DiabetesDiabetes

Texas Diabetes Prevention and Control Program

Jan Marie Ozias, PhD, RN

Texas Diabetes Council

Texas Department of

Health

Centers for Disease Control and Prevention

Community-based

organizations

Health care systems

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

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

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

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)

Metabolic Syndrome and Obese Youth

• Risk T2D and CVD (3+ criteria)– BMI > 97%ile– TG >95%ile– HDL< 5%ile– BP (systolic or diastolic)>95%ile– Impaired glucose tolerance (OGTT, not

fingerstick)

Source: Weiss et al. NEJM June 3 2004

Independent CVD Markers

• Underlying inflammation markers associated with obesity– elev C-reactive protein– elev Interleukin-6 (regulates C-reactive

protein) – lower Adiponectin (protective )

Insulin Resistance in Puberty

• Normally reduces insulin sensitivity• ?? lower in Tanner stages II-IV• Likely related to other hormones - GH, not

androgens• High insulin:glucose ratios• Can recover unless beta cells otherwise

compromised (genetics, obesity)

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

Estimated 1,558,004Adult Texans with Diabetes (Diagnosed + Undiagnosed)

1,055,002

503,002

0

200,000

400,000

600,000

800,000

1,000,000

1,200,000

Undiagnosed DiabetesAmong Adult Population 20

Years and Older

Diagnosed Diabetes AmongAdult Population 18 Years

and Older

Nu

mb

er

of

Pe

rso

ns

15,356,640Texas Adult Population (Age 18 Years and Older) 2001

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%

1994 1995 1996 1997 1998 1999 2000 2001 2002

Perc

ent(%

)

Texas

US

Age-Adjusted Prevalence of Diabetes

Texas vs. US, BRFSS, 1994-2002

Source: Centers for Disease Control, Division of Diabetes Translation

Co-morbid Conditions

60%

21%

56%

28% 29%

6%

0%

10%

20%

30%

40%

50%

60%

70%

Hypertension High Cholesterol Heart Disease

Diabetes

No Diabetes

Source: Texas BRFSS, 1998-2000

Complications

• Heart disease

• Stroke

• Digestive disturbance

• Blindness

• Kidney disease

• Neuropathy

• Amputation

• Dental disease

• Pregnancy Complications

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

Overweight in Texas School-Age Children

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

Estimated Number of Males and Females, Born in Texas, in the Year 2000, at Risk for Developing

Diabetes in Their Lifetime

19.521.7

8.5 9.8

38.542.9

2.5 2.8

0

5

10

15

20

25

30

35

40

45

50

White Black Hispanic Other

Males

Females

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

Nu

mb

er

in T

ho

us

an

ds

26.7%31.2%

40.2%49.0%

45.4%

52.5%

36.9% 43.3%

Evaluating Youth at Risk (ADA)

• Age 10 or (puberty if earlier) and every 2 yrs IF

• Overweight (BMI >85%ile) – 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

Ft Worth ISD Study

• Gd 5 (n=1076)• Findings:

– 1/3 overweight (>85%ile)– 1/4 at risk for T2D on ADA criteria

• Follow up Mx Am children at risk (n=61) and sibs (n=78)

– Source: Urrutia-Rojas X et al. J Adol Health 2004;34:290-99

Ft Worth (cont’d)

• ADA-criteria positive Mx Am group (139)– 76% BMI 85%ile; 54% BMI 95%ile – 49% AN positive– 60% elevated insulin (fasting glucose wnl)– 41% high LDL-C (>100 mg/dl)

Conclusion: use overweight and ADA criteria to identify families at risk

Primary Prevention

• Prevention and delay of type 2 diabetes algorithm (texasdiabetescouncil.org)

• Diabetes Prevention Program (http://diabetes.niddk.nih.gov/dm/pubs/preventionprogram/index.htm)

• NDEP Small Steps (ndep.nih.gov)

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

Evaluating for IR

• TDH resource information for primary care clinicians.

• Overweight (BMI 95th percentile-for-age) or “at risk of overweight” (85th to <95th 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.

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

Coordinated Approach to Child Health (CATCH)

• Systems-oriented

• Classroom, cafeteria and physical education

• Coordination of : – Health education– Physical education – Nutrition services– Parent involvement

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

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

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

Overweight Sensitivity

Fatness/Excess Fat

Obese

Large Size

Unhealthy BMI

Unhealthy Weight

Weight Problem

“Ideal” weight

Weight

Excess Weight

BMI

Overweight?

Lifestyle

Health

Reasonable weight loss

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

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

The physical health of Texas will determine its fiscal health…

Eduardo J. Sanchez, M.D., M.P.H.Texas Commissioner of Health