Alternative waist-to-height ratios associated with risk biomarkers in youth with diabetes: comparative models in the SEARCH for Diabetes in Youth Study.

BACKGROUND/OBJECTIVES: The waist-to-height ratio (WHtR) estimates cardiometabolic risk in youth without need for growth charts by sex and age. Questions remain about whether waist circumference measured per protocol of the National Health and Nutrition Examination Survey (WNHAHtR) or World Health Organization (WWHOHtR) can better predict blood pressures and lipid parameters in youth. PARTICIPANTS/METHODS: WHtR was measured under both anthropometric protocols among participants in the SEARCH Study, who were recently diagnosed with diabetes (ages 5-19 years; N = 2 773). Biomarkers were documented concurrently with baseline anthropometry and again ~7 years later (ages 10-30 years; N = 1 712). For prediction of continuous biomarker outcomes, baseline WNHAHtR or WWHOHtR entered semiparametric regression models employing restricted cubic splines. To predict binary biomarkers (high-risk group defined as the most adverse quartile) linear WNHAHtR or WWHOHtR terms entered logistic models. Model covariates included demographic characteristics, pertinent medication use, and (for prospective predictions) the follow-up time since baseline. We used measures of model fit, including the adjusted-R2 and the area under the receiver operator curves (AUC) to compare WNHAHtR and WWHOHtR. RESULTS: For the concurrent biomarkers, the proportion of variation in each outcome explained by full regression models ranged from 23 to 46%; for the prospective biomarkers, the proportions varied from 11 to 30%. Nonlinear relationships were recognized with the lipid outcomes, both at baseline and at follow-up. In full logistic models, the AUCs ranged from 0.75 (diastolic pressure) to 0.85 (systolic pressure) at baseline, and from 0.69 (triglycerides) to 0.78 (systolic pressure) at the prospective follow-up. To predict baseline elevations of the triglycerides/HDL cholesterol ratio, the AUC was 0.816 for WWHOHtR compared with 0.810 for WNHAHtR (p = 0.003), but otherwise comparisons between alternative WHtR protocols were not significantly different. CONCLUSIONS: Among youth with recently diagnosed diabetes, measurements of WHtR by either waist circumference protocol similarly helped estimate current and prospective cardiometabolic risk biomarkers.

Food insecurity is associated with high risk glycemic control and higher health care utilization among youth and young adults with type 1 diabetes.

AIMS: Household food insecurity (FI), i.e., limited availability of nutritionally adequate foods, is associated with poor glycemic control among adults with type 2 diabetes. We evaluated the association of FI among youth and young adults (YYA) with type 1 diabetes to inform recent clinical recommendations from the American Diabetes Association for providers to screen all patients with diabetes for FI. METHODS: Using data from the Washington and South Carolina SEARCH for Diabetes in Youth Study sites, we conducted an observational, cross-sectional evaluation of associations between FI and glycemic control, hospitalizations, and emergency department (ED) visits among YYA with type 1 diabetes. FI was assessed using the Household Food Security Survey Module, which queries conditions and behaviors typical of households unable to meet basic food needs. Participants' HbA1c were measured from blood drawn at the research visit; socio-demographics and medical history were collected by survey. RESULTS: The prevalence of FI was 19.5%. In adjusted logistic regression analysis, YYAs from food-insecure households had 2.37 higher odds (95% CI: 1.10, 5.09) of high risk glycemic control, i.e., HbA1c >9.0%, vs. peers from food-secure households. In adjusted binomial regression analysis for ED visits, YYAs from food-insecure households had an adjusted prevalence rate that was 2.95 times (95% CI [1.17, 7.45]) as great as those from food secure households. CONCLUSIONS: FI was associated with high risk glycemic control and more ED visits. Targeted efforts should be developed and tested to alleviate FI among YYA with type 1 diabetes.

Can preeclampsia be considered a renal compartment syndrome? A hypothesis and analysis of the literature.

