Screening practices for identifying type 2 diabetes in adolescents

Diabetes screening outcomes in youth presenting for paediatric weight management: A report of the Paediatric Obesity Weight Evaluation Registry

OBJECTIVE

Rising prevalence of obesity has led to increased rates of prediabetes and diabetes mellitus (DM) in children. This study compares rates of prediabetes and diabetes using two recommended screening tests (fasting plasma glucose [FPG] and haemoglobin A1c [HbA1c]).

STUDY DESIGN

Data were collected prospectively from 37 multi-component paediatric weight management programs in POWER (Paediatric Obesity Weight Evaluation Registry).

RESULTS

For this study, 3962 children with obesity without a known diagnosis of DM at presentation and for whom concurrent measurement of FPG and HbA1c were available were evaluated (median age 12.0 years [interquartile range, IQR 9.8, 14.6]; 48% males; median body mass index 95th percentile [%BMIp95] 134% [IQR 120, 151]). Notably, 10.7% had prediabetes based on FPG criteria (100-125 mg/dL), 18.6% had prediabetes based on HbA1c criteria (5.7%-6.4%), 0.9% had DM by FPG abnormality (≥126 mg/dL) and 1.1% had DM by HbA1c abnormality (≥6.5%). Discordance between the tests was observed for youth in both age groups (10-18 years [n = 2915] and age 2-9 years [n = 1047]).

CONCLUSION

There is discordance between FPG and HbA1c for the diagnosis of prediabetes and DM in youth with obesity. Further studies are needed to understand the predictive capability of these tests for development of DM (in those diagnosed with prediabetes) and cardiometabolic risk.

Prospective Test Performance of Nonfasting Biomarkers to Identify Dysglycemia in Children and Adolescents

INTRODUCTION

Test performance screening measures for dysglycemia have not been evaluated prospectively in youth. This study evaluated the prospective test performance of random glucose (RG), 1-h nonfasting glucose challenge test (1-h GCT), hemoglobin A1c (HbA1c), fructosamine (FA), and 1,5-anhydroglucitol (1,5-AG) for identifying dysglycemia.

METHODS

Youth ages 8-17 years with overweight or obesity (body mass index, BMI, ≥85th percentile) without known diabetes completed nonfasting tests at baseline (n = 176) and returned an average of 1.1 years later for two formal fasting 2-h oral glucose tolerance tests. Outcomes included glucose-defined dysglycemia (fasting plasma glucose ≥100 mg/dL or 2-h plasma glucose ≥140 mg/dL) or elevated HbA1c (≥5.7%). Longitudinal test performance was evaluated using receiver-operating characteristic (ROC) curves and calculation of area under the curve (AUC).

RESULTS

Glucose-defined dysglycemia, elevated HbA1c, and either dysglycemia or elevated HbA1c were present in 15 (8.5%), 11 (6.3%), and 23 (13.1%) participants at baseline, and 16 (9.1%), 18 (10.3%), and 28 (15.9%) participants at follow-up. For prediction of glucose-defined dysglycemia at follow-up, RG, 1-h GCT, and HbA1c had similar performance (0.68 (95% CI: 0.55-0.80), 0.76 (95% CI: 0.64-0.89), and 0.70 (95% CI: 0.56-0.84)), while FA and 1,5-AG performed poorly. For prediction of HbA1c at follow-up, baseline HbA1c had strong performance (AUC 0.93 [95% CI: 0.88-0.98]), RG had moderate performance (AUC 0.67 [95% CI: 0.54-0.79]), while 1-h GCT, FA, and 1,5-AG performed poorly.

CONCLUSION

HbA1c and nonfasting glucose tests had reasonable longitudinal discrimination identifying adolescents at risk for dysglycemia, but performance depended on outcome definition.

