Meeting Quality Standards for Self-Management Education in Pediatric Type 2 Diabetes Free

Curriculums should be developmentally focused to meet the educational needs of pediatric patients with type 2 diabetes.⁷  Because these youngsters are adolescents or sometimes school-age children, a two-pronged approach to curriculum formation is suggested, in contrast to curriculums for type 1 diabetes, which have traditionally included five levels of development based on cognitive developmental theory. Self-management teaching for adolescents should be child-focused, in contrast to self-management teaching for school-aged children, which involves a balance between the family and child.⁸ 

According to the national standards for DSME,⁹  a multidisciplinary instructional team is recommended for optimal educational intervention. Minimally, this team must consist of a registered nurse and a registered dietitian. Because weight reduction is a treatment focus in type 2 diabetes, the registered dietitian is an especially vital member of the instructional team. Other members of the multidisciplinary team may include family members, medical practitioners, certified diabetes educators, social workers, psychologists, exercise physiologists, and pharmacists.³ 

Scientific literature has been summarized in six quantitative reviews^10–15 and two integrative reviews^16,17 consistently suggesting that DSME has a moderate positive effect on various biological and psychosocial outcomes for individuals with type 2 diabetes. Only one review¹⁵ included studies with pediatric subjects. One integrative review of the literature addressed education in pediatric type 1 diabetes only.¹⁸ 

Diet instruction had large effects on psychological, knowledge, and compliance outcomes and a moderate effect on physical outcomes when pediatric and adult samples were combined in a meta-analysis of 93 published and unpublished studies from 1976 to 1986.¹⁵  Number of hours with an educator was associated with a significant decrease in hemoglobin A_1c (A1C), and DSME improved control in adults with type 2 diabetes when 31 published studies were combined in a more recent meta-analysis.¹⁴ Several reviews have suggested that DSME must be combined with behavioral strategies^15–17 and include follow-up with reinforcement^14,16,17 to achieve optimal outcomes. Randomized controlled trials of individual or group approaches to DSME are needed in the pediatric population with type 2 diabetes.

Before the education intervention, an individualized initial assessment of the child or adolescent with type 2 diabetes and his or her family should be completed.^3,4 The assessment includes questions pertaining to medical history, social history, diabetes knowledge, and readiness to learn(Table 1). Because minority youth are disproportionately affected,⁵  special attention to cultural background is important to obtain information about dietary influences and health beliefs or attitudes that will help to individualize the teaching plan. Although families may have family experience with the disease, they may have limited economic and social resources. Based on this specific information, suitable educational materials and interventions can be selected. Reassessment is important before each continuing education session.

Effective education plans are based on comprehensive assessment data. Once an assessment is completed, goals and content areas for teaching are identified. Published resources such as Diabetes Education Goals¹⁹  can be used. Age-appropriate goals for type 2 diabetes teaching sessions may be selected from this reference for either initial or continuing education with many goals applicable for youth as well as adults.

Based on reviews of the scientific literature, education interventions are most effective when they are combined with behavioral change strategies^16,17 and occur with an educator over an extended period of time.¹⁴  One approach would be for both the youth with diabetes and parent(s) or caregiver(s) to attend focused single-topic education sessions scheduled for no longer than 30-minute intervals. Opportunity for reinforcement of previous education is important to build into an education plan. Successful attainment of mutually defined self-management goals requires an ongoing effort for individuals with diabetes with support from their family and educator.

All 10 content areas identified in the national standards for DSME⁹  are applicable to pediatric patients with type 2 diabetes.³  However,not all 10 content areas must be addressed with every patient; teaching topics should be based on individual patient education needs. A DSME curriculum for children or adolescents with type 2 diabetes should be developmentally based and individualized based on the assessment. Content areas and specific topics applicable to pediatric patients with type 2 diabetes are shown in Table 2, although, practically,only a single content area might be addressed with the individual patient in an education session.

Youngsters and their parents need to have a fundamental understanding of the disease process for type 2 diabetes to have successful outcomes.⁸  Verbal explanation of the disease process is especially inadequate for teaching school-aged children or adolescents with type 2 diabetes. Concrete images,such as models of the human body or drawings of pathophysiology, are useful when describing the disease. Video recordings and workbooks need to be developed that depict images of youth with type 2 diabetes.