The morbidity and mortality associated with preeclampsia is staggering. The physiology of the Page kidney, a condition in which increased intrarenal pressure causes hypertension, appears to provide a unifying framework to explain the complex pathophysiology. Page kidney hypertension is renin-mediated acutely and ischemia-mediated chronically. Renal venous outflow obstruction also causes a Page kidney phenomenon, providing a hypothesis for the increased vulnerability of a subset of women who have what we are hypothesizing is a "renal compartment syndrome" due to inadequate ipsilateral collateral renal venous circulation consistent with well-known variation in normal venous anatomy. Dynamic changes in renal venous anatomy and physiology in pregnancy appear to correlate with disease onset, severity, and recurrence. Since maternal recumbent position is well known to affect renal perfusion and since chronic outflow obstruction makes women vulnerable to the ischemic/inflammatory sequelae, heightened awareness of renal compartment syndrome physiology is critical. The anatomic and physiologic insights provide immediate strategies to predict and prevent preeclampsia with straightforward, low-cost interventions that make renewed global advocacy for pregnant women a realistic goal.

Comparing Two Waist-to-Height Ratio Measurements with Cardiometabolic Risk Factors among Youth with Diabetes.

BACKGROUND: Waist circumference (WC) is commonly measured by either the World Health Organization (WHO) or National Health and Nutrition Examination Survey (NHANES) protocol. OBJECTIVE: Compare the associations of WHO vs. NHANES WC-to-height ratio (WHtR) protocols with cardiometabolic risk factors (CMRFs) in a sample of youth with diabetes. METHODS: For youth (10-19 years old with type 1 [N=3082] or type 2 [N=533] diabetes) in the SEARCH for Diabetes in Youth Study, measurements were obtained of WC (by two protocols), weight, height, fasting lipids (total cholesterol, triglycerides, HDL cholesterol, Non-HDL cholesterol) and blood pressures. Associations of CMRFs with WHO and NHANES WHtR were modeled stratified by body mass index (BMI) percentiles for age/sex: lower BMI (<85th BMI percentile; N=2071) vs. higher BMI (≥85th percentile; N=1594). RESULTS: Among lower-BMI participants, both NHANES and WHO WHtR were associated (p<0.005) with all CMRFs except blood pressure. Among higher-BMI participants, both NHANES and WHO WHtR were associated (p<0.05) with all CMRFs. WHO WHtR was more strongly associated (p<0.05) than NHANES WHtR with triglycerides, non-HDL cholesterol, and systolic blood pressure in lower-BMI participants. Among high-BMI participants, WHO WHtR was more strongly associated (p<0.05) than NHANES WHtR with triglycerides and systolic blood pressure. CONCLUSION: Among youth with diabetes, WHtR calculated from either WC protocol captures cardiometabolic risk. The WHO WC protocol may be preferable to NHANES WC.

Prevalence of type 1 and type 2 diabetes among children and adolescents from 2001 to 2009.

IMPORTANCE: Despite concern about an "epidemic," there are limited data on trends in prevalence of either type 1 or type 2 diabetes across US race and ethnic groups. OBJECTIVE: To estimate changes in the prevalence of type 1 and type 2 diabetes in US youth, by sex, age, and race/ethnicity between 2001 and 2009. DESIGN, SETTING, AND PARTICIPANTS: Case patients were ascertained in 4 geographic areas and 1 managed health care plan. The study population was determined by the 2001 and 2009 bridged-race intercensal population estimates for geographic sites and membership counts for the health plan. MAIN OUTCOMES AND MEASURES: Prevalence (per 1000) of physician-diagnosed type 1 diabetes in youth aged 0 through 19 years and type 2 diabetes in youth aged 10 through 19 years. RESULTS: In 2001, 4958 of 3.3 million youth were diagnosed with type 1 diabetes for a prevalence of 1.48 per 1000 (95% CI, 1.44-1.52). In 2009, 6666 of 3.4 million youth were diagnosed with type 1 diabetes for a prevalence of 1.93 per 1000 (95% CI, 1.88-1.97). In 2009, the highest prevalence of type 1 diabetes was 2.55 per 1000 among white youth (95% CI, 2.48-2.62) and the lowest was 0.35 per 1000 in American Indian youth (95% CI, 0.26-0.47) and type 1 diabetes increased between 2001 and 2009 in all sex, age, and race/ethnic subgroups except for those with the lowest prevalence (age 0-4 years and American Indians). Adjusted for completeness of ascertainment, there was a 21.1% (95% CI, 15.6%-27.0%) increase in type 1 diabetes over 8 years. In 2001, 588 of 1.7 million youth were diagnosed with type 2 diabetes for a prevalence of 0.34 per 1000 (95% CI, 0.31-0.37). In 2009, 819 of 1.8 million were diagnosed with type 2 diabetes for a prevalence of 0.46 per 1000 (95% CI, 0.43-0.49). In 2009, the prevalence of type 2 diabetes was 1.20 per 1000 among American Indian youth (95% CI, 0.96-1.51); 1.06 per 1000 among black youth (95% CI, 0.93-1.22); 0.79 per 1000 among Hispanic youth (95% CI, 0.70-0.88); and 0.17 per 1000 among white youth (95% CI, 0.15-0.20). Significant increases occurred between 2001 and 2009 in both sexes, all age-groups, and in white, Hispanic, and black youth, with no significant changes for Asian Pacific Islanders and American Indians. Adjusted for completeness of ascertainment, there was a 30.5% (95% CI, 17.3%-45.1%) overall increase in type 2 diabetes. CONCLUSIONS AND RELEVANCE: Between 2001 and 2009 in 5 areas of the United States, the prevalence of both type 1 and type 2 diabetes among children and adolescents increased. Further studies are required to determine the causes of these increases.

