Cases & Commentaries

Adolescent Diabetes: A Routine Visit?

Spotlight Case
Commentary By Gail B. Slap, MD, MSc

Case Objectives

  • Appreciate the increasing prevalence of
    obesity and type 2 diabetes mellitus (T2DM) among adolescents in
    the United States.
  • Understand the screening, diagnostic,
    and management guidelines for T2DM in adolescents.
  • Appreciate the importance of rapport,
    confidentiality, non-verbal cues, and hidden agenda to adolescent
    health care and health outcome.
  • Know the components and basic principles
    of the adolescent sexual history.
  • Review some common errors in the care of
    adolescent patients and strategies to prevent them.

Case & Commentary:
Part 1

A 15-year-old
adolescent presented to her pediatrician for ongoing management of
type 2 diabetes mellitus (T2DM). The girl had been overweight for
most of her childhood and continued to gain weight in her early
teen years. Her BMI of 29 placed her in the upper 99th percentile
for her age and sex. She had presented to the clinic 18 months
earlier with fatigue and polyuria. At the time, she had an elevated
fasting blood sugar and hemoglobin A1c (HbA1c; a serum
marker indicating elevated blood sugar levels for many months) and
was diagnosed with type 2 diabetes. She was treated with
long-acting insulin (glargine), short-acting insulin (aspart), and
an oral agent (exenatide). This clinic visit was part of routine
follow-up for her diabetes.

This patient presented with two chronic
conditions of increasing prevalence among adolescents in the United
States: obesity and T2DM. The Centers for Disease Control and
Prevention (CDC) defines overweight and obesity in adults 19 years
and older as body mass index (BMI) 25 and
30,
respectively, and in youth aged 2-19 years as BMI 85th
and 95th
percentile, respectively, for age and sex.(1) According
to the National Health and Nutrition Examination Surveys (NHANES),
obesity among adolescents aged 12-19 years increased from 5.0% in
1976-1980 to 17.6% in 2003-2006.(2,3) While
genetic susceptibility may increase the likelihood of obesity in an
individual, population genetics have not changed rapidly enough
over this period to explain the nearly fourfold rise among
adolescents (nor the threefold rise among younger
children).(2,3) Evidence
suggests that these trends are explained primarily by behavioral
and environmental changes resulting in higher caloric intake and
lower physical activity.(4-8)

Adolescent obesity is associated with physical,
emotional, and social adversity during adolescence and with
premature disability and death during adulthood.(9) Of
individuals with T2DM, 80% are overweight or obese, and the
prevalence of T2DM in adolescents is also increasing. A 2002-2003
multicenter study of diabetes in US youth younger than 20 years
found that T2DM accounted for 35% of new cases of diabetes
diagnosed in adolescents 10-19 years compared to 2% in children
younger than 10 years. The female-to-male relative risk was 1.6 for
T2DM, compared to 1.0 for type 1 diabetes mellitus (T1DM). The
estimated incidence rates (per 100,000 person-years) of T2DM among
15- to 19-year-old youth by race/ethnicity were as follows:
American Indian 49.4, Asian/Pacific Islander 22.7, African American
19.4, Hispanic 17.0, and non-Hispanic white 5.6.(10,11) A
separate study of African American and Latino children younger than
17 years with newly diagnosed diabetes demonstrated more females
(62% vs. 50%) and older age (13.1 years vs. 10.5 years) for T2DM
than T1DM.(12)

Both T1DM and T2DM in children
and adolescents usually present with symptoms of hyperglycemia
(i.e., polyuria, polydipsia, weight loss, blurred vision) in the
setting of glycosuria (glucose excretion in the urine). Factors
associated with T2DM in children and adolescents include the
following: non-white, non-European descent; age older than 10
years; Tanner stage 2;
overweight or obesity; T2DM in a first- or second-degree relative;
findings or conditions associated with insulin resistance (e.g.,
acanthosis nigricans, dyslipidemia, hypertension, polycystic ovary
syndrome [PCOS], small-for-gestational-age birthweight); and
absence of islet cell or glutamic acid decarboxylase antibodies.
However, no single factor can be used to differentiate types 1 and
2. For example, 15%-25% of youth with new T1DM are overweight or
obese.(13) Ketosis
and ketoacidosis are more common in patients with T1DM but occur in
more than 30% of youth with new T2DM.(13-15)
C-peptide levels and islet cell autoimmunity eventually can help
distinguish types 1 and 2, but levels in the two types may overlap
for up to a year following diagnosis.(13,16)

