A child may receive a life-altering diagnosis of a chronic health condition at the time of an acute hospitalization. At follow-up, the primary care provider must review the hospitalization course and laboratory data, perform a history and physical examination, consider family preferences for ongoing care and alternative treatment options, and, perhaps, refine a diagnosis. Most important, the primary care provider can be instrumental in assisting children and families to positively adapt to the new demands imposed by the chronic condition and promoting parent/adolescent shared responsibility for care.
1. Apply current guidelines for diagnosis and management of type 2 diabetes to an African American teen.
2. Identify common comorbidities of type 2 diabetes and screening guidelines.
3. Apply appropriate laboratory testing guidelines for an adolescent with type 2 diabetes.
4. Understand the need for a team approach in the delivery of care for a child with type 2 diabetes.
5. Consider developmental and sociocultural factors that may impact the diabetes management plan.
Case Presentation and Discussion
You first meet Mary Smith, a 14-year-old African American female, when she comes to your rural community health center for “follow-up.” Three weeks ago while visiting her aunt in another city during summer vacation, she became ill and was hospitalized for 3 days. She was diagnosed with diabetic ketoacidosis (DKA), required intensive care for 2 days, and was told she has diabetes. She was discharged from the hospital on a two injection per day regimen of combined short- and intermediate-acting insulin. During the hospitalization, she and her aunt met with a nutritionist and a diabetes educator. Mary is currently monitoring her blood glucose levels four times per day. She complains of feeling very hungry before lunch and at bedtime. Mary does not bring her blood glucose records but does bring her glucose meter to the visit. Review of blood glucose values stored in the glucometer memory demonstrate readings in the range of 80–100 mg/dL before breakfast and dinner and readings in the range of 60–80 before lunch and at bedtime (Figure 18-1).
Figure 18-1 Blood glucose diary highlighting pattern of hypoglycemia before lunch and at bedtime and recommended insulin adjustment.
You obtain a family history and discover that Mary’s maternal grandmother and uncle have type 2 diabetes. Mary’s uncle receives dialysis for diabetes-associated end stage renal disease. Mary has two younger siblings, an 11-year-old brother and a 5-year-old sister.
You ask Mary’s mother to wait in the waiting room while you talk to Mary and complete her physical examination.
What further data do you need to work with Mary and her diabetes diagnosis?
Your conversation with Mary reveals the following: Menarche occurred 2 years ago; her menstrual periods are irregular and occur every 2 to 3 months. She denies sexual activity, smoking, or drug use. Mary administers all insulin injections and talks about how hard it is to resist eating “junk food.” She plays softball on a school team 2 days per week but is inactive on other days. She is in the ninth grade and is a “B” student. She has several friends but has not told anyone about her diabetes. She asks you, “Will I always need to take insulin?” You respond by saying that for now, she needs to continue with injectable insulin to control her hyperglycemia, and that you need additional information before you can answer her question.
Physical Examination Findings
You go on to complete her physical examination before deciding on your plan of care for this long-term diagnosis.
Height: 63 inches (50th percentile); weight 150 pounds (90–95th percentile); body mass index (BMI) 26.6 kg/m2 (90–95th percentile); blood pressure 132/86 (> 95th percentile for age and height) (Frazier & Pruette, 2009; National High Blood Pressure Education Program Working Group, 2004); heart rate 78 beats per minute; respirations 14 per minute; office urinalysis pH 7.0, specific gravity 1.010; glucose, protein, and ketones negative. Mary’s physical examination is positive for the presence of moderate acanthosis nigricans on the back of her neck and at her axillae.
Diabetes: but what type?
Before you can set up the appropriate long-term plan for Mary, you need to have more information about the diabetes diagnosis Mary brings to you. Sometimes it is difficult to distinguish between type 1 and type 2 diabetes in adolescents at the time of diagnosis. Diabetic ketoacidosis (DKA), although a more common presentation of type 1 diabetes, does not exclude a diagnosis of type 2 diabetes (Gahagan & Silverstein, 2003). In one sample of urban youth with type 2 diabetes, 8% presented in DKA at diagnosis (Zdravkovic, Daneman, & Hamilton, 2004). It is important to differentiate between the types of diabetes because treatment options, education approaches, and screening recommendations will differ. The incidence of type 2 diabetes during childhood and adolescence is rising, particularly among adolescents in minority populations. This increase, largely attributed to the rising rate of obesity in childhood, has long-term implications from a public health perspective.
You need to set up a plan for today’s visit pending more information, so you ask Mary’s mother to authorize release of Mary’s hospital records in order to review her hospital record and laboratory evaluation at the time of diagnosis. Today, you note that Mary’s blood pressure is elevated and that she is having frequent episodes of hypoglycemia before lunch and at bedtime. Figure 18-1 illustrates the patterns of Mary’s blood glucose values. As you await data that will help to clarify Mary’s type of diabetes, you decide to decrease Mary’s short-acting insulin dose at breakfast and dinner by 10%, and review target blood glucose ranges and identification, as well as treatment of hypoglycemia with Mary and her mother. You also give them a handout from Children’s Hospital and Regional Center, Seattle, Washington, entitled “What Is Low Blood Sugar? Hypoglycemia for Children and Families” (this can be accessed online at http://cshcn.org/sites/default/files/webfm/file/WhatIsLowBloodSugar-English.pdf). You also provide information about diabetes for them to give to school personnel (see Table 18-1). You ask Mary to return for follow-up in 2 weeks. In the interim, you instruct Mary to continue to monitor her blood glucose level four times a day and to call you if her blood glucose levels are below 80 mg/dL on two consecutive readings or if her blood glucose levels fall below 80 mg/dL more than four times per week.
