Prevalence of Prediabetes Among Adolescents and Young Adults in the United States, 2005-2016

Youth Sports Participation Is More Important among Females than Males for Predicting Physical Activity in Early Adulthood: Iowa Bone Development Study

A gender difference in youth sports and physical activity participation is well documented. However, research is limited to understand potential gender difference in the long-term effects of youth sports participation. The study aim was to compare the likelihood of meeting the aerobic Physical Activity Guidelines (PAG) in early adulthood by youth sports participation patterns among females and males. The study sample included 582 Iowa Bone Development Study participants (Iowa, USA). Participation in organized sports was assessed using a physical activity questionnaire 19 times on average between age 6 and 17 years. Accelerometer and dual-energy X-ray absorptiometry assessments were conducted at an average age of 23 years. Group-based trajectory analysis was conducted to identify youth sports participation trajectory patterns. Multivariable logistic regression analysis was conducted to examine the association between youth sports participation patterns and meeting the PAG in adulthood. We identified three youth sports participation patterns: "continuous participation," "drop-out," and "no participation." Females in the continuous participation group were more likely to meet the aerobic PAG at age 23 years, compared to females in the no-participation group (OR = 2.63; 95% CI = 1.05, 6.55) or the drop-out group (OR = 2.55; 95% CI = 1.38, 4.69). However, among males, youth sports participation patterns were not significantly associated with meeting the aerobic PAG at age 23 years. In conclusion, this study suggests that youth sports participation could be more important among females than males for predicting physical activity in early adulthood.

Sex-based differences in screening and recognition of pre-diabetes and type 2 diabetes in pediatric primary care

BACKGROUND

Risk-based screening for type 2 diabetes (T2D) in youth with overweight/obesity is recommended, but rates remain low in practice. Identification of factors impacting provider ordering and patient completion of testing may guide strategies to improve screening.

OBJECTIVE

To evaluate predictors of hemoglobin A1c (A1c)-based T2D screening in pediatric primary care.

METHODS

This retrospective cohort study included 10 to 18 year-old patients with overweight/obesity (body mass index [BMI] Z-score ≥1.04) followed in a large academic-affiliated pediatric primary care network, 2009 to 2018. Percentages of patients with ordered and completed A1c were determined, and multivariable Cox proportional hazards regression was used to evaluate independent predictors of screening.

RESULTS

34 927 (48.0% female; 52.5% with BMI Z-score ≥1.64) youth followed for a median of 3.0 years were included. 21% (7457) of patients had screening ordered and 14% (4966) completed screening during follow-up. In multivariable regression, after controlling for race/ethnicity, BMI, family history of diabetes and age, males were significantly less likely to have ordered screening, but were equally or more likely to complete screening if ordered.

CONCLUSIONS

Male adolescents were less likely to undergo A1c-based T2D screening due to differential ordering practices. The source of this differential practice should be pursued to avoid under-recognition of cardiometabolic risk in at-risk male youth.

Lifestyle Intervention With or Without Lay Volunteers to Prevent Type 2 Diabetes in People With Impaired Fasting Glucose and/or Nondiabetic Hyperglycemia: A Randomized Clinical Trial

IMPORTANCE

Nearly half of the older adult population has diabetes or a high-risk intermediate glycemic category, but we still lack trial evidence for effective type 2 diabetes prevention interventions in most of the current high-risk glycemic categories.

OBJECTIVE

To determine whether a group-based lifestyle intervention (with or without trained volunteers with type 2 diabetes) reduced the risk of progression to type 2 diabetes in populations with a high-risk glycemic category.

DESIGN, SETTING, AND PARTICIPANTS

The Norfolk Diabetes Prevention Study was a parallel, 3-arm, group-based, randomized clinical trial conducted with up to 46 months of follow-up from August 2011 to January 2019 at 135 primary care practices and 8 intervention sites in the East of England. We identified 141 973 people at increased risk of type 2 diabetes, screened 12 778 (9.0%), and randomized those with a high-risk glycemic category, which was either an elevated fasting plasma glucose level alone (≥110 and <126 mg/dL [to convert to millimoles per liter, multiply by 0.0555]) or an elevated glycated hemoglobin level (≥6.0% to <6.5%; nondiabetic hyperglycemia) with an elevated fasting plasma glucose level (≥100 to <110 mg/dL).

INTERVENTIONS

A control arm receiving usual care (CON), a theory-based lifestyle intervention arm of 6 core and up to 15 maintenance sessions (INT), or the same intervention with support from diabetes prevention mentors, trained volunteers with type 2 diabetes (INT-DPM).

MAIN OUTCOMES AND MEASURES

Type 2 diabetes incidence between arms.

RESULTS

In this study, 1028 participants were randomized (INT, 424 [41.2%] [166 women (39.2%)]; INT-DPM, 426 [41.4%] [147 women (34.5%)]; CON, 178 [17.3%] [70 women (%39.3)]) between January 1, 2011, and February 24, 2017. The mean (SD) age was 65.3 (10.0) years, mean (SD) body mass index 31.2 (5) (calculated as weight in kilograms divided by height in meters squared), and mean (SD) follow-up 24.7 (13.4) months. A total of 156 participants progressed to type 2 diabetes, which comprised 39 of 171 receiving CON (22.8%), 55 of 403 receiving INT (13.7%), and 62 of 414 receiving INT-DPM (15.0%). There was no significant difference between the intervention arms in the primary outcome (odds ratio [OR], 1.14; 95% CI, 0.77-1.7; P = .51), but each intervention arm had significantly lower odds of type 2 diabetes (INT: OR, 0.54; 95% CI, 0.34-0.85; P = .01; INT-DPM: OR, 0.61; 95% CI, 0.39-0.96; P = .033; combined: OR, 0.57; 95% CI, 0.38-0.87; P = .01). The effect size was similar in all glycemic, age, and social deprivation groups, and intervention costs per participant were low at $153 (£122).

