Type 2 Diabetes in High-risk Youth: Improving Identification and Interventions in Community Health with a Decade of Quality Improvement Efforts.

INTRODUCTION: This manuscript describes quality improvement interventions with aims (1) to increase identification and follow-up testing of youth with prediabetes and type 2 diabetes (T2D) and (2) to improve outcomes for youth with prediabetes and low-range T2D (HbA1c 6.5-6.9%). METHODS: Interventions included (a) dissemination of evidence-based guidelines and (b) creation of in-house weight management (WM) programs and programs to increase prediabetes follow-up testing and T2D self-management. Data from the electronic health record are presented. RESULTS: Between 2009-2020, T2D screening for obese youth increased from 24% to 76%. Two WM programs served 2,726 unique youth for 11,110 billable visits. Youth with prediabetes seen in WM clinic had a lower risk of developing T2D if they attended three or more visits. Teaching self-monitoring blood glucose showed promise for improving HbA1c outcomes in youth with low-range T2D. CONCLUSIONS: Interventions have increased identification, access to preventive services, and treatment for youth with prediabetes and T2D.

Quality improvement efforts in a safety net institution: Increased diabetes screening is associated with lower HbA1c at diagnosis and improved HbA1c outcomes in youth with type 2 diabetes.

OBJECTIVES: Evaluate whether increased diabetes screening in youth is associated with lower HbA1c at T2D diagnosis and improved HbA1c outcomes in youth. RESEARCH DESIGN AND METHODS: Diabetes screening rates from 2009 to 2018 were calculated. Electronic medical records identified obese youth ages 8-18 with first HbA1c ≥6.5% from 2009 to 2018; chart review confirmed incident T2D. Demographics, BMI and HbA1c values, and use of glucometer and diabetes medications were collected. RESULTS: 142 youth had T2D. Median age was 14 years (range 8-18); 58% were female. 46% were identified on first HbA1c testing. 69 (49%) had 1st HbA1c 6.5%-6.9%, 43 (30%) 7.0%-7.9%, and 30 (21%) ≥8%. Follow-up from 1st to last HbA1c was median 2.6 years (range 0-10). 121 youth had follow-up testing ≥1 year after diagnosis; of these, 87 (72%) had persistent T2D-range HbA1c or were taking diabetes medications. 85% of youth with 1st HbA1c ≥7% had persistent T2D versus 52% of those with 1st HbA1c <7% (p < 0.001). Poorly controlled diabetes at last test was present in 19% of youth with baseline HbA1c 6.5%-6.9%, 30% with 7.0%-7.9%, and 63% with ≥8% (p < 0.001). 47 (68%) with HbA1c <7% were prescribed a glucometer; 9% of youth prescribed a meter and 41% of youth not prescribed a meter had poorly controlled diabetes at last test (p = 0.009). CONCLUSIONS: Youth with HbA1c <7% at diagnosis were less likely to have poorly controlled diabetes at follow-up. Prescription of glucometers for youth with HbA1c in this range was associated with improved HbA1c outcomes and deserves further study including components of glucometer teaching.

Weight Gain Patterns in Adolescent and Young Adult Women With the Etonogestrel Implant: Comparison by Weight Category.

