Pediatric Primary Care Case Studies (70 page)

Developmental Factors

Management of diabetes is complex and depends on daily performance of many behaviors and self-care tasks: taking medications for diabetes and possibly for blood pressure control and lipid reduction, monitoring blood glucose levels, and changing behaviors to incorporate healthy eating, weight control strategies, and physical activity into one’s daily routine. Though it may appear to many as not much of a challenge, both research (Kaufman & Schantz, 2007; Zeitler et al., 2007) and common sense remind us that behavior change is difficult for virtually everyone. Adolescence is a period of profound physical, cognitive, and psychosocial change. During late childhood and early adolescence, children develop cognitive capacity for organized logical thought and begin to think abstractly (Child Development Institute, n.d.). Capacity for abstraction enables an adolescent to contemplate future possibilities or events. Despite their ability to think about the future, however, adolescents with chronic illness are primarily concerned with the present (Weinger, O’Donnell, & Ritholz, 2001) and are less influenced by what they perceive to be long-term health risks (Mulvaney et al., 2006; Sawyer & Aroni, 2005). Adolescence is also a time of seeking independence from parents. For adolescents with a chronic health condition, this means beginning to assume increasing responsibility for their diabetes self-management tasks, which often causes tension and conflict within the family (Anderson et al., 2002; Mulvaney et al.; Weinger et al., 2001). In a recent study, parents of adolescents with type 2 diabetes identified adolescents’
food choices and failure to monitor blood glucose levels as common sources of family conflict (Mulvaney et al.).

The majority of research about transition of responsibility for diabetes self-management has been conducted with adolescents with type 1 diabetes. Although some issues may be similar, adolescents with type 2 diabetes have different physical, socioeconomic, and psychosocial issues compared to adolescents with type 1 diabetes. Because diagnosis of type 2 diabetes frequently occurs during mid-adolescence, these adolescents must adapt to the challenges imposed by a chronic health condition at the same time they are in the process of transitioning to greater autonomy.

Adolescents with type 2 diabetes need to deal with comorbid obesity within a family structure where obesity, type 2 diabetes, and poor lifestyle behaviors are prevalent (Pinhas-Hamiel et al., 1999); therefore, they may lack role models and/or emotional support needed to facilitate behavior change. Studies have shown that only a small minority of adolescents with type 2 diabetes exercised on a regular basis or followed their meal plan (Rothman et al., 2008). Obesity and its consequences may go unrecognized in these families (Skinner, Weinberger, Mulvaney, Schlundt, & Rothman, 2008).

Diabetes Comorbidities and Complications

Adolescents with type 2 diabetes are at risk for diabetes-related microvascular complications associated with poor glycemic control and psychosocial demands of living with a chronic health condition. In addition, similar to adults with type 2 diabetes, at diagnosis they are more likely to present with comorbidities, placing them at risk for future cardiovascular and renal disease: lipid disorders, hypertension, obesity, and insulin resistance.

Hypertension

Blood pressure should be measured at each visit. Hypertension is defined as a systolic and/or diastolic blood pressure that is ≥ 95th percentile for age, gender, and height using an appropriate-size cuff and confirmed on two or more repeated visits (National High Blood Pressure Education Program, 2004; Tan, 2009). If improved lifestyle behaviors are not sufficient in reducing blood pressure to target levels, first line therapy for treatment of hypertension is treatment using an angiotensin-converting enzyme (ACE) inhibitor. ACE inhibitors are contraindicated during pregnancy; therefore, sexually active girls treated with ACE inhibitors should be offered contraception counseling (Dean & Sellers, 2007).

Dyslipidemia

A fasting lipid profile should be measured at diagnosis and annually (Dean & Sellers, 2007) for all children with type 2 diabetes. Current guidelines (Dean & Sellers) support treatment of dyslipidemia (defined as LDL cholesterol ≥ 130 mg/dL) in children with diabetes age 8 years or older with either a bile
acid–binding resin such as cholestyramine or a 3-hydroxy-3-methyl-glutaryl coenzyme A reductase inhibitor (statin) medication, and nutrition counseling. Fasting lipid levels, liver enzymes, and creatine kinase should be monitored semi-annually for those treated with statins to assess for therapy effectiveness and safety (Dean & Sellers).

