Risk factors for type 2 diabetes in a sixth- grade multiracial cohort: the HEALTHY study

Automated temporalis muscle quantification and growth charts for children through adulthood

Lean muscle mass (LMM) is an important aspect of human health. Temporalis muscle thickness is a promising LMM marker but has had limited utility due to its unknown normal growth trajectory and reference ranges and lack of standardized measurement. Here, we develop an automated deep learning pipeline to accurately measure temporalis muscle thickness (iTMT) from routine brain magnetic resonance imaging (MRI). We apply iTMT to 23,876 MRIs of healthy subjects, ages 4 through 35, and generate sex-specific iTMT normal growth charts with percentiles. We find that iTMT was associated with specific physiologic traits, including caloric intake, physical activity, sex hormone levels, and presence of malignancy. We validate iTMT across multiple demographic groups and in children with brain tumors and demonstrate feasibility for individualized longitudinal monitoring. The iTMT pipeline provides unprecedented insights into temporalis muscle growth during human development and enables the use of LMM tracking to inform clinical decision-making.

Sarcopenic Obesity in Children and Adolescents: A Systematic Review

Sarcopenic obesity (SO) is defined as co-occurrence of increased fat mass and sarcopenia and may predict adverse health outcomes in the pediatric population. However, the prevalence of SO and its association with adverse health outcomes have not been well defined in children and adolescents. We systematically reviewed data on the SO definition, prevalence, and adverse outcomes in the pediatric population. A total of 18 articles retrieved from PubMed or Web of Science databases were included. Overall, there was a wide heterogeneity in the methods and thresholds used to define SO. The prevalence of SO ranged from 5.66% to 69.7% in girls, with a range between 7.2% and 81.3% in boys. Of the 8 studies that evaluated outcomes related to SO, all showed a significant association of SO with cardiometabolic outcomes, non-alcoholic fatty liver disease (NAFLD) severity, inflammation, and mental health. In conclusion, this review found that SO is highly prevalent in children and adolescents and is associated with various adverse health outcomes. Findings of this review highlight the need for the development of a consensus regarding definition, standardized evaluation methods, and age and gender thresholds for SO for different ethnicities in the pediatric population. Further studies are needed to understand the relationship between obesity and sarcopenia and SO impact on adverse health outcomes in children and adolescents.

Trends in Prevalence of Type 1 and Type 2 Diabetes in Children and Adolescents in the US, 2001-2017

IMPORTANCE

Changes in the prevalence of youth-onset diabetes have previously been observed.

OBJECTIVE

To estimate changes in prevalence of type 1 and type 2 diabetes in youths in the US from 2001 to 2017.

DESIGN, SETTING, AND PARTICIPANTS

In this cross-sectional observational study, individuals younger than 20 years with physician-diagnosed diabetes were enumerated from 6 areas in the US (4 geographic areas, 1 health plan, and select American Indian reservations) for 2001, 2009, and 2017.

EXPOSURES

Calendar year.

MAIN OUTCOMES AND MEASURES

Estimated prevalence of physician-diagnosed type 1 and type 2 diabetes overall and by race and ethnicity, age, and sex.

RESULTS

Among youths 19 years or younger, 4958 of 3.35 million had type 1 diabetes in 2001, 6672 of 3.46 million had type 1 diabetes in 2009, and 7759 of 3.61 million had type 1 diabetes in 2017; among those aged 10 to 19 years, 588 of 1.73 million had type 2 diabetes in 2001, 814 of 1.85 million had type 2 diabetes in 2009, and 1230 of 1.85 million had type 2 diabetes in 2017. The estimated type 1 diabetes prevalence per 1000 youths for those 19 years or younger increased significantly from 1.48 (95% CI, 1.44-1.52) in 2001 to 1.93 (95% CI, 1.88-1.98) in 2009 to 2.15 (95% CI, 2.10-2.20) in 2017, an absolute increase of 0.67 per 1000 youths (95%, CI, 0.64-0.70) and a 45.1% (95% CI, 40.0%-50.4%) relative increase over 16 years. The greatest absolute increases were observed among non-Hispanic White (0.93 per 1000 youths [95% CI, 0.88-0.98]) and non-Hispanic Black (0.89 per 1000 youths [95% CI, 0.88-0.98]) youths. The estimated type 2 diabetes prevalence per 1000 youths aged 10 to 19 years increased significantly from 0.34 (95% CI, 0.31-0.37) in 2001 to 0.46 (95% CI, 0.43-0.49) in 2009 to 0.67 (95% CI, 0.63-0.70) in 2017, an absolute increase of 0.32 per 1000 youths (95% CI, 0.30-0.35) and a 95.3% (95% CI, 77.0%-115.4%) relative increase over 16 years. The greatest absolute increases were observed among non-Hispanic Black (0.85 per 1000 youths [95% CI, 0.74-0.97]) and Hispanic (0.57 per 1000 youths [95% CI, 0.51-0.64]) youths.

CONCLUSIONS AND RELEVANCE

In 6 areas of the US from 2001 to 2017, the estimated prevalence of diabetes among children and adolescents increased for both type 1 and type 2 diabetes.

