Strategies to Motivate Teens to Prevent Diabetes Part2

Treatment for Type 2 Diabetes

Glucose Lowering Therapy

It is best to treat type 2 diabetes as vigorously as possible to avoid or delay the long term consequences of elevated blood glucose levels, high blood pressure, and dyslipidemia. Treatment focuses on discovering the most effective method to lower blood glucose levels, whether it is lifestyle modifications, insulin therapy, oral agents, or any combination of these factors. The diabetes team must work with the teen and the family to educate them about the importance of good control and to make the necessary adjustments in treatment every 4-6 weeks until acceptable control is achieved.

•         At diagnosis, teens with type 2 diabetes who are acutely ill with significant hyperglycemia (>300 mg/dl) and ketosis require insulin therapy. Insulin regimens are similar to those for teens with type 1 diabetes. In the less ill teen, initial treatment with medical nutrition therapy and exercise or a glucose lowering oral agent may be appropriate. In both circumstances, target blood glucose goals are similar to those with type 1 diabetes and treatment recommendations may change depending on blood glucose control.

•         Glucose-lowering oral agents may be effective with type 2 diabetes. See Table 10 for the types currently available in the US.

TABLE 10

Glucose-Lowering Oral Agents Commonly Used for Treatment of Type 2 Diabetes.

Type of Agent                  Mechanism of Action                                                        Generic Names

Biguanides                       Decrease hepatic glucose production, increase muscle

insulin sensitivity

Metformin

Sulfonylureas                   Increase insulin secretion                                                    Glyburide Glipizide Glimepiride

Meglitinide                       Short-term promotion of glucose-stimulated insulin secretion

Repaglinide

Glucosidase inhibitors      Decrease digestion and absorption of carbohydrate            Acarbose

Miglitol

Thiazolidenediones           Increase insulin action in muscle, adipose tissue and

probably the liver

Rosiglitazone Pioglitazone

•         The biguanide, metformin, is often the first oral agent used with teens. Metformin is effective at reducing blood glucose levels without the risk of hypoglycemia. It does not cause weight gain and it helps reduce total cholesterol, LDL cholesterol, and triglyceride levels. Nausea and abdominal discomfort may occur with initial use. Starting at low doses (500 mg/day) and increasing gradually to a maximum daily dose of 2200 mg may minimize these side effects. Because the kidney metabolizes biguanides, they should not be used if the teen is dehydrated. In young women with diabetes and polycystic ovary syndrome, metformin may normalize ovulatory abnormalities,  thereby increasing the risk for pregnancy in those who are sexually active and necessitating preconception counseling.

•         The other oral agents are used infrequently with teens due to concerns with hypoglycemia and weight gain (sulfonylureas), more severe gastrointestinal symptoms (glucosidase inhibitors) and safety (thiazolidinediones).

•         Combination regimens that include insulin with an oral agent may be used to help lower blood glucose levels. Combination therapy usually requires less insulin, however blood glucose monitoring is still essential.

Blood glucose monitoring is recommended to evaluate treatment. Teens whose diabetes is controlled with life style changes or oral agents are encouraged to perform blood glucose testing before breakfast and one other time during the day. Teens on insulin therapy need to test 2-4 times/day depending on the insulin regimen. In addition, blood glucose monitoring 2 hours after a meal provides information about the effectiveness of lifestyle changes. If 2 hour post-meal blood glucose levels are >180 mg/dl, the teen needs to decrease carbohydrate goals, increase activity or adjust medications. HbA1c are monitored quarterly. As in type 1 diabetes, a large clinical study, the United Kingdom Prospective Diabetes Study, has shown that better glycemic control (HbA1c < 7.0%) results in reduced cardiovascular and

microvascular complications.8

Medical Nutrition Therapy

At diagnosis, dietary recommendations should emphasize blood glucose control, not weight loss. Even though many teens with type 2 diabetes are overweight at diagnosis, it is preferable to educate

the teen about carbohydrate counting, the effects of food on blood glucose levels, and the health benefits of physical activity as opposed to putting them on a “diet.” A meal plan with regular meals and snacks and carbohydrate goals that are moderately less than their usual intake will often help lower blood glucose levels. Once the teen learns to identify carbohydrate-containing foods and monitor carbohydrate intake, cessation of weight gain, and even weight loss, may occur. (See Tables 11 and 12 for nutrition tips.)

