensitivity (74%) for insulin resistance, even though its specificity was lower (58%).

CONCLUSIONS

The presence of acanthosis nigricans alone was a specific, but not a sensitive, screening tool for identifying youth with insulin resistance. BMI at or above the 85th percentile was a more sensitive screening tool than acanthosis nigricans alone, or acanthosis nigricans and BMI together for identifying children and youth with IR who are at increased risk for type 2 diabetes.

Using nature and outdoor activity to improve children's health

Childhood obesity affects 17% or 12.5 million of America's children, contributing to the rise in children's health disparities. Type 2 diabetes, asthma, vitamin D deficiency, and attention-deficit/hyperactivity disorder have also increased over the past few decades. A shift toward a sedentary lifestyle is a major contributor to the decline in children's health. Children spend more time indoors using electronic media and less time engaged in outdoor unstructured play. This article reviews the current evidence of the mental and physical health benefits associated with unstructured, outdoor activities and time spent in a natural environment such as a park or other recreational area. Pediatric health care providers should recommend outdoor activities for children and refer families to safe and easily accessible outdoor areas. Pediatric health care providers can incorporate this simple, lifestyle-based intervention into anticipatory guidance.

Alaskan wild berry resources and human health under the cloud of climate change

Wild berries are integral dietary components for Alaska Native people and a rich source of polyphenolic metabolites that can ameliorate metabolic disorders such as obesity and diabetes. In this study, five species of wild Alaskan berries (Vaccinium ovalifolium , Vaccinium uliginosum , Rubus chamaemorus , Rubus spectabilis , and Empetrum nigrum) were screened for bioactivity through a community-participatory research method involving three geographically distinct tribal communities. Compositional analysis by HPLC and LC-MS(2) revealed substantial site-specific variation in anthocyanins (0.01-4.39 mg/g of FW) and proanthocyanidins (0.74-6.25 mg/g of FW) and identified A-type proanthocyanidin polymers. R. spectabilis increased expression levels of preadipocyte factor 1 (182%), and proanthocyanidin-enriched fractions from other species reduced lipid accumulation in 3T3-L1 adipocytes. Selected extracts reduced serum glucose levels in C57BL/6J mice by up to 45%. Local observations provided robust insights into effects of climatic fluctuations on berry abundance and quality, and preliminary site-specific compositional and bioactivity differences were noted, suggesting the need to monitor this Alaska Native resource as climate shifts affect the region.

Clinical management of type 2 diabetes in indigenous youth

Youth-onset type 2 diabetes is a serious public health problem for Indigenous people throughout the world. This article reviews the epidemiology, disease burden, treatment, and challenges in achieving successful clinical management of this disorder in Indigenous youth. Screening criteria and the complications and comorbidities of type 2 diabetes are also reviewed.

Obstructive sleep breathing disorders

Obstructive sleep apnea (OSA) is increasingly recognized in children. There is accumulating robust evidence to support early diagnosis and treatment of this condition. The purpose of this review is to provide an update on the epidemiology, clinical features, complications, and treatment of childhood OSA. The authors have also proposed an easy-to-follow flowchart on the management of children with snoring or sleep disturbance for clinical use by busy pediatricians.

Family history and parents' beliefs about consequences of childhood overweight and their influence on children's health behaviors

OBJECTIVES

The aims of this study were to examine factors related to 1) parental perception of health risks for overweight children and 2) parents' self-efficacy for influencing their children's dietary and physical activity behaviors, especially in relation to family history (FH) of diabetes and cardiovascular disease (CVD).

METHODS

A consecutive sample of parents was surveyed at 7 primary care practices about FH, perceptions of childhood obesity-related health risks, health beliefs, and perceptions. Generalized estimated equation models clustering on practice were developed to examine associations with perceptions and self-efficacy.

