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Diabetes in Population

VII. DIABETES CARE IN SPECIFIC POPULATIONS

A. Children and adolescents

1. Type 1 diabetes

Three-quarters of all cases of Type 1 diabetes are diagnosed in individuals <18 years of age. Because children are not simply “small adults,” it is appropriate to consider the unique aspects of care and management of children and adolescents with Type 1 diabetes. Children with diabetes differ from adults in many respects, including changes in insulin sensitivity related to sexual maturity and physical growth, ability to provide self-care, supervision in child care and school, and unique neurologic vulnerability to hypoglycemia and DKA. Attention to such issues as family dynamics, developmental stages, and physiologic differences related to sexual maturity are all essential in developing and implementing an optimal diabetes regimen. Although recommendations for children and adolescents are less likely to be based on clinical trial evidence, because of current and historical restraints placed on conducting research in children, expert opinion and a review of available and relevant experimental data are summarized in the ADA statement on care of children and adolescents with Type 1 diabetes.

Ideally, the care of a child or adolescent with Type 1 diabetes should be provided by a multidisciplinary team of specialists trained in the care of children with pediatric diabetes. At the very least, education of the child and family should be provided by health care providers trained and experienced in childhood diabetes and sensitive to the challenges posed by diabetes in this age-group. At the time of initial diagnosis, it is essential that diabetes education be provided in a timely fashion, with the expectation that the balance between adult supervision and self-care should be defined by, and will evolve according to, physical, psychological, and emotional maturity. MNT should be provided at diagnosis, and at least annually thereafter, by an individual experienced with the nutritional needs of the growing child and the behavioral issues that have an impact on adolescent diets, including risk for disordered eating.

a. Glycemic control

Recommendations

  • Consider age when setting glycemic goals in children and adolescents with Type 1 diabetes, with less stringent goals for younger children.

While current standards for diabetes management reflect the need to maintain glucose control as near to normal as safely possible, special consideration must be given to the unique risks of hypoglycemia in young children. Glycemic goals need to be modified to take into account the fact that most children <6 or 7 years of age have a form of hypoglycemic unawareness. Their counterregulatory mechanisms are immature and they may lack the cognitive capacity to recognize and respond to hypoglycemic symptoms, placing them at greater risk for severe hypoglycemia and its sequelae. In addition, and unlike the case in adults, young children below the age of 5 years are at risk for permanent cognitive impairment after episodes of severe hypoglycemia. Extensive evidence indicates that near normalization of blood glucose levels is seldom attainable in children and adolescents after the honeymoon (remission) period. The A1C level achieved in the “intensive” adolescent cohort of the DCCT group was >1% higher than that achieved by adult DCCT subjects and above current ADA recommendations for patients in general. However, the increased frequency of use of basal bolus regimens (including insulin pumps) in youth from infancy through adolescence has been associated with more children reaching ADA blood glucose targets in those families in which both parents and the child with diabetes are motivated to perform the required diabetes-related tasks.

In selecting glycemic goals, the benefits on long-term health outcomes of achieving a lower A1C must be weighed against the unique risks of hypoglycemia and the difficulties achieving near normoglycemia in children and youth. Age-specific glycemic and A1C goals are presented in Table 15.

b. Screening and management of chronic complications in children and adolescents with Type 1 diabetes

i. Nephropathy

Recommendations

  • Annual screening for microalbuminuria, with a random spot urine sample for microalbumin-to-creatinine ratio, should be initiated once the child is 10 years of age and has had diabetes for 5 years.
  • Confirmed, persistently elevated microalbumin levels on two additional urine specimens should be treated with an ACE inhibitor, titrated to normalization of microalbumin excretion if possible.

ii. Hypertension

Recommendations

  • Treatment of high-normal blood pressure (systolic or diastolic blood pressure consistently between the 90–95th percentile for age, sex, and height) should include dietary intervention and exercise aimed at weight control and increased physical activity, if appropriate. If target blood pressure is not reached with 6–12 months of lifestyle intervention, pharmacologic treatment should be initiated.
  • Pharmacologic treatment of high blood pressure (systolic or diastolic blood pressure consistently above the 95th percentile for age, sex, and height or consistently >130/80 mmHg for adolescents) should be initiated along with lifestyle intervention as soon as the diagnosis is confirmed.
  • ACE inhibitors should be considered for the initial treatment of hypertension.
  • The goal of treatment is a blood pressure consistently <130/80 or below the 90th percentile for age, sex, and height, whichever is lower.

