Chapter 14 DIABETES MELLITIS: TYPE 1 AND TYPE 2 Emily Loghmani SIGNIFICANCE
Diabetes mellitus is a group of metabolic diseases characterized by elevated blood glucose levels(hyperglycemia) resulting from defects in insulin secretion, insulin action or both. Insulin is a hormonemanufactured by the beta cells of the pancreas, which is required to utilize glucose from digested foodas an energy source. Chronic hyperglycemia is associated with microvascular and macrovascularcomplications that can lead to visual impairment, blindness, kidney disease, nerve damage,amputations, heart disease, and stroke. In 1997 an estimated 4.5% of the US population had diabetes. Direct and indirect health care expenses were estimated at $98 billion.1
The type of diabetes is based on the presumed etiology. This chapter provides information about thetwo most common types of diabetes: type 1 and type 2 diabetes (see Table 1). Characteristics of the Common Types of Diabetes
African Americans, Hispanics, NativeAmericans, Asian/Pacific Islanders
Source: Adapted from Orr, DP. Contemporary management of adolescents with diabetes mellitus. Part 1: Type 1 diabetes. Adolescent Health Update 2000;12(2), Table 2, p 3. In type 1 diabetes, the body does not produce insulin, and daily insulin injections are required. Over 700,000 people in the United States have type 1 diabetes; this is 5-10% of all cases of diabetes mellitus. Type 1 diabetes is usually diagnosed during childhood or early adolescence and it affects about 1 in every 600 children.
Stang J, Story M (eds) Guidelines for Adolescent Nutrition Services (2005)
GUIDELINES FOR ADOLESCENT NUTRITION SERVICES
Type 2 diabetes is the result of failure to produce sufficient insulin and insulin resistance. Elevatedblood glucose levels are managed with reduced food intake, increased physical activity, andeventually oral medications or insulin. Type 2 diabetes is believed to affect more than 15 millionadult Americans, 50% of whom are undiagnosed. It is typically diagnosed during adulthood. However with the increasing incidence of childhood obesity and concurrent insulin resistance, thenumber of children diagnosed with type 2 diabetes has also increased worldwide.2
For example, from 1982 to 1994 in one mid-western city, the proportion of children with type 2diabetes increased from approximately 4% to 16%.3 This increase is greatest among individuals fromcertain ethnic/racial groups (African Americans, Native Americans, Hispanics and Asians/PacificIslanders) and for those with a family history of type 2 diabetes. ETIOLOGY/CONTRIBUTING FACTORS Type 1 Diabetes
• Caused by the immune destruction of the beta cells of the pancreas. • Antibodies to islet cells and insulin are present at diagnosis. • Insulin secretion gradually diminishes. • May present at any age, but most common in childhood and adolescence. • Insulin by injection is necessary for survival. • Contributing factors:
– Environmental triggers (infection or other stress)
Type 2 Diabetes
• Caused by insulin resistance in the liver and skeletal muscle, increased glucose production in the
liver, over production of free fatty acids by fat cells and relative insulin deficiency.
• Insulin secretion decreases with gradual beta cell failure.
• Reductions in blood glucose levels often can be achieved with changes in food intake and
physical activity patterns. Oral medication and/or insulin injections are eventually required.
– Age (onset of puberty is associated with increased insulin resistance)
– Racial/ethnic background (African American, Native American, Hispanic and Asian/Pacific
– Conditions associated with insulin resistance, (e.g., polycystic ovary syndrome)
Chapter 14. Diabetes Mellitis: Type 1 and Type 2CONSEQUENCES Type 1 Diabetes Before diagnosis with type 1 diabetes, a teen with elevated blood glucose levels will develop symptoms of increased urination, thirst, and appetite in addition to weight loss or failure to grow normally. If not diagnosed soon enough, life-threatening ketoacidosis may result.
After diagnosis with type 1 diabetes, the teen must follow a daily management regimen that includesregularly scheduled insulin injections, blood glucose monitoring, and attention to food intake(especially carbohydrates) that adds stress to many families. Families must receive comprehensiveeducation, diabetes self-management training, frequent follow-up, and social support on an on-goingbasis. The burden of living with a chronic illness is a consequence that is often overlooked.
Consequences occur with administration of too much or not enough insulin. Too much insulin orinadequate food intake may lead to low blood glucose levels (hypoglycemia) and potentially, loss ofconsciousness and seizures. Chronic hyperglycemia, a reflection of insufficient insulin, results in eyedisease, kidney disease, nerve damage, and an increased risk of cardiovascular disease that mayappear 10-15 years after diagnosis. Type 2 Diabetes Before diagnosis with type 2 diabetes, a teen with elevated blood glucose levels may present with no symptoms or have mild glucosuria and/or ketosis with or without weight loss.
