571368
research-article2015
NASXXX10.1177/1942602X15571368NASN School NurseNASN School Nurse
Diabetes/Endocrine
Understanding Type 2 Diabetes in Students With Obesity and the Role of the School Nurse Mary Jane Berquist, MPH, BSN, RN, CPN, CDE Co-morbidities of obesity in children mirror those seen in adults. Virtually any body system can be affected. The January 2015 issue of the NASN School Nurse featured an introductory article on childhood obesity. This article is the first of six related articles focusing on co-morbidities of childhood obesity and focuses on type 2 diabetes (T2D). School nurses can play an integral role in the identification, prevention, and treatment of childhood obesity. With one in three of our nation’s school-age children diagnosed as overweight or obese, it is imperative that school nurses join families, public health agencies, and medical communities in mounting a coordinated attack against this threat. Keywords: childhood obesity comorbidities; type 2 diabetes; insulin resistance; school nurse role
What Is Diabetes? Diabetes Mellitus is a disorder of glucose metabolism in which blood glucose levels are above normal (hyperglycemia) (Centers for Disease Control and Prevention [CDC], 2014a).
For all types of diabetes, complications in multiple body systems can result from long-term hyperglycemia and other associated risk factors. Insulin, necessary for cell metabolism of glucose, is synthesized in the beta cells of the pancreas, and hyperglycemia is a result of beta cell dysfunction, resistance of insulin at the cell level, or other errors in cellular metabolism. The diagnosis of diabetes is made when an individual has symptoms of excessive thirst and urination, or unexplained weight loss, accompanied by fasting blood glucose above 126 mg/dL or by blood glucose above 200 mg/dL following a 2-hour glucose tolerance test. According to the American Diabetes Association, a hemoglobin A1C of 7.0% is used in diagnosis of diabetes in adults but is not standardized for diagnosis in children by the Pediatric Endocrine Society (Kapadia & Zeitler, 2012). Diabetes is one of the most common chronic diseases in children and affects more than 200,000 people under 18 years (CDC, 2011). Preventing or delaying these complications is currently a high priority of national health officials and health care providers, especially
considering the growing number of children with diabetes. This growing public health concern is due to increased risk for complications of heart disease, kidney disease, blindness, and stroke in people with diabetes and chronic hyperglycemia. Historically, type 1 diabetes mellitus (T1D) has been referred to as “juvenile onset diabetes” and is accompanied by one or more auto-antibodies detected by blood test. These antibodies are a signal that the immune system is involved in the destruction of the insulin-producing beta cells of the pancreas. T1D requires treatment with exogenous insulin via injections or insulin pump. Until the 1990s, T2D was more commonly diagnosed in adults and was referred to as “adult onset diabetes.” The American Association of Clinical Endocrinologists (AACE) states that T2D is not associated with the auto-immune process typical of T1D (Handelsman et al., 2011). Instead, individuals diagnosed with T2D demonstrate a combination of insulin resistance and progressive loss of beta cell function without the auto-antibodies present. Initially, the obesity-related
DOI: 10.1177/1942602X15571368 For reprints and permission queries visit SAGE’s Web site, http://www.sagepub.com/journalsPermissions.nav. Downloaded from nas.sagepub.com at WESTERN OREGON UNIVERSITY on May 28, 2015 © 2015 The Author(s)
March 2015 | NASN School Nurse 81
Figure 1. Rate of new cases of type 1 and type 2 diabetes among youth younger than 20 years, by race/ethnicity, 2002–2005
Source: SEARCH for Diabetes in Youth Study. NHW = non-Hispanic whites; NHB = non-Hispanic blacks; H = Hispanics; API = Asians/Pacific Islanders; AI = American Indians.
insulin resistance, which leads to T2D, is compensated by increased production of insulin by the beta cells (Bacha et al., 2012). Insulin resistance is also characterized by acanthosis nigricans, the darkening of pigment in skin folds around the neck or other places.
Prevalence of Diabetes in Children The number of cases of diagnosed diabetes among people younger than 20 years (T1D and T2D combined) was about 215,000 in 2010, representing 0.26% in this age group (CDC, 2011). The SEARCH data from 2002-2003 indicated that approximately 3,700 youth were being diagnosed annually with T2D, predominating in 10- to 19-year-old minority youth (see Figure 1). Estimates of undiagnosed diabetes are not available, which may be partly due to the gradual onset and early absence of symptoms. The rate of new cases varies among race/ethnicity and is estimated to increase dramatically over the next several decades.