Before you see Mary again, you need to review your knowledge of type 1 and type 2 diabetes. It is not clear to you which condition she has.
Diabetes in Children
Pathophysiology of Type 2 Diabetes
Type 2 diabetes is a complex metabolic disorder having a genetic predisposition and characterized by insulin resistance and inadequate insulin secretion by the β cells of the pancreas (American Diabetes Association, 2000). Maintenance of blood glucose levels within a physiologic range requires the orchestration of several metabolic activities: pancreatic β cells must accurately sense glucose concentration and synthesize and release insulin, and insulin must bind to its receptors and facilitate the uptake of glucose by muscle, fat, and liver (Rosenbloom & Silverstein, 2003). In an insulin-resistant state, the usual amount of insulin does not produce the desired effect; therefore, the pancreas must secrete additional insulin to maintain blood glucose levels within a physiologic range. In the early phases of insulin resistance, normal glucose tolerance is maintained by release of greater than normal levels of insulin. However, β cell function gradually declines over time, resulting in inadequate insulin secretion to meet the demands of blood glucose regulation in an insulin-resistant state.
Table 18–1 Diabetes Educational Resources for Parents, Adolescents, and School Personnel
Resources for Adolescents and Families
1. National Diabetes Education Program (NDEP)a: http://www.ndep.nih.gov/diabetes/pubs/
• What Is Diabetes (NDEP-63)
• Be Active (NDEP-64)
• Stay at a Healthy Weight (NDEPP-65)
• Make Healthy Food Choices (NDEP-66)
• Dealing with the Ups and Downs of Diabetes (NDEP-87)
• Examples of treatments for hypoglycemia: http://www.diabetesatwork.org/_files/handouts/I_B_01b_HO(1).pdf
2. American Diabetes Associationa
• Wizdom, Type 2 Diabetes: http://web.diabetes.org/wizdom/download/type2.asp
• Youth Zone: http://www.diabetes.org/youthzone/youth-zone.jsp
3. Children with Diabetes Web site
• What Is Type 2 Diabetes?: http://www.childrenwithdiabetes.com/type2/t2_whatistype2.htm
Resources for School Personnel
National Diabetes Education Programa
• Helping the Student with Diabetes Succeed: A Guide for School Personnela
aAvailable in English and Spanish
Puberty augments the problems imposed by insulin resistance for those predisposed to type 2 diabetes. Secretion of growth hormone as part of the pubertal growth spurt further increases resistance to insulin action. Adolescents with normally functioning pancreatic β cells secrete additional insulin to compensate for this puberty-related effect. However, when β cells do not function properly, metabolic decompensation begins and leads to a state of prediabetes (impaired fasting glucose and/or impaired glucose tolerance) with eventual progression to type 2 diabetes (American Diabetes Association, 2000). Table 18-2 identifies current American Diabetes Association definitions for prediabetes and diagnostic criteria for diabetes.
Epidemiology of Obesity and Type 2 Diabetes in Children
The phenomenon of type 2 diabetes in the pediatric population has emerged concurrent with the rising prevalence of overweight and obesity in U.S. youth. Data from the National Health and Nutrition Examination Survey (NHANES) indicate that approximately one third (31.9%) of U.S. children are either overweight or obese (BMI ≥ 85th percentile for age) (Ogden, Carroll, & Flegal, 2008). Among all age and gender categories, minority children have higher prevalence rates for overweight and obesity; for example, among teens, 44.5% of African American girls were overweight or obese compared to 31.7% of non-Hispanic white girls (Ogden et al., 2008).
The prevalence of type 2 diabetes has increased concurrent with the increase of pediatric overweight and obesity, with minority children disproportionately affected (Rosenbloom & Silverstein, 2003). In one large sample of Florida children cared for at pediatric diabetes centers, the percentage of children diagnosed with type 2 diabetes increased from 9.4% to 20% over a 5-year period (Macaluso et al., 2002), although the total number of children diagnosed with diabetes remained stable during these years. Compared to children with type 1 diabetes, children with type 2 diabetes were more likely to be overweight or obese, of Hispanic ethnicity or African American race, female, and of older age.
Table 18–2 American Diabetes Association Diagnostic Criteria for Prediabetes and Diabetes
Impaired fasting glucose
Fastinga plasma glucose between 100 and 125 mg/dL.
Impaired glucose tolerance
Plasma glucose between 140 and 199 mg/dL following a meal or glucose challenge as part of an oral glucose tolerance test.
Fastinga plasma glucose ≥ 126 mg/dL
symptoms of hyperglycemia (e.g., polyuria, polydipsia, unexplained weight loss, enuresis) AND plasma glucose ≥ 200 mg/dL
2-hour plasma glucose ≥ 200 mg/dL as part of an oral glucose tolerance test.
aFasting defined as no calorie intake for a minimum of 8 hours
Source: Adapted from American Diabetes Association. (2008). Standards of medical care in diabetes—2008. Diabetes Care, 31(Suppl 1), S12–S54.