PURPOSE: The purpose of this study was to determine if initiation and use of the etonogestrel implant was associated with differential weight gain in patients who were overweight or obese compared with normal-weight patients. METHODS: This is a cohort study of 1,024 patients between ages of 13 and 25 years seen in a Title X clinic who received the etonogestrel implant from 2007 to 2019 and had weight measurements at implant insertion and 6-18 months before (preinsertion) and after insertion (postinsertion). RESULTS: Patients, regardless of weight category (normal weight, overweight, and obese), increased weight in kilograms (kg) from preinsertion to insertion (1.16 ± 4.16 kg, 2.79 ± 5.35 kg, and 4.54 ± 7.71 kg, respectively) and from insertion to postinsertion (1.38 ± 4.37 kg, 2.94 ± 6.97 kg, and 3.66 ± 6.53, respectively). However, there was no increase in the amount gained comparing preinsertion to insertion with insertion to postinsertion. Patients who removed the implant (n = 84) for weight concerns did have increased weight change and a greater percent who gained ≥5% postinsertion as compared with those who removed the implant for other reasons or did not have the implant removed (65.5% vs. 34.2% vs. 39.2%, respectively, p = .03). CONCLUSIONS: Overweight and obese adolescents are at risk of weight gain over time, but placement of the implant did not accelerate the rate of gain from preinsertion to postinsertion. However, patients who removed the implant specifically because of weight gain did gain more weight after insertion compared with before. Clinicians should help patients evaluate the benefits and risks of highly effective contraceptive options as well as be aware of a subset of patients who do gain weight with use of the implant.

Longitudinal follow up of dysglycemia in overweight and obese pediatric patients.

OBJECTIVE: To examine factors related to progression of dysglycemia in overweight and obese youth in a large primary care setting. RESEARCH DESIGN AND METHODS: 10- to 18-year-old youth with body mass index (BMI) > 85 percentile and first-time A1c 5.7%-7.9% (39-63 mmol/mol) were identified retrospectively through electronic medical records (EMR). Levels of dysglycemia were defined as low-range prediabetes (LRPD; A1c 5.7%-5.9% [39-41 mmol/mol]), high-range prediabetes (HRPD; A1c 6.0%-6.4% [42-46 mmol/mol]), or diabetes-range (A1c 6.5%-7.9% [48 mmol/mol]). Follow-up A1c and BMI were extracted from the EMR. Follow up was truncated at the time of initiation of diabetes medication. RESULTS: Of 11 000 youth, 547 were identified with baseline dysglycemia (mean age 14.5 ± 2.2 years, 70% Hispanic, 23% non-Hispanic Black, 7% other). Of these, 206 had LRPD, 282 HRPD, and 59 diabetes. Follow-up A1c was available in 420 (77%), with median follow up of 12-22 months depending on A1c category. At follow-up testing, the percent with diabetes-range A1c was 4% in youth with baseline LRPD, 8% in youth with baseline HRPD, and 33% in youth with baseline diabetes-range A1c. There was a linear association between BMI increase and worsening A1c for LRPD (P < .001) and HRPD (P = .003). CONCLUSIONS: Most adolescents with an initial prediabetes or diabetes-range A1c did not have a diabetes-range A1c on follow up. Moreover, prediabetes-range A1c values do not all convey equal risk for the development of diabetes, with lower rates of progression for youth with initial A1c <6%. In youth with prediabetes-range A1c, BMI stabilization was associated with improvement of glycemia.

School-based health center-based treatment for obese adolescents: feasibility and body mass index effects.

BACKGROUND: School-based health centers (SBHCs) may be an ideal setting to address obesity in adolescents because they provide increased access to a traditionally difficult-to-reach population. The study evaluated the feasibility of adding a health educator (HE) to SBHC teams to provide support and increase the delivery of preventive services for overweight or obese adolescents. METHODS: Adolescents with BMI ≥85% recruited from two SBHCs were randomized to a control group (CG) or an intervention group (IG). Both groups received preventive services, including physical examinations and laboratory screening in the SBHC. The educator met with the IG during the academic year, utilizing motivational interviewing techniques to set lifestyle goals. Text messaging was used to reinforce goals between visits. RESULTS: Eighty-two students (15.7±1.5 years of age; BMI, 31.9±6.2 kg/m(2)) were enrolled in the IG and 83 in the control group (16.0±1.5 years of age; BMI, 31.6±6.5 kg/m(2)). Retention was 94% in the IG and 87% in the CG. A total of 54.5% of the IG and 72.2% of the CG decreased or maintained BMI z-score (less than 0.05 increase; p=0.025). Sports participation was higher in the CG (47% vs. 28% in the IG; p=0.02). Mean BMI z-score change was -0.05±0.2 for students participating in sports vs. 0.01±0.2 for those not (p=0.09). CONCLUSIONS: This SBHC intervention showed successful recruitment and retention of participants and delivery of preventive services in both groups. Meeting with an HE did not improve BMI outcomes in the IG. Confounding factors, including sports participation and SBHC utilization, likely contributed to BMI outcomes.

