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Reducing Cardiovascular Risk in the Insulin Resistant Patient
Module 5: Insulin Resistance - Focus on Children & Families
1 CE Credit
Release Date: January 2007
COURSE OVERVIEW:
The epidemic of overweight and obesity in children and adolescents in the US has focused increased attention on Insulin Resistance (IR), type 2 diabetes (T2DM), and risk factors for CVD in this population group. This module presents an overview of the research that has informed current recommendations for identifying and assessing children at risk for IR and related comorbidities. Individual/clinical and population-based approaches to the prevention of overweight and obesity are addressed with emphasis on strategies designed to promote heart-healthy patterns of dietary intake and physical activity.
PRESENTERS:
Laura L. Hayman, PhD, RN, FAAN
Associate Dean for Research and Professor of Nursing
College of Nursing & Health Sciences
University of Massachusetts Boston
Boston, MA

PRESENTER BIO:
Dr. Laura Hayman is the Associate Dean for Research and Professor of Nursing in the College of Nursing and Health Sciences at the University of Massachusetts Boston Dr. Hayman's research/scholarship and clinical practice focus on primary prevention of cardiovascular disease with emphasis on health promotion and risk reduction in children, adolescents, and families. Dr. Hayman has served on numerous national, interdisciplinary advisory and expert panels relevant to primary prevention of obesity and cardiovascular disease in childhood and adolescence. Currently, she is on the editorial boards of Annals of Behavioral Medicine, Journal of Cardiovascular Nursing, Progress in Cardiovascular Nursing and the American Journal of Maternal-Child Nursing. Dr. Hayman has been a member of PCNA's Board of Directors since 1997.

COURSE EDITORS:
Joanna D. Sikkema, MSN, ARNP
Carol M. Mason, ARNP, FAHA
CE Course Outline

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Step 1: Take Course
Step 2: Take CE Exam
Step 3: Quick Evaluation
Step 4: Print CE Certificate


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EDUCATIONAL OBJECTIVES:
Upon completion of this program, participants will be able to:
  1. Discuss evidence linking obesity, insulin resistance (IR), insulin resistance syndrome, (IRS), type 2 diabetes mellitus (T2DM) and accelerated atherosclerotic-cardiovascular disease processes in children and youth
  2. Describe currently recommended strategies for identifying and assessing children and adolescents at risk for IR and related comorbidities
  3. Describe current recommendations for individual and family-focused prevention of overweight and obesity children and adolescents
  4. Discuss nursing implications relevant to population-based approaches to prevention of overweight in childhood and adolescence
AUDIENCE:
The audience for this course consists of nurses and nurse practitioners specializing in cardiovascular disease prevention and management.

PRESENTER DISCLOSURES:
The presenter has no commercial relationships to disclose.

SPONSOR/ACCREDITOR:
This activity is sponsored by the Preventive Cardiovascular Nurses Association (PCNA). PCNA is approved as a provider of nurse practitioner continuing education by the American Academy of Nurse Practitioners (AANP) - provider number 030602. PCNA will provide 1 contact hour of continuing education for this program.

GRANTOR:
This continuing education activity is supported by unrestricted educational grants from KOS Pharmaceuticals and Cholestech Corporation.

COST:
This online educational activity is offered free of charge.

PARTICIPATION IN THE ACTIVITY AND RECEIPT OF CERTIFICATE OF CREDIT:
Complete the online course, online exam, and the evaluation form; and submit your results electronically. Exams will be graded and results displayed instantaneously. Participants who receive a passing score of 80% or higher will receive an electronic, printable certificate of completion following the exam. Participants will have 2 opportunities to successfully complete the exam.

MODULE 5 REFERENCES:

