|Year : 2017 | Volume
| Issue : 1 | Page : 4-9
Diabetes mellitus type II in school children: Risk evaluation and its genetic correlation
Santosh Mahajan1, Paramjot Kaur2
1 Department Biochemistry, Baba Jaswant Singh Dental College Hospital and Research Institute, Ludhiana, Punjab, India
2 Department Oral and Maxillofacial Surgery, Baba Jaswant Singh Dental College and Research Institute, Ludhiana, Punjab, India
|Date of Web Publication||3-Jul-2017|
Department Oral and Maxillofacial Surgery, Baba Jaswant Singh Dental College Hospital and Research Institute, Sector 40, Ludhiana
Source of Support: None, Conflict of Interest: None
Introduction: Diabetes mellitus type II (T2DM) is the leading cause of morbidity and mortality globally, with its increasing prevalence in children worldwide and is associated with their eating habits, sedentary lifestyle, obesity, and family history of the disease.
Aim: The present study was an attempt to screen the school children at risk of developing T2DM in their near future and to comprehend the cause of disease.
Materials and Methods: A total of 71 students (45 boys and 26 girls) of the age (mean ± standard deviation) 12.8 ± 2.1 years of Bhartiya Vidya Mandir School, Ludhiana, were scored using Indian diabetes risk score (IDRS), a questionnaire that is simple, validated, and had proven to be highly effective in the previous studies.
Results: The present study revealed that out of 71 children, 7%, 63%, and 30% of the children were in high-, moderate-, and low-risk groups, respectively. The study reflected that the boys would be at higher risk of developing T2DM in their near future than girls due to more pronounced diabetic history in their family (a nonmodifiable factor) than in girls and the presence of acanthosis nigricans (the marker of insulin resistance) only in the boys. Girls were at risk mainly because of their less physical activity and more abdominal waist (the modifiable factors).
Conclusions: IDRS provided a useful tool for identifying the cause for the risk of disease in children. Fathers might be responsible for the transmission of T2DM more to their sons. T2DM in childhood can be prevented to large extent by increasing physical activity periods in school, promoting healthy eating habits, and regular screening programs to identify the at-risk cases for early treatment and to control the long-term effects of the disease.
Keywords: Acanthosis nigricans, Indian diabetes risk score, school children, type II diabetes mellitus
|How to cite this article:|
Mahajan S, Kaur P. Diabetes mellitus type II in school children: Risk evaluation and its genetic correlation. Int J Oral Health Sci 2017;7:4-9
|How to cite this URL:|
Mahajan S, Kaur P. Diabetes mellitus type II in school children: Risk evaluation and its genetic correlation. Int J Oral Health Sci [serial online] 2017 [cited 2017 Nov 23];7:4-9. Available from: http://www.ijohsjournal.org/text.asp?2017/7/1/4/209343
| Introduction|| |
Diabetes mellitus type II (T2DM) is nonautoimmune, complicated, heterogeneous, and polygenic metabolic disease condition. It is characterized by a state of hyperglycemia due to defective production or action of insulin or both. Its pathogenesis involves complex interaction between genetic and environmental factors., The disease is associated with its long-term complications such as nephropathy, microalbuminuria, hypertension, atherosclerosis, polycystic ovarian syndrome, and poor blood control. Worldwide, the prevalence of disease has doubled for the last few decades. India leads the world with the largest number of patients with diabetes earning dubious distinction of being labeled as the “diabetic capital of the world.” International Diabetes Federation reported around 415 million people suffering from the disease in 2015 worldwide, and the number is expected to rise to 642 million by 2040. The numbers of diabetic people living in India were 40.9 million in 2006 that has increased to 69.2 million , and is likely to increase to 80 million by 2030 as per the WHO estimates. Unfortunately, more than 50% of the people with diabetes in India remain unaware of the disease that adds to the disease burden to the country. Previously considered, a disease of middle-aged and elderly people has now escalated in all age groups and is being detected in the children at alarming rate worldwide. The rising prevalence of the disease in children is closely associated with obesity due to nutritional transition toward fast foods, reduced physical activity, family history of T2DM in first-degree and second-degree relatives, relative insulin resistance due to the effect of sex hormones and growth hormones during puberty and maternal history of gestational diabetes., It has been concluded that obesity increases insulin level but decreases insulin receptors on the target tissue causing clinical insulin resistance. On the other hand, exercise increases the number of insulin receptors and improves insulin sensitivity. About 60%–90% of the youth who develop diabetes have acanthosis nigricans which presents as a velvety thickening and hyperpigmentation of the skin of neck, and the flexural areas and is due to insulin resistance. This manifestation is common at younger age than at adulthood and can be used as the marker for the youth who are at risk for developing T2DM., About 45%–80% of children who fall prey to the disease have either of their parent suffering from type II diabetes mellitus. Despite the disturbing trend of increasing T2DM in children, little is known about the epidemiology of the disease in children that further adds to the disease burden to the family and to the society. This underscores the need of screening children at risk of developing the disease at early stage. It has been suggested that identification of the individual at risk and suitable intervention in the form of weight reduction, change in dietary habits, and increased physical activity could greatly help cease or at least delay the onset of disease. There is evidence that premature detection of diabetes by suitable screening methods helps intercept or delay the long-term complication of the disease.
