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Presence of Type 2 Diabetes Risk Factors

In Children
Leslie K. Scott

iabetes mellitus is a very serious and costly disease.


Unfortunately, children are
not immune to this health
problem. There are 215,000 children
younger than 20 years of age in the
United States with diabetes (Centers
for Disease Control and Prevention
[CDC], 2011a); two million children
12 to 19 years of age have pre-diabetes
(CDC, 2008b). One in three children
born in 2000 will develop diabetes in
their lifetime (CDC, 2009). Diabetes is
the sixth leading cause of death, the
leading cause of blindness, and the
leading cause of end-stage renal disease, and is responsible for numerous
individuals with nerve disease/amputations and cardiovascular disease
(American Diabetes Association [ADA],
2010). Direct and indirect costs of diabetes and its related complications in
the U.S. total $174 billion annually
(CDC, 2008b). Historically, most children with diabetes develop type 1 diabetes; however, since 1996, there has
been an increase in the incidence of
type 2 diabetes in children, particularly in high-risk ethnic groups (for
example, African-American, Hispanic,
Asian-American, Pacific Islander, and
American Indian). Identifying children at high risk for the development
of type 2 diabetes is important because it has been well documented in
adults that the onset of type 2 diabetes can be prevented or at least
delayed (Bo-Abbas et al., 2002;
Knowler et al., 2002).

Review of the Literature


As early as 1916, diabetologists
recognized that some children with
diabetes had an unusually mild and
slowly progressive form of the disease

Leslie K. Scott, PhD, PNP-BC, CDE, is a


Coordinator, Pediatric Nurse Practitioner
Doctorate in Nursing Practice Program,
University of Kentucky, College of Nursing,
Lexington, KY.

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-

betes annually (CDC, 2008b). The


incidence rate of type 2 diabetes is 5.3
per 100,000 youth under 19 years of
age (Zeitler & Pinhas-Hamil, 2008).
Symptoms associated with hyperglycemia are insidious; adults with
type 2 diabetes are thought to have
hyperglycemia or impaired glucose tolerance for 7 to 10 years prior to diagnosis (Zeitler & Pinhas-Hamil, 2008).
Current literature now indicates the
insidious onset of type 2 diabetes in
children mirrors the disease onset of
adults (Bloomgarten, 2004). The
longer a person has diabetes, the
greater the chance of developing
complications associated with diabetes (National Institutes of Health
[NIH], 2010). Because complications
associated with diabetes occur due to
prolonged hyperglycemia, mounting
evidence suggests that children and
adolescents diagnosed with type 2
diabetes are at tremendous risk for
developing early/premature complications (Pinhas-Hamil & Zeitler,
2007). Due to the risk for the onset of
these diabetes-related complications,

PEDIATRIC NURSING/July-August 2013/Vol. 39/No. 4

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.

finding youth with unknown diabetes has been the impetuous of


youth diabetes screening programs.
Four primary risk factors as identified by the American Diabetes
Association (ADA) and the American
Academy of Pediatrics (AAP) place
children at risk for the development
of type 2 diabetes: obesity, ethnicity,
family history of diabetes, and the
presence of insulin resistance (see
Figure 1) (ADA, 2010). Although the
ADA and the AAP do not recognize
gender as an independent risk factor
for the development of type 2 diabetes in children, being female can
provide additional risk. In the U.S.,
the adult prevalence of type 2 diabetes is slightly higher in women
than men. Similarly in children,
females are 1.63 times more likely to
develop type 2 diabetes than males
(Dabelea et al., 2007).
Approximately 17% (or 12.5 million) children and adolescents 2 to 19
years of age in the U.S. are obese
(CDC, 2011b). Since 1980, obesity
prevalence rates among children and
adolescents have almost tripled.
Obesity is the most important, yet
modifiable risk factor for the development of type 2 diabetes. High-risk
ethnic groups (i.e., Native-American,
African-American, Mexican-American,
Asian-American, Pacific Islanders) are
particularly susceptible to the onset of
type 2 diabetes, especially if they are
overweight. Obese children produce
too much insulin as a result of excess
adipose tissue, which leads to insulin
resistance and compensatory hyperinsulinemia (Copeland, Becker,

