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DOI: 10.1177/000992280504400503 2005; 44; 393 Clin Pediatr (Phila)

Stuart A. Weinzimer, Elizabeth A. Doyle and William V. Tamborlane, Jr Strategies

Disease Management in the Young Diabetic Patient: Glucose Monitoring, Coping Skills, and Treatment

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Introduction

Both type 1 and type 2 dia-betes mellitus are increas-ingly important health

problems in children and adoles-cents today.1 Type 1 diabetes (ju-venile or insulin-dependent dia-betes) is due primarily to insulin

deficiency caused by autoimmunedestruction of the pancreatic betacells. During adolescence, or incases of poor control, superim-posed insulin resistance directlyinfluences the amount of insulinneeded for glucose control andcomplicates diabetes manage-ment.2 The major pathogenic fac-

tor in type 2 diabetes (adult-onsetor non–insulin-dependent dia-betes) is insulin resistance, result-ing in a functional or relative in-sulin deficiency.1 The complexmolecular events that lead to theevolution of type 2 diabetes melli-tus are not completely under-stood, especially in the pediatricpopulation.1 Historically, type 1diabetes was considered the pri-mary form of diabetes found inchildren.3 Today, however, 8% to46% of newly diagnosed cases ofdiabetes in children are type 2(Table 1).4,5 This surge in the inci-dence of type 2 diabetes has beendescribed as an epidemic.6

This review will discuss strate-gies for treating young patientswith diabetes, focusing on a treat-ment regimen that includes diet,

JUNE 2005 CLINICAL PEDIATRICS 393

Disease Management in the Young DiabeticPatient: Glucose Monitoring, Coping Skills,and Treatment Strategies

Stuart A. Weinzimer, MD1

Elizabeth A. Doyle, MSN, APRN, CDE1

William V. Tamborlane, Jr, MD1,2

Summary: Type 1 diabetes mellitus was thought to be the prevalent type of diabetes in children andadolescents; however, increasing numbers of juvenile patients appear to have type 2 diabetes.Management of all diabetes in young patients should include regular assessment, carefulmonitoring for glycemic control and the presence of hypoglycemia, and educational training on dis-ease management. Hypoglycemic episodes, especially nocturnal events, are frequent in the youngdiabetic patient. Improvements in glycemic control and nocturnal hypoglycemia have beenobserved with continuous subcutaneous insulin infusion and insulin glargine. A continuous glucose-monitoring system can provide important insight into 24-hour glycemic control. Overall, carefulmanagement, monitoring, and education can improve glycemic control and yield positive treatmentoutcomes in the child or adolescent with diabetes. Clin Pediatr. 2005;44:393-403

1Department of Pediatrics, Yale University School of Medicine, New Haven, CT; 2The GeneralClinical Research Center, Yale University, New Haven, CT.

Supported by grants from the National Institute of Health: K12 DK063709 (SAW), MO1RR00125 (WVT), and U01 HD 41096 (SAW, WVT); the Juvenile Diabetes Research Foundation(SAW, WVT), and the Stephen I. Morse Pediatric Diabetes Research Fund.

Reprint requests and correspondence to: Stuart A. Weinzimer, MD, Assistant Professor,Department of Pediatrics, Yale University School of Medicine, 333 Cedar Street, PO Box208064, New Haven, CT 06520.

© 2005 Westminster Publications, Inc., 708 Glen Cove Avenue, Glen Head, NY 11545, U.S.A.



Weinzimer, Doy l e , Tambor lane

exercise, pharmacologic inter-vention, monitoring of glycemiccontrol, and education/copingskills.