82 NASN School Nurse | March 2015
Causes and Risk Factors Several factors can cause diabetes. Hyperglycemia in children can be a result of other glucose metabolism disorders that result in elevated blood glucose. Cystic fibrosis causes progressive destruction of the pancreatic cells that produce digestive enzymes and the insulin-producing beta cells, leading to high blood glucose. Steroid therapy, which often accompanies chemotherapy use in treatment of various cancers, leads to hyperglycemia. This type of hyperglycemia is usually transient but, with repeated chemotherapy, can become long term. In both children and adults, we now know that other rare types of diabetes exist, which are distinctly inherited on an identifiable genome. These are referred to as “monogenic” diabetes and have sometimes been referred to as MODY, or mature onset diabetes of youth (National Diabetes Information Clearinghouse, 2014). T2D is more common in African Americans, Latinos, Native Americans,
and Asian Americans/Pacific Islanders (CDC, 2014c). In addition to higher risk by population and family history, risk for developing T2D increases with obesity, physical inactivity, and age. Risk for cardiovascular disease (CVD) is also increased in youth with T2D. The SEARCH for Diabetes in Youth Study found that 25% of youth ages 12 to 19 years with T2D have at least 2 additional CVD risk factors compared with 6.4% of the general population. These additional risk factors include HDL cholesterol < 40 mg/dl; waist circumference > 90th percentile for age and sex; systolic or diastolic blood pressure > 90th percentile for age, sex, and height, or taking medication for high blood pressure; and triglycerides > 110 mg/dl (Rodriguez et al., 2006).
Obesity and Diabetes The importance of obesity in the development and treatment of diabetes has been widely explored since the connection was discovered. In the 1990s, the National Institute of Diabetes and
Downloaded from nas.sagepub.com at WESTERN OREGON UNIVERSITY on May 28, 2015
Digestive and Kidney Diseases (NIDDK) of the National Institutes of Health sought to understand the increase of T2D in youth. They partnered with the CDC and established the SEARCH for Diabetes in Youth Study and the Treatment Options for T2D in Adolescents and Youth (TODAY) study. The SEARCH study provided populationbased statistics for diabetes in U.S. youth. The TODAY study sought to compare the efficacy and safety of three interventions to treat adolescents and youth with T2D (Arslanian et al., 2013). Data extracted from these studies are continuing to provide insight into the increase of T2D in youth and potentially ways to prevent and diminish the impact of diabetes on the general population. Excessive weight in children with either type of diabetes has been found to contribute to less optimal outcomes. Obesity (prior to developing diabetes) is accompanied by high circulating insulin, high circulating free fatty acids, and increasing blood glucose. In youth over 10 years of age, the prevalence of abnormal lipids was higher in those with T2D (33%) than in those with T1D (19%) (Kershnar et al., 2006). Outcomes in 354 patients with T2D who had onset between 15 and 30 years of age were compared with those of 470 patients with T1D who had similar age of onset. Cardiovascular risk factors were found with significantly higher levels of serum triglyceride levels, lower high-density lipoprotein cholesterol, and higher blood pressure readings (Constantino et al., 2013). Lastly, youths with severe obesity are at high risk for deterioration of glucose metabolism in short periods of time.
Treatment of Diabetes According to a clinical practice guideline published by the American Academy of Pediatrics (AAP), the treatment of children with T2D should include lifestyle modifications necessary to reduce body weight (AAP Subcommittee on Management of T2DM in Children and Adolescents, 2013). Changes in insulin sensitivity, strongly related to weight changes, can have a
significant impact on the 2-hour glucose level of obese children and adolescents. Decreasing body mass index (BMI) can improve their glucose metabolism (Weiss et al., 2005). However, improvements in nutrition and physical activity habits alone may not be sufficient. Youth with T2D will also likely require medication, most typically metformin (AAP Subcommittee on Management of T2DM in Children and Adolescents, 2013). Metformin is better tolerated when taken with food, and its use can be associated with gastrointestinal adverse effects. These are usually short-lived and disappear with continued treatment (AAP Subcommittee on Management of T2DM in Children and Adolescents). If target blood glucose levels are unable to be achieved and maintained, youth with T2D may require the use of insulin or another pharmacologic agent in addition to metformin, with accompanying daily blood glucose monitoring (AAP Subcommittee on Management of T2DM in Children and Adolescents).