Partnering for success and sustainability in community-based child obesity intervention: seeking to help families ACT!

Sustaining community-based obesity interventions for families represents an ongoing challenge. Many initially grant-funded initiatives lack a sustainable model to continue. After initial grant funding ended, we continued a partnership between Seattle Children's Hospital and YMCA of Greater Seattle to enhance and expand a community-based family obesity program, "ACT! Actively Changing Together." We used principles of continuous process improvement, community-based participatory research, and the RE-AIM framework to successfully transition from a grant-funded to a community-supported program. Our pilot evaluation demonstrated promising results in parent behaviors, youth quality of life, ongoing family participation at the Y, and youth body mass index.

Understanding family motivations and barriers to participation in community-based programs for overweight youth: one program model does not fit all.

CONTEXT: Successful obesity intervention efforts depend on effective recruitment and retention, an ongoing challenge for community-based programs. OBJECTIVE: We sought to provide insights into the most salient factors affecting family enrollment and retention in community-based programs for overweight youth and their families. We especially sought to understand potentially modifiable program factors affecting participation. DESIGN: : We conducted semistructured, in-depth, face-to-face interviews with parents of overweight children within 1 year of referral to a public health grant-funded community-based healthy lifestyle promotion program. Purposeful sampling was used to select participants across program sites, by level of program completion, and child age and sex. Transcribed interviews were coded independently by 2 staff with a structured codebook and then analyzed by themes through an iterative process using Atlas.ti. The Integrative Model of Behavior served as an orienting theoretical framework. SETTING: Community-based child obesity intervention program in King County, Washington. PARTICIPANTS: Twenty-three parents from diverse socioeconomic backgrounds were interviewed, of which 10 completed the program, 9 did not complete, and 4 did not enroll. MAIN OUTCOME MEASURE(S): Parent-reported factors related to enrollment and retention. RESULTS: Key parent reasons for program enrollment included: (a) addressing both eating and activity, (b) concern about child's weight, (c) seeking help outside the family, and (d) structured parent-child time. Parents perceived a lack of child motivation to enroll; some youth initially opposed attending, which was overcome through positive program experience. All families described barriers to attending, and some identified specific strategies or skills they used to overcome barriers. No single program design emerged to address every family's needs. Instead, using the themes of accessibility and accountability, we present parent- recommended design options. CONCLUSIONS: To meet different families' needs, public health and health care agencies offering youth health promotion programs should consider providing program options that vary intensity level and weight loss emphasis.

Projections of type 1 and type 2 diabetes burden in the U.S. population aged <20 years through 2050: dynamic modeling of incidence, mortality, and population growth.