  • ADA, Pediatrics, 2000;105,671-80; Hannon et al.,Pediatrics,2005;116:473-80. (Slide # 21)
  • Chi CH , Wang Y, Wilson DM, Robinson TH. J Pediatr. 2006;148:788-792. (Slides # 9 & 10)
  • Daniels et al. (2005) Circulation., 111:1999-2012. (Slides # 31-33)
  • Daniels et al. AAP, Pediatrics. 2003;112:424-430.
  • Fagot-Campagna et al., J Pediatr, 2000; 136:664-72. (Slide # 20)
  • Gidding et al., Circulation. 2005;112: 2061-2075. (Slide # 34)
  • Preventing Childhood Obesity; IOM publication; National Academies Press, 2004, Page 97. (Slide # 40)
  • Steinberger J, Daniels SR. Circulation. 2003;107:1448-1453 (AHA Scientific Statement, in revision, 2006) (Slides # 24-28)
  • Chen W, Srinivasan SR, Elkasabany A, Berenson GS. Cardiovascular risk factors clustering features of insulin resistance syndrome (Syndrome X) in a biracial (Black-White) population of children, adolescents, and young adults: The Bogalusa Heart Study. Am J Epidemiol. 1999;150:667-674.
  • Raitakari OT, Porkka KV, Ronnemaa T, Kinip M, Uhari M, Akerblom HK, et al. The role of insulin in clustering of serum lipids and blood pressure in children and adolescents. The Cardiovascular Risk in Young Finns Study. Diabetologia. 1995;38:1042-1050.
  • Lambert M, Paradis G, O&rquot;Loughlin J, Delvin EE, Hanley JA, Levy E. Insulin resistance syndrome in a representative sample of children and adolescents from Quebec, Canada. Int J Obes Relat Metab Disord. 2004; 28:833-841.
  • Weiss R, Dziura J, Burget TS, Tamborlane WV, Takasali SE, Yeckel CW, et al. Obesity and the metabolic syndrome in children and adolescents. N Engl J Med. 2004; 350:2362-2374.
  • Sinaiko A, Steinberger J, Moran A, Prineas RJ, Jacobs DR. Relation of BMI and insulin resistance to cardiovascular risk factors, inflammatory factors and oxidative stress during adolescence. Circulation. 2005;111: 1985-1991.
  • Goodman E, Daniels SR, Morrison JA, Huang B, Dolan LM. Contrasting prevalence of and demographic disparities in the World Health Organization and National Cholesterol Education Program Adult Treatment Panel III definitions of metabolic syndrome among adolescents. J Pediatr. 2004; 145:445-451.
  • Chi CH , Wang Y, Wilson DM, Robinson TH. J Pediatr. 2006;148:788-792
  • Steinberger J, Daniels SR. Obesity, insulin resistance, diabetes and cardiovascular risk in children. An American Heart Association Scientific Statement from the Atherosclerosis, Hypertension, and Obesity in the Young Committee (AHOY), Council on Cardiovascular Disease in the Young, and the Diabetes Committee, Council on Nutrition, Physical Activity and Metabolism. Circulation. 2003;107: 1448-1453.
  • Note: Revision of this statement is in progress, (Steinberger J et al., 2006), and will be published in Circulation.
  • American Academy of Pediatrics (AAP). Policy Statement. Prevention of pediatric overweight and obesity. Pediatrics. 2003;112:424-430.
  • Goodman E, Daniels SR, Morrison JA, Huang B, Dolan LM. Contrasting prevalence of and demographic disparities in the World Health Organization and National Cholesterol Education Program Adult Treatment Panel III definitions of metabolic syndrome among adolescents. J Pediatr. 2004; 145:445-451.
  • Goran Mi, Bergman RN, Cruz ML, Watanabe R. Insulin resistance and associated compensatory responses in African-American and Hispanic children. Diabetes Care. 2002; 25:2184-2190.
  • Jiang S, Srinivasan SR, Radhakrishnamurthy B, Dalferes ER, Berenson GS. Racial (Black-White) differences in insulin secretion and clearance in adolescents: The Bogalusa Heart Study. Pediatrics. 1996;97:357-360.
  • Arslanian S, Suprasongsin C, Janosky JE. Insulin secretion and sensitivity in Black versus White prepubertal healthy children. J Clin Endocrino Metab. 1997;82(6):1923-1927.
  • Bacha F, Gunghor N, Janosky JE, et al. Obesity, regional fat distribution, and syndrome X in obese black versus white adolescents: Race differential in diabetogenic and atherogenic risk factors. J Clin Endocrinol Metab. 2003; 88: 2534-2540 (Reference for slide # 12)
  • Whitaker RC, Dietz WH. Role of the prenatal environment in the development of obesity. J Pediatr. 1998;132:768-776.
  • Parsons TJ, Power C, Logan S, et al. Childhood predictors of adults obesity: A systematic review. Int J Obes Relat Metab Disord. 199;23 (suppl 8): 1S-107S.
