olescent girls (Pinhas-Hamiel & Hamiel, 2020). In one study, par- ticipants were randomized to a CBT group or a health education group (Shomaker et al., 2016). After 6 weeks, adolescents in the CBT group with moderately elevated depressive symptoms had greater reductions in those symptoms compared to the health ed- ucation group. These reductions were associated with improve- ments in insulin sensitivity. After 1 year of follow-up, patients in both groups had decreased depressive symptoms, but a major- ity of findings were not significantly different between the two groups (Shomaker et al., 2017). Another study demonstrated a re- duction in eating in the absence of hunger in adolescent girls who endorsed higher levels of dispositional mindfulness (Annameier et al., 2018). These findings suggest that mindfulness practices may be an important skill in the management of diabetes and related psychosocial concerns. Self-Assessment Quiz Question #9 At her endocrinology office visit, Julia is screened for symptoms of depression, anxiety, and other psychosocial concerns. She endorses sadness about her diabetes diagnosis as well as her difficulties with weight loss. Although these symptoms do not appear to be interfering with her adherence to therapy, she is interested in a referral for an intervention to help improve her depressive symptoms. Which of the following is the LEAST ap- propriate recommendation for Julia? a. Referral to a psychiatrist. b. Cognitive-behavioral therapy. c. Mindfulness-based interventions. d. Modification of therapy to an insulin-only regimen. In addressing barriers to glycemic control, the patient’s customs and culture may need to be incorporated into recommendations
(ADA et al., 2022g). Balanced nutrition and healthy habits should be individualized to accommodate different cuisines and ethnic traditions. Providers may be biased in their recommendations based on their own upbringing, and standard interventions may not be feasibly incorporated into the lives of individuals from dif- ferent cultural backgrounds. As an example, Native Americans are particularly prone to developing diabetes, and indigenous communities may differ regarding nutritional habits and well- ness practices. Effective diabetes-related interventions in these communities involve traditional cooking classes, holistic health self-management programs, and storytelling with elder teachings and prayers (Bonin et al., 2022). Evidence-Based Practice: Native Americans are a high-risk group for the development of type 2 diabetes. Eating fresh and nutritious food can aid in the prevention and management of diabetes, but resources are limited in some areas. Community gardening demonstrates improvement in physical activity, men- tal health, and access to fresh ingredients (Brown et al., 2020). A recent study evaluated the impact of a gardening program in a Native American community, which included the development of a gardening bed near the tribal diabetes clinic (Brown et al., 2020). The study found that growing food in traditional ways is of high importance to the group, and stakeholders felt positive- ly about gardening together. The intervention demonstrated some improvement in psychosocial questionnaires, although these findings were not statistically significant. Authors attribut - ed this to the short duration of the study and small sample size. Overall, gardening may be an effective community-based inter- vention to empower tribal groups to be active, stay connected, and eat nutritious food.
TYPE 2 DIABETES MELLITUS: FUTURE DIRECTIONS
Compared to adult patients with T2DM, pediatric patients cur- rently have limited therapeutic options for management (Wu et al., 2022). Although recent approval of GLP-1 receptor agonists expanded the armamentarium for children and adolescents, the rising rates of diagnosis and limitations of current agents highlight the need for expanded treatment options. A recent systematic review and meta-analysis examined trials that reported safety and efficacy of medications used for children and adolescents with T2DM (Wu et al., 2022). A total of four clinical trials and eight pub- lished articles were included in the review. Medications studied, in addition to the four currently approved treatment options, includ- ed saxagliptin, linagliptin, sitagliptin, glimepiride, and dapagli- flozin. Of the reviewed studies, the combination of saxagliptin plus metformin demonstrated the greatest reduction in HbA1C, although this conclusion is based on two clinical trials analyzing a total of 14 randomized patients. Saxagliptin is a dipeptidyl peptidase 4 (DPP-4) inhibitor currently approved for treatment of T2DM in adult patients (Lexicomp, 2022). This inhibition results in prolonged active incretin levels, which helps to regulate glucose homeostasis by increasing insulin synthesis and release while de- creasing glucagon secretion. Most notable adverse events in the adult population are arthralgia, dermatologic and hypersensitivi- ty reactions, and pancreatic events, including acute pancreatitis. There are also conflicting reports that saxagliptin may exacerbate underlying myocardial dysfunction. Additional safety and efficacy information in the pediatric population is required prior to ap- proval and routine use. Linagliptin and sitagliptin are also DPP-4 inhibitors approved for use in adult patients with T2DM (Lexicomp, 2022). Linagliptin was studied in a double-blind, randomized trial comparing two doses versus placebo (Tamborlane et al., 2018). The study demonstrat- ed a dose-dependent reduction in mean HbA1C, which was not- ed to be 0.63% in the higher-dose group. The medication was well tolerated, but additional studies are needed in the pediatric population. Most recently, sitaglipin was evaluated in two stud-
ies, one in combination with metformin and one as monotherapy (Jalaludin et al., 2022; Shankar et al., 2022). Both studies demon- strated that sitagliptin was relatively well tolerated but did not provide significant improvement in glycemic control. Glimepiride is a sulfonylurea, which stimulates release of insulin from pancreatic ß cells, reduces glucose output from the liver, and increases insulin sensitivity peripherally (Lexicomp, 2022). Due to this mechanism, glimepiride has the potential to cause hypogly- cemia, similar to exogenous insulin. One study compared glime- piride to metformin in pediatric patients and found that it resulted in a similar HbA1C reduction with comparable safety (Gottschalk et al., 2007). Although these findings are promising, the authors concluded that a larger sample size and study of longer duration would be necessary prior to widespread use in children and ado- lescents. These subsequent studies have not yet been conducted. Dapagliflozin, a sodium-glucose cotransporter 2 (SGLT2) inhibitor, was also recently studied in pediatric patients (Tamborlane, Laffel, et al., 2022). This medication and other SGL2 inhibitors are cur- rently approved for use in adult patients with T2DM (Lexicomp, 2022). They work by reducing reabsorption of filtered glucose in the proximal renal tubules, which increases urinary excretion of glucose and decreases plasma glucose concentrations. Dapagli- folizin can cause several adverse reactions related to this mech- anism, including acute kidney injury, volume depletion, and gen- itourinary infection. Unfortunately, the phase 3 study of children and young adults did not demonstrate a significant reduction in HbA1C compared with placebo in the intent-to-treat analysis (Tamborlane, Laffel, et al., 2022). In a subgroup of patients who were protocol-compliant, a significant difference was observed; however, these data may need confirmation in larger studies. The most common adverse events observed were headache, naso- pharyngitis, and vitamin D deficiency. Although 28% of partici - pants in the dapagliflozin arm experienced hypoglycemia, many were also receiving insulin as part of their T2DM regimen.
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