OBJECTIVE: To forecast the number of U.S. individuals aged <20 years with type 1 diabetes mellitus (T1DM) or type 2 diabetes mellitus (T2DM) through 2050, accounting for changing demography and diabetes incidence. RESEARCH DESIGN AND METHODS: We used Markov modeling framework to generate yearly forecasts of the number of individuals in each of three states (diabetes, no diabetes, and death). We used 2001 prevalence and 2002 incidence of T1DM and T2DM from the SEARCH for Diabetes in Youth study and U.S. Census Bureau population demographic projections. Two scenarios were considered for T1DM and T2DM incidence: 1) constant incidence over time; 2) for T1DM yearly percentage increases of 3.5, 2.2, 1.8, and 2.1% by age-groups 0-4 years, 5-9 years, 10-14 years, and 15-19 years, respectively, and for T2DM a yearly 2.3% increase across all ages. RESULTS: Under scenario 1, the projected number of youth with T1DM rises from 166,018 to 203,382 and with T2DM from 20,203 to 30,111, respectively, in 2010 and 2050. Under scenario 2, the number of youth with T1DM nearly triples from 179,388 in 2010 to 587,488 in 2050 (prevalence 2.13/1,000 and 5.20/1,000 [+144% increase]), with the greatest increase in youth of minority racial/ethnic groups. The number of youth with T2DM almost quadruples from 22,820 in 2010 to 84,131 in 2050; prevalence increases from 0.27/1,000 to 0.75/1,000 (+178% increase). CONCLUSIONS: A linear increase in diabetes incidence could result in a substantial increase in the number of youth with T1DM and T2DM over the next 40 years, especially those of minority race/ethnicity.

Obesity in pediatric specialty clinics: an underestimated comorbidity.

OBJECTIVES: (a) To examine the prevalence of obesity across 31 subspecialties in a tertiary care children's hospital and (b) to examine the percentage of obesity-specified diagnosis codes used for obese patient visits. METHODS: We analyzed 48 479 youth aged 2 to 18 years in 31 outpatient subspecialty clinics at Seattle Children's Hospital between 2005 and 2007. Body mass index (BMI) percentiles were determined by age- and gender-adjusted BMI calculated from height/weight obtained at clinic visits. For obese patients, the percentage of diagnoses coded as obesity-specific (278.11, 278.01, 272.02, 783.1) were determined by evaluation of standard diagnostic codes. RESULTS: Twenty-two of the 31 clinics had patient obesity rates greater than 15%. Analysis of International Classification of Diseases, 9th Revision, codes for obese patient visits as defined by BMI revealed only 2 clinics used obesity-specific codes for >5% of all diagnoses. CONCLUSIONS: Given the prevalence of obesity across all subspecialties, more recognition and resources are needed to screen, diagnosis, and provide coordinated services for healthy weight management.

Prevalence of overweight and obesity in youth with diabetes in USA: the SEARCH for Diabetes in Youth study.

OBJECTIVE: Obesity's association with type 2 diabetes (T2DM) is well established, but is less clear with type 1 diabetes (T1DM). We calculated the prevalence of overweight and obesity among diabetic youth in the USA from a six-center, population-based study of racially and ethnically diverse youth with diabetes, and we compared these rates with estimates among nondiabetic youth. DESIGN/SETTING: Diabetic participants were examined in 2001-2004 for the SEARCH for Diabetes in Youth study (SEARCH) and nondiabetic participants were examined during the same years of the National Health and Nutrition Examination Survey (NHANES). PARTICIPANTS: 3953 diabetic youth and 7666 nondiabetic youth aged 3-19 yr. MAIN OUTCOME MEASURES: Overweight was defined as body mass index (BMI) from the 85th to <95th percentile for age and sex and obesity defined as > or = 95th percentile. Diabetes type was categorized as T1DM or T2DM based on physician diagnosis. RESULTS: Among youth with T2DM, the prevalence of overweight was 10.4% and obesity was 79.4%. Among youth with T1DM, 22.1% were overweight. The prevalence of overweight among youth with T1DM was higher than among those without diabetes overall (22.1% vs. 16.1%) (P <.05). The obesity rate for T1DM was 12.6% overall (range Non-Hispanic White 10.7%-African-American 20.1%). CONCLUSIONS: As expected, most of the youth with T2DM were obese. Youth with T1DM had a higher prevalence of overweight, but not of obesity, than nondiabetic youth. Future studies of obesity among youth with diabetes of all types will further our understanding of the impact of obesity on diabetes both as a risk factor and a comorbidity.

Small steps to health: building sustainable partnerships in pediatric obesity care.

