A NEW FOCUS IN THE STANDARDS OF CARE FOR THE YOUNG ADULT POPULATION WITH TYPE 1 DIABETES Scott Dolan, BS, LMT, CPT [email protected]University of Western States Human Nutrition and Functional Medicine Abstract Despite the evolving evidence available for addressing the management of type 1 diabetes (T1D), clinicians are failing to address the concerns and complications in the young adult population. As the prevalence of T1D grows so does the average lifespan for each child-onset diagnosis. Yet, the early detection of diabetic complication for T1Ds are seen in the young adult years. The article discusses the common difficulties seen in this subpopulation around this transitional time and the possible barriers associated with meeting the daily demands of their condition. The article offers recommendations for clinicians to prioritize strategies for implementing an effective treatment plan for their T1D patients.
Transcript
A NEW FOCUS IN THE STANDARDS OF CARE FOR THE YOUNG ADULT
University of Western States Human Nutrition and Functional Medicine
Abstract Despite the evolving evidence available for addressing the management of type 1 diabetes (T1D), clinicians are failing to address the concerns and complications in the young adult population. As the prevalence of T1D grows so does the average lifespan for each child-onset diagnosis. Yet, the early detection of diabetic complication for T1Ds are seen in the young adult years. The article discusses the common difficulties seen in this subpopulation around this transitional time and the possible barriers associated with meeting the daily demands of their condition. The article offers recommendations for clinicians to prioritize strategies for implementing an effective treatment plan for their T1D patients.
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INTRODUCTION
The prevalence of diabetes continues to grow within various populations of the US, but for the
subpopulation of young adults with type 1 diabetes mellitus (T1DM), the condition can become
very challenging with unforeseen barriers in care methods. This emerging time into adulthood
has received more recent attention in the scientific literature, but very few studies are currently
available to guide clinicians in developing treatment strategies that address the challenges for
this age group (Peters, 2011). Papers that do address this concern, characterize this age-range
between 18 to 30 years. Due to this transitional time, young adults demonstrate different
characteristics that are separate from those younger than 18 and older than 30 years of age. The
transitional time has been described as an increased period of risk-taking, frequency in
geographical relocating, psychosocial stressors, and missed appointments with their general
practitioner (GP) (Hanna, 2013; Helgeson, 2014). As a result, diabetic complications have been
correlated to the behavioral changes and lack of preparations for this transitioning time (Farrell,
2014; Peter, 2011). In this article, it is proposed that the current standards of care for ‘emerging
adults’ with T1DM lack the proper perspectives to implement effective strategies to supporting
successful glycemic control that is specific to the characteristics found in this age group. As a
result, the article attempts to consider recommendations for new practice strategies in the
standard of care that are specific to the characteristics of the young adult population. Further
consideration is also given on the need to develop more methodologically strong studies that
produce effective standards of care strategies in this group. This article can provide clinicians
with a better understanding for the need to establish new standards of care that are separate and
distinct for this age group. Though overall guidelines on nutrition, diet, exercise, and
carbohydrate to insulin dosing should remain the same according to the standards of care given
by the American Diabetes Association (ADA), the treatment strategies and focus for each patient
requires a new perspective and adaptive aim to each patient’s individualistic goals.
The vast majority of individuals with T1DM will be diagnosed before the age of 20. It is
projected that individuals diagnosed with T1DM (before the age of 20) will triple from 179,388
from 2010 to 587,488 by 2050 (Imperatore, 2012). The precise population of young adults with
T1DM at any given time is difficult to know. Epidemiological data within the 18-30 age range is
limited due to the ‘volatile’ changes and characteristics within the age range. Due to this
limitation, there is a lack of understanding in how much economic cost that is associated with
this particular age range. When adding type 2 diabetes mellitus (T2DM) as an additional factor,
the ADA estimated the economic cost of diabetes at $245 billion in 2012 (Economic Costs of
Diabetes in the U.S. in 2012, 2013). Although the precise incidence of new-onset T1DM in
individuals over 20 years of age is unknown, we do know that individuals with childhood-onset
diabetes are living longer (Chiang, 2014; Miller, 2012).