The Role of School Nurses in the Prevention and Treatment of T2D Since children spend many of their waking hours in the school setting, responsibility inevitably falls on school nurses not only to manage students’ health but to educate and help prevent multiple chronic diseases. Reducing risks of diabetes is closely coupled with reducing obesity in children. For instance, school nurses can advocate individually or as members of school wellness committees for increased availability of physical activity options for all students. Exercise in moderate amounts (30 minutes for 5 days a week) has been shown to reduce risk of developing diabetes in adults (CDC, 2014b). Exercise affects the insulin signaling and glucose transport pathway by stimulation of glucose transport and increased insulin action (Youngren, n.d.). For this reason, people who are physically active have improved use of insulin, requiring less insulin production by the pancreas. Reducing the resistance
of the insulin at the cellular level leads to less stress on the beta cells to increase production. For students with T2D, at least 60 minutes of moderate to vigorous exercise daily is recommended to reduce BMI and improve glycemic control (McGavock, Sellers, & Dean, 2007). On the nutrition front, school nurses can support the improvement in healthfulness of school meals resulting from the passage of the Healthy Hunger-Free Kids Act, which should aid obesity prevention and treatment. School nurses should also be familiar with the Academy of Nutrition and Dietetics’ (AND) Pediatric Weight Management Evidence-Based Nutrition Practice Guidelines, which include specific recommendations for 6- to 12-year-olds and 13- to 18-year-olds with obesity (AND Evidence Library). They can also serve as valued, credible resources for nutrition education in the classroom. Not only can school nurses educate individual parents and parent groups in how to establish healthier eating and physical activity habits for their children, they can also encourage parents to role model these same behaviors to create and maintain family-based change. In addition to the above, school nurses are in a unique position to assist individual students with T2D. This aid may take the form of a nursing care plan, including blood glucose monitoring and tracking, medication administration, management of hypoglycemia, and being a trusted resource for students’ parents, primary care medical home, and/or pediatric endocrine medical providers. The National Diabetes Education Program provides excellent resources in this area (see www.ndep.nih.gov). In summary, understanding the etiologies and prevalence of T2D, as well as its diagnosis and treatment, can provide important background for today’s school nurses as they care for students with T2D. Local and national entities are engaged in focusing on promoting healthier lifestyles for children and families, including healthier eating, increasing physical activity, reducing consumption of sweetened beverages, and decreasing screen time of all types.
Downloaded from nas.sagepub.com at WESTERN OREGON UNIVERSITY on May 28, 2015
March 2015 | NASN School Nurse 83
School nurses are best positioned to advocate for all of these goals, to monitor students with T2D for multiple risk factors, and to assist them with appropriate referrals for medical evaluation if necessary. ■
References Academy of Nutrition and Dietetics. (2007). Pediatric weight management evidence-based nutrition practice guidelines. Retrieved from http://www.adaevidencelibrary.com/topic .cfm?cat=2721 American Academy of Pediatrics Subcommittee on Management of T2DM in Children and Adolescents. (2013). Management of newly diagnosed type 2 diabetes mellitus (T2DM) in children and adolescents. Pediatrics, 131, 364-382. Arslanian, S., Pyle, L., Payan, M., Bacha, F., Caprio, S., Haymond, M., . . . Willi, S. M. (2013). TODAY Study Group. Effects of metformin, metformin plus rosiglitazone, and metformin plus lifestyle on insulin sensitivity and B-cell function in TODAY. Diabetes Care, 36, 1749-1756. Retrieved September 10, 2014, from http://care.diabetesjournals.org/ content/36/6/1749.full.pdf Bacha, F., Pyle, L., Nadeau, K., Cuttler, L., Goland, R., Haymond, M., . . . Arslanian, S. (2012). Determinants of glycemic control in youth with type 2 diabetes at randomization in the TODAY study. Pediatric Diabetes, 13(5), 376-383. doi:10.1111/j.13995448.2011.00841.x Centers for Disease Control and Prevention. (2011). National diabetes fact sheet: National estimates and general information on diabetes and prediabetes in the United States, 2011. Atlanta, GA: U.S. Department of Health and Human Services. Retrieved September 10, 2014, from http://www.cdc.gov/diabetes/ pubs/pdf/ndfs_2011.pdf Centers for Disease Control and Prevention. (2014a). Basics about diabetes. Retrieved
84 NASN School Nurse | March 2015
complications. Diabetes and Vascular Disease Research, 4(4), 305-310.