Diabetes in Adolescents

The major landmark clinicaltrials in diabetes, the DiabetesControl and Complications Trial(DCCT) in patients with type 1diabetes and the United King-dom Prospective Diabetes Study(UKPDS) in patients ≥20 years of

age with type 2 diabetes, pro-vided strong evidence that inten-sive therapy with pharmacologicagents (insulin and oral antidia-betic agents) was needed toachieve lower daily blood glucoselevels and limit diabetic compli-cations. The increasing inci-dence of diabetes, especially inthe adolescent and pediatricpopulation, suggests that the par-adigms for treating diabetes inthe young (standard basal/bolustherapy in type 1 patients) mustchange so that young patients

with type 2 diabetes are also con-sidered. These changes can bemade by adopting the principleof intensive therapy as used in theDCCT and the UKPDS. Cur-rently, there are many agents (in-sulin, insulin analogs, oral antidi-abetic agents) and deliver ydevices and systems (insulinpumps, insulin pens, and contin-uous glucose sensors) for thetreatment of young patients withtype 1 or type 2 diabetes to safelycontrol daily blood glucose levelsand limit quality of life issues.

394 CLINICAL PEDIATRICS JUNE 2005

Table 1

ESTIMATES OF THE MAGNITUDE OF TYPE 2 DIABETES IN NORTH AMERICAN CHILDREN

Study Type Date Race/Ethnicity Age (y) Estimated Magnitude

Population-based Prevalence/1,000Arizona 1992–1996 Pima Indians 10–14 22.3

15–19 50.9Manitoba 1996–1997 First Nations 10–19 36.0 in girlsNHANES III (all US) 1988–1994 Whites, African Americans,

Mexican Americans 12–19 4.1*

Clinic-based Prevalence/1,000Indian health services (all US) 1996 Native Americans 0–14 1.3*

15–19 4.5*Manitoba 1998 First Nations 5–14 1.0

15–19 2.3

Clinic-based Annual Incidence/100,000Cincinnati, OH 1994 Whites, African Americans 10–19 7.2

Case series Percentage of type 2 diabetes cases amongall new diabetes cases

Cincinnati, OH 1994 Whites, African Americans 0–19 16Charleston, SC 1997 African Americans 0–19 46†

San Diego, CA 1993–1994 Whites, African Americans, Hispanics, Asian Americans 0–16 8

San Antonio, TX 1990–1997 Hispanics, Whites 0–19 18Ventura, CA 1990–1994 Hispanics 0–17 45

*Estimates include type 1 and 2 diabetes.

†Percentage of type 2 diabetes among nonincident cases of diabetes.

Adapted from Fagot-Campagna et al.5

NHANES III = Third National Health and Nutrition Examination Survey.



Diabe t e s Management in Juveni l e s

Young Patients with Type 1 Diabetes

Continuous SubcutaneousInsulin Infusion

In the 1970s, the technologyfor the delivery of continuous ex-ogenous insulin via battery-pow-ered pumps for the managementof type 1 diabetes was intro-duced.7,8 However, in 1998, lessthan 5% of patients starting ther-apy with continuous subcuta-neous insulin infusion (CSII)were under 20 years of age despitethe benefits offered by this innov-ative approach.9,10 The reasonsfor this low acceptance rate ofCSII in young patients vary frompsychosocial issues to cost.9,11

Perhaps the most critical bar-rier to the greater use of CSII inthe young was the lack of clinicalevidence correlating tight gly-cemic control and long-term ben-efits.12 However, a subpopulationanalysis of young diabetic patients(13–17 years of age) within theDCCT demonstrated the associa-tion between stringent glucosecontrol and significant benefitwith respect to both primary andsecondary prevention of long-term complications of type 1 dia-betes.13 The dramatic increase inthe number of children and ado-lescents starting on CSII therapytoday is due at least partly to thefindings of this study.12

