Tuesday, February 28, 2006

Novel Type 2 Diabetes Screening Program Helps Identify at-Risk Youth

Feb. 27, 2006 (Reno, Nevada) A new screening checklist may help identify children at risk for type 2 diabetes, according to a new study presented here at the annual meeting of the American College of Preventive Medicine. The checklist combined elevated body mass index (BMI) with other traditional risk factors, such as race/ethnicity, family history of type 2 diabetes, acanthosis nigrans, and hypertension."Our goal was to identify children ages 10 to 18 with type 2 diabetes, prediabetes, or metabolic syndrome, and to provide an intensive family-based healthy lifestyle program for children diagnosed with diabetes or prediabetes," said Elizabeth Tilson, MD, MPH, medical director of Community Care of Wake/Johnston Counties, North Carolina, a quality improvement program for Medicaid patients. Implementing the program required a collaborative community effort, involving private practitioners, the local health department, medical society, hospital, YMCA, and other agencies. Dr. Tilson and colleagues developed a screening checklist tool based on the American Academy of Pediatrics and American Diabetes Association guidelines with some modifications. Participating physicians were to screen all children aged 10 to 18 years for elevated BMI. Children with a BMI higher than the 85th percentile were assessed for the risk factors of race/ethnicity, family history of type 2 diabetes, acanthosis nigrans, and hypertension (defined as systolic blood pressure higher than the 90th percentile for age and height). If a child had one or more risk factors present in addition to a BMI higher than the 85th percentile, he or she was referred for a fasting blood glucose test and an oral glucose tolerance test. "Any child with a BMI higher than the 95th percentile was referred for a fasting blood glucose and a glucose tolerance test, even if no other risk factors were present because a BMI in this percentile is a strong risk factor for prediabetes or diabetes, Dr. Tilson said.A total of 89 physicians in 37 different practices used the new screening tool between July 2004 and December 2005. They referred a total of 747 children aged 10 to 18 years for laboratory tests during this 18-month period. At the start of the program, physicians referred fewer than 10 at-risk children per month for laboratory testing. By June 2005, however, physicians were referring about 50 children per month. Of the 747 children referred, 606 (81%) received fasting blood glucose and glucose tolerance tests. Considering the logistics of obtaining these tests in children, Dr. Tilson commented, "We were really excited about this. We thought 81% showed that the program was quite effective."Of the children who received laboratory tests, 272 (45%) had abnormal results. A majority of those children met criteria for metabolic syndrome with 3 or more factors present, such as elevated systolic blood pressure, triglycerides, and high-density lipoprotein levels, and impaired fasting blood glucose. Three children were diagnosed with type 2 diabetes (defined as a fasting blood glucose level higher than 126 mg/dL). "Of the kids that had abnormal lab results, keep in mind that the mean age of these children was 12. We are really dealing with a syndrome that used to only be seen in adults," Dr. Tilson stressed during her presentation.Children diagnosed with prediabetes or diabetes underwent a 12-week lifestyle intervention with their families, including educational classes and exercise coordinated with the YMCA and other organizations.Dr. Tilson identified several barriers to screening in private practice. "One barrier is actually parent refusal," she told Medscape. "Some parents don't want to acknowledge that their child is overweight or they aren't interested in any lifestyle interventions." She also cited time pressure on physicians. "The screening tool we have put together is to make [screening] as easy as possible in a busy clinic," Dr. Tilson said.Dr. Tilson added that physicians may not be identifying children at moderate risk for diabetes. "Physicians see so many kids that have BMIs off the chart greater than the 95th percentile so when we see kids with BMIs between the 85th and 95th percentile, we've been desensitized to referring them," she told Medscape.Commenting on Dr. Tilson's presentation, Neal Kohatsu, MD, MPH, president of the American College of Preventive Medicine, told Medscape, "The screening program is a thoughtful integration of medicine and public health. It involved working with other community constituencies to help identify populations at risk, so it was novel in that regard." He added, "I definitely think that this program could apply to many other settings where underserved children and minority populations are targeted. [The study results] would be useful information in developing a community-based diabetes screening program."The study was independently funded. The authors report no pertinent financial disclosures.Preventive Medicine 2006: Session 24 Submitted Abstracts Session. Presented February 24, 2006.Reviewed by Peggy Keen, PhD, FNP