After diagnosis with type 2 diabetes, the teen must follow a daily management regimen that includesattention to food intake (carbohydrates, as well as fats and total energy intake), exercise, and bloodglucose monitoring. Administration of medication (insulin or oral medications) may also be required. This new regimen may add stress to families. Families must receive comprehensive education,diabetes self-management training, frequent follow-up, and social support on an on-going basis. Theburden of living with a chronic illness is a consequence that is often overlooked.
Acute consequences will depend on the medication prescribed. Those teens treated with insulin orsulfonylureas are at risk for low blood glucose levels.
Long term consequences are similar to those resulting from poor control of type 1 diabetes– eyedisease, kidney disease, nerve damage and an increased risk of cardiovascular disease. SCREENING Early Warning Signs for Type 1 and Type 2 Diabetes A blood glucose level should be checked if one or more of these symptoms is present:
• Increased urination• Increased thirst• Increased appetite• Unexplained weight loss
Screening for Type 1 Diabetes • No screening recommendations for the diagnosis of type 1 diabetes in adolescents have been GUIDELINES FOR ADOLESCENT NUTRITION SERVICESScreening for Type 2 Diabetes The screening recommendations listed in Table 2 are from the American Diabetes Association.4 Testing for Type 2 Diabetes in Children and Adolescents Criteria*
Overweight (BMI ≥ 85th percentile for age and gender, weight for height ≥ 85th percentile or weight ≥ 120% of ideal for height). Plus any two of the following risk factors:
– Family history of type 2 diabetes in first- or second degree relative– Race/ethnicity (American Indian, African American, Hispanic, Asian/Pacific Islander)– Signs of insulin resistance or conditions associated with insulin resistance (acanthosis nigricans,
hypertension, dyslipidemia, polycystic ovary syndrome)
Age of initiation: age 10 years or at onset of puberty if puberty occurs at a younger age. Frequency: every 2 years. Test: fasting plasma glucose is the preferred method for screening.
*Clinical judgment should be used to test for diabetes in high-risk patients who do not meet these criteria.
Source: 2002 American Diabetes Association. From Standards of medical care for patients with diabetes mellitus. Diabetes Care 2002;25(1):213-229; Table 4, p. 215. Reprinted with permission from The American Diabetes Association. ASSESSMENT
A nutrition assessment should be done at diagnosis and at least once a year thereafter by a registereddietitian experienced with diabetes and adolescent nutrition. The assessment includes an evaluation oftypical food intake and eating habits in addition to identifying the many factors that influence foodintake (Table 3). A 24-hour dietary recall and an age appropriate nutrition questionnaire are usefultools to obtain this information (see Chapter 4). Then an initial meal plan can be determined andadjustments in total energy intake may be made to allow for stage of growth and activity level. Information about family support and barriers to learning will help the dietitian individualize theeducational experience. Factors that Influence Adolescent Food Intake
• Use body mass index to assess physical growth (see Chapter 4). A teen with weight loss prior to
diagnosis often needs additional calories for catch-up growth. Once healthy weight gain hasoccurred, it is important to check the meal plan 3-4 weeks after diagnosis and decrease total foodintake, if necessary, to prevent excess caloric intake and unwanted weight gain.
• Total energy and protein requirements can be estimated by a combination of typical food intake
and the Recommended Dietary Allowances. Adolescent energy and protein intake is oftencalculated by height to allow for changes in energy requirements related to growth during pubertyrather than chronological age. Chapter 14. Diabetes Mellitis: Type 1 and Type 2INTERVENTION AND COUNSELING STRATEGIES
Treatment for both types of diabetes is aimed at maintaining blood glucose values near normal levels. Additional goals are:
• Promote normal growth and development and achievement of a healthy weight. • Normalize blood glucose levels and minimize hyperglycemia and hypoglycemia. • Achieve normal lipid levels. • Prevent and delay complications. • Promote optimal health and well-being. Achieving these goals requires insulin or glucose-lowering medications that depend on the type ofdiabetes, medical nutrition therapy, frequent blood glucose monitoring to identify and evaluate bloodglucose patterns, and comprehensive education in diabetes, self-management and decision-makingskills at diagnosis and follow-up visits. Target blood glucose goals for teens are listed in Table 4. Blood Glucose Goals for Adolescents1
1 These values are generally not indicated for preadolescents. The values shown in this table are by necessity generalizedto the entire population of individuals with diabetes. Patients with comorbid diseases, the very young and older adults, andothers with unusual conditions or circumstances may warrant different treatment goals. These values are for nonpregnantadults.
