U.S. Department of Health and Human Services

Principle 9: Consider Needs of Special Populations

Children and adolescents

Diabetes is one of the most common chronic conditions in school-age children in the United States. About 208,000 youth under 20 years old have diabetes, 0.25 percent of all in this age group. 1 Type 1 diabetes accounts for nearly all diabetes in children under age 10. After age 10, type 1 is the most common form in U.S. youth overall, but type 2 is more common in new cases among minority groups, with the highest rates in American Indian youth. Distinction between type 1 and type 2 diabetes can be difficult but is important for determining appropriate treatment. 2 Testing for type 2 diabetes should be considered in overweight or obese youth with additional risk factors, such as family history, race or ethnicity, acanthosis nigricans, or polycystic ovary syndrome.

Most newly diagnosed cases of type 1 diabetes occur in individuals younger than 18. More children and teens are now getting type 2 diabetes, and the incidence of both type 1 and type 2 diabetes in youth is increasing. Therefore, the unique requirements for this age group must be addressed. Care of this group requires integration of diabetes management with the complicated physical and emotional growth needs of children, adolescents, and their families, as well as consideration of teens’ emerging autonomy and independence. Diabetes care for children and teens should be provided by a team that can deal with these special medical, educational, nutritional, and behavioral issues. The team usually consists of a physician, diabetes educator, dietitian, social worker or psychologist, and school nurse, along with the patient and family. Children should be seen by members of the team at diagnosis and follow-up, as determined by the primary care provider, the patient and family, and the team. Planning for transition of care from parents to self and from pediatric endocrinologists to adult care providers is essential during the vulnerable time as teens transition into adulthood.

Youth with diabetes need self-management support. This involves close communication and cooperation between the diabetes care team, school nurses, and other school personnel for optimal management, safety, and academic opportunities. The team, in partnership with the young person with diabetes and parents or other caregivers, needs to develop a personal diabetes management plan and daily schedule. The plan helps the child or teen follow a healthy meal plan, get regular physical activity (ideally, 60 minutes each day), check blood glucose levels, take insulin or oral medication as prescribed, and manage hyperglycemia and hypoglycemia. In children with type 1 diabetes, the most common problem encountered during physical activity is hypoglycemia. If possible, children and teens should check blood glucose levels before beginning a game or a sport and learn to prevent hypoglycemia. Family support for following the meal plan and setting up regular meal times is a key to success, especially if the child or teen is taking insulin.

Diabetes is stressful for both children and their families. Parents should be alert for signs of depression or eating disorders or insulin omission to lose weight and should seek appropriate treatment. Depression is a common comorbidity, affecting youth with both type 1 and type 2 diabetes, and should be assessed at each visit. Mental health specialists with expertise in diabetes can support the health care team, assess young people with diabetes for depression and other psychosocial problems, and provide ongoing contact and support.

Camps and local peer groups for children and teens with diabetes can provide positive role models and group activities. Peer encouragement often helps children perform diabetes-related tasks that they had been afraid to do previously and encourages independence in diabetes management. Talking with other children who have diabetes helps young people feel less isolated and less alone in having to deal with the demands of diabetes. Online chat rooms, such as Glu, have been successful in building diabetes communities for children and adolescents.

Glycemic control is particularly challenging for adolescents. In selecting glycemic goals for youth with diabetes, health care teams should balance the long-term health outcome benefits of achieving a lower A1C against the risks of hypoglycemia and the burdens of intensive regimens in children and adolescents. Because the benefit of glycemic control may persist for decades with reduced rates of microvascular complications, it is important to provide access to and education about evolving technologies that support the management of type 1 diabetes. This includes advances in insulin pump and continuous subcutaneous glucose monitoring technologies.

Youth with diabetes in the United States carry a substantial burden of cardiovascular disease (CVD) risk factors, especially youth who are overweight or obese. Fourteen percent of youth with type 1 diabetes and 92 percent of youth with type 2 diabetes have more than two CVD risk factors. 3 Overweight and obesity in children are strongly correlated with insulin resistance and associated hypertension and dyslipidemia, conditions that require intensive efforts to improve dietary intake and activity and to normalize body weight as a first-line approach. Pharmacologic treatment of hypertension should be initiated if blood pressure consistently exceeds the 95th percentile for age, sex, and height. Statin therapy is recommended as the preferred agent for treatment of dyslipidemia in children, but it is not approved for use in children less than 8 years old.

