Spotlight Case

1. Spotlight Case Adolescent Diabetes: A Routine Visit?

2. Source and Credits • This presentation is based on the February 2010 AHRQ WebM&M Spotlight Case • See the full article at http://webmm.ahrq.gov • CME credit is available • Commentary by: Gail B. Slap, MD, MSc, Children’s Hospital of Philadelphia • Editor, AHRQ WebM&M: Robert Wachter, MD • Spotlight Editor: Bradley A. Sharpe, MD • Managing Editor: Erin Hartman, MS

3. Objectives At the conclusion of this educational activity, participants should be able to: • Appreciate the increasing prevalence of obesity and type 2 diabetes mellitus (T2DM) among adolescents in the United States • Understand the screening, diagnostic, and management guidelines for T2DM in adolescents • Appreciate the importance of rapport, confidentiality, non-verbal cues, and hidden agenda to adolescent health care and health outcome • Know the components and basic principles of the adolescent sexual history • Review some common errors in the care of adolescent patients and strategies to prevent them

4. Case: Adolescent Diabetes A 15-year-old adolescent presented to her pediatrician for ongoing management of type 2 diabetes mellitus (T2DM). The girl had been overweight for most of her childhood and continued to gain weight in her early teen years. Her BMI of 29 placed her in the upper 99th percentile for her age and sex.

5. Case: Adolescent Diabetes (2) She had presented to the clinic 18 months earlier with fatigue and polyuria. At the time she had an elevated fasting blood sugar and hemoglobin A1c (a serum marker indicating elevated blood sugar levels for many months) and was diagnosed with Type 2 diabetes. She was treated with long-acting insulin (glargine), short-acting insulin (aspart), and an oral agent (exenatide). This clinic visit was part of routine follow-up for her diabetes.

6. Defining Overweight & Obesity • In adults (19 years and older), overweight is defined as BMI ≥ 25 and obesity as BMI ≥ 30 • In adolescents and youth aged 2–19, overweight is BMI ≥ 85th percentile for age and sex and obesity is BMI ≥ 95th percentile See Notes for reference.

7. Adolescent Obesity • Obesity among adolescents in the United States is increasing • According to one national survey, obesity among adolescents aged 12–19 years increased from 5.0% in 1976–80 to 17.6% in 2003–2006 • The trends are likely explained by higher caloric intake and lower physical activity See Notes for references.

8. Type 2 Diabetes in Adolescents • Type 2 diabetes mellitus (T2DM) in adolescents is also increasing • T2DM accounts for 20% of all new cases of diabetes in youth aged 10–19 years • Minority groups are disproportionately affected—T2DM comprises 46%–86% of all new cases of diabetes in minority youth See Notes for references.

9. Diabetes in Adolescents • Both type 1 diabetes mellitus (T1DM) and T2DM present with symptoms of hyperglycemia including polyuria, polydipsia, weight loss, and blurred vision • The factors associated with T2DM (as opposed to T1DM) in adolescents include: • Non-white race • Age older than 10 years • Overweight or obesity • T2DM in a 1st- or 2nd-degree relative

10. Who Should be Tested for Diabetes? • Overweight children and adolescents • BMI > 85th percentile for age and sex; weight for height > 85th percentile; or weight > 120% of ideal for height • With any two of the following risk factors: • Family history of T2DM in 1st- or 2nd-degree relative • Race/ethnicity of Native American, African American, Latino, Asian American, or Pacific Islander • Signs of insulin resistance or conditions associated with insulin resistance (e.g., acanthosis nigricans, hypertension, dyslipidemia, polycystic ovary syndrome, or small-for-gestational-age birthweight) • Maternal history of diabetes or gestational diabetes

11. Treating T2DM in Adolescents • Education (about diet, exercise, etc.) should begin at diagnosis for all patients • Metformin is first-line pharmacotherapy for those with mild symptoms and no ketosis • For adolescents with more severe symptoms or uncontrolled hyperglycemia, insulin can be added • Some providers will prescribe another oral hypoglycemic agent before adding insulin to metformin

12. Case: Adolescent Diabetes (3) The girl had often been a challenging historian, providing conflicting or sometimes vague answers to questions. On this visit, she complained of intermittent abdominal pain for a few days but could not be more specific. She complained that her acne had worsened and requested treatment for it. In screening for polycystic ovarian disease, she stated her periods were always regular and she had no new or excessive hair in a male pattern of distribution. She mentioned that 2 days earlier she had accidentally “peed my pants” but did not know why. The rest of the review of systems was unremarkable.