September 10, 2014, from http://www.cdc .gov/diabetes/basics/diabetes.html Centers for Disease Control and Prevention. (2014b). National diabetes prevention program. Physical activity and health. Retrieved September 10, 2014, from http:// www.cdc.gov/physicalactivity/everyone/ health/index.html Centers for Disease Control and Prevention. (2014c). National diabetes statistics report: Estimates of diabetes and its burden in the U.S. Atlanta, GA: U.S. Department of Health and Human Services. Retrieved September 10, 2014, from http://www.cdc.gov/diabetes/ pubs/statsreport14/national-diabetes-reportweb.pdf Constantino, M. I., Molyneaux, L., LimacherGisler, F., Al-Saeed, A., Luo, C., Wu, T., . . . Wong, J. (2013). Long-term complications and mortality in young-onset diabetes: Type 2 diabetes is more hazardous and lethal than type 1 diabetes. Diabetes Care, 36(12), 3863-3869.
National Diabetes Information Clearinghouse. (2014). Causes of diabetes. Retrieved September 10, 2014, from http://diabetes .niddk.nih.gov/dm/pubs/causes/index.aspx Rodriguez, B. L., Fujimoto, W. Y., Mayer-Davis, E. J., Imperatore, G., Williams, D. E., Bell, R. A., . . . Linder, B. (2006). Prevalence of cardiovascular disease risk factors in U.S. children and adolescents with diabetes. Diabetes Care, 29(8), 1891-1896. Weiss, R., Taksali, S. E., Tamborlane, W. V., Burgert, T. S., Savoye, M., & Caprio, S. (2005). Predictors of changes in glucose tolerance status in obese youth. Diabetes Care, 28(4), 902-909. Youngren, J. F. (n.d.). Exercise and the regulation of blood glucose. Retrieved September 10, 2014, from http:// diabetesmanager.pbworks.com/w/ page/17680187/Exercise%20and%20the%20 Regulation%20of%20Blood%20Glucose
Handelsman, Y., Mechanick, J. I., Blonde, L., Grunberger, G., Bloomgarden, Z. T., Bray, G. A., . . . Wyne, K. L. (2011). American Association of Clinical Endocrinologists medical guidelines for clinical practice for developing a diabetes mellitus comprehensive care plan. Endocrine Practitioner, 17(Suppl. 2), 1-53. Kapadia, C., & Zeitler, P. (2012). Hemoglobin A1c measurement for the diagnosis of type 2 diabetes in children. International Journal of Pediatric Endocrinology, 31. doi:10.1186/1687-9856-2012-31 Kershnar, A. K., Daniels, S. R., Imperatore, G., Palla, S. L., Petitti, D. B., Pettitt, D. J., . . . Rodriquez, B. L. (2006). Lipid abnormalities are prevalent in youth with type 1 and 2 diabetes: the search for diabetes in youth study. Journal of Pediatrics, 149(3), 314-319. McGavock, J., Sellers, E., & Dean, H. (2007). Physical activity for the prevention and management of youth-onset type 2 diabetes mellitus: Focus on cardiovascular
Downloaded from nas.sagepub.com at WESTERN OREGON UNIVERSITY on May 28, 2015
Mary Jane Berquist RN, BSN, MPH, CPN, CDE Certified Diabetes Educator Kansas City, MO Mary Jane (Janie) is a certified diabetes educator at Children’s Mercy Hospital in Kansas City, working with inpatient and outpatient children with type 1 and type 2 diabetes, and pre-diabetes, and their caregivers. She is also active in community education with the American Diabetes Association. She obtained both her undergraduate and graduate degrees from University of Kansas Medical Center.
