Initial Evaluation and Follow-up
All patients with type 1 diabetes need age-appropriate care, with an understanding of their specific needs and limitations. Infants and toddlers are approached quite differently from adolescents; the needs of young adults may vary from middle-aged or older adults. Regardless of age, the patient's needs are the same: an individualized care plan with ongoing education and support, ongoing assessment for acute and chronic complications, and access to medical providers with type 1 diabetes expertise. Just as patients change, the therapeutic approach should change and should be evaluated at each visit and modified as needed.
Type 1 diabetes care must be an iterative process, adapted as the needs of the individual evolve. Clinical assessments for type 1 diabetes in children and adults should incorporate age-appropriate and complication-focused evaluations, based on the likelihood that an abnormality will be present. For example, a young adult with low cardiovascular disease (CVD) risk and no complications may need more of an assessment of lifestyle adjustment as opposed to an older adult with longer duration of the disease who may need more evaluation of vascular and neurological issues.
Transition of Care From Pediatric to Adult Providers
As youth transition into emerging adulthood, the supportive infrastructure often abruptly disappears and glycemic control tends to deteriorate. The ADA recognizes that this is a challenging time and recommends a strong, practical transition plan to anticipate the upcoming changes. A successful transition plan should be initiated early (e.g., early teenage years) and include ongoing dialogue between the family and youth. The discussion should include finances, insurance, obtainment of supplies, identification of an adult care provider (ideally with communication between the two providers), psychosocial issues (e.g., depression), and other issues identified by the family/youth. Health care providers, family, and youth should agree to an achievable diabetes management plan and provide resources for unanticipated issues. We refer the reader to the ADA's position statement on diabetes care for emerging adults.
Assessing the history of acute complications (e.g., severe hypoglycemia/hyperglycemia and diabetic ketoacidosis [DKA]) is important. Providers should provide continuing education for the patient/family to prevent ongoing recurrence. For example, it is important to review exercise management to reduce hypoglycemia risk and discuss sick-day management to reduce DKA risk.
Risk factor (e.g., cardiovascular) evaluation for prevention and screening for early evidence of micro- and macrovascular complications for early intervention should be implemented starting in adolescence and continue through adulthood. For children, risk factors should be assessed shortly after diagnosis based on family history and initial screening laboratory test results. Providers should manage risk factors, considering age-specific goals and targets (e.g., blood pressure, lipid, depression, and BMI assessment and management). The frequency of ongoing screening for complications should be based on age and disease duration.
Celiac Disease. Celiac disease is an immune-mediated disorder that occurs with increased frequency in patients with type 1 diabetes (1–16% of individuals compared with 0.3–1% in the general population).[21,22] Symptoms of celiac disease include diarrhea, weight loss or poor weight gain, abdominal pain, bloating, chronic fatigue, malnutrition due to malabsorption, and unexplained hypoglycemia or erratic blood glucose levels. Screening for celiac disease with serum levels of tissue transglutaminase or antiendomysial antibodies should be considered soon after the diagnosis of diabetes and/or if symptoms develop. Individuals who test positive should be referred to a gastroenterologist for possible small-bowel biopsy to confirm the diagnosis, although this is not necessary in all cases. Symptomatic children with strongly positive antibodies and supportive genetic or HLA testing may not require a biopsy, but asymptomatic at-risk children should have a biopsy. In symptomatic individuals with type 1 diabetes and confirmed celiac disease, a gluten-free diet reduces symptoms and decreases rates of hypoglycemia.
Thyroid Disease. About one-quarter of children with type 1 diabetes have thyroid autoantibodies (thyroid peroxidase antibodies or antithyroglobulin antibodies) at the time of diagnosis.[25,26] The presence of thyroid autoantibodies is predictive of thyroid dysfunction, generally hypothyroidism and less commonly hyperthyroidism. Thyroid dysfunction is more common in adults with type 1 diabetes, although the exact prevalence is unknown. Women are more commonly affected than men. Subclinical hypothyroidism, hyperthyroidism, or coexistent Addison disease (adrenal insufficiency) may also deteriorate metabolic control with increased risk of symptomatic hypoglycemia and may reduce linear growth in children.
Additional Considerations for Pediatrics
All children require some level of adult supervision in managing their diabetes. Assessments of pediatric patients should address issues specific to infants/preschoolers, school-aged children, adolescents, and emerging adults (Table 2). Health care providers should do a thorough assessment of the developmental needs of the youth (and caregiver), focusing on physical and emotional development, family issues, and psychosocial needs. The diabetes treatment plan should be individualized and tailored to the needs of individual patients and their families. Efforts to achieve target blood glucose and A1C levels should be balanced with preservation of quality of life and protect against excessive hypoglycemia.