Comparing the Fasting and Random-Fed Metabolome Response to an Oral Glucose Tolerance Test in Children and Adolescents: Implications of Sex, Obesity, and Insulin Resistance

As the incidence of obesity and type 2 diabetes (T2D) is occurring at a younger age, studying adolescent nutrient metabolism can provide insights on the development of T2D. Metabolic challenges, including an oral glucose tolerance test (OGTT) can assess the effects of perturbations in nutrient metabolism. Here, we present alterations in the global metabolome in response to an OGTT, classifying the influence of obesity and insulin resistance (IR) in adolescents that arrived at the clinic fasted and in a random-fed state. Participants were recruited as lean (n = 55, aged 8–17 years, BMI percentile 5–85%) and overweight and obese (OVOB, n = 228, aged 8–17 years, BMI percentile ≥ 85%). Untargeted metabolomics profiled 246 annotated metabolites in plasma at t0 and t60 min during the OGTT. Our results suggest that obesity and IR influence the switch from fatty acid (FA) to glucose oxidation in response to the OGTT. Obesity was associated with a blunted decline of acylcarnitines and fatty acid oxidation intermediates. In females, metabolites from the Fasted and Random-Fed OGTT were associated with HOMA-IR, including diacylglycerols, leucine/isoleucine, acylcarnitines, and phosphocholines. Our results indicate that at an early age, obesity and IR may influence the metabolome dynamics in response to a glucose challenge.

Predicting youth diabetes risk using NHANES data and machine learning

Prediabetes and diabetes mellitus (preDM/DM) have become alarmingly prevalent among youth in recent years. However, simple questionnaire-based screening tools to reliably assess diabetes risk are only available for adults, not youth. As a first step in developing such a tool, we used a large-scale dataset from the National Health and Nutritional Examination Survey (NHANES) to examine the performance of a published pediatric clinical screening guideline in identifying youth with preDM/DM based on American Diabetes Association diagnostic biomarkers. We assessed the agreement between the clinical guideline and biomarker criteria using established evaluation measures (sensitivity, specificity, positive/negative predictive value, F-measure for the positive/negative preDM/DM classes, and Kappa). We also compared the performance of the guideline to those of machine learning (ML) based preDM/DM classifiers derived from the NHANES dataset. Approximately 29% of the 2858 youth in our study population had preDM/DM based on biomarker criteria. The clinical guideline had a sensitivity of 43.1% and specificity of 67.6%, positive/negative predictive values of 35.2%/74.5%, positive/negative F-measures of 38.8%/70.9%, and Kappa of 0.1 (95%CI: 0.06–0.14). The performance of the guideline varied across demographic subgroups. Some ML-based classifiers performed comparably to or better than the screening guideline, especially in identifying preDM/DM youth (p = 5.23 × 10⁻⁵).We demonstrated that a recommended pediatric clinical screening guideline did not perform well in identifying preDM/DM status among youth. Additional work is needed to develop a simple yet accurate screener for youth diabetes risk, potentially by using advanced ML methods and a wider range of clinical and behavioral health data.

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.

Paediatricians provide higher quality care to children and adolescents in primary care: A systematic review

AIM

The number of primary care paediatricians is decreasing in Europe without a justifiable reason. We aimed to compare the clinical practice of paediatricians and family doctors attending children and adolescents in primary care.

METHODS

MEDLINE, Embase, CENTRAL, TRIP and Google Scholar were searched from December 2008 to February 2018. No language or study design restrictions were applied. Three reviewers assessed eligibility of the studies. Seven pairs of reviewers performed the data extraction and assessed the methodological quality independently. Discrepancies were resolved by consensus.

RESULTS

Fifty-four, out of 1150 studies preselected, were included. We found that paediatricians show more appropriate pharmacology prescription patterns for the illness being treated; they achieve higher vaccination rates and have better knowledge of vaccines and fewer doubts about vaccine safety; their knowledge and implementation of different screening tests are better; they prescribe psychoactive drugs more cautiously and more in line with current practice guidelines; their evaluation and treatment of obesity and lipid disorders follow criteria more consistently with current clinical practice guidelines; and they perform fewer diagnostic test, show a more suitable use of the test and request fewer referrals to specialists.

