Table 4.

Summary of Support for Practices in Childhood Obesity Treatment for Prediabetes

Practice	Evidence quality A=well-designed randomized trials or diagnostic studies B=trials with minor limitations; overwhelmingly consistent observational studies C=observational studies or controlled trials with major limitations D=expert opinion, case reports, reasoning from first principles	Balance of benefits to harms -Clear preponderance of benefits over harms -Benefits outweigh harms -Unclear -Harms outweigh benefits	Current practice in obesity treatment programs -Consistent -Varied -Not reported on this survey	Support for practice -Strongly support -Support -Option to consider -No position -Do not support Comments on need for further study
Overweight children with cardiometabolic comorbidity and obese children should be screened for prediabetes or type 2 diabetes after age 10 years or after onset of puberty.	D Treatment of obesity in children with prediabetes or insulin resistance results in improvement of prediabetes and/or insulin resistance,69,70 but no study has examined prevention of progression to T2DM in children. Consistent with Expert Committee Recommendations.32	Benefits outweigh harms Harms: Financial cost, test-related anxiety, risk of false positives Benefits: The benefit of lifestyle intervention for prediabetes in adults is documented; the benefit of screening and preventive treatment is not as well known in adolescents. Programs may target limited weight management resources to those at highest risk.	Consistent: Testing was reported by all centers. Varied: Centers varied with regard to screening criteria by BMI status, age, and other risk factors.	Support Large, prospective trials are needed to determine the effect of weight management treatment for prevention of progression from prediabetes to T2DM. Additional study is needed testing the effectiveness of treatment for T2DM that is identified early through targeted screening.
Fasting plasma glucose, hemoglobin A1c (A1c), and OGTT can be used to screen for prediabetes in children presenting to tertiary weight management programs.	B Studies support use of these tests in making a diagnosis, but they are limited by small sample sizes or extrapolation from studies in adults. Test cutoffs are not as well validated in children, especially for prediabetes.	Benefits outweigh harms Harms: Financial cost and risk of false positives/ negatives Benefits: Sensitivity, specificity, cost, and convenience vary by test (see Table 2).	Consistent: Most centers use both A1c and fasting glucose. Varied: Varied BMI and age cutoffs are used to initiate screening; follow-up testing protocols also vary in frequency and choice of test.	Support Recognizing the clinician's option to select from one or more of the available tests Further research is needed to define the testing protocol with maximum sensitivity and specificity at lowest relative cost.
Testing for insulin resistance using fasting insulin and/or HOMA-IR	D Evidence is lacking about the benefits of using insulin screening.	Harms outweigh benefits Harms: Financial cost, lack of standardization in laboratory measures Benefits: Unknown; there is a lack of evidence to support changes in management based on insulin level; insulin level does not predict progression to T2DM; low insulin can reflect either improved insulin resistance or beta cell failure.	Varied: Majority of programs tested insulin, but based on variable criteria of BMI and comorbidity. Some centers have collected this as part of a research study and a few use this as a criteria to treat with metformin.	Do not support Further study is needed to determine the value of laboratory measurement of insulin for prognosis or targeting of interventions. Costs currently outweigh lack of known benefit.
Use of metformin to prevent progression of prediabetes to T2DM	C Metformin is less effective than intensive lifestyle management in adults. Consistent observational evidence shows reversion to normoglycemia in a high proportion of prediabetic youth without medication.	Unclear Harms: Medication cost given the prevalence of prediabetes is relatively high; short- and long-term adverse effects. Benefits: Unknown because T2DM prevalence is low and effect of metformin on prevention of T2DM in prediabetic children is unknown.	Varied: More than one third of programs (39%) prescribe metformin.	No position Further study of medication effects on T2DM prevention is needed, including establishing endpoints for terminating medication. A large number of youth at high risk for T2DM would need to be enrolled in a definitive study.
Low glycemic index diet to treat prediabetes in obese youth	B Small, high-quality studies consistently show metabolic improvement with low glycemic load diets.	Benefits outweigh harms Harms: Cost of dietary instruction, financial costs to families associated with changing diets Benefits: Metabolic improvement, potential weight loss	Not reported	Support Further study is needed to quantify the effects of low glycemic index diets and other diets, including very-low-carbohydrate diets, on T2DM prevention.
Increased moderate-to-vigorous activity to treat prediabetes in obese youth	B Physical activity is consistently correlated with better glucose regulation in obese children, independent of weight loss.	Clear preponderance of benefits over harms Harms: Risk of injury, time required for exercise Benefits: Metabolic improvement, potential weight loss, other health advantages of exercise	Not reported	Strongly support Further study is needed to quantify the effects of exercise dose and type on T2DM prevention in children.
Pediatric psychologists, or other behavioral health specialists, should be included on teams treating children with prediabetes or diabetes.	C High rates of psychological comorbidity exist among children with prediabetes/ diabetes. Behavior change is the mainstay of effective weight management, with evidence to support its effectiveness.	Clear preponderance of benefits over harms Harms: Cost Benefits: May improve weight outcomes, address psychopathology	Not reported	Strongly support Multidisciplinary team treatment including behavioral specialists is the standard of care for stage 3 and 4 treatment of obesity.32
Weight management specialists co-manage T2DM with a pediatric endocrinologist	D This practice is recommended by the AAP clinical practice guideline: “Management of Newly Diagnosed Type 2 Diabetes Mellitus (T2DM) in Children and Adolescents.”108	Benefits outweigh harms Harms: Cost Benefits: Expertise in medication management and surveillance for medications that are used infrequently by general pediatricians	Consistent: Weight management programs that do not include endocrinologists typically refer for T2DM, but not prediabetes	Support Pediatric weight management specialists may not be familiar with medication management of T2DM. Pediatric endocrinologists may not be available in all areas. Further study should evaluate how best to facilitate co-management in areas where subspecialists are lacking (e.g., telemedicine).

HOMA-IR, homeostatic model assessment for insulin resistance; T2DM, type 2 diabetes mellitus; A1c, glycosylated hemoglobin; OGTT, oral glucose tolerance test; AAP, American Academy of Pediatrics.