Taking control of T2D

With a chronic illness such as type 2 diabetes (T2D), patients and parents often want to make big changes, but just as often they fall short. Just think about plans to study for board recertification. Many physicians plan to spend significant time studying, but at some point they realize they have done very little actual studying. They fail to make necessary changes to get the study time in. Similarly, many patients vow to ban some food in their diet only to find themselves sitting with a big plate of the said banned food right in front of them.

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With a chronic disease like diabetes, an important goal is to help patients create sustainable, lifetime habits rather than make short-term drastic changes to habits such as diet and exercise. For patients with chronic disease, how they manage dietary indiscretion, physical inactivity, or other challenges is just as important as getting the patients to a position to take action in the first place.

The Treatment Options for type 2 Diabetes in Adolescents and Youth (TODAY) study¹ was the first large-scale randomized trial in the United States to compare 3 treatment approaches in new onset T2D in obese youth. The study found that metformin alone was insufficient to control half of all new onset diabetics. Whereas rosiglitazone plus metformin performed better than metformin alone, safety concerns with thiazolidinediones have precluded a recommendation for their use. Finally, intensive lifestyle intervention plus metformin did not lead to improved glycemic control compared to metformin alone.

Despite this finding, the American Academy of Pediatrics (AAP) clinical guideline “Management of newly diagnosed type 2 diabetes mellitus (T2DM) in children and adolescents”² recommends initiation of lifestyle modification as part of initial treatment. Although universally recommended, there are currently no data that would support lifestyle alone for the treatment of T2D in youth. Given high rates of “lost to follow-up” and potentially worse outcomes that might result, lifestyle modification is not recommended as the sole treatment.

Lifestyle changes are difficult, and many clinicians are frustrated by perceived lack of efficacy in real world settings or poor control because of behaviors that are not conducive with good glucose control. This article seeks to give the pediatrician a number of strategies that can be implemented in a busy office practice to achieve sustainable, long-term change and help patients make better day-to-day decisions by empowering them to take control of their disease.

Refer to a dietician and diabetic educator

The AAP guideline suggests implementation of the Academy of Nutrition and Dietetics’ Pediatric Weight Management Evidence-Based Nutrition Practice Guidelines.² The guidelines provide an evidence basis for its recommendations that include:

·  Incorporate lifestyle changes with a 900 kcal to 1200 kcal diet for 6- to 12-year-olds or no less than a 1200 kcal diet for those aged 13 years and older.

·  Protein-sparing ketogenic diets should be used only in very narrow situations.

·  Consume 3 meals per day.

·  Avoid eating while watching TV.

·  Use smaller plates to make portions appear larger.

·  Eat regular meals and snacks.

·  Reduce portion sizes.

·  Choose calorie-free beverages and limit juice.

·  Limit intake of high-fat foods.

Referral to a nutritionist with expertise in T2D for implementation of a dietary strategy is recommended. However, physicians in general under refer to these ancillary services, and many physicians do not feel skilled in dietary counseling at this level.

NEXT: Measure everything

Measure everything

The pediatrician and parents may be surprised if they begin measuring everything discussed in this article. Parents and adolescents are unlikely to correctly estimate the amount of activity or diets as measured by self-report of either child or parent.^3,4

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Consuming more calories than are burned throughout the course of a day results in weight gain and diabetes that is more difficult to control.² There are very good data that support that self-tracking of targeted behaviors leads to greater improvements in a desired activity. In many research studies, the sole activity of self-tracking demonstrates benefits in desired activities. Participants recording what and how much they eat will usually eat less and lose more weight as the result. When recording exercise levels, participants tend to not only exercise more but also, interestingly, seem to enjoy it more.⁵

It appears that the simple act of recording food intake or exercise levels stimulates eating less or exercising more rather then how accurate the measurement tool is or a specific method used. In research studies, dieters with the most weight loss, both short-term and long-term, are more adherent with self-tracking.⁵

One of the common reasons that diet and exercise attempts fail is because patients don’t see immediate results. Self-tracking provides an immediate reward and encouragement rather than waiting for large, delayed rewards of weight loss or better glucose control.⁵

Self-tracking can make eating, weight loss, or activity goals seem easier. If an adolescent’s goal is to lose 25 pounds over a year, the patient will have to eat approximately 85,000 fewer calories in 12 months. Although this may appear extreme, self-tracking can create small wins and make the task seem more manageable.⁶

A patient can reach this goal by setting a smaller goal of decreasing caloric intake by 250 calories per day or increasing activity to create a 250-calorie deficit each day.