CSII can be offered as a treat-ment alternative to multiple dailyinjections (MDI) of insulin in pe-diatric patients who are motivatedto reach tight glucose controlgoals, who measure blood glucoseat least 4 times per day, who expe-rience repetitive episodes of hy-poglycemia, particularly at night,and/or who desire increased flex-ibility for the amount and timingof meals and exercise.12,14 Com-pared with injection therapy, CSIIin this population has been suc-

cessful in achieving both meanglycosylated hemoglobin (HbA1c)concentrations of 7.5% and de-clines in severe hypoglycemia. Ac-ceptance of CSII is high, andmore than 98% of children whostarted on this therapy remainedon it.12 CSII has also been re-ported to decrease the rate of dia-betic ketoacidosis in young pa-tients with uncontrolled disease.10

A prospective study in adoles-cents evaluated the clinical andpsychosocial outcomes of CSIIand MDI of insulin over 12months.9 After 1 year, young pa-tients with type 1 diabetes treatedwith CSII needed significantly lessinsulin than those who used MDI(P=0.009).9 Both groups exhib-ited significantly decreased HbA1c

concentrations over the course ofthe study (P<0.02) vs. baseline.However, from 6 to 12 months,HbA1c concentrations reboundedmodestly in patients treated withMDI but not in those treated withCSII.9 CSII was associated with areduction of approximately 50%in hypoglycemic episodes result-ing in coma or requiring assis-tance compared with MDI. TheMDI-treated group experiencedmore weight gain and had moredifficulty in coping with diabetesthan did the CSII-treated group.9

Two recent reports15,16 illus-trate that even outside of a clinicalresearch experience, CSII can besuccessfully implemented andmaintained in a busy office prac-tice. In the first report,15 161 chil-dren with type 1 diabetes, 18months to 18 years of age, wereswitched from traditional mixed-dose insulin regimens to insulinpump therapy. HbA1c concentra-tions fell from 7.1% to 6.5% inpreschoolers, from 7.8% to 7.3%in school-age children, and from8.1% to 7.4% in adolescents dur-ing the first year on pump ther-apy. Simultaneously, rates of se-

vere hypoglycemia dropped sig-nificantly, from 56 to 38 episodesper 100 patient-years. These im-provements were sustained for upto 2.5 years of follow-up. Theanalysis of very young children(<7 years of age) was extendedand demonstrated that improve-ments in HbA1c and rates of se-vere hypoglycemia persisted forup to 4 years after pump initia-tion. Furthermore, children whoreceived daytime care from nan-nies or daycare centers benefitedthe most from CSII, showing thatpump care could be easily taughtto alternate care providers.16

Using CSII at night may be aviable treatment alternative forchildren who experience largefluctuations in nocturnal bloodglucose levels but do not wish touse a pump during the day. Anevaluation of 10 preadolescentchildren (7–10 years of age) withpoorly controlled diabetesdemonstrated a significant de-crease in mean average, breakfast,and 3 AM glucose levels with CSIIonly at night compared with MDI therapy during the day(P<0.003).17 Overall, in appropri-ately selected young diabetic pa-tients, CSII improves quality of life,disease knowledge, adherence totreatment regimens, and responsi-bility for diabetes management.17

Injection of Insulin AnalogsAlthough the success of CSII

has been documented, many pa-tients require or request other op-tions. Injectable insulin therapycan quickly restore glycemic con-trol, but the biochemical changesassociated with puberty that in-duce peripheral resistance to in-sulin18 typically make larger dosesnecessary, increasing the risk ofweight gain and/or unpre-dictable hypoglycemia.9 Insulinanalogs—such as insulin lispro,insulin aspart, and insulin





glargine modified for specificuses, either for prandial or basalinsulin needs—have become par-ticularly useful for adolescentswith type 1 diabetes.12 Humanneutral protamine Hagedorn(NPH) insulin remains a poorchoice for basal insulin in theyoung because of its substantialpeak and relatively short duration(Figure 1).19