For children and teens at risk for type 2 diabetes, the health care team can encourage, support, and educate the entire family to make lifestyle changes that may delay or lower the risk for the onset of type 2 diabetes. Such lifestyle changes include keeping at a healthy weight and staying active.

Resources for care of children and adolescents

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Women of childbearing age

Major congenital malformations remain the leading cause of mortality and serious morbidity in infants of mothers with pre-existing type 1 and type 2 diabetes. The risk of malformations appears to increase continuously with increasing maternal glycemia during the first 6 to 8 weeks of gestation. Intensive glycemic control and preconception planning have been shown to reduce the occurrence of these fetal losses and malformations. Therefore, all women with diabetes who have childbearing potential should receive:

  • Counseling about the importance of planning pregnancies
  • Preconception care to achieve glucose control and discontinuation of statins and angiotensin-converting enzyme (ACE) inhibitors prior to conception to reduce the risk of congenital malformations
  • Care from a skilled multidisciplinary team including diabetes educators and registered dietitians/registered dietitian nutritionists experienced in the management of diabetes before and during pregnancy
  • Support to maintain stable blood glucose values close to normal, as well as management of any existing long-term diabetic complications

Women of childbearing age with a history of gestational diabetes mellitus (GDM), prediabetes, or obesity or who are at very high risk for type 2 diabetes should be tested for diabetes prior to conception or very early in pregnancy.

Because of the risk of GDM to the mother and neonate, screening, diagnosis, and effective treatment are necessary. GDM increases infant macrosomia and adverse perinatal outcomes, including caesarean section, spontaneous preterm delivery, shoulder dystocia or birth injury, neonatal hypoglycemia, and need for intensive neonatal care. 9 Women with a history of GDM are at lifelong increased risk for diabetes and need proactive long-term primary care management. 10 The child of a GDM pregnancy is at increased risk for obesity and possible type 2 diabetes. See Principle 1 for testing recommendations for women with history of GDM.

Resources for women of childbearing age

Older adults

Older adults are at high risk for both type 2 diabetes and prediabetes; surveillance data suggest that half of older adults have prediabetes. 1 Almost 26 percent of people over the age of 65 (11.2 million) had diabetes in 2012. 1 Older people with diabetes have higher rates of premature death, functional disability, and coexisting illnesses such as hypertension, coronary heart disease, and stroke than those without diabetes. Older adults with diabetes also are at greater risk than other older adults for several common geriatric syndromes, such as polypharmacy, depression, cognitive impairment, urinary incontinence, injurious falls, and persistent pain. Assessment of risk factors for hypoglycemia and ascertainment of hypoglycemia are an important part of the clinical care of older adults on insulin or sulfonylureas.

Management goals must be individualized. Consensus recommendations provide a framework incorporating consideration of health and life expectancy of older adults with diabetes in selecting treatment goals for glycemia, blood pressure, and cholesterol. 11 For example, those who are healthy (few coexisting chronic illnesses, intact cognitive and functional status) could have an A1C goal of less than 7.5 percent, a blood pressure goal of less than 140/90 mmHg, and be prescribed a statin. Those with intermediate health status could have an A1C goal of less than 8.0 percent, a blood pressure goal of less than 140/90 mmHg, and be prescribed a statin, whereas those in the very complex/poor health group could have an A1C goal of less than 8.5 percent, a blood pressure goal of less than 150/90 mmHg, and be prescribed a statin if considered beneficial. Older adults with diabetes may be at increased risk of falls and other harm with overly aggressive blood pressure treatment. There is insufficient evidence to support the use of aspirin for primary prevention of CVD events among older adults with type 2 diabetes. 12

Older adults require special care in prescribing and monitoring therapy. Attention to patient preferences is important. Education and support, including nutrition therapy, can help older adults manage diabetes and coexisting chronic disease. Medications should be started at the lowest dose and titrated up gradually until targets are reached or side effects develop. While older adults can generally be treated with the same medications as younger people, glyburide and chlorpropamide should not be used because of the hypoglycemic activity of their metabolites. Metformin may be considered first-line therapy in the elderly, but its use is precluded if estimated glomerular filtration rate (eGFR) is below 30 mL/min, and it must be used with caution and at reduced dose if eGFR is below 45 mL/min.

Older adults with diabetes should maintain a current medication list for review by their clinicians. Polypharmacy increases the risk of drug side effects and drug interactions. Medication reconciliation, ongoing assessment of the indications for each medication, and assessment of medication adherence and barriers are needed at each visit. In addition, medications should be reviewed as a possible contributory factor if a person presents with depression, falls, cognitive impairment, or urinary incontinence.