RESULTS

Analyses included 386 parents of children aged 2 to 17 years. Sixty-seven percent had FH of CVD and 33% had FH of diabetes. Children were 57% white, 23% Hispanic, 12% African American, and 8% other race/ethnicity; 17% were overweight and 18% were obese. Parents whose child had FH of diabetes more often perceived higher risk of diabetes for overweight children than those with neither FH risk (adjusted odds ratio [OR] 1.4, 95% confidence interval [95% CI], 1.2-1.7), as did those with FH of CVD (adjusted OR 2.0, 95% CI, 1.6-2.5) and those with an obese child. Parents with less than college education or having African American and female children perceived risk less often. Parents had high self-efficacy for influencing their child if they had a strong belief in parental modeling and their child was aged <12 years.

CONCLUSIONS

Family history of diabetes and CVD and other factors are associated with parents' perceptions of health risks for overweight children. Strategies to use FH to motivate families with overweight children toward behavior change are needed.

Type 2 diabetes mellitus in children and adolescents: where do we stand with drug treatment and behavioral management?

Type 2 diabetes, once considered a disease of adults, is a growing problem in the pediatric population. The emergence of type 2 diabetes in this age group has paralleled the epidemic of childhood obesity. Lifestyle modifications represent first-line therapy for children and adolescents with type 2 diabetes. However, many children and adolescents go on to require treatment with oral medications or insulin for optimal control. A paucity of data exist regarding the optimal treatment regimen for children and adolescents with type 2 diabetes. Further research regarding the treatment of type 2 diabetes in youth is required.

Breastfeeding promotion: a rational and achievable target for a type 2 diabetes prevention intervention in Native American communities

Type 2 diabetes is a serious, costly, and increasingly common disease among Native American communities. Increasing evidence suggests that early infant nutrition, particularly breastfeeding, may have a significant impact on the development of diabetes in later life. In this report, the authors describe the scientific basis and development of an innovative program that targets promotion of breastfeeding among Native women as a type 2 diabetes prevention intervention. The program materials, evaluation methods, and outcomes are presented. By developing and sharing strategies that effectively support breastfeeding, the impact of diabetes in Native American communities will be reduced.

Diabetic nephropathy in children and adolescents

Type 1 diabetes mellitus (T1DM) commonly occurs in childhood or adolescence, although the rising prevalence of type 2 diabetes mellitus (T2DM) in these age groups is now being seen worldwide. Diabetic nephropathy (DN) develops in 15-20% of subjects with T1DM and in similar or higher percentage of T2DM patients, causing increased morbidity and premature mortality. Although overt DN or kidney failure caused by either type of diabetes are very uncommon during childhood or adolescence, diabetic kidney disease in susceptible patients almost certainly begins soon after disease onset and may accelerate during adolescence, leading to microalbuminuria or incipient DN. Therefore, all diabetics warrant ongoing assessment of kidney function and screening for the earliest manifestations of renal injury. Pediatric health care professionals ought to understand about risk factors, strategy for prevention, method for screening, and treatment of early DN. This review considers each form of diabetes separately, including natural history, risk factors for development, screening for early manifestations, and strategy recommended for prevention and treatment of DN in children and adolescents.

Diagnosis and management of type 2 diabetes and prediabetes

Treatment of type 2 diabetes mellitus (T2DM), a progressive disease, requires early and appropriate therapies, with frequent monitoring and reassessment to make certain goals are attained. Chronic hyperglycemia can cause macrovascular and microvascular complications, many of which may be apparent on initial diagnosis. As beta-cell function deteriorates and insulin resistance intensifies, patients find that oral pharmacologic therapy is becoming less effective at minimizing the effects of chronic hyperglycemia. Eventually, most will require exogenous insulin therapy. Primary care physicians manage over 90% of T2DM patients, so we must have a better understanding of our roles as patient educators, advocates, and medical providers, and do everything in our power to help our patients achieve the lowest and safest glycated hemoglobin (A1C) possible.

Behavioral Medicine Review: Promoting Healthy Lifestyles in Pediatric Populations

The upsurge in lifestyle-related, pediatric health problems has become the focus of widespread concern. This review discusses developmental considerations in lifestyle risk reduction and their implications for research, evidence-based practice, and public policy.