Gottschalk, & Hale, 2005). Acanthosis


nigricans has been well documented
as a clinical indicator of hyperinsulinemia and demonstrates evidence of
insulin resistance. Typically, the
greater the severity of acanthosis
nigricans, the more significant is the
degree of insulin resistance and
hyperinsulinemia. Other clinical indicators associated with insulin resistance include hyperlipidemia and
hypertension (Hu & Stampfer, 2005).
According to the ADA and AAP,
all obese children and those whose
body mass index (BMI) is greater than
the 85th percentile for age and gender, with any two risk factors highrisk ethnicity, family history of diabetes, or evidence of insulin resistance
should be screened beginning at 10
years of age or at the onset of puberty
if that develops earlier (see Figure 1)
(ADA, 2010). Many studies report
these screening guidelines are inconsistently applied (Zeitler & PinhasHamil, 2008). In the primary care setting, as few as 45% of children who
qualify for type 2 diabetes screening
are actually screened with further
ancillary testing (Anand, Mehta, &
Adams, 2006).
Children meeting criteria for type
2 diabetes screening should have further ancillary tests to assess their glucose response to carbohydrate metabolism. Children should also be further
screened for additional evidence of
insulin resistance and common comorbidities associated with type 2
diabetes. Common ancillary tests for
screening for type 2 diabetes in children and its complications include

PEDIATRIC NURSING/July-August 2013/Vol. 39/No. 4

fasting plasma glucose, 2-hour oral


glucose tolerance test, hemoglobin
A1c, blood pressure, lipid profile, and
thyroid-stimulating hormone (TSH)
(ADA, 2000).
Most studies investigating the
increased incidence of type 2 diabetes
in children and screening at-risk
youth have focused on very small
populations of high-risk children
(ADA, 2000; CDC, 2008a). Texas
screens children in grades 3, 5, and 8
for the presence of acanthosis nigricans (Texas Department of Health,
2002). Although youth are identified
for the presence of acanthosis nigricans, no statistics have been reported
indicating the incidence of type 2 diabetes or the prevalence of additional
risk factors in the students screened
(Hardin, 2006). Children were screened for acanthosis nigricans; however,
quantitative information regarding
acanthosis nigricans was not reported.
Burke, Hale, Hazuda, and Stern
(1999) developed a quantitative acanthosis nigricans screening tool. The
tool was tested on Mexican-American
adults and included a description of
each degree of acanthosis nigricans
severity at various anatomic locations. The neck was found to be the
only reliable location for accurate
detection of acanthosis nigricans
(Burke et al., 1999).
No current studies have specifically focused on identifying high-risk
children as described by the AAP/ADA
screening guidelines within the general population, particularly those
under 13 years of age. Therefore, the
purpose of this study was to determine the prevalence of type 2 diabetes risk factors among elementary
school-age children in grades 1
through 5 and identify the number of
youth eligible for further screening as
described by AAP/ADA screening
guidelines.

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

Presence of Type 2 Diabetes Risk Factors in Children


non-Hispanic Caucasian, 13.5%
African-American, and 5.5% Other
(U.S. Census Bureau, 2009).
Health record data from four
schools with 1,312 total student
enrollment were extracted for this
study. This represented 12% of the
elementary school-age population in
Fayette County (FCPS, 2002). It is a
requirement that each school-based
health clinic medical record includes
a completed health history form
(English or Spanish versions available) and be updated annually. State
education guidelines recommend that
elementary school-age children have
their height and weight assessed
annually as part of yearly school
health screenings (Kentucky Department of Education, 2009). Due to the
serendipitous finding of acanthosis
nigricans on the neck of numerous
students, the medical director of the
four school-based clinics added acanthosis nigricans screening to the
annual school health screening protocols at each elementary school. Student records that had height, weight,
acanthosis nigricans documentation,
and a completed heath history form
on file were included in this study.