CONCLUSIONS AND RELEVANCE

The Norfolk Diabetes Prevention lifestyle intervention reduced the risk of type 2 diabetes in current high-risk glycemic categories. Enhancing the intervention with DPM did not further reduce diabetes risk. These translatable results are relevant for current diabetes prevention efforts.

TRIAL REGISTRATION

ISRCTN Registry Identifier: ISRCTN34805606.

Antidiabetic medication use in commercially insured children and adolescents in the United States from 2004 to 2019

AIM

To describe the patterns of non-insulin antidiabetic medication use, initiation and adherence in the paediatric population.

METHODS

We conducted a descriptive study of non-insulin antidiabetic medication use in children and adolescents (aged 10-18 years) using real-world data from a nationwide US commercial claims database (January 2004-September 2019). Trends in the prevalence of non-insulin antidiabetic medication use overall and by class were evaluated. Among new users of non-insulin antidiabetic agents, medication adherence was examined using group-based trajectory models.

RESULTS

In a cohort of more than 1 million paediatric patients, the prevalence of any non-insulin antidiabetic medication use was 75.7 per 100 000 patients in 2004 and more than doubled to 162.0 per 100 000 in 2019. Biguanides (metformin) was by far the most widely used medication class. The use of newer classes was low (<10 per 100 000), but there was an uptake in the use of glucagon-like peptide-1 receptor agonists after liraglutide received paediatric approval in 2019. Medication adherence was poor during the 18 months after treatment initiation: 79.6% of initiators experienced an early treatment interruption (median time to interruption: 90 days among metformin monotherapy initiators) and 21% of initiators did not return for a prescription refill after the first month.

CONCLUSIONS

There was a substantial increase in non-insulin antidiabetic medication use among commercially insured paediatric patients from 2004 to 2019. Nearly all patients were treated with metformin, while the use of newer agents remained low. Despite the increase in medication use, short treatment episodes were observed, even among patients with a diagnosis of type 2 diabetes, raising concern over poor adherence.

Multisite Examination of Depression Screening Scores and Correlates Among Adolescents and Young Adults With Type 2 Diabetes

OBJECTIVES

Our aim was to evaluate self-reported depressive symptoms and clinical outcomes during routine screening for adolescents and young adults with type 2 diabetes (T2D), and examine associations among depressive symptoms and demographic and clinical characteristics.

METHODS

The Patient Health Questionnaire (PHQ) was administered to 197 adolescents and young adults with T2D using the PHQ-2 or PHQ-9 in routine pediatric diabetes care at 4 academic medical centres. Data from electronic health records were extracted from the screening date and 12 months earlier.

RESULTS

Adolescents and young adults with T2D (mean age, 16.85 years; 57% male; 77.2% non-Caucasian) completed the PHQ as part of routine diabetes care. On the PHQ, 19.3% of adolescents and young adults endorsed elevated depressive symptoms (PHQ score ≥10) and, among a subsample with item-level data (n=53), 18.9% endorsed thoughts of self-harm. Subsequently, 50.0% of those with depressive symptoms had a documented referral for mental health treatment in the electronic health record after the positive screening outcome. Older age, shorter diabetes duration, higher glycated hemoglobin level, being non-Hispanic white, more blood glucose checks per day and being prescribed oral medications were significantly associated with more depressive symptoms.

CONCLUSIONS

Screening for depressive symptoms identifies individuals in need of referral for mental health treatment. A focus on self-harm assessment, standardized methods for documentation of symptoms and mental health referrals and increased referral resources are needed.

Surgical Treatment of Type 2 Diabetes Mellitus in Youth

Bariatric surgery is currently the most effective weight loss treatment of severe obesity and its associated comorbidities and is being increasingly used to treat children and adolescents with severe obesity, including those with Type 2 Diabetes (T2D). This review focuses on the conventional management of T2D in children and adolescents, comparison of various types of bariatric surgeries, effect of bariatric surgery on gastrointestinal physiology and metabolism, current literature on the use of bariatric surgery to treat youth with severe obesity and T2D, and the potential complications of bariatric surgery in this population.

Prediabetes in Adolescents: Prevalence, Management and Diabetes Prevention Strategies

The ongoing obesity epidemic in children and adolescents has greatly increased the prevalence of related comorbidities. Prediabetes is defined based on levels of fasting glucose, oral glucose tolerance tests or hemoglobin A1c, that are intermediate between normal levels and thresholds that define type 2 diabetes mellitus (T2DM). As such, prediabetes represents a sign of early pathophysiology preceding T2DM development. Recent analyses of data from US adolescents estimate prediabetes to be present in 4-23% of adolescents, depending on criteria used, with other studies finding an 8% risk of progression from prediabetes to T2DM over a 3-year period. These data support the importance of intervention to avoid long-term sequelae, focusing on reducing degree of obesity and insulin resistance. Lifestyle modification, with increases in physical activity and dietary improvements, remains the first-line approach. Other interventions are based on additional long-term risks and range from metformin treatment for more moderate cases of prediabetes to bariatric surgery for adolescents with severe obesity and comorbidities. As data accumulate regarding sequelae of T2DM in adolescents, there remains a critical need for prevention of obesity and T2DM throughout childhood, and prediabetes should be a trigger for improving this risk profile.

Obesity and Prediabetes are Jointly Associated with Lipid Abnormalities Among Adolescents: A Cross-Sectional Study

PURPOSE

Obesity and prediabetes are common among adolescents; however, it is unclear whether they jointly influence lipid levels. Hence, this study sought to assess whether obesity and prediabetes independently or jointly influence lipid levels among adolescents.

