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

Alberta S. Kong; Robert L. Williams; Melissa Smith; Andrew L. Sussman; Betty Skipper; Andrew C. Hsi; Robert L. Rhyne

doi:10.1370/afm.678

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Response to Acanthosis Nigricans and Risk Factors for Type 2 Diabetes
Alberta S. Kong MD MPH

Published on: 08 June 2007
Acanthosis nigricans and risk factors for type 2 diabetes
Valeria Hirschler, M.D.

Published on: 05 June 2007

Published on: (8 June 2007)
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Response to Acanthosis Nigricans and Risk Factors for Type 2 Diabetes
Alberta S. Kong MD MPH, Albuquerque, USA
Other Contributors:
We appreciate Dr. Hirschler’s observation that “acanthosis nigricans is simpler and easier to screen compared with other risk factors for diabetes.” Her insight to the difficulty of obtaining valid assessments of traditional type 2 diabetes risk factors such as family history, body mass index and blood pressure within the clinical encounter is a sentiment felt by many primary care clinicians. We note with some sad irony...
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We appreciate Dr. Hirschler’s observation that “acanthosis nigricans is simpler and easier to screen compared with other risk factors for diabetes.” Her insight to the difficulty of obtaining valid assessments of traditional type 2 diabetes risk factors such as family history, body mass index and blood pressure within the clinical encounter is a sentiment felt by many primary care clinicians. We note with some sad irony Dr. Hirschler’s statement that overweight was “overrepresented” in our sample. The sample obtained during a consecutive two week period in primary care practices throughout New Mexico is an unfortunate, but valid representation of the patients we serve and the extent of the problem of overweight/obesity. Our study was not designed to assess the association of acanthosis nigricans with insulin resistance. While Dr. Hirshler’s work has suggested that there is no such independent association (1), a number of other studies provide evidence of an association (2-8). Our finding that acanthosis nigricans was independently associated with diagnosed type 2 diabetes in this young population would suggest that this group is indeed at high risk for insulin resistance. Further studies of the relationship of acanthosis nigricans to diabetes and to metabolic markers of prediabetic states may help to clarify the value of this skin condition to clinicians and patients in prevention of type 2 diabetes.
References
1. Hirschler V, Aranda C, Oneto A, Gonzalez C, Jadzinsky M. Is acanthosis nigricans a marker of insulin resistance in obese children? Diabetes Care 2002;25(12):2353.
2. Copeland K, Pankratz K, Cathey V, et al. Acanthosis Nigricans, insulin resistance (HOMA) and dyslipidemia among Native American children. J Okla State Med Assoc 2006;99(1):19-24.
3. Hud JA, Jr., Cohen JB, Wagner JM, Cruz PD, Jr. Prevalence and significance of acanthosis nigricans in an adult obese population. Arch Dermatol 1992;128(7):941-4.
4. Kobaissi HA, Weigensberg MJ, Ball GD, Cruz ML, Shaibi GQ, Goran MI. Relation between acanthosis nigricans and insulin sensitivity in overweight Hispanic children at risk for type 2 diabetes. Diabetes Care 2004;27(6):1412-6.
5. Mukhtar Q, Cleverley G, Voorhees RE, McGrath JW. Prevalence of acanthosis nigricans and its association with hyperinsulinemia in New Mexico adolescents. J Adolesc Health 2001;28(5):372-6.
6. Stoddart ML, Blevins KS, Lee ET, Wang W, Blackett PR. Association of acanthosis nigricans with hyperinsulinemia compared with other selected risk factors for type 2 diabetes in Cherokee Indians: the Cherokee Diabetes Study. Diabetes Care 2002;25(6):1009-14.
7. Stuart CA, Pate CJ, Peters EJ. Prevalence of acanthosis nigricans in an unselected population. Am J Med 1989;87(3):269-72.
8. Stuart CA, Smith MM, Gilkison CR, Shaheb S, Stahn RM. Acanthosis Nigricans among Native Americans: an indicator of high diabetes risk. Am J Public Health 1994;84(11):1839-42.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (5 June 2007)
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Acanthosis nigricans and risk factors for type 2 diabetes