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%)

*The term Other includes self-reported bi-racial, Hispanic, or Asian ethnicity.


detection and grading of acanthosis
nigricans on the posterior area of the
neck. Photos depicting the different
degrees of acanthosis nigricans as it
occurs in children of various ethnic
groups were used during the training
session. Descriptions of acanthosis
nigricans severity similar to a screening tool developed by Burke et al.
(1999) were also discussed.
The school nurse conducted
height and weight measurements according to recommendations set by
the County Board of Education and
the local health department (Kentucky
Department of Education, 2000).
Heights were obtained with a stadiometer and measured in inches to
the nearest one-fourth inch. Weight
was obtained with a standard balance
scale and measured in pounds to the
nearest one-fourth pound. Students
were screened for the presence of
acanthosis nigricans on the back of
the neck during the height/weight
screening. All measurements obtained
during the screening were recorded in
each students clinic medical record.
Absolute BMI was calculated for
each student using the standard
English measurement formula: weight
(lb) / height (in)2 x 703 (CDC, 2011b).
The BMI for each student was then
plotted on gender-appropriate, BMIfor-age percentiles chart to determine
each childs BMI percentile, then
placed in each childs clinic medical
record, which was then reviewed by
the clinic nurse or nurse practitioner.
Students with a BMI between the
85th and 95th percentiles for age and
gender were considered overweight,
and students whose BMI exceeded the
95th percentile for age and gender
were considered obese according to
CDC guidelines (CDC, 2011b).
An existing diagnosis of diabetes
in the student and the presence of a
family history of diabetes were obtained by the clinic nurse from the

health history form located in each


students clinic medical record. The
health history form is completed by
the parent at the beginning of each
school year and identifies any current
or previous health issues in the student as well as any family history of
common chronic diseases. All health
history forms are reviewed by the
school nurse as part of the routine
health screening/maintenance protocols for students enrolled in the
school-based health clinics.

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

PEDIATRIC NURSING/July-August 2013/Vol. 39/No. 4

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.

those 10 years of age or older (n =


369) for the purpose of analyzing
youth eligible for type 2 diabetes
screening. There were no statistically
significant differences between the
groups related to gender, ethnicity, or
presence of a family history of diabetes. However, students 10 years of
age or older were more obese (28%,
compared to 20.6% in younger
group). Older students had lower rates
of acanthosis nigricans, yet the severity was greater than that present in
the younger group (see Table 3).
Chi-square analyses were used to
evaluate relationships between BMI,
ethnicity, age, gender, a positive family history of diabetes, and the presence of acanthosis nigricans. Data
from all study participants, as well as
each group according to student age,
were analyzed. Among all three
groups similar significant relationships emerged.
The presence of acanthosis nigricans was compared with ethnicity,
age, gender, a positive family history
of diabetes, and BMI percentiles. BMI
was the best indicator for the presence
of acanthosis nigricans. Students with
a BMI greater than the 85th percentile
for age and gender had higher rates of
acanthosis nigricans when compared
to students with a BMI less than the
85th percentile for age and gender (2
= 132.911; p = < 0.001). Odd ratio of
5.7 0.158 (p = < 0.001) was calculated, indicating that overall, overweight
and obese students were nearly six

times more likely to have acanthosis


nigricans as compared to normal
weight students. Obese students 10
years of age or older were greater than
10 times more likely to have acanthosis nigricans as compared with older
students whose BMI was less than the
95th percentile for age and gender (2
= 86.237; p = < 0.001) (odds ratio 10.97
0.284; p = < 0.001). These findings,
although concerning, correlate with
previous data used to determine the
ADA/AAP type 2 diabetes screening
guidelines. Although screening guidelines do not support the screening of
younger children, it should be of concern that the presence of acanthosis
nigricans was identified in students as
young as 6 years of age.
An ethnic difference regarding
the presence of acanthosis nigricans
was found only in the older group
among African-American students
(2= 3.832; p = < 0.049). Among students 10 years of age or older, AfricanAmerican students were almost twice
as likely to have acanthosis nigricans
(odds ratio 1.6 0.25; p = 0.05) as
compared to all other ethnic groups
regardless of family history of diabetes, gender, or BMI. The lack of an
ethnic relationship related to the
presence of acanthosis nigricans may
have resulted from the high number
of non-Hispanic Caucasian students
represented in the study.
The presence of a family history
of diabetes and the presence of acanthosis nigricans were only affected by

PEDIATRIC NURSING/July-August 2013/Vol. 39/No. 4

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.

