U.S. Department of Health and Human Services
Indian Health Service: The Federal Health Program for American Indians and Alaska Natives
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Sunday, November 23, 2014

Division of Diabetes Treatment and Prevention - Leading the effort to treat and prevent diabetes in American Indians and Alaska Natives


Standards of Care and Clinical Practice
Recommendations: Type 2 Diabetes

Last updated: July 2012

Youth and Type 2 Diabetes

AI/AN youth have the highest prevalence rate of type 2 diabetes compared with youth of all other racial and ethnic groups in the U.S. Among AI/AN youth ages fifteen to nineteen, the prevalence of diabetes was 6.81 per 1000 in 2009. From 1990 to 2009, diabetes prevalence in this age group more than doubled – from 3.24 per 1000 in 1990 to 6.81 per 1000 in 2009, a 110% increase. Providers need to consider several important differences in approaches to testing and treatment of youth with diabetes, as compared with adults.

Clinical Practice Recommendations

Youth and Type 2 Diabetes

recommendations icon Recommendations for Testing for Type 2 Diabetes in Youth

  • Test overweight (BMI > 85th percentile) AI/AN youth with any of the following risk factors:
    • Family history of diabetes.
    • Signs of insulin resistance or conditions associated with it (e.g., acanthosis nigricans, PCOS, hypertension, dyslipidemia, small-for- gestational-age (SGA) or large-for-gestational-age (LGA) birth weight).
    • Maternal history of diabetes or gestational diabetes during child’s gestation.
  • Start testing these higher risk children at age 10 years (or younger if puberty occurs earlier).
  • Test at-risk children ≤ every 3 years.

treatment icon Treatment Issues for Diabetes in Youth

AI/AN youth with type 2 diabetes are at risk for developing or may even present with the same comorbidities as adults. Therefore, it is essential to measure blood pressure, blood lipids, and urine albumin upon diagnosis. While much of diabetes management for youth is similar to that for adults, there are a few differences to be aware of.

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Glycemic Control

recommendations icon Recommendations for Glycemic Control in Youth

  • Glycemic control targets for youth with type 2 diabetes are:
    • A1C < 8% for ages 6 to 12 years
    • A1C < 7.5% for ages 13 to 19 years.
  • The only FDA-approved diabetes medications for use in children are metformin and insulin. While other medications are sometimes used in clinical practice, there is less evidence to support their use, and that use would be off-label.

All targets and medication regimens need to take into consideration not only the age of the child but also adverse effects of medications such as hypoglycemia, the amount of appropriate and consistent adult assistance, and family resources.

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Blood Pressure Control

recommendations icon Recommendations for Blood Pressure (BP) Control in Youth

  • Screen youth with type 2 diabetes for hypertension at diabetes diagnosis and at every diabetes visit.
  • Consider pharmacologic treatment for patients with blood pressure (BP) > 95th percentile for gender, age, and height; or > 130/80 mmHg – whichever is less.
    • ACE inhibitors and ARBs are FDA-approved for treating hypertension in children.

Unlike in adults, BP norms in youth vary by gender, age, and height. To determine a patient’s BP percentile, categorized by gender, age, and height, use these tables Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]  developed by the National Heart, Lung, and Blood Institute. Once the BP percentile is obtained, use the table below to classify and diagnose hypertension in children and adolescents.

Classification of Blood Pressure in Children and Adolescents

Blood Pressure Category Definition

Source: National Heart, Lung, and Blood Institute, National Institutes of Health. Blood Pressure Tables for Children and Adolescents from the Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents, 2004. Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]

Normal < 90th percentile
Prehypertension 90th-95th percentile or 120/80 mmHg
Hypertension Stage 1 95th-99th percentile + 5 mmHg
Hypertension Stage 2 > 99th percentile + 5 mmHg
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Chronic Kidney Disease (CKD)

recommendations icon Recommendations for Chronic Kidney Disease in Youth

  • Order a UACR and eGFR at diabetes diagnosis and then at least annually:
    • In youth < 18 years of age, use the Bedside Schwartz equation to calculate eGFR: GFR (mL/min/1.73 m2) = (0.41 × Height in cm)/Creatinine in mg/dL.
    • An easy-to-use Bedside Schwartz equation calculator. Exit Disclaimer: You Are Leaving www.ihs.gov
  • Consider treatment with an ACE inhibitor for youth with albuminuria.