CONCLUSION

According to published data, in developed countries, paediatricians provide higher quality care to children than family doctors.

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.

Clinician Perceptions of a Computerized Decision Support System for Pediatric Type 2 Diabetes Screening

OBJECTIVE

With the increasing prevalence of type 2 diabetes (T2D) in youth, primary care providers must identify patients at high risk and implement evidence-based screening promptly. Clinical decision support systems (CDSSs) provide clinicians with personalized reminders according to best evidence. One example is the Child Health Improvement through Computer Automation (CHICA) system, which, as we have previously shown, significantly improves screening for T2D. Given that the long-term success of any CDSS depends on its acceptability and its users' perceptions, we examined what clinicians think of the CHICA diabetes module.

METHODS

CHICA users completed an annual quality improvement and satisfaction questionnaire. Between May and August of 2015 and 2016, the survey included two statements related to the T2D-module: (1) "CHICA improves my ability to identify patients who might benefit from screening for T2D" and (2) "CHICA makes it easier to get the lab tests necessary to identify patients who have diabetes or prediabetes." Answers were scored using a 5-point Likert scale and were later converted to a 2-point scale: agree and disagree. The Pearson chi-square test was used to assess the relationship between responses and the respondents. Answers per cohort were compared using the Mann-Whitney U-test.

RESULTS

The majority of respondents (N = 60) agreed that CHICA improved their ability to identify patients who might benefit from screening but disagreed as to whether it helped them get the necessary laboratories. Scores were comparable across both years.

CONCLUSION

CHICA was endorsed as being effective for T2D screening. Research is needed to improve satisfaction for getting laboratories with CHICA.

Comparison of HbA1c and OGTT for the diagnosis of type 2 diabetes in children at risk of diabetes

BACKGROUND

The aim of this study was to evaluate the correlation between plasma glucose and HbA1c and the diagnostic accuracy of HbA1c as a screening tool to identify asymptomatic diabetes mellitus in children and adolescents with obesity or asymptomatic glucosuria.

METHODS

A total of 190 subjects who underwent an oral glucose tolerance test (OGTT) to confirm diabetes were categorized into normal glucose tolerance (NGT; n = 117), impaired glucose tolerance (IGT; n = 33), and diabetes (DM; n = 40) according to the OGTT. Forty-seven patients with DM were diagnosed by either OGTT or HbA1c levels. The diagnostic accuracy for the detection of diabetes is based on 47 patients. Laboratory tests were performed after 12 h of fasting.

RESULTS

According to the HbA1c criterion, 107 (55.3%) subjects were in the NGT group, 41 (21.6%) were in the IGT group, and 42 (22.1%) were in the DM group. Diagnostic sensitivities of HbA1c and 2-hour plasma glucose level following OGTT (2-h OGTT) for DM were significantly higher than that of fasting plasma glucose, FPG (89.4, 85.1 vs. 63.8%). In addition, the area under the curves of diagnostic criteria was 0.970 for HbA1c, 0.939 for FPG and 0.977 for 2-h OGTT. Mean FPG and 2-h OGTT for HbA1c level >6.5% were 115.2 mg/dL and 181.8 mg/dL, respectively. The optimal HbA1c level cut-off point for predicting DM is 6.15%, with a sensitivity of 95.7% in Korean children and adolescents.

CONCLUSION

The HbA1c criterion ≥6.5% was adequate to detect DM among Korean children and adolescents with obesity or asymptomatic glucosuria. We also recommend HbA1c level of 6.15% as the optimal cut-off point for detecting DM in Korean children and adolescents.