A patient can get up each day and try to achieve these “bite-sized” goals repetitively. At the end of each day, the patient will know if he or she has achieved this goal and can wake up the next morning knowing he/she is 1 step closer or whether he/she needs to adjust the plan to achieve it. Measurement allows patients to not be overwhelmed by the larger goal, and the patient can see where he or she is on the path to achievement.

Older children and adolescents may do fine with tracking similar to adults while younger children will be more interested in tracking such as star charts commonly used for behavior.

More: Be a STAR

Be a STAR

It’s important for T2D patients to take ownership of their disease. This will involve eating healthy, exercising, taking medicine regularly if prescribed, and checking blood glucose levels. Parents and adolescents are often faced with both easy and hard decisions because much of everything patients do during the day will impact their diabetes. The STAR mnemonic⁷ was developed by the American Diabetes Association to help with the day-to-day decisions a diabetic must make and to help with problem solving. Think about being a STAR:

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• Stop. Before making a decision, the patient should stop and ask questions such as “What kind of snack would be best?” or “Should I go outside and play or watch TV?”

• Think. How will the choice the patient is about to make impact his or her diabetes control? A piece of fruit, a bag of chips, a handful of nuts, and a soda all will affect blood sugar differently. The patient should be instructed to think about the impact on blood sugar first, before eating.

• Act. Try to make a better choice. Remind patients about self-monitoring, and that change is slow. Tell patients it is normal to not always take the healthier option, and that small healthy choices added up over time can lead to significant results.

• Reflect. Tell patients to celebrate small successes and to think about how they can make a healthier choice next time if they make an unhealthy choice today.

Lifestyle modifications often fail for a number of reasons, including high loss to follow-up, mental health issues such as depression in teenagers, and peer pressure.² The STAR model addresses some of the failures of lifestyle modification and can be a model for helping adolescents think about topics other than just eating and physical activity, such as alcohol and sexual activity.

NEXT: Exercise more

Exercise more

Most American children get less exercise than is recommended by current guidelines.⁸ There are a number of benefits to exercise whether or not your patient has diabetes, including:

•   improved cholesterol;

•   reduced stress;

•   lower blood pressure;

•   improved sleep;

•   boost of the immune system; and

•   more energy.

Parents and children should think of physical activity as a medication, and like a medication, patients need to exercise regularly for it to be of benefit. It doesn’t matter what activity, but AAP currently recommends that children with T2D exercise for 60 minutes daily.²

Related to diabetes, physical activity promotes increased uptake of glucose by muscle and decreased blood glucose levels. Increased activity also increases insulin sensitivity and reduces the amount of insulin needed to assist in the uptake of insulin into cells.

Pediatricians generally recommend increased levels of activity, but how often do patients and parents listen? Or is it that parents do not have strategies to improve activity?

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Exercise does not need to be continuous, but can be accumulated throughout the day. Parents should be encouraged to be active with their children because reports indicate that active families have active kids.⁹ Variety is also important because children can become bored if they view the activity as required exercise. Children can easily invent games and activities. Adult-led activities are important because these activities tend to be where children attain more vigorous levels of activity.

Reducing opportunities for sedentary behaviors is another strategy. Limiting screen time (the AAP recommends no more than 2 hours per day) is one potential intervention because screen time is often associated with eating.² Screen time can be replaced with activity time. Additionally, the AAP recommends that parents not allow children to have TVs, computers, video games, and electronic devices in their bedrooms and to ban these devices where children eat to prevent distracted eating.

Eat what you like but eat less

The Academy of Nutrition and Dietetics’ Pediatric Weight Management Evidence-Based Nutrition Practice Guidelines recommends a number of evidence-based strategies that can be implemented.² There are also some simple and practical strategies that can be implemented by the pediatrician in the office.