Findings from the recent SEARCH for Diabetes in Youth Study (Liese et al., 2006), a large epidemiologic study, demonstrate that currently 154,000 children in the United States have diabetes; of these, approximately 39,000 (25%) have type 2 diabetes (Lipton, 2007). This study further suggests that the occurrence of type 2 diabetes in children less than 10 years of age is rare among U.S. children of all races and ethnicities. However, for children 10 years of age and older, race and ethnicity strongly influence the frequency of type 2 diabetes, with children of African American and Native American race most commonly affected. Therefore, it is important to consider type 2 diabetes in the differential diagnosis of older children who present with symptoms of diabetes. Although strongly linked to genetic predisposition, diet and lifestyle are also strongly implicated in the rise of type 2 diabetes in this age group. The combination of low physical activity with ingestion of high calorie, high fat foods of low nutritional quality creates an obesigenic environment leading to excess weight gain and obesity.
Obesity and Cardiovascular Disease Risk in Children
The Bogalusa Heart Study, a longitudinal epidemiologic study, was initiated in 1973 to study cardiovascular risk factors beginning in childhood. Several important relationships regarding obesity, insulin resistance, and cardiovascular risk have been identified using data from these participants. Investigators from the Bogalusa Heart Study (Svec et al., 1992) measured glucose and insulin levels in 377 children 7 to 11 years of age from a biracial community. Controlling for age, body weight, and pubertal stage, African American children had higher insulin levels compared to white children, placing African American children at higher risk for insulin resistance.
In another study (Freedman, Dietz, Srinivasan, & Berenson, 1999), researchers noted that children who were overweight were more likely to have elevations in a lipid profile component, blood pressure, and fasting insulin levels, thereby demonstrating a relationship between weight and cardio-metabolic risk. Importantly, more than half (58%) of the overweight children had at least one risk factor. Findings of this study demonstrate that, even among young children, presence of obesity is consistently related to cardiovascular risk factors. For example, among 5- to 6-year-old study participants, those who were overweight were 7.1 times more likely to have elevated triglyceride levels and 16 times more likely to have elevated systolic blood pressure compared to similar-age children of normal weight. In another study, autopsy reports of Bogalusa Heart study participants provided evidence of the presence of coronary and aortic atherosclerosis and its relationship to prior documented cardiovascular risk factors, and that severity of asymptomatic coronary artery disease increases with an increase in the number of cardiovascular risk factors (Berenson, Srinivasan, & Nicklas, 1998). Furthermore, childhood obesity results in a relative risk of about 1.5 for all-cause mortality and 2.0 for coronary heart disease mortality (Must & Strauss, 1999).
Pathophysiology of Type 1 Diabetes in Children
Type 1 diabetes, the second most common chronic disease in childhood, affects approximately 1 in 500 children in the United States, and is the more prevalent form of diabetes among children. Metabolic manifestations of both type 1 and type 2 diabetes are similar; however, the pathophysiology of type 1 diabetes differs from that of type 2 diabetes. Type 1 diabetes is an idiopathic and immune-mediated condition resulting in permanent loss of the body’s ability to produce insulin due to progressive autoimmune destruction of the β cells of the pancreas (Asp, 2005). Approximately 75% of individuals with type 1 diabetes will test positive for the presence of autoantibodies at the time of diagnosis (Haller, Silverstein, & Rosenbloom, 2007). Prior to discovery of insulin in 1921, type 1 diabetes was a fatal disease.
Pancreatic β cell destruction occurs insidiously until the number of functioning pancreatic β cells is no longer sufficient to regulate blood glucose levels, and hyperglycemia occurs. When blood glucose concentrations exceed the kidney’s ability to conserve glucose, glucose is excreted into the urine, leading to osmotic diuresis. Symptoms of diabetes, polydipsia and polyuria, are related to hyperglycemia. Type 1 diabetes has an abrupt clinical onset and generally occurs over a 2- to 3-week period (Roche, Menon, Gill, & Hoey, 2005). If diabetes is not recognized and treated, symptoms progress to weight loss, dehydration, and ketosis resulting from breakdown of body fat, and eventually progress to diabetic ketoacidosis, an absolute state of insulin deficiency (Haller et al., 2007). Approximately 20% to 40% of new cases of type 1 diabetes present in diabetic ketoacidosis, with young children and those with poor access to health care at particular risk (Mallare et al., 2003; Roche et al., 2005; Rosenbloom, 2007).
Epidemiology of Type 1 Diabetes in Children
The etiology of type 1 diabetes is multifactorial, combining a genetic predisposition with an environmental trigger (Rennert & Francis, 1999). The incidence of type 1 diabetes varies worldwide, ranging from Finland (greater than 40 per 100,000), where incidence is highest, to China (0.1 per 100,000), where incidence is lowest. In the United States the incidence of type 1 diabetes is estimated to be 16.1 per 100,000 per year (Soltesz, Patterson, & Dahlquist, 2007). Susceptibility to type 1 diabetes can be inherited; however, approximately 85% of cases occur sporadically. Siblings of an individual with type 1 diabetes have a 40-fold higher risk of developing diabetes; similarly, a child whose parent has type 1 diabetes has a 10-fold (if mother has diabetes) to 35-fold (if father has diabetes) increased risk (Winter, 2007). Researchers have studied the relationships between a variety of environmental agents such as cow’s milk, vitamin D deficiency, and enteroviruses and development of type 1 diabetes (Eisenbarth, 2007). The TRIGR study, an international multi-site randomized controlled trial, is testing the hypothesis that compared to cow’s milk–based formula, hydrolyzed infant formula decreases risk of developing type 1 diabetes in children with increased genetic susceptibility (TRIGR Study Group, 2007). However, to date, the factors responsible for activating autoimmune destruction of pancreatic β cells in children at risk for type 1 diabetes remain unknown.