Eligibility for Type 2 Diabetes


Screening
Crosstabs were used to compare
the various data to determine the
number of students who qualify for
further screening for type 2 diabetes.
Of the students 10 years of age or
older enrolled in the study, 39.3%
were eligible for further screening for
type 2 diabetes according to the
ADA/AAP guidelines (see Figure 1)
(ADA, 2000). Twenty-eight percent of
the students were obese. Nearly 11%
of the students screened were overweight with at least two risk factors
associated with type 2 diabetes, thus
meeting the criteria for further laboratory evaluation for type 2 diabetes
(see Table 4). Almost 40% of the stu193

Presence of Type 2 Diabetes Risk Factors in Children

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%)

+ Family history of diabetes

10

15

(4.1%)

+ Acanthosis nigricans

(1.9%)

Non-Hispanic Caucasian with family history of diabetes


and acanthosis nigricans

20

20 (5.4%)

70 (19.0%)

58 (15.7%)

17 (4.6%)

145 (39.3%)

Eligibility Criteria (Beginning at 10 Years of Age)


BMI greater than 95th percentile for age and gender
BMI 85th to 95th percentile for age and gender

Total

*N = 369
**The term Other includes self-reported bi-racial, Hispanic, or Asian ethnicity.

dents younger than 10 years of age


had risk factors associated with
screening criteria. Younger AfricanAmerican students were more likely
to be obese (15.4%) compared to nonHispanic Caucasian students (9%).
Younger African-American students
meeting screening criteria were also
more likely to be overweight (8%) as
compared to non-Hispanic Caucasian
peers (1.2%) (see Table 5).

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

of study subjects (ADA, 2000). Being


overweight or obese plays a major role
in the development of type 2 diabetes. Obesity in children is a growing
concern placing more children at risk
for the development of type 2 diabetes. Early identification of at-risk
youth may assist in the development
of intervention strategies targeted at
reducing modifiable risk factors associated with type 2 diabetes in children. Twenty-three percent of the students screened were obese, and nearly
40% had a BMI greater than the 85th
percentile for age and gender. At the
time data were collected, these findings exceeded national statistics on
overweight and obesity in children.

Due to the rise in rates of obesity in


children over the past decade, these
rates coincide with national estimates
that 19.6% of children 6 to 12 years of
age are obese (Ogden, Carroll,
Curtain, Lamb, & Flegal, 2010).
Thirty-two percent of children 6 to 19
years of age have a BMI greater than
85th percentile for age and gender
(Ogden et al., 2010).
Students 10 years of age or older
were more likely to be obese compared to children younger than 10
years of age (27.9%, 20.6% respectively). This finding demonstrates the
importance of early detection of
young overweight students, as well as
identifies a target population in

PEDIATRIC NURSING/July-August 2013/Vol. 39/No. 4

Table 5.
Students Less Than 10 Years of Age Meeting Eligibility Criteria*

Eligibility Criteria (Beginning at 10 Years of Age)


BMI greater than 95th percentile for age and gender

Non-Hispanic
Caucasian
n (%)
54

(9%)

AfricanAmerican
n (%)
93 (15.4%)

Other**
n (%)
30

(5.0%)

Total
n (%)
177 (29.4%)
33 (5.5%)

BMI 85th to 95th percentile for age and gender


+ Family history of diabetes

32

23

(3.8%)

+ Acanthosis nigricans

17

(1.1%)

Non-Hispanic Caucasian with family history of diabetes


and acanthosis nigricans

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.