2 “Action indicated” depends on individual patient circumstances. Such actions may include enhanced diabetes self-management education, comanagement with a diabetes team, referral to an endocrinologist, change in pharmacologicaltherapy, initiation of or increase in SMBG, or more frequent contact with the patient. HbA is referenced to a nondiabetic
range of 4.0-6.0% (mean, 5.0%, SD 0.5%).
3 Measurement of capillary blood glucose.
Adapted from: Orr, DP. Contemporary management of adolescents with diabetes mellitus. Part 1: Type 1 diabetes. Adolescent Health Update 2000;12(2), Table 1, p 2.
Successful education programs will include the following components:
• Involvement of the teen, family, key teachers, school nurses and/or coaches. • An individualized approach to treatment plans. • Culturally appropriate information, educational materials, and treatment plans. • Frequent follow-up to evaluate and adjust as needed. GUIDELINES FOR ADOLESCENT NUTRITION SERVICESTreatment for Type 1 Diabetes Insulin Therapy Insulin is the only medication that is effective in lowering blood glucose levels in type 1 diabetes. The use of insulin requires daily management of those factors that affect the insulin dose (food, physical activity, illness, stress). See Table 5 for common insulin preparations. Rapid-acting insulin may be given before, during, or immediately after a meal. Administration after a meal may help reduce the postprandial hyperglycemia associated with high fat meals. The number of insulin injections/day will vary; insulin may be delivered with insulin syringes, insulin pens or external insulin pumps.
• Conventional therapy– 2 daily injections of mixed insulin (rapid- or short-acting and
intermediate-acting) before breakfast and the evening meal.
• Conventional therapy with a split night-time dose– 1 injection of mixed insulin (rapid- or short-
acting and intermediate-acting) before breakfast, 1 injection of rapid- or short-acting insulinbefore the evening meal and 1 injection of intermediate-acting insulin before the bedtime snack. This regimen is used to help reduce fasting hyperglycemia associated with the long intervalbetween the evening meal and breakfast and the duration of action of the intermediate-actinginsulin and to facilitate management of the dawn phenomenon.
• Multiple daily injections (MDI) of rapid- or short-acting insulin before every meal (andsometimes large snacks) with intermediate- or long-acting insulin once or twice a day. Theaddition of rapid- or short-acting insulin before lunch helps reduce pre-supper hyperglycemiawith less risk of hypoglycemia associated with very large pre-breakfast doses of intermediate-acting insulin. With the exception of a bedtime snack to prevent hypoglycemia during the night,snacks usually are not required with MDI– an advantage for busy teens and those who wish tomaintain a target weight. This may be called intensive therapy depending on the level ofglycemic control that is targeted.
• Intensive therapy with a continuous subcutaneous insulin infusion (CSII or insulin pump)–
Rapid-acting insulin is delivered constantly to meet the body’s basal need to suppress hepaticglucose production. A bolus dose of insulin is given before meals and snacks based on theamount of carbohydrate eaten and the measured level of blood glucose. This regimen is formotivated teens who are willing to test frequently (>4 times/day), monitor carbohydrate intakeaccurately, adjust insulin doses and commit to frequent contact with the diabetes team. Description of Commonly Used Insulin Preparations
Adapted From: Orr, DP. Contemporary management of adolescents with diabetes mellitus. Part 1: Type 1diabetes. Adolescent Health Update 2000;12(2), Table 3, p 7. Chapter 14. Diabetes Mellitis: Type 1 and Type 2
The insulin dose depends on basal needs, food intake (especially the total amount of carbohydrate) andamount of physical activity. Changes in the dose of rapid- or short-acting insulin can be madeaccording to a sliding scale that increases the dose for higher blood glucose levels and decreases thedose when blood glucose levels are lower. In addition, average blood glucose levels at various times ofday can be calculated to further adjust the insulin recommended (rapid, short, intermediate and/or long-acting preparations).
Self-blood glucose testing is recommended before each meal and the bedtime snack to help assess thedose and make changes as needed. Testing at 2:00-3:00 am is useful for evaluating night-timehypoglycemia and fasting hyperglycemia (dawn phenomenon).