research-article2015
NASXXX10.1177/1942602X15571368NASN School NurseNASN School Nurse
Diabetes/Endocrine
Understanding Type 2 Diabetes in Students With Obesity and the Role of the School Nurse Mary Jane Berquist, MPH, BSN, RN, CPN, CDE Co-morbidities of obesity in children mirror those seen in adults. Virtually any body system can be affected. The January 2015 issue of the NASN School Nurse featured an introductory article on childhood obesity. This article is the first of six related articles focusing on co-morbidities of childhood obesity and focuses on type 2 diabetes (T2D). School nurses can play an integral role in the identification, prevention, and treatment of childhood obesity. With one in three of our nation’s school-age children diagnosed as overweight or obese, it is imperative that school nurses join families, public health agencies, and medical communities in mounting a coordinated attack against this threat. Keywords: childhood obesity comorbidities; type 2 diabetes; insulin resistance; school nurse role
What Is Diabetes? Diabetes Mellitus is a disorder of glucose metabolism in which blood glucose levels are above normal (hyperglycemia) (Centers for Disease Control and Prevention [CDC], 2014a).
For all types of diabetes, complications in multiple body systems can result from long-term hyperglycemia and other associated risk factors. Insulin, necessary for cell metabolism of glucose, is synthesized in the beta cells of the pancreas, and hyperglycemia is a result of beta cell dysfunction, resistance of insulin at the cell level, or other errors in cellular metabolism. The diagnosis of diabetes is made when an individual has symptoms of excessive thirst and urination, or unexplained weight loss, accompanied by fasting blood glucose above 126 mg/dL or by blood glucose above 200 mg/dL following a 2-hour glucose tolerance test. According to the American Diabetes Association, a hemoglobin A1C of 7.0% is used in diagnosis of diabetes in adults but is not standardized for diagnosis in children by the Pediatric Endocrine Society (Kapadia & Zeitler, 2012). Diabetes is one of the most common chronic diseases in children and affects more than 200,000 people under 18 years (CDC, 2011). Preventing or delaying these complications is currently a high priority of national health officials and health care providers, especially
considering the growing number of children with diabetes. This growing public health concern is due to increased risk for complications of heart disease, kidney disease, blindness, and stroke in people with diabetes and chronic hyperglycemia. Historically, type 1 diabetes mellitus (T1D) has been referred to as “juvenile onset diabetes” and is accompanied by one or more auto-antibodies detected by blood test. These antibodies are a signal that the immune system is involved in the destruction of the insulin-producing beta cells of the pancreas. T1D requires treatment with exogenous insulin via injections or insulin pump. Until the 1990s, T2D was more commonly diagnosed in adults and was referred to as “adult onset diabetes.” The American Association of Clinical Endocrinologists (AACE) states that T2D is not associated with the auto-immune process typical of T1D (Handelsman et al., 2011). Instead, individuals diagnosed with T2D demonstrate a combination of insulin resistance and progressive loss of beta cell function without the auto-antibodies present. Initially, the obesity-related
DOI: 10.1177/1942602X15571368 For reprints and permission queries visit SAGE’s Web site, http://www.sagepub.com/journalsPermissions.nav. Downloaded from nas.sagepub.com at WESTERN OREGON UNIVERSITY on May 28, 2015 © 2015 The Author(s)
March 2015 | NASN School Nurse 81
Figure 1. Rate of new cases of type 1 and type 2 diabetes among youth younger than 20 years, by race/ethnicity, 2002–2005
Source: SEARCH for Diabetes in Youth Study. NHW = non-Hispanic whites; NHB = non-Hispanic blacks; H = Hispanics; API = Asians/Pacific Islanders; AI = American Indians.
insulin resistance, which leads to T2D, is compensated by increased production of insulin by the beta cells (Bacha et al., 2012). Insulin resistance is also characterized by acanthosis nigricans, the darkening of pigment in skin folds around the neck or other places.
