|Year : 2014 | Volume
| Issue : 4 | Page : 705-710
Early detection of diabetes mellitus in high-risk children
Soheir S Abou El-Ella, Maha A Tawfik, Sahar A Hewait
Department of Pediatric, Faculty of Medicine, Menoufia University, Menoufia, Egypt
|Date of Submission||10-Feb-2014|
|Date of Acceptance||10-Apr-2014|
|Date of Web Publication||22-Jan-2015|
Sahar A Hewait
Source of Support: None, Conflict of Interest: None
The aim of this study was to determine the value of glycosylated hemoglobin (HbA1c) as an early diagnostic marker for diabetes mellitus in high-risk groups such as relatives of diabetic patients (siblings) and obese children.
Diabetes mellitus is a chronic illness that requires continuing medical care and ongoing patient self-management education and support to prevent acute complications and reduce the risk of long-term complications.
Patients and methods
This study was conducted on 60 children attending the Genetic and Endocrine Unit of the Pediatric Department, Faculty of Medicine, Menoufia University.
They were divided into two groups: group I [45 children who were relatives of diabetic patients (siblings)] and group II (15 obese children).
The studied groups were subjected to detailed history taking, thorough clinical examination, anthropometric measurements, investigations (routine and special investigations through the estimation of HbA1c), and family counseling.
At the start, five (8.3%) children were in prediabetic stage (HbA1c level ranging between 5.7 and 6.4%); of them, two (4.4%) were relatives of diabetic patients and three (20%) children were from the obese group. At the end of the 3-month follow-up, with proper family counseling, a child from among the relatives of diabetic patients (2.2%) and another from the obese group (6.7%) were seen to have HbA1c within the normal range. At the end of 6 months of follow-up, one (6.7%) obese female patient was still in prediabetic stage.
The HbA1c test is an early detector of diabetes mellitus among high-risk groups. Prediabetes occurs because of the interaction between genetic and environmental factors. Controlling the environmental factors by proper family counseling can delay and even inhibit the emergence of diabetes.
Keywords: Diabetes mellitus, family counseling, HbA1c, prediabetes
|How to cite this article:|
Abou El-Ella SS, Tawfik MA, Hewait SA. Early detection of diabetes mellitus in high-risk children. Menoufia Med J 2014;27:705-10
| Introduction|| |
Type 1 diabetes is the most common endocrine-metabolic disorder of childhood and adolescence with important consequences for physical and emotional development. Most cases (95%) of type 1 diabetes mellitus are the result of environmental factors interacting with a genetically susceptible individual .
Type 2 diabetes encompasses individuals who have insulin resistance and usually have relative (rather than absolute) insulin deficiency at least initially, and often throughout their life time .
Childhood obesity can adversely affect almost every organ system and often has serious consequences, including hypertension, dyslipidemia, insulin resistance, and diabetes .
The etiologic process in type 2 diabetes mellitus begins with obesity and insulin resistance, which in turn leads to inflammation and destruction of the pancreatic b cells by various chemical mediators .
Prediabetes is a state characterized by the presence of antibodies against several islet cell antigens and preceding the clinical onset of diabetes by months or even years. Prediabetic patients should be informed of their increased risk for diabetes as well as cardiovascular diseases and counseled on effective strategies to lower their risks .
Glycosylated hemoglobin (HbA1c) is a form of hemoglobin that is measured primarily to identify the average plasma glucose concentration over prolonged periods of time. It is formed in a nonenzymatic glycation pathway by hemoglobin's exposure to plasma glucose. Normal levels of glucose produce a normal amount of glycated hemoglobin .
The HbA1c test is a widely used marker for chronic glycemia, reflecting average blood glucose levels over the preceding 2-3 months .
The aim of this work was to study the value of HbA1c as an early diagnostic marker for diabetes among high-risk children.
| Patients and methods|| |
This study was conducted on 60 children. They were selected from the Genetic and Endocrine Unit, Pediatric Department, Menoufia University Hospital.
They were divided into two groups. Group I comprised 45 children (siblings of diabetic patients), their ages ranged from 2 to 18 years (22 male patients and 23 female patients), and none of them had a history of diabetes. Group II included 15 obese children according to BMI percentiles, and their ages ranged from 3 to 16 years (six male patients and nine female patients).
All studied children were subjected to the following:
Detailed history taking, assessment of family pedigree, thorough clinical examination, anthropometric measurements (including weight, height, BMI, waist circumference, and waist-hip ratio), laboratory investigations, and family counseling.
Laboratory investigations including, routine [complete blood count, fasting and postprandial glucose level (mg/dl), blood urea and serum creatinine, alanine aminotransferase and aspartate aminotransferase, and thyroid stimulating hormone level] and special investigations through the estimation of HbA1c by affinity chromatography.
| Results|| |
The results of this study are illustrated in [Table 1],[Table 2],[Table 3],[Table 4] and [Table 5].
