8/11/16

1

Adolescents With Diabetes: Improving the Numbers

TerriSchmittPhD,ARNP,FNP-BC,CDEPediatricEndocrineandDiabetes,PalmBeachGardens,FL

AssociateProfessor,ChamberlainCollegeofNursing

Objectives• ReviewdifferencesinType1andType2diabetesinadolescents.

• Reviewphysicalandpsychosocialdevelopmentalfactorsspecifictoadolescentsaffectingdiabetesdiseasemanagement.

• Identifyrisksspecifictotheadolescentwithdiabetesthatmaycontributetopoorhealthoutcomes.

• Identifyprovideractionsandcurrenttreatmentmodalitiesthatmaybenefittheadolescentpatientwithdiabetes.

• ReviewmedicationmanagementofType1andType2diabetesinadolescents

2

AdolescenceYoudon't havetosuffertobeapoet;adolescenceisenoughsuffering foranyone.--- John Ciardi

“AllmylifeI'vefeltliketherewassomethingwrong withme.Something missingordamaged…Everyteenagerinthe world feelslikethat, feelsbrokenor outofplace, different somehow,royaltymistakenlyborn intoafamilyofpeasants.”

CassandraClare, City ofBones

3

Adolescence

Adolescence• Period ofrapid physical, emotional, cognitive,andsocial development

• Initiation 11-12andcompletion 18-21• Westernteens complete puberty byage16-18• Passageofchildhood toadulthood steps:– Completingpubertyandsomaticgrowth– Developingsocially,emotionally, cognitively– Abstractthinking– Establishingindependentidentity– Preparingforcareer/vocation

5

Type1Diabetes

• SEARCHStudy• UKStudy• Increaseinautoimmunediseases

• Prevalence:2001– 1.48/1000,2009– 1.93/1000.(21%)

• HighestCaucasians2.55/1000• Increaseinallagegroups

6

8/11/16

2

Type2Diabetes

• Obesity• Increaseinnewcasesin1990’s,continuestoclimb

• Greaterburdeninminorities

• Currentresearch:SEARCH,HEALTHY,TODAY

7

OtherTypes

• MODY• Idiopathyic Diabetes• CysticFibrosis• Medication/treatment induced• Other exocrine pancreatic diseases

8

SEARCH

• Epidemiology totrackdiabetesin youth• Funded byCDC andNIDDK• Started 2000– continued through 2015• Lookedatincidence, prevalence, diabeteseducation, complications, treatment patterns

https://www.searchfordiabetes.org/public/dsphome.cfm

HEALTHY

• RCT• Middle Schools• Criteria: 50%minority, 50%reduced schoollunch• Fouraims: nutrition, physicalactivity, behavioralchange, communication

• Significant REDUCTION inobesityControl&Non-Control schools

• Control schools:decreased waist circumference &fasting insulin

www.healthystud y.org

TODAY

• TreatmentOptions forType2DiabetesinAdolescents andYouth• Metformin,Metformin +lifestyle,Metformin +Rosiglitazone• Inclusion: T2DM for2years,10-17 years• Outcome: time tolossof glycemic control, insulin

secretion/resistance, body composition, nutrition,physicalactivity,anddiabetes complications, cost,genetics

• Results: Complications https://portal.bsc.gwu.edu/web/today• DiabetesCare:

http://care.diabetesjournals.org/site/misc/todayseries.xhtml

TODAY

8/11/16

3

TODAYInsulinSensitivity

Overall Control:%of youth(Hgb A1c> 9.5%)

Race T1DM T2DM

Caucasian 12.3% 12.2%

African-American 35.5% 22.3%

Hispanic 27.3% 27.4%

Asian/PacificIslander

26.0% 36.4%

NativeAmerican 52.2% 43.8%

14Petitti D, etal, 2009

AdolescentDiabetics

• Pubertal effects• Weightincreases• Movetomoreindependent management• Peerinfluences• Mediainfluences• Changeinlifestyles• Diet