Height and weight should be measured at each visit and tracked via appropriate height and weight growth charts. An age-adjusted BMI can be calculated starting at age 2 years. These tools can be found for children and teens at https://apps.nccd.cdc.gov/dnpabmi. Blood pressure measurements should be determined correctly, using the appropriate size cuff and with the child seated and relaxed. Hypertension should be confirmed on at least 3 separate days. Normal blood pressure levels for age, sex, and height and appropriate methods for determinations are available online at www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.pdf.
Chronic Complications in Children
Retinopathy, nephropathy, and neuropathy rarely have been reported in prepubertal children and children with diabetes duration of only 1–2 years; however, they may occur after the onset of puberty or after 5–10 years of diabetes. As screening recommendations are based on recent evidence, these periodically change. Therefore, we refer the reader to the ADA Standards of Care for the current screening recommendations for children. It is recommended that those with expertise in diabetes management should conduct the assessments. For example, ophthalmologic exams should be performed by those skilled in diabetic retinopathy management and experienced in counseling pediatric patients and parents on the importance of early prevention/intervention. Another example, nephrologists with experience with diabetic nephropathy would be aware that intermittent elevations in urinary albumin excretion are common in pediatric patients, particularly in association with exercise.
Additional Considerations for Adults
Adults with type 1 diabetes now span a very large age spectrum—from 18 to 100 years of age and beyond. Unlike the well-characterized developmental stages of children, the life stages traversed through adulthood are often less well documented and underappreciated. However, an understanding of each individual's circumstances is vital. This is true for aging in general, but particularly true for those with significant comorbidities due to long-standing type 1 diabetes. Thus, it is important to assess the clinical needs of the patient, setting specific goals and expectations that may differ significantly between a healthy 26-year-old and a frail 84-year-old with CVD and retinopathy.
Recommendations. See 2014 ADA Standards of Medical Care for detailed screening information for CVD, nephropathy, retinopathy, neuropathy, and foot care.
Access to health care should include clinicians with expertise in type 1 diabetes management, including (but not limited to) an endocrinologist (or other health care provider with expertise in type 1 diabetes management), a registered dietitian, a diabetes educator, a mental health professional, an exercise specialist/physiologist, and specialists required to treat diabetes complications. (E)
Routine follow-up (generally quarterly) should include review of self-monitoring of blood glucose (SMBG), continuous glucose monitoring (CGM) and pump data (if applicable), A1C measurement, evidence for acute and/or chronic complications of diabetes (particularly episodes of DKA and mild and/or severe hypoglycemia), measurement of blood pressure and weight (and height in children), foot exam, inspection of injection/insertion sites, and discussion of psychosocial and educational needs (Table 4 and Table 5). (E)
Providers should routinely document the patient's age and disease duration. When clinically indicated, laboratory measures such as lipids, renal function measurements, and antibodies for associated autoimmune disease (thyroid or celiac disease) should be documented. (E)
Parent/guardian involvement in care is required throughout childhood, with a gradual shift in responsibility of care from the parent/guardian to the youth. (E)
Health care for adults should be focused on the needs of the individual throughout the various stages of their life, with age-appropriate evaluation and treatment. (E)
Evaluation and treatment of CVD risk should be individualized. (E)
Immunizations should be given as recommended by the Centers for Disease Control and Prevention (CDC) for children/adults in general and people with diabetes specifically. (C)
Consider screening for celiac disease by measuring IgA antitissue transglutaminase or antiendomysial antibodies, with documentation of normal total serum IgA levels, soon after the diagnosis of diabetes and/or if symptoms develop. Refer the patient to a gastroenterologist if the test is positive. (E)
Consider screening for thyroid peroxidase and thyroglobulin antibodies soon after diagnosis. (E)
Screen for thyroid dysfunction by measuring thyroid-stimulating hormone (TSH) concentrations soon after type 1 diabetes diagnosis (and after stable metabolic control). If normal, consider rechecking every 1–2 years or more frequently if the patient develops unusual glycemic variation or symptoms of thyroid dysfunction or thyromegaly. (E)
Assess for the presence of additional autoimmune conditions at diagnosis and if symptoms develop. (E)
Ongoing nutrition and diabetes self-management education (DSME) and support (DSMS) are needed to address changes in food preferences, access to food, daily schedules, activity patterns, and potential barriers to self-care, including the risk of an eating disorder. (E)
Assess psychosocial status annually and more often as needed; treat and/or refer to a mental health professional as indicated. (E)
Diabetes Care. 2014;37(7):2034-2054. © 2014 American Diabetes Association, Inc.