Hypertension in childhood is defined as an average systolic or diastolic blood pressure 95th percentile for age, sex, and height percentile measured on at least 3 separate days. “High-normal” blood pressure is defined as an average systolic or diastolic blood pressure 90th but <95th percentile for age, sex, and height percentile measured on at least 3 separate days. Normal blood pressure levels for age, sex, and height and appropriate methods for determinations are available online at www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.pdf.

iii. Dyslipidemia

Recommendations

Screening

  • If there is a family history of hypercholesterolemia (total cholesterol >240 mg/dl) or a cardiovascular event before age 55 years, or if family history is unknown, then a fasting lipid profile should be performed on children >2 years of age soon after diagnosis (after glucose control has been established). If family history is not of concern, then the first lipid screening should be performed at puberty (≥10 years). All children diagnosed with diabetes at or after puberty should have a fasting lipid profile performed soon after diagnosis (after glucose control has been established).
  • For both age-groups, if lipids are abnormal, annual monitoring is recommended. If LDL cholesterol values are within the accepted risk levels (<100 mg/dl [2.6 mmol/l]), a lipid profile should be repeated every 5 years.

Treatment

  • Initial therapy should consist of optimization of glucose control and MNT using a Step 2 AHA diet aimed at a decrease in the amount of saturated fat in the diet.
  • After the age of 10, the addition of a statin is recommended in patients who, after MNT and lifestyle changes, have LDL >160 mg/dl (4.1 mmol/l) or LDL cholesterol >130 mg/dl (3.4 mmol/l) and one or more CVD risk factors.
  • The goal of therapy is an LDL cholesterol value <100 mg/dl (2.6 mmol/l).

People diagnosed with Type 1 diabetes in childhood have a high risk of early subclinical and clinical CVD. Although intervention data are lacking, the AHA categorizes Type 1 children in the highest tier for cardiovascular risk and recommends both lifestyle and pharmacologic treatment for those with elevated LDL cholesterol levels. Initial therapy should be with a Step 2 AHA diet, which restricts saturated fat to 7% of total calories and restricts dietary cholesterol to 200 mg per day. Data from randomized clinical trials in children as young as 7 months of age indicate that this diet is safe and does not interfere with normal growth and development.

For children over the age of 10 with persistent elevation of LDL cholesterol despite lifestyle therapy, statins should be considered. Neither long-term safety nor cardiovascular outcome efficacy has been established for children. However, recent studies have shown short-term safety equivalent to that seen in adults and efficacy in lowering LDL cholesterol levels, improving endothelial function, and causing regression of carotid intimal thickening. No statin is approved for use under the age of 10, and statin treatment should generally not be used in Type 1 children before this age.

iv. Retinopathy

Recommendations

  • The first ophthalmologic examination should be obtained once the child is ≥10 years of age and has had diabetes for 3–5 years.
  • After the initial examination, annual routine follow-up is generally recommended. Less frequent examinations may be acceptable on the advice of an eye care professional.

Although retinopathy most commonly occurs after the onset of puberty and after 5–10 years of diabetes duration, it has been reported in prepubertal children and with diabetes duration of only 1–2 years. Referrals should be made to eye care professionals with expertise in diabetic retinopathy, an understanding of the risk for retinopathy in the pediatric population, and experience in counseling the pediatric patient and family on the importance of early prevention/intervention.

v. Celiac disease

Recommendations

  • Patients with Type 1 diabetes should be screened for celiac disease by measuring tissue transglutaminase or anti-endomysial antibodies, with documentation of normal serum IgA levels, soon after the diagnosis of diabetes.
  • Testing should be repeated if growth failure, failure to gain weight, weight loss, or gastroenterologic symptoms occur.
  • Consideration should be given to periodic re-screening of asymptomatic individuals.
  • Children with positive antibodies should be referred to a gastroenterologist for evaluation.
  • Children with confirmed celiac disease should have consultation with a dietitian and placed on a gluten-free diet.

Celiac disease is an immune-mediated disorder that occurs with increased frequency in patients with Type 1 diabetes (1–16% of individuals compared with 0.3–1% in the general population). Symptoms of celiac disease include diarrhea, weight loss or poor weight gain, growth failure, abdominal pain, chronic fatigue, malnutrition due to malabsorption, and other gastrointestinal problems and unexplained hypoglycemia or erratic blood glucose concentrations.

vi. Hypothyroidism

Recommendations

  • Patients with Type 1 diabetes should be screened for thyroid peroxidase and thyroglobulin antibodies at diagnosis.
  • TSH concentrations should be measured after metabolic control has been established. If normal, they should be rechecked every 1–2 years, or if the patient develops symptoms of thyroid dysfunction, thyromegaly, or an abnormal growth rate. Free T4 should be measured if TSH is abnormal.

Autoimmune thyroid disease is the most common autoimmune disorder associated with diabetes, occurring in 17–30% of patients with Type 1 diabetes. The presence of thyroid autoantibodies is predictive of thyroid dysfunction, generally hypothyroidism but less commonly hyperthyroidism. Subclinical hypothyroidism may be associated with increased risk of symptomatic hypoglycemia and with reduced linear growth. Hyperthyroidism alters glucose metabolism, potentially resulting in deterioration of metabolic control.

c. “Adherence.”