Updates:StandardsforDiabetesCare2015

• BMIcut-off forAsianAmericans forDiabetesscreening decreased to23kg/m2

• Limit sedentary timetono>90minsitting• Pre-meal glycemic target80-130 mg/dl• Newstandards forassessingCGMreadiness• Diastolic 90mmHg• Statin treatment nowbyrisk,notLDL• InChildren/Adolescents Hgb A1cTarget7.5%or>

Updates:StandardsforDiabetesCare2016

• Taking theterm ‘diabetic’outtorefertopatients

• Noonetestfordiagnosisispreferred• Encouragingtheuseofappsandtechnologyformanagement

Updates:2016KidSpecific T1DM• Mental health consideration: diabetes distress, fearofhypoglycemia/hyperglycemia, anxiety, disorderedeating behaviors, depression

• GOALS: Before meals – 90-130Bedtime 90-150,,A1c<7.5%,7.0% isreasonable ifitcanbeachieved.

• Screen forotherautoimmune disorders inT1DM,soonafter diagnosis (Thyroid, celiac)

• B/Pscreening - >90%systolicor>95% (HTN)havebloodpressureconfirmed on3separate days

• Lipids– Inchildren anLDL<100screen every 3-5yrs

8/11/16

4

Updates:2016KidSpecific T2DM

• Incidence projected toquadruple inthenext40years

• Obesitymakesdistinguishing typedifficult(T2DMcanpresent withketoacidosis)

• Onlyoral medication approved isMetformin• Sametreatment goals

Diabetesinkids

• Unfortunately– lackofclinicaltrialevidence inchildren

• Childrenatriskforhypoandhyperglycemiadueto:– PhysiologicGrowthanddevelopment– Medicationsensitivity– Self-careneeds– Environment– FamilyDynamics– Peerrelationships– Developmentalneeds

HemoglobinA1cCorrelationtoBloodGlucose

Hgb A1c% Avg.Bld Glucose6% 1357% 1708% 2049% 24010% 27511% 31012% 35013% 386

T1DM:NewOnset• Polyuria,polydipsea, polyphagia,

weightloss• Lab:

– Glucosefasting>,PP>– Hgb A1C>6.5%– Fastinginsulin- >126mg/dL– C-Peptide*Antibodies(Panel)– Isletcellcytoplasmicautoantibodies (ICA)

– Glutamic aciddecarboxylaseautoantibodies (GADA)

– Insulinoma-associated-2autoantibodies (IA-2A)

– Insulinautoantibodies (IAA)

• Ensure norecent steroid,othermeds

• PediatricEndocrinologyconsult

• DiabetesEducation:– Monitoring– Insulinadministration(storage, mixing,optionsfordelivery)

– Meals– Preventive education– Illnessmanagement

22

Case1• Lindsey- 16y/oCaucasian T1DMfemalewho isasophomore. ShehashadT1DMsinceage10

• Current insulin Regimen:Lantus 95units atHS,Humalog tocarbohydrate ratio atmeals1:5.Correction is(BG-100)/50.

• Problem: Sherefusestoseetheschool nurseprior tolunch forglycemicchecks.Oftenskipslunch. Hgb A1catvisitsisrunning 10-13%.Whenher blood sugarismonitored herlevelsarerunning 200-300mg/dl. Testing1-2times/day.

23

CriteriaforDiagnosisofDiabetes

2015Standards ofDiabetes CareA1C≥6.5%

OR

FPG≥126mg/dL

OR

2 HRPP ≥200mg/dL

ORPts w/signsofhyperglycemia-randomplasma

glucose≥200mg/dL

8/11/16

5

T1DM:Adolescents-WorseningControl• Almost2/3’sofadolescentswithT1DMdon’tmeettreatmentgoals

• Poormanagement• Insulinomission(intentionalvs.unintentional)

• Lackofmonitoring• Diet(grazing,notmeasuring,notconsistent)

• Support,home,family• Howdoesthatmakeyoufeel?

