Diabetes

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Diabetes

• Texas Diabetes Prevention and Control Program
• Jan Marie Ozias, PhD, RN

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Texas Diabetes Council
Texas Department of Health
Health care systems
Community-based organizations
Centers for Disease Control and Prevention
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Objectives

• Define Insulin Resistance and risks for type 2
  diabetes (T2D)/CVD
• Discuss estimated lifetime risk T2D for children
• Outline risk assessment
• Discuss primary prevention strategies
• List school staff activities
• Discuss NDEP guide for schools

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Natural Progression Intervention Landmarks

• From Low Risk (Lean Body)
• High Risk ( Obesity)
• Insulin Resistance
• Impaired Glucose Tolerance
• (pre-diabetes)
• Beta cell failure - reduced insulin secretion
• Established Diabetes
• Complications

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Insulin Resistance

• Insulin regulates blood glucose and influences
  cell growth
• Fat cells (abdominal) influence insulin
  sensitivity
• Muscle cells become less sensitive
• Incrs production insulin to keep blood glucose
  wnl
• Measure formula with fasting plasma insulin and
  glucose

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So what?

• Risk progression to pancreatic dysfunction
• Increasing IR increases odds of Metabolic
  Syndrome (MS)
• MS endothelial dysfunction (atherosclerotic
  lesions) and cardiovascular disease
• Accompanied by high blood pressure and
  dyslipidemias (low HDL, high TG)

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Metabolic Syndrome and Obese Youth

• Risk T2D and CVD (3 criteria)
• BMI gt 97ile
• TG gt95ile
• HDLlt 5ile
• BP (systolic or diastolic)gt95ile
• Impaired glucose tolerance (OGTT, not
  fingerstick)
• Source Weiss et al. NEJM June 3 2004

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Independent CVD Markers

• Underlying inflammation markers associated with
  obesity
• elev C-reactive protein
• elev Interleukin-6 (regulates C-reactive protein)
  
• lower Adiponectin (protective )

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Insulin Resistance in Puberty

• Normally reduces insulin sensitivity
• ?? lower in Tanner stages II-IV
• Likely related to other hormones - GH, not
  androgens
• High insulinglucose ratios
• Can recover unless beta cells otherwise
  compromised (genetics, obesity)

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IR and risks for T2D

• Unchangeable
• Genetic immediate family
• Abdominal fat distribution (apple v pear)
• Puberty (transient)
• Changeable
• Obesity (High BMI, adult waist circumference)
• Sedentary most days
• Food choices and portion size

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15,356,640 Texas Adult Population (Age 18 Years
and Older) 2001
Estimated 1,558,004 Adult Texans with Diabetes
(Diagnosed Undiagnosed)
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Age-Adjusted Prevalence of Diabetes Texas vs. US,
BRFSS, 1994-2002
Source Centers for Disease Control, Division of
Diabetes Translation
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Co-morbid Conditions
Source Texas BRFSS, 1998-2000
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Complications

• Neuropathy
• Amputation
• Dental disease
• Pregnancy Complications

• Heart disease
• Stroke
• Digestive disturbance
• Blindness
• Kidney disease

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Trends

• Prevalence of diagnosed type 2 in younger adults
  rising
• Highly correlated with obesity
• Highest risk non-Hispanic Blacks, Native
  Americans, Hispanic, Asian Americans
• 30-45 new onset pedi cases are type 2
• Pre-diabetes increases population of concern
• SEARCH (Incidence/ prevalence) study

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Overweight in Texas School-Age Children
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Kids at Risk for type 2 Diabetes

• Can grow into young adults at high risk
• Very overweight youth
• over 20 have impaired glucose tolerance
• 4 had type 2 diabetes
• co-morbidities (sleep apnea, cardiovascular)
• Source N E J M Feb 2002

