Transcript No Slide Title

Type 2 Diabetes in adolescents:
Issues for the SBHC provider
Kathy Love-Osborne MD, FAAP
Associate Professor of Pediatrics
CASBHC 5/3/13
Disclosures
 No financial disclosures
 I do plan to discuss the use of
Hemoglobin A1c as a screen for
diabetes. This test is not officially
recommended by the American
Academy of Pediatrics as a screening
test in adolescents
Type 2 Diabetes (T2D) screening


American Diabetes Association and AAP
recommend screening with fasting glucose
every two years starting at age ten or at onset
of puberty, whichever is first
 Insulin resistance increases in puberty
BMI > 85% and 2 risk factors for T2D:
 Family history of diabetes
 Minority race at higher risk
 Signs of insulin resistance
Diabetes screening options
Random glucose
 Poor sensitivity; not recommended
Fasting glucose
 Poor sensitivity
 Sinha et al 2003 – 60 obese children – 4% T2D,
25% IGT – all missed by fasting glucose
Oral glucose tolerance test
 More sensitive but time consuming
Hemoglobin A1c (A1c)
- Not officially recommended in teens
A1c as a screening tool
 A1c had previously not been recommended
as a screening test in adults due to lack of
assay standardization
 In 2010, an expert review committee
recommended using A1c as a screen for
diabetes in adults
 ≥ 6.5% presumptive diabetes
 6.5% correlated with increased rates of eye
and kidney disease
The International Expert Committee
2009
Denver Health adolescent T2D
screening recommendations
 All teens with BMI > 95% (FH often unknown):
 1st screen age 10 or pubertal: A1c or fasting
glucose
 Re-screen every 2 years, sooner if BMI
increases more than 1 kg/m²/year
 BMI 85-95% with 2 or more risks:
 Family history of T2D
 Acanthosis, hypertension, PCOS
 Ethnicity at increased risk for T2D
T2D diagnosis
 Confirmation of a single result is
required unless symptomatic
 Fasting plasma glucose (FPG) > 126
mg/dl
 Random or 2-hour after glucose
challenge glucose > 200 mg/dl
 A1c ≥ 6.5%
T2D: blood sugar monitoring
Patients should be instructed to check blood
sugars:
 If they are taking insulin or other medications
that can cause hypoglycemia
 If they are starting or changing their
treatment regimen
 If they are not meeting treatment goals
 If they are ill
Blood sugar monitoring
 Frequency of testing depends upon the
patient; most T2D patients are asked to check
1-3 times/day initially until at target A1c
 Post-prandial testing (2-hours after a meal)
may be very helpful in patients at diagnosis,
as they may notice patterns with foods that
tend to raise their blood sugar
 New onset diabetics are usually asked to
check sugars before meals and at bedtime
T2D A1c monitoring
 A1c should be checked every 3 months
 Target is < 7% for most adolescents
 Levels over 8% indicate possible need
for change in treatment regimen
 Levels over 9% (some endocrinologists
use 8%) indicate need for insulin
T2D: Metformin
 Studies in teens have shown 10% success
rates with lifestyle therapy alone
 Metformin should be started once the
diagnosis is confirmed*
 500 mg daily, increase by 500 mg every 1-2
weeks to goal of 2 g daily
 Lactic acidosis rare but serious side effect
Treatment of T2D in teens
 The TODAY trial of treatment of T2D in
adolescents showed very high rates of
treatment failure (needing insulin in
addition to oral medications)
 Insulin is typically added when A1c is ≥ 89% due to the presence of glucose
toxicity (oral medications may not work
well at these A1c levels)
T2D Treatment: insulin
 Insulin treatment recommended for:
 Random blood sugar ≥ 250 mg/dl
 A1c ≥ 9%
 Ketosis (present in 5-25% of
adolescents eventually diagnosed with
T2D)
Insulin therapy in T2D
 The most commonly used insulin regimen in
adolescents with T2D is long-acting (basal)
insulin, usually given once daily at bedtime
 Patients on insulin should check fasting blood
sugars daily and post-prandial sugar once
daily
 Short acting insulin may be needed if basal
insulin fails to attain A1c in target range
Case 1: laboratory differences
 JA 13 y.o. HF BMI 34.2 kg/m²
 A1c 6.9% at Denver Health
 Continuous glucose monitoring study at
Children’s Hospital: A1c 5.9%
 many glucose values > 140 mg/dl and some
> 200 mg
 Family missed f/u metabolic syndrome clinic
appointment: “I was told she didn’t have
diabetes so I didn’t see the point”
Local issues
 Due to differences such as in Case 1, it is
reasonable to follow patients with A1c
6.5-6.9 for 3 months with lifestyle
changes before starting medication or
referring to specialty care
 Consider glucometer use
 Consider ongoing research studies
Pre-diabetes
 Impaired fasting glucose (IFG)
 Fasting plasma glucose (FPG) > 100 mg/dl
but < 126 mg/dl
 Impaired glucose tolerance (IGT)
 2-hour glucose > 140 mg/dl but < 200 mg/dl
 A1c 5.7-6.4%
 A1c values >6.0% have higher risk for
progression to T2D than values of 5.7-5.9%
Denver Health data
• Obese adolescents ages 12-18 years seen
during two 18-month periods in community
or school settings
• Wave 1: 4/08-10/09 (n = 2949)
• Wave 2: 5/10-11/11 (n = 3944)
• Ethnicity: 13% black, 76% Hispanic, 8% white
and 3% other
Summary of participants
Wave 1
Wave 2
Adolescents served
% with BMI available
Obese teens
15,500
76%
2,949
17,200
95%
3,954
Number of diabetes tests
1,151
1,845
% with diabetes testing
39.0%
46.7%
New T2D cases identified
Diabetes rate
8
0.7%
13
0.7%
New diabetes cases
 21 confirmed incident T2D cases
 38% identified on the first screen
 43% identified on follow-up of normal
testing, mean 2.9 years later
 19% identified on follow-up of pre-diabetes,
mean 1.6 years later
Illustrates importance of regular screening
intervals
Case #2: SBHC diagnosis
 KF 13yo HF with BMI 39.4 kg/m²
 seen in SBHC for URI
 asked to return for PE
 PE 2 weeks later: A1c 8.7%, uninsured
 Seen within 1 week of abnormal result
at Barbara Davis Center
Case #3: Failure to f/u after initial
abnormal screen
 TG 10yo HF BMI 39.1 kg/m²
 SBHC physical: HbA1c 6.8%
Multiple attempts to schedule f/u by
SBHC, supervising physician and PCP
Mother agreed to follow up but NS
Case 3: Next school year, different SBHC
1st 2 visits for asthma do not note previous
elevated A1c. BMI up to 44.8 kg/m²
3rd visit: unable to draw blood in SBHC
Labs at community clinic: A1c 7.9%
Family now without health insurance.
Referred to enrollment specialist. Multiple
notes in chart about recommended f/u in
endocrinology and unsuccessful attempts to
reach mother
Case 3 follow-up
4 months and 5 visits later: multiple notes
documenting attempts to contact
mother:
• Repeat A1c 8.8%
• 1 week later mother came in to SBHC
• 3 weeks after that visit seen at
Barbara Davis Center, now > 1 year
since original abnormal A1c
Case 3: pearls
• Call your subspecialist. They can schedule the
appointment and help with insurance
• This is diabetes. Notes said “elevated A1c” and
“metabolic syndrome”
• Consider a medical neglect report
• Don’t forget to review the medical record
before you see every patient
Dysglycemia progression
 Obese adolescents 12-18 years old with firsttime A1c 5.7-7.9% were identified through
electronic medical record review
 Dysglycemia was defined as:
 A1c 5.7-5.9% (mild pre-diabetes)
 A1c 6.0-6.4% (moderate pre-diabetes)
 A1c 6.5-7.9% (diabetes range)
Results
281 adolescents with dysglycemia were
identified
 Participants were 15.4±2.0 years old
 67% Hispanic, 21% Black, 3% white, and 9%
other
 213 had mild A1c elevation
 60 had moderate A1c elevation
 8 had diabetes range A1c elevation

