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    How to test kids for diabetes

    For children at risk for type 2 diabetes, the HbA1c test may rival gold standard glucose testing, and it’s easier and cheaper.

    Testing glycated hemoglobin (HbA1c) appears to predict children’s diabetes risk as well as fasting plasma glucose and 2-hour postload plasma glucose, according to a study on more than 2000 American Indian children.1

    Researchers studied children without diabetes aged between 10 and 19 years and monitored them through age 39 years. Using a fasting plasma glucose of equal to or greater than 126 mg/dL, a 2-hour postload plasma glucose of 200 mg/dL, and an HbA1c of 6.5% or more to define incident diabetes, they found the sensitivity and specificity for identifying diabetes risk in children and adolescents were similar among the tests.1

    Girls were 7 times and boys 4 times as likely to get incident diabetes during the follow-up if they had an HbA1c of 5.7% or higher. The 10-year cumulative incidence of diabetes in those with an HbA1c of 5.7% or higher was 78% compared with 23% among children whose HbA1c was lower than 5.7%.1 That’s quite remarkable, according to Hebatullah M. Ismail, MBBCh, MSc, PhD, clinical director of diabetes, Children’s Hospital of Pittsburgh of UPMC, Pennsylvania.

    Recommended: Taking control of T2D

    “This study is of particular relevance to pediatricians, as it highlights the increasing rate of type 2 diabetes development in high-risk populations/ethnicities, which in this case is the American Indian overweight/obese population with a family history of diabetes,” Ismail says. “HbA1c measurement is particularly convenient in children given it is a single sample that does not require fasting.”

    Predicting risk for diabetes

    The study helps to fill an important gap in knowledge in that it looks longitudinally at trying to predict which children are going to develop type 2 diabetes, according to David W. Cooke, MD, associate professor of pediatrics and interim director of pediatric endocrinology at Johns Hopkins University School of Medicine, Baltimore, Maryland.

    “We’ve extrapolated from the adult literature with all these other measures of glucose control, whether it be fasting blood sugar or the 2-hour plasma glucose or the glycated hemoglobin (HbA1c),” Cooke says. “I don’t know that this study is a definitive one that gives us the absolute answer, but it’s the first one that says yes, there are markers of glucose control that identify an increased risk of diabetes in adults, which seem to correlate fairly similarly in children. The A1C that’s higher than normal but not diagnostic of diabetes in a child does put that child at a high risk of having a diabetes diagnosis in . . . the next 5 to 10 years.”

    For pediatricians at the front lines, it’s important to understand that the prevalence of type 2 diabetes in children, teenagers, and young adults has increased in the last 15 years, according to Eric I. Felner, MD, MSCR, professor, Division of Endocrinology and Diabetes, Department of Pediatrics, at Emory University School of Medicine, Atlanta, Georgia.

    The American Diabetes Association reported in its Diabetes Forecast magazine data that suggest type 2 diabetes in 10- to 19-year-olds increased 21% between 2001 and 2009—an increase driven by Hispanic and non-Hispanic white children and not Native Americans, Asian/Pacific Islanders, or African Americans.2 Also, there has been a rising prevalence of childhood obesity among American Indian children during the last 4 decades, according to a recent study.3

    “In addition, these children, teenagers, and young adults are at increased risk for fatty liver disease and cardiovascular disease,” Felner says. “The use of the HbA1c test in children at risk for diabetes appears to be an acceptable marker (as good as fasting and 2-hour post-glucola blood glucose levels) in determining which children, adolescents, and young adults are at risk to develop diabetes in the future.”

    Proceed with caution

    Physicians’ interpretation of the significantly high incidence rate of diabetes observed in children with HbA1c of 5.7% or higher enrolled in the study should be taken with caution, according to Mauri Carakushansky, MD, division chief of endocrinology, Department of Pediatrics, at Nemours Children’s Hospital, Orlando, Florida.

    “It should be noted that all subjects evaluated in the study were of American Indian origin, and young American Indians are known for having disproportionately high rates of diabetes and obesity,” Carakushansky says.

    American Diabetes Association statistics that show 7.6% of non-Hispanic whites compared with 15.9% of American Indians/Alaskan natives are diagnosed with diabetes.4

    “Therefore, additional studies are needed to determine more precisely the incidence rate of diabetes in children of different ethnicities presenting with an abnormal HbA1c,” Carakushansky says.

    Cooke says he agrees that generalizing the findings to other populations isn’t a given, but he notes that, in general, studies of American Indians have translated into the general population.

    Another potential limitation is the study’s size. Even though the study was done on thousands of children, the numbers that went on to diabetes were small, according to Cooke.

    “The number of actual children that had that higher risk A1C result that then went on to diabetes really only amounted to 2 boys and 16 girls [and only 62 children had that elevated A1C],” Cooke says.

    NEXT: Metabolic syndrome

    Lisette Hilton
    Lisette Hilton is president of Words Come Alive, based in Boca Raton, Florida.

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