Managing Adolescents With Type 2 Diabetes Mellitus

Over the past 3 decades, type 2 diabetes mellitus in adolescents, those between the ages of 12 and 18 years, has gone from unusual to increasingly common. The prevalence of type 2 diabetes in youth increased by 35% from 2001 to 2009 and has continued to rise. This rise in prevalence is attributed to the increase in pediatric and adolescent obesity. The aim of this article is to provide the nurse practitioner with the tools necessary to treat this unique population using a holistic approach. We address information regarding lifestyle and medical management, growth and development, and the social determinants of health.     

Food Insecurity and Metabolic Control Among U.S. Adults With Diabetes

OBJECTIVE

We sought to determine whether food insecurity is associated with worse glycemic, cholesterol, and blood pressure control in adults with diabetes.

RESEARCH DESIGN AND METHODS

We conducted a cross-sectional analysis of data from participants of the 1999–2008 National Health and Nutrition Examination Survey. All adults with diabetes (type 1 or type 2) by self-report or diabetes medication use were included. Food insecurity was measured by the Adult Food Security Survey Module. The outcomes of interest were proportion of patients with HbA_1c >9.0% (75 mmol/mol), LDL cholesterol >100 mg/dL, and systolic blood pressure >140 mmHg or diastolic blood pressure >90 mmHg. We used multivariable logistic regression for analysis.

RESULTS

Among the 2,557 adults with diabetes in our sample, a higher proportion of those with food insecurity (27.0 vs. 13.3%, P < 0.001) had an HbA_1c >9.0% (75 mmol/mol). After adjustment for age, sex, educational attainment, household income, insurance status and type, smoking status, BMI, duration of diabetes, diabetes medication use and type, and presence of a usual source of care, food insecurity remained significantly associated with poor glycemic control (odds ratio [OR] 1.53 [95% CI 1.07–2.19]). Food insecurity was also associated with poor LDL control before (68.8 vs. 49.8, P = 0.002) and after (1.86 [1.01–3.44]) adjustment. Food insecurity was not associated with blood pressure control.

CONCLUSIONS

Food insecurity is significantly associated with poor metabolic control in adults with diabetes. Interventions that address food security as well as clinical factors may be needed to successfully manage chronic disease in vulnerable adults.Diabetes is a common condition in the adult population (1). Failure to achieve recommended levels of cardiometabolic parameters such as HbA_1c, LDL cholesterol, and blood pressure is associated with significant morbidity and mortality (1). Socioeconomically disadvantaged patients have increased risk of diabetes-related morbidity (2) and mortality (3), prompting a search for specific actionable factors that drive these disparities in diabetes outcomes.One potentially modifiable risk factor for adverse diabetes outcomes among socially disadvantaged populations is food insecurity, which is defined as “limited or uncertain availability of nutritionally adequate and safe foods or limited or uncertain ability to acquire acceptable foods in socially acceptable ways” (4). Thus, food insecurity represents a state of uncertainty as to whether enough food will be available for the household. It may include changes in eating habits, such as substituting high-calorie, lower-cost food for healthier but more expensive choices (5), or forgoing meals altogether due to lack of resources. In 2011, ∼18 million American households were food insecure (6). Although related to household income, food insecurity exists in households with incomes far above the federal poverty line, whereas many in poverty remain food secure (6).Previous work has demonstrated an association between food insecurity and the prevalence of diabetes (7). Prior studies in safety-net clinics (8,9) have suggested that food insecurity may be associated with worse glycemic control but did not address control of lipids or hypertension. Furthermore, because of the setting of these studies, the generalizability of their results to adults outside of the safety net is unclear. A population-based study of all adults with diabetes could address these issues; such a study has not been conducted. To address these gaps in evidence, we examined the association between food insecurity and measures of cardiometabolic control in a national sample of adults with diabetes.     