In the 1980s, two international type 1 childhood population-based diabetes registries, Eurodiab and Diamond, were established to collect epidemiologic data (Soltesz et al., 2007) about type 1 diabetes in youth. These registries have provided important information regarding global incidence patterns, age and gender patterns, and trends over time. Incidence of type 1 diabetes increases with age, with children at highest risk during the pubertal years (10 to 14 years). Boys and girls are equally affected (Soltesz et al., 2007). The incidence of type 1 diabetes is rising globally, with the highest increase noted in children 5 years of age and younger (Dabelea et al., 2007; Gale, 2002). The SEARCH for Diabetes in Youth Study, a recent multi-center epidemiologic study of children in the United States (Dabelea et al.), demonstrates that the incidence of type 1 diabetes occurs among all racial/ethnic groups, with non-Hispanic white youth most commonly affected.
Treatment of type 1 diabetes in children has a strong evidence base. The Diabetes Control and Complications Trial (DCCT) (Diabetes Control and Complications Trial Research Group, 1993, 1994) clearly demonstrated that tight glycemic control achieved through intensive insulin therapy is critical in preventing or forestalling long-term complications of diabetes. The Epidemiology of Diabetes Interventions and Complications (EDIC) Study (White et al., 2001; Writing Team for the Diabetes Control and Complications Trial, 2002), a prospective epidemiologic study of DCCT participants, provides ongoing evidence that the improved metabolic control achieved for those in the intensively treated group remains protective against the long-term complications of diabetes. Application of DCCT findings to pediatric patients was initially cautious because of risk of hypoglycemia (DCCT Research Group, 1994) and safety of intensive insulin regimens when young children were away from parental supervision. Recent reports (Churchill, Ruppe, & Smaldone, 2009; DiMeglio et al., 2004; Fox, Buckloh, Smith, Wysocki, & Mauras, 2005; Jeha et al., 2005; Litton et al., 2002; Mack-Fogg, Orlowski, & Jospe, 2005; Wilson et al., 2005) provide evidence that intensive insulin regimens are both safe and efficacious, even when used in young children. Current American Diabetes Association standards of care for children with type 1 diabetes (Silverstein et al., 2005) reflect both lower glycemic targets and intensive insulin regimens using multiple daily injections or insulin pump therapy as the means to achieve them.
There is no diagnostic test to differentiate type 2 from type 1 diabetes; further, some features of diabetes formerly thought to be present only in type 1 diabetes (e.g., diabetic ketoacidosis and presence of autoantibodies) are now recognized as not being exclusive to one type of diabetes. Table 18-3 examines demographic, laboratory, and comorbidity factors and their frequency in type 1 and type 2 diabetes in childhood. The presence of a factor does not confirm or exclude one type of diabetes; however, a particular factor may occur more frequently in type 1 or type 2 diabetes (Dabelea et al., 2007).
Table 18–3 Differentiating Type 2 from Type 1 Diabetes
Rethinking Mary’s Diabetes Diagnosis
Hospital records document that Mary presented to the hospital emergency room with persistent vomiting, polyuria, and excessive thirst. She had been ill for the past 2 days. Her past medical history was uneventful and her prior health described as excellent. Although sluggish, she was oriented to time, person, and place. On physical examination her pulse was 108, respirations 30, temperature 37°C (98.6°F), blood pressure 130/90, and weight 142 lbs. Lungs were clear to auscultation, heart sounds were normal, and abdomen was soft without hepatosplenomegaly. Mary’s initial laboratory evaluation included a basic metabolic panel, venous blood gas, complete blood count, and urinalysis. Subsequent laboratory evaluation included hemoglobin A1c and islet cell antibody (ICA) and glutamic acid decarboxylase (GAD) titers.
Notable among Mary’s laboratory results, blood glucose was reported as 500 mg/dL (reference range 60–100 mg/dL), serum sodium 128 mEq/L (reference range 133–146 mEq/L), and blood urea nitrogen (BUN) 40 mg/dL (reference range 5–26 mg/dL). Venous blood gas results were indicative of a metabolic acidosis with pH 7.12 and pCO210. Urinalysis results demonstrated specific gravity > 1.030, large glucose, and large ketones. Hemoglobin A1c was 12% (reference range < 6%) and ICA and GAD antibodies were reported as negative.
She was admitted to the intensive care unit for diabetic ketoacidosis (DKA) management, which included fluid resuscitation with normal saline to restore fluid balance, titration of blood glucose using an insulin infusion drip, and potassium replacement. No sodium bicarbonate was given. She remained in the intensive care unit for 36 hours, was discharged to a pediatric hospital unit for diabetes education, and was subsequently discharged to her aunt’s home. The hospital discharge note indicated uncertainty regarding type of diabetes, a nonspecific plan for follow-up care in the child’s community, and pending results of ICA and GAD antibody levels.