METHODS

A cross-sectional study enrolled school students aged 14-19 years (n = 1584). Body mass index (BMI)-for-age z-scores were estimated, and glycated hemoglobin A1c (HbA1c) and lipid profile were measured in capillary blood. Prediabetes was defined as 5.7≤ HbA1c% ≤6.4. Geometric means of lipids were calculated, and linear regression was used to estimate the ratio of geometric means (RoGM) and their 95% confidence intervals (CI). All analyses were stratified by sex.

RESULTS

Of the total study participants, 52.1% (826/1584) were females and the majority were aged between 14.0 (5th percentile) and 18.0 (95th percentile) years. Based on BMI-for-age categories, 356 (22.5%) and 494 (31.2%) participants were classified as overweight and obese, respectively. Moreover, 34.3% (543/1584) of the study participants met the prediabetes definition. Compared to those with normal BMI and no prediabetes (reference category), participants classified as obese and having prediabetes had elevated levels of total cholesterol (TC; RoGM=1.09, 95% CI: 1.06-1.13), low-density lipoprotein cholesterol (LDL-C; 1.21, 1.13-1.29), non-high-density lipoprotein cholesterol (non-HDL-C; 1.20, 1.14-1.26), and triglycerides (TG; 1.18, 1.09-1.27) and reduced HDL-C (0.91, 0.88-0.95) levels. Independent of prediabetes, obesity was associated with all the investigated lipids. Prediabetes alone was associated with reduced levels of LDL-C and increased levels of HDL-C only among females.

CONCLUSION

Obesity independently and in combination with prediabetes demonstrated unfavorable effects on lipids among male and female adolescents, whereas prediabetes independently influenced LDL-C and HDL-C favorably only among females.

Reference intervals for routine biochemical markers and body mass index: A study based on healthcare center database in northeastern Iran

Age- and sex-specific reference intervals (RIs) for some biochemical tests may be useful for their interpretation, due to the variations in lifestyle and genetic, or ethnic factors. The aim of this study was to obtain RIs for some routine biochemical markers including a serum lipid profile, fasting blood glucose (FBG), aspartate and alanine aminotransferase (AST and ALT), uric acid, and body mass index (BMI) in subjects who attended primary healthcare centers. The large database of primary healthcare centers uses RIs to report results for children, adolescents, and young and old adults. RIs were obtained by using the indirect method, recommended by the CLSI Ep28-A3 guidelines. RIs for FBG, BMI, and serum lipid profile, including triglyceride, total cholesterol, high-density lipoprotein cholesterol, and low-density lipoprotein cholesterol in people aged 18 to 120 years, were obtained without age/sex segmentation. RIs for serum AST, ALT, and uric acid were obtained without age segmentation, though these RIs were higher in males than females. The RIs for AST, ALT, and uric acid were higher in men, while the RIs for the other variables were similar in both sexes. This is the first study reporting the use of indirect RIs for BMI.

Differences in Diet Quality between School Lunch Participants and Nonparticipants in the United States by Income and Race

Prior research has shown that participation in the United States' National School Lunch Program (NSLP) is associated with consuming higher-quality lunches and diets overall, but little is known about differences by income and race/ethnicity. This analysis used 24 h dietary recall data from the School Nutrition and Meal Cost Study to examine how NSLP participation affects the diet quality of students in different income and racial/ethnic subgroups. Diet quality at lunch and over 24 h was assessed using the Healthy Eating Index (HEI)-2010, where higher scores indicate higher-quality intakes. HEI-2010 scores for NSLP participants and nonparticipants in each subgroup were estimated, and two-tailed t-tests were conducted to determine whether participant-nonparticipant differences in scores within each subgroup were statistically significant. NSLP participants' lunches received significantly higher total HEI-2010 scores than those of nonparticipants for lower-income, higher-income, non-Hispanic White, and non-Hispanic Black students, suggesting that participating in the NSLP helps most students consume healthier lunches. These significantly higher total scores for participants' lunch intakes persisted over 24 h for higher-income students and non-Hispanic White students but not for lower-income students or students of other races/ethnicities. For NSLP participants in all subgroups, the nutritional quality of their 24 h intakes was much lower than at lunch, suggesting that the positive influence of the NSLP on their overall diet quality was negatively influenced by foods consumed the rest of the day (outside of lunch).

Approach to the cardiometabolic continuum. Narrative description

Atherosclerotic cardiovascular disease (ACVD) is the major adverse outcome in the evolution of several metabolic conditions. For around several decades, the cardiovascular continuum has been used as a fantastic tool to explain the evolution of ACVD from the onset of risk factor, to clinical outcomes, and to death. Nowadays, metabolic diseases such as obesity, prediabetes, and type2 diabetes have been increasing enough to become serious public health problems and notorious contributors to the morbidity and mortality rates due to ACVD, including arterial hypertension. Other conditions seem to increase the list, such as: physical inactivity with its metabolic cluster, sarcopenia, and non-alcoholic fatty liver disease (NAFLD). Moreover, obesity in childhood has been growing at an exponential rate so the excess of adiposity in children and adolescents will translate into an excess of cardiometabolic risk in adults. Several longitudinal studies confirm the strong association of paediatric obesity with the persistence of adult obesity, as well as the future development of cardiometabolic conditions, such as prediabetes, diabetes, obesity, increased risk of arterial hypertension, and ACVD. Therefore, it is time to conceptualise the cardiometabolic continuum as a tool of an early, wider and preventive intervention in order to reduce the morbidity and mortality due to ACVD.