The present study was an attempt to screen the school children at risk of developing T2DM in their near future using Indian diabetes risk score (IDRS) as an educative tool developed by Mohan et al. and to comprehend the cause of disease.
| Materials and Methods|| |
The present study was a cross-sectional study done on students of Bhartiya Vidya Mandir School, sector 39, Chandigarh road, Ludhiana, in the month of May, 2016 using IDRS questionnaire. The questionnaire is simple, cost-effective, validated, and easy to carry out and has proven to be a successful method of evaluating the risk of undetected and undiagnosed diabetes in Indian and South Indian populations.,, IDRS incorporates four simple parameters in its scoring, namely, age, abdominal obesity, physical activity, and family history of diabetes. The score distribution according to IDRS is mentioned in [Table 1]. The importance of the study was detailed to the school authority and to the children. A written consent was obtained from the children. A total of 71 children (45 boys, 26 girls) of the age group 9–15 years (mean age 12.8 ± 2.14 years) were randomly selected and were enquired for the four parameters stated in [Table 1] to check their risk for developing T2DM. A score of zero was allotted to all the students as they all belonged to age group <35 years. The waist circumference (indicative of central and general obesity) was measured using a measuring tape with an accuracy of 0.5 cm. Besides parental history, the diabetic history of their grandparents and other relatives was also enquired. The students were also checked for acanthosis nigricans, the marker of insulin resistance. Children who were already diabetic were not included in this study. The risk score of each student was calculated. The children were divided into three risk group, i.e., low-risk group (IDRS <30), moderate-risk group (IDRS = 30–50), and high-risk group (IDRS ≥60). The number of students and their percentage for each parameter and in each risk group was calculated and tabulated. The data thus obtained were analyzed statistically using one-way ANOVA and Chi-square tests.
| Results|| |
The present study revealed that out of 71 children (mean age 12.8 ± 2.1 years), 7%, 63%, and 30% children were in high-, moderate-, and low-risk groups with ages 11.7 ± 1.5 years, 12.8 ± 2.3 years, and 12.9 ± 1.7 years, respectively. Among these, 15 boys (33.3%) and 6 girls (23.1%) accounted low-risk group, 27 boys (60%) and 18 girls (69.2%) fall in moderate-risk group while the number of boys and girls in high-risk group was 3 and 2, respectively [Table 2] and [Figure 1]. Percentage of boys doing regular exercise and/or strenuous work was more (80%) than girls (53.8%). Out of 21 children, 20% of boys but 46.1% of girls were not doing any physical exercise. The waist circumference of 21 boys (46.7%) and 19 girls (73.1%) was above the normal reference range. The number of children having either of the parent or both the parents diabetic was 35 (49.3%) and 7 (9.9%), respectively. More boys (64.4%) were having the history of diabetes in their family than girls (50%). The number of boys and the number of girls who had the history of diabetes in their father were 21 (46.7%) and 8 (30.8%), respectively. While the mother of 4 boys (8.9%) and 2 girls (7.7%) was diabetic. Both parents were diabetic for 4 boys (8.9%) and 3 girls (11.5%). Diabetic history in grandparents was also more in boys (26.7%) than in girls (15.4%). Grandfather of 6 boys (13.3%) and 3 girls (11.5%) was diabetic, while the grandmother of 2 boys (4.4%) and 1 girl (3.8%) was diabetic. A total of 4 boys but none of the girl had their both grandparents suffering with the disease. One boy also had diabetes in his uncle and cousin in addition to his both parents and grandparents and his total IDRS was 70. Further, no girls but 2 boys were suffering from acanthosis nigricans [Table 3] and [Figure 2].