• Longerdiabetes• Non-Caucasian• Unmarriedcaregivers• Injections• Depression• Negativeattitudeofmonitoring

• Income

25

T1DM:EffectsofPubertyonInsulin

• DCCT – worsecontrol than adults• Insulin Resistance: GHandIGF-1– Insulinsensitivitydeclines25%to30%– Decreaseinsulinreleasebypancreases

• Luteal phasehyperglycemia• Irregular menses

26

T1DM:TheImportanceofFamily

BETTERMANAGEMENT• greaterparentalinvolvement

• monitoring• responsibility-sharing• lower familyconflict• greatercoping,self-regulation,includingproblem-solving

ASINTERVENTION• FACTS research

FAMILYSTRESS

27

T1DM:InsulinOmission– DisorderedEating

• Even infrequent increases riskofneg health outcomes• Insulinomissionunique/frequent (rates 7.4%-74%)

• Thoseat risk fororengaging inDEBs generally scorewithin ‘normal’

• T1DMadolescents without DEBs - lessdepression,better body image, andhigher self-esteem Importanthealth problem

• Difficult toidentify girlsat riskwithgeneralpsychometric measures

• Nolarge scaleprevention interventions todate 28

Media T1DM:Alcohol

• ADA– Adultsnomorethan2• HypoglycemiaSymptomsMimicIntoxication

• Delayedhepaticresponse

8/11/16

6

T1DM:AlternativesforTreatment

• MDI• Continuous insulin infusion• Closed loop insulin therapy• Pramlitidine• Metformin inobesity• TDD• Basal60%:Bolus 40%• RisksofContinuous infusion• Backtomanagement

31

T1DM:AlternativesforMonitoring

• Monitoring:AC,HS,Pre-driving,pre-exercise,2hourPost-Prandial

• CGM• Glucosewatch• iPhone bloodglucosemonitors

• Glucosetrackingapps

32

T1DM:CGM T1DM:PumpsANIMASVIBE

MEDTROINIC530g

T-SLIM

ASANTESNAP

T1DMP:PumpsOMNIPOD

Onset,Peak,DurationINSULIN1 ONSET PEAK DURATIONHumalog (lLspro) 5-10min 1-2hrs 3-4hrs

Novolog (Aspart) 5-10min 1-2hrs 3-4hrs

Apidra (Glulisine) <15min 1-2hrs 3-6hrs

Novolin R/Humulin R 30-60min 2-4hrs 6hrs

Novolin N/Humulin N 2-4hrs 4-8hrs 10-15hrs

Lantus (Galargine) 1-2hrs Nopeak 24hours

Levemir (Detemir) 1-2hrs Nopeak* Upto24hrs

8/11/16

7

Case1Lindsey• Follow upintheoffice:–Workwith,notagainstherandfamily.– Gotoher?Howcanwefacilitateinsteadofpunish?– Evaluate familyfunctioning– Involveherasleader– Healthychoicesatschool(exerciseanddiet)– Heroutsideschoolinvolvement– Keepparentsinformed–Workwithherprimarycareprovider– Beflexible

Case2• Steven isa12y/omiddleschoolerrecentlydiagnosedwithT1DM

• PlacedonNPHandHumalogtwicedailywithacorrectiondoseslidingscaleof1unitofHumalogbeforemealsforevery100over200.

• Problem:Hisparentsareseparatedandmotherisoverlyprotective.Shecallstheschooleverydayatlunchtofindouthisbloodsugaranddisparagesthecarefatherprovides.Stevenisin‘honeymoon’andhasbeenhavingbloodsugarsof65-70priortolunch,evenwithdecreasingdosing.

Hypoglycemiamanagement

• Ruleof15’s• 70to80???What’syourrange?• Sendtolunchifaboveyourruleorfollowwithprotein+carbohydratesnack

• Havechildrenwalkedtotheoffice• Discernreason– PE,activity,decreasedfoodintake,honeymoon,incorrectdose?

Case2:Howcanwehelp

• Bepositive• Be flexible• Involve schoolcounselor andteacher• Family counseling• Encourage thechild• Relationship with endocrinologist/primary careprovider

• Help thechildwithgrowing independence• Setupacontract withmom, affirm her fears,reassure her butspend time now

Case3• Michael- 15y/oblackHaitian malediagnosedlastyear,afterahospitalization andinitialinsulin 75/25start, withT2DM.

• Physical importance: B/P140/88, BMI39,acanthosis ofneck

• Problems:Hehasbeenplaced onMetforminathomeBID.Blood glucose monitoring israndom andthere havebeennodiet changesathome.Hehashadpoor follow up.