Obesity and Diabetes: A Sword of Damocles for Future Generations

Childhood obesity is one of the most challenging problem of the 21st century. The prevalence has increased, reaching an alarming rate. Furthermore, the problem is global and is also affecting low- and middle-income countries. This global obesity epidemic explains how the roots of cardiovascular disease, the most common cause of mortality among adults, begin in childhood. Overweight and obese children are likely to stay obese into adulthood and to develop noncommunicable diseases such as diabetes and cardiovascular diseases at a younger age. Thus, prevention should be the major goal and should start early in life. The aim of this review is to present an updated framework of the current understanding of the cardiovascular and metabolic risks in obese children and adolescents and to discuss the available therapeutic options.

Racial differences in prediabetes prevalence by test type for the US pediatric and adult population: NHANES 1999-2016

BACKGROUND

Previous studies have shown that US estimates of prediabetes or diabetes differ depending on test type, fasting plasma glucose (FPG) vs hemoglobin A1c (HbA1c). Given age, race, and test differences reported in the literature, we sought to further examine these differences in prediabetes detection using a nationally representative sample.

METHODS

Using the National Health and Nutrition Examination Survey (NHANES) 1999-2016, individuals were identified as having prediabetes with an HbA1c of 5.7% to 6.4% or a FPG of 100 to 125 mg/dL. We excluded individuals with measurements in the diabetic range. We ran generalized estimating equation logistic regressions to examine the relationship between age, race, and test type with interactions, controlling for sex and body mass index. We compared the difference in predicted prediabetes prevalence detected by impaired fasting glycemia (IFG) vs HbA1c by race/ethnicity among children and adults separately using adjusted Wald tests.

RESULTS

The absolute difference in predicted prediabetes detected by IFG vs HbA1c was 19.9% for white adolescents, 0% for black adolescents, and 20.1% for Hispanic adolescents; 21.4% for white adults, -1.2% for black adults, and 19.2% for Hispanic adults. Using adjusted Wald tests, we found the absolute differences between black vs white and black vs Hispanic individuals to be significant, but, not between Hispanic and white individuals among children and adults separately.

CONCLUSIONS

These observations highlight differences in test performance among racial/ethnic groups. Our findings corroborate the need for further studies to determine appropriate HbA1c cutoff levels for diagnosis of prediabetes by age group and race.

Left atrial strain and diastolic function abnormalities in obese and type 2 diabetic adolescents and young adults

Background

Adults with obesity and type 2 diabetes mellitus (T2DM) related to obesity are at increased risk of heart failure with preserved ejection fraction (HFpEF). Whether left ventricular (LV) diastolic function abnormalities related to obesity and T2DM start in adolescence and early adulthood is unknown. We non-invasively evaluated the differences seen in LV diastolic and left atrial (LA) function in adolescents and young adults with obesity and T2DM.

Methods

We analyzed echocardiographic measures of LV diastolic function in patients with structurally normal hearts which were divided into 3 groups (normal weight, obese, and T2DM). Spectral and tissue Doppler and 2-D speckle tracking measurements of diastolic function were obtained. Logistic regression was performed to compare the prevalence of abnormalities in diastolic function based on the worst 25th percentile for each measure to determine the prevalence of diastolic and LA function abnormalities in obese and T2DM patients.

Results

331 teenagers and young adults (median age 22.1 years) were analyzed (101 normal weight, 114 obese, 116 T2DM). Obese and T2DM group had lower E/A and higher E/e′. Obese and T2DM patients had significantly lower atrial reservoir, conduit, and booster strain and worse reservoir and conduit strain rate compared to normal patients (p < 0.001 for all measures). All patients had normal LA volumes. On multivariable analysis, conduit strain and reservoir and conduit strain rate were independently associated with having below the 25th percentile e′. Conduit strain rate was independently associated with having below the 25th percentile for mitral E/A ratio on multivariable analysis.

Conclusions

Abnormal indices of LV diastolic function are detected in adolescents and young adults with obesity and T2DM. LA function and strain analysis were able to detect evidence of decreased reservoir, conduit, and booster strain in these patients although LA volume was normal. The use of LA function strain may increase our ability to detect early diastolic function abnormalities in this population.

The Effect of Resistance Exercise Intensity on Acute Hyperglycemia in Young Adult Males

The purpose of this study was to examine the effect of resistance exercise (RE) intensity on acute hyperglycemia, in young adult males. Thirteen males (age 23.43 ± 2.18 years, height 175.16 ± 10.44 cm, weight 77.02 ± 8.91 kg, body fat 20 ± 0.03%) participated in three randomized testing sessions, each separated by 96 h. The three testing conditions were: control (CON; induction of hyperglycemia with no-exercise), high (HI; induction of hyperglycemia followed by high-intensity RE: 5 × 4, 90% 1-repetition maximum (1-RM)), and moderate (MO; induction of hyperglycemia followed by low-intensity RE: 3 × 14, 65% 1-RM). In all three testing conditions, participants orally ingested a D100 (100 g/10 oz) glucose beverage at a dosage of 2 g glucose/kg body weight and capillary blood was obtained for plasma glucose and insulin analysis at 0 (fasting), 30, 60, 90 and 120 min, following glucose ingestion. At 30-min post-ingestion in the HI and MO conditions, participants began the respective RE protocols. Acute hyperglycemia was achieved throughout all three 2-h testing conditions; mean 2-h plasma glucose levels during CON (7.1 ± 1.3 mmol∙L-1), MO (7.5 ± 0.6 mmol∙L-1) and HI (8.2 ± 1.9 mmol∙L-1) were all significantly (p < 0.05) greater than mean fasting plasma glucose (5.6 ± 0.46 mmol∙L-1). Plasma glucose and insulin did not differ (p < 0.05) between treatment conditions at any times points over the 120 min, however, 2-h glucose area under the curve in the HI condition was significantly greater (p < 0.05) than CON and MO. In conclusion, this study indicates that hyperglycemia, induced prior to RE, may be exacerbated by high-intensity RE.