Perioperative respiratory adverse events during ambulatory anesthesia in obese children

Obesity is one of the most common clinical conditions in the pediatric population with an increasing prevalence ranging from 20 to 30% worldwide. It is well known that during ambulatory anesthesia, obese children are more prone to develop perioperative respiratory adverse events (PRAEs) associated with obesity. To avoid or at least minimize these adverse effects, a thorough preoperative assessment should be undertaken as well as consideration of specific anesthetic approaches such as preoxygenation before induction of anesthesia and optimizing drug dosing. The use of short-acting opioid and nonopioid analgesics and the frequent implementation of regional anesthesia should also be included. Noninvasive airway management, protective mechanical ventilation, and complete reversion of neuromuscular blockade and awake extubation also proved to be beneficial in preventing PRAEs. During the postoperative period, continuous monitoring of oxygenation and ventilation is mandatory in obese children. In the current review, we sought to provide recommendations that might help to reduce the severity of perioperative respiratory adverse events in obese children, which could be of particular importance for reducing the rate of unplanned hospitalizations and ultimately improving the overall postoperative recovery.

Increased serum circulating asprosin levels in children with obesity

BACKGROUND

Childhood obesity is a growing and significant problem worldwide. Asprosin is a novel adipokine that is significantly associated with glucose and insulin production in the liver during fasting. In the present study, we aimed to demonstrate whether there would be differences between obese, overweight, and normal weight children in terms of serum asprosin levels.

METHODS

Forty-four children with obesity, 54 overweight children, and 60 normal weight children were compared in terms of serum asprosin levels and other anthropometric, biochemical, and hormonal parameters that are associated with being overweight and with obesity.

RESULTS

Serum asprosin levels were found to be significantly different between groups: 70.903 ± 17.49 ng/mL, 79.744 ± 29.54 ng/mL, and 106.293 ± 122.69 ng/mL in normal weight, overweight, and obese children respectively. Post-hoc analysis revealed that the asprosin level was significantly higher in obese children compared with normal weight children (P = 0.009). Additionally, asprosin was found to be a predictor of obesity in multiple regression analysis.

CONCLUSION

Our study is the first to demonstrate increased levels of asprosin in obese children compared with normal weight children. Further studies are needed to demonstrate the role of asprosin in the etiology of childhood obesity, as well as other diseases that might be associated with effects of asprosin.

Prevalence of Overweight and Obesity in Hungarian Children and Adolescents

BACKGROUND/AIMS

The prevalence of overweight and obesity in children and adolescents is increasing worldwide, and this condition is a risk factor for cardiovascular mortality. The aim of this study was to assess the prevalence of overweight and obesity among the 3-18-year-old population in Szolnok City and the surrounding areas.

METHODS

Anthropometric data from healthy, white individuals recruited from nursery, elementary, and secondary schools were used to assess the prevalence of obesity and overweight in Szolnok City and the surrounding area, Jász-Nagykun-Szolnok county, Hungary. Healthy subjects numbering 6,824 (54% boys) were included; overweight and obesity were defined according to the relevant guidelines.

RESULTS

Overweight individuals constituted 13.4% of the population and 6.6% were obese. The total prevalence was higher in boys (21.6%) than in girls (18.1%). The peak of the prevalence was observed at age 10 in both sexes (boys 33%, girls 27%) followed by a gradual decrease, which was more significant in the case of girls.

CONCLUSIONS

On the basis of the recent Hungarian data, we have not detected any changes in overweight and obesity in the age group 3-9 years and we have found a significant decrease in the age group 7-14 years. Prevention of overweight and obesity in early childhood is essential.

A Systematic Review and Meta-Analysis of the Effect of Lifestyle Modification on Metabolic Control in Overweight Children

Childhood obesity is associated with type 2 diabetes mellitus. We aimed to determine the effects of lifestyle modification programs on fasting plasma glucose (FPG) levels in overweight children. We queried six relevant electronic databases and manually searched for studies published before December 2016. Overweight/obese children who underwent a lifestyle modification for more than 6 months were included. A total of 3923 children from eight randomized controlled trials (RCTs) were included. Compared with the control group, the lifestyle modification group had significantly lower FPG levels by 1.3 mg/dL. The mean differences were significantly decreased for both secondary outcomes; BMI z-score decreased by 0.16 units and insulin levels decreased by 2.4 mU/L. The metaregression showed that the follow-up duration was associated with FPG levels and BMI and insulin levels and half year is a suitable follow-up duration for this population. This study showed that lifestyle modification programs may be effective in reducing the FPG levels of overweight/obese children. Further high-quality RCTs with longer follow-up periods are needed to evaluate the long-term effect of this complementary approach for diabetes mellitus prevention on overweight/obese children.

Review of Childhood Obesity: From Epidemiology, Etiology, and Comorbidities to Clinical Assessment and Treatment

Childhood obesity has emerged as an important public health problem in the United States and other countries in the world. Currently 1 in 3 children in the United States is afflicted with overweight or obesity. The increasing prevalence of childhood obesity is associated with emergence of comorbidities previously considered to be "adult" diseases including type 2 diabetes mellitus, hypertension, nonalcoholic fatty liver disease, obstructive sleep apnea, and dyslipidemia. The most common cause of obesity in children is a positive energy balance due to caloric intake in excess of caloric expenditure combined with a genetic predisposition for weight gain. Most obese children do not have an underlying endocrine or single genetic cause for their weight gain. Evaluation of children with obesity is aimed at determining the cause of weight gain and assessing for comorbidities resulting from excess weight. Family-based lifestyle interventions, including dietary modifications and increased physical activity, are the cornerstone of weight management in children. A staged approach to pediatric weight management is recommended with consideration of the age of the child, severity of obesity, and presence of obesity-related comorbidities in determining the initial stage of treatment. Lifestyle interventions have shown only modest effect on weight loss, particularly in children with severe obesity. There is limited information on the efficacy and safety of medications for weight loss in children. Bariatric surgery has been found to be effective in decreasing excess weight and improving comorbidities in adolescents with severe obesity. However, there are limited data on the long-term efficacy and safety of bariatric surgery in adolescents. For this comprehensive review, the literature was scanned from 1994 to 2016 using PubMed using the following search terms: childhood obesity, pediatric obesity, childhood overweight, bariatric surgery, and adolescents.

