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That dark patch may be a red flag

KINGWOOD, W.Va. -- When Aubrey Duckworth was 10 years old, West Virginia University's CARDIAC screeners came to Preston County's Kingwood Elementary. They checked fifth-graders' blood pressure, cholesterol, height and weight.

They also checked the back of each child's neck. They were looking for a dark patch of skin, a signal that the child is at risk of type 2 diabetes.

A week or so later, Aubrey's mother, Gwen, got a letter from CARDIAC saying they had found an AN marker, a dark linear patch, on Aubrey's neck. "They said to show the letter to her doctor," Gwen said.

She took Aubrey to the family doctor. "He looked at the back of her neck and said, 'We need to keep an eye on that.'"

"An AN marker is a warning signal to check for type 2 diabetes," said pediatrician Dr. Pamela Murray, chief of the Division of General Pediatrics and Adolescent Medicine at WVU Medical Center.

West Virginia is facing a diabetes epidemic that threatens to swamp the state health-care system, Murray said. One in 3 Americans will be diabetic by 2050 if preventative measures are not taken, the Centers for Disease Control and Prevention predicts.

"If we can catch it now in children, we absolutely should," Murray said.

Thousands of West Virginia children -- 1 in 20 -- have the diabetes-linked marker, according to the CARDIAC project, which screens statewide.

"The fancy name is acanthosis nigricans," Murray said. It translates "dark area."

"Lots of times, it looks like a smudge or dirt," she said. "It used to be only adults, but now, as kids get type 2 diabetes too, it turns up on children too."

In the past 11 years, CARDIAC screeners have checked 78,751 West Virginia fifth-graders' necks. On average, 5.2 percent had a marker. That's 762 children in the fifth grade alone.

When insulin behaves abnormally in the body, AN markers may appear as brown-to-black velvety areas encircling the back of the neck, under the arms or in the crook of the elbow or knee, Murray said. "The bad thing is, many parents don't know what it is," she said.

Many teachers don't recognize it either, said Kelli Caseman, director of the West Virginia School-Based Health Assembly. Teachers sometimes refer children to the health center for hygiene issues, she said, "only to find that the dirt on the back of students' necks was AN."

Murray emphasizes that:

 

  • The marker is not a diagnosis of diabetes. It is a red flag for pre-diabetes, according to the American Diabetes Association and American Academy of Pediatrics.
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  • All pre-diabetic people do not develop a marker. One in 5 children do, according to CARDIAC figures, usually those most at risk. If 762 fifth-graders have markers, five times that number could be pre-diabetic.
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  • Most people who develop the darkened patches are overweight, another diabetes risk factor.
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    "It's usually easier to identify on darker-skinned individuals, but in West Virginia, it's frequent and more visible on white children," Murray said. Nationwide, black children develop AN -- and diabetes -- at a higher rate than white children do.

    AN markers often fade away if people bring their blood sugar into normal range, she said.

    Aubrey Duckworth's marker didn't fade, but she did gain weight. By age 13, she was 6-foot-1 and weighed 287 pounds. Her family doctor referred her to Morgantown.

    Murray -- who specializes in childhood diabetes and obesity -- ordered blood tests. They showed that Aubrey has type 2 diabetes.

    "The good news is, we caught it early enough to prevent serious damage," Murray said. Exercise and eat right, she told Aubrey, and you may eventually be able to manage it without medication.

    Now Aubrey and her mother do Zumba four times a week. "It's great her mother does it with her," Murray said. The whole family improved their diet, Gwen Duckworth said. "We're all in this with her," she said.

    Aubrey has lost 35 pounds so far, more than 10 percent of her weight. Her three-month blood sugar level dropped 32 percent, into normal range. Her AN marker has disappeared. "If you lose 10 percent and exercise, your numbers should drop," Murray said.

    This semester, Aubrey's in the marching band, and she has physical education every day, "so she's active every day," her mother said. But West Virginia high school students take only one semester of P.E. in four years. "That's going to be a problem," her mother said.

    Once a person has diabetes, it doesn't go away. On a recent band trip, Aubrey almost passed out while marching. Now she carries high-protein foods like peanut butter. "If I don't like the school lunch, I can still eat," she said.

    "At 14, she's not ready to do this on her own," her mother said. "We're trying to help her develop lifelong habits that will let her manage this disease. We're very grateful this was caught early."

    'Can't we check all kids for this?'

    Aubrey's story is an excellent argument for screening children for the marker, Murray said.

    "It's important that every parent, teacher, doctor and school nurse be familiar with it. There is a huge amount of diabetes in West Virginia, and this is one way to catch many children early."

    "Even if it doesn't catch everybody," thousands could be prevented from getting diabetes, said Jamie Jeffrey, director of the Children's Medicine Center at Charleston Area Medical Center. "Can't we figure out how to check all kids for this?"

    Few people disagree. But discussion often bogs down on the question: Who should screen?

    "School nurses do other screenings, don't they?" Murray said. "Why not just check the neck too?"

    Rebecca King, who directs the state's school nurse program, says school nurses are already overwhelmed and are not the right people for the job. Most counties have only one or two nurses, she said.

    Doctors should do any AN screening, she recommends. However, the state Department of Education does not require that doctors check for the marker in the well-child exams children must get for school.

    Many children do not have regular doctors, Murray said. "Urgent Care is about the closest they get.

    "I do think there needs to be a medical conversation on this subject, and soon," she said.

    DOE officials want families to have a regular doctor for each child, King said, "so screening would be more appropriately done in the child's medical home."

    "The reality is, we have many kids who never see a doctor any time, except in the ER or an occasional well-child check," said Kelli Caseman of the School-Based Health Center Assembly.

    "There may be other ways of doing this that don't add a lot to people's duties," said Sharon Carte, Children's Health Insurance Program director. "For instance, phys-ed teachers check children at the beginning of school. Maybe they could do it."

    "AN screening of children is relatively new, so it's still controversial," King argued. As evidence, she points to a 2001 CDC posting that discouraged AN screening, saying insufficient research supports the connection with diabetes.

    That posting is now marked "archived for historical purposes."

    In June 2012, the Journal of School Nursing summarized recent AN research, most published since 2001 and concluded that "the AN screening tool is easy to use and reliable for use with elementary school-age children of various ethnic groups." Sixteen of 19 studies concluded there is an AN-diabetes association, the Journal said.

    "The bottom line is, a lot of kids are developing pre-diabetes who could fairly easily be helped with little expense," Jeffrey said. "Surely we can be creative and find a way to do this."

    "Glucose and insulin tests for all children are expensive, but this is a cost-effective screening tool," said Lesley Cottrell, vice chairman of pediatric research at WVU.

    The School-Based Health Center Assembly recently created a roundtable to identify areas where children are falling between the cracks, Caseman said.

    "We want to look at who's covering what, what needs to be done, and where children fall in the gap," she said. "This an excellent case in point."

    Reach Kate Long at katelong@wvgazette.com or 304-348-1798.

    "The Shape We're In" has been partially funded by a Dennis A. Hunt Fund for Health Journalism fellowship, administered by the California Endowment Health Journalism Fellowships at the University of Southern California's Annenberg School for Communication and Journalism.                                 


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