which intervention strategies should


particularly focus on the prevention
of obesity.
Within the overall group of students, grades 1 through 5, AfricanAmerican students were more obese
compared to non-Hispanic Caucasian
students (25%, 10.9% respectively).
However, by 10 years of age, there was
no difference in BMI related to ethnicity. The lack of ethnic differences in
BMI percentiles by 10 years of age may
be attributed to the geographically
close proximity of the study participants to the Appalachia region and the
known high rates of obesity in nonHispanic Caucasian adults within in
the region (CDC, 2009). Further studies are needed to determine if these
findings are only representative of the
region or an emerging trend in the U.S.
Acanthosis nigricans was identified in 23.4% of the students
screened. Nationally, prevalence rates
among children range from 17% to
55% of children 7 to 19 years of age
(Hirschler, Aranda, Oneto, Gonzalez,
& Jadzinsky, 2002; Kong et al., 2007).
Similar to current research, significantly more African-American students
had acanthosis nigricans as compared
with their non-Hispanic Caucasian
peers. Given that the presence of acanthosis nigricans is a known clinical
surrogate for laboratory-determined
hyperinsulinemia, findings indicate a
number of students have evidence of
insulin resistance and are at risk for
future development of type 2 diabetes
(Litonjua, Pinero-Pilona, Aviles-Santa,
& Raskin, 2004).
Nearly one-half of the students
screened identified a family history of

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.

Limitations of the Study


Limitations of this study include
possible measurement errors of height,
weight, and acanthosis nigricans
screening due to multiple examiners
collecting data. Another limitation was

PEDIATRIC NURSING/July-August 2013/Vol. 39/No. 4

the completeness of the health history


form. The form required self-reported
information. Various forms had areas
that were left blank. These errors may
have been due to the ambiguity of the
questions or the familys inability to
read, write, or comprehend English.
Additional limitations include the lack
of further biological data, such as blood
pressure and blood lipid levels collected
on the participants. Hypertension and
hyperlipidemia are both indicators of
insulin resistance. Seventy percent of
obese youth have at least one risk factor
for cardiovascular disease, such as high
cholesterol or hypertension (Freedman,
Zuguon, Srinivasan, Berenson, & Deitz,
2007). Students eligible for further type
2 diabetes screening may have been
missed because they could have had
evidence of insulin resistance other than
acanthosis nigricans, such as hypertension or hyperlipidemia. Screening for
hypertension and hyperlipidemia are
not presently part of required, schoolbased health screenings in Kentucky
schools.
The lack of known pubertal status
is an additional limitation. Children
younger than 10 years of age in
puberty may have been excluded
from the screening results, yet qualify
for further screening due to their
pubertal status. Screening for pubertal
status is an invasive technique currently not included during routine,
school-based health screenings in
Kentucky schools.
A final limitation addresses the
generalizability of the study findings.
Although a cross-sectional design was
used for the study, the ethnic makeup of the study population exceeds
195

Presence of Type 2 Diabetes Risk Factors in Children


national percentages for AfricanAmerican and Hispanic/Other populations (U.S. Census Bureau, 2011).
More African-American and Hispanic/
Other students were included in the
study than representative of the U.S.
population. However, ethnic differences in BMI did not exist beyond 9
years of age within the study findings.
Acanthosis nigricans rates were much
higher in African-American students
as compared to non-Hispanic Caucasian and Hispanic/Other students.
These findings are similar to previous
studies and further support the
AAP/ADA screening criteria for identifying at-risk youth.

Implications for School Nurses


School nurses are in a unique
position to assist in screening for risk
factors associated with type 2 diabetes
in children. As an integral part of
health maintenance and assessment,
annual height/weight, and acanthosis
nigricans screenings can easily assist
the school nurse with early identification of at-risk children. Through early
identification, strategies can be implemented to further screen at-risk youth.
The school nurse can also target
efforts to possibly reduce modifiable
risk-factor development in those atrisk youth through health education
and lifestyle modification strategies.
School nurses can collaborate
between school personnel, students,
their family, and health care providers/professionals. Through this
collaborative role, school nurses have
the skill and ability to assist high-risk
students and their families to institute
behavior change strategies that focus
on the reduction of controllable risk
factors associated with the development of type 2 diabetes. Their knowledge of health and wellness strategies
and their understanding of child
development also place them in a key
position to help guide school leaders
and community leaders into making
key changes in school dietary and
activity offerings.
Due to the potential economic
impact and insidious onset of type 2
diabetes, conducting early screening
of at-risk youth is important. Study
findings support the need to identify
target groups/populations. Schoolbased health screenings can provide
an opportunity to identify these atrisk youth and initiate early implementation of modifiable risk-reduction strategies.