Vitamin D levels, prediabetes risk and hemoglobin A1c levels in young non-diabetic Saudi women

AIMS/INTRODUCTION

Vitamin D levels are negatively correlated with prediabetes risk and hemoglobin A1c levels in individuals with prediabetes. The data are, however, scarce and inconsistent among different populations. We aimed to assess the association of vitamin D with prediabetes risk and hemoglobin A1c levels in young Saudi women with normoglycemia and prediabetes.

MATERIALS AND METHODS

We analyzed the data of individuals without diabetes (without diabetes history and hemoglobin A1c <6.4%) from the Princess Nourah bint Abdulrahman University's non-communicable diseases student registry. Demographic data, anthropometric and blood pressure measurements, and hemoglobin A1c and vitamin D results were retrieved and analyzed.

RESULTS

In total, 345 participants were included in the analysis. The prediabetes status showed no association with vitamin D levels, but it was significantly associated with the participants' weight and body mass index. Additionally, there was no correlation between the levels of vitamin D and hemoglobin A1c across the whole population, even after correction for body mass index. However, in the body mass index subgroups, when individuals with potentially harmful levels of vitamin D (>125 nmol/L) were excluded, a positive association was detected between vitamin D and hemoglobin A1c levels in the underweight individuals. Hemoglobin A1c values showed a positive correlation only with bodyweight and body mass index.

CONCLUSIONS

Vitamin D levels did not predict prediabetes status and showed no correlation with hemoglobin A1c levels in this population. Vitamin D levels' effect on the risk of prediabetes might be small compared with other well-established risk factors, such as obesity.

Screening and Diagnosis of Prediabetes and Diabetes in US Children and Adolescents

BACKGROUND

The optimal approach to screening and diagnosis of prediabetes and diabetes in youth is uncertain.

METHODS

We conducted a cross-sectional analysis of 14 119 youth aged 10 to 19 years in the 1999-2016 NHANES. First, we examined the performance of American Diabetes Association risk-based screening criteria. Second, we evaluated the performance of current clinical definitions of prediabetes and diabetes based on hemoglobin A1c (HbA1c), fasting plasma glucose (FPG), either HbA1c or FPG, or both HbA1c and FPG (confirmatory definition) to identify youth at high cardiometabolic risk.

RESULTS

Overall, 25.5% of US youth (10.6 million in 2016) were eligible for screening. Sensitivity and specificity of the screening criteria for detecting any hyperglycemia were low for both HbA1c ≥5.7% (sensitivity = 55.5%, specificity = 76.3%) and FPG ≥100 mg/dL (sensitivity = 35.8%, specificity = 77.1%). Confirmed undiagnosed diabetes (HbA1c ≥6.5% and FPG ≥126 mg/dL) was rare, <0.5% of youth. Most (>85%) cases of diabetes were diagnosed. Associations with cardiometabolic risk were consistently stronger and more specific for HbA1c-defined hyperglycemia (specificity = 98.6%; sensitivity = 4.0%) than FPG-defined hyperglycemia (specificity = 90.1%; sensitivity = 19.4%).

CONCLUSIONS

One-quarter of US youth are eligible for screening for diabetes and prediabetes; however, few will test positive, especially for diabetes. Most cases of diabetes in US youth are diagnosed. Regardless of screening eligibility, we found that HbA1c is a specific and useful nonfasting test to identify high-risk youth who could benefit from lifestyle interventions to prevent diabetes and cardiovascular risk in adulthood.

Physical Activity Programs during Pregnancy Are Effective for the Control of Gestational Diabetes Mellitus

Gestational diabetes mellitus has an incidence of 14% worldwide and nursing is responsible for its monitoring during pregnancy. Excessive weight gain during pregnancy is directly related to gestational diabetes mellitus development. Gestational diabetes mellitus (GDM) has negative repercussions on the evolution of the pregnancy and the fetus. The objective of this systematic review is to establish how physical activity influences pregnant women with gestational diabetes mellitus and to analyze what benefits physical activity has in the control of gestational diabetes mellitus. A systematic search was carried out in different databases (Cochrane, Superior Council of Scientific Investigations (CSIC), EBSCOhost, Pubmed, Scopus, Web os Science, and Proquest) for papers published within the last 12 years, taking into account different inclusion and exclusion criteria. Six randomized controlled studies and one observational case-control study of a high quality were selected. Fasting, postprandial glucose and HbcA1 were assessed, as well as the requirement and amount of insulin used. Thus, there is a positive relationship between the performance of physical activity and the control of gestational diabetes mellitus. Resistance, aerobic exercise, or a combination of both are effective for the control of glucose, HbcA1, and insulin. Due to the variability of the exercises of the analyzed studies and the variability of the shape of the different pregnant women, it does not permit the recommendation of a particular type of exercise. However, any type of physical activity of sufficient intensity and duration can have benefits for pregnant women with GDM. Pregnant women with gestational diabetes mellitus should exercise for at least 20–50 min a minimum of 2 times a week with at a least moderate intensity.

