Assessment of children at risk
Despite his reservation on the utility of using a diagnosis of prediabetes in children, Zeitler spent time addressing a main question that many clinicians have when considering how to assess the diabetes risk in children. That is: What is the best measure to use for this assessment? Table 1 lists the current measures used.
Saying there is a lot of noise in the literature about which test is better, Zeitler said that none of these current tests can be considered standard in children as they were developed to diagnose prediabetes in adults. “All the approaches we use for screening children for prediabetes are flawed in that they were extrapolated from adults,” he said.
With that understanding, he nonetheless noted that both a glucose tolerance test and A1c test can be used, as some people advocate, but he cautioned that such an approach is expensive “for what turns out to be a pretty rare disorder.”
Instead, Zeitler recommended using the A1c test, citing it as an imperfect but efficient test for evaluating high-risk kids. Table 2 lists several practical benefits of the A1c test over glucose tolerance testing. However, he also cautioned that, similar to measurement of glucose tolerance, the use of A1c is limited in that it will identify prediabetes in some kids but not others. “Both glucose tolerance testing and the A1c will identify overlapping but not identical populations,” he said, emphasizing the heterogeneity of children at risk of developing diabetes. Other disadvantages of the A1c test for which clinicians should be aware are listed in Table 2.
As to the value of measuring insulin, Zeitler recommended against it, saying it is a waste of time outside the research setting as it doesn’t provide any additional information about insulin resistance that is not already found on other labs. In addition, he cited problems with the test itself because it is not standardized and may measure insulin metabolites of uncertain significance, making it unreliable as a measure of insulin resistance. Also, he emphasized that the results of the test can be misleading as often insulin levels fall right before the onset of diabetes.
“I think there is a misunderstanding among pediatricians that they should be measuring insulin levels,” he said, “but it doesn’t tell you anything you need to know.”
Management of prediabetes
As to how to manage children at risk of developing diabetes, Zeitler emphasized one thing only: lose weight. “There is no magic to treating this,” he said. “It is weight loss.” The basic recipe to do this is to reduce caloric intake and increase caloric expenditure. Zeitler cited recommendations by an expert committee of the American Academy of Pediatrics (AAP) on the prevention, assessment, and treatment of overweight or obese children (Table 4).
Regarding the use of metformin, Zeitler emphatically discouraged its use, saying that there is no clear evidence for pharmacologic treatment of prediabetes in children. “A lot of people think they are supposed to [prescribe metformin], but there is no evidence supporting its use in kids,” he said.
Although some small studies suggest a minor benefit of metformin either alone or in conjunction with lifestyle interventions in select children, Zeitler underscored that the true benefit of metformin or any pharmacologic treatment of prediabetes in children needs to be weighed against the fact that most kids with high glucose or A1c levels will have spontaneous regression back to normal levels without any intervention.
“Progression rates of prediabetes are much different in children than in adults,” he said. “About 60% of kids with prediabetes will reverse on their own, so why would you start them on a drug?”
Unfortunately, Zeitler said, conducting a study to test the true benefit of metformin in children is almost impossible given this high incidence of spontaneous regression that would require a very large sample population.
To help pediatricians approach assessment and management of a child they suspect may have prediabetes, Zeitler offered a simple guide (Table 5). He underscored the need to avoid being too “glucose centric” and to recognize that prediabetes is frequently a transient disorder in children that may not require intervention. In addition, he stressed the importance of recognizing and evaluating the more common abnormalities associated with obesity, such as hypertension, hepatic steatosis, sleep disturbances, mood disorders, and other complications. Finally, he stressed the need to address obesity in all children through lifestyle intervention.
1. Zeitler P. Not yet diabetes: Assessing and managing children at risk (F4019). Presented at: American Academy of Pediatrics National Conference and Exhibition; September 19, 2017; Chicago, IL.