Childhood cardiovascular risk factors, a predictor of late adolescent overweight

Background:

We conducted a prospective study to elucidate the effects of increased cardiovascular risk factors on future weight gain and also the relation between body mass index (BMI) and other cardiovascular risk factors in children and adolescents.

Materials and Methods:

This study was conducted on 1525 nonobese children and adolescents with an age range of 3-16 years old, participating in the 1^st phase and follow-up phases of Tehran Lipid and Glucose Study. The subjects were evaluated 4 times with a 3-year time interval regarding lipid profile status and BMI, and other cardiovascular disease (CVD) risk factors. All the cases had a BMI <85% and had been appraised in at least two evaluation points.

Results:

Cardiovascular risk factors, high-density lipoprotein (HDL) (P = 0.019), low-density lipoprotein (P = 0.016), triglyceride (TG) (P < 0.001), and blood pressure (BP) (P = 0.001); had significant effects on weight gain. There was also no difference between boys and girls and no age trend for increasing weight in both groups. The associations between BMI with cardiovascular risk factors were assessed cross-sectionally. For both sexes, BMI was significantly correlated to systolic and diastolic BP and TG (P = 0.05). For girls, BMI was significantly related to HDL (P = 0.05) regardless to age, but in boys, the relation of BMI with HDL only increased with age (P = 0.05).

Conclusion:

Increased CVD risk factors are predictors of future overweight in childhood and adolescent and increased weight is linked significantly with dyslipidemia and hypertension in this age group.

The changing face of diabetes in youth: lessons learned from studies of type 2 diabetes

The incidence of youth type 2 diabetes (T2D), linked with obesity and declining physical activity in high-risk populations, is increasing. Recent multicenter studies have led to a number of advances in our understanding of the epidemiology, pathophysiology, diagnosis, treatment, and complications of this disease. As in adult T2D, youth T2D is associated with insulin resistance, together with progressive deterioration in β cell function and relative insulin deficiency in the absence of diabetes-related immune markers. In contrast to adult T2D, the decline in β cell function in youth T2D is three- to fourfold faster, and therapeutic failure rates are significantly higher in youth than in adults. Whether the more aggressive nature of youth T2D is driven by genetic heterogeneity or physiology/metabolic maladaptation is yet unknown. Besides metformin, the lack of approved pharmacotherapeutic agents for youth T2D that target the pathophysiological mechanisms is a major barrier to optimal diabetes management. There is a significant need for effective therapeutic options, in addition to increased prevention, to halt the projected fourfold increase in youth T2D by 2050 and the consequences of heightened diabetes-related morbidity and mortality at younger ages.

A randomized controlled study of a healthy corner store initiative on the purchases of urban, low-income youth

OBJECTIVE

Although many initiatives exist to improve the availability of healthy foods in corner stores, few randomized trials have assessed their effects. This study evaluated, in a randomized controlled trial, the effects of a first-generation healthy corner store intervention on students' food and beverage purchases over a 2-year period.

METHODS

Participants (n = 767) were fourth-, fifth-, and sixth-grade students. Ten schools and their nearby corner stores (n = 24) were randomly assigned to the healthy corner store intervention or an assessment-only control. Intercept surveys directly assessed the nutritional characteristics of students' corner store purchases at baseline, 1 and 2 years. Students' weight and heights were measured at baseline, 1 and 2 years.

RESULTS

There were no differences in energy content per intercept purchased from control or intervention schools at year 1 (P = 0.12) or 2 (P = 0.58). There were no differences between control and intervention students in BMI z score (year 1, P = 0.83; year 2, P = 0. 98) or obesity prevalence (year 1, P = 0.96; year 2, P = 0.58).

CONCLUSIONS

A healthy corner store initiative did not result in significant changes in the energy content of corner store purchases or in continuous or categorical measures of obesity. These data will help to inform future interventions.

Obesity and type 2 diabetes in children: epidemiology and treatment

The incidence of overweight and obesity among children has increased dramatically in recent decades, with about one-third of children in the U.S. currently being either overweight or obese. Being overweight in early childhood increases risk for later obesity. There is evidence for the efficacy of family-based behavioral treatment to control weight and improve health outcomes. Obesity-related health risks have been documented, including metabolic syndrome. There is also increasing incidence of type 2 diabetes (T2D) among youth in recent years, with obesity and family history of T2D generally present. Lower income and ethnic minority status are associated with both obesity and T2D in youth. Most youth with T2D do not achieve optimal glycemic control, and are at high risk for later health complications. Obesity and T2D represent significant public health issues with potentially great personal and societal cost. Research addressing the prevention of obesity and T2D among youth is urgently needed.

Prevalence of type 1 and type 2 diabetes among children and adolescents from 2001 to 2009

IMPORTANCE

Despite concern about an "epidemic," there are limited data on trends in prevalence of either type 1 or type 2 diabetes across US race and ethnic groups.

OBJECTIVE

To estimate changes in the prevalence of type 1 and type 2 diabetes in US youth, by sex, age, and race/ethnicity between 2001 and 2009.