196

References
American Diabetes Association (ADA).
(2000). Type 2 diabetes in children and
adolescents: Consensus statement.
Diabetes Care, 23(3), 381-389.
American Diabetes Association (ADA).
(2010). Standards of medical care in
diabetes 2010. Diabetes Care,
33(Suppl. 1), S11-S61.
Anand, S.G., Mehta, S.D., & Adams, W.G.
(2006). Diabetes mellitus screening in
pediatric primary care. Pediatrics,
118(5), 1888-1895.
Bloomgarten, Z. (2004). Type 2 diabetes in
the young, the evolving epidemic.
Diabetes Care, 27(4), 998-1010.
Bo-Abbas, Y., Brousseau, V.J., Louria, D.B.,
Benjamin, S.M., Valdez, R., Vinicor, F.,
& Knowler, W.C. (2002). Reduction in
the incidence of type 2 diabetes with
lifestyle intervention or metformin. New
England Journal of Medicine, 346(6),
393-403.
Burke, J.P., Hale, D.E., Hazuda, H.P., &
Stern, M.P. (1999). A quantitative scale
of acanthosis nigricans. Diabetes Care,
22(10), 1655-1659.
Centers for Disease Control and Prevention
(CDC). (2008a). CDC statement on
screening for acanthosis nigricans in
schools and communities. Retrieved
from http://www.cdc.gov/diabetes/news/
docs/an.htm
Centers for Disease Control and Prevention
(CDC). (2008b). National diabetes fact
sheet: General information and national
estimates on diabetes in the U.S., 2007.
Atlanta: U.S. Department of Health and
Human Services, Centers for Disease
Control and Prevention.
Centers for Disease Control and Prevention
(CDC). (2009). Diabetes successes and
opportunities for population-based prevention and control: At a glance 2009.
Retrieved from http://www.cdc.gov/
chronicdisease/resources/publications/AAG/ddt.htm.
Centers for Disease Control and Prevention
(CDC). (2011a). National diabetes fact
sheet: National estimates and general
information on diabetes and prediabetes in the United States, 2011.
Atlanta: U.S. Department of Health and
Human Services, Centers for Disease
Control and Prevention.
Centers for Disease Control and Prevention
(CDC). (2011b). Overweight and obesity: Data and statistics. Retrieved from
http://www.cdc.gov/obesity/childhood/d
ata.html
Copeland, K.C., Becker, D., Gottschalk, M.,
& Hale, D. (2005). Type 2 diabetes in
children and adolescents: Risk factors,
diagnosis, and treatment. Clinical
Diabetes, 23(4), 181-185.
Dabelea, D., Bell, R.A., DAgostino, R.B., Jr.,
Imperatore, G., Johansen, J.M., Linder,
B, Waitzfelder, B. (2007). Incidence
of diabetes in youth in the United
States. Journal of the American Medical
Association. 297(24), 2716-2724.
Fayette County Public School System
(FCPS). (2002). About our schools.
Retrieved from http://www.fcps.net/
schools/about.