Trends in Receipt of American Diabetes Association Guideline-Recommended Care Among U.S. Adults With Diabetes: NHANES 2005–2018

OBJECTIVETo characterize national trends and characteristics of adults with diabetes receiving American Diabetes Association (ADA) guideline-recommended care.RESEARCH DESIGN AND METHODSWe performed serial cross-sectional analyses of 4,069 adults aged ≥20 years with diabetes who participated in the 2005–2018 National Health and Nutrition Examination Survey (NHANES).RESULTSOverall, the proportion of U.S. adults with diabetes receiving ADA guideline-recommended care meeting all five criteria by self-report in the past year (having a primary doctor for diabetes and one or more visits for this doctor, HbA_1c testing, an eye examination, a foot examination, and cholesterol testing) increased from 25.0% in 2005–2006 to 34.1% in 2017–2018 (P-trend = 0.004). For participants with age ≥65 years, it increased from 29.3% in 2005–2006 to 44.2% in 2017–2018 (P-trend = 0.001), whereas for participants with age 40–64 and 20–39 years, it did not change significantly during the same time period: 25.2% to 25.8% (P-trend = 0.457) and 9.9% to 26.0% (P-trend = 0.401), respectively. Those who were not receiving ADA guideline-recommended care were more likely to be younger, of lower socioeconomic status, uninsured, newly diagnosed with diabetes, not on diabetes medication, and free of hypercholesterolemia.CONCLUSIONSReceipt of ADA guideline-recommended care increased only among adults with diabetes aged ≥65 years in the past decade. In 2017–2018, only one of three U.S. adults with diabetes reported receiving ADA guideline-recommended care, with even a lower receipt of care among those <65 years of age. Efforts are needed to improve health care delivery and equity in diabetes care. Insurance status is an important modifiable determinant of receiving ADA guideline-recommended care.     

Incidence of Remission in Adults With Type 2 Diabetes: The Diabetes & Aging Study

OBJECTIVETo estimate the incidence of remission in adults with type 2 diabetes not treated with bariatric surgery and to identify variables associated with remission.RESULTSThe incidence density (remissions per 1,000 person-years; 95% CI) of partial, complete, or prolonged remission was 2.8 (2.6–2.9), 0.24 (0.20–0.28), and 0.04 (0.01–0.06), respectively. The 7-year cumulative incidence of partial, complete, or prolonged remission was 1.47% (1.40–1.54%), 0.14% (0.12–0.16%), and 0.007% (0.003–0.020%), respectively. The 7-year cumulative incidence of achieving any remission was 1.60% in the whole cohort (1.53–1.68%) and 4.6% in the subgroup with new-onset diabetes (<2 years since diagnosis) (4.3–4.9%). After adjusting for demographic and clinical characteristics, correlates of remission included age >65 years, African American race, <2 years since diagnosis, baseline HbA_1c level <5.7% (<39 mmol/mol), and no diabetes medication at baseline.CONCLUSIONSIn community settings, remission of type 2 diabetes does occur without bariatric surgery, but it is very rare.     

All-Cause and Cardiovascular Mortality in Middle-Aged People With Type 2 Diabetes Compared With People Without Diabetes in a Large U.K. Primary Care Database

OBJECTIVE

Middle-aged people with diabetes have been reported to have significantly higher risks of cardiovascular events than people without diabetes. However, recent falls in cardiovascular disease rates and more active management of risk factors may have abolished the increased risk. We aimed to provide an up-to-date assessment of the relative risks associated with type 2 diabetes of all-cause and cardiovascular mortality in middle-aged people in the U.K.

RESEARCH DESIGN AND METHODS

Using data from the General Practice Research Database, from 2004 to 2010, we conducted a cohort study of 87,098 people, 40–65 years of age at baseline, comparing 21,798 with type 2 diabetes and 65,300 without diabetes, matched on age, sex, and general practice. We produced hazard ratios (HRs) for mortality and compared rates of blood pressure testing, cholesterol monitoring, and use of aspirin, statins, and antihypertensive drugs.