DESIGN, SETTING, AND PARTICIPANTS

Case patients were ascertained in 4 geographic areas and 1 managed health care plan. The study population was determined by the 2001 and 2009 bridged-race intercensal population estimates for geographic sites and membership counts for the health plan.

MAIN OUTCOMES AND MEASURES

Prevalence (per 1000) of physician-diagnosed type 1 diabetes in youth aged 0 through 19 years and type 2 diabetes in youth aged 10 through 19 years.

RESULTS

In 2001, 4958 of 3.3 million youth were diagnosed with type 1 diabetes for a prevalence of 1.48 per 1000 (95% CI, 1.44-1.52). In 2009, 6666 of 3.4 million youth were diagnosed with type 1 diabetes for a prevalence of 1.93 per 1000 (95% CI, 1.88-1.97). In 2009, the highest prevalence of type 1 diabetes was 2.55 per 1000 among white youth (95% CI, 2.48-2.62) and the lowest was 0.35 per 1000 in American Indian youth (95% CI, 0.26-0.47) and type 1 diabetes increased between 2001 and 2009 in all sex, age, and race/ethnic subgroups except for those with the lowest prevalence (age 0-4 years and American Indians). Adjusted for completeness of ascertainment, there was a 21.1% (95% CI, 15.6%-27.0%) increase in type 1 diabetes over 8 years. In 2001, 588 of 1.7 million youth were diagnosed with type 2 diabetes for a prevalence of 0.34 per 1000 (95% CI, 0.31-0.37). In 2009, 819 of 1.8 million were diagnosed with type 2 diabetes for a prevalence of 0.46 per 1000 (95% CI, 0.43-0.49). In 2009, the prevalence of type 2 diabetes was 1.20 per 1000 among American Indian youth (95% CI, 0.96-1.51); 1.06 per 1000 among black youth (95% CI, 0.93-1.22); 0.79 per 1000 among Hispanic youth (95% CI, 0.70-0.88); and 0.17 per 1000 among white youth (95% CI, 0.15-0.20). Significant increases occurred between 2001 and 2009 in both sexes, all age-groups, and in white, Hispanic, and black youth, with no significant changes for Asian Pacific Islanders and American Indians. Adjusted for completeness of ascertainment, there was a 30.5% (95% CI, 17.3%-45.1%) overall increase in type 2 diabetes.

CONCLUSIONS AND RELEVANCE

Between 2001 and 2009 in 5 areas of the United States, the prevalence of both type 1 and type 2 diabetes among children and adolescents increased. Further studies are required to determine the causes of these increases.

The WHO Health Promoting School framework for improving the health and well-being of students and their academic achievement

BACKGROUND

The World Health Organization's (WHO's) Health Promoting Schools (HPS) framework is an holistic, settings-based approach to promoting health and educational attainment in school. The effectiveness of this approach has not been previously rigorously reviewed.

OBJECTIVES

To assess the effectiveness of the Health Promoting Schools (HPS) framework in improving the health and well-being of students and their academic achievement.

SEARCH METHODS

We searched the following electronic databases in January 2011 and again in March and April 2013: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, CINAHL, Campbell Library, ASSIA, BiblioMap, CAB Abstracts, IBSS, Social Science Citation Index, Sociological Abstracts, TRoPHI, Global Health Database, SIGLE, Australian Education Index, British Education Index, Education Resources Information Centre, Database of Education Research, Dissertation Express, Index to Theses in Great Britain and Ireland, ClinicalTrials.gov, Current controlled trials, and WHO International Clinical Trials Registry Platform. We also searched relevant websites, handsearched reference lists, and used citation tracking to identify other relevant articles.

SELECTION CRITERIA

We included cluster-randomised controlled trials where randomisation took place at the level of school, district or other geographical area. Participants were children and young people aged four to 18 years, attending schools or colleges. In this review, we define HPS interventions as comprising the following three elements: input to the curriculum; changes to the school's ethos or environment or both; and engagement with families or communities, or both. We compared this intervention against schools that implemented either no intervention or continued with their usual practice, or any programme that included just one or two of the above mentioned HPS elements.

DATA COLLECTION AND ANALYSIS

At least two review authors identified relevant trials, extracted data, and assessed risk of bias in the trials. We grouped different types of interventions according to the health topic targeted or the approach used, or both. Where data permitted, we performed random-effects meta-analyses to provide a summary of results across studies.

MAIN RESULTS

We included 67 eligible cluster trials, randomising 1443 schools or districts. This is made up of 1345 schools and 98 districts. The studies tackled a range of health issues: physical activity (4), nutrition (12), physical activity and nutrition combined (18), bullying (7), tobacco (5), alcohol (2), sexual health (2), violence (2), mental health (2), hand-washing (2), multiple risk behaviours (7), cycle-helmet use (1), eating disorders (1), sun protection (1), and oral health (1). The quality of evidence overall was low to moderate as determined by the GRADE approach. 'Risk of bias' assessments identified methodological limitations, including heavy reliance on self-reported data and high attrition rates for some studies. In addition, there was a lack of long-term follow-up data for most studies.We found positive effects for some interventions for: body mass index (BMI), physical activity, physical fitness, fruit and vegetable intake, tobacco use, and being bullied. Intervention effects were generally small but have the potential to produce public health benefits at the population level. We found little evidence of effectiveness for standardised body mass index (zBMI) and no evidence of effectiveness for fat intake, alcohol use, drug use, mental health, violence and bullying others; however, only a small number of studies focused on these latter outcomes. It was not possible to meta-analyse data on other health outcomes due to lack of data. Few studies provided details on adverse events or outcomes related to the interventions. In addition, few studies included any academic, attendance or school-related outcomes. We therefore cannot draw any clear conclusions as to the effectiveness of this approach for improving academic achievement.