  • Mi J, Law C, Zhang KL, et al. Effects of infant birth weight and maternal body mass index in pregnancy on components of the insulin resistance syndrome in China. Ann Intern Med. 2000; 132:253-260.
  • Barker M, Robinson S, Osmond C, et al. Birth weight and body fat distribution in adolescent girls. Arch Dis Child. 1997;77:381-383.
  • Barker DJP. Mothers, Babies, and Health in Later Life. 2nd ed. Edinburgh, UK: Churchill Livingstone, 1998.
  • Bhargava SK, Dachdev AS, Fall CH, et al. Relation of serial changes in childhood body-mass index to impaired glucose tolerance in young adulthood. N Engl J Med. 2004;350:865-875.
  • Stettler N, Zemel BS, Kumanyika S, et al. Infant weight gain and childhood overweight status in a multicenter cohort study. Pediatrics. 2002;109:194-199.
  • Bao W, Srinivasan SR,Valdez R, Greenlund KJ, Wattigney WA, Berenson GS. Longitudinal changes in cardiovascular risk from childhood to young adulthood in offspring of parents with coronary artery disease: The Bogalusa Heart Study. JAMA. 1997;278:1749-1754.
  • Pankow JS, Jacobs DR, Steinberger J, Moran A, Sinaiko AR. Insulin resistance and cardiovascular disease risk factors in children of parents with the insulin resistance (metabolic) syndrome. Diabetes Care. 2004;27:775-780.
  • Lillioja S, Mott D, Zawadzki J, Young A, Abbot W, Knowler W. In vivo insulin action is familial characteristic in nondiabetic Pima Indians.Diabetes. 1987;36:1329-1335.
  • Ho L, Chang Z, Wang J, Li S, Liu Y, Chen YD. Insulin sensitivity in offspring of parents with type 2 diabetes mellitus. Diabetic Medicine. 1990;7:31-34.
  • Danadian K, Balasekaran G, Lewy V, Meza MP, Robertson R, Arslanian SA. Insulin sensitivity in African-American children with and without family history of type 2 diabetes. Diabetes Care. 1999;22:1325-1329.
  • Carmelli D, Cardon LR, Fabsitz R. Clustering of hypertension,diabetes, and obesity in adult male twins: Same genes or same environments? Am J Hum Genet. 1994;55: 566-573.
  • Shear CL, Webber LS, Freedman DS, Srinivasan SR, Berenson GS. The relationship between parental history of vascular disease and cardiovascular disease risk factors in children: The Bogalusa Heart Study. Am J Epidemiol. 1985;122:762-771.
  • Mitchell BD, Kammerer CM, Mahaney MC, Blangero J, Comuzzie AG, Atwood LD, et al. Genetic analysis of the IRS. Pleiotropic effects of genes influencing insulin levels on lipoprotein and obesity measures. Arterioscler Thromb Vasc Biol. 1996;16 (2): 281-288.
  • Report of the Expert Panel on Blood Cholesterol Levels in Children and Adolescents. Pediatrics. 1992; 89 (suppl): 529-594.
  • Kavey RE, Daniels, SR, Lauer RL, Atkins DL, Hayman LL, Taubert K. American Heart Association guidelines for primary prevention of atherosclerotic cardiovascular disease beginning in childhood. Circulation. 2003;107:1562-1566.
  • Daniels SR, Arnett DK, Eckel RH, Gidding SS, Hayman LL, Kumanyika S, Robinson TH, Scott BJ, St. Jeor S, Williams CL. Overweight in children and adolescents: Pathophysiology, consequences, prevention and treatment. Circulation. 2005; 111:1999-2012.
  • Freedman DS, Dietz WH, Srinivasan SR, et al. The relation of overweight to cardiovascular risk factors among children and adolescents: The Bogalusa Heart Study. Pediatrics. 1999;103 (6 pt 1):1175-1182.
  • Viner P, Segal T, Lichtarowicz-Krynska F, Hindmarsh P. Prevalence of the insulin resistance syndrome in obesity. Arch Dis Child. 2005;90:10-14.
  • Hayman LL, Meininger JC, Coates PM, et al. Nongenetic influences of obesity on risk factors for cardiovascular disease during two phases of development. Nursing Research. 1995;44 (5):277-283.
  • Chen W, Bao W, Begun S, et al. Age-related patterns of clustering of cardiovascular risk variables of Syndrome X from childhood to adulthood in a population made up of Black and White subjects: The Bogalusa Heart Study. Diabetes. 2000;49 (6): 1042-1048.
  • Ford ES, Galuska D, Gillespie C, et al. C-reactive protein concentration and cardiovascular disease risk factors in children: Findings from the National Health and Nutrition Examination Survey, 1999-2000. Circulation. 2003;108:1053-1058.
  • Cook DG, Mendall MA, Whincup PH, et al. C-reactive protein concentration in children: Relationship to adiposity and other cardiovascular risk factors. Atherosclerosis. 2000;149:139-150.