RESULTS

People with type 2 diabetes, compared with people without diabetes, had a twofold increased risk of all-cause mortality (HR 2.07 [95% CI 1.95–2.20], adjusted for smoking) and a threefold increased risk of cardiovascular mortality (3.25 [2.87–3.68], adjusted for smoking). Women had a higher relative risk than men, and people <55 years of age had a higher relative risk than those >55 years of age. Monitoring and medication rates were higher in those with diabetes (all P < 0.001).

CONCLUSIONS

Despite efforts to manage risk factors, administer effective treatments, and develop new therapies, middle-aged people with type 2 diabetes remain at significantly increased risk of death.In the U.K., cardiovascular disease (CVD) mortality rates in adults have fallen dramatically in recent years (1), by >40% in those 35–69 years of age during 2000–2010 alone (2). The fall in the rates of CVD in the general adult U.K. population may be attributed in part to using aspirin, hydroxymethylglutaryl-CoA reductase inhibitors (statins), and antihypertensive drugs and successfully incorporating lifestyle interventions, in particular reducing smoking (3). In people with type 2 diabetes, who are at increased risk of death from CVD, evidence has shown that statins, antihypertensive drugs (4), and smoking cessation (3,5) reduce the incidence of CVD (6,7). Consequently, these interventions, in addition to weight management strategies to target obesity, a known risk factor for CVD events (3), have been incorporated into the various clinical guidelines, national standards, and incentives relating to managing diabetes (8–10) and implemented by general practitioners with the aim of reducing the risk of complications.The magnitude of the increase in risk of CVD and all-cause mortality in middle-aged people with diabetes, compared with those without diabetes, has been reported at two to four times higher, but these estimates are largely based on data from the 1990s or earlier (11–16). Given that the rates of CVD mortality in the general population have rapidly fallen in recent years (2), and since 2004, the remuneration for general practice actively rewards intensive management for cardiovascular risk factors in people with diabetes (10), the differences may have narrowed even in the past 8 years. Most studies with post-2000 data on relative risk have not distinguished type 1 from type 2 diabetes (17–20), or have been restricted to newly diagnosed type 2 diabetes (21,22). One exception, reporting relative risks for prevalent type 2 diabetes, was the National Diabetes Audit in England (23). Using follow-up data from 2008 to 2009, they presented standardized mortality ratios in the absence of a nondiabetic comparator group; the report’s authors proposed that their results need replicating using survival analysis methods. Using data from the General Practice Research Database (GPRD), we aimed to provide a more up-to-date assessment of the risk of mortality in middle-aged people with prevalent type 2 diabetes in England, overcoming the acknowledged limitation of the National Diabetes Audit study and additionally considering mortality from CVD.     

Depression in Adolescents With Diabetes

TOPIC: Prevalence and interventions for depression in youth with type 1 diabetes. PURPOSE: To explore the co-morbidity of youth with diabetes and psychiatric conditions, and evaluate the relationship of youth with co-morbid depression and diabetes on glycemic control, quality of life, family support, behavioral problems, attributional style, and self-esteem. SOURCES: Relevant literature in both child and adolescent populations of psychiatry, psychology, and nursing. CONCLUSIONS: Youth with type 1 diabetes have significantly higher rates of depression over the general population. Seratonin reuptake inhibitors, cognitive behavioral treatment, interpersonal therapy, improving family communication and problem-solving skills, and diabetes education hold promise as treatment that can decrease depression in youth with diabetes. Advanced practice nurses are positioned to provide these interventions and treatments.     