Making the Diagnosis
After thorough review of the pathophysiology and epidemiology of type 2 diabetes, the history and physical examination data, and Mary’s hospital records, you begin to rethink Mary’s initial diabetes diagnosis. Following review of Mary’s family history and hospital laboratory data with your collaborating physician, you conclude that Mary has type 2 diabetes. Her laboratory results on hospital admission definitively document diabetes (blood glucose 500 mg/dL with symptoms of polyuria and polydipsia) (see Table 18-2) and presence of diabetic ketoacidosis (blood glucose 500 mg/dL, low serum pH, and low CO2) (Frazier & Pruette, 2009; National High Blood Pressure Education Program, 2004). Her strong family history of type 2 diabetes, age, race, and negative ICA and GAD antibody status help to clarify her type of diabetes as type 2. Table 18-3 compares characteristics of children with type 1 and type 2 diabetes.
Mary returns accompanied by her mother for her 2-week follow-up visit since her last visit with you. Mary has been well and brings blood glucose records with her today. She states that she has not had many low blood glucose readings and that she has been eating an apple for a snack instead of chips if she is hungry between meals. Her weight today is 147 pounds (3-pound weight loss) and blood pressure is 122/78 (90th percentile for age and height (Frazier & Pruette, 2009). Her blood glucose records show that most readings are in a range of 80–140, with occasional episodes of hypoglycemia after softball games.
Managing a teenager with diabetes is complex. Fortunately, a great deal of work has been done in this area that can help you develop a complete long-term healthcare plan.
Goals of Therapy
First, you need to establish goals for your care as well as goals for Mary and her family to achieve. Treatment goals for the adolescent diagnosed with type 2 diabetes are the following:
• Maintain blood glucose values as close to a normal range as possible while minimizing hypoglycemic episodes.
• Maintain hemoglobin A1c values at ≤ 7%.
• Prevent and/or identify comorbidities of diabetes and long-term microvascular complications of diabetes.
• Promote normal growth and development.
• Promote weight loss.
• Engage in healthy lifestyle behaviors.
Although diabetes treatment and education approaches for children and adolescents with type 1 diabetes are well defined and supported by findings of the Diabetes Complications and Control Trial (DCCT) (DCCT Research Group, 1993, 1994), treatment of type 2 diabetes in youth remains in its infancy and currently lacks a strong evidence base. The TODAY Study, a multi-center randomized controlled trial presently in progress, was designed to identify the best “Treatment Options for Type 2 Diabetes in Adolescents and Youth.” (Information about the TODAY Study may be accessed online at http://www.todaystudy.org/index.cgi.) The study is comparing the effectiveness of three treatment options for youth with type 2 diabetes: 1) metformin (currently the only oral diabetes agent approved for use in children), 2) metformin plus rosiglitazone, and 3) metformin plus an intensive behavioral intervention (Zeitler et al., 2007).
The hallmark of management of children and adolescents with type 2 diabetes is instituting a change from unhealthy to healthy nutritional and physical activity behaviors leading to weight loss. In the United States, fewer than 10% of individuals with type 2 diabetes are successful in achieving glycemic control with diet and exercise alone. Therefore, pharmacologic therapy is recommended in addition to diet and exercise.
Although a wide variety of medication choices are currently available for management of type 2 diabetes, metformin and insulin are the only medications currently approved by the Food and Drug Administration for use in the pediatric population (Atkinson & Radjenovic, 2007; Zeitler et al., 2007). However, because the pathophysiology of type 2 diabetes in children and adolescents is similar to that of adults, recent advances in different classes of medications for adults with type 2 diabetes have led to their off label use in children. Therefore, it is important that health professionals are well versed in the medications used in their particular setting.
Oral medications used in the treatment of type 2 diabetes lower blood glucose levels by increasing sensitivity to insulin (biguanides, thiazolidenediones, α-glucosidase inhibitors) or increasing insulin secretion (sulfonylureas, meglitinides) (Ludwig & Ebbeling, 2001). Over time, the natural course of type 2 diabetes will result in the body’s inability to produce sufficient insulin and insulin replacement so that long- and/or short-acting insulin will be necessary.
Metformin, a biguanide, is recommended as the initial drug of choice in management of type 2 diabetes in adolescents. Metformin improves blood glucose levels without risk of hypoglycemia, and treatment is associated with a mild decrease in weight and decrease in low-density lipoprotein (LDL) and triglyceride levels. In girls with irregular menses or polycystic ovarian syndrome, treatment with metformin may also improve ovarian abnormalities and, therefore, increase the risk of unplanned pregnancy (American Diabetes Association, 2000). Metformin is contraindicated in patients with impaired renal function or hepatic disease, and treatment should be temporarily discontinued during any illness accompanied by dehydration or hypoxemia because of risk of lactic acidosis (American Diabetes Association). If monotherapy with metformin is unsuccessful in achieving glycemic targets, an agent from a different class or insulin may be added to the therapeutic regimen.
