COMMENTARY

Entering Adulthood With Diabetes

Even Parental Divorce Affects Diabetes Management

Gregory A. Nichols, PhD

Disclosures

July 13, 2017

Does Transferring to Adult Care Affect Glycemic Control?

Diabetes in young adults can present somewhat different medical challenges and opportunities from those in children or older adults. Furthermore, these young adults will experience a transition from pediatric to adult care that can disrupt the continuity of care; even small differences in continuity of care are associated with considerable differences in medical care costs, utilization, and complications.[3]

A retrospective cohort study[4] of patients with T1DM examined glycemic control between the last 2 years in pediatric care and first 2 years in adult care. Primary outcome was change in A1c and included associations with demographics, comorbidity, and family structure. Associations between acute hospital admissions and glycemic control also were examined.

A total of 126 people were included in the analyses; median age at transfer from pediatric to adult care was 18 years, and 52% were men. Mean A1c during the 2 years in pediatric care was 9.7%, declining to 9.4% after transfer to adult care.

About 16% of participants had a learning disability or mental health condition, a factor that was associated with an A1c that was 0.7% higher in pediatric care. Nearly a third of the study sample had divorced parents, and these individuals had A1c values that were 1.2% higher in both pediatric and adult care when compared with patients whose parents had remained together.

During the 4-year study period, 27% of patients had at least one hospital admission. Higher baseline A1c, having a learning disability or mental health condition, and divorced parents were strongly associated with hospital admission.[4]

Parental divorce was associated with a more than one-percentage-point-higher A1c.

Not surprisingly, this study found that longer transition periods were associated with a higher A1c at the first adult visit. The American Diabetes Association recognized the challenges relating to the transition period with a 2011 position statement,[5] and it includes a section on children and adolescents and the transition to adulthood in its annually published Standards of Medical Care.[6]

Fortunately, management goals are essentially the same for young people with type 1 and type 2 diabetes.[6] However, as we now know, T2DM conveys over twice the risk of developing complications compared with type 1.[2]

That said, an alarmingly high hospitalization rate in young adults with T1DM[4] demonstrates that they are at an immediate risk for a serious event. Perhaps this is due to high A1c values, but poor glycemic control in youth is much more likely than excellent control.[7]

It's interesting that parental divorce was associated with a more than one-percentage-point-higher A1c; young people with divorced parents may need additional training and perhaps psychosocial counseling to facilitate their diabetes care.

Maybe most important, there is no question that good glycemic control early in the course of diabetes is important, regardless of diabetes type. The Diabetes Control and Complications Trial (DCCT), with additional follow-up from the Epidemiology of Diabetes Interventions and Complications (EDIC), demonstrated substantial reductions in the risk for retinopathy, nephropathy, and cardiovascular complications among T1DM participants who were randomly assigned to the tight-glycemic-control arm compared with the standard-therapy group. These benefits persist for up to 30 years despite the DCCT intervention lasting just 6.5 years.[8,9]

It is never too late to optimize glycemic control, especially among young adults.

Early glycemic control also benefits patients with T2DM. Participants in the United Kingdom Prospective Diabetes Study (UKPDS) randomized to intensive therapy enjoyed significant risk reductions in microvascular disease and myocardial infarction for at least 10 years after the trial ended.[10]

It is never too late to optimize glycemic control among young adults because they will live with diabetes for much longer periods than older patients. Regardless of diabetes type, successful diabetes management can help young people living with diabetes to enjoy longer and healthier lives.

Despite the challenges, the transition from pediatric to adult care represents an opportunity for doctors and patients to take a fresh look at glycemic goals and attempt more aggressive glycemic control if appropriate.

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