|Table 2: Number and percentage of children in different Indian diabetes risk score groups|
Click here to view
|Figure 1: Percentage of children in different risk group of developing diabetes mellitus type II|
Click here to view
|Figure 2: Family history of diabetes, obesity, and acanthosis nigricans (marker of insulin resistance) in boys and girls|
Click here to view
Analysis of the data using one-way anova did not find any statistical difference in the ages (mean ± standard deviation) of children falling in low-, moderate-, and high-risk groups risk groups (sig. 628). Pearson Chi-square test found that the difference in IDRS of boys, girls, and total students of different risk groups was not significant (value = 4.534, df = 2 sig. (two-sided) =0.104). However, the percentage of boys within the IDRS score group was more (63.4%) than girls (36.4%). Chi-square test and nonparametric correlation of the data revealed significant association of IDRS of the children with their abdominal obesity, physical activity, and family history of the disease and acanthosis nigricans [Table 4].
|Table 4: Chi-square test and nonparametric correlation of Indian diabetes risk score with risk factors|
Click here to view
| Discussion|| |
The risk factors for the development of T2DM such as age, gender, and family history are nonmodifiable factors while others such as smoking, diet, physical activity, and hypertension are modifiable. IDRS provides a useful tool to identify the people at risk of developing the disease and to target those individuals for further screening and educating them for healthy lifestyle so that the occurrence of the disease can be delayed or prevented. It also helps know the proportion of males and females suffering with the disease and correlate the sex-related transmission of the disease to the future generation. In the present study, out of 71 children, 7% of the children were at high risk of developing the disease with the ratio of 3 boys: 2 girls. Recently, out of 114 males and 108 females students, 2 male but no female students were found in high risk of developing T2DM. The risk of developing the disease in girls would be largely because of lack of exercise and more abdominal obesity than boys and thus can be protected from the disease by adopting a healthy lifestyle. On the other hand, family history of the disease along with the occurrence of acanthosis nigricans would be the factors responsible for the boys to be at higher risk of developing type 2 DM. These views find support from the significant association of IDRS with physical activity, family history of disease, and acanthosis nigricans found in the present study [Table 4]. Acanthosis nigricans is found in as many as 90% of children withT2DM. Further, IDRS of boys was more than girls suggesting their more susceptibility to develop T2DM in their near future. The study also revealed that fathers and grandfathers suffering from the disease were more than mothers and grandmothers, and this number was more in boys than in girls thus indicating that fathers and grandfathers might be responsible for the transmission of disease more to their sons and grandsons than to their daughters and granddaughters. This hypothesis finds support from Gale and Gillespie  who reviewed higher number of males suffering from T2DM than females in European population aged 15–40 with a ratio of 3:2. They also revealed that fathers affected with type I diabetes mellitus were more likely to transmit the disease than the affected mothers. More susceptibility of the males toward T2DM disease may be due to their tendency to develop central obesity making them more insulin resistant in contrast to the females of childbearing age group who develop peripheral obesity., Less susceptibility of women to the disease may also be because of their more estrogen, sex hormone binding globulin, and HDL in their childbearing age than men. Reduced estrogen after menopause in women coincides with increased risk of elevated fasting plasma glucose.,
| Conclusions|| |
IDRS provided a useful tool for screening the children at risk of developing T2DM in their future and help identifying the cause of the disease. Boys included in the present study would be at more of risk of developing the disease because of more pronounced diabetic history in their families, presence of acanthosis nigricans, and their higher IDRS than girls. Fathers might be responsible for the transmission of T2DM more to their sons. Risk of developing the disease in girls would largely be because of their less physical activity and more abdominal waist.
Pitfalls and future recommendations
This was a cross-sectional study with short sample size. The findings of the present study may not be similar in children from other regions of different socioeconomic, racial, and ethnic backgrounds. Regular screening programs should be carried out in schools of different parts of the country to get a generalized data as schools are central to lives of the children and information can be quickly dissipated through this channel. Childhood T2DM can be prevented to a large extent by creating health awareness in children in terms of healthy eating habits and exercises. Physical activity periods in the schools should be increased. Children at moderate and high risks should be followed by glucose tolerance test to further confirm the risk of disease for their early treatment and to protect the future of the country from the dangerous effects of the disease.
We are highly thankful to the staff and students of BVM School, Ludhiana, for the successful completion of the study. We are also acknowledged to the technical staff of biochemistry department for smooth collection of the data. We are also thankful to 7th standard student Raunak Mahajan (s/o Dr. Santosh Mahajan) in helping to prepare the manuscript.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Gupta V, Khadgawat R, Saraswathy KN, Sachdeva MP, Kalla AK. Emergence of TCF7L2 as a most promising gene in predisposition of diabetes type II. Int J Hum Genet 2008;8:199-215.
Prasad AN. Type 2 diabetes mellitus in young need for early screening. Indian Pediatr 2011;48:683-8.
Pranita A, Phadke A, Kharche J, Balsubramaniyan B, Joshi A. Screening of young adults for future risk of type 2 diabetes mellitus – A big concern for society and nation. J Clin Diagn Res 2012;6:1610-1.
