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In Children
Leslie K. Scott
190
This study aimed to identify the prevalence of type 2 diabetes risk factors among
elementary school-age children and determine eligibility for type 2 diabetes
screening. A cross-sectional review of 971 school-based health clinic medical
records of children in grades 1 through 5 was conducted. Relationships of risk
factors associated with type 2 diabetes mellitus were examined to determine the
prevalence of these risk factors in elementary school-age children. Screening
guidelines for type 2 diabetes were applied to determine the prevalence of students meeting criteria for further screening. Almost 40% of the students had a
body mass index (BMI) above the 85th percentile for age and gender. Forty-nine
percent of the students belonged to a high-risk ethnic group. Acanthosis nigricans, an indicator of insulin resistance, was identified in nearly 27% of the student records. Forty-eight percent of the records identified the student as having
a family history of diabetes. Significant correlations were found between the
presence of acanthosis nigricans, high BMI, and a family history of diabetes.
According to screening guidelines for type 2 diabetes in children, 39.3% of the
elementary school children 10 years of age and older were eligible for type 2 diabetes screening. Almost 40% of children younger than 10 years of age had risk
factors associated with screening criteria. These findings support the need for
early detection of high-risk children and intervention strategies to decrease modifiable risk factors in elementary school-age children. The school nurse is in a pivotal role of identifying such at-risk students during annual, routine health screening practices.
that did not require insulin for survival (Ludwig & Ebbeling, 2001).
Until the last decade, little attention
was paid to this form of diabetes that
closely resembled type 2 diabetes, typically diagnosed in adults.
Before 1990, fewer than 4% of
children diagnosed with diabetes had
type 2 diabetes (Pinhas-Hamil &
Zeitler, 2005). Although type 2 diabetes remains rare in youth under 10
years of age, rates have increased
among individuals 10 to 19 years of
age, particularly those in high-risk
ethnic groups. Prior to 1994, most
epidemiologic studies focused on
small, high-risk ethnic groups of adolescents, such as Pima Indians,
American-Indians, First Nations,
Mexican-Americans, and AfricanAmericans (Nadeau & Dabelea, 2008).
More recent studies have identified
that up to 45% of African-American
and Caucasian children diagnosed
with diabetes in the U.S. have type 2
diabetes (CDC, 2008a; Soltesz, 2006).
Based on 2002-2003 data, 3,700
youth are diagnosed with type 2 dia-
Figure 1.
Screening Criteria for Type 2 Diabetes in Children
The following children should be screened beginning at 10 years of age or the onset
of puberty, if puberty occurs earlier.
Weight Criteria: All children with body mass index (BMI) greater than the 85th
percentile for age and gender, weight for height above the 85th percentile for age
and gender, or weight greater than 120% of ideal for height.
All children meeting at least one weight criterion and any two of the following:
Family history of diabetes (first or second degree relative).
High-risk ethnic group (African-American, Hispanic/Latino-American, NativeAmerican, Asian-American or Pacific Islander).
Evidence of insulin resistance (acanthosis nigricans, hypertension, dyslipidemia,
polycystic ovary syndrome [PCOS], or small-for-gestational-age birth weight).
Maternal history of diabetes or gestational diabetes during childs gestation.
Source: ADA, 2010.
Methods
Population
The medical records of children
in grades 1 through 5 enrolled in
school-based health clinics in
Kentucky public schools during the
2001-2002 academic years were eligible for review. Fayette County currently has 32 elementary schools supporting a community with a population of 270,000 individuals (Fayette
County Public School System [FCPS],
2002). Fayette County consists of 81%
191
Study Design
A cross-sectional study of existing
clinic medical records from the 20012002 academic year were used to evaluate the presence of risk factors associated with type 2 diabetes among elementary school-age children in grades
1 through 5 following four, schoolwide height/weight screenings. Data
were used to determine the prevalence of risk factors associated with
type 2 diabetes mellitus as described
by the AAP/ADA screening criteria
(see Figure 1).