Prevalence of Diabetes in Children The number of cases of diagnosed diabetes among people younger than 20 years (T1D and T2D combined) was about 215,000 in 2010, representing 0.26% in this age group (CDC, 2011). The SEARCH data from 2002-2003 indicated that approximately 3,700 youth were being diagnosed annually with T2D, predominating in 10- to 19-year-old minority youth (see Figure 1). Estimates of undiagnosed diabetes are not available, which may be partly due to the gradual onset and early absence of symptoms. The rate of new cases varies among race/ethnicity and is estimated to increase dramatically over the next several decades.
82 NASN School Nurse | March 2015
Causes and Risk Factors Several factors can cause diabetes. Hyperglycemia in children can be a result of other glucose metabolism disorders that result in elevated blood glucose. Cystic fibrosis causes progressive destruction of the pancreatic cells that produce digestive enzymes and the insulin-producing beta cells, leading to high blood glucose. Steroid therapy, which often accompanies chemotherapy use in treatment of various cancers, leads to hyperglycemia. This type of hyperglycemia is usually transient but, with repeated chemotherapy, can become long term. In both children and adults, we now know that other rare types of diabetes exist, which are distinctly inherited on an identifiable genome. These are referred to as “monogenic” diabetes and have sometimes been referred to as MODY, or mature onset diabetes of youth (National Diabetes Information Clearinghouse, 2014). T2D is more common in African Americans, Latinos, Native Americans,
and Asian Americans/Pacific Islanders (CDC, 2014c). In addition to higher risk by population and family history, risk for developing T2D increases with obesity, physical inactivity, and age. Risk for cardiovascular disease (CVD) is also increased in youth with T2D. The SEARCH for Diabetes in Youth Study found that 25% of youth ages 12 to 19 years with T2D have at least 2 additional CVD risk factors compared with 6.4% of the general population. These additional risk factors include HDL cholesterol < 40 mg/dl; waist circumference > 90th percentile for age and sex; systolic or diastolic blood pressure > 90th percentile for age, sex, and height, or taking medication for high blood pressure; and triglycerides > 110 mg/dl (Rodriguez et al., 2006).
Obesity and Diabetes The importance of obesity in the development and treatment of diabetes has been widely explored since the connection was discovered. In the 1990s, the National Institute of Diabetes and
Downloaded from nas.sagepub.com at WESTERN OREGON UNIVERSITY on May 28, 2015
Digestive and Kidney Diseases (NIDDK) of the National Institutes of Health sought to understand the increase of T2D in youth. They partnered with the CDC and established the SEARCH for Diabetes in Youth Study and the Treatment Options for T2D in Adolescents and Youth (TODAY) study. The SEARCH study provided populationbased statistics for diabetes in U.S. youth. The TODAY study sought to compare the efficacy and safety of three interventions to treat adolescents and youth with T2D (Arslanian et al., 2013). Data extracted from these studies are continuing to provide insight into the increase of T2D in youth and potentially ways to prevent and diminish the impact of diabetes on the general population. Excessive weight in children with either type of diabetes has been found to contribute to less optimal outcomes. Obesity (prior to developing diabetes) is accompanied by high circulating insulin, high circulating free fatty acids, and increasing blood glucose. In youth over 10 years of age, the prevalence of abnormal lipids was higher in those with T2D (33%) than in those with T1D (19%) (Kershnar et al., 2006). Outcomes in 354 patients with T2D who had onset between 15 and 30 years of age were compared with those of 470 patients with T1D who had similar age of onset. Cardiovascular risk factors were found with significantly higher levels of serum triglyceride levels, lower high-density lipoprotein cholesterol, and higher blood pressure readings (Constantino et al., 2013). Lastly, youths with severe obesity are at high risk for deterioration of glucose metabolism in short periods of time.
Treatment of Diabetes According to a clinical practice guideline published by the American Academy of Pediatrics (AAP), the treatment of children with T2D should include lifestyle modifications necessary to reduce body weight (AAP Subcommittee on Management of T2DM in Children and Adolescents, 2013). Changes in insulin sensitivity, strongly related to weight changes, can have a
significant impact on the 2-hour glucose level of obese children and adolescents. Decreasing body mass index (BMI) can improve their glucose metabolism (Weiss et al., 2005). However, improvements in nutrition and physical activity habits alone may not be sufficient. Youth with T2D will also likely require medication, most typically metformin (AAP Subcommittee on Management of T2DM in Children and Adolescents, 2013). Metformin is better tolerated when taken with food, and its use can be associated with gastrointestinal adverse effects. These are usually short-lived and disappear with continued treatment (AAP Subcommittee on Management of T2DM in Children and Adolescents). If target blood glucose levels are unable to be achieved and maintained, youth with T2D may require the use of insulin or another pharmacologic agent in addition to metformin, with accompanying daily blood glucose monitoring (AAP Subcommittee on Management of T2DM in Children and Adolescents).