Insulin lispro, a rapid-actinginsulin analog, is associated withreduced glucose fluctuation andless postprandial hyperglycemiaand nocturnal hypoglycemia inyoung patients with type 1 dia-betes than regular insulin.20 Thepharmacokinetics of insulin as-part have been evaluated inchildren and adolescents withtype 1 disease.21 Its more rapidonset of action compared withregular insulin was confirmed inthis pediatric population. Insulin

glargine, a new, long-acting in-sulin analog, forms microprecipi-tates after subcutaneous injec-tion, allowing the slow release ofsmall amounts of drug. The re-sultant relatively constant con-centration-time profile makes itideal for once-daily dosing as abasal insulin.22 The efficacy andsafety of insulin glargine havebeen established in 5 clinicalstudies in children and adoles-cents with type 1 diabetes (Table2).23-27 Insulin glargine therapyresulted in a dramatic reductionin hypoglycemia, including se-vere and nocturnal episodes,compared with short- and inter-mediate-acting insulins. Long-term (≤36 months) efficacy andsafety have been established inthis population.25 A suggestedmanagement algorithm for youthwith type 1 diabetes is illustrated(Figure 2).

Young Patients with Type 2 Diabetes

The UKPDS was conducted inpatients 25 to 65 years of age withnewly diagnosed type 2 diabetes.28

Tight glucose control with eithersulfonylureas or insulin produceda substantial decrease in the riskof microvascular complications.28

Although children and adoles-cents did not participate in thislandmark study, the resultsdemonstrated the importance ofintensive blood glucose control inpatients with type 2 diabetes, re-gardless of age.

Compared with type 1 dia-betes, type 2 disease has a moreinsidious onset, with more subtleincreases in thirst or urination,hypertension, and acanthosis ni-gricans.3 It is almost always associ-ated with obesity and a family his-tory of type 2 diabetes. In addition,


Figure 1. Insulin time-action profiles during glucose infusion. Glucose infusion rate required to maintaineuglycemia indicates potency of insulin action. Adapted with permission from Lepore et al.19 CSII = con-tinuous subcutaneous insulin infusion; NPH = neutral protamine Hagedorn; sc = subcutaneous.




30% of young diabetic patientswill present with ketosis, and 5%will present with ketoacido-sis.3,4,29,30 Normal or elevated fast-ing insulin and C-peptide levelsare more common in patients withtype 2 diabetes,3 while low or un-detectable levels of serum insulinand C-peptide, and elevation of au-toantibodies (i.e., anti-insulin,

anti-islet cell, antiglutamic acid de-carboxylase, antityrosine phos-phatase), are more characteristicin type 1 disease.3 There is oftenno family history of type 1 diabetesor other autoimmune disease.

Several risk factors for type 2diabetes in adolescents have beenidentified (Table 3).3,31,32 All haveinsulin resistance as a common

denominator32 and are consistentwith the risk factors for type 2 dis-ease in adults.29 It is estimatedthat one third to one half of allcases of type 2 diabetes in adultsare undiagnosed.31,33-35 If this pro-file also holds true for adoles-cents, many young people may re-main undiagnosed for sometime,31 resulting in an increased


Table 2

SUMMARY OF CLINICAL TRIAL EXPERIENCE WITH INSULIN GLARGINE IN YOUNG PATIENTS WITH TYPE 1 DIABETES

Study Description Treatment Population Results with Insulin Glargine

Schober et al.23 Open-label, 1 bedtime injection of n = 349 • Lower fasting blood glucose levels multicenter, IG or NPH insulin once Age, 5–16 y • (P=0.02)randomized or twice daily • Less risk of hypoglycemia, especially

• nocturnal hypoglycemia

Kordonouri et al.24 Open-label, 2–4 injections of NPH n = 30 • Significant reduction in nighttimecrossover and/or zinc lente insulin Age, 14.2 y • hypoglycemia (P=0.002)

switched to 1 bedtime (median) • No change in HbA1c

injection of IG for 4.5–18.3 y • Similar hypoglycemic and4–8 wk (range) • hyperglycemic glucose levels as with