Medication may also be prescribed to control hypertension (National High Blood Pressure Education Program Working Group, 2004; Tan, 2009) and dyslipidemia, two frequent comorbidities of type 2 diabetes in youth. Guidelines for treatment of dyslipidemia in pediatric patients were recently amended to include children 8 years of age or older, particularly when accompanied by other cardiovascular risk factors such as obesity or diabetes (Daniels & Greer, 2008).
Children and families should receive both verbal and written instruction for each prescribed medication including purpose, dose, frequency, and potential side effects. It can be helpful to write medication changes in the blood glucose diary as an additional daily reminder. Medication adherence should not be assumed; it is important that adherence be assessed routinely at each patient encounter, particularly during adolescence.
Healthful eating, in terms of both nutritional value and portion size, and improving physical activity are important components of the treatment plan for youth with type 2 diabetes. At diagnosis, the family should meet with a dietician experienced in nutritional management of children with diabetes to receive individualized, culturally appropriate medical nutrition therapy to achieve diabetes treatment goals, prevent cardiovascular disease, and promote behavior change (Gidding et al., 2005). Medical nutrition therapy recommendations should be reviewed with families at least yearly. Modest weight loss has been shown to decrease insulin resistance (American Diabetes Association, 2008). The Centers for Disease Control and Prevention (CDC) recently launched a “Healthy Weight” Web site (http://www.cdc.govhealthyweight/index.htm) that provides nutrition information geared to parents and a site with interactive games specifically designed to promote healthy food choices and physical activity for children (http://www.smallstep.gov/kids/flash/index.html).
Physical Activity Changes
It is recommended that adolescents engage in 60 minutes of physical activity most days of the week (U.S. Department of Health and Human Services, 2005). Physical activity has multiple benefits for the child or adolescent with type 2 diabetes. In addition to lowering blood glucose levels, activity helps to burn fat, increase insulin sensitivity, and increase energy expenditure, and has beneficial effects on blood pressure and lipid levels. Because of their more sedentary lifestyle pattern, many children/adolescents with type 2 diabetes may need ongoing encouragement to initiate an exercise program and should be counseled to start slowly, gradually increase intensity, and build physical activity into lifetime habits. Overweight or obese adolescents may lack self-esteem or motivation to participate in school sports activities but may be willing to walk as a form of exercise. Use of pedometers has been effective in improving physical activity levels in adolescents, particularly when individualized behavioral goals are set (Butcher, Fairclough, Stratton, & Richardson, 2007; Schofield, Mummery, & Schofield, 2005).
Management of diabetes is complex and depends on daily performance of many behaviors and self-care tasks: taking medications for diabetes and possibly for blood pressure control and lipid reduction, monitoring blood glucose levels, and changing behaviors to incorporate healthy eating, weight control strategies, and physical activity into one’s daily routine. Though it may appear to many as not much of a challenge, both research (Kaufman & Schantz, 2007; Zeitler et al., 2007) and common sense remind us that behavior change is difficult for virtually everyone. Adolescence is a period of profound physical, cognitive, and psychosocial change. During late childhood and early adolescence, children develop cognitive capacity for organized logical thought and begin to think abstractly (Child Development Institute, n.d.). Capacity for abstraction enables an adolescent to contemplate future possibilities or events. Despite their ability to think about the future, however, adolescents with chronic illness are primarily concerned with the present (Weinger, O’Donnell, & Ritholz, 2001) and are less influenced by what they perceive to be long-term health risks (Mulvaney et al., 2006; Sawyer & Aroni, 2005). Adolescence is also a time of seeking independence from parents. For adolescents with a chronic health condition, this means beginning to assume increasing responsibility for their diabetes self-management tasks, which often causes tension and conflict within the family (Anderson et al., 2002; Mulvaney et al.; Weinger et al., 2001). In a recent study, parents of adolescents with type 2 diabetes identified adolescents’ food choices and failure to monitor blood glucose levels as common sources of family conflict (Mulvaney et al.).
The majority of research about transition of responsibility for diabetes self-management has been conducted with adolescents with type 1 diabetes. Although some issues may be similar, adolescents with type 2 diabetes have different physical, socioeconomic, and psychosocial issues compared to adolescents with type 1 diabetes. Because diagnosis of type 2 diabetes frequently occurs during mid-adolescence, these adolescents must adapt to the challenges imposed by a chronic health condition at the same time they are in the process of transitioning to greater autonomy.
Adolescents with type 2 diabetes need to deal with comorbid obesity within a family structure where obesity, type 2 diabetes, and poor lifestyle behaviors are prevalent (Pinhas-Hamiel et al., 1999); therefore, they may lack role models and/or emotional support needed to facilitate behavior change. Studies have shown that only a small minority of adolescents with type 2 diabetes exercised on a regular basis or followed their meal plan (Rothman et al., 2008). Obesity and its consequences may go unrecognized in these families (Skinner, Weinberger, Mulvaney, Schlundt, & Rothman, 2008).
Diabetes Comorbidities and Complications
Adolescents with type 2 diabetes are at risk for diabetes-related microvascular complications associated with poor glycemic control and psychosocial demands of living with a chronic health condition. In addition, similar to adults with type 2 diabetes, at diagnosis they are more likely to present with comorbidities, placing them at risk for future cardiovascular and renal disease: lipid disorders, hypertension, obesity, and insulin resistance.