• Lab:Hgb A1c10%,Vit D25OH13,FastingInsulin 40 41

Diagnosing

• SameADAcriteria• Noantibodies• Makinginsulin (C-peptide)• PhysicalExam:signsofhyperinsulinemia,central adipose deposition, ‘buffalo hump’,fusiform fingers, striae, irregular menses

• MissingType1inanobesechild

42

8/11/16

8

T2DM:RiskFactors• Obesity• Genetics/ +FamilyHistory• Ethnicity• Maternaldiabetes during

pregnancy +maternalobesity• Puberty• Diet,glycemic response, types of

foods• Low vitaminD(25-OH <25)• Fructose• Sleep• Stress/cortisol• PCOS

43

T2DM:Longterm

• Monitor, Meals,Movement, Management,Medications

• Diabetes Education• Pediatric Endocrinologist• Better control with insulin?• Monitor for complications• FamilyInvolvement• Inflammation

44

T2DM:Diet,Diet,Diet

• Decreased Calorie Intake• Processed carbohydrate consumption• Lower Glycemic load• Portion sizes• Flavinoids• Protein forblood glucose stabilization

45

Problems?

T2DM:Who’smoving?

• Adolescentsstopmoving• AAP=1hourperday• Exerciseimprovescardiovascularoutcomes

• Increasingmusclemass• Hardexercise• Shortbursts• Family

47

T2DM:FamilySupport

• Diseaseofthefamily• Parents orgrandparents with poor control• Familydiabetes education• InvolvementinDiabetes groups• Sometimes nottakenasseriously

48

8/11/16

9

T2DM:Treatment

Metformin – 500mgQD.Canincreasetomax1000mgBID.

InsulinRadical lifestylechangesExerciseVitamin D310,000 to50,000IUperweek

49

ImprovingtheNumbers• Reduced wait timesforcare• Reduce economic burden (lossofwork/school)

• Improveretention• Useoftechnology• Not adult care• Specialists• Accesstocareforlow-income

Screening&TreatingComplications

• Hypertension– B/Pmeasured ateach visit– High>90th %,HTN >95%– Measure ontwodifferent days– HighNormal Initial:Diet,exercise,weightcontrol (3-6months only)

– Hypertension: ACEinhibitors– GoalB/P consistently <90%

Percentiles inchildren -http://www.nhlbi.nih.gov/files/docs/resources/heart/hbp_ped.pdf

Screening&TreatingComplications

• Dyslipidemia– Obtainsoonafterdiagnosis&glucosestabilization– Yearly ifabnormal,every5yearsifnormal– Initialtreatment: Glucosestabilization– Olderthan10years– Statin ifLDL>160,orif>130+1ormoreCVDriskfactor.

– Goal:LDL<100mg/dl.

Screening&TreatingComplications

• Nephropathy– Annualscreenforalbuminuria,randomalbumin-to-creatinine ratio(UACR)>5years

– NephropathyDx withatleast2UACR>30mg/g of2outof3urinesamplesover6monthswithgoodglycemic control

– Treatment ifUACR>30mg/g isACEinhibitor.Startlow(i.e. Lisinopril 5mg)

– Nephrologyconsult

Screening&TreatingComplications

• Obesity: Non-alcoholic fatty liver disease, sleepAPNEA

• LowVitamin D– <30– 2000 unitsperdayOTC, or50,000 IUweeklytoeveryotherweek(Replesta, Ergocalciferol)

• Depression– Screening recommended inpoor control– Depression 3timesmore common inyouthwithdiabetes

– Psychiatric specialtycare

8/11/16

10

Pre-Diabetes:DiagnosingADAGuidelines

FPG100- 125mg/dL

OR

2-hPG/75-gOGTT140 - 199mg/dL

OR

A1C5.7–6.4%

55

Pre-Diabetes:RiskFactors

• Sedentary• Obesity• Familymembers with T2DM• PhysicalExamFindings• Femaleswith PCOS• High-risk ethnicity

56

Resources

• National DiabetesEducation Programyourdiabetes.org

• 2015ADAManagementGuidelines -http://care.diabetesjournals.org/content/38/Supplement_1/S8.full