Emergency Department Visits by and Hospitalizations of Senior Diabetics in the Three Years Following Hurricanes Katrina and Rita

While prior studies have investigated health care utilization immediately following disasters, few have examined utilization beyond that period. We use individual-level U.S. Medicare claims data for three years prior to (2002-2004) and after (2006-2008) Hurricanes Katrina and Rita to investigate whether senior diabetics affected by the storms had a greater number of emergency department visits and days hospitalized in the three years following the storms. An event study was conducted using regression analysis that controlled for all fixed individual characteristics. While the 2006 and 2007 rates of increase in utilization were relatively similar across the control group and the two affected groups, in 2008 the affected groups exhibited substantially greater increases in both emergency department visits and days hospitalized. The differences correspond to an additional 380,907 days hospitalized and 21,583 emergency department visits in 2008. The results indicate that, in addition to short term effects previously estimated, disasters may have longer term effects on utilization of healthcare services. These potential effects suggest that improved post-disaster care may significantly reduce the healthcare costs of disasters.

Biological and socioeconomic determinants of prediabetes in youth: an analysis using 2007 to 2011 Canadian Health Measures Surveys

OBJECTIVES

To describe rates of prediabetes among youth in Canada and the associated social and biological characteristics.

METHODS

We analyzed the cross-sectional data from the first (2007-2009) and second (2009-2011) cycles of the Canadian Health Measures Survey (CHMS) for youth aged 6-19 years. Prediabetes was defined using the glycated hemoglobin (A1C) guidelines set out by the American Diabetes Association (ADA) and the Canadian Diabetes Association (CDA) of A1C ranges 5.7-6.4% (38.8-46.4 mmol/mol) and 6.0-6.4% (42.1-46.4 mmol/mol), respectively.

RESULTS

An elevated A1C was observed in 22.8% of our sample (n = 3449) based on the ADA definition and 5.2% of youth using the CDA definition. Independent predictors in a fully adjusted model for prediabetes were non-White (odds ratio (OR) 2.62: 95% Confidence intervals 2.05-3.35), obese (OR 1.53: 1.19-1.96), less physically active youth (0.97: 0.95-0.99), and parents with high school education or less (1.34: 1.02-1.74). Moreover, significant regional variations were noted with higher rates for all regions except Ontario.

CONCLUSION

Prediabetes is relatively common in Canada and associated with common biologic and socioeconomic factors. Importantly, regular physical activity was significantly associated with reduced odds of prediabetes. Targeted screening and continued emphasis on physical activity may help curb the increasing rates of prediabetes.

Identifying Prediabetes and Type 2 Diabetes in Asymptomatic Youth: Should HbA1c Be Used as a Diagnostic Approach?

PURPOSE OF REVIEW

Because the incidence of type 2 diabetes and prediabetes in children is rising, routine screening of those at risk is recommended. In 2010, the ADA made the recommendation to include hemoglobin A1c (HbA1c) as a diagnostic test for diabetes, in addition to the oral glucose tolerance test or fasting plasma glucose. Our objective was to assess the pediatric literature with regard to HbA1c test performance and discuss advantages and disadvantages of use of the test for diagnostic purposes.

RECENT FINDINGS

HbA1c has a number of advantages, including elimination of the need for fasting, lower variability, assay standardization, and long-term association with future development of diabetes. It also has many drawbacks. It can be affected by a number of non-glycemic factors, including red blood cell turnover, hemoglobinopathies, medications, race, and age. In particular, it performs differently in children compared with adults, generally with lower sensitivity for prediabetes (as low as 0-5% in children vs 23-27% in adults) and lower area under the receiver operating characteristic curve (AUC) (0.53 vs 0.73 for prediabetes), and it has lower efficacy at a higher cost, compared with other tests of glycemia. Finally, HbA1c may perform very differently across diverse populations according to race/ethnicity; in Chinese populations, the proportion of individuals classified with prediabetes based on HbA1c predominates compared with IFG (77% for HbA1c vs 27.7% for IFG), whereas in US populations, it is the opposite (24.8% for HbA1c vs 80.1% for FPG). HbA1c is controversial because although it is convenient, it is not a true measure of glycemia. The interpretation of HbA1c results requires a nuanced understanding that many primary care physicians who are ordering the test in greater numbers do not possess. Alternative markers of glycemia may hold promise for the future but are not yet endorsed for use in practice. Further studies are needed to determine appropriate thresholds for screening tests and the long-term impact of screening and identification.

