IncreasingIncidenceofType2DiabetesinthePediatricPopulation在兒科人群2型糖尿病的發(fā)病率增加

DiabetesMellitusinChildrenandAdolescentsMaureenMcGrath,PNP-BC,CDEEmory-Children’sCenterDivisionofEndocrinologyandDiabetesDIABETES=DefectinEnergyUtilizationGlucoseisprimaryenergysourceofallcellsInsulinisnecessarytotransportglucoseintomostcellsInsufficientinsulinresultsininadequateglucoseforenergyinsidecell,needalternativeenergysource(fat)Insufficientinsulinresultsinhighextracellularorbloodglucose(hyperglycemia)HowtheBodyUsesFoodasFuelIGLUCOSEBloodStreamCellGGGGGGDigestionofMacronutrients(CHO,FAT,PRO)Pancreas(Insulin)IIIIIInsulinPATHOPHYSIOLOGYHYPERGLYCEMIABloodglucoseincreasingabovetherenalthreshold(~180mg/dL)resultsinglycosuriaGlucoseurinatedout=polyuriaDecreasedextracellularwaterstimulatesthirst=polydipsiaLostglucoseislostcaloriesandstimulateshunger=polyphagiaInsulin:

BeforeandAfterTYPE1DIABETESMostcommonpresentationinchildrenandadolescentsAutoimmunepathophysiologyPrevalence:1of350children3-5%riskinsiblings;30%foridenticaltwinsRiskofketoacidosisDependentoninsulinforsurvival

Type1diabetes:insulindeficiencyGlucoseBloodStreamCellGGGPancreas(Insulin)XXXXXTYPE2DIABETESTYPE2DIABETES~30%ofchildren>10y.o.presentwithtype2diabetesAfrican-Americans,Latinos,NativeAmericans,PacificIslandersInsulinresistanceassociatedwithobesityandacanthosisnigricansPrevalence:increasingVerystrongfamilyhistoryMayalsohaveketonuriaandketosis(ketosis-pronetype2DM)Treatment:lifestyle,metformin,insulinType2diabetes:insulinresistanceIGLUCOSEBloodStreamCellGGGPancreas(Insulin)IIIIIInsulinIACANTHOSISNIGRICANSPRESENTINGSYMPTOMSSymptoms%Type1%Type2P(n=48)(n=40)valueAbdominalPain4633>.10Dizziness1533>.10Headache3343>.10Nocturia7165>.10Polydipsia9685>.10Polyphagia6960>.10Polyuria9488>.10VisualProblem1720>.10Weightloss7140.005PRESENTINGSYMPTOMS

andSIGNSVulvovaginitis,severecandidadiaperrashVomitingDehydrationDifficultybreathing(Kussmaulrespirations)Fruityodortobreath(ketones)AlteredmentalstatusPATHOPHYSIOLOGYof

DIABETICKETOACIDOSIS(DKA)Lowinsulin

hyperglycemiaandglycosuria, insufficientsuppressionoflipolysisandketogenesis Glycosuria

osmoticdiuresis

polyuria

dehydration

polydipsiaDehydration

increaseincounter-regulatoryhormones,whichleadstofurtherhyperglycemiaandketosisHyperosmolarity

alteredmentalstatusDIABETICKETOACIDOSISHyperglycemiaBloodSugar>300AcidosispH<7.3orBicarb<15Mortality2-10%DIAGNOSISofDIABETESMELLITUSSymptomsofdiabetesandrandomglucosegreaterthan200mg/dlFastinglabplasmaglucose(notfingerstick)of>126mg/dL(2separateoccasions)OGTT2hourplasmaglucose>200mg/dl-fasting,1.75gm/kg,max75gmglucoseloadHbA1cof6.5%orgreater(labverified)5.7-6.4%consideredsignforincreasedriskMANAGEMENTofTYPE1DIABETESInsulinGlucosemonitoringNutritionExerciseSickDaymanagementPsychosocialMANAGEMENT

ofTYPE2DIABETESEliminatesymptomsofhyperglycemiaWeightstabilizationImprovecardiovascularriskfactors Hypertension Hyperlipidemia HyperglycemiaPsychosocialOralmeds/insulin

DIABETESSELFMANAGEMENTEDUCATIONBasicpathophysiologyShortandlongtermcomplicationsMealplanningExerciseguidelinesBloodglucosemonitoringPatient-centeredgoalsettingINSULINInsulinActionNormalinsulindeliveryThisisa24hourrepresentationoftheinsulinprofileforsomeonewhodoesnothavediabetes.Thepancreasreleasesinsulinforeachmeal,butthereisalwaysaconstantbackgroundorbasalamountpresentthathasnothingtodowithfood.INSULINS

