Alberta S. Kong

Acanthosis Nigricans and Diabetes Risk Factors: Prevalence in Young Persons Seen in Southwestern US Primary Care Practices

PURPOSE Evidence shows acanthosis nigricans is often associated with hyperinsulinemia and may indicate increased risk of type 2 diabetes mellitus. The purpose of this study was to determine the association of acanthosis nigricans with type 2 diabetes risk factors and disease in young persons. METHODS We conducted a cross-sectional study in the Research in Outpatient Settings Network, a practice-based research network in southwestern US communities. Participating clinicians (N = 96) collected data on children and young adults aged 7 to 39 years seen during a 2-week sampling period. The main outcomes were the prevalence of acanthosis nigricans, type 2 diabetes risk factors (ethnicity, family history of type 2 diabetes, hypertension, overweight/obesity), type 2 diabetes, and the relationships among these. RESULTS Among 1,133 patients sampled, risk factors for type 2 diabetes were common: 69% had a family history of the disease; 3% of children (aged 7 to 19 years) and 12% of adults had hypertension; 43% of children and 73% of adults were overweight or obese; and 80% were members of ethnic minorities. Acanthosis nigricans was found in 17% of children and 21% of adults. Among children and adults alike, the more type 2 diabetes risk factors that were present, the higher the prevalence of acanthosis nigricans (P <.001). The prevalence ratio for type 2 diabetes in patients with acanthosis nigricans was 1.97 (95% confidence interval, 1.18–3.27; P = .01) after controlling for age, body mass index, and the number of type 2 diabetes risk factors. Clinicians reported that the identification of acanthosis nigricans frequently led to discussions about lifestyle modification for decreasing the risk of type 2 diabetes. CONCLUSIONS Patients with acanthosis nigricans are likely to have multiple risk factors for type 2 diabetes. Acanthosis nigricans may be an independent risk factor for this disease. Detection of acanthosis nigricans may help clinicians more rapidly identify high-risk individuals for diabetes counseling.

Acanthosis Nigricans: High Prevalence and Association with Diabetes in a Practice-based Research Network Consortium—A PRImary care Multi-Ethnic Network (PRIME Net) Study

Background: Previous work has established a surprisingly high prevalence of acanthosis nigricans (AN) and its association with increased risk of type 2 diabetes in a Southwestern practice-based research network (PBRN). Our objective was to establish whether this high prevalence of AN would be present in other areas. Methods: We examined the prevalence of type 2 diabetes and its risk factors and the prevalence of AN among patients aged 7 to 65 years who had been seen by one of 86 participating clinicians in a national PBRN consortium during a 1-week data collection period. In a subsample of nondiabetic matched pairs who had or did not have AN, we compared fasting glucose, insulin, and lipid levels. Results: AN was present in 19.4% of 1730 patients from among all age ranges studied. AN was most prevalent among persons with more risk factors for diabetes. Patients with AN were twice as likely as those without AN to have type 2 diabetes (35.4% vs 17.6%; P < .001). In multivariable analysis, the prevalence ratio for diabetes was 2.1 (95% CI, 1.3–3.5) among non-Hispanic whites with AN and 1.4 (95% CI, 1.1–1.7) among minority patients with AN. In a subsample of 11 matched pairs, those with AN had higher levels of insulin and insulin resistance. Conclusions: We found high rates of AN among patients in primary care practices across the country. Patients with AN likely have multiple diabetes risk factors and are more likely to have diabetes.

School-Based Health Center Intervention Improves Body Mass Index in Overweight and Obese Adolescents