A systematic review reported that when young adults transition from pediatric care there is a
breakdown of treatment structure that can include routine pediatric visits, dietary modification
plans, or transition into a new glucose monitor or an insulin pump. A multicenter RCT illustrated
the description of a ‘treatment structure’ by utilizing a transition coordinator that ensured patient-
centered follow through with each plan moving from pediatric care to a new GP (Spaic, 2013).
As a result, young adults who were identified as having an unstructured intervention showed a
higher rate of hospital visits and complications associated with poor glycemic control (Farrell,
2014; Spaic, 2013). To better understand these findings, a longitudinal study with a questionnaire
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was done to help examine the perspective of young adults and found a greater desire for a more
structured process that is tailored to their individual needs (Betz, 2013). Emerging adults with
T1DM experience less consolidated care often seen in their younger years with pediatrics. As
this population transitions into seeing a GP, there is the difficulty of optimally managing their
condition as they move into the adult years. What once was supervised by parents and other
adults now requires self-care management skills that can be lacking for many. Their increase in
independence coincides with added responsibilities for making their own healthcare decisions
and maintaining their own treatment regimen. These shifting factors along with the same
standards of care implemented in pediatrics are met with less patient compliance and success in
adult care (Sheehan, 2015). The dynamics between the clinician and patient are no longer the
same as they were before emerging into young adulthood. Though there is still the need for
routines in diet, medication, and blood testing, the need to individualize a treatment plan specific
to their transition becomes crucial. This requires a new perspective on establishing successful
goals that can be accomplished only through establishing effective interventions.
A Fundamental Change in Perspective
The need to adapt a more effective intervention for young adults with T1DM also stems from the
need to produce a fundamental shift in how interventional methods are practiced in medicine.
For T1Ds, the focus from clinicians should be geared towards directing the person to manage
his/her diabetes that is congruent with their lifestyle goals. This non-disease specific paradigm
can direct the clinician and patient to create a treatment plan with a multifaceted approach that is
more lifestyle-modification focused. The ADA continues to release updates for the standards of
care within only two main categories; type 1 or type 2 diabetes mellitus (American Diabetes
Association, 2015). Until recently, the ADA has never introduced the standard-of-care-
guidelines that are directed demographically by age or lifestyle. The newest standards of medical
care given by the ADA in 2016 emphasize stronger recommendations to individualistic care
strategies that can be age-specific for clinicians (American Diabetes Association, 2016). This
change mostly stems from the exponential increase in literature papers written about the
transitional time for TIDs in their young adult years and the associated complications. So
naturally, the acknowledgment of this concern begs us to consider all possible reasons for its rise
in the last decade.
The moment a person is diagnosed with T1DM (usually at a young age), they are taught that the
only way to successfully control their glucose levels is with the correct delivery of multiple
injections of insulin each day. The fundamental challenge in treating T1Ds is in replacing the
insulin your body is no longer making and taking just enough insulin to match your body’s
needs. It is simple to learn and consider T1Ds as a primary insulin deficiency, but as we do so,
we continue to presuppose that the only way to control a pathological process is to figure out
which physiological pathway has become dysfunctional. It is proposed that clinicians need to
focus beyond the immediate pathophysiology and combine the understanding of this
autoimmune disorder with lifestyle modifications that affect it as much as the needed insulin. In
turn, this creates a better understanding of how to prevent future underlying issues that contribute
to future complications. According to one literature, the first incidence of ketoacidosis, along
with other symptoms, occurs during the young adult years (Matteucci, 2015) within the lifespan
of a T1D. Recently, the prevalence of celiac disease (CD) among T1Ds is estimated to be 4.7-8%
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among patients (Elfstrom, 2014). One article has found that as an autoimmune disease, T1DM
and CD both share a clinical and pathogenic overlap that is influenced by immune dysregulation
and environmental triggers (Cohn, 2014). Another report also indicates a high prevalence of
undetected CD in T1Ds that contributes to poor glycemic control and that correlates to
complications in retinopathy and nephropathy (Leeds, 2011). Among the many studies on CD
found in T1D patients were reports that indicated the success found in implementing a gluten-
free diet (GFD) to help reverse the negative effects (Cohn, 2014; Elfstrom, 2014; Leeds, 2011).