Who should be tested for diabetes? The 2009
Standards of Medical Care in Diabetes published by the American
Diabetes Association (ADA) recommends that asymptomatic children
and adolescents who are overweight or obese and have at least two
additional risk factors for T2DM be tested with a fasting glucose
level every 3 years, beginning at age 10 years or pubertal
onset.(17)
Additional risk factors include family history of T2DM, findings or
conditions associated with insulin resistance (see above), and
maternal history of diabetes or gestational diabetes. Once ADA
diagnostic criteria for diabetes are met, type 2 is presumed in the
patient with obesity and at least two other risk factors.(17)

Although adolescents with T2DM
are treated similarly to adults, there are a few key differences.
Education about diet, exercise, and glucose monitoring should begin
at diagnosis for all patients and may be the only therapy for those
who are asymptomatic and able to achieve glycemic control (i.e.,
pre-prandial blood glucose 250
mg/dL, HbA1c >9%, or ketosis. When glycemic control is achieved,
the insulin can be tapered off.(13,17,18) Although
metformin and insulin are the only medications for T2DM approved in
the United States for patients younger than 18 years (13), another
oral hypoglycemic agent typically is prescribed before insulin for
adolescents with inadequate glycemic control and without ketosis.
It may be added to metformin or used alone if metformin is not
tolerated.

The regimen prescribed for
the patient in the case presentation is both unusual and unclear.
First, although metformin is the preferred pharmacotherapy for this
patient, no comment is made of past or current use. Second, while
insulin glargine has demonstrated effectiveness in adults with
T2DM, it is best used with metformin to boost insulin
sensitivity.(13,19) Third,
exenatide, described as an oral agent in the case presentation, is
available only for subcutaneous administration; is indicated for
adjunctive therapy with metformin, a sulfonylurea, or a
thiazolidinedione; is not approved for use in patients younger than
18 years; and is associated with gastrointestinal symptoms in up to
40% of adults.(20)
Fatalities from acute, fulminant pancreatitis have been reported
among patients using exenatide. It therefore should be discontinued
immediately if pancreatitis or unexplained abdominal pain
develops.

Case & Commentary:
Part 2

The girl had often been a
challenging historian, providing conflicting and sometimes vague
answers to questions. On this visit, she complained of intermittent
abdominal pain for a few days but could not be more specific. She
also complained that her acne had worsened, and she requested
treatment for it. As part of screening for polycystic ovarian
disease, she stated that her periods were always regular and she
had no new or excessive hair in a male pattern of distribution.
However, she did mention that, 2 days earlier, she had accidentally
"peed my pants" but did not know why. The rest of the review of
systems was unremarkable.

On physical examination, she
was a quiet and depressed morbidly obese girl in no distress. She
had acanthosis nigricans on her neck, groin, and axilla and had
severe acne on her face. The examination of her abdomen was limited
by obesity, but she was non-tender and there were no masses or
enlarged organs palpated. The rest of the examination was
unremarkable. On her laboratory studies, her HbA1c remained
elevated. She was prescribed a topical cream for her acne, and her
insulin was increased slightly. She was told to watch her menstrual
cycles closely and call back if they were noted to be irregular or
if the abdominal pain worsened.

The following day, the pediatrician's office
received a call from an obstetrician reporting that the patient had
delivered a healthy baby girl by Caesarian section in the early
hours of the morning. The gestational age was thought to be around
34 weeks. The pediatrician realized that the "abdominal pain" may
have been contractions and that the incontinence may have been
amniotic fluid ("water breaking"). On further history, the
adolescent girl stated that she was raped 7 months earlier and was
afraid to tell anyone. She and her family were provided appropriate
counseling and resources.

The remarkable events that unfold in Part 2
quickly turn our attention away from T2DM. The patient description
in the first sentence prepares us for, and may bias us toward,
discounting the nonspecific complaints that follow. The challenge
for all providers who care for adolescent patients is to consider
prevalent issues of adolescence that may underlie the patient's
demeanor. Reticence, conflicting information, and symptoms without
apparent explanation suggest an adolescent who is unable or
unwilling to discuss symptoms, ask questions, or describe events
that are frightening, confusing, or embarrassing. Any concerning or
unusual behavior during a visit may cue the clinician to explore
those aspects of the adolescent history summarized by the mnemonic
"HEADSS": Home, Education (i.e., school),
Activities (e.g., peers, work), Depressive or
other symptoms, Sexuality, and Substance use. On
the first visit and periodically thereafter, the clinician should
discuss confidentiality with the patient and parent(s). Adolescents
who are assured conditional confidentiality (i.e., confidentiality
will be protected unless the risk of harm is high) are more likely
to disclose personal information about sexuality, mental health,
and substance use than those with whom it is not
discussed.(21)