• NPH and/or zinc lente insulin

Dunger et al.25 Open-label, 1 bedtime injection of n = 143 • Maintenance of HbA1c <9.0%multinational, IG plus regular human Age, 11.9 ± 2.5 y • No unexpected safety findings:uncontrolled insulin before meals for (mean ± SD) • severe hypoglycemia in 7 patientsextension ≥36 mo • (4.9%); injection site reactions

• (subsided with no change in dose) • in 10 patients (7.0%)

Murphy et al.26 Open-label, Two 16-wk treatment n = 26 • Lower fasting blood glucose levels randomized, periods: 1 bedtime Age, 14.8 ± 1.7 y • (P<0.0001)active-controlled, injection of IG or NPH (mean ± SD) • Lower glucose levels in morning and2-way crossover insulin plus preprandial • before and after lunch (P<0.01 and

lispro or regular insulin • P<0.002, respectively)

• Lower incidence (43%) of • asymptomatic nocturnal • hypoglycemia (P<0.05)

• Lower overall insulin use (P<0.01)

Pearson et al.27 Retrospective MDI of short- and n = 140 • Reduction (73%) in severeintermediate-acting Age, 2–21 y • hypoglycemic episodesinsulin switched to IG for ≥3 mo

HbA1c = glycosylated hemoglobin; IG = insulin glargine; NPH = neutral protamine Hagedorn; MDI = multiple daily injections.




potential for long-term complica-tions of uncontrolled diabetes.

In the United States, 25% ofchildren and adolescents areobese or are at risk for becomingobese. Obesity is the number onenutritional disease of children to-day.36 Environmental and geneticfactors play a part in the increas-ing prevalence of obesity in theyoung. However, in both adultsand children, it is a modifiablerisk factor that responds to in-creased physical activity and goodeating habits.3 Not only is obesity

a risk factor for developing type 2diabetes, it also increases the po-tential for impaired glucose toler-ance. A recent clinical study of167 obese children (body mass in-dex >95th percentile for age andgender) demonstrated a highprevalence of impaired glucosetolerance and insulin resistancedespite relatively well-preservedbeta-cell function.37

Insulin is approved for treat-ing children with type 2 diabetes;a strategy for insulin initiation isshown in Figure 3. However, these

patients may benefit from treat-ment with oral agents to improveglycemic control, facilitate admin-istration and compliance, main-tain weight, and address comor-bid conditions.38 Used worldwidefor more than 40 years, met-formin, an oral antihyper-glycemic agent, has been ap-proved by the US Food and DrugAdministration (FDA) for chil-dren and adolescents, 10 to 16years of age, with type 2 dia-betes.38 It was studied in a ran-domized, multicenter, placebo-


Figure 2. Suggested algorithm for insulin use (MDI or CSII) in youth with type 1 diabetes. CSII = continuous subcutaneousinsulin infusion; FPG = fasting plasma glucose; HbA1c = glycosylated hemoglobin; IAI = intermediate-acting insulin; MDI =multiple daily injection; PG = preprandial glucose; RAIA = rapid-acting insulin analog; TDI = total daily insulin. RAIA to cor-rect hyperglycemia: 1 unit RAIA lowers glucose by approximately 1,800/TDI.* RAIA to cover carbohydrates: 1 unit RAIA cov-ers approximately 500/TDI g carbohydrate.* *These are guidelines and should obviously be adjusted by results of self-mon-itoring blood glucose.




controlled trial in patients, 8 to 16years of age, known to have type 2diabetes.39 Forty-two patientswere randomized to receive met-formin (≤2000 mg/day) for amean of 80 days; 40 others re-ceived placebo for a mean of 44days.39 Metformin was associatedwith a significant decrease in fast-ing plasma glucose and HbA1c

concentrations compared withplacebo (P<0.001).39 Currently,the safety and efficacy of other an-tidiabetic agents used in adultswith type 2 diabetes are being in-vestigated in children.38 Insulintherapy may also be introduced iforal agents fail in adolescents astheir disease progresses.

