ADA Issues New Guidance on Type 1 Diabetes in Youth

Miriam E. Tucker

August 10, 2018

A new position statement from the American Diabetes Association (ADA) addresses the challenges of type 1 diabetes in children and adolescents, offering advice on comprehensive management. 

The 19-page document was published online August 9 in Diabetes Care by senior author Desmond Schatz, MD, professor of pediatrics and medical director of the Diabetes Center at the University of Florida, Gainesville, and five other US pediatric diabetes experts.   

The statement replaces the previous one specifically addressing pediatric type 1 diabetes published in 2005. A separate statement on type 2 diabetes in youth is in development.

In 2014, ADA issued guidance for type 1 diabetes across the lifespan, which first introduced the general pediatric HbA1c target of less than 7.5%, subject to individualization. That target is maintained in the new statement.

But much of the information in the latest guidance is new since 2014, and far, far more has changed since 2005. In addition to the basics on diagnosis and clinical management, the document addresses new technology, behavioral and psychosocial issues, and the importance of a multidisciplinary team approach, Schatz told Medscape Medical News.

"There have been so many innovations and advances in therapies since 2005, and with the complexities of these and of the healthcare system, we thought it was really important to re-energize and update the position statement to improve the health of all children and youth with type 1 diabetes."

A multipronged approach is essential, including specialists in nutrition, psychology, and exercise, he said. "We need to understand that insulin and glucose is only one part of the management. It is, to a large extent, a behavioral disease...We need to optimize all our resources and develop a personalized care plan."

The new statement, Schatz said, also emphasizes "that children are not young adults and there are unique challenges children and their families face. We have tried to provide a comprehensive approach to that."

Revolution in Technology Needs Diabetes Educator to Advise

As has been the case in the past, intensive insulin therapy — either by multiple daily injections or pumps — is recommended as the standard of care for most children and teens with type 1 diabetes.

Now, however, there is a greater emphasis on the use of continuous glucose monitoring (CGM). The recommendation states, "CGM should be considered in all children and adolescents with type 1 diabetes, whether using injections or insulin pump therapy, as an additional tool to help improve glycemic control. Benefits of CGM correlate with adherence to ongoing use of the device."

Schatz called the availability of CGM "one of the most important advances for children and adolescents with type 1 diabetes," but also pointed out that the advances in pump and glucose sensing technology — including new hybrid closed-loop artificial pancreas systems — has been so rapid that it may be hard for a physician to keep up with all the new devices that keep rolling out.

"You need an educator, someone who is sophisticated in technology. With all the changes...we really need to stay up to date."

And in a nod to additional patient-related challenges, the document also states, "Patients would benefit from device manufacturers enabling data interoperability, regulatory agencies expediting and harmonizing approvals, and payors reimbursing the numerous supplies needed to optimize type 1 diabetes management in a timely manner, especially for the pediatric population."

"All patients with type 1 diabetes should have access to appropriate insulin therapy and advanced diabetes technologies."

And in keeping with the 2017 ADA statement on psychosocial care for all people with diabetes, the new document recommends assessing psychosocial issues including family stresses, peer relationships, and school problems that could affect diabetes management, as well as diabetes-specific distress, eating disorders, and other high-risk behaviors that can also derail glycemic control and overall health.

"We need to help support the child, the interactions with the family, the challenges that are faced," Schatz said.

Emphasis on Improving Transition to Adult Care, Treating the Individual  

The document also includes a section on the transition from pediatric to adult medicine, which can lead to gaps in care and loss of glycemic control. The recommendations say, "Pediatric diabetes providers should begin to prepare youth for transition in early adolescence and, at the latest, at least 1 year before the transition to adult healthcare."

That's an area in need of improvement, Schatz believes.

"When kids go off to college, they're in a new environment, away from home. They have to understand insurance, how to communicate with their provide...It's no wonder that HbA1c during later adolescence and early college years are spiraling out of control…We need to make it easier."

Other aspects of care addressed in the document include staging of type 1 diabetes and referral of first-degree relatives of patients to clinical trials, distinguishing between type 1 diabetes, type 2 diabetes, and monogenic forms of diabetes, and screening for complications and additional autoimmune conditions.  

Most important, Schatz said, is the recognition that care must be individualized.

"We've provided comprehensive recommendations, but in the end it's that particular child and that particular family with which decisions need to be made...As we understand more and more about the disease process, therapies will be individualized more and more. Each person's diabetes is different."

Schatz has reported serving as a consultant to Sanofi, being on the external advisory board for Sankyo, and receiving grants from JDRF, Helmsley Charitable Trust, and a TrialNet grant in part from Sanofi.  Disclosures for the other authors are listed in the article.

Diabetes Care. Published online August 9, 2018. Abstract

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