Metabolic syndrome also is a growing health concern in the United States and around the world, according to Carakushansky.
“With the global epidemic of childhood obesity, there is growing concern that the metabolic complications associated with obesity, such as insulin resistance/type 2 diabetes and hyperlipidemia, are on the rise in the pediatric population,” Carakushansky says. “People with metabolic syndrome can have diabetes, and vice versa. Both are risk factors for cardiovascular disease and both are closely associated with obesity.”
The most common medical comorbidities associated with obesity include metabolic risk factors for type 2 diabetes—high blood pressure, high cholesterol, impaired glucose tolerance; and metabolic syndrome—according to a review published in 2014.5
Metabolic syndrome, or insulin-resistance syndrome, is closely tied to prediabetes and type 2 diabetes development, according to Ismail. The body’s attempt to compensate for increased insulin demands and decreased insulin sensitivity, secondary to weight gain and physical inactivity, often is a losing battle. The beta cells cannot keep up with increased insulin demands, which increases risks for progression to prediabetes and diabetes, she says.
“Losing weight and exercising can reverse insulin resistance and help prevent or delay development of obesity-related type 2 diabetes in children and adolescents at risk for diabetes. Therefore, it is crucial that pediatricians emphasize the importance of and counsel patients on maintaining a healthy weight and exercising daily,” Ismail says.
Cooke says a takeaway from this study is that the same aspects about metabolic syndrome in adults pertain to children.
“The fact that adults with metabolic syndrome have an increased risk of diabetes is also true in kids. This isn’t earth-shaking news. We’ve known that kids with metabolic syndrome are at risk for type 2 diabetes, so this just reinforces that this similarity also pertains to the general magnitude risk of dysglycemia,” Cooke says.
The study, according to Cooke, should reassure primary care providers that risk identification with A1C seems to be as useful as gold-standard tests and is a lot easier to do.
“The accuracy—the positive predictive value and negative predictive value of the area under the curve—seems to be better with the A1C than with the actual glucose measures,” Cooke says. “The caveat there is that very small numbers of children were diagnosed, so I’m not sure that I would say with any degree of confidence that A1C is better as a predictor than those other tests, but it appears to be as good, at least in terms of how accurate it is.”
Pediatricians and others are still left with the uncertainty of how treatment might differ for a child identified as having prediabetes. Would it be different than how pediatricians would treat an overweight child?
“You’re still going to suggest that they lose weight and increase their activity level, but I don’t think we have enough data to say that you should start metformin on these individuals. So, I don’t know . . . if it changes recommendations on what you do with [patients with prediabetes],” Cooke says. “I think you can be honest with individuals that their risk of going on to develop diabetes is higher if they have A1C in that higher category than if their A1C is in a lower category. I haven’t seen any data to indicate that that information and knowledge alters the success of that individual losing weight and increasing [his/her] activity level.”
Lifestyle changes are considered the mainstay of prediabetes and metabolic syndrome management, Carakushansky says.
“The overweight or obese child with mild HbA1c elevation (between 5.7% and 5.9%) requires counseling on healthy diet and exercise along with additional labs (such as fasting glucose, insulin, and C-peptide) to determine if there is a state of insulin resistance. [Higher] HbA1c levels [at or greater than] 6.0% would require a more immediate referral to a pediatric endocrinologist,” Carakushansky says.
Pediatricians should reserve HbA1c screening for type 2 diabetes or prediabetes in asymptomatic children aged 10 years or older with a body mass index equal to or greater than the 85th percentile and have at least 2 additional type 2 diabetes risk factors. Those risk factors include type 2 diabetes in a first- or second-degree relative, being an at-risk minority race or ethnicity, having signs of insulin resistance, or maternal gestational diabetes, Carakushansky says.
One important note, according to Ismail: HbA1c is not reliable in patients with anemia or hemoglobinopathies, and in certain ethnic groups such as African, Mediterranean, and Southeast Asian populations.6
Drs Ismail, Cooke, Feiner, and Carakushansky have nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.
1. Vijayakumar P, Nelson RG, Hanson RL, Knowler WC, Sinha M. HbA1c and the prediction of type 2 diabetes in children and adults. Diabetes Care. 2017;40(1):16-21.
2. Gebel E. More kids than ever have type 2 diabetes. Diabetes Forecast. Available at: http://www.diabetesforecast.org/2012/nov/more-kids-than-ever-have-type-2-diabetes.html. Published November 2012.
3. Vijayakumar P, Wheelock KM, Kobes S, et al. Secular changes in physical growth and obesity among southwestern American Indian children over four decades. Pediatr Obes. December 6, 2016. Epub ahead of print.
4. American Diabetes Association. Statistics about diabetes. Overall numbers, diabetes and prediabetes. Available at: http://www.diabetes.org/diabetes-basics/statistics/. Last edited December 12, 2016. Accessed January 30, 2017.
5. Pulgaron ER, Delamater AM. Obesity and type 2 diabetes in children: epidemiology and treatment. Curr Diab Rep. 2014;14(8):508.
6. National Institute of Diabetes and Digestive and Kidney Diseases. For people of African, Mediterranean, or Southeast Asian heritage: important information about diabetes blood tests. Available at: https://www.niddk.nih.gov/health-information/health-topics/diagnostic-tests/people-african-mediterranean-southeast-asian-heritage-important-information-diabetes-blood-tests/Pages/index.aspx. Published October 2011. Accessed January 30, 2017.