Adolescents Committed to Improvement of Nutrition and Physical Activity (ACTION) was undertaken to determine feasibility of a school-based health center (SBHC) weight management program. Two urban New Mexico SBHCs were randomized to deliver ACTION or standard care. ACTION consisted of eight visits using motivational interviewing to improve eating and physical activity behavior. An educational nutrition and physical activity DVD for students and a clinician toolkit were created for use as menu of options. Standard care consisted of one visit with the SBHC provider who prescribed recommendations for healthy weight. Sixty nondiabetic overweight/obese adolescents were enrolled. Measures included BMI percentile, waist circumference, insulin resistance by homeostasis model assessment (HOMA-IR), blood pressure, triglycerides, and HDL-C levels. Pre- to postchanges for participants were compared between groups. Fifty-one students (mean age 15 years, 62% female, 75% Hispanic) completed pre- and postmeasures. ACTION students (n = 28) had improvements in BMI percentile (P = 0.04) and waist circumference (P = 0.04) as compared with students receiving standard care (n = 23). No differences were found between the two groups in blood pressure, HOMA-IR, triglycerides, and HDL-C. The ACTION SBHC weight management program was feasible and demonstrated improved outcomes in BMI percentile and waist circumference.

An Adaptive Community-Based Participatory Approach to Formative Assessment with High Schools for Obesity Intervention.

BACKGROUND In the emerging debate around obesity intervention in schools, recent calls have been made for researchers to include local community opinions in the design of interventions. Community-based participatory research (CBPR) is an effective approach for forming community partnerships and integrating local opinions. We used CBPR principles to conduct formative research in identifying acceptable and potentially sustainable obesity intervention strategies in 8 New Mexico school communities. METHODS We collected formative data from 8 high schools on areas of community interest for school health improvement through collaboration with local School Health Advisory Councils (SHACs) and interviews with students and parents. A survey based on formative results was created to assess acceptability of specific intervention strategies and was provided to SHACs. Quantitative data were analyzed using descriptive statistics while qualitative data were evaluated using an iterative analytic process for thematic identification. RESULTS Key themes identified through the formative process included lack of healthy food options, infrequent curricular/extracurricular physical activity opportunities, and inadequate exposure to health/nutritional information. Key strategies identified as most acceptable by SHAC members included healthier food options and preparation, a healthy foods marketing campaign, yearly taste tests, an after-school noncompetitive physical activity program, and community linkages to physical activity opportunities. CONCLUSION An adaptive CBPR approach for formative assessment can be used to identify obesity intervention strategies that address community school health concerns. Eight high school SHACs identified 6 school-based strategies to address parental and student concerns related to obesity.

Beta-Test Results for an HPV Information Web Site: GoHealthyGirls.org—Increasing HPV Vaccine Uptake in the United States

A Web site, GoHealthyGirls, was developed to educate and inform parents and their adolescent daughters about human papillomavirus (HPV) and HPV vaccines. This article provides an overview of web site development and content followed by the results of a beta-test of the Web site. Sixty-three New Mexican parents of adolescent girls tested the site. Results indicated that GoHealthyGirls was a functioning and appealing Web site. During this brief educational intervention, findings suggest that the Web site has the potential to increase HPV vaccine uptake. This research supports the Internet as a valuable channel to disseminate health education and information to diverse populations.

Acanthosis nigricans predicts the clustering of metabolic syndrome components in Hispanic elementary school-aged children

Abstract Background: Acanthosis nigricans (AN) is a dermatologic condition associated with hyperinsulinemia, a marker of insulin resistance that is the principal abnormality in metabolic syndrome (MetS). We examined the association of AN with the clustering of MetS components. Methods: A cross-sectional study was conducted in an urban school-based health center in New Mexico. Students without diabetes were evaluated for AN, a family history of type 2 diabetes, body mass index (BMI), and MetS components. The clustering of MetS components by BMI category and AN status was assessed by comparing the group means of summed average z-scores of fasting insulin, triglycerides, high-density lipoprotein-cholesterol, and systolic blood pressure among the students. A multivariate model with BMI category and AN status controlling for Tanner stage was performed to identify the variables associated with the clustering of MetS components. Results: Complete data were available for 90 children (age, 9.7±1.4 years; 94% Hispanic; 60% female). In multivariate modeling of MetS cluster z-score, significant differences were found between the students with BMI <85th percentile [–0.27; 95% confidence interval (95% CI)=–0.42 to –0.11] and (a) the students with BMI 85th–94.9th percentile with AN (0.74; 95% CI=0.17–1.31) and (b) the students with BMI ≥95th percentile with AN (0.86; 95% CI=0.54–1.18). No significant differences in the MetS cluster z-score were seen between the students with BMI <85th percentile and those with BMI 85th–94.9th percentile without AN (0.24; 95% CI=–0.33 to 0.81) or those with BMI ≥95th percentile without AN (0.31; 95% CI=–0.13 to 0.75). Conclusions: Overweight/obese Hispanic elementary school-aged children with AN exhibit clustering of MetS components and could benefit from early intervention.