A variety of blood glucose testing meters are available. Many contain memory to store the date, timesand test results. Some can be downloaded to personal computers that graphically display blood glucosereadings. New meters are available that allow the user to obtain blood from other areas beside thefingertips.
Average blood glucose levels over the last 3 months are measured by a blood test called glycatedhemoglobin. Different assays are available, each with their own normal (nondiabetic) range;hemoglobin A1c (HbA1c) is the preferred method. It is recommended to use the same laboratory toavoid confusion. The teen should have the test performed before visiting the physician to facilitateearly discussion of results and if necessary, strategies to improve control. The 1994 Diabetes Controland Complications Trial (DCCT) that included 195 adolescents (13-18 years old) demonstrated thatbetter blood glucose control significantly reduced the risk for long-term complications.5 Based uponthe DCCT results, the target HbA1c is 7%. Medical Nutrition Therapy Food intake influences the amount of insulin required to meet blood glucose target goals. Dietary carbohydrate influences postprandial blood glucose levels the most and is the major determinant of meal-related insulin requirements. The intermediate- or longer-acting insulin usually covers the effects of protein and fat.
At diagnosis, the teen and the family are taught how to monitor food intake with basic carbohydrate-counting guidelines (see Table 6 for teaching ideas). Two types of counting methods are available tomonitor carbohydrate intake.
• Counting carbohydrate servings: Standard servings of foods in the starch/bread, fruit and milk
groups are considered to be approximately equal in carbohydrate value (1 serving = approximately15 g carbohydrate). Carbohydrate values are obtained from food lists and nutrition labels. Forexample, a teen who eats 2 pieces of toast (2 carbs) with margarine and 1 cup of milk (1 carb) forbreakfast is eating a 3 carb breakfast. If premeal insulin is calculated on the basis of units of short-acting insulin per carb and the teen’s dose is 1 unit/1 carb, the insulin dose would be 3 units tocover the carbohydrate in this breakfast.
• Counting grams of carbohydrate: The specific carbohydrate gram value for all foods eaten is
determined, thus increasing the accuracy of the carbohydrate count. For example, the abovebreakfast is equal to approximately 45 g carbohydrate (3 carbohydrate servings x 15 g/serving =45 g total carbohydrate). However, if the bread is actually 20 g/slice and the milk is 12 g/cup, thecarbohydrate intake is 52 g. If the same teen is taking 1 unit/15 g carbohydrate, the insulin dosewould be 3.5 units for this breakfast instead of 3 units. GUIDELINES FOR ADOLESCENT NUTRITION SERVICES Teaching Ideas for Carbohydrate-Counting
Use food models to illustrate portion sizes.
Plan sample menus that incorporate schoollunches, snacks from vending machines, and fast
Provide opportunities to weigh and measure
Teach how to work-in sugar-containing foods in
Teach how to read nutrition labels with labels from
Carbohydrate counting guidelines are provided by a stepped approach (see Table 7). Withconventional insulin therapy, a structured meal plan with defined carbohydrate goals is necessary tosynchronize the timing of carbohydrate intake with the time-action of the insulin used and to promotea consistent intake of dietary carbohydrate. Once teens are comfortable with the basics and learn howto identify blood glucose patterns, they may choose to begin a more intensive insulin regimen. At thislevel carbohydrate/insulin ratios and corrective dose adjustments are used to increase flexibility withthe timing of meals and snacks and the amount of carbohydrate eaten. Carbohydrate counting as ameal planning approach offers varied food choices and many strategies for achieving target bloodglucose levels.6
Carbohydrate Counting Guidelines Level 1 – Basic Carbohydrate Counting
To identify usual carbohydrate (CHO) intake and promote consistent CHO at meals and snacks.
Why CHO relates to blood glucose levels.
Importance of consistent amounts of CHO at meals and snacks.
Which foods contain CHO, protein and fat.
How to identify portion sizes of common foods.
How to read nutrition labels to determine number of CHO choices. Level 2 – Advanced Carbohydrate Counting
1. To learn how to identify patterns in blood glucose levels that relate to insulin, food intake and/or exercise
and make changes to improve blood glucose levels.
Importance of monitoring blood glucose levels.
How to identify blood glucose patterns.
How to adjust insulin, food and/or exercise to reduce high and/or low blood glucose levels.
Suggestions to help avoid unwanted weight gain.
Suggestions for treating low blood glucose episodes.
2. To learn how to adjust rapid- or short-acting acting insulin when CHO intake and timing of meals and
How to calculate the amount of insulin needed to cover the amount of CHO eaten.