Mohan V, Sandeep S, Deepa R, Shah B, Varghese C. Epidemiology of type 2 diabetes: Indian scenario. Indian J Med Res 2007;125:217-30.
] [Full text]
International Diabetes Federation. Diabetes Atlas. 7th
ed. Belgium: International Diabetes Federation; 2015. p. 1-34.
Mishra T, Ishwar A, Pandey P, Singh A, Chandrakar MP, Pharmani S. Cronary artery disease (CAD) in patients with type 2 diabetes mellitus and comparison with non diabetic CAD patients. Int J Med Res 2016;1:30-3.
Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes: Estimates for the year 2000 and projections for 2030. Diabetes Care 2004;27:1047-53.
Mohan D, Raj D, Shanthirani CS, Datta M, Unwin NC, Kapur A, et al.
Awareness and knowledge of diabetes in Chennai – The Chennai Urban Rural Epidemiology Study [CURES-9]. J Assoc Physicians India 2005;53:283-7.
Huizinga MM, Rothman RL. Addressing the diabetes pandemic: A comprehensive approach. Indian J Med Res 2006;124:481-4.
] [Full text]
Misra A, Pandey RM, Devi JR, Sharma R, Vikram NK, Khanna N. High prevalence of diabetes, obesity and dyslipidaemia in urban slum population in northern India. Int J Obes Relat Metab Disord 2001;25:1722-9.
Young TK, Martens PJ, Taback SP, Sellers EA, Dean HJ, Cheang M, et al.
Type 2 diabetes mellitus in children: Prenatal and early infancy risk factors among native canadians. Arch Pediatr Adolesc Med 2002;156:651-5.
Vernillo AT. Diabetes mellitus: Relevance to dental treatment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;91:263-70.
Dean H, Flett B. Natural history of type 2 diabetes diagnosed in childhood: Long term follow-up in young adult years. Diabetes 2002;51 Suppl 1:A24.
American Diabetes Association. Classification and diagnosis of diabetes. Section 2. In standards of medical care in diabetes. Diabetes Care 2017;40 Suppl 1:S11-24.
SEARCH for Diabetes in Youth Study Group, Liese AD, D'Agostino RB Jr., Hamman RF, Kilgo PD, Lawrence JM, et al.
The burden of diabetes mellitus among US youth: Prevalence estimates from the SEARCH for Diabetes in Youth Study. Pediatrics 2006;118:1510-8.
Ambady R, Chamukuttan S. Early diagnosis and prevention of diabetes in developing countries. Rev Endocr Metab Disord 2008;9:193-201.
Mohan V, Deepa R, Deepa M, Somannavar S, Datta M. A simplified Indian Diabetes Risk Score for screening for undiagnosed diabetic subjects. J Assoc Physicians India 2005;53:759-63.
Chaturvedi V, Reddy KS, Prabhakaran D, Ramakrishanan L, P
Shah, B Shah. Development of clinical risk score in predicting undiagnosed diabetes in urban Asian Indian adults: A population based study. CVD Prev Control 2008;3:141-51.
Manjula Devi AJ. The Indian diabetic risk score – To nip in the bud. IOSR J Dent Med Sci 2013;9:76-7.
Bhatia T, Oka M, Dharamdasani V, Bhattaccharjee S, Fortwengel G, Limaye V, et al.
Type 2 diabetes mellitus: Risk evaluation and advice in undergraduate students in Mumbai. Int J Pharma Sci Invent 2014;3:37-40.
Vardhan A, Adhikari Prabha MR, Kotian Shanidhar M, Saxena N, Gupta S, Tripathy A. The value of Indian diabetic risk score as a tool for reducing the risk of diabetes in Indian medical students. J Clin Diagn Res 2011;5:718-20.
Fagot-Campagna A, Pettitt DJ, Engelgau MM, Burrows NR, Geiss LS, Valdez R, et al.
Type 2 diabetes among North American children and adolescents: An epidemiologic review and a public health perspective. J Pediatr 2000;136:664-72.
Gale EA, Gillespie KM. Diabetes and gender. Diabetologia 2001;44:3-15.
Williams CM. Lipid metabolism in women. Proc Nutr Soc 2004;63:153-60.
Geer EB, Shen W. Gender differences in insulin resistance, body composition, and energy balance. Gend Med 2009;6 Suppl 1:60-75.
Szalat A, Raz I. Gender-specific care of diabetes mellitus: Particular considerations in the management of diabetic women. Diabetes Obes Metab 2008;10:1135-56.
Ding EL, Song Y, Malik VS, Liu S. Sex differences of endogenous sex hormones and risk of type 2 diabetes: A systematic review and meta-analysis. JAMA 2006;295:1288-99.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]