BACKGROUND: Given the prevalence of childhood obesity and the limited support for preventing and managing obesity in primary care settings, the Seattle Children's Hospital's Children's Obesity Action Team has partnered with Steps to Health King County to develop a pediatric obesity quality-improvement project. METHODS: Primary care clinics joined year-long quality-improvement collaboratives to integrate obesity prevention and management into the clinic setting by using the chronic-disease model. Sustainability was enhanced through integration at multiple levels by emphasizing small, consistent behavior changes and self-regulation of eating/feeding practices with children, teenagers, and families; building local community partnerships; and encouraging broader advocacy and policy change. Cultural competency and attention to disparities were integrated into quality-improvement efforts. RESULTS: . Participating clinics were able to increase BMI measurement and weight classification; integrate management of overweight/obese children and family and self-management support; and grow community collaborations. Over the course of 4 years, this project grew from a local effort involving 3 clinics to a statewide program recently adopted by the Washington State Department of Health. CONCLUSIONS: This model can be used by other states/regions to develop pediatric obesity quality-improvement programs to support the assessment, prevention, and management of childhood obesity. Furthermore, these health care efforts can be integrated into broader community-wide childhood-obesity action plans.

Diabetes in non-Hispanic white youth: prevalence, incidence, and clinical characteristics: the SEARCH for Diabetes in Youth Study.

OBJECTIVE: To investigate the incidence, prevalence, and clinical characteristics of diabetes among U.S. non-Hispanic white (NHW) youth. RESEARCH DESIGN AND METHODS: Data from the SEARCH for Diabetes in Youth Study (SEARCH study), a multicenter study of diabetes among youth aged 0-19 years, were examined. Incidence rates were calculated per 100,000 person-years across 4 incident years (2002-2005), and prevalence in 2001 was calculated per 1,000 youths. Information obtained by questionnaire, physical examination, and blood and urine collection was analyzed to describe the characteristics of youth who completed an in-person visit. RESULTS: The prevalence of type 1 diabetes (at ages 0-19 years) was 2.00/1,000, which was similar for male (2.02/1,000) and female (1.97/1,000) subjects. The incidence of type 1 diabetes was 23.6/100,000, slightly higher for male compared with female subjects (24.5 vs. 22.7 per 100,000, respectively, P = 0.04). Incidence rates of type 1 diabetes among youth aged 0-14 years in the SEARCH study are higher than all previously reported U.S. studies and many European studies. Few cases of type 2 diabetes in youth aged <10 years were found. The prevalence of type 2 diabetes (at ages 10-19 years) was 0.18/1,000, which is significantly higher for female compared with male subjects (0.22 vs. 0.15 per 1,000, P = 0.01). Incidence of type 2 diabetes was 3.7/100,000, with similar rates for female and male subjects (3.9 vs. 3.4 per 1,000, respectively, P = 0.3). High levels of abnormal cardiometabolic and behavioral risk factor profiles were common among youth with both type 1 and type 2 diabetes. For example, within each of four age-groups for youth with type 1 diabetes and two age-groups for youth with type 2 diabetes, >40% had elevated LDL cholesterol, and <3% of youth aged >10 years met current recommendations for intake of saturated fat. Among youth aged >or=15 years, 18% with type 1 and 26% with type 2 diabetes were current smokers. CONCLUSIONS: The SEARCH study is one of the most comprehensive studies of diabetes in NHW youth. The incidence of type 1 diabetes in NHW youth in the U.S. is one of the highest in the world. While type 2 diabetes is still relatively rare, rates are several-fold higher than those reported by European countries. We believe efforts directed at improving the cardiometabolic and behavioral risk factor profiles in this population are warranted.

Type 1 and Type 2 diabetes in Asian and Pacific Islander U.S. youth: the SEARCH for Diabetes in Youth Study.