How to determine the amount of insulin needed to lower your blood glucose level.
Importance of accurate CHO counting.
How to make insulin adjustments for high fat meals, high fiber foods and unusually largeamounts of CHO or protein. Chapter 14. Diabetes Mellitis: Type 1 and Type 2
Carbohydrate intake is adjusted for other circumstances, such as increased physical activity and lowerblood glucose levels before the evening snack to reduce the risk of low blood glucose levels. • For increased physical activity beyond the usual routine: Eat or drink 15 g carbohydrate for every
hour of extra activity before the activity. For longer, more strenuous exercise (>1 hour), includeprotein with the carbohydrate. These guidelines may be individualized depending on the insulinregimen, blood glucose level before exercise, and training intensity (Table 8).
• For lower blood glucose levels before the evening snack: If blood glucose levels are 70-100 mg/dl,
eat or drink an additional 15 grams of carbohydrate with the regular evening snack. If bloodglucose levels are < 70 mg/dl, treat the low blood glucose first with 15 g carbohydrate or glucose;wait 15 minutes and retest; eat or drink another 15 g carbohydrate if the blood glucose level is still< 70 mg/dl. Otherwise, have the regular evening snack with an additional 15 g carbohydrate. Guidelines for Exercise
For most people, the safe pre-exercise blood glucose (BG) range is from 100-250 mg/dl.
If BG is less or close to 100 mg/dl, have a snack to raise it before exercising, as shown below.
When BG is 100-150 mg/dl, many people do not require a snack unless exercise is intense. However, testduring exercise and be prepared to snack to keep BG up if necessary.
For every hour of exercise, be ready to consume 10-15 grams of carbohydrate.
A BG 151-250 mg/dl is optimal for safe exercise.
Avoid exercise if fasting BG is >350 mg/dl or >250 mg/dl and ketones are present.
Identify usual BG response to exercise to determine if insulin must be reduced
Be prepared to test in the middle of the night if the exercise is intense or of long duration.
Have carbohydrate (CHO) foods available at all times – before, during and after exercise. Examples of regimens tailored to intensity of exercise
30g CHO* - Large banana or 16 oz sports drink
45g CHO* - Sandwich and 8 oz sports drink
basketball, strenuous cycling,swimming, shoveling snow
* Some guidelines suggest adding a protein serving with moderate or intense exercise
Adapted From: Orr, DP. Contemporary management of adolescents with diabetes mellitus. Part 1: Type 1 diabetes. Adolescent Health Update 2000;12(2), Table 7, p 10.
Nutritional recommendations for teens are similar to those for other young people. Macronutrientdistribution should be approximately 50-60% carbohydrate, 10-20% protein and 30% fat. Saturated fatshould be limited to < 10% of total calories and dietary cholesterol to < 300 mg/day to help reduce therisk of cardiovascular disease. Further adjustments in fat intake may be required with elevated lipidlevels and/or unhealthy weight gain. Guidelines for dietary fiber and sodium are the same as for thegeneral population. GUIDELINES FOR ADOLESCENT NUTRITION SERVICES
Scientific evidence no longer supports the need to restrict sucrose and sucrose-containing foods to reduce hyperglycemia. Therefore, teens can continue to eat many common foods, such as sweetened cereal, cookies, brownies, and ice cream, in the context of a healthy eating plan as long as they estimate the amount of carbohydrate eaten and make appropriate adjustments. Special Considerations Hypoglycemia (a blood glucose level < 70 mg/dl). (See Table 9.) • Also called low blood sugar, insulin reaction or insulin shock. • Usually caused by too little food, too much insulin, extra physical activity or delayed meals and
• May occur at any time, but is most likely before meals, during peak action time of insulin and
• Frequent or severe hypoglycemia is unpleasant and many teens will tolerate higher blood glucose
levels and not increase insulin doses as recommended in order to avoid these episodes. The diabetesteam should be sensitive to this and work with the teen to promote gradual improvements in bloodglucose levels.