The Role of School Nurses in the Prevention and Treatment of T2D Since children spend many of their waking hours in the school setting, responsibility inevitably falls on school nurses not only to manage students’ health but to educate and help prevent multiple chronic diseases. Reducing risks of diabetes is closely coupled with reducing obesity in children. For instance, school nurses can advocate individually or as members of school wellness committees for increased availability of physical activity options for all students. Exercise in moderate amounts (30 minutes for 5 days a week) has been shown to reduce risk of developing diabetes in adults (CDC, 2014b). Exercise affects the insulin signaling and glucose transport pathway by stimulation of glucose transport and increased insulin action (Youngren, n.d.). For this reason, people who are physically active have improved use of insulin, requiring less insulin production by the pancreas. Reducing the resistance
of the insulin at the cellular level leads to less stress on the beta cells to increase production. For students with T2D, at least 60 minutes of moderate to vigorous exercise daily is recommended to reduce BMI and improve glycemic control (McGavock, Sellers, & Dean, 2007). On the nutrition front, school nurses can support the improvement in healthfulness of school meals resulting from the passage of the Healthy Hunger-Free Kids Act, which should aid obesity prevention and treatment. School nurses should also be familiar with the Academy of Nutrition and Dietetics’ (AND) Pediatric Weight Management Evidence-Based Nutrition Practice Guidelines, which include specific recommendations for 6- to 12-year-olds and 13- to 18-year-olds with obesity (AND Evidence Library). They can also serve as valued, credible resources for nutrition education in the classroom. Not only can school nurses educate individual parents and parent groups in how to establish healthier eating and physical activity habits for their children, they can also encourage parents to role model these same behaviors to create and maintain family-based change. In addition to the above, school nurses are in a unique position to assist individual students with T2D. This aid may take the form of a nursing care plan, including blood glucose monitoring and tracking, medication administration, management of hypoglycemia, and being a trusted resource for students’ parents, primary care medical home, and/or pediatric endocrine medical providers. The National Diabetes Education Program provides excellent resources in this area (see www.ndep.nih.gov). In summary, understanding the etiologies and prevalence of T2D, as well as its diagnosis and treatment, can provide important background for today’s school nurses as they care for students with T2D. Local and national entities are engaged in focusing on promoting healthier lifestyles for children and families, including healthier eating, increasing physical activity, reducing consumption of sweetened beverages, and decreasing screen time of all types.
Downloaded from nas.sagepub.com at WESTERN OREGON UNIVERSITY on May 28, 2015
March 2015 | NASN School Nurse 83
School nurses are best positioned to advocate for all of these goals, to monitor students with T2D for multiple risk factors, and to assist them with appropriate referrals for medical evaluation if necessary. ■
References Academy of Nutrition and Dietetics. (2007). Pediatric weight management evidence-based nutrition practice guidelines. Retrieved from http://www.adaevidencelibrary.com/topic .cfm?cat=2721 American Academy of Pediatrics Subcommittee on Management of T2DM in Children and Adolescents. (2013). Management of newly diagnosed type 2 diabetes mellitus (T2DM) in children and adolescents. Pediatrics, 131, 364-382. Arslanian, S., Pyle, L., Payan, M., Bacha, F., Caprio, S., Haymond, M., . . . Willi, S. M. (2013). TODAY Study Group. Effects of metformin, metformin plus rosiglitazone, and metformin plus lifestyle on insulin sensitivity and B-cell function in TODAY. Diabetes Care, 36, 1749-1756. Retrieved September 10, 2014, from http://care.diabetesjournals.org/ content/36/6/1749.full.pdf Bacha, F., Pyle, L., Nadeau, K., Cuttler, L., Goland, R., Haymond, M., . . . Arslanian, S. (2012). Determinants of glycemic control in youth with type 2 diabetes at randomization in the TODAY study. Pediatric Diabetes, 13(5), 376-383. doi:10.1111/j.13995448.2011.00841.x Centers for Disease Control and Prevention. (2011). National diabetes fact sheet: National estimates and general information on diabetes and prediabetes in the United States, 2011. Atlanta, GA: U.S. Department of Health and Human Services. Retrieved September 10, 2014, from http://www.cdc.gov/diabetes/ pubs/pdf/ndfs_2011.pdf Centers for Disease Control and Prevention. (2014a). Basics about diabetes. Retrieved
84 NASN School Nurse | March 2015
complications. Diabetes and Vascular Disease Research, 4(4), 305-310.
