Determinants of Course of Type 2 Diabetes in Indian Adolescents.

OBJECTIVES: To identify determinants of the course of Type 2 diabetes in Indian adolescents. METHODS: Records of 37 adolescents (24 boys; 29 post pubertal and eight pubertal) with Type 2 diabetes (initial HbA1C 10.1 ± 1.9% and BMI SDS 2.0 ± 0.8; family history of diabetes in 33, 89.2%) diagnosed at 15.2 ± 2.5 y and followed up for 3.8 ± 2.2 y till 19.1 ± 3.3 y of age, were reviewed. RESULTS: Initial treatment included insulin in 11 (29.7%), metformin alone in 22 (59.5%), and a combination of anti-diabetic medication in four (10.8%). Eleven subjects (29.7%) achieved remission at a median period of 5.3 mo (IQR- 17.13) after diagnosis; six of these relapsed within 0.9 ± 0.3 (range 0.4-1.3) y. The proportion of subjects requiring multiple anti-diabetic agents increased over follow-up (19% at six months, 32.5% at one year, 50% at two years, 59.1% at three, and 64.8% at four years), with the need for combination therapy after 0.9 ± 1.4 y. At the last follow-up, five were off treatment (13.5%), 10 (27%) were on metformin alone, and 22 (59.5%) were on multiple medications. The need for combination therapy at the last follow-up was lower in subjects with remission (27% against 73.1%, p = 0.02). CONCLUSIONS: The findings of this study suggest delayed presentation and rapid progression of Type 2 diabetes in Indian adolescents. Diagnosis on screening and achievement of remission were predictors of good outcome.

Comparison of the Predictive Value of IAP 2015 and WHO Body Mass Index Criteria for Hypertension in Indian Children and Adolescents.

OBJECTIVE: To compare the predictive value of the IAP and WHO criteria in identifying obesity complications in Indian children and adolescents. METHODS: Blood pressure and body mass index was measured in 4434 children and adolescents [2539 boys; mean age 11.9 (3.0), 5.1-18 y] from affluent schools. The predictive accuracy of IAP 2015 and WHO BMI criteria in identifying hypertension was assessed. RESULTS: IAP 2015 BMI criteria labelled 203 more children obese than the WHO reference (649 as against 446). Hypertension was present in 75 (37%) of these. The difference in the prevalence of hypertension in subjects obese as per IAP 2015 criteria and their nonobese counterparts (50.2% as against 10.8%, p < 0.0001) was greater than that between subjects obese only by IAP 2015 or by both the criteria (36.9% as against 56.3%, p < 0.0001). The difference in the proportion of subjects with hypertension between two consecutive IAP 2015 BMI SDS category was highest for + 1.5 in boys (32.3% as against 49.8%, p < 0.0001) and + 2 in girls (25.9% as against 59.3%, p < 0.00012). CONCLUSION: IAP BMI criteria better predict hypertension in Indian children than WHO cutoffs and should be used in clinical practice to predict obesity complications.

Development and validation of a mobile application for point of care evaluation of growth failure.

OBJECTIVES: Lack of systematic evaluation of short stature results in unnecessary work-up on one hand while missing pathology on the other. We have developed a mobile application that guides work-up based on age, auxology (height, BMI, and corrected standard deviation score), and skeletal maturation with an aim of reducing the diagnostic errors. Aim of this study is to develop and validate a mobile application for point of care evaluation of short stature. METHODS: The application was developed (n=400) and validated (n=412) on children and adolescents (2-18 years of age) presenting to our Pediatric Endocrinology Clinic with short stature. Height standard deviation score thresholds determining the need for workup were derived from Receiver Operating Characteristics (ROC) curve. Student's t-test and ROC curves were used to identify the most appropriate parameter differentiating constitutional delay of growth and puberty (CDGP) from pathological and nutritional from endocrine causes. The validation of the application involved comparing the application predicted and clinical diagnosis at each step of the algorithm. RESULTS: The mobile application diagnosis was concordant with clinical diagnosis in 408 (99.0%) with discordance in four (two with CDGP labeled as growth hormone deficiency [GHD] and two with GHD labeled as CDGP). CONCLUSIONS: Mobile application guided short stature assessment has a high concordance with the clinical diagnosis and is expected to help point of care short stature evaluation.

Determinants and Predictors of Body Fat in Indian Children and Adolescents.

OBJECTIVE: To study determinants and predictors of body fat in Indian children and adolescents. METHODS: In this cross-sectional study, 5175 children and adolescents [3014 boys, age 12.8 (3) y, 5-18 y] participated. Determinants and predictors of body fat were assessed using partial correlation (corrected for age, and gender) and linear regression. RESULTS: Fat percentage correlated negatively with the duration of physical activity (r = -0.091, p < 0.01) and sleep (r = -0.044, p = 0.01) and positively with parental body mass index (BMI) (r = 0.202, p < 0.01 for father and r = 0.235, p < 0.01 for mother), and birth weight (r = 0.050, p < 0.01). On linear regression, fat percentage was positively associated with parental BMI and birth weight, and negatively with physical activity and sleep duration. All adiposity markers [BMI standard deviation score (SDS) (r = 0.863, p < 0.01), weight SDS (r = 0.827, p < 0.01) waist to height ratio (r = 0.819, p < 0.01), waist circumference SDS (r = 0.765, p < 0.01) wrist circumference (r = 0.21, p < 0.01), and neck circumference (r = 0.19, p < 0.01)] correlated significantly with fat percentage, showing highest correlation with BMI SDS. CONCLUSION: Reduced sleep and physical activity are the key modifiable risk factors for adiposity. BMI SDS is the best clinical surrogate of body fat in Indian children and adolescents. There is a need to explore the impact of lifestyle interventions targeting sleep and physical activity on adiposity.