Renal Disease

Children with type 2 diabetes should be screened at diagnosis for the presence of pre-existing renal disease with random urine microalbumin-to-creatinine ratio, and this screening should be repeated yearly (Dean & Sellers, 2007). First morning specimens are best to rule out the presence of orthostatic proteinuria.

Depression

Children with chronic illness are at higher risk to develop depression compared to healthy peers (Bennett, 1994; Grey, Whittemore, & Tamborlane, 2002; Hood et al., 2006). The combination of diabetes with comorbid depression places a child at further risk for poor glycemic control and poor medical outcomes (Dantzer, Swendsen, Maurice-Tison, & Salamon, 2003; Garrison, Katon, & Richardson, 2005; Grey et al., 2002; Stewart, Rao, Emslie, Klein, & White, 2005). In two recent cross-sectional studies (Hood et al.; Lawrence et al., 2006), 15–23% of youth with diabetes reported depressive symptoms. These findings highlight the importance of routine screening for depression in children and adolescents with diabetes, maintaining a high index of suspicion of depression in adolescents with poor diabetes control, and prompt initiation of treatment when depression is identified.

Microvascular Complications

Children with type 2 diabetes should be screened for the presence of retinopathy, nephropathy, and neuropathy at diagnosis with annual screening thereafter. A foot exam should be performed on an annual basis (Peterson, Silverstein, Kaufman, & Warren-Boulton, 2007).

Sociocultural Factors Affecting Diabetes Management

Cultural values are learned behaviors and influence how individuals receive and adopt health education messages. This section discusses how food, body weight perception, and spirituality may influence diabetes management in African Americans diagnosed with type 2 diabetes.

African Americans have retained some of their original culture through food, commonly referred to as “soul food.” Preparation and consumption of foods high in fat reflect cultural practices (Airhihenbuwa et al., 1996). In one study (Maillet, D’Eramo Melkus, & Spollett, 1996), African American women with type 2 diabetes expressed concerns about their ability to include ethnic foods and participate in social occasions involving food while managing diabetes. Assisting families with modification of recipes, such as oven roasting
rather than frying meat, for their preferred foods may improve dietary adherence (Kulkarni, 2004).

Accurate perception of body size is fundamental to the recognition of overweight/obesity and engagement in weight loss behaviors. In one sample of African Americans, caregivers of overweight children did not associate their child’s body size with health risk (Young-Hyman, Schlundt, Herman-Wenderoth, & Bozylinski, 2003). Other studies found that African American girls perceived their female caregivers as role models for body size (Boyington et al., 2008; Katz et al., 2004) and were satisfied with their larger body size (Hesse-Biber, Howling, Leavy, & Lovejoy, 2004).

Religion and spirituality assume a central role in the lives of many African Americans (Quinn, Cook, Nash, & Chin, 2001). In one study, African American women associated the role of religion with health, life satisfaction, social support, coping, and stress management (Samuel-Hodge et al., 2000). On the other hand, religious beliefs and attitudes, such as beliefs that diabetes can be managed by prayer alone, may interfere with diabetes management.

What will you do to educate Mary and her mother about type 2 diabetes and its management?

Education Plan

Children and adolescents with type 2 diabetes and their families should receive age-appropriate, ongoing diabetes self-management education (Funnell et al., 2007). The goal of diabetes education is to provide the adolescent and family with the knowledge and skill required to perform daily self-care tasks, manage acute situations such as sick days and hypoglycemia episodes, and make lifestyle changes for effective disease management. Involving the family in lifestyle interventions to improve eating and exercise behaviors is an opportunity to improve health not only for the adolescent, but also for his or her family. The National Diabetes Education Program offers education materials specifically targeted to type 2 diabetes in youth (see
Table 18-1
). The diabetes management plan needs to emphasize lifetime behavior change as the key to successfully managing type 2 diabetes (Burnet, Plaut, Courtney, & Chin, 2002; Kaufman & Schantz, 2007).