Acute Cataract Development in a Pediatric Patient With Type 1 Diabetes

BackgroundType 1 diabetes mellitus (T1DM) is the most common form of diabetes mellitus in the pediatric population, with an estimated 500,000 children living with T1DM and an estimated 80,000 new cases each year in the United States. Ophthalmologic complications of diabetes are common in adult patients and those with longstanding disease, but can also be seen in patients with a recent diagnosis, even among the pediatric population.Case ReportWe present the case of a 13-year-old girl with recently diagnosed T1DM who presented to the pediatric emergency department with acute onset of bilateral blurry vision due to cataract formation. Prompt recognition of the condition and ophthalmologic consultation allowed for timely diagnosis and restorative surgery.Why Should an Emergency Physician Be Aware of This?We present this case to increase awareness among emergency physicians of the potential for cataract formation in pediatric patients with T1DM, as well as the fact that it may be the first presenting sign of the disease. Furthermore, emergency physicians should be aware that pediatric patients who present with severe T1DM, either with extremely high hemoglobin A1c or glycemic blood levels, are at increased risk for cataract formation and should be evaluated for subtle signs of cataract formation even in the absence of obvious cataracts. We also discuss the pathophysiologic theories of cataract formation in patients with T1DM.     

Hmong American Women Living With Diabetes

Purpose: To understand how to better care for Hmong women with diabetes using nursing theory praxis.
Design: Qualitative phenomenologic design, specifically community-based collaborative action research based on Margaret Newman's theory of health as expanding consciousness (HEC).
Methods: Five Hmong women with Type 2 diabetes and HgbA1c levels over 7.0 were recruited from a community-health clinic. Audiotaped in-home interviews were conducted and data were analyzed to identify common patterns and then developed into a play by the research team with the help of a female Hmong playwright. Community dialogue about the findings generated meaningful actions for health.
Conclusions: This study indicates the value of nursing praxis rooted in the theory of health as expanding consciousness and the importance of engaging communities to identify meaningful patterns of health and needed actions.
Clinical Relevance: Evidence-based practice is lacking in the care of Hmong women with diabetes. Community-based collaborative action research rooted in the HEC perspective is a new way to envision models of care.     

Relationship Styles and Mortality in Patients With Diabetes

OBJECTIVE

Prior research has shown that less social support is associated with increased mortality in individuals with chronic illnesses. We set out to determine whether lower propensity to seek support as indicated by relationship style, based on attachment theory, is associated with mortality in patients with diabetes.

RESEARCH DESIGN AND METHODS

A total of 3,535 nondepressed adult patients with type 1 and type 2 diabetes enrolled in a health maintenance organization in Washington State were surveyed at baseline and followed for 5 years. Relationship style was assessed at baseline. Patients with a greater propensity to seek support were classified as having an interactive relationship style and those less inclined to seek support as having an independent relationship style. We collected Washington State mortality data and used Cox proportional hazards models to estimate relative risk (RR) of death for relationship style groups.

RESULTS

The rate of death in the independent and interactive relationship style groups was 39 and 29 per 1,000 individuals, respectively. Unadjusted RR of death was 1.33 (95% CI 1.12–1.58), indicating an increased risk of death among individuals with an independent relationship style. After adjustment for demographic and clinical covariates, those with an independent relationship style still had a greater risk of death compared with those with an interactive relationship style (hazard ratio 1.20 [95% CI 1.01–1.43]).

