Transition to Adult Care: Emerging Adults with Type 1 Diabetes
For patients with type 1 diabetes mellitus (T1DM) who are in their late teens or early twenties, the transition to adult health care services is a high-risk period. Given the currently longer periods of education, older age at marriage and establishing a separate home, the period from age 18 to 30 years has been called “emerging adulthood.”1 Medical practices may move an 18-year-old to adult care, but the psychological transition to full management of diabetes is a gradual process for most individuals.
The issues of this life stage—eg, separating oneself from the family yet still requiring support, wanting to blend in with peers, engaging in high-risk behaviors (such as smoking, alcohol and substance abuse, and sex without protection and contraception), as well as, in some cases, incipient mental illness—affect diabetes management. The shift from the “warm and fuzzy,” supportive atmosphere in pediatrics to the brisk, businesslike appointments in adult health care services, along with an aversion to assuming responsibility for self-injection, also conspire to raise the risk of worsening glycemic control and withdrawal from medical care.2
Among youth with diabetes (type 1 or type 2), teens have the highest rate of poor control (23.3%, ages 13-18; 28.5%, ≥19 years). Nearly one-third (32.4%) of adolescents ages 13 to 18 years old have good control; this drops to 17.8% for those ≥19 years of age.3
Self-reported depressive symptoms, which affected 15.2% of youth with type 1 diabetes in one series, have been associated with less frequent blood glucose monitoring and higher glycated hemoglobin (A1C) values.4 Anxiety disorders also can complicate diabetes management.2
Eating disorders often surface in adolescence and pose a particular danger for individuals with diabetes. Type 1 diabetes has been associated with a 2.4-fold higher risk of developing an eating disorder.5 Disordered eating was identified in 26% of young females with type 1 diabetes in one study.6 More than one-third of the full cohort (35.6%) and 61% of the subset with a history of disordered eating reported reducing or skipping insulin doses to control weight,6 a practice known as diabulimia.7 Disordered eating and insulin misuse were each associated with an increased risk of having two or more serious diabetes complications.6
Tobacco, alcohol, and substance abuse. Evidence suggests that teens with diabetes engage in these risky behaviors at rates similar to those of their peers without diabetes.2 Discussing these difficult topics with young patients—especially their effect on diabetes management—is an important element of health care. Marijuana use has been associated with lower fasting blood glucose levels.8 Alcohol and substance abuse in adolescents have been associated with poorer glycemic control.2,9 Cigarette smoking has been linked to elevated triglycerides and physical inactivity10 and, in patients with poor glycemic control, microalbuminuria.11
This supplement is intended for physicians, nurses, nurse practitioners, physician assistants, CDEs, and other clinicians involved in the diagnosis and management of metabolic and endocrine disorders.
DONNA L. JORNSAY, MS, CPNP, CDE, CDTC
CHRISTINE KESSLER, CNS, ANP, BC-ADM, CDTC, FAANP
DAVIDA F. KRUGER, MSN, APRN-BC, BC-ADM
ELLEN D. MANDEL, DMH, MPA, PA-C, RDN, CDE
LUCIA M. NOVAK, MSN, ANP-BC, BC-ADM, CDTC
JOYCE ROSS, MSN, ANP, CRNP, FPCNA, FNLA
SCOTT URQUHART, PA-C, DFAAPA
KIM ZUBER, PA-C
Method of Participation
Participants should read the activity information, review the activity in its entirety, and complete the online post-test and evaluation. Upon completing this activity as designed and achieving a passing score on the post-test, you will be directed to a webpage that will allow you to receive your certificate of credit via email or you may print it out at that time.
The online post-test and evaluation can be accessed at https://tinyurl.com/meds16suppl
Inquiries may be directed to Global Academy for Medical Education email@example.com or (973) 290-8225.
This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the University of Cincinnati and Global Academy for Medical Education, LLC The University of Cincinnati is accredited by the ACCME to provide continuing medical education for physicians.
The University of Cincinnati designates this Live Activity for a maximum of 2.0 AMA PRA Category 1 CreditsTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Postgraduate Institute for Medicine (PIM) is accredited with distinction as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. This educational activity for 1.3 contact hours is provided by Postgraduate Institute for Medicine. Pharmacotherapy contact hours are .4 for Advance Practice Registered Nurses and will be designated on your certificate.
Primary care providers are often the first point of care for diabetes and kidney disease. The Metabolic & Endocrine Disease Summit 2016, a CME/CE conference, explored the latest advances in the management of these conditions. Obesity raises the risk of many other conditions. Providers would benefit from a discussion of how to address this frequently encountered problem in clinical practice. Lipoprotein (Lp) (a) is an inherited, independent risk factor for atherosclerotic cardiovascular disease. New therapies show some promise for addressing this form of dyslipidemia. Diabetes raises the risk of major depressive disorder, and depression increases the risk of diabetic complications. Psychosocial intervention can improve glycemic control and symptoms of diabetes-related distress. Nephropathy is a common complication of diabetes but glycemic control, careful choice of medications, and regular monitoring can promote renoprotection.