Youth should be screened for chronic kidney disease using the same two screening tests used in adults: eGFR and UACR. There is no difference in UACR testing between adults and youth. However, while eGFR in adults with diabetes is calculated using the MDRD equation, this equation is not accurate in youth. Instead, the Bedside Schwartz equation should be used to calculate eGFR in patients < 18 years of age.

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Resources

Tools for Clinicians and Educators

tools and resources icon Key Tools and Resources

Chronic Kidney Disease (CKD)

IHS Division of Diabetes Treatment and Prevention. Indian Health Diabetes Best Practice—Youth and Type 2 Diabetes Prevention and Treatment, 2011. [PDF - 401KB]

Flint A and Arslanian S. Treatment of Type 2 Diabetes in Youth. Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]  Diabetes Care. 2011;34:Suppl 2, S177-83.

International Diabetes Federation. International Society for Pediatric and Adolescent Diabetes. Global IDF/ISPAD Guideline for Diabetes in Childhood and Adolescence. 2011. Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]

additional resources icon Additional Resources

Centers for Disease Control and Prevention.

  • CDC Clinical Growth Charts. Exit Disclaimer: You Are Leaving www.ihs.gov
    The revised growth charts consist of 16 charts (eight for boys and eight for girls). These charts represent revisions to the 14 previous charts, as well as the introduction of two new body mass index-for-age (BMI-for-age) charts for boys and for girls, ages two to 20 years. 2000.
  • CDC Growth Chart Training Modules. Exit Disclaimer: You Are Leaving www.ihs.gov
    Offers a set of self-directed, interactive training modules for health care professionals using the pediatric growth charts in clinical and public health settings to assess growth of infants, children, and adolescents. 2000.
    • Overview of the CDC Growth Charts
    • Using the BMI-for-age Growth Charts
    • Overweight Children and Adolescents: Recommendations to Screen, Assess and Manage.

Envision New Mexico, University of New Mexico Health Sciences Center Department of Pediatrics

  • Pediatric Nutrition Telehealth (PNT). Exit Disclaimer: You Are Leaving www.ihs.gov
    Web-based presentations help nutrition providers develop their skills in pediatric nutrition assessment, MNT, counseling, and working with individuals on treatment goals.

Indian Health Service Division of Diabetes Treatment and Prevention.

  • Youth Staying Healthy: A Type 2 Diabetes Curriculum for Teens
    This curriculum and CD ROM provides health professionals working with American Indian and Alaska Natives with a framework for diabetes education for adolescents, ages 13-18; can be used one-on-one or in group settings. The curriculum provides basic information about type 2 diabetes and general wellness for adolescents. 2010.
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Patient Education Materials

Indian Health Service Division of Diabetes Treatment and Prevention.

  • Gen 7.
    A magazine to help American Indian and Alaska Native teens prevent and manage diabetes.
  • Teens Talk About Diabetes.
    A DVD video about four American Indian teens who talk about having type 2 diabetes.

National Diabetes Education Program.

Substance Abuse and Mental Health Services Administration (SAMHSA).

U. S. Department of the Interior.

  • Let’s Move! In Indian Country. Exit Disclaimer: You Are Leaving www.ihs.gov
    First Lady Michelle Obama and four federal agencies have launched Let’s Move! in Indian Country to support and advance work to improve the health of American Indian and Alaska Native children.
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Bibliography

Acton KJ, Burrows NR, Moore K, Querec L, Geiss LS, Engelgau MM. Trends in diabetes prevalence among American Indian and Alaska Native children, adolescents, and young adults. Exit Disclaimer: You Are Leaving www.ihs.gov Am J Public Health. 2002 Sep;92(9):1485-90.