AUTHORS' CONCLUSIONS

The results of this review provide evidence for the effectiveness of some interventions based on the HPS framework for improving certain health outcomes but not others. More well-designed research is required to establish the effectiveness of this approach for other health topics and academic achievement.

Challenging recruitment of youth with type 2 diabetes into clinical trials

PURPOSE

To better understand and overcome difficulties with recruitment of adolescents with type 2 diabetes into clinical trials at three United States institutions, we reviewed recruitment and retention strategies in clinical trials of youth with various chronic conditions. We explored whether similar strategies might be applicable to pediatric patients with type 2 diabetes.

METHODS

We compiled data on recruitment and retention of adolescents with type 2 diabetes at three centers (National Institutes of Health, Bethesda, Maryland; Baylor College of Medicine, Houston, Texas; and Children's National Medical Center, Washington, DC) from January 2009 to December 2011. We also conducted a thorough literature review on recruitment and retention in adolescents with chronic health conditions.

RESULTS

The number of recruited patients was inadequate for timely completion of ongoing trials. Our review of recruitment strategies in adolescents included monetary and material incentives, technology-based advertising, word-of-mouth referral, and continuous patient-research team contact. Cellular or Internet technology appeared promising in improving participation among youths in studies of various chronic conditions and social behaviors.

CONCLUSIONS

Adolescents with type 2 diabetes are particularly difficult to engage in clinical trials. Monetary incentives and use of technology do not represent "magic bullets," but may presently be the most effective tools. Future studies should be conducted to explore motivation in this population. We speculate that (1) recruitment into interventional trials that address the main concerns of the affected youth (e.g., weight loss, body image, and stress management) combined with less tangible outcomes (e.g., blood glucose control) may be more successful; and (2) study participation and retention may be improved by accommodating patients' and caregivers' schedules, by scheduling study visits before and after working hours, and in more convenient locations than in medical facilities.

Development, implementation, and effects of community-based diabetes prevention program for obese latino youth

OBJECTIVE

Obesity and type 2 diabetes have emerged as critical health issues among Latino youth. Although both conditions manifest early in life, very few diabetes prevention programs have been developed to specifically meet the needs of this population. The authors describe the development, implementation, and metabolic impact of a culturally informed, community-based diabetes prevention program for obese Latino youth.

METHODS

A lifestyle education program was developed to address the health needs of Latino youth served by a community-based medical clinic. The program consisted of group education sessions delivered to children and their families to address nutrition, physical activity, family roles and responsibilities, and self-esteem. The metabolic impact of the program was evaluated by assessing body mass index (BMI), high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, total cholesterol, triglycerides, glucose, and insulin.

RESULTS

On entry, the prevalence of risk factors among the 102 youth (mean BMI, 30.4 ± 4.9 kg/m(2)) was substantial (68.6% with low HDL cholesterol, 32.1% with elevated triglycerides, 9.4% with impaired fasting glucose, 39.4% with elevated total cholesterol, 43.0% with elevated LDL cholesterol, and 60.6% with hyperinsulinemia). The 50 youth who returned after the program for follow-up measurements exhibited significant health improvements, including a 3.8% reduction in BMI; 5.4% and 8.6% decreases in total and LDL cholesterol, respectively; a 9.3% increase in HDL cholesterol; and a 24.0% decrease in fasting insulin (all P values < .05).

CONCLUSIONS

These promising findings suggest that a community-based diabetes prevention program for obese Latino youth is a feasible strategy for improving health in this high-risk population. Further studies are warranted to examine whether similar programs can be implemented in diverse communities and settings.

Diabetes screening with hemoglobin A(1c) versus fasting plasma glucose in a multiethnic middle-school cohort

OBJECTIVE

To characterize middle-school students from the HEALTHY study with glycemic abnormalities, specifically high-risk hemoglobin A(1c) (A1C) (hrA1C; A1C = 5.7-6.4%) and impaired fasting glucose (IFG; fasting plasma glucose [FPG] = 100-125 mg/dL).

RESEARCH DESIGN AND METHODS

History was collected by self-report, physical measurement was collected by trained study staff, and fasting blood was drawn by trained phlebotomists and analyzed centrally.

RESULTS

At baseline, among 3,980 sixth graders, 128 (3.2%) had hrA1C and 635 (16.0%) had IFG. Compared with A1C <5.7%, hrA1C was associated with non-Hispanic black race/ethnicity, family history of diabetes, and higher measurements of BMI, waist circumference, and fasting insulin. Compared with FPG <100 mg/dL, IFG was associated with Hispanic ethnicity; increased BMI, waist circumference, and fasting insulin; higher frequency of high blood pressure; and higher mean triglycerides. Two years later, children with hrA1C persisted as hrA1C in 59.4%, and one child (0.8%) developed A1C ≥6.5%; children with IFG persisted with IFG in 46.9%, and seven children (1.1%) developed FPG ≥126 mg/dL. Those with hrA1C compared with IFG had a higher BMI in sixth grade, which persisted to eighth grade.

CONCLUSIONS

In the HEALTHY study cohort, hrA1C and IFG define different groups of youth with differentially increased diabetes risk markers. IFG is approximately fivefold more common, but hrA1C is more persistent over time. Optimal screening strategies for diabetes in youth remain unresolved.

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.

