Type 2 Diabetes in Youth A Road Less Travelled

Transcription

1 Type 2 Diabetes in Youth A Road Less Travelled Julie Halipchuk, RN MN CDE Clinical Nurse Specialist Diabetes Education Resource for Children & Adolescents, Winnipeg, MB Objectives Discuss current trends in the incidence of Type 2 diabetes (T2D) in youth Identify individual factors that may influence the management of youth with T2D Describe an approach to the management and education of youth with T2D Disclosure Conflicts of Interest None A conflict of interest exists when an individual is in a position to profit directly or indirectly through application of authority, influence, or knowledge in relation to the affairs of PENS. A conflict of interest also exists if a relative benefits or when the organization is adversely affected in any way. 1

2 Outline What is Type 2 diabetes in youth Describe pathophysiology The Road Today Population description & incidence rates Barriers to Health The Clinical Program Where to from here? What is type 2 diabetes? What is Type 2 Diabetes? A metabolic disorder characterised by hyperglycemia and altered lipid metabolism caused by varying degrees of insulin resistance in the context of an inability to compensate with increased insulin secretion Nolan, Damm & Prentki, 2011 Of mixed etiology with social, behavioural and environmental risk factors exposing the effects of genetic susceptibility Reinehr, 2013 U.S. diabetes related costs in 2012 were estimated at $245 billion; an increase of 41% over 5 year period American Diabetes Association,

3 Pathophysiology of T2DM Environment Genes Insulin resistance Impaired insulin secretion High Blood Sugars The Road Today The Road Today The pandemic of type 2 diabetes in adults is upon us, however we remain especially alarmed at the rapidly rising rates of type 2 diabetes in youth around the world Pettitt et al., 2014 Youth onset T2DM, also defined by hyperglycemia, is compounded by the medical complications of obesity, insulin resistance, adolescence, poverty, and family beliefs or myths Dean & Sellers, 2007 Prevalence rates of youth onset T2DM range from 2.22/1000 youth <20 years to a higher prevalence of 5.0/1000 for ages years. Pettitt et al., 2014; Pelletier et al., 2012 The high rates of youth onset T2DM that have been documented in Manitoba garner special attention Amed et al.,

4 Pediatric T2DM in Canada Amed et al, Diabetes Care, 2010 Sellers, Dean & Wicklow, CJD 2012 Manitoba - Incidence cases/year (T2D) New Diabetes in Manitoba Children 49% 4

5 Face of Youth Onset T2DM in Canada Mean age: 13.2 years 9.7% presented before age % were obese Sellers, Wicklow & Dean, 2012 Ethnic minorities overrepresented, though 25% were Caucasian 37% had at least one comorbidity at diagnosis Amed et al., % of moms of youth with T2D had pre-pregnancy diabetes vs. 2% of moms of those youth who did not Halipchuk, 2014 Ethnicity of Youth with T2D in Canada 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Caucasian Indigenous African/Carribbean Asian Amed 2010 Diabetes Care HNF-1α G319S Polymorphism Private polymorphism in the Oji-Cree people Results is an insulin secretory defect Results determined with genetic blood work Hegele et al., 2000 Triggs-Raine et al., 2002 Sellers et al.,

6 Barriers To Health What barriers exist in Manitoba? Remote, isolated communities; limited road access Limited or overcrowded housing High rates of unemployment, poverty, low education Barriers to physical activity Less transfer of traditional/basic life skills from parents/elders Increased rates of hospital admissions Coish, Dean CPS Abstract Poorer quality of life Allan 2008, Hood 2014 Depression in 10-20% Levitt 2005, Anderson 2011 More than 65% report 1 major stressful life event in the past year TODAY 2014 past year TODAY 2014 SOCIAL DETERMINANTS OF HEALTH environment parental education, income, housing, social environment 6

7 Clinical Program The goal of our clinical program & treatment plans are to help families overcome barriers. Pediatric T2D Clinics Interdisciplinary Team Pediatric Endocrinologists Diabetes Educators RN & RD Social Work & Psychology Transition Coordinator Maestro Dental hygiene students Appointments may be individual or group education or both Outreach clinics throughout the year 7

8 Education Group Education What is Diabetes? Living Well with Diabetes Healthy Eating Physical Activity Blood Glucose Monitoring Insulin Complications Retinal Screening 23 Physical Activity Assess: Total screen/sedentary time Daily physical activity time Sleep patterns Include some measure of intensity Reduce screen time Set small, realistic goals 8

9 Physical Activity Healthy Eating Insulin Therapy In youth with T2DM and A1C>9.0% (and/or in DKA at diagnosis) insulin therapy is initiated May be successfully weaned once glycemic targets are achieved, particularly if lifestyle changes are effectively adopted Important to address myths associated with insulin use Further studies are needed to discern safety & efficacy of medications that have been only studied in adults. 9