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Estimated Number of Males and Females, Born in
Texas, in the Year 2000, at Risk for Developing
Diabetes in Their Lifetime
Number in Thousands
52.5
45.4
31.2
26.7
49.0
40.2
43.3
36.9
Sources Narayan, K.M., et al. (October 8,
2003) "Lifetime Risk for Diabetes Mellitus in
the United States, JAMA,290(14). Birth numbers
based on 2000 population, Texas Department of
Health, Bureau of Vital Statistics
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Evaluating Youth at Risk (ADA)

• Age 10 or (puberty if earlier) and every 2 yrs
  IF
• Overweight (BMI gt85ile)
• AND at least 2 risk factors
• Family hx first and second degree relative
• High risk ethnic group
• Signs of insulin resistance hypertension,
  polycystic ovary syndrome, dyslipidemia,
  acanthosis nigricans
• FPG preferred in medical home

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Ft Worth ISD Study

• Gd 5 (n1076)
• Findings
• 1/3 overweight (gt85ile)
• 1/4 at risk for T2D on ADA criteria
• Follow up Mx Am children at risk (n61) and sibs
  (n78)
• Source Urrutia-Rojas X et al. J Adol Health
  200434290-99

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Ft Worth (contd)

• ADA-criteria positive Mx Am group (139)
• 76 BMI 85ile 54 BMI 95ile
• 49 AN positive
• 60 elevated insulin (fasting glucose wnl)
• 41 high LDL-C (gt100 mg/dl)
• Conclusion use overweight and ADA criteria to
  identify families at risk

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Primary Prevention

• Prevention and delay of type 2 diabetes algorithm
  (texasdiabetescouncil.org)
• Diabetes Prevention Program (http//diabetes.nidd
  k.nih.gov/dm/pubs/preventionprogram/index.htm)
• NDEP Small Steps (ndep.nih.gov)

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School Nurse Menu

• Be informed health of community, coordinated
  school health program
• Model healthful practices
• Include BMI in assessment and reports to parents
  open door to other risks
• Assist teachers with interesting lessons

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Evaluating for IR

• TDH resource information for primary care
  clinicians.
• Overweight (BMI ? 95th percentile-for-age) or at
  risk of overweight (85th to lt95th percentile)
  sans co-morbidity is a finding
• AN is a skin marker, finding or risk factor, not
  a disease. Evaluate for several possible
  conditions, including insulin resistance.

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Environmental Factors

• School food service
• Healthy foods, food pricing, taste testing
• Physical Education
• Daily PE, High MVPA, Fun activities
• Vending machines and fundraising
• Family/parent
• Modeling, norms, family practices
• After school programs

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Coordinated Approach to Child Health (CATCH)

• Systems-oriented
• Classroom, cafeteria and physical education
• Coordination of
• Health education
• Physical education
• Nutrition services
• Parent involvement

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School Food Policy

• Texas Dept Agriculture - administering state
  agency for National School Lunch and School
  Breakfast Programs in Texas public schools
• TDA enforces policy on Foods of Minimal
  Nutritional Value

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All Schools

• Eliminate deep-fat frying
• Portion size restrictions
• Limit fats and sugar per serving
• Fruits and vegetables offered
• Low and no-fat milk
• Request for trans fat information
• 100 percent real fruit and/or vegetable juices

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Intervention

• Weight leveling, not reduction in growing kids
• Consider age, residual linear growth potential,
  BMI and abdominal fat deposition, complications
• Treat early
• Family Involvement
• Increase physical activity/ movement
• Limit high fat/calorie foods
• Support

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Overweight Sensitivity
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Legislative Issues

• Children with diabetes in school
• Screening youth for obesity and/or AN
• Children -physical activity, nutrition, and
  healthy body weight
• Jt Comm Health and Nutrition in Schools
• Pediatric Diabetes Research registry

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Resources

• National Diabetes Educ Program www.ndep.nih.gov
• Small Steps Big Rewards Paso a Paso
• Guide for Schools
• CDC www.cdc.gov
• School Health Index
• BMI values ages 2 to 20 yrs
• Guidelines for increasing physical activity

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• The physical health of Texas will determine its
  fiscal health
• Eduardo J. Sanchez, M.D., M.P.H.
• Texas Commissioner of Health