An approach to obesity management in primary care: yes, we can make a difference.

Obesity is a problem encountered in primary care on a daily basis. The author reviews the literature in the area of adolescent obesity and discusses an approach to managing obesity in the office, including screening for comorbidities and motivating teenagers to make lifestyle changes. Medications used for the treatment of comorbidities are reviewed also.

Treatment of non-alcoholic fatty liver disease with metformin versus lifestyle intervention in insulin-resistant adolescents.

The presence of fatty liver per ultrasound and liver-associated enzymes were measured in a select cohort of youth with both obesity and insulin resistance, and the effect of metformin on these parameters evaluated. Fifty obese, multiethnic, insulin-resistant adolescents (mean age 15.1 yr, mean body mass index 39.8 kg/m2) were randomized to receive lifestyle recommendations plus either twice per day doses of 850 mg of metformin or placebo. Fasting and post-glucose challenge biochemistries and liver ultrasounds were compared at baseline and 6 months. The prevalence of fatty liver was 74%, elevated alanine aminotransferase (ALT) 14%, aspartate aminotransferase (AST) 14%, and gamma-glutamyl transferase (GGT) 17%. Fatty liver was mild in 23%, moderate in 31%, and severe in 46%. Fatty liver was more common in male and Hispanic subjects and elevated ALT more common in Hispanic subjects. Subjects with fatty liver appeared more insulin resistant (higher fasting insulin and triglycerides, lower high-density lipoprotein cholesterol) and had higher ALT and AST. At 6 months, mean ALT, GGT, and fasting insulin improved significantly in all subjects. Fatty liver prevalence (p < 0.04), severity (p < 0.04), and fasting insulin (p < 0.025) improved significantly with metformin compared to placebo. Non-alcoholic fatty liver disease (NAFLD) occurs with a high prevalence and severity in obese, insulin-resistant adolescents. While metformin plus lifestyle intervention appears promising, defining NAFLD therapies capable of preventing fibrosis and cirrhosis requires further study.

Presence of the metabolic syndrome in obese adolescents predicts impaired glucose tolerance and nonalcoholic fatty liver disease.

PURPOSE: To evaluate whether the presence of metabolic syndrome (MS) in obese adolescents is associated with other comorbidities of obesity METHODS: A total of 85 obese teens (70% female and 30% male) with fasting insulin >25 microU/ml and family history of type 2 diabetes mellitus and/or acanthosis nigricans were studied. Mean age was 15.8 +/- 1.7 years and body mass index (BMI) was 39.3 +/- 6.6 kg/m(2). Of the subjects, 54% were Hispanic and 35% black, 5% white, 5% American Indian, and 1% Asian. Laboratory analysis included fasting lipids, glucose, gamma-glutamyl transpeptidase (GGT), and oral glucose tolerance testing. Additional liver transaminase levels were determined and liver ultrasound (US) was performed to evaluate the presence and severity of fatty liver. RESULTS: All subjects met MS criteria for children for waist circumference, 49% for blood pressure, 54% for high-density lipoprotein, 54% for triglycerides, and 20% for impaired fasting glucose (IFG) or impaired glucose tolerance [IGT]). In all, 47 subjects had three or more MS criteria. BMI was no different between groups with and without MS. Subjects with three or more MS criteria were more likely to have IGT (p = .004), elevated alanine aminotransferase (p = .039), elevated GGT (p = .036), fatty liver on US (p < .001), and more severe fatty liver (p = .001). CONCLUSIONS: Abnormal glucose regulation and evidence of nonalcoholic fatty liver disease (NAFLD) were more common in subjects meeting three criteria for MS than in those meeting fewer criteria. The identification of MS provides value to the primary care provider. Those patients meeting criteria for MS should be evaluated for glucose intolerance and NAFLD.