OBJECTIVE: Given limited reports on diabetes among U.S. Asian and Pacific Islander youth, we describe the clinical characteristics, incidence, and prevalence of diabetes among Asian, Pacific Islander, and mixed Asian-Pacific Islander youth. RESEARCH DESIGN AND METHODS: Data were collected from 245 Asian, Pacific Islander, and Asian-Pacific Islander participants in the SEARCH for Diabetes in Youth Study, a population-based study of diabetes in youth (aged <20 years). Additionally, we estimated the incidence and prevalence of type 1 and type 2 diabetes for Asian, Pacific Islander, and Asian-Pacific Islander youth combined. RESULTS: Most participants with type 2 diabetes were obese (range Asian 71% to Pacific Islander 100%) with mean BMI >33 kg/m(2). In those with type 1 diabetes, Pacific Islanders were more likely to be obese, with a mean BMI of 26 vs. 20 kg/m(2) for Asian and Asian-Pacific Islander youth (P < 0.0001). The incidence of type 1 diabetes for youth aged 0-9 years was 6.4 per 100,000 person-years and 7.4 per 100,000 person-years for youth aged 10-19 years. The incidence of type 2 diabetes was 12.1 per 100,000 person-years for youth aged 10-19 years. CONCLUSIONS: While Asian and Asian-Pacific Islanders with type 1 and type 2 diabetes had lower mean BMIs than Pacific Islanders, all Asian, Pacific Islander, and Asian-Pacific Islanders with type 2 diabetes had mean BMIs above adult ethnicity-specific definitions of obesity. While the majority of Asian, Pacific Islander, and Asian-Pacific Islander youth had type 1 diabetes, older Asian, Pacific Islander, and Asian-Pacific Islander youth (aged 10-19 years) have an incidence of type 2 diabetes almost double that of type 1 diabetes. Public health efforts to prevent type 2 diabetes and obesity in Asian, Pacific Islander, and Asian-Pacific Islander adolescents are needed.

Incidence of diabetes in youth in the United States.

CONTEXT: Data on the incidence of diabetes mellitus (DM) among US youth according to racial/ethnic background and DM type are limited. OBJECTIVE: To estimate DM incidence in youth aged younger than 20 years according to race/ethnicity and DM type. DESIGN, SETTING, AND PARTICIPANTS: A multiethnic, population-based study (The SEARCH for Diabetes in Youth Study) of 2435 youth with newly diagnosed, nonsecondary DM in 2002 and 2003, ascertained at 10 study locations in the United States, covering a population of more than 10 million person-years. MAIN OUTCOME MEASURE: Incidence rates by age group, sex, race/ethnicity, and DM type were calculated per 100,000 person-years at risk. Diabetes mellitus type (type 1/type 2) was based on health care professional assignment and, in a subset, further characterized with glutamic acid decarboxylase (GAD65) autoantibody and fasting C peptide measures. RESULTS: The incidence of DM (per 100,000 person-years) was 24.3 (95% confidence interval [CI], 23.3-25.3). Among children younger than 10 years, most had type 1 DM, regardless of race/ethnicity. The highest rates of type 1 DM were observed in non-Hispanic white youth (18.6, 28.1, and 32.9 for age groups 0-4, 5-9, and 10-14 years, respectively). Even among older youth (> or =10 years), type 1 DM was frequent among non-Hispanic white, Hispanic, and African American adolescents. Overall, type 2 DM was still relatively infrequent, but the highest rates (17.0 to 49.4 per 100,000 person-years) were documented among 15- to 19-year-old minority groups. CONCLUSIONS: Our data document the incidence rates of type 1 DM among youth of all racial/ethnic groups, with the highest rates in non-Hispanic white youth. Overall, type 2 DM is still relatively infrequent; however, the highest rates were observed among adolescent minority populations.

The burden of diabetes mellitus among US youth: prevalence estimates from the SEARCH for Diabetes in Youth Study.

OBJECTIVE: Our goal was to estimate the prevalence of diabetes mellitus in youth <20 years of age in 2001 in the United States, according to age, gender, race/ethnicity, and diabetes type. METHODS: The SEARCH for Diabetes in Youth Study is a 6-center observational study conducting population-based ascertainment of physician-diagnosed diabetes in youth. Census-based denominators for 4 geographically based centers and enrollment data for 2 health plan-based centers were used to calculate prevalence. Age-, gender-, and racial/ethnic group-specific prevalence rates were multiplied by US population counts to estimate the total number of US youth with diabetes. RESULTS: We identified 6379 US youth with diabetes in 2001, in a population of approximately 3.5 million. Crude prevalence was estimated as 1.82 cases per 1000 youth, being much lower for youth 0 to 9 years of age (0.79 cases per 1000 youth) than for those 10 to 19 years of age (2.80 cases per 1000 youth). Non-Hispanic white youth had the highest prevalence (1.06 cases per 1000 youth) in the younger group. Among 10- to 19-year-old youth, black youth (3.22 cases per 1000 youth) and non-Hispanic white youth (3.18 cases per 1000 youth) had the highest rates, followed by American Indian youth (2.28 cases per 1000 youth), Hispanic youth (2.18 cases per 1000 youth), and Asian/Pacific Islander youth (1.34 cases per 1000 youth). Among younger children, type 1 diabetes accounted for > or = 80% of diabetes; among older youth, the proportion of type 2 diabetes ranged from 6% (0.19 cases per 1000 youth for non-Hispanic white youth) to 76% (1.74 cases per 1000 youth for American Indian youth). We estimated that 154,369 youth had physician-diagnosed diabetes in 2001 in the United States. CONCLUSIONS: The overall prevalence estimate for diabetes in children and adolescents was approximately 0.18%. Type 2 diabetes was found in all racial/ethnic groups but generally was less common than type 1, except in American Indian youth.