September 10, 2014, from http://www.cdc .gov/diabetes/basics/diabetes.html Centers for Disease Control and Prevention. (2014b). National diabetes prevention program. Physical activity and health. Retrieved September 10, 2014, from http:// www.cdc.gov/physicalactivity/everyone/ health/index.html Centers for Disease Control and Prevention. (2014c). National diabetes statistics report: Estimates of diabetes and its burden in the U.S. Atlanta, GA: U.S. Department of Health and Human Services. Retrieved September 10, 2014, from http://www.cdc.gov/diabetes/ pubs/statsreport14/national-diabetes-reportweb.pdf Constantino, M. I., Molyneaux, L., LimacherGisler, F., Al-Saeed, A., Luo, C., Wu, T., . . . Wong, J. (2013). Long-term complications and mortality in young-onset diabetes: Type 2 diabetes is more hazardous and lethal than type 1 diabetes. Diabetes Care, 36(12), 3863-3869.
National Diabetes Information Clearinghouse. (2014). Causes of diabetes. Retrieved September 10, 2014, from http://diabetes .niddk.nih.gov/dm/pubs/causes/index.aspx Rodriguez, B. L., Fujimoto, W. Y., Mayer-Davis, E. J., Imperatore, G., Williams, D. E., Bell, R. A., . . . Linder, B. (2006). Prevalence of cardiovascular disease risk factors in U.S. children and adolescents with diabetes. Diabetes Care, 29(8), 1891-1896. Weiss, R., Taksali, S. E., Tamborlane, W. V., Burgert, T. S., Savoye, M., & Caprio, S. (2005). Predictors of changes in glucose tolerance status in obese youth. Diabetes Care, 28(4), 902-909. Youngren, J. F. (n.d.). Exercise and the regulation of blood glucose. Retrieved September 10, 2014, from http:// diabetesmanager.pbworks.com/w/ page/17680187/Exercise%20and%20the%20 Regulation%20of%20Blood%20Glucose
Handelsman, Y., Mechanick, J. I., Blonde, L., Grunberger, G., Bloomgarden, Z. T., Bray, G. A., . . . Wyne, K. L. (2011). American Association of Clinical Endocrinologists medical guidelines for clinical practice for developing a diabetes mellitus comprehensive care plan. Endocrine Practitioner, 17(Suppl. 2), 1-53. Kapadia, C., & Zeitler, P. (2012). Hemoglobin A1c measurement for the diagnosis of type 2 diabetes in children. International Journal of Pediatric Endocrinology, 31. doi:10.1186/1687-9856-2012-31 Kershnar, A. K., Daniels, S. R., Imperatore, G., Palla, S. L., Petitti, D. B., Pettitt, D. J., . . . Rodriquez, B. L. (2006). Lipid abnormalities are prevalent in youth with type 1 and 2 diabetes: the search for diabetes in youth study. Journal of Pediatrics, 149(3), 314-319. McGavock, J., Sellers, E., & Dean, H. (2007). Physical activity for the prevention and management of youth-onset type 2 diabetes mellitus: Focus on cardiovascular
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Mary Jane Berquist RN, BSN, MPH, CPN, CDE Certified Diabetes Educator Kansas City, MO Mary Jane (Janie) is a certified diabetes educator at Children’s Mercy Hospital in Kansas City, working with inpatient and outpatient children with type 1 and type 2 diabetes, and pre-diabetes, and their caregivers. She is also active in community education with the American Diabetes Association. She obtained both her undergraduate and graduate degrees from University of Kansas Medical Center.
