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Frequently Asked Questions - Pediatric Diabetes

What is Pediatric Diabetes Tracking?

Pediatric diabetes tracking, or surveillance, is the ongoing collection, analysis, and interpretation of diabetes data in a population of students in grades K - 8. The Massachusetts Department of Public Health/Bureau of Environmental Health (MDPH/BEH) elected to track diabetes, following the success of the pediatric asthma surveillance program.  This program captures diabetes information in children enrolled in approximately 1900 public, private, and charter schools serving any grades K- 8, in order to learn how much diabetes exists in the state and which communities have a higher prevalence of diabetes, both type 1 and type 2.  This enables the MDPH/BEH to plan targeted public health interventions.

Why is the Massachusetts Department of Public Health tracking pediatric diabetes?

Diabetes is on the rise worldwide. In 2010 an estimated 215,000 Americans younger than age 20 had diabetes, type 1 or type 2.   In the U.S. the prevalence of type 1 diabetes in people 1-19 years of age rose 23% between 2001 and 2009.  Type 1 diabetes occurs equally among males and females but is more common in whites than in nonwhites.   Given this rise in prevalence, diabetes surveillance began in Massachusetts with the 2008-2009 school year in order to measure how much disease exists in the state.

Which schools participate in the MDPH/BEH pediatric diabetes tracking program?

All schools in Massachusetts (public, private, and charter) that enroll children in any of grades kindergarten through 8th are asked to participate in the pediatric diabetes surveillance program. Participation rates have been near 100% (approximately 1900 schools) since collection of diabetes data started in the 2008-2009 school year.

What information is requested from schools?

School nurses or administrative staff report basic information including school name and address and the number of students with types 1, 2, or unknown diabetes.  Aggregate student information also includes gender, grade, race/ethnicity and city/town of residence.  This data enables MDPH/BEH to estimate pediatric asthma prevalence by school, city/town of residence, and county.  No child-specific information that could identify a particular student is ever collected.   Overall participation of public, private, and charter schools is nearly 100% each year.  

What statistic is used to measure the amount of diabetes in a school or community?

In this surveillance summary, prevalence is the statistic used to measure the amount of pediatric diabetes in each school, city/town, or county.  Prevalence in schools is defined as the percentage of enrolled students reported by school nurses to have diabetes during a school year.  Prevalence in communities is defined as the percentage of students who are residents of the community and enrolled in a Massachusetts public or private school reported by school nurses to have diabetes during a school year. School nurses gather this information from the student’s school health record, physician reports, and parent information forms.  Prevalence is presented per 1,000 students and confidence intervals shown indicate the precision of the prevalence estimate.  Note that when less than 6 cases of diabetes (either type) are reported for a city/town and the total population of students within the city/town is less than 1200, “NS” (not shown) is reported due to the small numbers.

How do I interpret prevalence estimates?

To determine if the prevalence in schools and communities is significantly different from the state rate or if the difference may be due solely to chance, a 95% confidence interval (CI) is calculated for each rate.  A 95% CI assesses the magnitude and stability of a rate.  Specifically, a 95% CI is the range of estimated prevalence values that has a 95% probability of including the true prevalence for the population.  One method for determining if one prevalence estimate is statistically significantly different from another is by comparing the confidence intervals.  If the 95% CI for one community or population does not overlap the CI of another, then it can be concluded that the two populations are statistically significantly different from each other.  If they do overlap, then it can be concluded that the two populations are likely not statistically significantly different.  “Statistically significantly different” means that the difference observed between the rates will occur by chance less than 5 percent of the time.  For example, if the prevalence for community A is 5.6 with a 95% confidence interval of 4.8-6.4 and the state prevalence is 10.2 with a confidence interval of 10.0-10.4, when the two intervals are compared, the interval for community A does not fall within the range of the state confidence interval.  Therefore, it is concluded that community A’s prevalence estimate of 5.6 is statistically significantly different than the state rate of 10.2.  And because community A’s rate is lower than the state’s, it can be concluded that the community’s rate is statistically significantly lower than the state rate.   

Are there certain limitations about the data to be aware of?

Yes. These data are for children in grades kindergarten through 8th only. It is important to note that community-based prevalence estimates are based on the residential location of the student. School-based prevalence estimates are based on all children attending that school, which may in some instances include students from multiple cities/towns. Prevalence is not age-adjusted and therefore some of the observed differences in prevalence estimates between communities may be due to differences in the age distribution of students in each community. Also please keep in mind that a variety of factors (genetic and environmental) may impact the prevalence of diabetes.

What is the relationship between diabetes and environmental factors?

Type 1 diabetes is diagnosed more often in children and young adults whereas type 2 is more prevalent in adults but can occur in children.  Type 1 is thought to be an autoimmune disease or triggered by a virus but a clear cause is unknown.  Possible risk factors for type 1 diabetes include genetics and environmental exposures. However, research suggests that in the case of identical twins, if one twin has type 1 diabetes, the other twin may get the disease only half the time at most.  Environmental causes of type 1 diabetes may be related to diet such as the early or late introduction of certain foods (e.g., cow’s milk, dietary gluten, or vitamin D) and drinking water that contains nitrates, or may be related to the perinatal period of development.  Viral infections such as congenital rubella virus and human enteroviruses (e.g., coxsackie) which can infect the beta cells of the pancreas have been hypothesized as possible causes.  An increase in psychological stress has also been suggested as an environmental cause. Type 1 diabetes is usually controlled with insulin injections, diet, and exercise.  People with type 1 diabetes need to take insulin for the rest of their life.

Type 2 diabetes also has a genetic basis with the likelihood of the disease being approximately 3 in 4 for identical twins if their twin sibling is diagnosed with type 2 diabetes.  Research into the role of Persistent Organic Pollutants (e.g., dioxin, PCBs, chlorinated pesticides, etc.) suggest a possible association between exposure to POPs and diabetes in adults but little research has been conducted on children to date.  POPs may alter insulin action, however a specific mechanism is not known.  Air pollution, specifically exposure to particulate matter (PM2.5) may contribute to diabetes prevalence in adults but no information exists for children at this time.  According to the American Diabetes Association, being overweight is a risk factor for developing type 2 diabetes, but other risk factors related to family history, ethnicity, and age can also play a role. Treatment for people with type 2 diabetes includes insulin pills or injections, healthy eating, and increased physical activity.

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