Infant-juvenile type 2 diabetes

In recent years, we have witnessed an increase in the number of cases of type 2 diabetes mellitus (DM2) in children and adolescents, which has paralleled the increase in the worldwide prevalence of obesity. Although screening the general population does not appear to be cost-effective, special attention should be paid to children with excess weight, obesity or other factors that predispose them to a state of insulin resistance. When faced with the diagnosis of childhood DM2, the presence of comorbidities (such as hypertension, dyslipidemia and microalbuminuria) should be assessed, and appropriate treatment and follow-up should be administered to prevent the onset of complications, given that the DM2 in this population group will last longer than that started in adulthood.

Alternate glycemic markers reflect glycemic variability in continuous glucose monitoring in youth with prediabetes and type 2 diabetes

OBJECTIVE

To determine whether the alternate glycemic markers, fructosamine (FA), glycated albumin (GA), and 1,5-anhydroglucitol (1,5AG), predict glycemic variability captured by continuous glucose monitoring (CGM) in obese youth with prediabetes and type 2 diabetes (T2D).

STUDY DESIGN

Youth with BMI ≥85th%ile, 10-18 years, had collection of fasting plasma glucose (FPG), hemoglobin A1c (HbA1c), FA, GA, and 1,5AG and 72 hours of CGM. Participants with HbA1c ≥5.7% were included. Relationships between glycemic markers and CGM variables were determined with Spearman correlation coefficients. Linear models were used to examine the association between alternate markers and CGM measures of glycemic variability-standard deviation (SD) and mean amplitude of glycemic excursions (MAGE)-after controlling for HbA1c.

RESULTS

Total n = 56; Median (25th%ile, 75th%ile) age = 14.3 years (12.5, 15.9), 32% male, 64% Hispanic, 20% black, 13% white, HbA1c = 5.9% (5.8, 6.3), FA=211 mmol/L (200, 226), GA= 12% (11%, 12%), and 1,5AG = 22mcg/mL (19, 26). HbA1c correlated with average sensor glucose, AUC, SD, MAGE, and %time > 140 mg/dL. FA and GA correlated with average and peak sensor glucose, %time >140 and >200 mg/dL, and MAGE. GA also correlated with SD and AUC180. 1,5AG correlated with peak glucose, AUC180, SD, and MAGE. After adjusting for HbA1c, all 3 markers independently predicted MAGE; FA and GA independently predicted SD.

CONCLUSIONS

Alternate glycemic markers predict glycemic variability as measured by CGM in youth with prediabetes and T2D. After adjusting for HbA1c, these alternate markers continued to predict components of glycemic variability detected by CGM.

Examining trends in prediabetes and its relationship with the metabolic syndrome in US adolescents, 1999-2014

AIMS

We sought to investigate temporal trends in prediabetes prevalence among US adolescents using two definitions and evaluate relationships with obesity and a MetS-severity score.

METHODS

We evaluated data from 5418 non-Hispanic white, non-Hispanic black, and Hispanic adolescents aged 12-19 participating in the National Health and Nutrition Examination Survey 1999-2014 with complete data regarding MetS and hemoglobin A1c (HbA1c). Prediabetes status was defined by American Diabetes Association (ADA) criteria: fasting glucose 100-125 mg/dL or HbA1c 5.7%-6.4%. MetS severity was assessed with a MetS-severity Z-score.