Internet-based Training in a Practice-based Research Network Consortium: A Report from the Primary Care Multiethnic Network (PRIME Net)

Background: Continuing growth of the research spectrum of practice-based research networks (PBRNs) creates a need (1) for new approaches to training clinicians in research protocols and (2) to standardize clinician data collection. Each existing training method has shortcomings when used in geographically dispersed PBRNs. We describe here the use and costs of Internet-based training in support of a research protocol across a PBRN consortium. Methods: Clinicians in 4 PBRNs in the PRIME Net consortium participated in training for a study of acanthosis nigricans (AN). We compared results of pre- and posttraining assessments of knowledge and ability to correctly diagnosis AN. We also calculated costs for placement of the training on the Internet. Results: Among 103 participating clinicians, statistically significant increases in knowledge acquisition were demonstrated for all but 2 of the individual topics and in total scores on the assessments. AN diagnostic sensitivity increased from 52% to 99% to 96% to 100%, whereas specificity increased from 70% to 96% to 74% to 97%. Total costs for the web aspects of the training were

An Adaptive CBPR Approach to Create Weight Management Materials for a School-Based Health Center Intervention

3732. Conclusion: The Internet can be an effective and feasible alternative method for training clinicians in support of PBRN research.

A Pilot Walking School Bus Program to Prevent Obesity in Hispanic Elementary School Children: Role of Physician Involvement With the School Community

Purpose. From our previous clinical work with overweight/obese youth, we identified the need for research to create an effective weight management intervention to address the growing prevalence of adolescent metabolic syndrome. Formative assessment through an adaptive community-based participatory research (CBPR) approach was conducted toward the development of a nutritional and physical activity (DVD) and clinician toolkit for a school-based health center (SBHC) weight management intervention. Methods. We first conducted parent and adolescent interviews on views and experiences about obesity while convening a community advisory council (CAC) recruited from two participating urban New Mexico high schools. Thematic findings from the interviews were analyzed with the CAC to develop culturally and developmentally appropriate intervention materials. Results. Themes from the parent and adolescent interviews included general barriers/challenges, factors influencing motivation, and change facilitators. The CAC and university-based research team reached consensus on the final content of nutrition and physical activity topics to produce a DVD and clinician toolkit through six monthly sessions. These materials used in the SBHC intervention resulted in a greater reduction of body mass index when compared to adolescents receiving standard care. Conclusions. Formative assessment using an adaptive CBPR approach resulted in the creation of culturally and age appropriate weight reduction materials that were acceptable to study participants. This trial is registered with ClinicalTrials.gov NCT00841334.

Training Primary Care Providers in the Use of Motivational Interviewing for Youth Behavior Change

Forty-three percent of Hispanic children, 6 to 11 years old, in the United States are overweight or obese.1 Minority status and poverty in urban communities have been found to contribute to childhood obesity.2,3 Given the clear role of environmental contributors to obesity, physicians are increasingly asked to go beyond their clinical practice to support school and community programs that help prevent obesity.4 The Walking School Bus (WSB), an innovative program designed to cut down on traffic congestion while providing a safe way to walk children to school, may offer clinicians a novel approach to obesity prevention.5 Walking to school is an affordable mode of transportation that may help reduce the high prevalence of childhood obesity.6 This brief report outlines principal findings from a pilot WSB program used by school-based health center physicians in collaboration with their school and community. Full details of implementation are reported elsewhere.7 The University of New Mexico School-Based Health Center (UNM SBHC) provides primary care to a predominantly Hispanic elementary school located in the zip code area with the highest percentage of families less than 185% of the federal poverty level in Albuquerque. Student obesity was voiced as a concern by parents and teachers to SBHC physicians at the elementary school. This prompted UNM SBHC to collaborate with the school and community to test the feasibility of a modified WSB program as a strategy to prevent obesity among the elementary school students.