- An overall 6.7% of relatives of diabetic patients and 46.7% of the obese group showed an android pattern of obesity.
- 8.9% of relatives of diabetic patients and 13.3% of obese children had chronic bronchial asthma.
- 13.3% of relatives of diabetic patients and 20% of obese children had hepatomegaly.
- 13.3% of relatives of diabetic patients were hypertensive.
- 6.7% of the obese group showed acanthosis nigricans.
- 22.2% among relatives of diabetic patients had hypothyroidism.
As regards the family history of diabetes mellitus of other siblings of diabetic patients, first-degree prevalence was found in 100% of proband diabetic patients. Of those, 6.7% were of paternal origin and 13.3% were of maternal origin.
As regards anthropometric measurements, highly significant difference among relatives of diabetic patient and the obese group with respect to weight (P = 0.005), BMI (P < 0.001), and head circumference (P < 0.001) and significant difference with respect to hip circumference (P = 0.04) and sitting height (P = 0.01) was observed. There were no significant differences with respect to height, span, waist circumference, and waist-hip ratio.
As regards the range of HbA1c (%), there were no significant differences among the studied groups. HbA1c estimation for 60 children (45 were other siblings of diabetic patients and 15 were obese children) showed the following:
At the start, two (4.4%) siblings among the relatives of diabetic patients were in the prediabetic range (HbA1c 5.7-6.4%), compared with three children from the obese group (20%).
At the end of the 3-month follow-up for HbA1c (%), one (2.2%) of the other siblings of diabetic patients was still in the prediabetic range, compared with two (13.6%) obese children still in the prediabetic range.
At the end of the 6-month follow-up for HbA1c (%), the other siblings of diabetic patients returned to the normal range for HbA1c (%), whereas one (6.7%) obese female patient was still in the prediabetic range. The obese female patient showed positive consanguinity, positive family history, chronic bronchial asthma, and acanthosis nigricans.
| Discussion|| |
The results of the present study demonstrated that 6.7% of the relatives of diabetic patients and 46.7% of the obese group showed android (central) obesity. Yusuf et al.  reported that there is a strong correlation between central obesity and diabetes mellitus and cardiovascular diseases; visceral fat cells release their metabolic by-products in the portal circulation, and thus the excess of triglycerides and free fatty acids created by the visceral fat cells go into the liver and accumulate there and cause lipotoxicity.
The results of the present study demonstrated that 8.9% of the relatives of diabetic patients and 13.3% of obese children had chronic bronchial asthma. This coincides with the results of Tedeschi and Airaghi , who reported that positive association between type 1 diabetes and bronchial asthma has been demonstrated at the population level. This association could be explained by common risk factors predisposing to both disorders and altered environmental and lifestyle conditions .
In this study, 13.3% of the relatives of diabetic patients and 20% of obese children had hepatomegaly. This coincides with the results of Mathur et al. , who reported that nonalcoholic steatohepatitis is associated with obesity, diabetes, insulin resistance, and hypertriglyceridemia. Nonalcoholic steatohepatitis is an entity in the spectrum of NAFLDs, ranging from fat in the liver (simple steatosis) to advanced fibrosis and cirrhosis .
In this study, 13.3% of the relatives of diabetic patients were hypertensive. This coincides with the results of Lu et al. , who found in a study on a large school-based population in Shanghai (China) that BMI and waist circumference are positively correlated with systolic blood pressure and diastolic blood pressure. Being overweight or obese greatly increased the risk of primary hypertension in Chinese children and adolescents .
In our study, 6.7% of the obese group showed acanthosis nigricans. This coincides with the results of Guran et al. , who reported that acanthosis nigricans is an important predictor of insulin resistance in childhood obesity and that obese children with acanthosis nigricans show higher insulin levels. Insulin secretory dynamics seem to be disrupted in fasting state initially, which is reflected as the loss of fasting insulin-glucose correlation .
In this study, 22.2% of the relatives of diabetic patients had hypothyroidism (free T3 <0.8 pg/ml, free T4 <0.8 ng/dl, and thyroid stimulating hormone >5.0 mIU/l). This coincides with the results of Wu , who reported that diabetic patients have a higher prevalence of thyroid disorders compared with the normal populations, because patients with one organ-specific autoimmune disease are at risk of developing other autoimmune disorders.
The percentage of a positive family history among relatives of diabetic patients was 100% with respect to siblings. This is in agreement with the results of Nathan et al. , who stated that close relatives (children, siblings) of an individual with type 1 diabetes have an increased risk of developing type 1 diabetes compared with an individual with no family history (5-6 vs. 0.4%, respectively) .
