TREATMENT: NONPHARMACOLOGIC INTERVENTIONS
All pediatric patients with T2DM should be educated on appro- priate lifestyle adjustments, and patients’ caregivers should be included in the discussion and planning (ADA et al., 2022g). A family-centered approach is optimal for implementing change. Adolescents who are overweight or obese are recommended to achieve a 7%–10% decrease in excess weight. The plans for achieving this goal should incorporate culturally appropriate and sustainable methods of weight reduction so that patients can ad- here to the new lifestyle in the long term. The plan should incor- porate recommendations for exercise and nutrition management, similar to those recommended in the prevention of T2DM. Chil- dren and adolescents should complete at least 60 minutes of daily moderate to vigorous physical activity along with strength training multiple days of the week, ideally at least three times weekly (ADA et al., 2022g). Sedentary behavior is linked to worsened outcomes and should be strongly discouraged. Although there is no standard diet for diabetes management in children, some general recommendations exist (Karavana- ki et al., 2022). Children and adolescents should consume two to three portions of fresh fruit and vegetables daily, along with whole grains, nuts, low-fat dairy products, fish, and lean meats. Of course, dietary preferences may limit or modify the sources of nutrition for select patients. Carbohydrate counting, which is part of standard T1DM management, is not necessary for the vast majority of patients with T2DM. Beverages should be sugar free, and snacks with added sugar should be limited or eliminated. Salt intake should also be limited and maintained within recom- mended values for age. Regular, consistent meals, including daily breakfast, should be enforced to promote satiety and improve metabolic outcomes. Since pediatric patients are still growing and developing, calorie restrictions should not be extreme and should still provide the nutrients necessary for healthy maturation. Insulin resistance in T2DM may be mitigated by weight loss and exercise; however, these measures alone are unlikely to restore normal pancreatic function (ADA et al., 2022a). While lifestyle in- terventions should be recommended to all patients who are over- weight or obese with diabetes, concomitant medication is often necessary to achieve glycemic control.
Evidence-Based Practice: As technology becomes more inte- grated into society, children are exposed to a variety of screens, such as phones, tablets, and televisions, which may increase sedentary time. Exergames are video games that require phys- ical activity, and these products can transform sedentary game playing into active play. In a recent study, a group of overweight/ obese children were provided with a gaming console with ex- ergames and given a gameplay curriculum consisting of 1-hour sessions 3 times per week along with virtual fitness coaching (Staiano et al., 2018). After a 24-week study period, children in the exergames program were compared to those in a control group. Compared to the control group and with the exclusion of one outlier, those playing exergames significantly reduced their body mass index. Although based on a small sample size, these findings indicate that exergaming can improve health in pediatric patients, especially if paired with fitness coaching to encourage and monitor adherence. Healthcare Consideration: Lifestyle management for type 2 di- abetes should include nutritional changes and physical activity (ADA et al., 2022g). Patients must be encouraged to maintain a healthy weight and eat a balanced diet consisting of a variety of nutrients, including fruits and vegetables. Physical activity should include both muscle-strengthening and bone-strength- ening exercises in addition to aerobic activity. Interventions tar- geted only at the patient may not be sufficient, especially for a child who is dependent on caregivers for sustenance and daily planning. A family-centered approach is far more likely to be sustained, since the child will feel supported and surrounded by a positive environment. While immediate interventions are critical, the goal of care is to create lifelong healthy habits.
TREATMENT: PHARMACOLOGIC INTERVENTIONS
Patients who progress from prediabetes to diabetes despite lifestyle changes will require pharmacologic therapy to achieve glycemic control (ADA et al., 2022g). Upon diagnosis of T2DM, pharmacologic therapy should be implemented alongside nutri- tion and physical activity changes. Table 2 summarizes treatment options and associated adverse effects of available pharmacolog- ic therapy. The medication of choice will depend on the patient’s initial presentation. For patients that are metabolically stable and asymptomatic with an HbA1c < 8.5%, metformin is the treatment of choice (ADA et al., 2022g). Of note, the youngest age of approval for the use of metformin is 10 years. Metformin is classified as a biguanide and works by decreasing hepatic glucose production and intes- tinal absorption of glucose (Lexicomp, 2022). It improves insulin sensitivity by increasing peripheral glucose uptake and utilization. While it is not metabolized by the liver, it is renally cleared, so re- nal function should always be assessed prior to initiation. Therapy may need to be delayed in patients with acute kidney injury, which may be a finding in those that present in DKA. In addition, patients at risk for lactic acidosis should not receive metformin, as this is a dose-related effect of the medication. Metformin can inhibit mi- tochondrial electron transport, thereby increasing anaerobic me- tabolism, which can lead to the accumulation of lactate. Patients are at increased risk for this effect if clearance is decreased, which can occur in the setting of acute kidney injury, if hepatic function is impaired, or in hypoxic states. Metformin is generally withheld in patients who are critically ill. Symptoms of lactic acidosis are often nonspecific but may present as abdominal pain, malaise, or
muscle aches. Patients with acidosis in the absence of ketoacido- sis should be evaluated for metformin-associated lactic acidosis. Metformin is typically dosed at 500 mg to 1,000 mg by mouth per day and incrementally titrated every 1 to 2 weeks, as tolerat- ed, to a maximum daily dose of 2,000 mg/day (Lexicomp, 2022). There are tablets and oral suspensions on the market to accom- modate patients unable to swallow pills. The traditional imme- diate-release formulations are typically dosed twice daily, but newer extended-release formulations enable once-daily dosing and may result in fewer adverse effects. The dose-limiting effect is typically gastrointestinal symptoms, including diarrhea, nausea, vomiting, and abdominal pain. While the mechanism is not fully understood, these symptoms most frequently occur at the onset of therapy and subside after several weeks of continuous use. An- other major adverse effect of metformin is vitamin B12 deficiency, as absorption may be affected. Unlike gastrointestinal symptoms, this effect takes time and is detected after chronic use. Patients should be evaluated every 2 to 3 years for vitamin B12 deficiency or sooner if corresponding anemia or neuropathy are detected. Supplementation may be needed if adequate levels cannot be achieved via nutritional optimization.
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