Diabetes presents issues throughout a patient’s life; three touchpoints are the transition of a young adult from pediatrics to adult care, the detection and management of diabetes during pregnancy, and diabetes in the older adult. Anticipation of the relevant issues and implementation of a transition program can contribute to retaining young adults in care. Preconception counseling and early detection of diabetes can reduce the risk of adverse outcomes. Clinicians must be knowledgeable about how to balance the many complex issues to consider when establishing glycemic targets and selecting a treatment plan for an older adult with diabetes. At this writing, four new insulin-only preparations have been approved by the US Food and Drug Administration (FDA) since February 2015. The ability to differentiate these options is important for clinicians.
After reading and studying this journal supplement, participants should be better able to:
- Differentiate the many insulin options available to treat people with diabetes, and their applications in clinical practice
- Display an understanding of the contributors to and consequences of obesity, and interventions to address unhealthy weight
- Evaluate the contribution of elevated Lp (a) to vascular risk and its influence on treatment
- Apply the American Diabetes Association (ADA) and American Association of Clinical Endocrinologists (AACE) glycemic goals and pharmacologic recommendations in the context of individual patient concerns and practical limitations.
- Incorporate consideration of renal function in monitoring, medication choice, and general management of diabetes
- Understand common errors in medication choice and dosing that are associated with kidney injury, and plan how to avoid them
- Demonstrate an understanding of the effect of depression—and its treatment—on diabetes
- List tools to assess and manage depression in patients with diabetes
- Identify risks of transition of young adults with diabetes from pediatric to adult services, and list elements of successful transition
- Demonstrate familiarity with assessment and treatment recommendations for older adults with diabetes
- Detect and manage pregestational and gestational diabetes mellitus to reduce risk of complications for the mother and child during and after pregnancy
In accordance with the ACCME Standards for Commercial Support of CME, the speakers for this course have been asked to disclose to participants the existence of any financial interest and/or relationship(s) (e.g., paid speaker, employee, paid consultant on a board and/or committee for a commercial company) that would potentially affect the objectivity of his/her presentation or whose products or services may be mentioned during their presentation. The following disclosures were made:
Planning Committee Members
Susan P. Tyler No Relevant Relationships
Rick Ricer, MD No Relevant Relationships
Eileen McCaffrey No Relevant Relationships
Sylvia Reitman No Relevant Relationships
Shirley Jones No Relevant Relationships
The following PIM planners and managers, Judi Smelker-Mitchek, RN, BSN, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, and Jan Schultz, RN, MSN, CHCP, hereby state that they or their spouse/ life partner do not have any financial relationships or relationships to products or devices with any commercial interest related to the content of this activity of any amount during the past 12 months.
Donna L. Jornsay, MS, CPNP, CDE, CDTC, has indicated that she is a Consultant for Becton, Dickinson and Company and Eli Lilly; a Shareholder of Medtronic Diabetes; and is on the Speaker’s Bureau for Insulet.
Christine Kessler, CNS, ANP, BC-ADM, CDTC, FAANP, is a Consultant for AstraZeneca, Medtronic, and Novo Nordisk; and is on the Speaker’s Bureau for Novo Nordisk.
Davida F. Kruger, MSN, APRN-BC, BC-ADM, has indicated that she is on the Advisory Board of Abbott, Dexcom, Eli Lilly, Janssen Pharmaceuticals, Novo Nordisk; and Intarcia; on the Speaker’s Bureau for Abbott, Astra Zeneca, Boehringer Ingelheim, Dexcom, Eli Lilly, Janssen Pharmaceuticals, Novo Nordisk, Valeritas; has stock in Dexcom; and received grants/research support from Astra Zeneca, Dexcom, Eli Lilly, Helmsley Foundation, Lexicon, and Novo Nordisk, and receives research support of 40% salary from NIH.
Ellen D. Mandel, DMH, MPA, PA-C, RDN, CDE, has nothing to disclose.
Lucia M. Novak, MSN, ANP-BC, BC-ADM, CDTC, has indicated that she is on the Speaker’s Bureau for AstraZeneca, Janssen Pharmaceuticals, and Novo Nordisk.
Joyce Ross, MSN, ANP, CLS, CRNP, FPCNA, FNLA, has indicated that she is a on the Advisory Board for Akcea Therapeutics, Kaneka America, Kastle Pharma; and on the Speaker’s Bureau for AbbVie, Amarin, Amgen, Kaneka America, KOWA, and Sanofi/Regeneron.
Scott Urquhart, PA-C, DFAAPA, has indicated that he is on the Advisory Board for AstraZeneca and Shire; a Consultant for Abbott and Acella Pharma; and on the Speaker’s Bureau for Abbott and AstraZeneca.
Kim Zuber, PA-C, has indicated that she is on the Speaker’s Bureau for Amgen and Janssen Pharmaceuticals.
All information provided by program participants is confidential and will not be shared with any other parties for any reason without permission.
Contact Information for Technical Questions
Please technical questions or concerns to Global Academy for Medical Education at 973-290-8225 or email firstname.lastname@example.org.
