Diabetes and obesity in Indigenous Australian children

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Diabetes and obesity in Indigenous Australian
children adolescentsLouise
Maple-BrownMenzies School of Health Research
Royal Darwin Hospitallouise.maple-brown_at_menzies.
edu.au
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Children adolescents

• recent global increase in prevalence of
  metabolic syndrome, obesity type 2 diabetes
  (T2DM)
• Rates disproportionately ?amongst socio/eco
  disadvantaged groups ethnic minority groups (of
  non-white European background)
• Ethnicity may play ? role in youth than
  adult-onset T2DM
• high prevalence in Indigenous (USA, Canada
  Australia), Asian, Hispanic African American
  youths

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USA

• 1999-2004 among new diabetes in youth, of T2DM
  ? from lt3 to 45
• Ethnic differences in proportion T2DM among new
  diabetes
• 6 for non-Hispanic whites
• 22 for Hispanics
• 33 for African Americans
• 40 for Asians/Pacific Islanders
• 76 for Native Americans

Pinhas-Hamiel, J Pediatr 2005. SEARCH Study, JAMA
2007.
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USA/Canada

• Importance of exposure to diabetic intra-uterine
  environment
• Pima Indians signif more childhood diabetes in
  offspring of diabetic mothers
• First Nation Canadians (Mannitoba) 47 of
  offspring of diab mothers have T2DM by age 10yrs

Pettitt, Diab Care 1993 Cloutier, IDF 2009
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Australian youths

• ?prev of obesity
• Aus 2x overweight/obesity 1985-97 (7-15yrs)
• Vic 2006 19 overweight, 8 obese (4-12yrs)
• ?incidence of T2DM
• WA 27 avg annual ? 1990-2002 (lt17yr)

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Indigenous Australian youths

• T2DM occurs at a younger age
• assoc with socio-economic disadvantage
• Greater ?rates of T2DM recently
• Associated with central obesity
• Co-morbidities are very common ? ?cv risk

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Torres Study Obesity MetS

• cross-sectional
• 158 youth (aged 5-17 yrs), outer Torres Strait Is
• Findings
• 31 overweight, 15 obese
• 38 ? waist circumference
• 43 acanthosis nigricans,
• 27 hypertension
• 17 met syn (IDF definition, for n113 10yr)
• Of those who were overweight or obese
• 33 had metabolic syndrome
• ?levels of circulating insulin, HOMA insulin
  resistance HbA1c (vs normal weight)

Valery, Obes Rev 2009.
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NT data Obesity MetS

• Aboriginal Birth Cohort Study Top End, NT, 486
  children aged 9 14 yrs
• 6.4 overweight, 4.9 obese by BMI
• 26 ?waist circumference
• 59 of those with ?waist were NOT
  overweight/obese by BMI
• 14 MetS, 70 had at least 1 component
• Darwin Region Urban Indigenous Diabetes Study
• 1000 participants aged 15 yrs
• WHR index of obesity most closely assoc with
  T2DM

Sellers, J Ped 2008. ODea, Diab Res Clin Prac,
2008
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Importance of waist

• Central obesity ? metabolic cardiovasc risk
• WA cross-sectional study, n148, aged 6-13 yrs
• Waist circ (gt90th p) better indicator of cv risk
  than BMI
• ?Waist assoc with ?HDL, ?trig, SBP, insulin, HOMA
  insulin resistance
• (vs BMI assoc with 2hr glucose only)
• IDF included waist in definition of MetS in youth
• waist assoc with insulin resistance, lipids, BP
• waist corr with visceral adipose tissue
• non-invasive screening tool for risk assessment

Watts, J Ped Ch Health, 2008. Zimmet, Ped Diab
2007.
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Diabetes data WA study

• review of all children/adol presenting with T2DM
  1990-2002 to paed diab service at Princess
  Margaret Hospital for Children (lt17yrs)
• 43 cases
• 53 Indigenous
• 42 rural residence
• median age (at diagnosis) 13.6 years
• mean BMI Z score (at diagnosis) 1.94
• co-morbidities
• 59 hypertension
• 24 hyperlipidaemia
• 72 acanthosis nigricans

McMahon, MJA 2004.
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WA Study
Type 2 diabetes diagnosed each yr per
100 000 population lt 17 yrs in WA
Overall incidence rate ratio (IRR), 1.27 (95 CI,
1.151.41). IRR for the Indigenous group,
1.23 (95 CI, 1.071.40). IRR for the
non-Indigenous group, 1.31 (95 CI, 1.121.52).
McMahon, MJA 2004.
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Diabetes data NSW Study

• prospective study of T2DM incidence (10-18 yrs,
  2001-06) using Aus Paediatric Endocrine Group of
  NSW database National Diabetes Register
• ? incidence T2DM in Indigenous group
• Indigenous vs non-indigenous
• incidence rate ratio 6.1
• (95CI 3.9-9.7, plt0.001)

Craig, MJA 2007.
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NSW Study

• 23 cases of T2DM in Indigenous youths
• median age at diagnosis 13.7 years,
• 50 males
• 65 rural residence
• 75 with family history of type 2 diabetes
• median BMI SD score 2.3