• Teens with limited cognitive ability, those who skip or delay meals, those lacking awareness of
hypoglycemia (increasingly common after having diabetes for 10 years) and those who are startingintensive insulin therapy are at risk for increased hypoglycemia. If this persists, higher bloodglucose levels may be acceptable. Hypoglycemia Guidelines Moderate SYMPTOMS TREATMENT Chapter 14. Diabetes Mellitis: Type 1 and Type 2Unwanted weight gain Teens who improve their blood glucose control may gain unwanted weight unless the meal plan or activity routine is modified. In addition, they may experience more frequent hypoglycemia that requires additional carbohydrate and adds calories. This is especially problematic for young women who may begin to give less insulin or omit doses altogether. Regular attention to the teen’s pattern of weight gain or loss is important. The teen needs to work with the diabetes team to decide how to adjust insulin doses or food intake. Chronic poor control with reported large insulin doses and unexplained weight loss may indicate intentional under-dosing or insulin omission in an attempt to lose weight. The incidence of eating disorders is no greater in teens with diabetes than those without diabetes. Promotion of healthy eating, regular physical activity, and acceptance of the diversity of body shapes and sizes should be discussed regularly. Alcohol use Although many alcoholic drinks contain carbohydrate, alcohol is not converted to glucose. It tends to inhibit gluconeogenesis and interferes with the counter-regulatory response to hypoglycemia. It also impairs judgment. Guidelines to prevent low blood glucose levels with alcohol use include: • Do not skip meals or snacks when drinking.
• Consume additional carbohydrate if drinking more than the equivalent of two alcoholic beverages. • Inform someone with you that you have diabetes. • Do not drive after drinking.
• Do not take extra insulin when drinking. Driving Teens should be reminded of the dangers of driving when blood glucose levels are low.
Guidelines to prevent or treat low blood glucose levels immediately include:• Keep carbohydrate-containing foods (glucose tablets, juice, hard candy, regular soda) in your car
• Wear an ID bracelet. • Test before driving at times when the teen may have a greater risk for hypoglycemia (after
exercising, after skipped or delayed meals). Pregnancy • Young women with diabetes need education about contraception. All commonly used hormonal
contraceptives are safe with diabetes and do not influence blood glucose levels.
• The physician should consider early pregnancy in the differential diagnosis of unexplained
• Young women with diabetes should be referred to a diabetes program for intensive insulin
management as soon as they learn they are pregnant. Developmental issues • Adolescence is a time for developing a teen’s sense of identity and increasing autonomy and
independence. More free time is spent with friends and social activities are loosely structured,unplanned, and often include food. School and work schedules become more challenging andphysical activity may be erratic. GUIDELINES FOR ADOLESCENT NUTRITION SERVICES
• Despite a normal appearance, teens with type 1 diabetes must alter their lifestyle to follow
treatment recommendations and minimize serious hypoglycemia and hyperglycemia. They mustmonitor blood glucose levels, food intake, and exercise as well as inject insulin several times eachday. The physical, emotional, and social demands of self-management are often associated withneglect of self-monitoring, dietary recommendations, and insulin injections during adolescence. Depression and avoidance also may contribute to poor blood glucose control. At a time whenteens are seeking independence, parents often have to increase their involvement to make suredaily diabetes care is done.
• An interdisciplinary diabetes team can help support the teen and match treatment plans with
his/her motivation, ability, and level of functioning. Behavioral interventions, such as coping-skills training to teach problem-solving skills and communication, have been shown to helpimprove blood glucose control and quality of life in teens starting intensive insulin regimens.7
• Teens preparing to live away from home (in college dormitories or apartments) may initiate more
intensive insulin regimens in order to increase flexibility and allow for less structured routines. Workshops for juniors and seniors in high school can help them make these transitions. Strategies to motivate teens (especially those in poor control) • Identify the reason for poor control and negotiate a plan with the teen.
• Decide on one reasonable and measurable action-oriented goal (number of blood glucose tests,
recording carbohydrate at a specific meal, adjusting insulin based on blood glucose orcarbohydrate intake).
• Identify short-term benefits relevant to the teen– less hypoglycemia, less frequent nocturia,
improved physical performance, more flexibility in timing and content of meal, rewards fromparents, greater independence.
• Establish a realistic time for accomplishment based on behavior and goal (e.g., average fasting
blood glucose level will be 20% lower over the next 2 weeks).
• Provide frequent feedback. See the teen more often.
• Find out how much supervision or support the parents provide. Request more parental involvement. Treatment for Type 2 Diabetes Glucose Lowering Therapy It is best to treat type 2 diabetes as vigorously as possible to avoid or delay the long term consequences of elevated blood glucose levels, high blood pressure, and dyslipidemia. Treatment focuses on discovering the most effective method to lower blood glucose levels, whether it is lifestyle modifications, insulin therapy, oral agents, or any combination of these factors. The diabetes team must work with the teen and the family to educate them about the importance of good control and to make the necessary adjustments in treatment every 4-6 weeks until acceptable control is achieved.