TABLE 11

General Guidelines for Food Intake

Eat 3 meals and 1 snack on a regular schedule. Try not to skip meals.

Follow carbohydrate goals for meal planning from the dietitian. Try to eat about the same amount of carbohydrate at the same time each day.

Eat smaller portions at meals. Decrease saturated fat intake. Work towards a healthy weight.

TABLE 12

Ways to Limit Carbohydrate Intake

Drink calorie-free beverages (e.g., water, tea, diet soda).

Limit fruit juice to 1 cup/day.

Limit carbohydrate servings to 3-4/meal. If necessary decrease to 1-2 at breakfast.

Check blood glucose level 2 hours after eating. (If >180 mg/dl, you ate more carbohydrate than your body could handle).

•         Modest weight loss (5-10% of body weight) may improve blood glucose control but treatment should focus more on modifying the factors that contribute to excess weight gain–poor eating habits and sedentary lifestyle–than on low calorie diet plans. For more information on healthy weight loss strategies, see Chapter 6.

•         Exercise is another factor that may improve insulin sensitivity independent of weight loss (see Table 13). It is important to find out what activities teens enjoy and to identify easy ways to incorporate more physical activity into their daily routines. Forty-five to sixty minutes of aerobic exercise at least 3 times/week is recommended.

•         Hyperlipidemia may improve as blood glucose levels normalize. If cholesterol and triglyceride levels do not improve, weight loss, a decreased intake in saturated fat or treatment with a lipid- lowering medication may be indicated. See Chapter 10 for dietary strategies to reduce lipid levels.

Helps you feel better and increases your energy

Reduces HbA1c

Improves insulin sensitivity

TABLE 13

Benefits of Exercise

Helps in reaching a healthy weight

Increases strength and flexibility

Decreases risk factors for heart disease

Reduces body fat and increases muscle mass

Type 1 Diabetes

PREVENTION

Presently there is no way to prevent type 1 diabetes.

•         Current research with relatives of people with type 1 diabetes is studying how to prevent or delay the autoimmune destruction of the beta cells. If a simple blood test detects the presence of islet cell antibodies, the person is eligible to enter. Participants in the Type 1 Diabetes TrialNet  studies are randomly assigned to either a Natural History or Prevention Study and followed by a medical team (see Internet Resources in RESOURCES section).

Type 2 Diabetes

Prevention requires identifying those children and teens at risk and providing them appropriate knowledge, resources, and support to help reduce risk factors.

•         Since 40-80% of teens diagnosed with type 2 diabetes are overweight and the incidence of overweight is increasing, primary prevention of type 2 diabetes in young people should include a public health approach that targets the general population. Health professionals need to be involved in developing and implementing community programs in schools, churches, and health centers that promote positive lifestyle modifications (healthy food choices, increased physical activity, and achievement/maintenance of a healthy weight) for children and their families.

•         The Diabetes Prevention Program conclusively showed that people can prevent the development of type 2 diabetes by making changes in food intake and increasing physical activity. A 5-10% decrease in body weight and 30 minutes/day of moderate physical activity produced a 58% reduction in diabetes.9

Teens with newly diagnosed type 1 or type 2 diabetes should be referred for initial education and treatment to an interdisciplinary diabetes program. Their care should be coordinated by a physician experienced in the care of children and adolescents with diabetes, a nurse, a registered dietitian, and a social worker who have expertise in diabetes management as well as the physical and emotional needs of teens and their families. Once a firm educational base is established, the well-informed physician who has access to a certified diabetes educator (a nurse or dietitian) can follow the teen with diabetes. Other circumstances that require referral to the diabetes specialist are the following:

•         Recurrent diabetic ketoacidosis.

•         Severe or frequent hypoglycemia.

•         Multiple psychosocial problems that contribute to poor glycemic control.

•         Pregnancy.

•         Initiation of intensive insulin therapy with multiple injections or an insulin pump.

End The Series 

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