Resources for care of older adults

High-risk racial and ethnic groups

Certain racial and ethnic minorities have a higher prevalence and greater burden of diabetes compared with whites, and some minority groups also have higher rates of complications. Despite medical advances and increasing access to medical care, disparities in health and health care persist. 13, 14

To provide optimal diabetes care, the health care team needs to understand how patients view and treat diabetes within their respective cultures. A practical approach to avoid stereotyping involves treating each patient encounter as unique and asking questions that elicit the patient’s perspective on diagnosis and management, such as “What is hardest for you about having diabetes?” or “Do you have any family beliefs or customs that affect how you care for your health?” This patient-centered approach enables collaboration and negotiation between the patient and health care team to develop and implement an effective diabetes management plan that addresses individual needs and customs. It is important to provide patients with appropriate and culturally sensitive diabetes education materials.

Members of some minority populations may be carriers of variant hemoglobins, which can alter some A1C test results. NGSP has information on which assays may have interference from variant hemoglobins. Members of some Asian populations have increased risk for type 2 diabetes at lower body mass indexes than the general population. However, all racial and ethnic groups studied had similar benefit from the Diabetes Prevention Program’s lifestyle intervention and metformin for diabetes prevention.

Resources for high-risk racial and ethnic groups

References

1. Centers for Disease Control and Prevention. National Diabetes Statistics Report: Estimates of Diabetes and Its Burden in the United States, 2014. Atlanta, GA: U.S. Department of Health and Human Services; 2014.

2. Dabelea D, Bell RA, D’Agostino RB, Jr., et al. Incidence of diabetes in youth in the United States. JAMA. 2007;297(24):2716–24.

3. Rodriguez BL, Fujimoto WY, Mayer-Davis EJ, et al. Prevalence of cardiovascular disease risk factors in U.S. children and adolescents with diabetes: the SEARCH for diabetes in youth study. Diabetes Care. 2006;29(8):1891–6.

4. American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care. 2014;37(Suppl 1):S14–80.

5. Copeland KC, Silverstein J, Moore KR, et al. Management of newly diagnosed type 2 diabetes mellitus (T2DM) in children and adolescents. Pediatrics. 2013;131(2):364–82.

6. Riley M, Bluhm B. High blood pressure in children and adolescents. Am Fam Physician. 2012;85(7):693–700.

7. Kavey RE, Allada V, Daniels SR, et al. Cardiovascular risk reduction in high-risk pediatric patients: a scientific statement from the American Heart Association Expert Panel on Population and Prevention Science; the Councils on Cardiovascular Disease in the Young, Epidemiology and Prevention, Nutrition, Physical Activity and Metabolism, High Blood Pressure Research, Cardiovascular Nursing, and the Kidney in Heart Disease; and the Interdisciplinary Working Group on Quality of Care and Outcomes Research: endorsed by the American Academy of Pediatrics. Circulation. 2006;114(24):2710–38.

8. Delamater AM. Psychological care of children and adolescents with diabetes. Pediatr Diabetes. 2009;10(Suppl 12):175–84.

9. Metzger BE, Lowe LP, Dyer AR, et al. Hyperglycemia and adverse pregnancy outcomes. N Engl J Med. 2008;358(19):1991–2002.

10. Gabbe SG, Landon MB, Warren-Boulton E, Fradkin J. Promoting health after gestational diabetes: a National Diabetes Education Program call to action. Obstet Gynecol. 2012;119(1):171–6.

11. Kirkman MS, Briscoe VJ, Clark N, et al. Diabetes in older adults. Diabetes Care. 2012;35(12):2650–64.

12. American Geriatrics Society Expert Panel on Care of Older Adults with Diabetes Mellitus, Moreno G, Mangione CM, Kimbro L, Vaisberg E. Guidelines abstracted from the American Geriatrics Society Guidelines for Improving the Care of Older Adults with Diabetes Mellitus: 2013 update. J Am Geriatr Soc. 2013;61(11):2020–6.

13. Chow E, Foster H, Gonzalez V, McIver L. The disparate impact of diabetes on racial/ethnic minority populations. Clinical Diabetes. 2012;30(3):130–3.

14. Golden SH, Brown A, Cauley JA, et al. Health disparities in endocrine disorders: biological, clinical, and nonclinical factors—an endocrine society scientific statement. J Clin Endocrinol Metab. 2012;97(9):E1579–639.