As regards family history of the obese group, 66.7% of obese children had a positive family history. This coincides with the results of Yang et al. , who found that obesity tends to run in families. An overall 80% of the offspring of two obese parents were obese in contrast to less than 10% of the offspring of two parents who were of normal weight. The percentage of obesity that can be attributed to genetics varies from 6 to 85% depending on the population examined.
In this study there was significant difference between the two studied groups with respect to anthropometric measurements. The mean weight and height of the obese group were significantly higher (50.20 ± 15.50 and 132.33 ± 17.32, respectively). This result coincides with that of De Leonibus et al. , who reported that obese children tend to be taller during prepuberty but lose this growth advantage during puberty.
The results of the present study demonstrated that the mean range of BMI was 27.10 ± 3.67 for the obese group, which is higher than the normal range; this is also seen for both waist circumference, with a mean range of 63.93 ± 7.39, and hip circumference, with a mean range of 72.13 ± 10.57, as well as waist-hip ratio, with a mean range of 0.90 ± 0.09. According to Speiser et al. , waist circumference or waist-hip ratios are used as indirect markers of intra-abdominal adipose tissue. This parameter is also a predictor of cardiovascular and metabolic risk factors in obese children .
In this study there was significant difference between the two studied groups with respect to head circumference. The mean range among relatives of diabetic patients was 53.26 ± 4.93, being lower than that of the obese group (56.26 ± 1.90). This result coincides with that of Greene et al. , who reported that 0.11% of the studied diabetic group had microcephaly. Microcephaly is caused by a variety of genetic and environmental factors, as well as by diabetes mellitus .
The results of the present study reported higher levels of fasting blood sugar that ranged between 110 and 126 mg/dl and postprandial blood sugar that ranged between 140 and 200 mg/dl in 4.4% (two children) among relatives of diabetic patients and in 20% (three children) of the obese group being in prediabetic range.
Range of glycosylated hemoglobin (%) study
At the start of screening of the studied groups, our study demonstrated that 4.4% (two children) of other siblings of diabetic patients were in the prediabetic range (5.7-6.4%), compared with 20% (three children) of the obese group (5.7-6.4%). During this time, family counseling on lifestyle modifications, healthy food, and physical activity to delay the occurrence of diabetes mellitus should be conducted.
At the end of the 3-month follow-up, HbA1c of the studied group showed that the range in one (2.2%) of the other siblings of diabetic patients was still in the prediabetic range, compared with two (13.3%) obese children. At this point in time, we insisted on proper family counseling on lifestyle modifications, healthy food, and physical activity.
At the end of the 6-month follow-up, HbA1c of the studied group showed the range in other siblings of diabetic patients to have returned to normal (%), whereas one (6.7%) obese child was still in the prediabetic range.
The obese child still in prediabetic range was an obese female patient of positive consanguinity and positive family history (sister and aunt). Examination revealed hypertension, chronic bronchial asthma, and acanthosis nigricans. This child had multiple predisposing factors for the development of type 2 diabetes mellitus.
Karam et al.  reported that progression from prediabetes to type 2 diabetes is not inevitable. With healthy lifestyle changes such as eating healthy food, physical activity in one's daily routine, and maintaining a healthy weight, blood sugar level might be brought back to normal .
This child was advised to see pediatrician at least once every 6 months to monitor general health and to do standard screening tests.
An International Expert Committee, after an extensive review of both established and emerging epidemiological evidence, recommended the use of the HbA1c test to diagnose diabetes, with a threshold of 6.5% or more.
Family counseling of the studied cases had been carried out on six visits:
At the first visit the importance of the study was discussed, consent was taken from the families, and samples were obtained.
At the second visit families were informed about the results of the investigations.
Children in prediabetic range and their families were counseled about prediabetes and how to prevent the occurrence of diabetes mellitus through lifestyle modifications, healthy food, and physical activity.
At the third visit the information was revised with families and follow-up samples were obtained.
At the fourth visit families were informed about the results of the investigations. Children in the prediabetic range whose blood sugar level returned to normal were encouraged to continue the prescribed lifestyle modifications. We insisted on continuing the study in children still in the prediabetic range.
At the fifth visit the information was revised with families and follow-up samples were obtained.
Families were informed about the results of follow-up investigations at the sixth visit. The prediabetes children were advised to make lifestyle modifications, lose weight, follow a healthy diet, and appear for follow-up investigations every 6 months for evaluation of HbA1c.
HbA1c is recommended as an early detection of prediabetes among the high-risk groups, including other siblings of diabetic patients and obese children.
Prevention of childhood obesity should be implemented early with the help of the family and whole community.
Family counseling is an important part of prediabetes management, which includes effective diet, exercise, behavioral changes, and lifestyle modifications.
| Acknowledgements|| |
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]