In young patients with type 2diabetes, glycemic control is asimportant as it is in young pa-tients with type 1 disease. How-ever, some of these patients, espe-cially teenagers, are reluctant to

use intensive MDI regimens. Thispopulation may benefit fromlong-acting insulin analogs, suchas insulin glargine, or from theuse of mixed-dose insulin pensthat reduce the burdens of self-care.40 For successful manage-ment of diabetes in this popula-tion, self-monitoring of bloodglucose (SMBG), particularly ininsulin-treated patients, compre-hensive education and copingskills training, and regular assess-ment for comorbidity, such as hy-pertension, dyslipidemia, and mi-croalbuminuria, are essential.40

Monitoring GlycemicControl in YoungDiabetic Patients

Hypoglycemia is the mostcommon acute complication oftype 1 diabetes, particularly in

younger patients, who have a lim-ited capacity for timing meals andactivities and maintaining self-care regimens.41 SMBG has en-abled young patients with type 1disease to achieve better glycemiccontrol. However, SMBG providesonly “snapshots” of daily glycemicpatterns. Marked excursions in24-hour blood glucose levels arefrequent, even in patients whosediabetes is considered well-con-trolled, and these wide glucosefluctuations are often not cap-tured by SMBG42 (Figure 4). Con-tinuous glucose sensors that cap-ture glycemic trends missed withSMBG are powerful adjuncts toSMBG.

The continuous glucose moni-toring system (CGMS®) devel-oped by Medtronic MiniMed(Northridge, CA) is the first suchsystem approved by the FDA.Used as a Holter-type monitor, itmeasures glucose in subcuta-neous tissue with a glucose oxi-dase–based sensor, inserted via aremovable needle and a spring-loaded device.12 Glucose mea-surements are not read by the pa-tient but are downloadedelectronically by the physician, al-lowing retrospective review of the72-hour glucose profile, includ-ing postprandial and nocturnallevels.12 The CGMS has been eval-uated in clinical studies in youngpatients with type 1 diabetes.42-45

This method of glucose monitor-ing detected abnormal patterns ofglycemic control and allowedphysicians to make changes in thediabetes regimens of patients thatled to improvements in HbA1c con-centrations even after 1 reading.

The other approved continu-ous glucose sensor, the GlucoW-atch® Biographer (Cygnus, Red-wood City, CA) is a watch-likedevice that uses reverse ion-tophoresis to draw interstitialfluid across the skin surface onto


Table 3

RISK FACTORS FOR INSULIN RESISTANCE AND TYPE 2 DIABETES IN ADOLESCENTS

Type of Factor Risk Factor

Modifiable • Obesity3,31,32

• Inactivity3

• High caloric intake with excessive carbohydrates and fats3

• Syndrome X*31

Nonmodifiable • Familial history of type 2 diabetes in first- or second-degreerelative3

• Member of high-risk ethnic group (African American,Hispanic, Native American, Asian/Pacific Islander)3

• Puberty31

• Acanthosis nigricans31

• Polycystic ovarian syndrome31

*Characterized by hyperinsulinemia, glucose intolerance, increased very low-density lipoproteins andtriglycerides, decreased high-density lipoproteins, and hypertension.




a hydrogel disk for analysis of glu-cose concentrations. The Glu-coWatch may be worn for up to 13hours before the disks must be re-placed and the device recali-brated. The GlucoWatch providesnear real-time glucose levels at 10-minute intervals and is equippedwith hypoglycemia alarms. In asmall, short-term study, use of thisdevice has been associated withimprovements in HbA1c concen-trations and the detection of hypoglycemia.45

Current techniques of contin-uous glucose monitoring cannotreplace SMBG because their accu-

racy has been shown to be inferiorto that of traditional home glu-cose meters,46-48 thus limitingtheir use as hypoglycemia alarms49

(Figure 5). However, their use toanalyze trends in glycemic excur-sions over time is becoming in-creasingly common.