No matter how sound the medical regimen, it can only be as good as the ability of the family and/or individual to implement it. Family involvement in diabetes remains an important component of optimal diabetes management throughout childhood and into adolescence. Health care providers who care for children and adolescents, therefore, must be capable of evaluating the behavioral, emotional, and psychosocial factors that interfere with implementation and then must work with the individual and family to resolve problems that occur and/or to modify goals as appropriate.

d. School and day care.

Since a sizable portion of a child's day is spent in school, close communication with school or day care personnel is essential for optimal diabetes management, safety, and maximal academic opportunities. See Section V.III.B, Diabetes Care in the School and Day Care Setting, for further discussion.

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2. Type 2 diabetes

The incidence of Type 2 diabetes in adolescents is increasing, especially in ethnic minority populations. Distinction between Type 1 and Type 2 diabetes in children can be difficult, since the prevalence of overweight in children continues to rise and since autoantigens and ketosis may be present in a substantial number of patients with features of Type 2 diabetes (including obesity and acanthosis nigricans). Such a distinction at the time of diagnosis is critical because treatment regimens, educational approaches, and dietary counsel will differ markedly between the two diagnoses. Because Type 2 diabetes has a significant incidence of hypertension, dyslipidemia, and microalbuminuria at diagnosis, it is recommended that screening for the comorbidities and complications of diabetes, including fasting lipid profile, microalbuminuria assessment, and dilated eye examinations, begin at the time of diagnosis. The ADA consensus statement on this subject provides guidance on the prevention, screening, and treatment of Type 2 diabetes and its comorbidities in young people.

B. Preconception care

Recommendations

  • A1C levels should be as close to normal as possible (<7%) in an individual patient before conception is attempted.
  • Starting at puberty, preconception counseling should be incorporated in the routine diabetes clinic visit for all women of child-bearing potential.
  • Women with diabetes who are contemplating pregnancy should be evaluated and, if indicated, treated for diabetic retinopathy, nephropathy, neuropathy, and CVD.
  • Medications used by such women should be evaluated before conception, since drugs commonly used to treat diabetes and its complications may be contraindicated or not recommended in pregnancy, including statins, ACE inhibitors, ARBs, and most noninsulin therapies.
  • Major congenital malformations remain the leading cause of mortality and serious morbidity in infants of mothers with Type 1 and Type 2 diabetes. Observational studies indicate that the risk of malformations increases continuously with increasing maternal glycemia during the first 6–8 weeks of gestation, as defined by first-trimester A1C concentrations. There is no threshold for A1C values below which risk disappears entirely. However, malformation rates above the 1–2% background rate of nondiabetic pregnancies appear to be limited to pregnancies in which first-trimester A1C concentrations are >1% above the normal range for a nondiabetic pregnant woman.

Preconception care of diabetes appears to reduce the risk of congenital malformations. Five nonrandomized studies compared rates of major malformations in infants between women who participated in preconception diabetes care programs and women who initiated intensive diabetes management after they were already pregnant. The preconception care programs were multidisciplinary and designed to train patients in diabetes self-management with diet, intensified insulin therapy, and SMBG. Goals were set to achieve normal blood glucose concentrations, and >80% of subjects achieved normal A1C concentrations before they became pregnant. In all five studies, the incidence of major congenital malformations in women who participated in preconception care (range 1.0–1.7% of infants) was much lower than the incidence in women who did not participate (range 1.4–10.9% of infants). One limitation of these studies is that participation in preconception care was self-selected rather than randomized. Thus, it is impossible to be certain that the lower malformation rates resulted fully from improved diabetes care. Nonetheless, the evidence supports the concept that malformations can be reduced or prevented by careful management of diabetes before pregnancy.

Planned pregnancies greatly facilitate preconception diabetes care. Unfortunately, nearly two-thirds of pregnancies in women with diabetes are unplanned, leading to a persistent excess of malformations in infants of diabetic mothers. To minimize the occurrence of these devastating malformations, standard care for all women with diabetes who have child-bearing potential, beginning at the onset of puberty or at diagnosis, should include 1) education about the risk of malformations associated with unplanned pregnancies and poor metabolic control and 2) use of effective contraception at all times, unless the patient has good metabolic control and is actively trying to conceive.
Women contemplating pregnancy need to be seen frequently by a multidisciplinary team experienced in the management of diabetes before and during pregnancy. The goals of preconception care are to 1) involve and empower the patient in the management of her diabetes, 2) achieve the lowest A1C test results possible without excessive hypoglycemia, 3) assure effective contraception until stable and acceptable glycemia is achieved, and 4) identify, evaluate, and treat long-term diabetic complications such as retinopathy, nephropathy, neuropathy, hypertension, and CHD.