U-100HumanRecombinantDNAorAnalogInsulinOnsetPeakDurationBasal/BolusRegimens

(physiologic/MDI/BBT)Thisshowsthebasal/bolusregimenwiththebackgroundorbasalinsulinasthethickblacklineatthebottom.Mealorbolusdosesaredeliveredinvaryingamountsandtimesaccordingtomeals.INSULINS

MixedNovolog70/30Humalog75/25Humalog50/50Twoorthreeinjections/dayPeopleonthisinjectionregimenwouldbegettingshotsatbreakfastandsupper.Thebreakfastshotcombinesashort-actinginsulinwhichcoversjustthatmeal.Theintermediate-actinginsulinmixedinthesameshotcoverslunchandthehoursuntilsupper.Thesuppershotcoverstheeveningmealandthenighttimehours.Whyonlytwoorthreeinjectionsperday?SchoolissuesInjectionavoidancePossiblynon-specialtycareAdherenceissuesLackofparentalsupervisionDevelopmentalissuesAge-inappropriateexpectationsTeenagers(awayfromparentalsupportandsupervision)WaystoGiveInsulin-InjectionsInsulincanbeinjectedwithastandardvialandsyringeorbyusingapre-filledinsulinpen.WaystoGiveInsulin-

InsulinPumps Insulinpumpsarecomputersthatdeliverinsulincontinuouslyinsteadoftakingmultipleinjections.Deliverprogrammedinsulin(bolus)Deliverpre-programmedinsulindelivery(basal)DonotmeasureglucoselevelsPumpSitesPumpsitesgenerallychangedevery3daysPumpscanbedisconnected foractivitiesand/orshowersSitesmayhavetobechangedmorefrequentlyasthecatheterfallsout,becomesuntapedCatheter-smallplastictubethatremainsundertheskin.

Real-timeContinuousGlucoseMonitoringTREATMENTofTYPE2DIABETES-DRUGSINSULINInitialRxifDKA,FBS>250mg/dlorifsymptomaticLargedosemaybeneededbecauseofinsulinresistanceOftenuse70/30UsedincombinationwithoralagentTREATMENTofTYPE2DIABETES-DRUGSBiguanide-metforminSulfonylurea-Glipizide,Glyburide,GlimepirideMeglitinide-Repaglinade(Prandin)α-Glucosidaseinhibitor-AcarboseThiazolidinedione-Avandia,ActosMETFORMIN(Glucophage)Inhibitshepaticglucoseproduction,alsodecreaseselevatedandrogensNohypoglycemiaDoesn’tcauseweightgainAnorexia,gastrointestinalsymptomsHelpfuliftakenwithfoodRiskofLacticAcidosisUSUALINITIATIONOFTHERAPYEducationandMonitoring -IfketoticorFBS>300startinsulinNutritionandExerciseGuidelinesEvaluationover3months,Ifoninsulinandmeetingguidelines,progresstoMetforminanddecreaseinsulin

Ifnotoninsulinandnotmeetingguidelines,progresstoMetforminGLUCOSEMONITORING

BGshouldbecheckedbeforeallmealsandbedtimeAdditionalchecksasneededPhysicalactivityDrivingSickdaysSnacksGLUCOSEMONITORING

MetersMemoryfor30-120days(3-4xdaily)Smallbloodvolumes(0.3,0.6,1.0,1.5μl)Rapidresults(5-10seconds)UseofsitesotherthanfingersSerumketonemonitoringMeasurementofserumβhydroxybutyrateDiabetesCare,2021AmericanDiabetesAssociation-BGandHbA1cgoalsforT1DMbyagegroupAgeBeforeMealsBedtime/OvernightHbA1c<6years100-180110-2007.5-8.5%6-12years90-180100-180<8%13-19years90-13090-150<7.5%SPECIFICTREATMENTGOALSforTYPE2DIABETESFBS<140mg/dl,HgbA1C<7%LDLcholesterol<100mg/dlBP<90%forageAnnualScreeningTIDMFamilyhistoryofhypercholesterolemia*IfLDL<100screenevery5years.Annualmicroalbumin/creatinineratio:age10andTIDMfor5years,Annualophthalmologicexam:age10and3-5yearsofTIDMScreenforThyroidPeroxidaseandThyroglobulin,TransglutaminaseorEndomysialAbsatdiagnosisTSHq1-2yrs*TC>240and/orCardiacEvent<55Screenage>2otherwisebeginscreenat>12.T2DMLipidPanelyearlyMicroalbumin/creatinineratioatdiagnosisandyearlyDilatedeyeexamatdiagnosisandyearlyLiverfunctionevery6monthsifonmetforminNUTRITIONWhyCarbohydrateCounting?MorePreciseMealPlanningMethodGreaterFlexibilitywithFoodChoicesOnlyOneMainNutrientCountedBetterBloodGlucoseControlNUTRITIONPRINCIPLES50-55%carbohydrates,15-20%protein,30%fatSufficientcaloriesforgrowthPatternoffooddistribution-Exchanges-CarbohydratecountingDistributedas3mealsand2-3snacksIndividualizeplanCARBOHYDRATECOUNTINGInsulindoseistiedtoamountofcarbohydrateReadtotalcarbohydratesonfoodlabel,notsugarMostchildrendon’tneedtoeataparticularnumberofcarbspermealThoseonbasal/bolusregimensorinsulinpumpscanvaryinsulindosewithamountofcarbohydrateCarbohydrates:

Theseareexamplesof15gramportions1sm.apple,orangeorpeach15grapes?largebanana?cup(4oz.)juice?cuppasta3oz.Bakedpotato1slicebread?cupcereal1cupmilk3cupspopcornTheMisconceptionAboutSweetsACarbisaCarbisaCarb-butthereareHealthyCarbs:fruits,vegetables,wholegrainsMANAGEMENTofTYPE2DIABETES-NUTRITIONPreventfurtherweightgainDecreaseenergyintaketo65-80%ifBMI>40or90%ifBMI>30and<40CHO50-55%,fat30%,protein10-15%EXERCISEEXERCISE

RecommendationsMoremonitoring,bettercontrolExtracarbohydratesifBGnormal-low 15gmper30minintenseexerciseNoexerciseifBG>300orketonuriaGoalforpeoplewithdiabetesis150minutesperweekofmoderate-intensityaerobicexerciseMANAGEMENTofTYPE2DIABETES-EXERCISEIncreasephysicalactivityDecreasesedentarybehaviorMANAGEMENTofHYPOGLYCEMIA

Prevention -Mealsontime -Exercisepre-treatmentMonitoringBloodGlucoseTreatment–give15gCHO,wait15min. -Glucosetabs,glucosegel -GlucagonEmergencyKitMANAGEMENTofILLNESS

KETOSISPrevention -NeveromitinsulinevenifvomitingorNPO -Monitoringbloodglucose -Monitorurineorbloodforketonesif BG>300orifillTreatment -Consultationwithdiabetesteam–mayuse Zofranorphenerganifvomiting -FluidsandinsulinCOMPLICATIONSofHYPERGLYCEMIADiabeticNephropathy-majorityofkidneyfailureandtransplantsDiabeticRetinopathy-majorityofblindnessDiabeticNeuropathy-painfulordecreasedsensation(contributestofootdisease),abnormalstomachfunction(gastroparesis),impotenceIncreasedriskforcoronaryheartdiseaseandstroke

Hugeexpense!PREVENTIONOFCOMPLICATIONSDCCT-1993 Controlofhyperglycemiapreventsordelaysretinopathy,nephropathyTreatmentofmicroalbuminuria ACEinhibitorpreventsprogressionandmaydecreaseproteinexcretionPSYCHOSOCIALDEVELOPMENTALISSUESToddler/PreschoolerAtinitialdiagnosis,oftenfearfulStrugglesovercontrol,includingfoodBehaviorcanbereflectedinglucoselevelsSchoolAgeVeryconcreteandtask-orientedOftenwanttodoownBGchecks,maybemorehesitantwithself-injectionsDEVELOPMENTALISSUESTeensincreasingageassociatedwithdecreasedadherencetoexercise,injectionregularity,dietandmonitoringexternalinterests(peers,school,sports)takeprecedenceoverdiabetesADOLESCENTDEVELOPMENTSocial/BehavioralDevelopment25%ofteenssurveyedfalsifyBGresultssoasnottobejudged25%ofteenssurveyedmissinjectionsduetoforgettingADOLESCENTDEVELOPMENT

HealthBeliefModelAdolescentswithdiabeteswhoperceivedhighbenefitstoregimenweremorelikelytoadheretoitAdherencewashighestwhenbenefits/costswerehighandthreatwaslowWhenperceivedthreatistoopowerful,adherencedecreasesADOLESCENTPSYCHOSOCIALISSUESDepressionismorecommonEatingdisordersathigherincidenceInsulinomissionforweightlossverycommonMAJORROLESofthePNPRecognitionofsignsandsymptomsandriskgroupsofdiabetesinchildrenReinforcingtheprescribedplanandregularf/uwithspecialistsHelpingparentsunderstandnormaldevelopmental