Prevalence of cardiovascular disease risk factors in U.S. children and adolescents with diabetes: the SEARCH for diabetes in youth study.

OBJECTIVE: The purpose of this study was to determine the prevalence and correlates of selected cardiovascular disease (CVD) risk factors among youth aged <20 years with diabetes. RESEARCH DESIGN AND METHODS: The analysis included 1,083 girls and 1,013 boys examined as part of the SEARCH for Diabetes in Youth study, a multicenter, population-based study of youth 0-19 years of age with diabetes. Diabetes type was determined by a biochemical algorithm based on diabetes antibodies and fasting C-peptide level. CVD risk factors were defined as follows: HDL cholesterol <40 mg/dl; age- and sex-specific waist circumference >90th percentile; systolic or diastolic blood pressure >90th percentile for age, sex, and height or taking medication for high blood pressure; and triglycerides >110 mg/dl. RESULTS: The prevalence of having at least two CVD risk factors was 21%. The prevalence was 7% among children aged 3-9 years and 25% in youth aged 10-19 years (P < 0.0001), 23% among girls and 19% in boys (P = 0.04), 68% in American Indians, 37% in Asian/Pacific Islanders, 32% in African Americans, 35% in Hispanics, and 16% in non-Hispanic whites (P < 0.0001). At least two CVD risk factors were present in 92% of youth with type 2 and 14% of those with type 1A diabetes (P < 0.0001). In multivariate analyses, age, race/ethnicity, and diabetes type were independently associated with the odds of having at least two CVD risk factors (P < 0.0001). CONCLUSIONS: Many youth with diabetes have multiple CVD risk factors. Recommendations for weight, lipid, and blood pressure control in youth with diabetes need to be followed to prevent or delay the development of CVD as these youngsters mature.

Use of a respiratory clinical score among different providers.

Respiratory assessment of children with asthma or bronchiolitis is problematic because both the components of the assessment and their relative importance vary among care providers. Use of a systematic standard assessment process and clinical score may reduce interobserver variation. Our objective was to determine observer agreement among physicians (MD), nurses (RN), and respiratory therapists (RT), using a standard respiratory clinical score. A clinical score was developed incorporating four physiologic parameters: respiratory rate, retractions, dyspnea, and auscultation. One hundred and sixty-five provider pairs (e.g., MD-MD, RN-RT) independently assessed a total of 55 patients admitted for asthma, bronchiolitis, or wheezing at an urban tertiary-care hospital. A weighted kappa statistic measured agreement beyond chance. Rater pairs had high observed agreement on total score of 82-88% and weighted kappas ranging from 0.52 (MD-RN; 95% CI, 0.19, 0.79) to 0.65 (RN-RN; 95% CI, 0.46, 0.87). Observed agreement on individual components of the score ranged from 58% (auscultation) to 74% (dyspnea), with unweighted kappas of 0.36 (respiratory rate; 95% CI, 0.26, 0.46) to 0.53 (dyspnea; 95% CI, 0.41, 0.65). In conclusion, this respiratory clinical score demonstrates good interobserver agreement between MDs, RNs, and RTs. Future research is needed to examine validity and responsiveness in clinical settings. By standardizing respiratory assessments, use of a clinical score may facilitate care coordination by physicians, nurses, and respiratory therapists and thereby improve care of children hospitalized with asthma and bronchiolitis.