Education content should be structured, age-appropriate, and include blood glucose monitoring, nutrition therapy, and physical activity with an emphasis on lifestyle changes and should be culturally sensitive and individualized to meet the needs of the family. Education may be delivered either individually or in group settings and should be based on assessment of attitudes, beliefs, learning style, baseline knowledge, and readiness to learn (Swift, 2007).
Table 18-1
lists educational resources specifically geared to the needs of children and adolescents with type 2 diabetes.

Diabetes education and care is most successful when provided by a diabetes team. In the majority of situations, a child with diabetes will be co-managed by
a primary care provider in conjunction with a pediatric endocrinologist and pediatric diabetes team. In cases where geographic access to specialty care is limited, telehealth services may be available through tertiary care centers; these have demonstrated some success with adolescents with diabetes (Batch & Smith, 2005; Heidgerken et al., 2006).

You review the laboratory results from her hospitalization with Mary and her mother and explain that Mary has type 2 diabetes. You discuss the option of initiating an oral antidiabetes agent, metformin, with gradual insulin reduction and the need for some baseline screening. You order the following laboratory tests to be completed prior to her next visit: fasting lipid panel, repeat hemoglobin A1c, and first morning urine for microalbumin, and refer Mary to an ophthalmologist for a dilated eye examination. You prescribe metformin 500 mg twice a day (before breakfast and before dinner) and explain the purpose, action, and possible side effects of the medication. In addition, you decrease Mary’s insulin dose and ask Mary’s mother to call in 1 week to review blood glucose records, sooner if hypoglycemia is present. You ask Mary’s mom to supervise all medication administration and ask that she schedule Mary’s 11-year-old brother for an office visit so that he may be screened for diabetes. You applaud Mary’s efforts to make healthy food choices and to engage in physical activity and schedule Mary to return for follow up in a month.

In 1 month, Mary returns for follow-up. She is smiling and engages in conversation. Since her last visit, her insulin dose has been decreased on a weekly basis and her metformin titrated upward. Currently her metformin dose is 750 mg before breakfast and before dinner. She is monitoring blood glucose levels twice a day with occasional additional postprandial readings. Her blood glucose levels are recorded in her logbook and are all within her target range of 80–150. She is not experiencing hypoglycemia. Her last menstrual period occurred 1 week ago. The regional pediatric diabetes center has a satellite clinic located 50 miles from your community health center that meets quarterly. The diabetes center providers will follow Mary every 3 months.

Review of her laboratory results shows hemoglobin A1c level 6.5% (target ≤ 7%), fasting total cholesterol 165 mg/dL (normal < 170), LDL cholesterol 106 mg/dL (normal < 110), triglycerides 100 mg/dL (normal < 104), urine microalbumin 15 mcg/mg (normal 0–30), creatinine 0.6 mg/dL (normal 0.5–1 mg/dL). All are within normal ranges. The report from her screening eye exam is negative for retinopathy.

Mary reports that she is involved in an after-school program and is learning to swim. On weekends she is walking to the park with her family. She says her mom no longer purchases soda, and the family is drinking water as a beverage with meals. The family has decreased the amount of fried foods; they now eat fried chicken only once a week. She says that her brother has an appointment scheduled for next week and she thinks her mother is worried that he may have diabetes too.

On physical examination today, Mary’s weight is 142 pounds (75–90th percentile for age) so she has lost 5 more pounds, and her blood pressure is 120/76 (90th percentile for age and height). Acanthosis nigricans is still present but less noticeable, and Mary mentions that she notices the difference and is pleased with the improvement. The remainder of her exam is negative.