Freedman, D.S., Zuguon, M., Srinivasan,


S.R., Berenson, G.S., & Deitz, W.H.
(2007). Cardiovascular risk factors and
excess adiposity among overweight
children and adolescents: The
Bogalusa heart study. Journal of
Pediatrics, 150(1), 12-17.
Hardin, D.S. (2006). Screening for type 2 diabetes in children with acanthosis nigricans. The Diabetes Educator, 32(4),
547-552.
Hirschler, V.H., Aranda, C., Oneto, A.,
Gonzalez, C., & Jadzinsky, C. (2002). Is
acanthosis nigricans a marker of insulin
resistance with obese children.
Diabetes Care, 25(12), 2353.
Hu, F.B., & Stampfer, M. (2005). Insulin
resistance and hypertension, Circulation, 112, 1678-1680.
Kentucky Department of Education. (2009).
Height and weight screening. Health
service resource guide. Retrieved from
http://www.education.ky.gov/users/jneal
/HSRG/ch3/Screening_Programs.pdf
Knowler, W.C., Barrett-Connor, E., Fowler,
S.E., Hamman, R.F., Lachin, J.M.,
Walker E.A., Diabetes Prevention
Research Group. (2002). Reduction in
the incidence of type 2 diabetes with
lifestyle intervention or metformin. New
England Journal of Medicine, 346(6),
393-403.
Kong, A.S., Williams, R., Smith, M.,
Sussman, A., Skipper, B. His, A.,
RIOS Net Clinicians. (2007). Acanthosis
nigricans and diabetes risk factors:
Prevalence in young persons seen in
Southwest primary care practices.
Annals of Family Medicine, 5(3), 202208.
Litonjua, P., Pinero-Pilona, A., Aviles-Santa,
L., & Raskin, P. (2004). Prevalence of
acanthosis nigricans in newly diagnosed type 2 diabetes. Endocrine
Practice, 10(2), 101-106.
Ludwig, D.S., & Ebbeling, C.B. (2001). Type
2 diabetes in children. JAMA, 286(12),
1427-1430.
Nadeau, K., & Dabelea, D. (2008). Epidemiology of type 2 diabetes in children and
adolescents. Endocrine Research, 33,
35-58.
National Institutes of Health (NIH). (2010).
Many obese youth have a condition that
precedes type 2 diabetes. Retrieved
from http://www.nichd.nih.gov/news/
releases/obese.cfm.
Ogden, C.L., Carroll, M.D., Curtain, L.R.,
Lamb, M.M., & Flegal, K.M. (2010).
Prevalence of high body mass index in
U.S. children and adolescents: 20072008. JAMA, 303(3), 242-249.
Pinhas-Hamil, O., & Zeitler, P. (2005). The
global spread of type 2 diabetes mellitus in children and adolescents. Journal
of Pediatrics, 146(5), 693-700.
Pinhas-Hamil, O., & Zeitler, P. (2007). Acute
and chronic complications of type 2 diabetes in children and adolescents. The
Lancet, 369, 1823-1831.
Soltesz, G. (2006). Type 2 diabetes in children: An emerging clinical problem.
Diabetes Research and Clinical
Practice, 74(2, Suppl.), S9-S11.

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Type 2 Diabetes Risk Factors


continued from page 196
Texas Department of Health. (2002). Acanthosis nigricans and insulin
resistance. Disease Prevention News, 62(2), 1-4. Retrieved from
http://www.dshs.state.tx.us/diabetes/PDF/dpn62n02.pdf
U.S. Census Bureau. (2009). State and county quick facts. Retrieved
from http://quickfacts.census.gov/qfd/states/21/2146027.html
U.S. Census Bureau. (2011). U.S.A. quick facts. Retrieved from
http://quickfacts.census.gov/qfd/states/00000.html
Zeitler, P., & Pinhas-Hamil, O. (2008). Prevention and screening for
type 2 diabetes in youth. Endocrine Research, 33(1-2), 73-91.

Additional Readings
Centers for Disease Control and Prevention (CDC). (2005). Growth
charts. Retrieved from http://www.cdc.gov/growthcharts
Centers for Disease Control and Prevention (CDC) (2011). Healthy
weight: Its not a diet, its a lifestyle. Retrieved from
http://www.cdc.gov/healthyweight/assessing/bmi/childrens_bmi/a
bout_childrens_bmi.html
Stuart, C.A., Gilkison, C.R., Smith, M.M., Sosma, A.M., Keenan, B.S.,
& 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
10-year-old overweight/obese African-American children.
Diabetes Care. 24(8), 1359-1364.

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