CONCLUSIONS

In a large sample of adult patients with diabetes, a lower propensity to reach out to others is associated with higher mortality over 5 years. Further research is needed to examine possible mechanisms for this relationship and to develop appropriate interventions.The presence of a supportive social network positively affects health by increasing access to instrumental, informational, and emotional support (1). In patients with diabetes, a higher level of social support is associated with improved treatment adherence, better glycemic control, and greater diabetes knowledge (2). Conversely, lower social support has been associated with higher mortality in patients with various chronic conditions (3,4), including patients with diabetes (5).Clinicians treating patients with chronic conditions generally understand these associations and attempt to encourage patients to seek and receive greater support from patients'' family, friends, peers, and social agencies. Clinicians may also encourage greater collaboration in the patient-provider relationship. Although many patients are receptive to such suggestions and efforts, a significant proportion is less receptive or not receptive at all. For example, regardless of the ready availability of a social network, many patients do not benefit from their support at times of need. Among patients who do not collaborate well with others, many have long-term patterns of not doing so, suggesting the influence of stable characteristics. If there are measurable patient characteristics that predict an individual''s capacity to use supports over time, such information may be useful for shaping approaches and recommendations that providers make in clinical settings.Attachment theory provides a theoretical, evidence-based model for understanding the propensity and ability of individuals to reach out to others for support. This theory posits that all individuals develop a cognitive map based on prior experiences that determines one''s comfort and ability to interact with or reach out to others, particularly at times of distress (6). On the basis of empirical research in infants, children, and adults over the past 30 years, distinct relationship styles arising from these cognitive maps have been identified (7) and demonstrate high levels of stability and continuity between early childhood and adulthood (8). Two of the styles, “dismissing” and “fearful” attachment style, are characterized by difficulty reaching out for support or trusting others, and patients with these styles and characteristics have been described as having an independent relationship style (9). Among clinical populations with diabetes, 48% of patients are typically found to have an independent relationship style (10). The remainder have an interactive relationship style, comprising those with “secure” and “preoccupied” attachment styles. Patients with an interactive relationship style have greater comfort reaching out to others, although individuals with a preoccupied style are often characterized as being highly dependent on others (11).In a large sample of primary care patients with diabetes (9,12), an independent relationship style has been associated with more missed primary care visits, lower satisfaction with care, higher A1C levels, and decreased adherence to exercise, quitting smoking, foot care, diet, and oral hypoglycemic medications. Another study showed that having a relationship style characterized by difficulty trusting or reaching out to others is associated with decreased adherence to glucose monitoring and insulin injections among patients with diabetes (13).In a recent article, we demonstrated that patients with major depression in this epidemiological sample were more likely to die over a 5-year period (hazard ratio [HR] 1.53) (14). In the current study, we set out to determine whether relationship styles are associated with mortality in patients with diabetes. Because depression status is associated with poorer collaboration as measured by relationship style (15), we conducted our analyses in nondepressed patients. In the current study, we hypothesized that among nondepressed patients with diabetes, those with an independent relationship style would have higher mortality over a 5-year period than patients with an interactive relationship style.     

Diabetes Genetic Predisposition Score and Cardiovascular Complications Among Patients With Type 2 Diabetes

OBJECTIVE

To examine the association between genetic predisposition to type 2 diabetes (T2D) and risk of cardiovascular disease (CVD) among patients with T2D.

RESEARCH DESIGN AND METHODS

The current study included 1,012 men and 1,310 women with T2D from the Health Professionals Follow-up Study and Nurses’ Health Study, including 677 patients with CVD and 1,645 non-CVD control subjects. A genetic predisposition score (GPS) was calculated on the basis of 36 established independent diabetes-predisposing variants.

RESULTS

Each additional diabetes-risk allele in the GPS was associated with a 3% increased risk of CVD (odds ratio [OR] 1.03 [95% CI 1.00–1.06]). The OR was 1.47 (1.11–1.95) for CVD risk by comparing extreme quartiles of the GPS (P for trend = 0.01). We also found that the GPS was positively associated with hemoglobin A_1c levels (P = 0.009).

CONCLUSIONS

Genetic predisposition to T2D is associated with an increased risk of cardiovascular complications in patients with T2D.It has been postulated that type 2 diabetes (T2D) and cardiovascular disease (CVD) might spring from a “common soil” where both conditions share common genetic and environmental antecedents (1). Identification of the shared genetic risk factors may improve our understanding of the etiological link of these two diseases. A recent study reported a significant association between a genetic score based on multiple diabetes-predisposing variants and increased risk of coronary heart disease (CHD) in a general population (2). In this study, we constructed a genetic predisposition score (GPS) on the basis of 36 established T2D-predisposing variants, and examined its association with cardiovascular complications among people with T2D.