sample. Next, using a lancing device and lancet, the side of a fin - gertip should be pricked. Lancing the side of the finger tends to be less painful than the tip and is preferred by many patients. If no blood appears, the finger can be gently massaged or squeezed around the lanced area. The user should then take the inserted test strip and touch the edge of the strip to the drop of blood. Within seconds, the meter should display a blood glucose level. The test strip can be disposed of in a regular trash can, but the lancet should be ejected into a sharps container. In patients receiving insulin, continuous glucose monitors may be helpful to capture more precise metrics (ADA et al., 2022f). A con- tinuous glucose monitor trends serum glucose levels throughout the day and can be worn in water and during sleep. Similar to traditional monitors, instructions for use are manufacturer depen- dent. Generally, the user should clean and dry the site of applica- tion, and then a sensor can be inserted under the skin. The sensor stays in place with adhesive edges and may remain on the patient for up to two weeks, depending on the model. Blood glucose levels are automatically checked by the sensor, and these data can be linked to a smart device or receiver. Alarms may be set on the monitor for hyperglycemia or hypoglycemia, and historical data can be downloaded to share with providers for evaluation of Other considerations In addition to approval for treatment of T2DM, liraglutide can be utilized at higher doses for weight management in children and adolescents 12 years of age and older (ADA et al., 2022g). Patients must weigh at least 60 kg with an elevated BMI, corre- sponding to that of ≥30 kg/m2 in adults. For this indication, the dose is still initiated at 0.6 mg and titrated up, but it is titrated to a higher maximum dose of 3 mg (Lexicomp, 2022). Several small trials evaluated the efficacy of exenatide for treatment of pediatric obesity. Study results demonstrate modest reduction in BMI, but data are currently insufficient for approval for this indication (Ryan et al., 2021). Metformin has limited data for treatment of obesity as an adjunct therapy to lifestyle interventions. Studies included patients as young as 6 years, but data and efficacy are limited, so metformin is not routinely recommended for this indication in pediatric patients (Lexicomp, 2022). The ADA guidelines address the option of metabolic surgery in adolescents with T2DM and severe obesity, defined as BMI >35
glucose control. These metrics serve to minimize periods of hypo- glycemia and increase time within normal blood glucose range. Evidence-Based Practice: Continuous glucose monitoring is becoming more widely adopted in patients with type 1 diabe- tes, but adolescents with type 2 diabetes may benefit as well. In a small pilot study of adolescents and young adults with type 2 diabetes and hemoglobin A1C >7%, patients were given con- tinuous glucose monitors to use over a 12-week period (Chess- er et al., 2022). A majority of participants were using insulin as part of their treatment regimen. A statistically significant in - crease in patients’ diabetes-related quality of life was observed, as measured by a validated survey. In subsequent focus groups, patients noted an increased awareness of their glucose levels, which motivated positive behavioral changes. Due to the small sample size of the study, glycemic benefits were not deter - mined, but similar studies in adults demonstrate improvement in glycemic control. This is the first study in pediatric patients with type 2 diabetes to demonstrate the feasibility and assess the impact of continuous glucose measurement. Larger studies may elucidate other benefits in addition to quality-of-life im - provement.
kg/m2 (ADA et al., 2022g). These patients must also have either uncontrolled glycemic values or serious comorbidities that persist despite optimization of lifestyle changes and pharmacologic ther- apy. Referral to a specialized team is required for evaluation and
preparation for surgical management. Self-Assessment Quiz Question #8
Julia is prescribed liraglutide in addition to her current diabetes regimen. Her mother is concerned about the risks of taking this medication. Which of the following adverse effects is/are most likely to occur? a. Medullary thyroid carcinoma. b. Constipation, diarrhea, and nausea.
c. Weight gain. d. Anaphylaxis.
TYPE 2 DIABETES MELLITUS: PSYCHOSOCIAL BARRIERS TO SUCCESS
Education and empowering patients to self-manage their di- abetes are key components of glycemic control and long-term success in management. The ADA recommends utilizing empow- ering language with patients and their families to encourage own- ership over their chronic illnesses (ADA et al., 2022c). Although descriptive in assessing therapy compliance, common terms such as nonadherence and noncompliance infer passivity. Because disease control is highly dependent on self-management, these terms are not preferable when communicating with patients and can come across as judgmental. Facilitating communication via open-ended questions and empathy is key in optimizing motiva- tion and identifying barriers to success. Patients should be contin- uously educated and assessed for psychosocial factors that limit nonpharmacologic and pharmacologic adherence. Psychosocial care should be implemented for all patients with di- abetes and integrated into each office visit (ADA et al., 2022d). Screening may include general quality-of-life questions to assess the patient’s attitude toward the diagnosis, as well as inquiries about medication management. Providers should evaluate pa- tients for symptoms of depression, anxiety, disordered eating, and diabetes-related distress. Lifelong management of diabetes presents emotional and financial stressors that may worsen life outlook and self-management of the disease. Poor emotional and psychosocial health can have a negative impact on glycemic con- trol and clinical outcomes. Lack of motivation and psychological comorbidities may limit medication adherence, positive lifestyle habits, and long-term self-care. Interventions for psychosocial
concerns, including referral to specialists, are demonstrated to improve HbA1C and other health-related outcomes. A recent meta-analysis evaluated the prevalence of depression and anxiety among children with diabetes (Akbarizadeh et al., 2022). The analysis included 109 studies of more than 50,000 chil- dren with T1DM and T2DM. Among the children with T2DM, the prevalence of depression and anxiety was found to be 17.7%, and the prevalence of depression was 22.7%. Overall, the prevalence of depression tended to be higher among girls and in lower-mid- dle-income countries. In adult patients with T2DM, studies evaluated cognitive behav- ioral therapy and mindfulness interventions as a means of improv- ing depression, anxiety, and glycemic control (Pinhas-Hamiel & Hamiel, 2020). These studies variably demonstrate improvement in one or more of those outcomes. Cognitive-behavioral thera- py (CBT) aims to identify unconscious negative thoughts that are associated with events and affect moods and actions. The goal is to modify this association over time as a means of improving depression and other psychiatric disorders. Third-wave CBT sim- ilarly identifies these thoughts, but rather than changing them, aims to create distance that minimizes their effects on feelings and actions. Mindfulness interventions involve practicing aware- ness of negative thoughts and emotions without judgment while centering oneself in the present moment. Very limited data exist regarding CBT and mindfulness in the pe- diatric T2DM population, and all published reports focus on ad-
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