• At diagnosis, teens with type 2 diabetes who are acutely ill with significant hyperglycemia (>300
mg/dl) and ketosis require insulin therapy. Insulin regimens are similar to those for teens with type1 diabetes. In the less ill teen, initial treatment with medical nutrition therapy and exercise or aglucose lowering oral agent may be appropriate. In both circumstances, target blood glucose goalsare similar to those with type 1 diabetes and treatment recommendations may change depending onblood glucose control.
• Glucose-lowering oral agents may be effective with type 2 diabetes. See Table 10 for the types
Chapter 14. Diabetes Mellitis: Type 1 and Type 2Glucose-Lowering Oral Agents Commonly Used for Treatment of Type 2 Diabetes. Type of Agent Mechanism of Action Generic Names
Decrease hepatic glucose production, increase muscle
Short-term promotion of glucose-stimulated insulin
Decrease digestion and absorption of carbohydrate
Increase insulin action in muscle, adipose tissue and
• The biguanide, metformin, is often the first oral agent used with teens. Metformin is effective at
reducing blood glucose levels without the risk of hypoglycemia. It does not cause weight gain and ithelps reduce total cholesterol, LDL cholesterol, and triglyceride levels. Nausea and abdominaldiscomfort may occur with initial use. Starting at low doses (500 mg/day) and increasing graduallyto a maximum daily dose of 2200 mg may minimize these side effects. Because the kidneymetabolizes biguanides, they should not be used if the teen is dehydrated. In young women withdiabetes and polycystic ovary syndrome, metformin may normalize ovulatory abnormalities,thereby increasing the risk for pregnancy in those who are sexually active and necessitatingpreconception counseling.
• The other oral agents are used infrequently with teens due to concerns with hypoglycemia and
weight gain (sulfonylureas), more severe gastrointestinal symptoms (glucosidase inhibitors) andsafety (thiazolidinediones).
• Combination regimens that include insulin with an oral agent may be used to help lower blood
glucose levels. Combination therapy usually requires less insulin, however blood glucosemonitoring is still essential.
Blood glucose monitoring is recommended to evaluate treatment. Teens whose diabetes is controlledwith life style changes or oral agents are encouraged to perform blood glucose testing before breakfastand one other time during the day. Teens on insulin therapy need to test 2-4 times/day depending on theinsulin regimen. In addition, blood glucose monitoring 2 hours after a meal provides information aboutthe effectiveness of lifestyle changes. If 2 hour post-meal blood glucose levels are >180 mg/dl, the teenneeds to decrease carbohydrate goals, increase activity or adjust medications. HbA1c are monitoredquarterly. As in type 1 diabetes, a large clinical study, the United Kingdom Prospective Diabetes Study,has shown that better glycemic control (HbA1c < 7.0%) results in reduced cardiovascular andmicrovascular complications.8
Medical Nutrition Therapy At diagnosis, dietary recommendations should emphasize blood glucose control, not weight loss. Even though many teens with type 2 diabetes are overweight at diagnosis, it is preferable to educate GUIDELINES FOR ADOLESCENT NUTRITION SERVICES
the teen about carbohydrate counting, the effects of food on blood glucose levels, and the healthbenefits of physical activity as opposed to putting them on a “diet.” A meal plan with regular mealsand snacks and carbohydrate goals that are moderately less than their usual intake will often helplower blood glucose levels. Once the teen learns to identify carbohydrate-containing foods andmonitor carbohydrate intake, cessation of weight gain, and even weight loss, may occur. (SeeTables 11 and 12 for nutrition tips.)
General Guidelines for Food Intake
Eat 3 meals and 1 snack on a regular schedule.
Follow carbohydrate goals for meal planning from
the dietitian. Try to eat about the same amount ofcarbohydrate at the same time each day. Ways to Limit Carbohydrate Intake
Drink calorie-free beverages (e.g., water, tea, diet
eating. (If >180 mg/dl, you ate morecarbohydrate than your body could handle).
Limit carbohydrate servings to 3-4/meal. Ifnecessary decrease to 1-2 at breakfast.
• Modest weight loss (5-10% of body weight) may improve blood glucose control but treatment
should focus more on modifying the factors that contribute to excess weight gain–poor eatinghabits and sedentary lifestyle–than on low calorie diet plans. For more information on healthyweight loss strategies, see Chapter 6.
• Exercise is another factor that may improve insulin sensitivity independent of weight loss (see
Table 13). It is important to find out what activities teens enjoy and to identify easy ways toincorporate more physical activity into their daily routines. Forty-five to sixty minutes of aerobicexercise at least 3 times/week is recommended.