Pizza is not ideal for the patient with T2D, but the concept of “forbidden foods” is also not likely to be successful. Children and adolescents need to have fun and are not likely to stick to a restrictive diet for any length of time. Giving patients this freedom may increase their own sense of self-control and allow them to take responsibility for their diabetes. Similarly, advise patients and parents to eat more slowly and control portion size.

One concept to help control portion size and improve eating habits is the “healthy plate.” On a 9-inch dinner plate (or consider even a smaller plate), a healthy meal would include:⁷

• Half the plate comprised of nonstarchy vegetables;

• One-quarter of the plate with protein; and

• One-quarter of the plate with grains or starchy vegetables.

Eating slowly gives the stomach time to tell the brain that it is full. This normally takes about 20 minutes. If patients are still hungry, they should be encouraged to eat non-starchy vegetables.

Starchy vegetables include corn, potatoes, green peas, and squash. These vegetables have more carbohydrates and can raise blood sugar. Nonstarchy vegetables have fewer carbs and will have significantly less impact on blood sugar. The Table lists beneficial nonstarchy vegetables.⁷

NEXT: Learning to read labels

Learn to read labels

Referral to a dietician to help adolescents read labels⁷ can help them make correct choices, but some basic instructions from the pediatrician also may improve patients’ eating habits.

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Instruct the patient to:

• Look for the serving size. The label should contain both the number of servings in the container as well as calories per serving. Calories will increase as the portion size increases or the patient will eat more than the serving size.

• Look at grams of “Total Carbohydrate.” Foods with 25 grams of carbohydrate per serving or less are better choices. Likewise, foods that have 3 or more grams of fiber per serving are also good choices.

• Look at “Calories” and “Total Fat.” Good choices are foods with 0 to 3 grams of total fat per 100-calorie serving.

Medication management alone is a tremendous burden for the pediatrician to master in addition to suggesting effective lifestyle interventions with which the pediatrician likely does not feel comfortable. The pediatrician should become familiar with local resources for more intensive lifestyle interventions while attempting to incorporate simple office-based interventions such as those presented in this article.

REFERENCES

1. Narasimhan S, Weinstock RS. Youth-onset type 2 diabetes mellitus: lessons learned from the TODAY study. Mayo Clin Proc. 2014;89(6):806-816.

2. Copeland KC, Silverstein J, Moore KR, et al; American Academy of Pediatrics. Management of newly diagnosed type 2 diabetes mellitus (T2DM) in children and adolescents. Pediatrics. 2013;131(2):364-382. Erratum in: Pediatrics. 2013;131(5):1014.

3. Elliott SA, Baxter KA, Davies PS, Truby H. Accuracy of self-reported physical activity levels in obese adolescents. J Nutr Metab. 2014;2014:808659.

4. Visser M, Brychta RJ, Chen KY, Koster A. Self-reported adherence to the physical activity recommendation and determinants of misperception in older adults. J Aging Phys Act. 2014;22(2):226-234.

5. Burke LE, Wang J, Sevick MA. Self-monitoring in weight loss: a systematic review of the literature. J Am Diet Assoc. 2011;111(1):92-102.

6. Hall KD. What is the required energy deficit per unit weight loss? Int J Obes (Lond). 2008;32(3):573-576.

7. American Diabetes Association. Be Healthy Today; Be Healthy for Life. Information for Youth and Their Families Living with Type 2 Diabetes. Available at: http://main.diabetes.org/dorg/PDFs/Type-2-Diabetes-in-Youth/Type-2-Diabetes-in-Youth.pdf. Accessed March 15, 2016.

8. Foltz JL, Cook SR, Szilagyi PG, et al. US adolescent nutrition, exercise, and screen time baseline levels prior to national recommendations. Clin Pediatr (Phila). 2011;50(5):424-433.

9. Physical Activity Guidelines for Americans Midcourse Report Subcommittee of the President’s Council on Fitness, Sports, and Nutrition. Physical Activity Guidelines for Americans Midcourse Report: Strategies to Increase Physical Activity Among Youth. Washington, DC: US Department of Health and Human Services; 2012:19. Available at: http://health.gov/paguidelines/midcourse/pag-mid-course-report-final.pdf. Accessed March 15, 2016. 

Dr Bass is chief medical information officer and associate professor of medicine and of pediatrics, Louisiana State University Health Sciences Center–Shreveport. The author has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.