Blood pressure should be measured at each visit. Hypertension is defined as a systolic and/or diastolic blood pressure that is ≥ 95th percentile for age, gender, and height using an appropriate-size cuff and confirmed on two or more repeated visits (National High Blood Pressure Education Program, 2004; Tan, 2009). If improved lifestyle behaviors are not sufficient in reducing blood pressure to target levels, first line therapy for treatment of hypertension is treatment using an angiotensin-converting enzyme (ACE) inhibitor. ACE inhibitors are contraindicated during pregnancy; therefore, sexually active girls treated with ACE inhibitors should be offered contraception counseling (Dean & Sellers, 2007).
A fasting lipid profile should be measured at diagnosis and annually (Dean & Sellers, 2007) for all children with type 2 diabetes. Current guidelines (Dean & Sellers) support treatment of dyslipidemia (defined as LDL cholesterol ≥ 130 mg/dL) in children with diabetes age 8 years or older with either a bile acid–binding resin such as cholestyramine or a 3-hydroxy-3-methyl-glutaryl coenzyme A reductase inhibitor (statin) medication, and nutrition counseling. Fasting lipid levels, liver enzymes, and creatine kinase should be monitored semi-annually for those treated with statins to assess for therapy effectiveness and safety (Dean & Sellers).
Children with type 2 diabetes should be screened at diagnosis for the presence of pre-existing renal disease with random urine microalbumin-to-creatinine ratio, and this screening should be repeated yearly (Dean & Sellers, 2007). First morning specimens are best to rule out the presence of orthostatic proteinuria.
Children with chronic illness are at higher risk to develop depression compared to healthy peers (Bennett, 1994; Grey, Whittemore, & Tamborlane, 2002; Hood et al., 2006). The combination of diabetes with comorbid depression places a child at further risk for poor glycemic control and poor medical outcomes (Dantzer, Swendsen, Maurice-Tison, & Salamon, 2003; Garrison, Katon, & Richardson, 2005; Grey et al., 2002; Stewart, Rao, Emslie, Klein, & White, 2005). In two recent cross-sectional studies (Hood et al.; Lawrence et al., 2006), 15–23% of youth with diabetes reported depressive symptoms. These findings highlight the importance of routine screening for depression in children and adolescents with diabetes, maintaining a high index of suspicion of depression in adolescents with poor diabetes control, and prompt initiation of treatment when depression is identified.
Children with type 2 diabetes should be screened for the presence of retinopathy, nephropathy, and neuropathy at diagnosis with annual screening thereafter. A foot exam should be performed on an annual basis (Peterson, Silverstein, Kaufman, & Warren-Boulton, 2007).
Sociocultural Factors Affecting Diabetes Management
Cultural values are learned behaviors and influence how individuals receive and adopt health education messages. This section discusses how food, body weight perception, and spirituality may influence diabetes management in African Americans diagnosed with type 2 diabetes.
African Americans have retained some of their original culture through food, commonly referred to as “soul food.” Preparation and consumption of foods high in fat reflect cultural practices (Airhihenbuwa et al., 1996). In one study (Maillet, D’Eramo Melkus, & Spollett, 1996), African American women with type 2 diabetes expressed concerns about their ability to include ethnic foods and participate in social occasions involving food while managing diabetes. Assisting families with modification of recipes, such as oven roasting rather than frying meat, for their preferred foods may improve dietary adherence (Kulkarni, 2004).
Accurate perception of body size is fundamental to the recognition of overweight/obesity and engagement in weight loss behaviors. In one sample of African Americans, caregivers of overweight children did not associate their child’s body size with health risk (Young-Hyman, Schlundt, Herman-Wenderoth, & Bozylinski, 2003). Other studies found that African American girls perceived their female caregivers as role models for body size (Boyington et al., 2008; Katz et al., 2004) and were satisfied with their larger body size (Hesse-Biber, Howling, Leavy, & Lovejoy, 2004).
Religion and spirituality assume a central role in the lives of many African Americans (Quinn, Cook, Nash, & Chin, 2001). In one study, African American women associated the role of religion with health, life satisfaction, social support, coping, and stress management (Samuel-Hodge et al., 2000). On the other hand, religious beliefs and attitudes, such as beliefs that diabetes can be managed by prayer alone, may interfere with diabetes management.
What will you do to educate Mary and her mother about type 2 diabetes and its management?
Children and adolescents with type 2 diabetes and their families should receive age-appropriate, ongoing diabetes self-management education (Funnell et al., 2007). The goal of diabetes education is to provide the adolescent and family with the knowledge and skill required to perform daily self-care tasks, manage acute situations such as sick days and hypoglycemia episodes, and make lifestyle changes for effective disease management. Involving the family in lifestyle interventions to improve eating and exercise behaviors is an opportunity to improve health not only for the adolescent, but also for his or her family. The National Diabetes Education Program offers education materials specifically targeted to type 2 diabetes in youth (see Table 18-1). The diabetes management plan needs to emphasize lifetime behavior change as the key to successfully managing type 2 diabetes (Burnet, Plaut, Courtney, & Chin, 2002; Kaufman & Schantz, 2007).