Diabetes technologies for children and adolescents with type 1 diabetes are highly dependent on coverage and reimbursement: results from a worldwide survey.

INTRODUCTION: To study healthcare professionals' (HCP) perceptions on decision making to start insulin pumps and continuous glucose monitoring (CGM) systems in pediatric type 1 diabetes. RESEARCH DESIGN AND METHODS: An electronic survey supported by the International Society for Pediatric and Adolescent Diabetes (ISPAD) was disseminated through a weblink structured as follows: (1) HCP's sociodemographic and work profile; (2) perceptions about indications and contraindications for insulin pumps and (3) for CGM systems; and (4) decision making on six case scenarios. RESULTS: 247 responses from 49 countries were analyzed. Seventy per cent of respondents were members of ISPAD. Most of participants were women over 40 years old, who practice as pediatric endocrinologists for more than 10 years at university/academic centers and follow more than 500 people with type 1 diabetes. Although insulin pumps and CGMs are widely available and highly recommended among respondents, their uptake is influenced by access to healthcare coverage/insurance. Personal preference and cost of therapy were identified as the main reasons for turning down diabetes technologies. Parental educational level, language comprehension and income were the most relevant socioeconomic factors that would influence HCPs to recommend diabetes technologies, while gender, religious affiliation and race/ethnicity or citizenship were the least relevant. CONCLUSIONS: Responders seem to be markedly supportive of starting people on diabetes technologies. However, coverage/insurance for devices holds the biggest impact on the extent of their recommendations.

Predictive Value of IAP 2015, IAP 2007 and WHO Growth Charts in Identifying Pathological Short Stature.

OBJECTIVE: To compare the diagnostic accuracy of IAP 2015, WHO and IAP 2007 growth charts in identifying pathological short stature in Indian children. METHODOLOGY: The predictive value of the growth charts for pathological short stature was assessed in 500 (266 boys) short subjects (age 5-17.9 years) presenting to our pediatric endocrine clinic. RESULTS: WHO, IAP 2015, IAP 2007 criteria classified 500, 410 (82%) and 331 (66.2%) subjects short respectively. A total of 218 (43.6%) subjects had a pathological cause. Two out of 90 subjects short by WHO criteria but normal as per IAP 2015 had a pathological cause (2.2%) whereas 38 out of 79 subjects short as per WHO and IAP 2015 criteria but normal by IAP 2007 had pathological short stature. The diagnostic measures of IAP 2015 and IAP 2007 charts in identifying pathological short stature showed a sensitivity 99.1% and 81.7%, negative predictive value 97.8% as against 76.3%, positive predictive value 52.7% and 53.8%, and specificity of 31.2% and 45.7%, respectively. CONCLUSION: IAP 2015 growth charts are superior in identifying pathological growth failure compared to WHO and IAP 2007.

Metabolic Impact of Subclinical Hypothyroidism in Obese Children and Adolescents.

OBJECTIVE: Subclinical hypothyroidism is common in children and adolescents with obesity and has been considered to be its effect with no need for treatment. Its metabolic impact has not been evaluated. Therefore the present study was conducted to determine the metabolic impact of obesity related subclinical hypothyroidism. METHODS: Retrospective record review of obese children and adolescents between 5 and 18 y of age presenting to pediatric endocrine clinic was done. Four hundred four obese children and adolescents [251 boys, 11.8 (3.2); 5.1-18 y, BMI SDS 2.4 (0.7); 1.4-6.6] were assessed regarding thyroid functions, adiposity (clinical and DXA derived) and metabolic complications. RESULTS: Subclinical hypothyroidism was observed in 122 (30.2%) and was associated with higher fat percentage [49.2 (5.8) vs. 47.2 (6.4) p = 0.009], android to gynoid ratio [1.1 (0.1) vs. 1.0 (0.1), p = 0.007] and alanine aminotransferase (ALT) levels [49.3 (31.5) vs. 40.8 (38.1), p = 0.04]. Subjects with subclinical hypothyroidism had 1.9 times greater odds of having non-alcoholic steatohepatitis (47.3% vs. 31.8%, p = 0.005) with no difference in the prevalence of dyslipidemia, dysglycemia or hypertension. Subclinical hypothyroidism was the only determinant of non-alcoholic steatohepatitis on binomial logistic regression (WALD = 11.04, p = 0.001) with no impact of BMI SDS, waist circumference SDS, fat percentage or android to gynoid ratio. Thyroid stimulating hormone (TSH) was the most important determinant of ALT on linear regression (B = 3.027, p < 0.005). CONCLUSIONS: Obesity related subclinical hypothyroidism predisposes to increased ALT and non-alcoholic steatohepatitis independent of severity adiposity. The impact of thyroid supplementation in this setting needs to be explored.