Dabelea D, DeGroat J, Sorrelman C, Glass M, Percy CA, Avery C, et al. Diabetes in Navajo youth—prevalence, incidence and clinical characteristics: the SEARCH for Diabetes in Youth Study. Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]  Diabetes Care. 2009;32(2) Suppl:S141-7.

Dabelea D, Mayer-Davis EJ, Lamichhane AP. Association of intrauterine exposure to maternal diabetes and obesity with type 2 diabetes in youth: the SEARCH Case-Control Study. Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]  Diabetes Care. 2008;31(7):1422-6.

Dabelea D, Pihoker C, Talton JW, D'Agostino RB Jr, Fujimoto W, Klingensmith GJ, et al.; SEARCH for Diabetes in Youth Study. Etiological approach to characterization of diabetes type: the SEARCH for Diabetes in Youth Study. Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]  Diabetes Care. 2011 Jul;34(7):1628-33.

Dart AB, Sellers EA, Martens PJ, Rigatto C, Brownell MD, Dean HJ. High burden of kidney disease in youth-onset type 2 diabetes. Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]  Diabetes Care. 2012 Jun;35(6):1265-71. Epub 2012 Mar 19. Exit Disclaimer: You Are Leaving www.ihs.gov

Flint A, Arslanian S. Treatment of type 2 diabetes in youth. Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]  Diabetes Care. 2011 May;34 Suppl 2: S177-83.

Indian Health Service diabetes care and outcomes audit, unpublished data. Albuquerque (NM): Department of Health and Human Services (US), Indian Health Service, Office of Clinical and Preventive Services, Division of Diabetes Treatment and Prevention; 1990-2009.

IHS Division of Diabetes Treatment and Prevention. Indian Health Diabetes Best Practice—Youth and Type 2 Diabetes Prevention and Treatment, 2011. [PDF - 401KB]

International Diabetes Federation. International Society for Pediatric and Adolescent Diabetes. Global IDF/ISPAD Guideline for Diabetes in Childhood and Adolescence. 2011. Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]

Krebs NF, Himes JH, Jacobson D, Nicklas T, Guilday P, Styne D. Assessment of child and adolescent overweight and obesity. Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]  Pediatrics. 2007 Dec 1;120 Suppl 4:S193-228.

Moore K. Youth – Onset type 2 diabetes among American Indians and Alaska Natives. Exit Disclaimer: You Are Leaving www.ihs.gov J Public Health Manag Pract. 2010;16(5):388-93.

National High Blood Pressure Education Program. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]  Bethesda (MD): National Heart, Lung, and Blood Institute (US); 2005 May. (NIH Publication No. 05-5267).

Peterson K, Silverstein J, Kaufman F, Warren-Boulton E. Management of type 2 diabetes in youth: an update. Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]  Am Fam Physician. 2007 Sep 1;76(5):658-64.

Reynolds K, Liese AD, Anderson AM, Dabelea D, Standiford D, Daniels SR, 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. Exit Disclaimer: You Are Leaving www.ihs.gov J Pediatr. 2011 Apr;158(4):594-601.e1. Epub 2010 Dec 3. Exit Disclaimer: You Are Leaving www.ihs.gov

Rosenbloom AL, Silverstein JH, Amemiya S, Zeitler P, Klingensmith G. Type 2 diabetes in children and adolescents. Exit Disclaimer: You Are Leaving www.ihs.gov [PDF]  Pediatric Diabetes. 2009;10 Suppl 12: 17-32.

TODAY Study Group, Zeitler P, Hirst K, Pyle L, Linder B, Copeland K, Arslanian S, et al. A clinical trial to maintain glycemic control in youth with type 2 diabetes. N Engl J Med. 2012 Jun 14;366(24):2247-56. Epub 2012 Apr 29. Exit Disclaimer: You Are Leaving www.ihs.gov

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Division of Diabetes Treatment and Prevention | Phone: (505) 248-4182 | Fax: (505) 248-4188 | diabetesprogram@ihs.gov