Obesity and preference-weighted quality of life of ethnically diverse middle school children: the HEALTHY study

To date, studies examining the relation between body mass index percentile (BMI%) categories and health-related quality of life (QOL) measurements have not reported preference-weighted scores among ethnically diverse children. We report the associations between BMI% categories and preference-weighted scores among a large cohort of ethnically diverse sixth grade children who participated in the HEALTHY school-based type 2 diabetes risk factor prevention study. Health Utility Index 2 (HUI2) and Health Utility Index 3 (HUI3) and the feeling thermometer (FT) were the preference-weighted QOL instruments used to measure student's preference scores. Of 6358 consented students, 4979 (78.3%) had complete QOL, height, weight, and covariate data. Mean (SD) preference scores were 0.846 (0.160), 0.796 (0.237), and 0.806 (0.161) for the HUI2, HUI3, and FT, respectively. After adjusting for age, sex, blood glucose and insulin, Tanner stage, race/ethnicity, family history of diabetes, and educational attainment, children with severe obesity (>99%) had significantly lower preference scores compared to normal weight on all three instruments (HUI2 P = 0.013; HUI3 P = 0.025; and FT P < 0.001). Obese and severe obese categories were significantly associated with lower HUI2 functional ratings in the mobility domain and with lower HUI3 functional ratings in the speech domain.

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.

A primary care-based, multicomponent lifestyle intervention for overweight adolescent females

BACKGROUND AND OBJECTIVE

Most clinic-based weight control treatments for youth have been designed for preadolescent children by using family-based care. However, as adolescents become more autonomous and less motivated by parental influence, this strategy may be less appropriate. This study evaluated a primary care-based, multicomponent lifestyle intervention specifically tailored for overweight adolescent females.

METHODS

Adolescent girls (N = 208) 12 to 17 years of age (mean ± SD: 14.1 ± 1.4 years), with a mean ± SD BMI percentile of 97.09 ± 2.27, were assigned randomly to the intervention or usual care control group. The gender and developmentally tailored intervention included a focus on adoptable healthy lifestyle behaviors and was reinforced by ongoing feedback from the teen's primary care physician. Of those randomized, 195 (94%) completed the 6-month posttreatment assessment, and 173 (83%) completed the 12-month follow-up. The primary outcome was reduction in BMI z score.

RESULTS

The decrease in BMI z score over time was significantly greater for intervention participants compared with usual care participants (-0.15 in BMI z score among intervention participants compared with -0.08 among usual care participants; P = .012). The 2 groups did not differ in secondary metabolic or psychosocial outcomes. Compared with usual care, intervention participants reported less reduction in frequency of family meals and less fast-food intake.

CONCLUSIONS

A 5-month, medium-intensity, primary care-based, multicomponent behavioral intervention was associated with significant and sustained decreases in BMI z scores among obese adolescent girls compared with those receiving usual care.

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.

Student public commitment in a school-based diabetes prevention project: impact on physical health and health behavior

BACKGROUND

As concern about youth obesity continues to mount, there is increasing consideration of widespread policy changes to support improved nutritional and enhanced physical activity offerings in schools. A critical element in the success of such programs may be to involve students as spokespeople for the program. Making such a public commitment to healthy lifestyle program targets (improved nutrition and enhanced physical activity) may potentiate healthy behavior changes among such students and provide a model for their peers. This paper examines whether student's "public commitment"--voluntary participation as a peer communicator or in student-generated media opportunities--in a school-based intervention to prevent diabetes and reduce obesity predicted improved study outcomes including reduced obesity and improved health behaviors.

METHODS

Secondary analysis of data from a 3-year randomized controlled trial conducted in 42 middle schools examining the impact of a multi-component school-based program on body mass index (BMI) and student health behaviors. A total of 4603 students were assessed at the beginning of sixth grade and the end of eighth grade. Process evaluation data were collected throughout the course of the intervention. All analyses were adjusted for students' baseline values. For this paper, the students in the schools randomized to receive the intervention were further divided into two groups: those who participated in public commitment activities and those who did not. Students from comparable schools randomized to the assessment condition constituted the control group.

RESULTS

We found a lower percentage of obesity (greater than or equal to the 95th percentile for BMI) at the end of the study among the group participating in public commitment activities compared to the control group (21.5% vs. 26.6%, p = 0.02). The difference in obesity rates at the end of the study was even greater among the subgroup of students who were overweight or obese at baseline; 44.6% for the "public commitment" group, versus 53.2% for the control group (p = 0.01). There was no difference in obesity rates between the group not participating in public commitment activities and the control group (26.4% vs. 26.6%).

CONCLUSIONS

Participating in public commitment activities during the HEALTHY study may have potentiated the changes promoted by the behavioral, nutrition, and physical activity intervention components.

TRIAL REGISTRATION

ClinicalTrials.gov number, NCT00458029.

Metabolic risk and health behaviors in minority youth at risk for type 2 diabetes

OBJECTIVE

The purpose of this study was to determine the impact of sex and race/ethnicity on metabolic risk and health behaviors in minority youth.

RESEARCH DESIGN AND METHODS

A total of 173 seventh graders (46% male and 54% female; 49% Hispanic and 51% African American) with BMI ≥85th percentile and a family history of diabetes were assessed with weight, height, BMI, percent body fat, and waist circumference measures. Laboratory indexes included 2-h oral glucose tolerance tests with insulin levels at 0 and 2 h, fasting A1C, and lipids. Insulin resistance was estimated by homeostasis model assessment (HOMA-IR). Youth also completed questionnaires evaluating health behaviors.

