What are the screening recommendations for type 2 diabetes in Canadian children

In Canada, the prevalence of type 2 diabetes in children is very low despite the rising prevalence of obesity. The estimated incidence is approximately one per 100,000 children per year (1). There are some regions of Canada where the incidence is many times higher than the national average, with different ethnic groups affected (1). Thus, screening for type 2 diabetes in Canadian children must reflect this regional variation and must be limited to children who are carefully selected for risk factors. The current consensus criteria in Canada for defining the risk of type 2 diabetes in children 10 years of age and older are presented in Appendix 1. Screening should only occur in health care settings that have the capacity for comprehensive follow-up of results. Screening children for type 2 diabetes in community settings such as schools, feasts or fairs is not recommended, except under research conditions, such as the study reported by Wahi et al (2) in the present issue of Paediatrics & Child Health. This community-based participatory research project in a remote First Nations community in northern British Columbia is important because it adds to the growing body of evidence supporting the screening guidelines for type 2 diabetes in Canadian children. It must not be used to sanction community-based screening programs. Because many of the Gitga'at First Nations children in Hartley Bay, British Columbia, have a family history of type 2 diabetes, it was good clinical practice to assess the growth parameters of all children at regular clinical visits in the community health centre, and then screen all of the obese children who were 10 years of age and older for type 2 diabetes with a fasting blood glucose, and in some cases, with a blood glucose test 2 h after a 75 g glucose load. What makes this clinical surveillance program in Hartley Bay a research study is that all school-aged children between six and 18 years of age were screened for abnormalities of glucose tolerance and other metabolic markers of insulin resistance, namely hypertension and dyslipidemia. The authors adhered to rigorous ethical principles of participatory clinical research. The clinical practice guidelines that were available at the time of this study for screening for type 2 diabetes in Canadian children recommended that all obese children 10 years of age and older be screened if they had two other risk factors (3). The only difference between the 2003 guideline and the current 2008 guideline is that obesity has been moved to one of the risk factors rather than a mandatory precondition for screening. This reflects the variation in type 2 diabetes in some of the Oji-Cree children of central Canada who have a coexistent genetic decrease in insulin secretion resulting in type 2 diabetes without obesity (4). The Hartley Bay study group was also investigating other metabolic abnormalities associated with obesity and insulin resistance. The use of the term ‘the metabolic syndrome’ in clinical practice to describe these abnormalities is controversial. Many practitioners believe that the term has limited clinical value because each component requires independent surveillance with long-term lifestyle modifications. However, the term continues to be used in research studies. The authors of the Hartley Bay study chose a priori to use the definition for the metabolic syndrome used by the International Diabetes Federation. This choice compelled them to use the definition for impaired fasting glucose (IFG) used by the American Diabetes Association (ADA). Unfortunately, using the ADA definition of IFG (ie, fasting plasma glucose [FPG] = 5.6 mmol/L to 6.9 mmol/L), resulted in an inflated rate of seven children with IFG in the Hartley Bay population compared with only one abnormal result using the Canadian definition of IFG (ie, FPG = 6.1 mmol/L to 6.9 mmol/L). The recent 2008 Canadian guidelines committee considered the evidence for decreasing the lower level of FPG for IFG, and concluded that there were insufficient long-term outcome data to support the lower level used by the ADA. The Hartley Bay study highlights the importance of using the Canadian definition for IFG in clinical practice settings. The natural history and implications of finding IFG in children is not yet established. The authors found no new cases of type 2 diabetes in this screening project. The Hartley Bay study is important for other reasons. It is a long-term community project that will provide important population-based evidence to understand regional differences, particularly regarding remote northern communities. Second, if the project achieves sustainable funding, it may also provide evidence regarding the natural history and implications of a diagnosis of IFG in this population. Third, it ascribes to the principles of community-based participatory research and it involves paediatric residents in data collection in the community. Fourth, it provides support for selective screening for type 2 diabetes only. In this small community, the only two children with abnormal glucose levels were morbidly obese and were 10 years of age and older, and thus, would have been identified in regular clinical practice. Finally, the authors highlight the opportunity for interprofessional partnering with oral health colleagues who can identify children at risk, and whose messages for optimal oral health echo the messages for prevention of obesity and type 2 diabetes. Screening for type 2 diabetes in Canadian children should be encouraged for selected children with risk factors, and should be performed in a health care setting using Canadian standards for diagnosis and follow-up. Children 10 years of age, or younger if puberty is established, should be screened for type 2 diabetes every two years using a fasting plasma glucose test if they have two or more of the following risk factors (Grade D, consensus): Obesity (body mass index greater than or equal to the 95th percentile for age and sex) Member of a high-risk ethnic group and/or family history of type 2 diabetes and/or exposure to diabetes in utero Signs or symptoms of insulin resistance (including acanthosis nigricans, hypertension, dyslipidemia and nonalcoholic fatty liver disease) Impaired glucose tolerance Use of antipsychotic medications/atypical neuroleptics

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