We are not told explicitly
whether during this or prior visits the clinician had taken an
appropriate sexual history. CDC practice guidelines call for a
sexual history and testing for sexually transmitted infections and
pregnancy in all adolescent females with unexplained abdominal pain
and urinary symptoms.(22) Despite
these recommendations, a 2009 review of emergency department visits
by adolescents with urinary complaints revealed that 30% of records
did not document a sexual history.(23) Even when
physicians believe it is pertinent to the patient's presentation,
24% in one survey admitted they would not obtain a sexual
history.(24)

A sensitive and thoughtful
sexual history in a confidential setting may have revealed this
patient's prior sexual assault and led to the pregnancy diagnosis.
The following principles can help guide discussion of sexuality
with an adolescent patient: confidentiality, within the limits of
state law and patient safety; normalization of the topic as a
routine component of health care; development of interview
techniques that convey clinician comfort with the topic; respect
for sexual diversity, including sexual orientation; avoidance of
jargon or terms that may be misinterpreted (e.g., "sexual
activity"); and knowledge about local resources related to
adolescent sexual health. The clinician should be prepared to ask
specific, usually open-ended questions pertaining to oral, vaginal,
and anal intercourse; age of first intercourse and number of
lifetime partners; use of condoms and other birth control; and sex
by force or coercion, or in exchange for money, food, or
shelter.

In addition to the unasked
questions noted above, the case illustrates the disjunctions that
may exist between clinician questions and adolescent answers or
between past history and current findings on physical examination.
An adolescent who has always had menstrual periods of varying
interval and duration may perceive her cycles as regular. An
adolescent with a family history of PCOS may not perceive her
pattern or quantity of hair growth as different, excessive, or new.
The BMI of 29 noted in Part 1 is below the threshold for adult
obesity, yet the patient is described as "morbidly obese" on
physical examination in Part 2. Although there is no firm
definition of morbid obesity in children and adolescents, the term
typically refers to BMI greater than 35. This discrepancy suggests
that something besides adiposity is contributing to this patient's
appearance.

Teen pregnancy and childbearing
are prevalent and increasing in the United States. After a 30%
decline between 1991 and 2005, the rates are again on the
rise.(25-27)
Pregnancy rates in 2007 per 1000 females aged 15-19 years varied
nearly threefold by race/ethnicity (Hispanic 132.8, black 128,
white 45.2).(27) As shown
in the Table, the
proportion of mothers with third-trimester or no prenatal care was
15.6% for mothers aged 10-14 years compared with 4.7% for those
20-24 years, and the proportions with preterm delivery were 22.2%
and 12.7%, respectively.(27) This
patient delivered prematurely at 34 weeks.

One may wonder if the adolescent
in this case was aware of her pregnancy. Adolescents are less
likely than adults to recognize or acknowledge pregnancy, even when
seeking care for pregnancy-related symptoms. A study of pregnant
adolescents younger than 16 years seen in the emergency department
of a university-affiliated hospital revealed that 91% of those in
whom pregnancy was diagnosed presented with abdominal or
genitourinary symptoms, compared with 22% of those in whom
pregnancy was missed. Of those adolescents in whom pregnancy was
diagnosed, less than 10% had mentioned the possibility of
pregnancy, and 10.5% denied history of sexual
intercourse.(28)

Rates of sexual abuse in the United States peak
during adolescence. In 2004-2006, there were 152.6 and 163.7
emergency department visits for sexual assault per 100,000 females
aged 15-17 years and 18-19 years, respectively.(27) A 2009
meta-analysis of 21 studies revealed that a history of childhood
sexual abuse increased the odds of teen pregnancy by 2.2-fold and
estimated that 45% of pregnant teens have a history of sexual
abuse.(29)

The issues with which this
adolescent presents are disturbingly common yet often unrecognized.
Remaining alert to population trends and individual cues may help
us care for adolescents with greater sensitivity, efficiency, and
effectiveness
.