RESULTS

Prevalence of prediabetes as defined by HbA1c abnormalities significantly increased from 1999-2014, while prevalence of prediabetes as defined by fasting glucose abnormalities showed no significant temporal trend. There were variations in these trends across different racial/ethnic groups. MetS Z-score was overall more strongly correlated with HbA1c, fasting insulin, and the homeostasis model of insulin resistance than was BMI Z-score. These correlations were true in each racial/ethnic group with the exception that in non-Hispanic white adolescents, in whom the MetS Z-score was not significantly correlated with HbA1c measurements.

CONCLUSION

We found conflicting findings of temporal trends of US adolescent prediabetes prevalence based on the ADA's prediabetes criteria. The increasing prevalence of prediabetes by HbA1c assessment is concerning and raises the urgency for increased awareness and appropriate measures of prediabetes status among physicians and patients.

Effectiveness of Computer Automation for the Diagnosis and Management of Childhood Type 2 Diabetes: A Randomized Clinical Trial

Importance

Type 2 diabetes (T2D) is increasingly common in young individuals. Primary prevention and screening among children and adolescents who are at substantial risk for T2D are recommended, but implementation of T2D screening practices in the pediatric primary care setting is uncommon.

Objective

To determine the feasibility and effectiveness of a computerized clinical decision support system to identify pediatric patients at high risk for T2D and to coordinate screening for and diagnosis of prediabetes and T2D.

Design, Setting, and Participants

This cluster-randomized clinical trial included patients from 4 primary care pediatric clinics. Two clinics were randomized to the computerized clinical decision support intervention, aimed at physicians, and 2 were randomized to the control condition. Patients of interest included children, adolescents, and young adults 10 years or older. Data were collected from January 1, 2013, through December 1, 2016.

Interventions

Comparison of physician screening and follow-up practices after adding a T2D module to an existing computer decision support system.

Main Outcomes and Measures

Electronic medical record (EMR) data from patients 10 years or older were reviewed to determine the rates at which pediatric patients were identified as having a body mass index (BMI) at or above the 85th percentile and 2 or more risk factors for T2D and underwent screening for T2D.

Results

Medical records were reviewed for 1369 eligible children (712 boys [52.0%] and 657 girls [48.0%]; median [interquartile range] age, 12.9 [11.2-15.3]), of whom 684 were randomized to the control group and 685 to the intervention group. Of these, 663 (48.4%) had a BMI at or above the 85th percentile. Five hundred sixty-five patients (41.3%) met T2D screening criteria, with no difference between control and intervention sites. The T2D module led to a significant increase in the percentage of patients undergoing screening for T2D (89 of 283 [31.4%] vs 26 of 282 [9.2%]; adjusted odds ratio, 4.6; 95% CI, 1.5-14.7) and a greater proportion attending a scheduled follow-up appointment (45 of 153 [29.4%] vs 38 of 201 [18.9%]; adjusted odds ratio, 1.8; 95% CI, 1.5-2.2).

Conclusions and Relevance

Use of a computerized clinical decision support system to automate the identification and screening of pediatric patients at high risk for T2D can help overcome barriers to the screening process. The support system significantly increased screening among patients who met the American Diabetes Association criteria and adherence to follow-up appointments with primary care clinicians.

Trial Registration

clinicaltrials.gov Identifier: NCT01814787.

Screening for type 2 diabetes and prediabetes in obese youth: evaluating alternate markers of glycemia - 1,5-anhydroglucitol, fructosamine, and glycated albumin