Coping Skills Training

Adolescents with diabetes mayfind the physical, emotional, andsocial demands of managing achronic disease difficult.50 A re-cent study evaluated the potential

benefits of a 12-month behavioralprogram that included copingskills training and intensive dia-betes management.51 All patientsreceived intensive diabetes man-agement consisting of 3 or moredaily injections or CSII, SMBG atleast 4 times a day, monthly out-patient visits, and interim tele-phone contacts. Patients wererandomized to receive this diseasemanagement with (n = 41) or with-out (n = 34; control group) copingskills training. Regardless of treat-ment, all patients experienced sig-nificant declines in HbA1c concen-trations from baseline after 12


Figure 3. Suggested algorithm for management of youth with type 2 diabetes. FPG = fasting plasma glucose; HbA1c = gly-cosylated hemoglobin; IAI = intermediate-acting insulin; IBG = initial blood glucose; PG = preprandial glucose; RAIA = rapid-acting insulin analog; TZD = thiazolidinedione. TZDs: pioglitazone 15–45 mg daily or rosiglitazone 2–8 mg bid.* Secreta-gogues: glimepiride 1–4 mg/day, glipizide 2.5–10 mg daily bid, nateglinide 60–120 mg before meals, repaglinide 0.5–2 mgbefore meals.* *TZDs and newer secretagogues have not been approved for use in children.





Figure 4. Illustrative example of wide glycemic swings (including postprandial hyperglycemia and nocturnal hypoglycemia)demonstrated with the continuous glucose monitoring system (CGMS) but missed by routine capillary glucose monitoring.

Figure 5. Point accuracy of currently available continuous glucose monitoring devices is inferior to traditional homeglucose meters, particularly in the hypoglycemic range. GWB = GlucoWatch® Biographer, CGMS = Continuous Glu-cose Monitoring System®, RAD = relative absolute deviation, Ultra = One Touch® Ultra home glucose meter.




months (P<0.001). However, thosewho also received coping skillstraining experienced a faster andgreater decline in HbA1c concen-trations after 6 and 12 months(7.9% and 7.5%, respectively)than did the control patients(8.4% and 8.5%, respectively).

The greatest improvement as-sociated with training in copingskills was in quality of life and itoccurred during the f irst 3months, an effect that was main-tained throughout the 12-monthstudy.51 Such training coupledwith intensive diabetes manage-ment increased the adolescents’sense of competence by replacinginappropriate coping styles withmore positive behavior patterns.Overall, these patients felt morecapable of handling diabetes-spe-cific situations than did the con-trol group.51

Conclusions

Morbidity and prematuremortality associated with diabeteshave created a major socioeco-nomic burden. Historically, type 1diabetes was considered the onlyprevalent type of diabetes inyoung and adolescent patients.However, the increasing inci-dence of type 2 disease (generallythought to be a disease of adults)in this population has been de-scribed as a new epidemic. Type 2diabetes in juveniles or adoles-cents is due to a variety of factors,including obesity, sedentar ylifestyle, and diets high in fat, car-bohydrates, and sugars. The long-term complications of both type 1and type 2 diabetes can be re-duced by tight glycemic control,changes in nutrition and physicalactivity, and, when required, in-tervention with an oral antidia-betic agent or insulin regimen.Therapy with insulin or its

analogs has been approved foruse in young patients with eithertype 1 or type 2 disease. Most im-portant, improved glycemic con-trol—the goal of diabetes care—has been demonstrated with CSIIor subcutaneous injection of in-sulin glargine.

Self-management of diabetesis often difficult for children andadolescents and requires supportand education. Devices that con-tinuously monitor glucose levelsallow physicians to evaluate 24-hour glycemic control, also an im-portant step in treatment. In thefuture, further improvements intechnology promise to revolution-ize the treatment of diabetes.Overall, careful management,monitoring, and education canimprove glycemic control, bringabout a better understanding ofthe disease process, and yield pos-itive treatment outcomes inyoung patients with diabetes.

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