Follow-up testing rates
 F/U testing one year after identification
to most recent f/u was available in:
 57% of patients with mild A1c elevation
 82% of patients with moderate A1c
elevation
 88% of patients with diabetes-range A1c
Follow-up of A1c 5.7-5.9%
 There was a linear trend between BMI
change and worsening A1c (p=0.01 for
trend)
 A1c < 5.7% at f/u: 35% +0.2 kg/m2
 A1c 5.7-5.9 at f/u: 40%
+0.8 kg/m2
 A1c 6.0-6.4% at f/u: 24%
+1.5 kg/m2
 A1c > 6.5 at f/u: 1%
+2.3 kg/m2
Follow up of A1c 6.0-6.4%
 There was not a similar trend with
regards to BMI change in patients with
A1c over 6.0%
 There was a much higher rate of
progression to diabetes (16% in one
year)
Patients with A1c ≥ 6% need close
follow-up
Follow-up of A1c 6.5-7.9%
 20 patients had A1c values in this range
during the study period; 19 had f/u
 65% were not on medication at last f/u
20%continued with A1c values > 6.5% but
were managed with lifestyle alone
 40% improved to A1c < 6.5%
 35% had T2D treated with medication
Dysglycemia conclusions
 Dysglycemia in some adolescents may be
transient, even those with initial A1c results in
the diabetes range
 Weight stabilization lead to resolution of prediabetes in patients with A1c values in the
5.7-5.9 range
 Patients with higher baseline A1c values
(6.0% and higher) had significant rates of
progression to T2D over the next year
Patient notification
 Chart audits were done on 234 patients
with A1c ≥ 5.7%
•Documentation of patient notification
of elevated A1c was recorded
•Patients seen after lecture to peds/SBHC
providers advised use of A1c and
defined pre-diabetes
Results: counseling
 62% of tests were sent during or shortly
after an appointment for a physical
 38% documented generic diet/exercise
counseling
 47% documented specific goals set
 15% had no counseling documented
Results: A1c 5.7-6.4
 37% had no documentation that abnormal
results were recognized
 10% results were inaccurately documented
as normal
 24% notified in clinic
 17% notified by phone
 8% notified by letter
 3% unable to contact
Results: Patient informed of
elevated A1c
Informed
n
Laboratory
Follow-up
A1c change
BMI change
(median)
No
119
57 (48%)
+0.12%
+ 0.7 kg/m2
Yes
115
114 (75%)
-0.04%
+ 0.4 kg/m2
< 0.001
0.18
0.3
p-value
Discussion: Patient notification
 Patient notification of abnormal
laboratory results was associated with
increased rates of follow-up testing
 Patient notification was associated
with trends towards improved BMI
outcomes and improved follow-up A1c
values
Lack of documentation
 Provider awareness?
 Failure to document conversations?
 Documentation of unsuccessful attempt to
contact, but no further attempt to notify
patient in other way
 Chart documentation of message left, but
unclear if patient received needed
information
Sample letter
 When you were at the clinic, you had a diabetes test called a Hemoglobin A1c
done. Your blood test is in the range that is considered “pre-diabetes” (5.7% to
6.4%). This means that you have a higher than normal chance of getting
diabetes over the next 2 years. If your Hemoglobin A1c gets higher than 6.5%,
that means you have diabetes.