The importance of developing care strategies is to first understand the common physiological
associations found in the disease of each person. As a multifactorial disease with genetic factors,
there are multiple susceptibilities that stem from environmental triggers. Another area of concern
that has gained exponential attention in the scientific literatures is the onset and progression of
increase in the intestinal permeability of diabetics (De Kort, 2011). In some studies, biopsies
performed on T1Ds have revealed altered tight junction structure with increased paracellular
space in the epithelial cells of the small intestines (De Kort, 2011). This same report found that a
lactulose/mannitol lab test could help detect the early signs of leaky gut (increased IP) and
prevent any resultant complications (De Kort, 2011).
These factors should obligate clinicians to discontinue the assumption that it’s only a matter of
identifying the most influential agent to overcome the deficiency and, therefore, prioritize around
the treatment plan. We need to concern ourselves with the managing of the individuals lifestyle
that impacts the immune system and supplemental dysfunctions. As we do so, we no longer
isolate the disease as just a pancreas that no longer produces insulin with a simple diagnosis and
solution – create and inject synthetic insulin. Though our pathophysiological knowledge of
diabetes has grown from scientific discoveries to evidence-based standardization of care, both
the medical community and general public still continue to view the management of T1DM as a
simple solution to a complex problem. While the discovery of insulin should be applauded as a
life-saving discovery, it should not reflect an ultimate solution to the current problem in a linear-
solving perspective. This T1DM and insulin correlation does not seem to meet the challenges
that face young adults. The emphasis and priority to implement dietary strategies have shown
significant success rates in managing glycemic control (Matteucci, 2015) and it should be
considered in line with what type of insulin to prescribe. Consequently, excess in simple
carbohydrate intake that requires large doses of postprandial insulin has been shown to increase
the frequency of both hyperglycemic and hypoglycemic events (Matteucci, 2015; Nielsen, 2012).
Addressing the everyday challenge is how you achieve good control and how you balance the
day-to-day demands of diabetes with the other demands of life. The challenges, in turn, have
given rise and advent to various technologies such as insulin pumps and continuous glucose
monitoring systems (GCMS) commonly used to accommodate the daily demands. We continue
to advance our understanding of the disease and the technologies that improve our ability to
manage it. Yet, despite these medical advancements, diabetics complications continue to rise
(Bell, 2016). The focus should always be on learning methods to adapt and prepare for various
life circumstances. The primary learning-focus should not be to understand the limits of living
with diabetes, but how to utilize technologies and other new medical advances to accommodate
the individual lifestyle changes. The process of learning the individual needs of the patient will
ensure a better understanding of how that patients diabetes interacts not only with other
physiological conditions but with the other facets of life such as food, exercise, emotional stress,
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or unexpected weight gains. As we embrace these paradigm shifts in the management of T1DM,
we effectively utilize the support of technologies, standards of care, and medications because
they better support the needs of the patient rather than just the disease in and of itself.
METHODS
Search strategy and selection criteria of the comprehensive literature review
Multiple literature searches with a special emphasis on research findings published over the past
8 (2008 to 2016) years on Diabetes Mellitus was carried out using PubMed, Medline and Google
Scholar databases through the University of Western State library database online. PubMed and
Medline contain citations published mostly from 2009 to 2015, whereas Google Scholar database
dates from 2008 to 2016. The following keywords were employed to search the above-mentioned
databases: "Type 1 Diabetes Mellitus", "young adults" and "standard of care". Another search
was conducted using keywords "type 1 diabetes," and "carbohydrate to insulin ratio." Lastly,
another search was conducted using the keywords: "type 1 diabetes," "low glycemic index diet"
and "continuous glucose monitoring system". Original research and review articles related to
young adult patients with diabetes mellitus were considered for the review, excluding diabetes
related to pregnant women and elderly adults. Inclusion criteria comprised reports of data from
systematic review articles and meta-analysis reports related studies with young adult patients
who ranged from 18 to 30 years of age, including data reported by the American Diabetes
Association. Literature that included ages outside the 18 to 30 years were used to illustrate the
transition into young adulthood as it relates to the informed subject matter. Narrative reviews
that expanded a better understanding of social and pathophysiology concerns for the T1D
population were also utilized and reported.