• JDRF– http://jdrf.org/• ADA- http://www.diabetes.org/

ReferencesAmericanDiabetesAssociation.Standardsof DiabetesCare.2015.Retrievedfrom-

http://care.diabetesjournals.org/content/38/Supplement_1BarataDS,etal. Theeffectof themenstrualcycleonglucosecontrolinwomenwithtype1diabetesevaluated

usingacontinuousglucosemonitoringsystemDiabetesCare.2013;36(5) :e70CopelandKC,SilversteinJ,MooreKR,Prazar GE,Raymer T,etal.Managementof NewlyDiagnosedType2

DiabetesMellitus(T2DM)inChildrenandAdolescents.Pediatrics.Feb2013;131(2):364-82HilliardME,WuYP,RauschJ,DolanLM,HoodKK.PredictorsofDeteriorationsinDiabetesManagementand

ControlinAdolescentsWithType1Diabetes.DiabetesEducator.2012Jul-Aug;38(4):562-79.doi:10.1177/0145721712445216.

InternationalSocietyforPediatricandAdolescentDiabetes.GlobalIDF/ISPADguielines fordiabetesinchildhoodandadolescence.2011.Retrievedfromhttp://www.idf .org/sites/default/f iles/Diabetes- in-Childhood-and-Adolescence-Guidelines.pdf

Livesey G,TaylorR,Livesy H,LiuS.Isthereadose-responserelationof dietaryglycemic loadtoriskoftype2diabetes?Meta-analysisof prospectivecohortstudies. AmJClin Nutr.2013;97(3) :584-596

Lim,E.L., Hollingsworth,K.G., Aribisala,B.S., Chen,M.J.,Mathers,J.C., Taylor,R.Reversalof type2diabetes:normalisation of betacellfunctioninassociationwithdecreasedpancreasandlivertriacylglycero.Diabetologia.2012;54(10) ,2506-2514.

Murphy,H.R.,etal."FamiliesandAdolescentsCommunicationandTeamworkStudy(FACTS)Group:Randomizedtrialof adiabetesself -managementeducationandfamilyteamworkinterventioninadolescentswithType1diabetes."DiabeticMed.2012;29(8):e249-54.

ReferencesNanselTR, IannottiRJ,LiuA. Clinic-IntegratedBehavioralInterventionforFamiliesof

YouthWithType1Diabetes:RandomizedClinicalTrial. Pediatrics. 2012;129(4):e866-e873doi:10.1542/peds.2011-2858

Raush, JR,Hood,KK, Delamater,A,Shrof Pendley,J,Rohan,JM,Reeves,G,Dolan,JL,Drotar,D.ChangesinTreatmentAdherenceandGlycemic ControlDuringtheTransitiontoAdolescenceinType1Diabetes.DiabetesCare.2012;35(6):1219-1224

Selvin E,SteffesMW,Ballantyne CM,HoogeveenRC,Coresh J,BrancatiFL.Racialdifferencesinglycemic markers:across-sectionalanalysisofcommunity-baseddata.Ann InternMed2011;154:303–309

SpringerSC,Silberstein J,CopelandK,etal. ManagementofType2DiabetesMellitusinChildrenandAdolescents. Pediatrics. 2013;131(2):e648-e664

SongY,WantL,PittasAG,DelGobboLC,ZhangC,MansonJE,HuFB.Blood25-HydroxyVitaminDLevelsandIncidentType2DiabetesAmeta-analysisofprospectivestudies. DiabetesCare, 2013,36(5):1422-1428

TfayliH,Arslanian S.Thechallengeofadolescence:hormonalchangesandsensitivitytoinsulin DiabetesVoice:BulletinoftheInternationalDiabetesFederation.2007;52:28–30

Whittmore R, Jaswer S,ChaoA,GreyM.Psychologicalexperienceofparentsofchildrenwith type1diabetes:asystematicmixed-studiesreview.2012;38(4):562-79.doi:10.1177/0145721712445216.

WilcoxG.Insulinandinsulin resistance.ClinicalBiochem Review.2005;26(2):19–39