RESULTS

Average BMI (31.6 ± 6.4 kg/m²) and percent body fat (39.5 ± 10.6%) were high. All participants demonstrated insulin resistance with elevated HOMA-IR values (8.5 ± 5.2). Compared with African American youth, Hispanic youth had higher triglycerides and lower HDL cholesterol despite similar BMI. Hispanic youth reported lower self-efficacy for diet, less physical activity, and higher total fat intake. Male youth had higher glucose (0 and 2 h) and reported more physical activity, more healthy food choices, and higher calcium intake than female youth.

CONCLUSIONS

Screening high-risk youth for insulin resistance and lipid abnormalities is recommended. Promoting acceptable physical activities and healthy food choices may be especially important for Hispanic and female youth.

Children with type 2 diabetes mellitus and the prevalence of psychiatric disorders

OBJECTIVE

Type 2 diabetes is a common disease, afflicting more than 20 million Americans. Psychiatric disorders, particularly depression, have been previously correlated with diabetes.

METHODS

The objectives of this study were to determine the frequency of psychiatric illnesses in a type 2 pediatric diabetic cohort and to examine if there were any significant demographic differences between diabetic children with psychiatric disorders and diabetic children without psychiatric disorders. A retrospective chart review was performed on patients from two southeastern children's hospitals.

RESULTS

In our study, 26.2% (67 of 256) of diabetic patients were diagnosed with neuropsychiatric disorders (NPD). A comparison between gender frequencies of affected and unaffected patients suggested a statistical difference (P = 0.009). It appears that pediatric diabetic males are affected with NPD to a greater extent than females. Patients diagnosed with neurological disorders showed a body mass index average of 39.03, which was statistically different from non-diagnosed NPD patients (P = 0.0313).

CONCLUSIONS

To our knowledge, this is the first report to demonstrate the frequency of psychiatric disorders in a cohort of pediatric type 2 diabetics in the southeastern US. This study provides information regarding children afflicted with type 2 diabetes mellitus and the frequency of neuropsychiatric morbidities. This information may be useful for crafting future health policies and quality improvement interventions.

Severe obesity and selected risk factors in a sixth grade multiracial cohort: the HEALTHY study

The purpose of this study was to document the prevalence of severe obesity and associated risk in the HEALTHY cohort. A total of 6,365 students were assessed at school-based screenings. Results showed that 6.9% of students were severely obese. Severe obesity was associated with elevated cardiometabolic risk and race/ethnicity. Severe obesity is common and requires preventive intervention.

Pulsatile intermittent intravenous insulin therapy for attenuation of retinopathy and nephropathy in type 1 diabetes mellitus

Many hormones are secreted in a pulsatile fashion that is more efficient than continuous secretion when tested in vivo. A trial of multiple daily insulin doses with or without the addition of weekly pulsatile insulin infusion therapy was designed to determine if deterioration of renal and retinal function could be blunted. Sixty-five study subjects were evaluated prospectively in 7 centers. Thirty-six patients were randomly allocated to the infusion group and 29 to the standard therapy group. Mean serum creatinine was 1.6 mg/dL in both groups. Subjects were excluded if clearance was less than 30 mL/min. There were no significant differences between the groups with respect to age, duration of diabetes, sex distribution, glycohemoglobin, blood pressure, angiotensin-converting enzyme inhibitor use, proteinuria, or baseline diabetic retinopathy (DR) severity level (all eyes exhibited DR; 8 were deemed technically not amenable to evaluation). Progression of DR was noted in 31.6% of 57 patients (32.3% treated, 30.8% control; P = 1.0) with both eyes evaluable. For patients with 12 or more months of follow-up, 27.9% of 43 patients demonstrated progression of DR (32.0% treated, 22.2% control; P = .57). There were no significant differences between study groups with respect to progression or marked progression, nor was there any influence of duration of follow-up. Progression of DR was noted in 18.8% of 122 eyes that could be adequately evaluated (17.9% of 67 treated, 20% of 55 controls; P = .39). Serum creatinine increased to 1.7 mg/dL in the treatment group and to 1.9 mg/dL in the control group (P = .03). Statistically significant preservation of renal function by pulsatile insulin infusion was not matched by a statistically significant prevention of DR progression compared with standard diabetes care. Inadequate statistical power or duration of the study, or lack of further benefit of pulsatile insulin infusion on the retina in the presence of angiotensin-converting enzyme inhibition may be responsible.

A school-based intervention for diabetes risk reduction

BACKGROUND

We examined the effects of a multicomponent, school-based program addressing risk factors for diabetes among children whose race or ethnic group and socioeconomic status placed them at high risk for obesity and type 2 diabetes.

METHODS

Using a cluster design, we randomly assigned 42 schools to either a multicomponent school-based intervention (21 schools) or assessment only (control, 21 schools). A total of 4603 students participated (mean [+/- SD] age, 11.3 [+/- 0.6 years; 54.2% Hispanic and 18.0% black; 52.7% girls). At the beginning of 6th grade and the end of 8th grade, students underwent measurements of body-mass index (BMI), waist circumference, and fasting glucose and insulin levels.

RESULTS

There was a decrease in the primary outcome--the combined prevalence of overweight and obesity--in both the intervention and control schools, with no significant difference between the school groups. The intervention schools had greater reductions in the secondary outcomes of BMI z score, percentage of students with waist circumference at or above the 90th percentile, fasting insulin levels (P=0.04 for all comparisons), and prevalence of obesity (P=0.05). Similar findings were observed among students who were at or above the 85th percentile for BMI at baseline. Less than 3% of the students who were screened had an adverse event; the proportions were nearly equivalent in the intervention and control schools.