Addition of metformin to a lifestyle modification program in adolescents with insulin resistance.

OBJECTIVE: To evaluate whether metformin, when added to a program of personal goal setting, improves weight loss and clinical status in obese adolescents. STUDY DESIGN: In a randomized double-blind placebo controlled trial, 85 adolescents with insulin resistance were randomized to receive metformin (70%) or placebo (30%), along with monthly goal setting for diet and exercise modification. Anthropometric measures, fasting blood analysis, and glucose tolerance tests were performed at baseline and 6 months. RESULTS: Mean age was 15.7 years. Mean body mass index (BMI) was 39.7 kg/m(2). 71% were female, 58% were Hispanic, and 34% were African-American. 76% of participants completed the study. Goal setting alone did not result in significant weight loss. In addition, there were no group differences between metformin and placebo in weight loss or measures of glucose metabolism. However, among females taking metformin, there was a significant decrease in BMI not seen in the placebo group. Furthermore, metformin adherence, when accompanied by lifestyle change, was a predictor of BMI decrease of 5% or more. 60% of 10 subjects who adhered to metformin and decreased portion size decreased BMI by >5%. CONCLUSIONS: In this group of predominately minority adolescents, monthly goal setting alone did not lead to weight loss. Although the addition of metformin had no effect on weight loss overall, the agent did significantly increase weight loss among females and weight loss was predicted by degree of metformin adherence. However, weight loss was only found in those participants also reporting lifestyle change, particularly a decrease in portion sizes. These results suggest that metformin may be a useful agent to promote short-term weight loss among girls making modest lifestyle changes.

Elevated fasting triglycerides predict impaired glucose tolerance in adolescents at risk for type 2 diabetes.

OBJECTIVE: The aim of this study was to evaluate whether fasting laboratory values can predict impaired glucose tolerance (IGT) in adolescents who are at risk for developing type 2 diabetes mellitus (T2DM). HYPOTHESIS: Elevated fasting triglycerides, a marker for worsening insulin resistance, predict risk for IGT. DESIGN: Following a fast of at least 9 h, laboratory measures, body mass index (BMI), and demographic information were obtained. The subjects then underwent a 75-g oral glucose challenge with a 2-h postchallenge glucose determination. SUBJECTS: Eighty-four adolescents aged 12-20 yr with at least two risk factors for developing T2DM (obesity, family history of T2DM, or acanthosis nigricans) and with either a fasting insulin level > or =25 microU/mL or a homeostasis model assessment of insulin resistance (HOMA-IR) > or =3.5 were recruited for the study. RESULTS: Ten subjects (12%) had IGT [2-h glucose > or =140 mg/dL (7.77 mmol/L)], and 10 subjects (12%) had impaired fasting glucose [IFG; fasting glucose > or =100 mg/dL (5.55 mmol/L)]. However, only three (30%) subjects with IGT had IFG, though all subjects with IGT had a fasting triglyceride level > or =150 mg/dL (1.70 mmol/L). Of those subjects with elevated triglycerides, 29% had IGT. As a screening test to predict risk for IGT, elevated triglycerides >150 mg/dL had a sensitivity of 100% and a specificity of 68%. The positive predictive value was 29%, and the negative predictive value was 100%. CONCLUSIONS: Screening with fasting glucose alone would have missed 70% of subjects with IGT in this population of insulin-resistant adolescents. However, a fasting triglyceride level > or =150 mg/dL was strongly associated with IGT and may help to identify at-risk adolescents who should undergo formal glucose tolerance testing.