Diabetes Mellitus in the Transition Period: From Childhood to Adulthood

http://www.sxc.hu/photo/483163

Type 2 Diabetes Mellitus Iris Thiele Isip Tan MD, MSc,
FPCP, FPSEM
in the Transition Period Chief, Medical Informatics Unit
from Childhood to Adulthood Assoc. Professor 4, UPCM

Saturday, August 4, 12

Peters et al. Diabetes Care for Emerging Adults:
Recommendations for Transition from
Pediatric to Adult Diabetes Care Systems. Reference
Diabetes Care Nov 2011;34:2477-85

http://www.ﬂickr.com/photos/dullhunk/3389581452/

Diabetes transition care

Peters et al. Diabetes Care for Emerging Adults: Recommendations for
Transition from Pediatric to Adult Diabetes Care Systems. Diabetes Care 2011

Dearth of empirical evidence Challenges in the
on best approaches transition

http://www.ﬂickr.com/photos/pasukaru76/4320261170/

Fundamental diﬀerences
Challenges in the
in pediatric and adult
transition
health care providers Peters et al. Diabetes Care 2011

http://www.ﬂickr.com/photos/jurvetson/3031088430/

Lack of well-deﬁned criteria to Challenges in the
determine transition readiness transition
Peters et al. Diabetes Care 2011

https://www.facebook.com/AlodiaGosiengﬁao

Changing social and
Challenges in the
demographic characteristics
transition
of young adults Peters et al. Diabetes Care 2011

http://www.ﬂickr.com/photos/hawee/3527878000/

Diﬀerences in learning styles Challenges in the
in the transition period transition

http://www.ﬂickr.com/photos/andresrueda/3454095552/

Deﬁciencies in training
Challenges in the
in care delivery for
transition
emerging adults with diabetes Peters et al. Diabetes Care 2011

Approaches
Issues

Recommendations

Issues



Differences between
Issues
pediatric and adult care

http://www.ﬂickr.com/photos/aldenchadwick/4293213857/

Poor control of glycemia
Issues
and other risk factors

NNHES: 56% of adults achieved A1c <7%


Only 32% of youth with T1DM
aged 13-18 y and 18% of those SEARCH for diabetes in Youth
Study. J Pediatr 2009;155:688-672
aged >19 y achieved ADA targets

Greatest proportion of youth with T1DM or T2DM
in poor glycemic control were teenagers


One of every 4 patients SEARCH for diabetes in Youth
aged >12 y had A1c >9.5% Study. J Pediatr 2009;155:688-672


⬆ hypertension and dyslipidemia
related to obesity


⬆Prevalence of CV risk factors SEARCH for diabetes in Youth
in youth with T2DM vs T1DM Study. Diabetes Care 2006;29:1891-96


http://www.ﬂickr.com/photos/78428166@N00/4296824658/

Fatty liver disease is more SEARCH for diabetes in Youth
common among obese children case-control study. Diabetes Care
2009;32:416-20
with insulin resistance and diabetes


Loss to follow-up Issues


Increased risk
for acute complications
Issues


Psychosocial Issues Issues


Anxiety disorders can complicate
self-management of diabetes Psychosocial Issues

Depressive symptoms in DM

15-33% of adolescents
(including 18 to 20 year-olds)

23-35% of emerging
adults (18-28 y)

Clinically signiﬁcant
symptoms in 20% of
older adolescent females


Depression is a well-known
comorbid condition. Psychosocial Issues

Poor metabolic control
Reduced adherence

⬆risk of DKA
⬆risk of microvascular complications

Adolescent and
postadolescent women with DM Psychosocial Issues
at risk for eating disorders Peters et al. Diabetes Care 2011

16% of teens aged 13-19 y
with DM reported
using birth control vs
67% of those
ever sexually active

Fewer than 1 in 4
young women
aged 16-20 y aware of
risks of pregnancy

Sexual and
reproductive health issues
Issues

Alcohol use worsens
glycemic control

Smoking ⬆CV risk
and risk for
microalbuminuria

Alcohol, smoking and
drug abuse
Issues

Microalbuminuria in teens:
10% T1DM and 30% T2DM
Neuropathy in 20% of
adolescents with DM

Emergence of signs of chronic
diabetes complications
Issues

Approaches


http://www.ﬂickr.com/photos/53370644@N06/4976497160/

Fragmented
follow-up care

Poorer glycemic
control & ⬆ rate
of hospitalization

Gaps in follow-up care with a Easing the transfer
decrease in MD visits after transfer process


Observational studies or No published RCTS
uncontrolled programs

http://www.ﬂickr.com/photos/alancleaver/2661425133/

Time is a major challenge to
maintaining contact after transfer

Evening hours or ﬂexible clinics

Longer visit as the initial
meeting with the adult provider

Provision of special clinic times
exclusively for young adults up
to age 30 y

Provide written information re: Provide medical summary
transfer process and new MD to receiving MD

http://www.ﬂickr.com/photos/absorbingman/6035479910/

Transfer to an adult clinic or Models of
different hospital transition care


Transition to a combination of Models of
pediatric and adult care providers transition care


Transfer to a young adult clinic Models of
within the same pediatric hospital transition care

Patient navigators
Care ambassadors

Models of
Transition Coordinators transition care

Workshops to prepare Models of
the transitioning teen transition care

Recommendations

Prepare for the transition at least
one year prior; likely during ADA Recommendation
early adolescent years.

Beyond glucose self-monitoring
and insulin administration

Include scheduling appointments
and ensuring medication supply

Gradual transfer of diabetes care ADA Recommendation
responsibilities to the teen

Inform re: differences between ADA Recommendation
pediatric and adult providers

Active problem list Summary of past
glycemic control & DM-
Medication list related comorbidities

Summary of any
mental health
Assessment of diabetes problems and
self-care skills referrals

Pediatric provider should provide
both the patient and future adult ADA Recommendation
care provider a written summary

Provide support and
links to resources that ADA Recommendation
could beneﬁt the patient.


Directory of adult
ADA Recommendation
health care providers

Schedule ﬁrst
appointment with
adult care provider
within 3-4 months of
the ﬁnal pediatric visit.

Empower with resources to help
reconnect to care if lost to follow-up ADA Recommendation



Emphasize consistent use of
glucose-lowering medications to ADA Recommendation
prevent complications.


Evaluate and treat for
disordered eating behaviors ADA Recommendation
and affective disorders.


Visits q3 mos if taking insulin and
q3-6 mos for T2DM not on insulin. ADA Recommendation


Screen for micro- and
macrovascular complications. ADA Recommendation



Discuss birth control, pregnancy
planning and risks and prevention ADA Recommendation
of sexually transmitted illnesses.

Discuss use of alcohol and
drugs, smoking and driving. ADA Recommendation


Ensure that patients receive ongoing
primary & preventive health care ADA Recommendation
(separate from diabetes specialty care)

Thank You
@endocrine_witch


Diabetes Mellitus in the Transition Period: From Childhood to Adulthood

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