Hemoglobin A1c (HbA1c) is increasingly performed over the oral glucose tolerance test (OGTT) as the initial screening test for type 2 diabetes in youth. However, the optimal strategy for identifying type 2 diabetes in youth remains controversial. Alternate glycemic markers have been proposed as potentially useful tools for diabetes screening. We examined the relationships among fructosamine (FA), glycated albumin (GA), and 1,5-anhydroglucitol (1,5-AG) with traditional screening tests, HbA1c and OGTT. Youth 10-18 yrs, BMI ≥85th‰, and HbA1c <7.5% had a single visit with measurement of HbA1c, 1,5-AG, FA, GA, and a standard OGTT. Distributions of FA, GA, and 1,5-AG by HbA1c and 2-hour glucose (2hG) categories were compared. Receiver operating characteristic (ROC)-curves were generated to determine the cut points at which alternate markers maximized sensitivity and specificity for predicting prediabetes and diabetes. One hundred and seventeen, 62% female, 59% Hispanic, 22% White, 17% black, median 14.1 yr, and body mass index (BMI) z-score 2.3 participated. Median values of each alternate marker differed significantly between prediabetes and diabetes HbA1c and 2hG categories (p < 0.017). Only GA medians differed (p = 0.006) between normal and prediabetes HbA1c. Area under the receiver operating characteristic curves (ROC-AUCs) for alternate markers as predictors of prediabetes (0.5-0.66) were low; however, alternate marker ROC-AUCs for identifying diabetes (0.82-0.98) were excellent. Although the alternate markers were poor predictors of prediabetes, they all performed well predicting diabetes by 2hG and HbA1c. Whereas the usefulness of these markers for identifying prediabetes is limited, they may be useful in certain scenarios as second line screening tools for diabetes in overweight/obese youth.

The prevalence, risk factors, and screening measure for prediabetes and diabetes among Emirati overweight/obese children and adolescents

Background

The aim of the study was to estimate the prevalence of prediabetes and type 2 diabetes (T2D) among overweight/obese children and adolescents using different diagnostic/screening methods in comparison.

Methods

We recruited overweight/obese Emirati students; grade 6–12 (age 11–17 years) from 16 government schools in Sharjah (UAE). Anthropometric, demographic, and clinical history data was measured by standard methods. Body mass index (BMI) was categorized according to BMI percentile charts for age and sex – CDC. Capillary fasting blood glucose (FBG) and glycated hemoglobin (HbA1c) were measured by finger prick test, followed by confirmatory oral glucose tolerance tests (OGTT) and venous HbA1c for students with abnormal capillary FBG and/or HbA1c.

Results

Of a total of 1034 participants (45 % females) median age 14.7 years, 443 (43 %) students had abnormal screening results. The prevalence of prediabetes and T2D was 5.4 % and 0.87 %, respectively, based on OGTT (gold standard). HbA1c showed a considerable discrepancy regarding the prevalence of prediabetes (21.9 %), but not diabetes. There was a statistically significant difference in the BMI Z-scores between the three different groups of students showing normal glycemic testing, prediabetes and T2D (p = 0.041). Univariate logistic regression analysis showed that glycemic status was significantly associated with family history of T2D first-degree relatives [OR 1.87: 95 % CI: 1.04–3.36; P = 0.036], parents employment [OR 1.79: 95 % CI: 1.06–3.02; P = 0.029] and levels of triglycerides [OR 2.28: 95 % CI: 1.11–4.68; P = 0.024].

Conclusions

The prevalence of prediabetes and diabetes was high among overweight/obese Emirati children and adolescents. The numbers for prediabetes were considerably higher when using HbA1c as compared to OGTT. Overall adiposity, family history of T2D, employment and high levels of triglycerides were risk factors associated with abnormal glycemic testing.

Continuous glucose monitoring and its relationship to hemoglobin A1c and oral glucose tolerance testing in obese and prediabetic youth

CONTEXT

The optimal screening test for diabetes and prediabetes in obese youth is controversial.

OBJECTIVE

We examined whether glycosylated hemoglobin (HbA1c) or the oral glucose tolerance test (OGTT) is a better predictor of free-living glycemia as measured by continuous glucose monitoring (CGM).

DESIGN

This was a cross-sectional study of youth 10-18 years old, body mass index (BMI) 85th percentile or greater, with diabetes risk factors.

SETTING AND PARTICIPANTS

Participants (n = 118) with BMI 85th percentile or greater, not on medications for glucose management, were recruited from primary care and pediatric endocrinology clinics around Denver, Colorado.

INTERVENTION

HbA1c, fasting plasma glucose, and 2-hour glucose were collected and all participants wore a blinded CGM for 72 hours.