Research Procedure
The University of Kentucky
Medical Institutional Review Board
and the Medical Director of the
Fayette County, Kentuckys schoolbased health clinics, approved the
study. Each school-wide height/
weight screening was scheduled independently based on school schedule
and availability of students. Prior to
each of the school-wide screenings,
school-based clinic nurses and nurse
practitioners participated in a 30minute education session that
focused on the assessment of acanthosis nigricans as provided by a certified diabetes educator. Key areas of
these training sessions included the
192
Table 1.
Student Demographics of All Study Participants
Non-Hispanic
Caucasian
n (%)
AfricanAmerican
n (%)
Other*
n (%)
Males
246 (25.3%)
194 (20.0)
52 (5.3%)
492
(50.6%)
Females
243 (25.0%)
177 (18.2)
59 (6.1%)
479
(49.3%)
489 (50.4%)
371 (38.2)
111 (11.4%)
Total
n (%)
Gender
Total
971 (100.0%)
Results
The clinic records of 971 students, grades 1 through 5, met inclusion criteria and were reviewed for the
purpose of this study. The study
group represented 74% of the population of the four schools included in
the screening. Self-reported ethnicity
and gender of the student records
enrolled in this study consisted of
50.4% non-Hispanic Caucasians,
38.2% African Americans, and 15.8%
Other (Hispanic and other students) and consisted of equal numbers of each gender (see Table 1).
Other was self-described by the parent completing the health history
form and included bi-racial,
Hispanic, and Asian ethnicities.
Almost 40% of the overall group of
students had a BMI greater than the
85th percentile for age and gender.
Nearly 17% were overweight (BMI
85th to 95th percentile for age and
gender). Conversely, more than 23%
of the students were obese (BMI
greater than the 95th percentile for
age and gender). Acanthosis nigricans
was present in 26.9% of the students
(see Table 2). Medical history forms in
the clinic record indicated that 48%
of the students identified a family history of diabetes. Data were then divided into two groups students younger than 10 years of age (n = 602) and
Table 2.
All Students Enrolled: Body Mass Index, Acanthosis Nigricans, and Family History of
Diabetes Mellitus by Ethnicity and Gender*
Body Mass Index for Age and Gender
Less Than
85th Percentile
n (%)
85th to 95th
Percentile
n (%)
Greater Than
95th Percentile
n (%)
Acanthosis
Nigricans
Present
n (%)
Family History
of Diabetes
Mellitus
n (%)
Ethnicity
Non-Hispanic Caucasian
301 (31.0%)
82
(8.4%)
106 (10.9%)
African-American
212 (21.8%)
61
(6.3%)
98 (25.0%)
17
(1.8%)
23 (20.0%)
160 (16.5%)
Other**
Total
71
(7.3%)
584 (60.1%)
(9.0%)
230 (23.7%)
134 (13.8%)
87
179 (18.4%)
40
(4.0%)
58
(6.0%)
227 (23.4%)
261 (26.9%)
467
(48%)
Gender
Males
285 (29.4%)
85
(8.8%)
119 (12.3%)
128 (13.2%)
231 (23.8%)
Females
299 (30.8%)
75
(7.7%)
108 (11.1%)
133 (13.7%)
236 (24.3%)
*N = 971
**The term Other includes self-reported bi-racial, Hispanic, or Asian ethnicity.
BMI. Regardless of age, gender, or ethnicity, students with a BMI less than
the 85th percentile for age and gender
were 2.3 times (p = < 0.001) less likely
to have acanthosis nigricans and a
family history of diabetes (2 = 51.86;
p = < 0.001) when compared to students whose BMI is greater than the
95th percentile for age and gender.
Older obese students were almost
eight times more likely to have acanthosis nigricans and a family history
of diabetes as compared to those
whose BMI is less than the 95th percentile for age and gender. This finding supports the importance of
screening for a family history of diabetes in older students who are obese
with acanthosis nigricans.
Table 3.