The next process included searches within the websites of the following organizations: World
Health Organization (WHO) and American Diabetes Association (ADA) for verification of facts
related to rates of mortality, incidence, prevalence, and key findings reported in journals
referencing the two organizations. For searches that accounted for more than 15 results, priority
was given to systematic reviews, meta-analysis, and large-scale randomized control trials with
more than 100 participants.
DISCUSSION
Standards of Care for Diabetes
Each year, the ADA produces a report called the “Standards of Medical Care in Diabetes,” that is
comprised of all the current and key clinical practice recommendations. The report is derived
from a multidisciplinary Professional Practice Committee (PPC) that is organized annually to
establish any necessary revisions and updates. As such, the PPC reviews any new evidence or, in
some cases, to clarify the prior recommendations. Information on the committee’s criteria for
recommendations are based on high-level evidence and low-level evidence. The ADA then
associates an evidence-based grading system for any recommendations given on clinical
practices.
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For the purposes of this paper, references from the “Standards of Medical Care in Diabetes-
2015” were limited to recommendations given in the following categories: a) optimal glucose
range, b) hemoglobin A1c (HbA1c) levels, c) establishing a carbohydrate to insulin ratio
(carbohydrate counting) (CIR), d) diabetes self-management support (DSMS), and e) support of
patient-behavioral changes. Within each category, references are made on recommendations that
pertain to nutrition and eating habits, insulin dosing, and subsequent glycemic control methods.
Given the volume of updated information provided by the standards of medical care in diabetes,
two additional references are used to collaborate ADA recommendations that pertain to young
adults with T1DM specifically. The National Diabetes Education Initiative (NDEI) provides an
annual summary of the ADA recommendations for the standards of medical care in diabetes. The
second reference utilized to consolidate the information given by ADA's annual report is a paper
called "Type 1 Diabetes Through the Life Span: A Position Statement of the American Diabetes
Association." Both papers serve as a cross-reference to information provided in the "Standards of
Medical Care in Diabetes" with a specific element of focus for young adults with T1DM.
Recommendation 1: Beyond the Carbohydrate to Insulin Ratio
Once a diabetic requires insulin to sustain optimal glucose control, priority for health care
providers is to establish a carbohydrate to insulin ratio (CIR) that supports the patient’s diet of
carbohydrate consumption. According to the ADA, the majority of T1Ds should be educated in
methods that match the carbohydrate intake with required insulin dosage, pre-meal blood glucose
testing, and anticipated activity levels (American Diabetes Association, 2015). As the ADA
continues to combine overall dietary recommendations for type 1 and type 2 diabetics, there
overlapping similarities for each condition still requires a focus on the particular person within
that particular age. The assumption is that educating adults with type 2 diabetes mellitus (T2DM)
about food choices is a relative solution to the very problem that initially caused the disease to
manifest itself. Given the one major difference of T1DM (inability to produce insulin) in
contrast, being unable to manage the disease through food alone has remained a safe assumption.
This knowledge has led the ADA and medical community to establish a CIR with every T1D on
multiple injections per day as a strong recommendation for managing their blood sugars. This
recommendation from the ADA has received an E grade according to the evidence-based grading
system. The American Diabetes Association developed a grading system for clinical
recommendations changed or added each year. This grading system was used to clarify and
codify evidence that forms the basis for each of the recommendations in the “Standards of
Medical Care in Diabetes—2014.” The level of evidence that supports each recommendation is
listed after each recommendation using the letters A, B, C, or E. The ADA maintains a strong
recommendation of carbohydrate counting with a B evidence grading level - “Monitoring
carbohydrate intake, whether by carbohydrate counting or experience-based estimation remains
a key strategy in achieving glycemic control” (Evert, 2014, page 2).