Valeria Hirschler, M.D., Buenos Aires, Argentina
Acanthosis Nigricans is a skin condition observed on the back of the neck, axillae and flexural areas in obese subjects (1). Using a cross- sectional design, this study examined 1133 young individuals, 43% of them being children. Authors were interested in analyzing whether acanthosis nigricans was associated with the risk factors for type 2 diabetes. Family history for type 2 diabetes, overweight, hypertension and minorit...
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Acanthosis Nigricans is a skin condition observed on the back of the neck, axillae and flexural areas in obese subjects (1). Using a cross- sectional design, this study examined 1133 young individuals, 43% of them being children. Authors were interested in analyzing whether acanthosis nigricans was associated with the risk factors for type 2 diabetes. Family history for type 2 diabetes, overweight, hypertension and minority ethnicity were considered as risk factors. The presence of acanthosis nigricans on the neck was recorded by primary care clinicians at the office. Authors reported that acanthosis increased with the increased of BMI, hypertension and the number of risk factors for type 2 diabetes. Consistent with this study, a large study of hypertension among elementary school children showed those with overweight and acanthosis were at least twice as likely to present hypertension after controlling for confounding factors (2). A recent study also showed that acanthosis nigricans increased with child BMI z-score (3). Using regression analysis, this study showed that acanthosis was independently associated with type 2 diabetes adjusted for BMI, age, and the number of diabetes risk factors.
Acanthosis is simpler and easier to screen compared with other risk factors for diabetes. The risk factor family history for type 2 diabetes is difficult to screen because of the bias of the recall. BMI requires accurate weighing with removal of shoes and most clothing. It also requires the use of a high-quality scale that should be calibrated. Blood pressure needs to be measured in children at least three times while the subjects are seated (4). BMI and blood pressure percentiles should be done for analysis. These risk factors take more time to screen and many clinicians do not record them, increasing rates of undiagnosed overweight and hypertension. Acanthosis is a non-invasive method for identifying individuals at risk for type 2 diabetes (5). However, there are a number of issues in the manuscript that are incompletely addressed. Overweight was overrepresented in the sample, (73% of adults) and as the design did not include blood sample, authors were not able to associate acanthosis with insulin-resistance.
This study demonstrates that acanthosis is associated with type 2 diabetes after controlling for other risk factors. Their findings confirm previous relationships seen in other studies and emphasize the importance of acanthosis as a risk factor for type 2 diabetes in a group of young individuals.
1- Stuart Ch, Gikinson CH, Smith M, Bosma A, Bruce K, Nagamani M. Acantthosis Nigricans as a Risk Factor for Non Insulin Dependent Diabetes Mellitus. Clin Pediatr. 1998; 37:73-80.
2- Urrutia-Rojas X, Egbuchunam CU, Bae S, Menchaca J, Bayona M, Rivers PA, Singh KP. High blood pressure in school children: prevalence and risk factors. BMC Pediatr. 2006 Nov 16; 6:32.
3- Bell LM, Byrne S, Thompson A, Ratnam N, Blair E, Bulsara M, Jones TW, Davis EA. Increasing body mass index z-score is continuously associated with complications of overweight in children, even in the healthy weight range. J Clin Endocrinol Metab. 2007 Feb; 92(2):517-22.
4- National High Blood Pressure Education Working Group on High Blood Pressure in Children and Adolescents: The Fourth Report on the Diagnosis, Evaluation and Treatment on High Blood Pressure in Children and Adolescents. Pediatrics. 2004; 114:555–576.
5- Stuart Ch, Driscoll MS, Lundquist Kf, Gilkinsob CR, Shaheb S, Smith MM. Acanthosis Nigricans. J Basic Clin Physiol Pharmacol. 1998; 9(2- 4):407-418.
Competing interests: None declared
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Competing Interests: None declared.