Dietary and Physical Activity Behaviors Among High School Students - Youth Risk Behavior Survey, United States, 2019

Establishing healthy dietary and physical activity patterns among youths is an important public health strategy for improving health and preventing chronic diseases; however, few adolescents meet U.S. government recommendations for dietary or physical activity behaviors, and disparities by sex and race/ethnicity exist. CDC analyzed data from the 2019 Youth Risk Behavior Survey to update estimates of dietary and physical activity behaviors among U.S. high school students overall and by sex and race/ethnicity. In addition, 2-year comparisons (2017 and 2019) and trends in prevalence of these behaviors during 2009–2019 were examined. In 2019, overall, during the 7 days before the survey, 41.8% of students had eaten fruit or drunk 100% fruit juices <1 time/day; 40.7% had eaten vegetables <1 time/day; and 16.7% had not eaten breakfast on all 7 days. Moreover, although 57.4% of students had played on ≥1 sports team during the 12 months before the survey, less than half of students had been physically active for ≥60 minutes/day on all 7 days (23.2%), had exercised to strengthen or tone their muscles on ≥3 days/week (49.5%), had met both aerobic and muscle-strengthening physical activity guidelines (16.5%), or had attended physical education classes on all 5 days in an average school week (25.9%). Trend data indicate limited progress in shifting dietary and physical activity behaviors. That is, with the exception of decreases in the percentage of students who had consumed soda ≥1 time/day (2009: 29.2%; 2019: 15.1%), sports drinks ≥1 time/day (2015: 13.8%; 2019: 10.6%), and <3 glasses/day of plain water (2015: 50.5%; 2019: 44.6%), high school students’ dietary and physical activity behaviors have not improved and, in certain cases, have worsened. These findings support the need for multicomponent approaches, including policy and environmental changes, and opportunities for adolescents to learn about and practice making healthy choices.

Community Pharmacy Engagement in Diabetes Prevention: Key Informant Interviews with Pharmacy Executives

Introduction

Even though evidence-based diabetes prevention interventions exist, more than 1 in 3 Americans have prediabetes; the use of pharmacies has been explored as a way to reach and care for this population. The objective of this study was to analyze factors that influence adoption of type 2 diabetes prevention programs by community pharmacies.

Methods

We conducted 21 semistructured interviews in 2018 with decision makers from 11 independent pharmacies in 6 US states and the District of Columbia and from 10 chain pharmacies operating in 1 state, multiple states, and nationwide. We identified participants by using purposive sampling. We used qualitative methods to analyze data and conducted interviews until we reached saturation.

Results

Multiple themes emerged: 1) initiation of services is more likely if initial financial support is received; 2) patient demand for services, actual or perceived, is paramount; 3) diabetes prevention services often fit within the existing operations of a pharmacy and allow maximum use of resources; 4) customer loyalty is a clearly articulated advantage against competition; and 5) engagement in diabetes prevention affirms an expanded role and the value of pharmacies to serve communities.

Conclusion

Pharmacies are well situated to deliver diabetes prevention programs to communities. Although considerable opportunity exists for pharmacies to address diabetes prevention, more could be done to reduce barriers to their use.

Yields and costs of recruitment methods with participant phenotypic characteristics for a diabetes prevention research study in an underrepresented pediatric population

Background/aims

Prediabetes and diabetes disproportionately impact Latino youth, yet few diabetes prevention programs have prioritized inclusion of this underrepresented population. This report describes the recruitment process, yields, associated costs, and phenotypic characteristics of Latino youth with obesity and prediabetes enrolled in a randomized controlled diabetes prevention study in the USA.

Methods

Recruitment efforts included referrals from clinics, community outlets, local media, and word of mouth with the goal of enrolling 120 Latino adolescents aged 12–16 with obesity (BMI > 95th percentile) and prediabetes. Prediabetes eligibility was determined by any of the following: HbA1c between 5.7 and 6.5%, fasting glucose between 100 and 125 mg/dL, or a 2-h glucose between 120 and 199 mg/dL following a 75-g oral glucose tolerance test (OGTT), but not meeting any of the diagnostic criteria for diabetes. Eligible participants were randomized 2:1 to either a 6-month community-based lifestyle intervention that included group nutrition and health education classes (1 day/week) and group exercise classes (2 days/week) or usual care control arm. Recruitment yields were determined by review of referral source in the study screening database. Recruitment costs were determined by an after-the-fact financial review of actual and in-kind costs. Participant phenotypic characteristics (i.e., demographics, anthropometrics, and biochemical data) were compared by recruitment strategy using a one-way ANOVA.

Results

Recruitment efforts covered 160 mile² (414 km²) across 26 ZIP codes (postcode) in the Phoenix Metropolitan Area and yielded 655 referrals from clinics (n = 344), community (n = 143), media (n = 137), and word-of-mouth (n = 31). From this pool, 26% (n = 167) did not meet general, pre-screening eligibility criteria; 29% (n = 187) declined participation; and 10% (n = 64) were unable to be contacted. A total of 237 youth were invited to the clinical research unit to determine final eligibility. Following the OGTT, 52% (n = 122) met prediabetes criteria and 117 were subsequently randomized. Clinical recruitment yielded the highest number of referrals (53%; n = 344) while word-of-mouth yielded the highest proportion (35%; n = 11) of randomized participants per referred youth. There were no significant differences in anthropometric or biochemical measures among youth by recruitment strategy. Based upon final enrollment numbers, community recruitment was the costliest approach ($486/randomized participant) followed by clinical ($248/randomized participant) and media ($236/randomized participant).

Conclusions

The ability to meet enrollment goals for a clinical trial of an underrepresented population required multiple recruitment strategies. Although strategies vary in yields and costs, it appears they produce similar phenotypical risk profiles of eligible youth.

Trial registration

ClinicalTrials.gov NCT02615353. Registered on 26 November 2015

Type 2 Diabetes in Youth: the Role of Early Life Exposures

PURPOSE OF REVIEW

This review examines the impact of early life exposures on glucose metabolism in the offspring and explores potential metabolic mechanisms leading to type 2 diabetes in childhood.