Medical nutrition therapy is one of the most important areas of diabetes education for all patients with type 2 diabetes.^4,7 Working with children and adolescents raises great difficulty when designing and implementing a nutrition program if the whole family does not participate. Youngsters have to eat what is available to them. When fast food, pizza, or junk food make up a family's main form of nutrition, it is extremely difficult for a child to make dietary changes. Consequently, it is important to involve the entire family in planning behavioral and lifestyle changes. Achieving nutritional goals begins with bringing home healthy foods for meals and snacks.⁴ 

Dietary changes should be focused on decreasing high-calorie, high-fat foods and increasing fruits, vegetables, and whole grains.²⁰  Fluid intake should be limited to water and beverages containing artificial sweeteners. Skipping meals and eating unhealthy between-meal snacks should be discouraged.²¹ Visual tools, such as food models and the new food pyramid, aid in the educational process. Many existing nutrition materials designed for use with adults with type 2 diabetes are suitable for use with pediatric patients.

Referral should be made to a dietitian who is knowledgeable about the nutritional needs of children and adolescents with diabetes.³  Children need adequate caloric intake for normal linear development. Therefore,promotion of weight maintenance for younger children is a primary goal to allow time for children to grow into their present weight. Dieting for pediatric type 2 diabetes patients is not generally recommended unless supervised by a pediatric dietitian.⁴  As with school-aged children, adolescents need ample caloric intake for pubertal growth spurts. However, if the growth spurt has already occurred, a recommended decrease of 250–500 calories daily is sufficient,⁹  and careful monitoring of growth is necessary. Dietary interventions for severely obese older adolescents with comorbid conditions should be individualized.²² 

Regular physical activity is another important content area for type 2 diabetes education.^3,7 Exercise helps to burn fat, increase energy expenditure, decrease comorbidities such as hypertension and dyslipidemia, and maintain weight loss. It not only has favorable effects on cardiovascular health and lipid status,but it also decreases insulin resistance, therefore helping to normalize blood glucose levels.⁷ 

Exercise programs should also involve the whole family and be enjoyable.⁴  Physical activities should start slowly and gradually increase in intensity as tolerance builds. For sedentary individuals, Beck et al.²³  suggest starting with a short walk of 15–20 minutes in duration a few times a week. These walks should progressively build up to 30-minute workouts 5–7 times a week while alternating to either increase duration or intensity. Parents can help children incorporate activity into their day by going on family walks or bike rides or playing ball in the yard. Individual activity should be encouraged instead of group sports because of decreased physical ability. Prolonged daily TV viewing and computer and electronic game playing should be limited.²¹ 

Only two pharmacological agents—insulin and metformin—are approved for use in pediatric type 2 diabetes. Insulin is approved for use with all pediatric patients, whereas metformin is only approved for children≥ 10 years of age.⁵  Other oral medications available for adults with type 2 diabetes, such as sulfonylureas,meglitinides, or thiazolidenediones, may be used in pediatric patitents,although the U.S. Food and Drug Administration has not approved these medications for use in children and adolescents.

Educational materials about insulin preparation and administration for pediatric patients with type 1 diabetes can also be used for teaching patients with type 2 diabetes. Written medication information about oral diabetes medications is useful for explaining the medication action, appropriate dosing, and side effects.

Pharmacological treatment for hypertension or hyperlipidemia may be prescribed. Written medication information should also be provided to explain the medication action, appropriate dosing, and side effects.

Self-monitoring of blood glucose (SMBG) is indicated for children and adolescents with type 2 diabetes to prevent and detect hypoglycemia, avoid severe hyperglycemia, adjust medications, and determine exercise and meal plan effects on blood glucose levels.⁷  Rationale;techniques of SMBG, including meter quality control; and use of results must be clearly taught. Based on the youngster's individual needs and goals, the timing and frequency of blood glucose testing is recommended by the practitioner.⁷  SMBG skills should be demonstrated, and return demonstrations should be observed when a new meter is prescribed.

A daily written glucose log is a good reference for assessing blood glucose goals and adjusting the medication regimen. Individuals can be taught to interpret data and respond to blood glucose patterns by adjusting food intake,exercise activity, and possibly pharmacological therapy to achieve optimal glucose control.⁷  It is also very important to educate individuals and families about how to deal with blood glucose fluctuations on sick days, especially for individuals who are taking insulin.

Routine follow-up care every 3–4 months is needed for youngsters being treated for type 2 diabetes to assess diabetes control and screen for any possible comorbid conditions and complications.²⁴ Youth with diabetes are able to understand a simple explanation of the meaning of A1C results and treatment goals for optimal diabetes control.

