jugate vaccine, but those with diabetes should also receive the 23-valent polysaccharide vaccine after completion of the primary conjugate series. In patients due for both, the conjugate vaccine should be prioritized, and a minimum 8- week interval of time must pass between administration of the pneumococcal conju- gate vaccine and pneumococcal polysaccharide vaccine. Immu- nization recommendations related to the COVID-19 pandemic are evolving, and up-to-date guidance can be found on the CDC vaccination schedule (CDC, 2022b).
Self-Assessment Quiz Question #3 Billy undergoes screening for diabetes-related complications. Which of the following tests are used to detect a microvascular
complication? a. Foot exam. b. Blood pressure monitoring. c. Lipid profile. d. Liver enzymes.
TYPE 2 DIABETES MELLITUS: MANAGEMENT
Goals of therapy Functionally, goals of T2DM treatment in children include pres- ervation of pancreatic ß cells, achieving healthy weight loss that does not interfere with growth and development, and maintain- ing glucose control (Karavanaki et al., 2022). Glycemic control aims to reduce the development of long-term microvascular and macrovascular complications related to diabetes. Psychologically, providers should aim to reduce diabetes-related stress, manage concomitant psychosocial issues that may become barriers to therapy, and incorporate the patient’s cultural and social values into lifestyle plans. Generally, the target for glycemic control is a goal HbA1C lev- el, which reflects average glucose levels over a 3-month period (ADA et al., 2022e). Although HbA1C is a good indicator of chron- ic glycemic values, it does not capture daily fluctuations of blood glucose levels, including periods of hypoglycemia. As previous- ly discussed, this value may not be reliable in patients with cer- tain conditions that affect red blood cell turnover. A goal HbA1C <7% is generally recommended to reduce the risk of microvascu- lar complications. This HbA1C level corresponds to an average blood glucose of 154 mg/dL. While stricter goals may offer slight- ly improved outcomes in select patients, the risk of hypoglycemia may outweigh this marginal benefit. As an alternative to HbA1C, Prevention Primary prevention of T2DM is best targeted at individuals with impaired glucose tolerance, as opposed to those with isolated im- paired fasting glucose or elevated HbA1C (ADA et al., 2022a). In children and young adults with prediabetes, progression to diabe- tes can be prevented or slowed via several strategies (ADA et al., 2022b). Lifestyle modifications are the primary therapy aimed at adolescents with prediabetes (Esquivel Zuniga & DeBoer, 2021). Physical activity can reduce abdominal fat and improve insulin sensitivity, which is why the ADA recommends at least 150 min- utes per week of moderate- intensity activity. Optimally, a combi- nation of daily aerobic activity, such as brisk walking, and three- times-weekly resistance training should be implemented. Along with physical activity, nutrition should be optimized to promote healthy weight loss. While there is no single superior dietary pat- tern, general recommendations include limiting processed food and consuming more whole grains, fruits, and vegetables. Saturat- ed fat intake should be reduced, and sugar-sweetened beverages eliminated. Diets including high fiber intake may aid in slowing absorption of carbohydrates and increasing satiety. For successful intervention, nutritional strategies must be individualized based on the patient’s age, level of activity, and food preferences. Smoking, including electronic cigarette use, should be discour- aged in all patients, especially those with diabetes (ADA et al., 2022d). Tobacco use increases the risk of long-term cardiovas- cular disease, diabetes-related microvascular complications, and even premature death.
glucose monitors may be utilized to gauge daily control of blood glucose. This method of measurement is especially valuable in patients at risk for hypoglycemia on insulin therapy. Blood glu- cose meters measure glucose periodically throughout the day, and new technology can even measure these values continuously. Continuous glucose monitors are becoming more widely used in the T1DM population and may have a role in T2DM patients who have substantial enough insulin deficiency to require exogenous insulin as part of their therapy. Healthcare Consideration: A hemoglobin A1C target of <7% is typically recommended to reduce microvascular complications in patients with type 2 diabetes (ADA et al., 2022e). Although there may be an additional yet smaller benefit of lowering this goal to 6%, the extra reduction in the risk of microvascular complications must be weighed against the risk of hypoglyce- mia. This risk is of particular concern in patients controlled on medications that may induce hypoglycemia, such as insulin. If patients are able to maintain a hemoglobin A1C closer to 6% without significant hypoglycemic events, therapy need not be de-intensified. Evidence-Based Practice: Pediatric patients with prediabetes are at increased risk of progression to type 2 diabetes (ADA et al., 2022a). In a 4-year retrospective study, more than 100 adolescents with prediabetes received medical nutrition ther- apy (Parajuli et al., 2022). Patients who attended two or more nutrition visits per year, compared to those who attended one or no visit, were observed to achieve a fourfold reduction in the likelihood of progression to type 2 diabetes. In addition, those who progressed to diabetes in the higher visit group had a mean delayed onset of diagnosis in comparison to the low- er visit group. Overall, nutrition visits, which are indicative of lifestyle modifications, demonstrate a significant preventative benefit in children at high risk for developing diabetes. Self-Assessment Quiz Question #4 Which of the following exercise regimens is most appropriate to recommend for prevention of progression from prediabetes to diabetes? a. Core exercises, including planks and crunches, to improve abdominal strength. b. Running five miles every day. c. Brisk 30-minute walks five days per week with resistance training on Mondays, Wednesdays, and Fridays. d. Resistance training once weekly with 20-minute jogs twice weekly.
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