 Your hemoglobin A1c was: ________

 For preventing diabetes, the most important change you can make is cutting
down on sugary drinks and other foods with a lot of carbohydrates (sugars),
such as cookies, candy, sweet cereals, white bread, and flour tortillas. This will
cut down the amount of work your body has to do to use sugars and may lower
your chance of getting diabetes.

 Exercise is also important because when you exercise, your body doesn’t have
to work as hard to use carbohydrates that you eat. Try to exercise an hour or
more every day.
Management of A1c 6.5-7.0
 Repeat A1c, glucose, UA for ketones within 1
week
 Consider glucometer to check 2-hour glucose
daily for 2 weeks (with outside PCP)
 Blood sugar log sheet
 Immediate feedback is often helpful to
promote lifestyle changes
 F/U 2 weeks to review results
 F/U 3 months for repeat A1c
Case 4: how the SBHC can help
 KDTC 16 y.o. HF BMI 32 kg/m²
 diagnosed in Community Health center
with T2d 3/12, A1c 9.2%; seen at BDC
 No f/u notes in Community Health
 Multiple SBHC visits for family planning
 Found on chart review 1/13 to have been
lost to follow-up by BDC after 2nd visit 5/12
 Patient recalled to SBHC and re-started on
medication, facilitated follow-up with BDC
Follow-up of diabetics in SBHC
 Any patient with serious medical
problems (including diabetics) should
be co-managed with an outside PCP to
minimize loss to follow –up over school
breaks or in the case of school change
 Keep diabetics on your “tickler” to see
every three months and make sure they
are not lost to specialty follow-up
Conclusions
 Remember to screen at-risk adolescents
every 2 years with either fasting (not
random) glucose or A1c
 Don’t forget to screen early adolescents (1012 years old) as diabetes risk ≈ 50% higher
References
 Management of newly diagnosed Type 2 Diabetes
Mellitus (T2DM) in children and adolescents
 Clinical practice guideline by American Academy of
Pediatrics 2013
Website with great handouts for teens dealing with
diabetes:
www.yourdiabetesinfo.org
(go to healthcare provider and enter children/teens
as age group)
Acknowledgements
 Pediatric QI committee for their thoughtful
input and inquiring minds
 Dr. Phil Zeitler (Children’s hospital
endocrinology)
 Dr. Steve Daniels
 Denver Health providers for such a fantastic
job documenting lifestyle recommendations
and improving diabetes screening rates in
adolescents