Take-Home Points

  • The rates of overweight, obesity, and
    T2DM are increasing among US adolescents. The incidence of T2DM in
    children and adolescents is highest in 15- to 19-year-old females
    who are Native American, Asian/Pacific Islander, African American,
    and Hispanic.
  • The management of T2DM in adolescents
    begins with education about diet, exercise, body weight, and
    glucose monitoring. Metformin and insulin are the only medications
    for T2DM approved in the United States for patients younger than 18
    years.
  • The sexual history is an essential
    component of adolescent health care. Principles that facilitate the
    history include confidentiality, clinician comfort, respect for
    sexual diversity, avoidance of jargon, and knowledge about local
    resources related to adolescent sexual health.
  • Adolescents are less likely than adults
    to recognize or acknowledge pregnancy, even when seeking care for
    pregnancy-related symptoms.
  • Sexual abuse in the United States peaks
    during adolescence and is associated with a twofold increased risk
    of pregnancy.

Gail B. Slap,
MD, MSc

Professor of Pediatrics and Medicine

University of Pennsylvania School of Medicine

Chief,
Division of Adolescent Medicine

The Children's Hospital of
Philadelphia

Faculty Disclosure: Dr. Slap has declared
that neither she, nor any immediate member of her family, has a
financial arrangement or other relationship with the manufacturers
of any commercial products discussed in this continuing medical
education activity. In addition, the commentary does not include
information regarding investigational or off-label use of
pharmaceutical products or medical devices.

References

1. Defining Childhood Overweight and Obesity.
Atlanta, GA: Centers for Disease Control and Prevention. [Available
at]

2. National Center for Health Statistics (NCHS)
Health E-Stat. Prevalence of Overweight Among Children and
Adolescents: United States, 2003-2004.
[Available at]

3. Ogden CL, Carroll MD, Flegal KM. High body
mass index for age among US children and adolescents, 2003-2006.
JAMA. 2008;299:2401-2405. [go to
PubMed]

4. Preventing Childhood Obesity: Health in the
Balance. Institute of Medicine. Washington, DC: The National
Academies Press; 2005. ISBN: 9780309091961.

5. Ludwig DS, Peterson KE, Gortmaker SL. Relation
between consumption of sugar-sweetened drinks and childhood
obesity: a prospective, observational analysis. Lancet.
2001;357:505-508. [go to
PubMed]

6. Lowry R, Brener N, Lee S, Epping J, Fulton J,
Eaton D. Participation in high school physical
education—United States, 1991-2003. MMWR Morb Mortal Wkly
Rep. 2004;53:844-847. [go to
PubMed]

7. Gortmaker SL, Must A, Sobol AM, Peterson K,
Colditz GA, Dietz WH. Television viewing as a cause of increasing
obesity among children in the United States, 1986-1990. Arch
Pediatr Adolesc Med. 1996;150:356-362. [go to PubMed]

8. Crespo CJ, Smit E, Troiano RP, Bartlett SJ,
Macera CA, Andersen RE. Television watching, energy intake, and
obesity in US children: results from the third National Health and
Nutrition Examination Survey, 1988-1994. Arch Pediatr Adolesc Med.
2001;155:360-365. [go to
PubMed]

9. Story M, Sallis JF, Orleans CT. Adolescent
obesity: towards evidence-based policy and environmental solutions.
J Adolesc Health. 2009;45(suppl 3):S1-S5. [go to PubMed]

10. SEARCH Study Group. SEARCH for Diabetes in
Youth: a multicenter study of the prevalence, incidence and
classification of diabetes mellitus in youth. Control Clin Trials.
2004;25:458-471. [go to
PubMed]

11. Writing Group for the SEARCH for Diabetes in
Youth Study Group, Dabelea D, Bell RA, D'Agostino RB Jr, et al.
Incidence of diabetes in youth in the United States. JAMA.
2007;297:2716-2724. [go to
PubMed]

12. Lipton R, Keenan H, Onyemere KU, Freels S.
Incidence and onset features of diabetes in African-American and
Latino children in Chicago, 1985-1994. Diabetes Metab Res Rev.
2002;18:135-142. [go to
PubMed]

13. Rosenbloom AL, Silverstein JH, Amemiya S,
Zeitler P, Klingensmith GJ: International Society for Pediatric and
Adolescent Diabetes. ISPAD Clinical Practice Consensus Guidelines
2006-2007. Type 2 diabetes mellitus in the child and adolescent.
Pediatr Diabetes. 2008;9:512-526. [go to
PubMed]

14. American Diabetes Association. Type 2
diabetes in children and adolescents: consensus conference report.
Diabetes Care. 2000;23:381-389. [go
to PubMed]

15.Pinhas-Hamiel O, Zeitler P. Acute and chronic
complications of type 2 diabetes mellitus in children and
adolescents. Lancet. 2007;369:1823-1831. [go
to PubMed]

16. Reinehr T, Schober E, Wiegand S, Thon A, Holl
R, on behalf of the DPV-Weiss Study Group. Beta-cell autoantibodies
in children with type 2 diabetes mellitus: subgroup or
misclassification? Arch Dis Child. 2006;91:473-474. [go
to PubMed]

17. American Diabetes Association. Standards of
medical care in diabetes—2009. Diabetes Care. 2009;32(suppl
1):S13-S61. [go to PubMed]

18. Tosh AK, Orr DP. Diabetes mellitus. In: Slap
GB. Adolescent Medicine: Requisites in Pediatrics. Philadelphia,
PA: Elsevier Health Sciences; 2008. ISBN: 9780323040730.