10 Complications & Co-morbidities Influenced by emerging evidence that suggests that complications may be more aggressive, occur earlier in youth onset T2DM Dabelea et al., Diabetes, Dart et al, Diabetes Care, Poor renal survival in youth with type 2 diabetes 60% on dialysis after 20 years T1D T2D Renal Failure 4-fold higher than T1D Dean & Flett 2002A Dart

11 Where to from here? Barriers to Health Barra Poverty Food Security Geographical Jurisdictional Cultural Prevention & intervention efforts must be directed at lessening these barriers to health. Willows, Hanley & Delormier,

12 Addressing Financial Barriers to Health An inverse relationship of income to risk of youth onset T2DM is not only evident when comparing the lowest income quintile to the highest, but additionally when a linear trend test was completed. Halipchuk, 2014 Intervention studies and health care initiatives, grounded within a multifactorial socio-ecological model and directed at narrowing the economic disparity amongst these vulnerable populations are necessary. Drugs in children with type 2 diabetes Recruitment of pediatric patients with type 2 diabetes for clinical trials 1. Low prevalence of disease 2. Disadvantaged populations 3. Geography Nguyen 2014; Ortiz 2013; Karres 2013; Tamborlane 2013 Transition: The Maestro Program Initiated in 2002 to help facilitate transition from pediatric to adult diabetes care Provide support and advocacy Help navigate complex adult system Assist with accessing and coordinating services Building relationships Next steps include continued efforts aimed at securing adult care partnerships for this vulnerable population. 12

13 Breastfeeding Breastfeeding has been shown to be protective when compared with formula feeding. Halipchuk, 2014 Could we support women with diabetes to feed their offspring breast milk exclusively while in hospital? Next Generation Cohort September 2014 Research Efforts Genetics and epigenetics Intrauterine environment Infant nutrition Stress & intergenerational trauma Growth patterns Efforts aimed at detecting, treating and documenting the natural history of this disease has begun, but our work is far from over. 13

14 Summary T2DM diabetes is no longer just an adult disease. They are many barriers to health for these families. Lifestyle interventions need to be family focused & transgenerational. Treatment & education programs require creativity and cultural sensitivity. Thank you for your kind attention. References Amed, S., Dean, H. J., Panagiotopoulos, C., Sellers, E. A., Hadjiyannikis, S., Laubscher, T. A.,,Hamilton, J.K. (2010). Type 2 Diabetes, Medication-Induced Diabetes, and Monogenic Diabetes in Canadian Children: a prospective national surveillance study. Diabtetes Care (33) 4, Dabelea, D., Mayer-Davis, E. J., Lamichhane, A. P., D'Agostino, R. B., Liese, A. D., Vehik, K.,, Hamman, R.F. (2008). Association of Intrauterine Exposure to Maternal Diabetes and Obesity With Type 2 Diabetes in Youth. Diabetes Care (31)7, Dart, A.B., Sellers, E.A., Martens, P.J., Rigatto, C., Brownell, M.D., & Dean, H.J. (2012). High burden of kidney disease in youth-onset type 2 diabetes. Diabetes Care, 35(6), Dart, A. B., Martens, P.J., Rigatto, C., Brownell, M.D., Dean, H.J., & Sellers, E.A. (2014). Earlier onset of complications in youth with type 2 diabetes. Diabetes Care, 37(2), Dean, H.J., & Sellers, E.A.C. (2007). Comorbidities and microvascular complications of type 2 diabetes in children and adolescents. Pediatric Diabetes, 8, Hegele, R. A., Zinman, B., Hanley, A. J., Harris, S. B., Barrett, P. H., & Cao, H. (2003). Genes, environment and Oji-cree type 2 diabetes. Clinical Biochemistry, 36(3),

15 References Nolan, C. J., Damm, P., & Prentki, M. (2011). Type 2 diabetes across generations: from pathophysiology to prevention and management. The Lancet, 378, Pettitt, D.J., Talton, J., Dabelea, D., Divers, J., Imperatore, G., Lawrence, J.M.,, & Hammon, R.F. (2014). Prevalence of diabetes in U.S. youth in 2009: The SEARCH for diabetes in youth study. Diabetes Care, 37(2), Reinehr, T. (2013). Type 2 diabetes mellitus in children and adolescents. World Journal of Diabetes, 4(6), Sellers, E. A., Triggs-Raine, B., Rockman-Greenberg, C., & Dean, H. J. (2002). The Prevalence of the HNF-1Alpha G319S mutation in Canadian Aboriginal Youth with Type 2 Diabetes. Diabetes Care, 25(12), Sellers, E.A.C., Wicklow, B. A., & Dean, H.J. (2012). Clinical and Demographic Characteristics of Type 2 Diabetes in Youth at Diagnosis in Manitoba and Northwestern Ontario ( ). Canadian Journal of Diabetes, 36,