RECENT FINDINGS

One in five adolescents is diagnosed with prediabetes. Recent studies have elucidated the impact of early exposures such as maternal diabetes, but also hyperglycemia below the threshold of gestational diabetes, obesity, hyperlipidemia, and paternal obesity on the future metabolic health of the offspring. Mechanisms affecting the developmental programing of offspring toward type 2 diabetes include epigenetic modifications, alterations in stem cell differentiation, metabolome and microbiome variation, immune dysregulation, and neonatal nutrition. The risk of type 2 diabetes in offspring is increased not only by diabetes exposure in utero but also by exposure to a heterogeneous milieu of factors that accompany maternal obesity that provoke a vicious cycle of metabolic disease. The key period for intervention to prevent type 2 diabetes is within the first 1000 days of life.

Association between prediabetes diagnosis and body mass index trajectory of overweight and obese adolescents

BACKGROUND

Prediabetes awareness in adults has been associated with improved weight management. Whether youth with prediabetes diagnosis experience similar improvements is unknown.

OBJECTIVE

To investigate the association between prediabetes identification and body mass index (BMI) trajectory in overweight and obese adolescents.

SUBJECTS

Youth who were followed longitudinally in a large academic-affiliated primary care network and who were overweight/obese while 10 to 18 years old.

METHODS

Retrospective cohort study. Subjects were categorized as "screened" if at least 1 hemoglobin A1c (HbA1c) result was available. Time series analysis was used to determine the difference in difference (DID) in BMI Z-score (BMI-Z) slope before and after HbA1c between: (a) screened youth found to have prediabetes-range HbA1c (5.7%-6.4%, 39-46 mmol/mol) versus normal HbA1c and (b) screened versus age-matched unscreened obese youth.

RESULTS

A total of 4184 (55.6% female) screened subjects (median follow-up 9.7 years) were included. In which, 637 (15.2%) had prediabetes-range HbA1c. Prediabetes was associated with a greater decrease in BMI-Z slope than normal HbA1c (DID: -0.023/year [95% CI: -0.042 to -0.004]). When compared to age-matched unscreened subjects (n = 2087), screened subjects (n = 2815) experienced a greater decrease in BMI-Z slope after HbA1c than unscreened subjects at a matched age (DID: -0.031/y [95% CI -0.042 to -0.021]).

CONCLUSIONS

BMI-Z trajectory improved more among youth with prediabetes-range HbA1c but also stabilized in screened youth overall. Prospective studies are needed to identify provider- and patient-level drivers of this observation.

Prevalence of Selected Chronic Conditions Among Children, Adolescents, and Young Adults in Acute Care Settings in Hawai'i

Introduction

Chronic disease prevalence among young people is understudied generally and specifically for Native Hawaiian, Filipino, and Pacific Islander youth who are at high risk for these conditions. We determined the statewide prevalence of chronic diseases in acute care for those aged 5 to 29 years, including Native Hawaiians, Filipinos, and Pacific Islanders.

Methods

We used Hawai‘i statewide inpatient and emergency department (ED) data across all payers from 2015–2016 to determine the presence of at least 1 of 5 chronic conditions (ie, asthma, hypertension, chronic kidney disease, diabetes, stroke) from 13,514 inpatient stays by 9,467 unique individuals and 228,548 ED visits by 127,854 individuals.

Results

Twenty-eight percent of youth who were hospitalized and 12% with an ED visit had at least 1 chronic condition. Medicaid covered more than half of these visits. When comparing patients with and without a chronic condition, race/ethnicity, age group, and payer varied significantly in both inpatient and ED settings. Patients with a chronic condition were disproportionately Native Hawaiian, Filipino, and Pacific Islander; 32.3% of those with an inpatient chronic condition and 34.9% of those with an ED chronic condition were Native Hawaiian. Prevalence of chronic conditions among racial/ethnic groups varied significantly by age.

Conclusion

Chronic diseases, including those more often seen in adulthood, are prevalent in young people in acute care settings in Hawai‘i, with notable disparities. These findings can help justify, guide, and support programs that are needed to address these changing epidemiological trends, which may be of particular interest for Medicaid.

Childhood Obesity and Cardiovascular Disease Risk: Working Toward Solutions

The prevalence of obesity in childhood is high and continues to increase globally. It is currently estimated that 381 million children worldwide have overweight or obesity. This disease stems from multiple complex pathways that can present early in life. This is particularly concerning because childhood obesity is associated with cardiovascular risk factors that can lead to early atherosclerosis and premature cardiovascular disease (CVD). Hypertension, dysglycemia, dyslipidemia, and systemic inflammation are associated with vascular changes in childhood, and these contribute to increased risk of cardiovascular events in adulthood if not adequately treated. Interventions to treat childhood obesity include multicomponent family-based behaviour modification programs, which have been demonstrated to have moderate short-term effects on weight-related outcomes; their effects on cardiovascular risk factors, however, are less well understood. Although supervised, structured exercise interventions result in improvements in blood pressure, inflammation, carotid artery intima media thickness, dysglycemia, dyslipidemia, and endothelial dysfunction in children with obesity in the short term, our understanding of how to translate these interventions into long-term sustainable exercise or physical activity recommendations remains uncertain. Research focus in these areas will help in treating childhood obesity and associated CVD risk factors to prevent CVD development in adulthood.