CONCLUSIONS

Our comprehensive school-based program did not result in greater decreases in the combined prevalence of overweight and obesity than those that occurred in control schools. However, the intervention did result in significantly greater reductions in various indexes of adiposity. These changes may reduce the risk of childhood-onset type 2 diabetes. (Funded by the National Institutes of Health and the American Diabetes Association; ClinicalTrials.gov number, NCT00458029.)

Noninvasive Screening for Risk Factors of Type 2 Diabetes in Young, Rural, Caucasian Children

School nurses play an important role in identifying students who are at risk for Type 2 diabetes mellitus (T2DM). Few studies have screened Caucasian students, and none have targeted rural, low-income, elementary children. The five noninvasive risk factors used for this study were family history, high body mass index (BMI) for age/sex, racial/ethnic background, hypertension, and acanthosis nigricans. Two thirds of those screened ( n = 299) had at least one of the five risk factors for T2DM. Seventeen students (5.6% of those screened) had three or more of the five risk factors and were considered at risk for T2DM. Fifteen percent ( n = 43) had hypertension or prehypertension, and 18% (n = 53) were morbidly obese. Hypertension and acanthosis nigricans were significantly associated with being at risk in morbidly obese students. School nurses play an important role as frontline health professionals who are aware that risk factors for T2DM exist in all schools, regardless of students' age, size of community, or ethnic background.

Manifestation of renal disease in obesity: pathophysiology of obesity-related dysfunction of the kidney

Albuminuria in individuals whose body mass index exceeds 40 kg/m(2) is associated with the presence of large glomeruli, thickened basement membrane and epithelial cellular (podocyte) distortion. Obstructive sleep apnea magnifies glomerular injury as well, probably through a vasoconstrictive mechanism. Insulin resistance from excess fatty acids is exacerbated by decreased secretion of high molecular weight adiponectin from adipose cells in the obese state. Adiponectin potentiates insulin in its post-receptor signaling resulting in glucose oxidation in mitochondria. Recent studies of podocyte physiology have concentrated on the structural and functional requirements that prevent glomerular albumin leakage. The architecture of the podocyte involves nephrin and podocin, proteins that cooperate to keep slit pores between foot processes competent to retain albumin. Insulin and adiponectin are necessary for high-energy phosphate generation. When fatty acids bind to albumin, the toxicity to proximal renal tubules is magnified. Albumin and fatty acids are elevated in urine of individuals with obesity related nephrotic syndrome. Fatty acid accumulation and resistin inhibit insulin and adiponectin. Study of cytokines produced by adipose tissue (adiponectin and leptin) and macrophages (resistin) has led to a better understanding of the relationship between weight and hypertension. Leptin, is presumably secreted after food intake to inhibit the midbrain/hypothalamic appetite centers. Resistance to leptin results in excess signaling to hypothalamic sympathetics leading to hypertension. Demonstration of the existence of a cerebral receptor mutation provide evidence for a role in hypertension of a central nervous reflex arc in humans. Further understanding of obesity-related renal dysfunction has been accomplished recently using experimental models. Rapid weight loss following bariatric surgery may reverse renal pathology of obesity with restoration of normal blood pressure.

Snacking in children: the role of urban corner stores

OBJECTIVE

Childhood obesity is higher among ethnic minorities. One reason may be the limited access to affordable, healthy options. The disparate prevalence of urban corner stores in low-income and high-minority communities has been well documented. There are no data, however, on what children purchase in these environments before and after school. The purpose of this study was to document the nature of children's purchases in corner stores proximal to their schools.

METHODS

This was an observational study from January to June 2008. Participants were children in grades 4 through 6 from 10 urban K-8 schools with >or=50% of students eligible for free or reduced-price meals. A total of 833 intercept surveys of children's purchases were conducted outside 24 corner stores before and after school. The main outcomes were type and energy content of items purchased.

RESULTS

The most frequently purchased items were energy-dense, low-nutritive foods and beverages, such as chips, candy, and sugar-sweetened beverages. Students spent $1.07 +/- 0.93 on 2.1 +/- 1.3 items (1.6 +/- 1.1 food items and 0.5 +/- 0.6 beverage items) per purchase. The total number of calories purchased per trip was 1497.7 +/- 1219.3 kJ (356.6 +/- 290.3 kcal). More calories came from foods than from beverages.

CONCLUSIONS

Purchases made in corner stores contribute significantly to energy intake among urban school children. Obesity prevention efforts, as well as broader efforts to enhance dietary quality among children in urban settings, should include corner store environments proximal to schools.

A multifaceted school-based intervention to reduce risk for type 2 diabetes in at-risk youth

OBJECTIVE

To evaluate the impact of a multifaceted, school-based intervention on inner city youth at high risk for type 2 diabetes mellitus (T2DM) and to determine whether the addition of coping skills training (CST) and health coaching improves outcomes.

METHOD

198 students in New Haven, CT at risk for T2DM (BMI>85th percentile and family history of diabetes) were randomized by school to an educational intervention with or without the addition of CST and health coaching. Students were enrolled from 2004 to 2007 and followed for 12 months.

RESULTS

Students in both groups showed some improvement in anthropometric measures, lipids, and depressive symptoms over 12 months. BMI was not improved by the intervention. Students who received CST showed greater improvement on some indicators of metabolic risk than students who received education only.

CONCLUSION

A multifaceted, school-based intervention may hold promise for reducing metabolic risk in urban, minority youth.