Within the numerous studies on carbohydrate counting and insulin dosing, there are conflicting
results. One systematic review that included 21 observational studies concluded a lack of
evidence to support carbohydrate counting as the only method of insulin dosing (Schmidt, 2014).
The process of carbohydrate counting usually requires numeracy skills and knowledge of
nutrition in order to accurately read food labels, measure portion sizes, and determine actual
glycemic content. Limited literature exists on how well people with T1DM are accurately
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quantifying carbohydrate content, but a few studies have suggested that people can count
carbohydrate with 10-15 grams of accuracy (Brazeau, 2013; Smart, 2009). Though these studies
suggest an effective method for carbohydrate counting, its approximation illustrates another
reason to solely rely on its merits as a better management technique for T1DM.
While studies have shown a positive correlation between the establishment of a CIR and a strict
regimen of dietary patterns and self-monitoring glucose control (SMGC), the studies fail to
account for confounding variables found in various age groups (Wylie-Rosett, 2012). Did the
studies account for the various types of carbohydrates or insulins, individual activity levels, or
other conditions that affect the CIR? Such variables exist enough to question the results as a
strong recommendation for all insulin-dependent diabetics.
Corresponding studies have also explored that as adolescents emerge into adulthood, the
transition generates less routine and stability to manage their blood sugars. In turn, this lack of
routine produces poor glycemic control, especially within the workplace (Balfe, 2014). In terms
of flexibility, there are ongoing controversies with the CIR strategy used by many physicians
(Wylie-Rosett, 2012). For many physicians, using the CIR is better than other alternatives, but it
still lacks enough solid evidence for many to confidently use. There is also controversy regarding
the type of carbohydrate and whether that should affect the ratio for T1Ds in general (Bell,
2015). Furthermore, while following a CIR has shown glycemic-control improvements in
research, the studies do not establish a clear understanding of the effects of insulin’s interaction
with the type of carbohydrates on the blood sugar itself (Dias, 2010). Both the quantity, the type
and source of carbohydrate consumed have been known to influence the postprandial glucose
levels. Even with the various types of carbohydrates (monosaccharides, disaccharides,
oligosaccharides), many clinicians assume that the ‘total carbohydrate intake’ is a relatively
reliable predictor of postprandial glucose levels (Bell, 2015; Sheard, 2004). For other studies, the
prevailing fact remains that inaccurate carbohydrate counting is frequent among this
subpopulation and therefore associated with higher blood glucose variability (Brazeau, 2013).
Some studies have illustrated a non-linear relationship existing between the carbohydrate
consumed and the insulin required (Bell, 2015; Marran, 2013). Despite the positive impact of
insulin pump technology to support the management of the disease, complications continue to
ensue (Bell, 2015; Atkinson, 2014) and consequently point towards a more fundamental concern.
All the studies with various results indicate an overall uncertainty to establishing a CIR for
young adults that can be effectively utilized to manage their blood sugar levels and lifestyle. Due
to this uncertainty, the question should prompt the medical community to redirect the CIR from a
common strategy to another direction in the standard of care practices. This requires the focus to
be on implementation of dietary habits as they pertain to the individual’s lifestyle and behavioral
changes; meal planning, education on healthy eating, and management of BG levels during times
of sickness or exercise (Chiang, 2014; Matteucci, 2015) As clinicians, these changes can help
guide us through a fundamental truth – blood glucose levels in T1Ds will vary with increasing
unpredictability as the consumption of carbohydrate increases (Nielsen, 2012). Studies have
illustrated this truth by conducting experiments that reduce carbohydrate intake to a low
glycemic index and resulted in less insulin with an increase in overall glycemic control (Nielsen,
2012). Another study investigated the association between the types of carbohydrate intake and
the biomarkers of epithelial dysfunction and subsequent low-grade inflammation in T1Ds
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(Ceriello, 2012; van Bussel, 2013). With this in mind, the focus should be directed to educating
and implementing young adults with T1DM towards a more accommodating carbohydrate diet.