13. Case: Adolescent Diabetes (4) On physical examination, she was a quiet, depressed morbidly obese girl in no distress. She had acanthosis nigricans on her neck, groin, and axilla and severe acne on her face. Abdominal examination was limited by obesity, but was non-tender and no masses or enlarged organs were palpated. The rest of the examination was unremarkable. Laboratory studies revealed that her hemoglobin A1c remained elevated. She was prescribed a topical cream for acne and her insulin was increased slightly. She was told to watch her menstrual cycles closely and call back if they were noted to be irregular or if the abdominal pain worsened.

14. Case: Adolescent Diabetes (5) The following day, the pediatrician’s office received a call from an obstetrician reporting that the patient had delivered a healthy baby girl by Caesarian section in the early hours of the morning. The gestational age was thought to be around 34 weeks. The pediatrician realized that the patient’s abdominal pain may have been contractions and that the incontinence may have been amniotic fluid (“water breaking”).

15. Case: Adolescent Diabetes (6) On further history, the adolescent girl stated that she had been raped 7 months earlier and was afraid to tell anyone. She and her family were provided appropriate counseling and resources.

16. The Adolescent Patient • In adolescent patients, reticence, conflicting information, or symptoms without clear explanation may indicate an unwillingness or inability to discuss difficult topics • Addressing confidentiality may help—adolescents who are assured confidentiality are more likely to disclose personal information about sexuality, mental health, and substance use See Notes for reference.

17. The Sexual History in Adolescents • The CDC recommends a sexual history and testing for sexually transmitted infections and pregnancy in all females with unexplained abdominal pain or urinary symptoms • Despite these recommendations, sexual histories in adolescents are sometimes inappropriately omitted See Notes for references.

18. The Sexual History in Adolescents (2) • In obtaining a sexual history from an adolescent, providers should ensure confidentiality, be comfortable, be respectful, and avoid jargon or unclear terminology • The clinician should be prepared to ask specific, open-ended questions regarding: • Oral, vaginal, and anal intercourse • Age of first intercourse and number of partners • Use of condoms or other birth control • Sex by force; coercion; or in exchange for money, food, or shelter

19. Teen Pregnancy • After a 30% decline in teen pregnancy rates from 1991 to 2005, rates are again on the rise • Pregnancy rates in teenagers may be threefold higher in minority groups • Teen mothers are less likely to receive prenatal care and more likely to deliver prematurely See Notes for references.

20. Teen Pregnancy (2) • Teenagers are less likely to recognize or acknowledge pregnancy • In one hospital, in adolescents in whom pregnancy was diagnosed, less than 10% had mentioned the possibility and 10.5% denied a history of sexual intercourse See Notes for reference.

21. Sexual Abuse in Adolescence • Rates of sexual abuse peak during adolescence • In a meta-analysis, a history of childhood sexual abuse increased the odds of teen pregnancy 2.2-fold • The analysis estimated that 45% of pregnant teens have a history of sexual abuse See Notes for references.

22. Summary • This adolescent presented with issues that are disturbingly common yet often unrecognized • Remaining alert to population trends and individual cues may help providers care for adolescents with greater sensitivity, efficiency, and effectiveness

23. Take-Home Points • The rates of overweight, obesity, and T2DM are increasing among US adolescents • In children and adolescents, the incidence of T2DM is highest among 15–19 year-old females of Native American, Asian/Pacific Islander, African American, and Hispanic descent • Management of T2DM in adolescents begins with education about diet, exercise, body weight, and glucose monitoring • Metformin and insulin are the only medications for T2DM approved in the US for patients younger than 18 years

24. Take-Home Points (2) • The sexual history is an essential component of adolescent health care • Principles that facilitate the history include confidentiality, clinician comfort, respect for sexual diversity, avoidance of jargon, and knowledge about local resources related to adolescent sexual health • Adolescents are less likely than adults to recognize or acknowledge pregnancy, even when seeking care for pregnancy-related symptoms • Sexual abuse in the US peaks during adolescence and is associated with a two-fold increased risk of pregnancy