Diabetes in young patients

	Excerpted from page 44 of the November/December 2018 edition of AOA Focus

A sense of urgency creeps into the conversations of David Masihdas, O.D., and Linda Chous, O.D., as they talk about diabetes and its troublesome rise in children and young adults.

According to studies published online in 2017, the incidence of diabetes grew among young people.

For instance, in a study published in The New England Journal of Medicine, researchers tracked over a 10-year period the prevalence of the disease among 11,245 youths ages 0 to 19 and another 2,846 youths with type 2 diabetes ages 10 to 19.

Adjusting for such variables as age, sex and race/ethnic group, the number of newly diagnosed diabetes type 1 cases rose 1.8% per year, while the annual rate for newly diagnosed diabetes type 2 cases increased by 4.8%, the researchers say. The study calls the diagnosis of diabetes in youth "a substantial clinical and public health burden."

"The lines are being blurred," Dr. Chous says. "Younger people are getting type 2 diabetes, and we're seeing type 1 in older patients as well. I was 35 when I developed type 1.

"If you're developing diabetes when you're 14 years old, and you're developing blinding retinopathy, your quality of life may not be great. It's something we have to be concerned about when you still have a lot of productive life ahead of you."

Complications in youth

About 10 risk factors—from age (being 45 or older) to autoimmune conditions (e.g., Graves' disease) to viral exposure (e.g., Epstein-Barr virus)—are listed in the AOA's landmark, evidence-based, clinical practice guideline, Eye Care of the Patient with Diabetes Mellitus, published in 2014.

"A lot of that age group are very inactive (due to digital device use, for instance) and eat a lot of what I would call not healthy food," says Dr. Masihdas, who practices in Utah and is chair of the AOA Evidence-Based Optometry Committee currently updating the 2014 practice guideline.

The updated guideline, expected to be released in 2019, will likely shine a brighter spotlight on diabetes among children. Dr. Chous, who practices in Minnesota and is chief eye care officer at UnitedHealthcare, also is a member of the committee.

The same risk factors, an inactive lifestyle and poor diet, apply to adults, Dr. Chous says. Yet, she adds, children and young adults with diabetes can pose other complications. For instance, says Dr. Chous, puberty and its accompanying hormonal changes, which can impact blood sugar control, matter. Further, a sense of youthful invincibility potentially poses a challenge when it comes to compliancy with a care plan, she says.

"Imagine puberty and having a chronic disease that is 24/7," Dr. Chous says. "They never get a break from the disease. You have to worry about what you eat. You have to worry about what you're not eating. It's not an easy disease to deal with."

Patients with unhealthy self-images may manipulate their insulin treatments in order to lose weight.

"Diabulimia is an eating disorder," Dr. Chous says. "It can cause the A1c to be out of control, and that can increase the likelihood of retinopathy."

4 ways to make a difference

Drs. Masihdas and Chous suggest taking the following actions to make a positive impact on patients.

1. Provide patient education.
   Patient education is key, the doctors say, especially because the disease is manageable through diet, exercise and medication. Patient education pamphlets need to be available, and a healthy relationship with a patient's primary care physician should be cultivated. "Dealing with diabetes is a lifestyle," says Dr. Chous, adding that doctors of optometry also need to have frank conversations with patients about their eating habits, as well as their overall health. Dr. Masihdas speaks highly of diabetes educators.
2. Connect with other care providers.
   Doctors of optometry should be an integral part of the patient care team. "We need to connect with pediatricians and other primary care providers," says Dr. Chous, who has written letters to patients' primary care physicians in cases of diabetes. That list of contacts might also include dentists and even dieticians, they say. Diabetes has been linked to gum disease. Together they would all deliver and re-enforce the same message.
3. Raise public awareness.
   "You should be getting out of your office," says Dr. Chous, who is a member of her local Lions Club, which has a diabetes-related initiative. "You need to be connecting with pediatricians and other primary care providers. But you've also got to get out there where the people are. There are always speaking engagements at public health fairs. The American Diabetes Association has regional events, and you can get involved in those."
4. Educate yourself.
   Doctors of optometry need to be well-informed on diabetes, beyond diagnosing diabetic retinopathy, Dr. Masihdas argues. They should know what kind of exercise or diet to recommend to patients, he says. "We need to be well-informed about the side effects of the medications diabetic patients are being prescribed by their primary care doctors," he adds. "We need to go further, be more pre-emptive."