MAIN OUTCOME MEASURES

CGM outcomes were determined and descriptive statistics calculated. Performance characteristics at current American Diabetes Association cutpoints were compared with CGM outcomes.

RESULTS

CGM data were successfully collected on 98 obese youth. Those with prediabetes had significantly higher average glucose, area under the curve (AUC), peak glucose, and time greater than 120 and greater than 140 mg/dL (P < .01) on CGM than youth with normal HbA1c or OGTT. HbA1c had a greater magnitude of correlation to CGM average glucose, AUC, and minimum glucose; 2-hour glucose had a greater magnitude of correlation to CGM SD, peak glucose, and time greater than 140 and greater than 200 mg/dL. However, there were no overall differences in the strength comparisons between 2-hour glucose and HbA1c correlations to CGM outcomes.

CONCLUSIONS

In obese youth, HbA1c and 2-hour glucose performed equally well at predicting free-living glycemia on CGM, suggesting that both are valid tests for dysglycemia screening.

Hemoglobin A1c assay variations and implications for diabetes screening in obese youth

BACKGROUND

Standardization of the hemoglobin A1c (A1c) assay has led to its increasing utilization as a screening tool for the diagnosis of prediabetes and type 2 diabetes in youth. However, significant A1c assay variability remains and has implications for clinical management.

OBJECTIVE

To describe our center's experiences with A1c results in youth and to evaluate inter-method differences and their clinical implications.

SUBJECTS

Seventy-five youth (aged 10-18 yr old), body mass index (BMI) ≥85th‰ participated.

METHODS

Seventy-two participants had two A1c values performed on the same sample, one via immunoassay (DCA Vantage Analyzer, A1c1 ) and the other via high performance liquid chromatography (Bio-Rad Variant II, A1c2 ). Nineteen had A1c run on two immunoassay devices (A1c1 and Dimensions Vista, A1c3 ).

RESULTS

Mean age of participants was 13.9 years, BMI% 97.89%, 33% male, 16% white, 21% black, and 61% Hispanic (H). Mean A1c1 was 5.68% ± 0.38 vs. a mean A1c2 of 5.73% ± 0.39, p = 0.049. Concordance in diabetes status between methods was achieved in 79% of subjects. Nineteen subjects with A1c3 results had testing performed an average of 22 ± 9 days prior to A1c1 . Mean A1c3 was 6.24% ± 0.4, compared to a mean A1c1 of 5.74% ± 0.31, (p < 0.0001). A1c1 was on average systematically -0.5 ± 0.28 lower compared to A1c3 . There was poor agreement in diabetes classification between A1c1 and A1c3 , with a concordance in classification between methods of only 36.8%.

CONCLUSIONS

Clinically significant inter-method A1c variability exists that impacts patient classification and treatment recommendations. In the screening of obese youth for diabetes, A1c results should be interpreted with caution.

Overweight and obesity in children and adolescents

Obesity among children, adolescents and adults has emerged as one of the most serious public health concerns in the 21st century. The worldwide prevalence of childhood obesity has increased remarkably over the past 3 decades. The growing prevalence of childhood obesity has also led to appearance of obesity-related comorbid disease entities at an early age. Childhood obesity can adversely affect nearly every organ system and often causes serious consequences, including hypertension, dyslipidemia, insulin resistance, dysglycemia, fatty liver disease and psychosocial complications. It is also a major contributor to increasing healthcare expenditures. For all these reasons, it is important to prevent childhood obesity as well as to identify overweight and obese children at an early stage so they can begin treatment and attain and maintain a healthy weight. At present, pharmacotherapy options for treatment of pediatric obesity are very limited. Therefore, establishing a comprehensive management program that emphasizes appropriate nutrition, exercise and behavioral modification is crucial. The physician's role should expand beyond the clinical setting to the community to serve as a role model and to advocate for prevention and early treatment of obesity.