The European Journal of Clinical Nutrition published an article that provides a valuable
statement in the assessment of how clinicians should view carbohydrate intake for T1Ds.
“Although there is a close relationship between the amount of carbohydrate in a meal, pre-meal
short-acting insulin requirement and post-meal blood glucose response, not all types of
carbohydrates are fully metabolised to blood glucose. Moreover, there is a considerable intra-
and inter-individual variability of the absorption and metabolic effect of subcutaneously injected
insulin. Physical activity is also highly variable from day to day, and people with type 1 diabetes
have to adjust carbohydrate intake and insulin dosage to avoid hypoglycaemia.” (Matteucci,
2015, paragraph 11)
Recommendation 2: Educate and Implement Carbohydrate Types
The dietary and nutritional recommendations from each diabetic care provider will vary (Chiang,
2011). As stated by the ADA, “It is the position of the American Diabetes Association (ADA)
that there is not a “one-size-fits-all” eating pattern for individuals with diabetes. The ADA also
recognizes the integral role of nutrition therapy in overall diabetes management and has
historically recommended that each person with diabetes be actively engaged in self-
management, education, and treatment planning with his or her health care provider, which
includes the collaborative development of an individualized eating plan. Therefore, it is
important that all members of the health care team be knowledgeable about diabetes nutrition
therapy and support its implementation.” (Yancy, 2014, page 4)
Regardless of the type of diet, any regimen that requires less insulin while maintaining healthy
outcomes have shown to be highly successful (Matteucci, 2015; Paterson, 2011). In a past
comparison of ADA recommendations, there is a continual decrease in the suggested level of
carbohydrate intake, followed by the recommended level of carbohydrate intake according to
type. A minimum of 175 g carbohydrate/day (distributed throughout the day in three small- to
moderate-sized meals and two to four snacks) was still recommended in 2008 (Bantle, 2008),
whereas 2014 recommendations suggest that food choices should be based on current dietary
habits and preferences to effectively reach metabolic goals (American Diabetes Association,
2014). The use of high-fiber, low-glycemic index foods may be helpful in maintaining glycemic
goals, but the ADA has found insufficient evidence to support the use or non-use of low
glycemic diets for T1Ds (Franz, 2008). One proposed concern is that limiting carbohydrate
consumption to low glycemic foods will restrict T1Ds with dietary-flexibility and result in poor
adherence. However, successful studies have shown a positive correlation with educating
participants on food choices before implementing a low glycemic index (GI) diet (Bell, 2015).
Comparatively, other studies have also demonstrated that blood glucose results under the curve
were 20% lower after a low GI meal than a high GI meal containing the same amount of
carbohydrate (Parillo, 2011). A more recent RCT study has suggested that adjusting insulin for
glycemic load has shown to produce more accurate glycemic control than by adjusting for
carbohydrate content alone (Bozzetto, 2015). This study was also conducted on adults with
T1DM and provided results that are more relevant to the young adult population.
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In a greater effort to understand the positive results of many studies as they compare to the
recommendations given by the ADA, a few comparative studies have been conducted. N.D.
Barnard et al (2009) conducted an RCT study that compared the ADA’s recommended diet
(2003) to a low-fat vegan diet for diabetics (predominantly type 2 diabetics) for 74 weeks. The
results showed a significant difference in the decrease in medications, increase in weight loss and
overall lower HbA1c measures in the low-fat vegan group. Though reductions were also seen
from participants in the ADA study, the participants showed lower adherence and higher drop-
out rates. This suggested a difficulty with participants to adhere to required portion sizes
commonly found in the ADA recommendations. This comparative study among others illustrates
a need for the ADA to provide more specific recommendations on carbohydrate diets that are the
predominant determinant of glycemia and, therefore, insulin requirements. As the adolescent
youth emerge into young adulthood, the focus should be prioritized to replacing high GI
carbohydrates with low GI ones to improve diet quality and reduce a higher susceptibility to
periodic glucose excursions. Therefore, it is imperative that healthy eating remains central in
diabetes education, with an emphasis on selecting foods for their nutritional value rather than
based on their ease of carbohydrate quantification. Nutrition education needs to be frequently
reviewed and reinforced as patients move through the life stages, with simple and practical
advice to promote adherence (Smart, 2009).