Cardiovascular morbidity, diabetes and cancer risk among children and adolescents with severe obesity

Severe obesity among children and adolescents is a significant global public health concern. The prevalence has markedly increased over the last decades, becoming common in many countries. Overwhelming rates of obesity among youth have prompted efforts to identify an evidence-based immediate- and long-term cardiometabolic risk factor profile in childhood-onset severe obesity, and to highlight gaps that require further investigation. The PubMed database was systematically searched in accordance with PRISMA guidelines. The search yielded 831 results, of which 60 fulfilled stringent criteria and were summarized in this review. The definition of severe obesity was variable, with only one half the publications using the definition BMI > 120% of the 95th percentile. Point estimates of the prevalence of at least one cardiometabolic risk factor in children with severe obesity reportedly range from 67 to 86%. Cross-sectional studies indicate that children and adolescents with severe obesity are at greater risk than those with mild obesity for type 2 diabetes, hypertension, fatty liver disease and dyslipidemia, already at childhood and adolescence. Robust epidemiological data on the long-term risk and actual point estimates in adulthood are lacking for these diseases as well as for other diseases (coronary heart disease, stroke, chronic kidney disease and cancer). Recent longitudinal studies indicate an increased risk for cardiomyopathy, heart failure, cardiovascular mortality and all-cause mortality in adulthood for adolescents with severe obesity compared to those with mild obesity. Given the alarming increase in the prevalence of severe obesity, the persistence of adiposity from childhood to adulthood and the precarious course of young adults with chronic comorbidities, the economic and clinical services burden on the healthcare system is expected to rise.

Prevention and management of cardiovascular disease in patients with diabetes: current challenges and opportunities

More than 100 million people in the USA have diabetes or prediabetes and are at high risk for developing cardiovascular disease. Current evidence-based guidelines support a multifactorial approach in patients with diabetes, including lifestyle intervention and pharmacological treatment of hyperglycemia, hypertension, and dyslipidemia. In addition, recent cardiovascular outcome trials demonstrated that sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide 1 receptor agonists improve cardiovascular outcomes in patients with diabetes. Albeit this evidence, over 80% of patients with diabetes do not achieve the recommended treatment goals. Considering the rising burden of cardiovascular complications, there is need to improve the quality of care in patients with diabetes. In this review, we discuss the current quality of health care in patients with diabetes in the USA, identify barriers to achieve guideline-recommended treatment goals and outline opportunities for the improvement in caring for patients with diabetes.

Food Liking-Based Diet Quality Indexes (DQI) Generated by Conceptual and Machine Learning Explained Variability in Cardiometabolic Risk Factors in Young Adults

The overall pattern of a diet (diet quality) is recognized as more important to health and chronic disease risk than single foods or food groups. Indexes of diet quality can be derived theoretically from evidence-based recommendations, empirically from existing datasets, or a combination of the two. We used these methods to derive diet quality indexes (DQI), generated from a novel dietary assessment, and to evaluate relationships with cardiometabolic risk factors in young adults with (n = 106) or without (n = 106) diagnosed depression (62% female, mean age = 21). Participants completed a liking survey (proxy for usual dietary consumption). Principle component analysis of plasma (insulin, glucose, lipids) and adiposity (BMI, Waist-to-Hip ratio) measures formed a continuous cardiometabolic risk factor score (CRFS). DQIs were created: theoretically (food/beverages grouped, weighted conceptually), empirically (grouping by factor analysis, weights empirically-derived by ridge regression analysis of CRFS), and hybrid (food/beverages conceptually-grouped, weights empirically-derived). The out-of-sample CRFS predictability for the DQI was assessed by two-fold and five-fold cross validations. While moderate consistencies between theoretically- and empirically-generated weights existed, the hybrid outperformed theoretical and empirical DQIs in cross validations (five-fold showed DQI explained 2.6% theoretical, 2.7% empirical, and 6.5% hybrid of CRFS variance). These pilot data support a liking survey that can generate reliable/valid DQIs that are significantly associated with cardiometabolic risk factors, especially theoretically- plus empirically-derived DQI.

Sex Differences in the Prevalence of and Risk Factors for Abnormal Glucose Regulation in Adults Aged 50 Years or Older With Normal Fasting Plasma Glucose Levels

AIMS

Abnormal glucose regulation, which can present as diabetes and prediabetes, has become one of the most common chronic conditions. However, sex differences in the prevalence of and factors associated with abnormal glucose regulation remain unclear. Thus, we aimed to explore sex differences in the prevalence of and factors associated with abnormal glucose regulation in low-income adults in China aged ≥50 years with normal fasting plasma glucose levels.

MATERIALS AND METHODS

A total of 2,175 individuals aged ≥50 years with normal fasting plasma glucose levels were recruited into this study. After an overnight fast of at least 10 h, individuals underwent an oral glucose tolerance test. Fasting and 2-h plasma glucose levels were measured to determine the state of glucose regulation.

RESULTS

Women were more likely than men to have isolated-impaired glucose tolerance (i-IGT) overall (24.7% vs 20.8%; P= 0.034), among individuals aged <65 years (21.7% vs 15.9%; P= 0.012). Among men, independent risk factors for i-IGT were an age of ≥65 years, hypertension, and high serum uric acid (SUA) and triglyceride levels; independent risk factors for diabetes mellitus (DM) were an age of ≥75 years and alcohol consumption. Among women, independent risk factors for i-IGT were central obesity and high levels of high-sensitivity C-reactive protein and SUA; independent risk factors for DM were low education and an elevated white blood cell count.

CONCLUSIONS

Our findings suggest that conventional cardiovascular disease risk factors (i.e., age, hypertension, and dyslipidemia) associated with high risk of developing DM in men, but poor life style (i.e., obesity) and low education attainment in women. It is necessary for delay or stopping the development of DM among low-income adults in China to implement the personalized scheme of prevention DM between men and women, especially highlight control the risk factors in young and middle aged women.