Students 10 Years of Age or Older: Body Mass Index, Acanthosis Nigricans, and Family History of
Diabetes Mellitus by Ethnicity and Gender*
Body Mass Index for Age and Gender
Less Than
85th Percentile
n (%)
85th to 95th
Percentile
n (%)
Greater Than
95th Percentile
n (%)
Acanthosis
Nigricans
Present
n (%)
Family History
of Diabetes
Mellitus
n (%)
Ethnicity
116 (31.4%)
24
(6.5%)
50 (13.6%)
33
(8.9%)
88 (23.8%)
African-American
85 (23.0%)
16
(4.3%)
45 (12.2%)
41 (11.1%)
68 (18.4%)
Other**
17
(2.2%)
10
16
Non-Hispanic Caucasian
(4.6%)
218 (59.0%)
48 (13.0%)
Males
101 (27.4%)
27
Females
117 (31.7%)
21
Total
(2.2%)
(2.7%)
(4.3%)
103 (27.9%)
84 (22.8%)
172 (46.6%)
(7.3%)
54 (14.6%)
43 (11.7%)
81 (22.0%)
(5.7%)
49 (13.3%)
41 (11.1%)
91 (24.7%)
Gender
*N = 369.
**The term Other includes self-reported bi-racial, Hispanic, or Asian ethnicity.
Table 4.
Eligible for Type 2 Diabetes Mellitus Screening*
Non-Hispanic
Caucasian
n (%)
AfricanAmerican
n (%)
Other**
n (%)
Total
n (%)
50 (13.6%)
45 (12.2%)
8 (2.2%)
103 (28.0%)
10
15
(4.1%)
+ Acanthosis nigricans
(1.9%)
20
20 (5.4%)
70 (19.0%)
58 (15.7%)
17 (4.6%)
145 (39.3%)
Total
*N = 369
**The term Other includes self-reported bi-racial, Hispanic, or Asian ethnicity.
Discussion
Type 2 diabetes now accounts for
up to 45% of the new cases of diabetes
in children within the U.S. depending
on geographical region and ethnicity
194
Table 5.
Students Less Than 10 Years of Age Meeting Eligibility Criteria*
Non-Hispanic
Caucasian
n (%)
54
(9%)
AfricanAmerican
n (%)
93 (15.4%)
Other**
n (%)
30
(5.0%)
Total
n (%)
177 (29.4%)
33 (5.5%)
32
23
(3.8%)
+ Acanthosis nigricans
17
(1.1%)
7
61 (10.1%)
Total
142 (23.6%)
37
240 (39.9%)
(6.1%)
*N = 602
**The term Other includes self-reported bi-racial, Hispanic, or Asian ethnicity.
diabetes. No ethnic differences existed within the group relating to a family history of diabetes. These findings
vary from national norms most likely
due to the close proximity of the
research area to the Appalachian
region and the known higher incidence of diabetes in Appalachia
(CDC, 2009). No data exist in the literature reporting the prevalence of a
positive family history of diabetes
within the general population, particularly in children. Further epidemiologic studies are indicated to better
determine the prevalence of a positive
family history of type 2 diabetes within the general population.
According to AAP and ADA guidelines (ADA, 2000), nearly 40% of the
students were eligible for further
screening for type 2 diabetes. Similar
to the literature, high-risk ethnic
groups were likely to have multiple
risk factors for the development of
type 2 diabetes. Further research is
needed to evaluate current screening
practices of high-risk children and to
better understand acanthosis nigricans as it occurs in children, particularly to determine if regional differences in its occurrence exist. Additional studies focusing on prevention
and intervention strategies targeting
controllable risk factors are needed
and should be directed toward these
high-risk students.
196
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Additional Readings
Centers for Disease Control and Prevention (CDC). (2005). Growth
charts. Retrieved from http://www.cdc.gov/growthcharts
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weight: Its not a diet, its a lifestyle. Retrieved from
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bout_childrens_bmi.html
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& Nagamani, M. (1998). Acanthosis nigricans as a risk factor for
non-insulin dependent diabetes mellitus. Clinical Pediatrics,
37(2), 73-79.
Young-Hyman, D., Schlundt, D.G., Herman, L., DeLuca, F., & Counts,
D. (2001). Evaluation of the insulin resistance syndrome in 5- to
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Diabetes Care. 24(8), 1359-1364.
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