schmitt adolescent diabetes (read-only)
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Adolescents With Diabetes: Improving the Numbers
TerriSchmittPhD,ARNP,FNP-BC,CDEPediatricEndocrineandDiabetes,PalmBeachGardens,FL
AssociateProfessor,ChamberlainCollegeofNursing
Objectives• ReviewdifferencesinType1andType2diabetesinadolescents.
• Reviewphysicalandpsychosocialdevelopmentalfactorsspecifictoadolescentsaffectingdiabetesdiseasemanagement.
• Identifyrisksspecifictotheadolescentwithdiabetesthatmaycontributetopoorhealthoutcomes.
• Identifyprovideractionsandcurrenttreatmentmodalitiesthatmaybenefittheadolescentpatientwithdiabetes.
• ReviewmedicationmanagementofType1andType2diabetesinadolescents
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AdolescenceYoudon't havetosuffertobeapoet;adolescenceisenoughsuffering foranyone.--- John Ciardi
“AllmylifeI'vefeltliketherewassomethingwrong withme.Something missingordamaged…Everyteenagerinthe world feelslikethat, feelsbrokenor outofplace, different somehow,royaltymistakenlyborn intoafamilyofpeasants.”
CassandraClare, City ofBones
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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
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Type1Diabetes
• SEARCHStudy• UKStudy• Increaseinautoimmunediseases
• Prevalence:2001– 1.48/1000,2009– 1.93/1000.(21%)
• HighestCaucasians2.55/1000• Increaseinallagegroups
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Type2Diabetes
• Obesity• Increaseinnewcasesin1990’s,continuestoclimb
• Greaterburdeninminorities
• Currentresearch:SEARCH,HEALTHY,TODAY
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OtherTypes
• MODY• Idiopathyic Diabetes• CysticFibrosis• Medication/treatment induced• Other exocrine pancreatic diseases
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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
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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
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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
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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.
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CriteriaforDiagnosisofDiabetes
2015Standards ofDiabetes CareA1C≥6.5%
OR
FPG≥126mg/dL
OR
2 HRPP ≥200mg/dL
ORPts w/signsofhyperglycemia-randomplasma
glucose≥200mg/dL
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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
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T1DM:EffectsofPubertyonInsulin
• DCCT – worsecontrol than adults• Insulin Resistance: GHandIGF-1– Insulinsensitivitydeclines25%to30%– Decreaseinsulinreleasebypancreases
• Luteal phasehyperglycemia• Irregular menses
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T1DM:TheImportanceofFamily
BETTERMANAGEMENT• greaterparentalinvolvement
• monitoring• responsibility-sharing• lower familyconflict• greatercoping,self-regulation,includingproblem-solving
ASINTERVENTION• FACTS research
FAMILYSTRESS
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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
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T1DM:AlternativesforTreatment
• MDI• Continuous insulin infusion• Closed loop insulin therapy• Pramlitidine• Metformin inobesity• TDD• Basal60%:Bolus 40%• RisksofContinuous infusion• Backtomanagement
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T1DM:AlternativesforMonitoring
• Monitoring:AC,HS,Pre-driving,pre-exercise,2hourPost-Prandial
• CGM• Glucosewatch• iPhone bloodglucosemonitors
• Glucosetrackingapps
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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
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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
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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
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T2DM:Longterm
• Monitor, Meals,Movement, Management,Medications
• Diabetes Education• Pediatric Endocrinologist• Better control with insulin?• Monitor for complications• FamilyInvolvement• Inflammation
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T2DM:Diet,Diet,Diet
• Decreased Calorie Intake• Processed carbohydrate consumption• Lower Glycemic load• Portion sizes• Flavinoids• Protein forblood glucose stabilization
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Problems?
T2DM:Who’smoving?
• Adolescentsstopmoving• AAP=1hourperday• Exerciseimprovescardiovascularoutcomes
• Increasingmusclemass• Hardexercise• Shortbursts• Family
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T2DM:FamilySupport
• Diseaseofthefamily• Parents orgrandparents with poor control• Familydiabetes education• InvolvementinDiabetes groups• Sometimes nottakenasseriously
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T2DM:Treatment
Metformin – 500mgQD.Canincreasetomax1000mgBID.
InsulinRadical lifestylechangesExerciseVitamin D310,000 to50,000IUperweek
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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
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Pre-Diabetes:DiagnosingADAGuidelines
FPG100- 125mg/dL
OR
2-hPG/75-gOGTT140 - 199mg/dL
OR
A1C5.7–6.4%
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Pre-Diabetes:RiskFactors
• Sedentary• Obesity• Familymembers with T2DM• PhysicalExamFindings• Femaleswith PCOS• High-risk ethnicity
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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/
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