Education content should be structured, age-appropriate, and include blood glucose monitoring, nutrition therapy, and physical activity with an emphasis on lifestyle changes and should be culturally sensitive and individualized to meet the needs of the family. Education may be delivered either individually or in group settings and should be based on assessment of attitudes, beliefs, learning style, baseline knowledge, and readiness to learn (Swift, 2007). Table 18-1 lists educational resources specifically geared to the needs of children and adolescents with type 2 diabetes.
Diabetes education and care is most successful when provided by a diabetes team. In the majority of situations, a child with diabetes will be co-managed by a primary care provider in conjunction with a pediatric endocrinologist and pediatric diabetes team. In cases where geographic access to specialty care is limited, telehealth services may be available through tertiary care centers; these have demonstrated some success with adolescents with diabetes (Batch & Smith, 2005; Heidgerken et al., 2006).
You review the laboratory results from her hospitalization with Mary and her mother and explain that Mary has type 2 diabetes. You discuss the option of initiating an oral antidiabetes agent, metformin, with gradual insulin reduction and the need for some baseline screening. You order the following laboratory tests to be completed prior to her next visit: fasting lipid panel, repeat hemoglobin A1c, and first morning urine for microalbumin, and refer Mary to an ophthalmologist for a dilated eye examination. You prescribe metformin 500 mg twice a day (before breakfast and before dinner) and explain the purpose, action, and possible side effects of the medication. In addition, you decrease Mary’s insulin dose and ask Mary’s mother to call in 1 week to review blood glucose records, sooner if hypoglycemia is present. You ask Mary’s mom to supervise all medication administration and ask that she schedule Mary’s 11-year-old brother for an office visit so that he may be screened for diabetes. You applaud Mary’s efforts to make healthy food choices and to engage in physical activity and schedule Mary to return for follow up in a month.
In 1 month, Mary returns for follow-up. She is smiling and engages in conversation. Since her last visit, her insulin dose has been decreased on a weekly basis and her metformin titrated upward. Currently her metformin dose is 750 mg before breakfast and before dinner. She is monitoring blood glucose levels twice a day with occasional additional postprandial readings. Her blood glucose levels are recorded in her logbook and are all within her target range of 80–150. She is not experiencing hypoglycemia. Her last menstrual period occurred 1 week ago. The regional pediatric diabetes center has a satellite clinic located 50 miles from your community health center that meets quarterly. The diabetes center providers will follow Mary every 3 months.
Review of her laboratory results shows hemoglobin A1c level 6.5% (target ≤ 7%), fasting total cholesterol 165 mg/dL (normal < 170), LDL cholesterol 106 mg/dL (normal < 110), triglycerides 100 mg/dL (normal < 104), urine microalbumin 15 mcg/mg (normal 0–30), creatinine 0.6 mg/dL (normal 0.5–1 mg/dL). All are within normal ranges. The report from her screening eye exam is negative for retinopathy.
Mary reports that she is involved in an after-school program and is learning to swim. On weekends she is walking to the park with her family. She says her mom no longer purchases soda, and the family is drinking water as a beverage with meals. The family has decreased the amount of fried foods; they now eat fried chicken only once a week. She says that her brother has an appointment scheduled for next week and she thinks her mother is worried that he may have diabetes too.
On physical examination today, Mary’s weight is 142 pounds (75–90th percentile for age) so she has lost 5 more pounds, and her blood pressure is 120/76 (90th percentile for age and height). Acanthosis nigricans is still present but less noticeable, and Mary mentions that she notices the difference and is pleased with the improvement. The remainder of her exam is negative.
You congratulate her on her excellent progress, noting her improved laboratory results, weight loss, and work to improve her diet and exercise habits. You also note that the family changes will be helpful to everyone. You tell Mary that you will continue to slowly reduce her insulin each week and titrate her metformin upward to the appropriate therapeutic dose.
When do you want this patient to return for follow-up?
Children and adolescents with type 2 diabetes should be evaluated every 3 months. In most cases, these children will receive diabetes follow-up from the diabetes care team with primary care services provided by the primary care provider. In cases where access to a pediatric diabetes team is geographically limited, primary care providers will assume a greater role in diabetes management. In either case, ongoing communication between primary and diabetes care providers is essential for achieving glycemic goals for adolescents with type 2 diabetes.
Today, you make no changes in Mary’s metformin therapy, and encourage her to keep up the good work with her exercise and diet habits. You provide Mary’s mother with a prescription for Mary’s brother (fasting blood glucose) in preparation for his office visit next week. You schedule Mary for primary care follow-up in 3 months and send a note to the diabetes team regarding her progress.
Key Points from This Case
1. The incidence of type 2 diabetes is rising, particularly among African American teens. The presence of diabetic ketoacidosis at onset of disease does not exclude this diagnosis.
2. Screening for presence of diabetes comorbidities and complications should be initiated at diagnosis.
3. Type 2 diabetes is a family affair. Frequently, others in the family may have type 2 diabetes and may be either a positive or negative influence for the newly diagnosed adolescent. The diagnosis of type 2 diabetes in an adolescent may prompt screening in siblings or other family members for presence of the disease. The hallmark of management of type 2 diabetes is behavioral change leading to improvement in eating and physical activity behaviors for the entire family.
4. Diabetes management requires a team approach and coordination of services between primary care providers and the diabetes specialty team. In rural areas, this may require creative approaches for access to the diabetes team.
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