Among the drugs commonly used in the treatment of patients with diabetes, a number may be relatively or absolutely contraindicated during pregnancy. Statins are category X (contraindicated for use in pregnancy) and should be discontinued before conception, as should ACE inhibitors. ARBs are category C (risk cannot be ruled out) in the first trimester but category D (positive evidence of risk) in later pregnancy and should generally be discontinued before pregnancy. Among the oral antidiabetic agents, metformin and acarbose are classified as category B (no evidence of risk in humans) and all others as category C. Potential risks and benefits of oral antidiabetic agents in the preconception period must be carefully weighed, recognizing that data are insufficient to establish the safety of these agents in pregnancy.

For further discussion of preconception care, see the ADA's technical review and position statement on this subject.

C. Older adults

Recommendations

  • Older adults who are functional, cognitively intact, and have significant life expectancy should receive diabetes treatment using goals developed for younger adults.
  • Glycemic goals for older adults not meeting the above criteria may be relaxed using individual criteria, but hyperglycemia leading to symptoms or risk of acute hyperglycemic complications should be avoided in all patients.
  • Other cardiovascular risk factors should be treated in older adults with consideration of the time frame of benefit and the individual patient. Treatment of hypertension is indicated in virtually all older adults, and lipid and aspirin therapy may benefit those with life expectancy at least equal to the time frame of primary or secondary prevention trials.
  • Screening for diabetes complications should be individualized in older adults, but particular attention should be paid to complications that would lead to functional impairment.

Diabetes is an important health condition for the aging population; at least 20% of patients over the age of 65 years have diabetes, and this number can be expected to grow rapidly in the coming decades. Older individuals with diabetes have higher rates of premature death, functional disability, and coexisting illnesses such as hypertension, CHD, and stroke than those without diabetes. Older adults with diabetes are also at greater risk than other older adults for several common geriatric syndromes, such as polypharmacy, depression, cognitive impairment, urinary incontinence, injurious falls, and persistent pain.

The American Geriatric Society's guidelines for improving the care of the older person with diabetes have influenced the following discussion and recommendations. The care of older adults with diabetes is complicated by their clinical and functional heterogeneity. Some older individuals developed diabetes years earlier and may have significant complications; others who are newly diagnosed may have had years of undiagnosed diabetes with resultant complications or may have few complications from the disease. Some older adults with diabetes are frail and have other underlying chronic conditions, substantial diabetes-related comorbidity, or limited physical or cognitive functioning. Other older individuals with diabetes have little comorbidity and are active. Life expectancies are highly variable for this population, but often longer than clinicians realize. Providers caring for older adults with diabetes must take this heterogeneity into consideration when setting and prioritizing treatment goals.

There are few long-term studies in older adults demonstrating the benefits of intensive glycemic, blood pressure, and lipid control. Patients who can be expected to live long enough to reap the benefits of long-term intensive diabetes management and who are active, have good cognitive function, and are willing to undertake the responsibility of self-management should be encouraged to do so and be treated using the goals for younger adults with diabetes.

For patients with advanced diabetes complications, life-limiting comorbid illness, or substantial cognitive or functional impairment, it is reasonable to set less intensive glycemic target goals. These patients are less likely to benefit from reducing the risk of microvascular complications and more likely to suffer serious adverse effects from hypoglycemia. However, patients with poorly controlled diabetes may be subject to acute complications of diabetes, including dehydration, poor wound healing, and hyperglycemic hyperosmolar coma. Glycemic goals at a minimum should avoid these consequences.

Although control of hyperglycemia may be important in older individuals with diabetes, greater reductions in morbidity and mortality may result from control of other cardiovascular risk factors rather than from tight glycemic control alone. There is strong evidence from clinical trials of the value of treating hypertension in the elderly. There is less evidence for lipid-lowering and aspirin therapy, although the benefits of these interventions for primary and secondary prevention are likely to apply to older adults whose life expectancies equal or exceed the time frames seen in clinical trials.

Special care is required in prescribing and monitoring pharmacologic therapy in older adults. Metformin is often contraindicated because of renal insufficiency or significant heart failure. TZDs can cause fluid retention, which may exacerbate or lead to heart failure. They are contraindicated in patients with CHF (New York Heart Association class III and IV) and if used at all should be used very cautiously in those with, or at risk for, milder degrees of CHF. Sulfonylureas, other insulin secretagogues, and insulin can cause hypoglycemia. Insulin use requires that patients or caregivers have good visual and motor skills and cognitive ability. Drugs should be started at the lowest dose and titrated up gradually until targets are reached or side effects develop.

Screening for diabetes complications in older adults also should be individualized. Particular attention should be paid to complications that can develop over short periods of time and/or that would significantly impair functional status, such as visual and lower-extremity complications.