Type 2 Diabetes in adolescents: Issues for

the SBHC provider

Kathy Love-Osborne MD, FAAPAssociate Professor of

PediatricsCASBHC 5/3/13

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

Disclosures

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

Type 2 Diabetes (T2D) screening

Random glucose Poor sensitivity; not recommendedFasting 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 consumingHemoglobin A1c (A1c)- Not officially recommended in teens

Diabetes screening options

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 diseaseThe International Expert Committee 2009

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

Denver Health adolescent T2D screening recommendations

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 diagnosis

Patients should be instructed to check blood sugars:If they are taking insulin or other medications that can cause hypoglycemiaIf they are starting or changing their treatment regimenIf they are not meeting treatment goalsIf they are ill

T2D: 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

Blood sugar monitoring

A1c should be checked every 3 monthsTarget is < 7% for most adolescentsLevels over 8% indicate possible need for change in treatment regimen

Levels over 9% (some endocrinologists use 8%) indicate need for insulin

T2D A1c monitoring

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

T2D: Metformin

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 ≥ 8-9% due to the presence of glucose toxicity (oral medications may not work well at these A1c levels)

Treatment of T2D in teens

Insulin treatment recommended for:Random blood sugar ≥ 250 mg/dlA1c ≥ 9%Ketosis (present in 5-25% of

adolescents eventually diagnosed with T2D)

T2D Treatment: insulin

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

Insulin therapy in T2D

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”

Case 1: laboratory differences

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 useConsider ongoing research studies

Local issues

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%

Pre-diabetes

• 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

Denver Health data

Wave 1 Wave 2

Adolescents served 15,500 17,200 % with BMI available 76% 95%

Obese teens 2,949 3,954

Number of diabetes tests 1,151 1,845

% with diabetes testing 39.0% 46.7%

New T2D cases identified 8 13 Diabetes rate 0.7% 0.7%

Summary of participants

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 laterIllustrates importance of regular

screening intervals

New diabetes cases

KF 13yo HF with BMI 39.4 kg/m²seen in SBHC for URIasked to return for PE

PE 2 weeks later: A1c 8.7%, uninsured

Seen within 1 week of abnormal result at Barbara Davis Center

Case #2: SBHC diagnosis

TG 10yo HF BMI 39.1 kg/m²SBHC 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: Failure to f/u after initial abnormal screen

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: Next school year, different SBHC

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 follow-up

• 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

Case 3: pearls

Obese adolescents 12-18 years old with first-time 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)

Dysglycemia progression

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

Results

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 testing rates

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 5.7-5.9%

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 6.0-6.4%

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

Follow-up of A1c 6.5-7.9%

Dysglycemia in some adolescents may be transient, even those with initial A1c results in the diabetes rangeWeight stabilization lead to resolution

of pre-diabetes 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

Dysglycemia conclusions

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

Patient notification

62% of tests were sent during or shortly after an appointment for a physical38% documented generic

diet/exercise counseling 47% documented specific goals set15% had no counseling documented

Results: counseling

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: A1c 5.7-6.4

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

p-value < 0.001 0.18 0.3

Results: Patient informed of elevated A1c

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

Discussion: Patient notification

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

Lack of documentation

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.

Sample letter

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

Management of A1c 6.5-7.0

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

Case 4: how the SBHC can help

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

Follow-up of diabetics in SBHC

Remember to screen at-risk adolescents every 2 years with either fasting (not random) glucose or A1c

Don’t forget to screen early adolescents (10-12 years old) as diabetes risk ≈ 50% higher

Conclusions

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)

References

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

Acknowledgements