• Hyperlipidemia may improve as blood glucose levels normalize. If cholesterol and triglyceride
levels do not improve, weight loss, a decreased intake in saturated fat or treatment with a lipid-lowering medication may be indicated. See Chapter 10 for dietary strategies to reduce lipidlevels. Benefits of Exercise Chapter 14. Diabetes Mellitis: Type 1 and Type 2PREVENTION Type 1 Diabetes Presently there is no way to prevent type 1 diabetes.
• Current research with relatives of people with type 1 diabetes is studying how to prevent or delay
the autoimmune destruction of the beta cells. If a simple blood test detects the presence of isletcell antibodies, the person is eligible to enter. Participants in the Type 1 Diabetes TrialNetstudies are randomly assigned to either a Natural History or Prevention Study and followed by amedical team (see Internet Resources in RESOURCES section). Type 2 Diabetes Prevention requires identifying those children and teens at risk and providing them appropriate knowledge, resources, and support to help reduce risk factors.
• Since 40-80% of teens diagnosed with type 2 diabetes are overweight and the incidence of
overweight is increasing, primary prevention of type 2 diabetes in young people should include apublic health approach that targets the general population. Health professionals need to beinvolved in developing and implementing community programs in schools, churches, and healthcenters that promote positive lifestyle modifications (healthy food choices, increased physicalactivity, and achievement/maintenance of a healthy weight) for children and their families.
• The Diabetes Prevention Program conclusively showed that people can prevent the development
of type 2 diabetes by making changes in food intake and increasing physical activity. A 5-10%decrease in body weight and 30 minutes/day of moderate physical activity produced a 58%reduction in diabetes.9
Teens with newly diagnosed type 1 or type 2 diabetes should be referred for initial education andtreatment to an interdisciplinary diabetes program. Their care should be coordinated by a physicianexperienced in the care of children and adolescents with diabetes, a nurse, a registered dietitian, anda social worker who have expertise in diabetes management as well as the physical and emotionalneeds of teens and their families. Once a firm educational base is established, the well-informedphysician who has access to a certified diabetes educator (a nurse or dietitian) can follow the teenwith diabetes. Other circumstances that require referral to the diabetes specialist are the following:
• Recurrent diabetic ketoacidosis.
• Severe or frequent hypoglycemia.
• Multiple psychosocial problems that contribute to poor glycemic control.
• Initiation of intensive insulin therapy with multiple injections or an insulin pump. GUIDELINES FOR ADOLESCENT NUTRITION SERVICESRESOURCES Books Betschart J, Thom S. In control – A guide for teens with diabetes. Minneapolis, MN: Chronimed
Boland, E. Teens pumping it up! 2nd ed. Sylmar, CA: Minimed Inc., 1998. Monk A, Pearson J, Hollander P, Bergenstal RM. Managing type II diabetes: your invitation to a
healthier lifestyle. Minneapolis, MN: IDC Publishing, 1996. Booklets Basic Carbohydrate Counting; Advanced Carbohydrate Counting. Alexandria, VA: American
Nutrition in the fast lane: The fast food dining guide. Indianapolis, IN: Franklin Publishing
Internet Resources American Diabetes Association Juvenile Diabetes Association Type 1 Diabetes Research Studies National Diabetes Education Program REFERENCES
1. American Diabetes Association. Economic consequences of diabetes mellitus in the U.S. in 1997. Diabetes
2. Rosenbloom AL, Joe JR, Young RS, Winter WE. Emerging epidemic of type 2 diabetes in youth. Diabetes
3. Pinhas-Hamiel O, Dolan L, Daniels SR, Standiford D, Khoury PR, Zeitler P. Increased incidence of non-
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Selected References Relevant to Access To Nature for Older Adults Babyak, M., J. A. Blumenthal, et al. (2001). "Exercise was more effective in the long term than sertraline or exercise plus setraline for major depression in older adults." Evidence-based Mental Health 4 (4): 105. Barnicle, T. and K. S. Midden (2003). "The effects of a horticulture activity program on
Rotary District 5580 Grants Subcommittee World Community Service Final Report (updated Dec. 28/03) A. Project District 5580 Project # 11.4.18 TRF-MG #: ___________CRCID-MG#__________ Location: Lougou, Haiti Brief description/objectives: Install 100 Sawyer Water Filter Systems so villagers in Lougou, Haiti have clean, safe water for drinking, cooking, and bathing. Urgency t