Craig, MJA 2007.
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Diabetes data FNQ

• 20 cases T2DM youth
• mean age at diagnosis 13 years
• Male female 1 2.5
• mean BMI 33kg/m2
• 66 acanthosis nigricans
• 100 family history of diabetes (first-deg rel)

Sinha, Diab Res Clin Prac 2000.
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Acanthosis Nigricans
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Presentation of T2DM in youth

• 38 present with symptoms (polyuria, polydipsia)
• 5-10 present in ketoacidosis
• Male female
• 11 Asians
• 14-6 Native Americans

Rosenbloom, Ped Diab 2008.
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Diagnosis

• Clinical features
• Family History
• Obesity
• Acanthosis nigricans
• Lab Ix fasting insulin, glu, c-peptide (not
  diagnostic), ketones
• Auto-antibody useful b/c
• some overlap in T1 T2
• Guide treatment eg. Insulin, test thyroid etc

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Complications co-morbidities

• Assess at diagnosis then annual
• Urine ACR
• Lipids
• LFTs
• Clin Hx puberty, menstruation, contraception,
  obstructive sleep apnoea
• Eyes feet
• BP at diagnosis every subsequent visit

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Management

• Complex challenging!
• Multi-disciplinary team
• Diet lifestyle paramount
• Metformin first-line oral agent
• Often need additional orals /or insulin
• Little evidence for meds in youth
• Intro long acting basal insulin relatively early
  ? ?glucotoxicity then withdraw insulin

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CV Risk management

• ACE inhibitors for BP or ACR (check
  contraception)
• Statins if lipid targets (LDLlt2.6) not achieved
  w/i 3-6mths diet
• Short-term safety data in youth but not long-term
• Aspirin not recommended in youth

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Markers of CV risk in young

• DRUID participants aged 15-24 yrs
• High trig or low HDL-chol assoc w measures of
  cardiovasc risk (CIMT, pulse wave analysis)
• CV risk factors 15-34 yr olds w/o diabetes
• 45 with 2 CV risks
• 18 with 0 CV risks

Maple-Brown, Atheroscler 2009. ODea, Diab Res
Clin Pract 2008.
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T1DM in Indigenous youth

• Seen much less often than T2DM
• Cases have been reported
• Basal-bolus insulin required
• Consider use of insulin pump

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Summary

• Indigenous Australian youth are at high risk of
  T2DM assoc premature morbidity mortality
• Urgent need for strategies to prevent development
  of obesity / MetS / T2DM targeting children
  adolescents in this high risk population

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eGFR Study

• Accurate assessment of renal function and
  progression of chronic kidney disease in
  Indigenous Australians
• INVESTIGATORS
• Louise Maple-Brown, Paul Lawton, Kerin ODea,
  Wendy Hoy, Alan Cass, George Jerums, Richard
  MacIsaac, Robyn McDermott, Leigh Ward, Mark
  Thomas, Jaqui Hughes, Alex Brown, Sajiv Cherian,
  Kevin Warr, Graham Jones, Ashim Sinha, Sianna
  Panagiotopoulos, Leonard Sunil Piers, Andew Ellis
• Differences in body builds compositions in
  Indigenous Australians
• eGFR derived for Europeans may under-estimate
  risk
• A validated measure of GFR is vital in this high
  risk population in order to
• guide best-practice clinical care to ameliorate
  rapid CKD progression
• its impact on health well-being of
  Indigenous individuals communities
•  

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Methods Participants

• n600

Top End
CA
FNQld
WA

• Strata of kidney function
• healthy
• Diabetes eGFRgt90mls/min/1.73m2
• eGFR 60-90
• eGFR 30-60
• eGFRlt15-29

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eGFR Study Team
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Healthy Top-Enders Study

• We want to learn
• WHAT keeps Top-Enders healthy even if they live
  in different parts of Top End, have a different
  lifestyle or a different body shape.
• HOW body shape (and composition) protects
  Top-Enders from chronic illness (like diabetes
  and kidney damage)
• Learning from healthy people helps us work out
  how to prevent people from developing illness,
  like diabetes.
• Then well work hard to fix the problems!

• Can I be involved?
• Yes if you are 17-25 years old and live in the
  Top End
• Who cant be tested?
• Children (lt16 years old),
• Women who are pregnant or breast feeding
• If you have a chronic illness (diabetes, heart
  and Kidney disease).

If youd like more information, or want to
participate, please contact the Sian Graham on
89228283 or Dr Jaqui Hughes (89228412) at Menzies
School of Health Research
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Thank you RDH Diabetes Team Cherie Whitbread,
Sumaria Corpus, Dr Diane Howard, Michelle
Walding Collaborators Dr Liz Davis, Perth Dr
Ashim Sinha, Cairns LMB Funding NHMRC 320860,
Centre of Clinical Research Excellence Clinical
Science in Diabetes (Uni Melb) DRUID
participants, staff, Indigenous steering
committee, partner organisations, NHMRC 236207.
eGFR 545202