The faculty acknowledge the editorial assistance of Global Academy for Medical Education, LLC, and Eileen McCaffrey, medical writer, in the development of this supplement. It has been reviewed and approved by the faculty as well as the editors of Clinical Endocrinology News.
Neither the editors of Clinical Endocrinology News nor the Editorial Advisory Board nor the reporting staff contributed to its content. The opinions expressed are those of the faculty and do not necessarily reflect the views of the supporter or of the Publisher.
Copyright © 2017 by Global Academy for Medical Education, LLC, Frontline Medical Communications Inc., and its Licensors. All rights reserved. No part of this publication may be reproduced or transmitted in any form, by any means, without prior written permission of the Publisher. Global Academy for Medical Education, LLC, will not assume responsibility for damages, loss, or claims of any kind arising from or related to the information contained in this publication, including any claims related to the products, drugs, or services mentioned This continuing medical education (CME) supplement was developed from faculty presentations at the Metabolic & Endocrine Disease Summit October 5 - 8, 2016.
1. Arnett JJ. Emerging adulthood. A theory of development from the late teens through the twenties. Am Psychol. 2000;55:469-480.
2. Peters A, Laffel L. American Diabetes Association Transitions Working Group. Diabetes care for emerging adults: Recommendations for transition from pediatric to adult diabetes care systems: A position statement of the American Diabetes Association, with representation by the American College of Osteopathic Family Physicians, the American Academy of Pediatrics, the American Association of Clinical Endocrinologists, the American Osteopathic Association, the Centers for Disease Control and Prevention, Children with Diabetes, The Endocrine Society, the International Society for Pediatric and Adolescent Diabetes, Juvenile Diabetes Research Foundation International,
the National Diabetes Education Program, and the Pediatric Endocrine Society (formerly Lawson Wilkins Pediatric Endocrine Society). Diabetes Care. 2011;34:2477-2485. doi: 10.2337/dc11-1723.
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8. Penner EA, Buettner H, Mittleman MA. The impact of marijuana use on glucose, insulin, and insulin resistance among US adults. Am J Med. 2013;126(7):583-589. doi: 10.1016/j.amjmed.2013.03.002.
9. Glasgow AM, Tynan D, Schwartz R, et al. Alcohol and drug use in teenagers with diabetes mellitus. J Adolesc Health. 1991;12(1):11-14.
10. Reynolds K, Liese AD, Anderson AM, et al. Prevalence of tobacco use and association between cardiometabolic risk factors and cigarette smoking in youth with type 1 or type 2 diabetes mellitus. J Pediatr. 2011;158(4):594-601. e591. doi: 10.1016/j.jpeds.2010.10.011.
11. Scott LJ, Warram JH, Hanna LS, Laffel LM, Ryan L, Krolewski AS. A nonlinear effect of hyperglycemia and current cigarette smoking are major determinants of the onset of microalbuminuria in type 1 diabetes. Diabetes. 2001;50(12):2842-2849.
12. Schwarz EB, Sobota M, Charron-Prochownik D. Perceived access to contraception among adolescents with diabetes: Barriers to preventing pregnancy complications. Diabetes Educ. 2010;36(3):489-494. doi: 10.1177/0145721710365171.
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14. Lyons SK, Becker DJ, Helgeson VS. Transfer from pediatric to adult health care: effects on diabetes outcomes. Pediatr Diabetes. 2014;15(1):10-17. doi: 10.1111/pedi.12106.
15. Kipps S, Bahu T, Ong K, et al. Current methods of transfer of young people with Type 1 diabetes to adult services. Diabet Med. 2002;19(8):649-654.
16. Jacobson AM, Hauser ST, Willett J, Wolfsdorf JI, Herman L. Consequences of irregular versus continuous medical follow-up in children and adolescents with insulin-dependent diabetes mellitus. J Pediatr. 1997;131(5):727-733.
17. Cadario F, Prodam F, Bellone S, et al. Transition process of patients with type 1 diabetes (T1DM) from paediatric to the adult health care service: A hospital-based approach. Clin Endocrinol (Oxf). 2009;71(3):346-350. doi: 10.1111/j.1365-2265.2008.03467.x.
18. Holmes-Walker DJ, Llewellyn AC, Farrell K. A transition care programme which improves diabetes control and reduces hospital admission rates in young adults with Type 1 diabetes aged 15-25 years. Diabet Med. 2007;24(7):764-769. doi: 10.1111/j.1464-5491.2007.02152.x.
19. Vanelli M, Caronna S, Adinolfi B, Chiari G, Gugliotta M, Arsenio L. Effectiveness of an uninterrupted procedure to transfer adolescents with Type 1 diabetes from the Paediatric to the Adult Clinic held in the same hospital: eight-year experience with the Parma protocol. Diabetes Nutr Metab. 2004;17(5):304-308.
20. Van Walleghem N, Macdonald CA, Dean HJ. Evaluation of a systems navigator model for transition from pediatric to adult care for young adults with type 1 diabetes. Diabetes Care. 2008;31(8):1529-1530. doi: 10.2337/dc07-2247.