19. Bretzel RG, Nuber U, Landgraf W, Owens DR,
Bradley C, Linn T. Once-daily basal insulin glargine versus
thrice-daily prandial insulin lispro in people with type 2 diabetes
on oral hypoglycaemic agents (APOLLO): an open randomised
controlled trial. Lancet. 2008;371:1073-1084. [go
to PubMed]

20. Information for Healthcare Professionals:
Exenatide (marketed as Byetta). Rockville, MD: US Food and Drug
Administration; August 2008. [Available
at]

21. Ford CA, Millstein SG, Halpern-Felsher BL,
Irwin CE Jr. Influence of physician confidentiality assurances on
adolescents' willingness to disclose information and seek future
health care. A randomized controlled trial. JAMA. 1997;278:1029.
[go to PubMed]

22. Sexually Transmitted Disease Surveillance,
2006. Atlanta, GA: Centers for Disease Control and Prevention;
2007. [Available at]

23. Musacchio NS, Gehani S, Garofalo R. Emergency
department management of adolescents with urinary complaints:
missed opportunities. J Adolesc Health. 2009;44:81-83. [go
to PubMed]

24. Wimberly YH, Hogben M,
Moore-Ruffin J, Moore SE, Fry-Johnson Y. Sexual history-taking
among primary care physicians. J Natl Med Assoc. 2006;98:1924-1929.
[go to PubMed]

25. Santelli JS, Orr M,
Lindberg LD, Diaz DC. Changing behavioral risk for pregnancy among
high school students in the United States, 1991-2007. J Adolesc
Health. 2009;45:25-32. [go
to PubMed]

26. Ventura SJ, Abma J, Mosher W, Henshaw SK.
Estimated pregnancy rates by outcome for the United States,
1990-2004. Natl Vital Stat Rep. 2008;56:1-25, 28. [go
to PubMed]

27. Gavin L, MacKay AP, Brown K, et al. Sexual
and reproductive health of persons aged 10-24 years—United
States, 2002-2007. MMWR Surveill Summ. 2009;58:1-58. [go
to PubMed]

28. Causey AL, Seago K, Wahl NG, Voelker CL.
Pregnant adolescents in the emergency department: diagnosed and not
diagnosed. Am J Emerg Med. 1997;15:125-129. [go to
PubMed]

29. Noll JG, Shenk CE, Putnam KT. Childhood
sexual abuse and adolescent pregnancy: a meta-analytic update. J
Pediatr Psychol. 2009;34:366-378. [go
to PubMed]

Table

Table. Pregnancies, Births, and Sexual
Violence among Females Aged 10-24 Years—National Vital
Statistics System and Multiple Surveillance Studies, United States,
2004-2006.(27)

 

Age Group (Years)

Characteristic

10-14

15-17

18-19

20-24

Estimated no. of pregnancies 16,000

252,000

477,000

1,665,000

No. of births 6396

138,943

296,493

1,080,437

No prenatal care (%) 3.8

2.0

1.5

1.3

Third-trimester or no prenatal care (%) 15.6

7.6

5.8

4.7

Preterm ( 22.2

14.7

12.7

Pregnancy unwanted or mistimed at conception as
reported by mothers within 5 years of delivery and stratified by
age at delivery (%)
  88.0

71.4

44.7

No. of emergency department (ED) visits attributed
to nonfatal sexual assault injuries
27,469

28,388

19,777

29,553

Rate per 100,000 population of ED visits for
nonfatal sexual assault injuries (CI)

90.0

(59.3-120.7)

152.6

(92.8-212.4)

163.7

(101.7-225.6)

97.1

(59.9-134.26)

Source: Gavin L,
MacKay AP, Brown K, et al. Sexual and reproductive health of
persons aged 10–24 years—United States,
2002–2007. MMWR Surveill Summ. 2009;58:1-58. http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5806a1.htm#tab4p