Recommendation 3: HbA1c is Just an Average
The use of the HbA1c test as a diagnostic and evaluation of treatment has been considered a
‘gold standard’ for the medical community for over 20 years now (Sacks, 2011). Within that
time-frame, the ADA has altered the recommended A1C goals from one to goals associated with
various age groups. The traditional recommendations are an A1C goal of 8.5% for youth under
the age of 6 years, 8% for those 6–12 years old, and 7.5% for those 13–19 years old (Chiang,
2014). The HbA1c measurement expressing how much glucose is attached to the actual
hemoglobin. Since the average half-life of a hemoglobin is roughly 120 days, the lab results are
used to indicate a diabetics average 3-month glucose levels. A large RCT study funded by the
ADA concluded that HbA1c levels can be interpreted as the estimated average glucose (eAG) for
most patients with type 1 and type 2 diabetes (Nathan, 2008; Nathan, 2014). The results of this
study along with others have gone on to be utilized as the standard of medical care that in turn
judge the adequacy of diabetes treatment and adjust therapy.
The emergence of continuous glucose monitoring systems (CGMS) in medical technology has
started to shift the view of how the medical profession uses HbA1c to determine diabetic
treatment. The CGMS has helped to identify some fundamental drawbacks to utilizing HbA1c to
measure overall glycemic success as a standard for medical care. The availability of CGMS
quickly found its way into research that soon challenged the way HbA1c tests were viewed. In
2006, a study was conducted to find an association between blood glucose fluctuations and
complications associated to diabetes. Using a CGMS, the study found that HbA1c measures were
poor predictors for assessing acute blood glucose excursions. The results indicated that poor
glycemic control cannot be accurately assessed using only HbA1c measurements (McCall,
2006). Though further studies were needed at the time, the use of a CGMS in this study gave a
strong indication for it to become a highly sought-after tool for supporting the needs of diabetics.
In a systematic review and meta-analysis of randomized trials, studies indicated an overall higher
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success rate in glycemic control and lower HbA1c measures using real-time CGMS compared to
self-blood glucose measurement (SBGM) methods (Szypowska, 2012). In another systematic
review and meta-analysis directed towards adults found that utilizing a CGMS improved their
glycemic control and helped overcome common barriers associated with managing their
condition (Poolsup, 2013).
CONCLUSION
The time after adolescence and the transition to young adulthood for T1Ds is a dangerous and
challenging time-frame. It becomes imperative that young adults be better prepared to achieve
positive glycemic control in order to prevent long-term complications. Though the ADA
recognizes this subgroup of T1Ds as a challenging time, they strongly recommend making
specific plans with the family and healthcare provider team to help ease the difficult transition
(Chiang, 2014; Evert, 2014). Regardless of any recommendation provided, it becomes vital for
the healthcare provider to establish a relationship with the patient before they will adhere to
necessary changes that need to be implemented. It is just as important to understand how to
improve the patient-provider relationship as it is to know how to implement the best strategies to
effectively manage their condition. Studies have shown improvements in combining a
multidisciplinary diabetes self-management training (DSMT) and medical nutrition therapy
techniques (Chiang, 2014).
Adolescents face numerous obstacles that have strong associations to glycemic control. Another
strategy that has shown positive results among teens before emerging into adulthood is
“motivational interviewing.” This strategy along with the most effective intervention methods
can provide the best chances for success and ultimately maintain a healthier lifestyle (Boros,
2010). The three subtitles listed in the discussion section are provided as a more specific
consideration to the broad recommendations given by the ADA, but that are unique to the young
adult populations with T1DM. Further studies are needed to better grasp the various methods of
intervention that will provide the most effective results for this age group. As the CIR and
HbA1c measures are prioritized less compared to the carbohydrate diet that best fits the
individual’s lifestyle behaviors, the patient becomes more compliant with the clinician’s
recommendations.
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