Acute complications. Recognition and treatment of hypoglycemia is important with insulin therapy or oral medications that stimulate insulin production, although youth with type 2 diabetes may not experience symptomatic low blood glucose because of insulin resistance.⁵ School-aged children and adolescents with type 2 diabetes who are at risk for developing hypoglycemia must be equipped with rapid-acting carbohydrate-containing foods or fluids for treatment of hypoglycemia. Personalized strategies for safely dealing with hypoglycemia can be developed during the education session.

Chronic complications. All practitioners should educate individuals with diabetes about the seriousness of chronic hyperglycemia.² Youngsters are at greater risk for developing complications because of the early age of disease onset. Complications may even be present at the time of diagnosis.⁵  With the increasing numbers of youth developing the disease, the consequences for patients, health care professionals, and economic resources will be catastrophic if proper interventions are not implemented in a timely manner. Young people have the advantage of being able to adopt optimal lifestyle behaviors early in life to prevent heart, dental, and eye disease; skin disorders; and foot complications. The significance of foot examinations among school-aged children and adolescents is unclear, but these examinations are inexpensive, fast, and can be a good time for education of proper foot care;therefore, they should not be excluded.³ 

Goal setting. Lifestyle modification is needed to meet therapeutic goals successfully. Contracting is useful for setting mutually defined goals related to daily activities, such as SMBG, healthy eating,regular physical exercise, and accurate, safe medication use. Goal statements are written in measurable and attainable terms within a realistic time frame and evaluated at follow-up appointments.³ 

Effective problem-solving of day-to-day issues in the self-management of diabetes is important for youth with type 1 or type 2 diabetes. Emotional support for children and families is integral to lifestyle change.²¹ Evaluation of the teaching process should incorporate assessment of ability to safely apply information from DSME to everyday living.

Psychosocial adjustment. Transition to independent self-care is a goal in late adolescence. The peak age of onset for pediatric type 2 diabetes is adolescence.⁴ Adolescence is a difficult time and is complicated by demands of chronic illness. Youth diagnosed with diabetes face many psychosocial issues that are compounded by a regimen with complex care requirements, which renders success at optimal self-care a daily challenge.

Many youngsters with type 2 diabetes follow their treatment regimen strictly at diagnosis, but later rebel and refuse to comply.⁴  During this time in life, blood glucose becomes increasingly harder to control, perhaps because of the negative effects of growth hormone on insulin usage.³  Feelings of frustration may precipitate a desire to refuse to adhere to the treatment plan. Adolescents with diabetes may also struggle with fitting in with their peers, and when diabetes is associated with obesity, additional issues of negative self-image and self-esteem make coping more difficult. All teenagers need to be educated about the dangers of smoking and alcohol use. Teenagers with diabetes can learn how smoking and alcohol use are especially problematic for someone with diabetes.

Practitioners are in a position to help teenagers develop the skills they need to overcome the frustrations of life during this time. The multidisciplinary team needs to support individuals and their family members in exploring potential barriers to self-care and strategies to overcome them. Frequent contact with educators or referral to a psychologist or mental health professional may be helpful.

Preconception care. Education about pregnancy prevention and safe sex is the same for teens with type 2 diabetes as it is for teens with type 1 diabetes.²⁴ Excellent diabetes control is a prerequisite for healthy pregnancy outcomes. For young women taking oral diabetes medications, pregnancy must be avoided because of risk from teratogenic drug effects. Education about preconception care involves discussion about specific measures to either abstain from sex or use contraception.

Few curriculums and educational materials have been published that are specifically targeted to youngsters with type 2 diabetes. Children are not simply small adults, so pediatric materials and methods must be developed and tested with this population. An annotated bibliography of selected available written and web-based educational material is presented in Table 3. Currently, there is not a single reference that completely addresses every topic area. Consequently, additional material would be useful to meet the needs of this population.

Type 2 diabetes among youth is a significant clinical problem for practitioners treating pediatric patients. This relatively new phenomenon,especially in school-aged children, remains poorly investigated, especially in terms of the effectiveness of interventions for DSME in this population. Until data from pediatric type 2 diabetes education studies are available,approaches to lifestyle change that are known to be effective with obese children without diabetes may be useful. During the past decade, treatment regimens have been designed to mimic that of adult patients with the same disease. The goal of therapy is to normalize blood glucose and A1C levels,promote weight control, and control any comorbidities that may develop. Successful treatment plans for pediatric patients with type 2 diabetes include multiple lifestyle changes, increased physical activity, and diet modification, as well as improvement in quality of life and maintenance of normal growth and development. Primary prevention, rather than management, of obesity and type 2 diabetes in youth is the ultimate goal in our society.