  • Sinaiko A, Steinberger J, Moran A, Prineas RJ, Jacobs DR. Relation of BMI and insulin resistance to cardiovascular risk factors, inflammatory factors and oxidative stress during adolescence. Circulation. 2005;111:1985-1991.
  • Kissebah AH, Krakower GR. Regional adiposity and morbidity. Physiol Rev. 1994;24:761-811.
  • Bjorntorp P. Abdominal fat distribution and disease:An overview of epidemiological data. Ann Med. 1992;24: 15-18.
  • Wajchenberg BL. Subcutaneous and visceral adipose tissue: Their relation to the metabolic syndrome. Endocr Rev. 2000;21:697-738.
  • Goran MI, Gower BA. Abdominal obesity and cardiovascular risk in children. Coron Artery Dis. 1998; 9 (8):483-487.
  • Kahn HS, Imperatore G, Cheng YJ. A population-based comparison of BMI percentiles and waist-to-hip ratio for identifying cardiovascular risk in youth. J Pediatr.2005;146:482-488.
  • Hara M, Saitou E, Iwata F, Okada T, Harada K. Waist-to-height ratio is the best predictor of cardiovascular disease risk factors in Japanese school children. J of Athero and Thromb. 2002;9:127-132.
  • Savva SC, Tornaritis M,Savva ME, Kourides Y, Panagi A, Silikiotou N, Georgiou C, Kafatos A. Waist circumference and waist-to-height ratio are better predictors of cardiovascular disease risk factors in children than body mass index. Int J Obes. 2000;24:1453-1458.
  • Fagot-Campagna A, Flegal KM, Saadine JB, et al. Diabetes, impaired fasting glucose, and elevated HbA1c in US adolescents: The Third National Nutrition and Health Examination Survey. Diabetes Care. 2001;24:834-837.(Reference for slide # 20)
  • Pinhas-Hamiel O, Dolan LM, Daniels SR, et al. Increased incidence of non-insulin dependent diabetes mellitus among adolescents. J Pediatr. 1996;128:608-615.
  • Pinhas-Hamiel O, Zeitler P. The global spread of type 2 diabetes mellitus in children and adolescents. J Pediatr. 2005;116:1178-1182.
  • Diabetes in children and adolescents work group of the National Diabetes Education program. An update on type 2 diabetes in youth from the National Diabetes Education Program. Pediatrics. 2004;114:259-262.
  • American Diabetes Association (ADA). Type 2 diabetes in children and adolescents. Diabetes Care. 2000;23 (3):389.
  • Hannon TS, Goutham R, Arslanian SA. Childhood obesity and type 2 diabetes mellitus. Pediatrics. 2005;116:473-480.
  • Moran A, Jacobs DR, Steinberger J, et al. Insulin resistance during puberty: Results from clamp studies in 357 children. Diabetes. 1999;48:2039-2044.
  • Ebbeling CB, Leidig MM, Sinclair KB, et al. A reduced glycemic load diet in the treatment of adolescent obesity. Arch Pediatr Adol Med. 2003;157:773-779. (HOMA model in adolescent IR).
  • Gidding S, Dennison BA, Birch LL, et al. Dietary recommendations for children and adolescents: A guide for practitioners. Consensus Statement from the American Heart Association. Circulation. 2005;112:2061-2075.
  • Hayman LL. Putting research into practice. Pediatric Basics. 2003;101:7
  • Hayman LL, Reineke, PR. Promoting cardiovascular health in children and adolescents. Journal of Cardiovascular Nursing. 2006;21(4):269-275.
  • Ockene IR, Hayman LL. Pasternak RC, et al. Adherence issues and behavior change: Achieving a long term solution. J Am Coll Cardiol. 2002;40(4):49-59.
  • Harrell JS, Jessup A, Greene N. Changing our future: Obesity and the metabolic syndrome in children and adolescents. Journal of Cardiovascular Nursing. 2006;21(4):322-330.
  • Hayman LL, Williams CL, Daniels SR, et al. Cardiovascular health promotion in the schools: A statement for health and education professionals and child health advocates from the Committee on Atherosclerosis, Hypertension, and Obesity in Youth (AHOY) of the council on Cardiovascular Disease in the young, American Heart Association. Circulation. 2004;110:2266-2275.
  • McGinnis JM, Kraak VI. Food Marketing to Children and Youth: Threat or Opportunity? Institute of Medicine of the National Academies. Washington, DC: The National Academies Press, 2006.
  • S.2507. Child Nutrition and WIC Reauthorization Act of 2004. Sec 204. Local Wellness Policy. 2004. Available from: http://www.schoolwellnesspolicies.org/resources/Section204LocalWellnessPolicies.pdf
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