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    Taking control of T2D

    Taking ownership of one’s diabetes begins by making small, daily lifestyle changes that are sustainable for the long term. Here are office strategies pediatricians can use to motivate their patients with diabetes to make better personal choices regarding eating, weight loss, and physical activity.

    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.

    More: New therapy to fight pediatric hypoglycemia

    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

    Pat F Bass III, MD, MS, MPH
    Dr Bass is Chief Medical Information officer and professor of Medicine and of Pediatrics, Louisiana State University Health Sciences ...


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