Health Literacy: Diabetes Mellitus Type II in Adolescents

Health Literacy: Diabetes Mellitus Type II in Adolescents 

A family nurse practitioner plays a key role in the facilitation of education to patients and families regarding many illnesses and diseases treated within the primary care setting. Type 2 Diabetes Mellitus (T2DM) is a commonly diagnosed and treated condition in primary care.  While type 2 diabetes has generally affected adults, there has been a 4.8 percent increase in rates of adolescents diagnosed in the years 2000 to 2012 (National Institutes of Health, 2017). Type 2 diabetes is linked with multiple comorbidities that can lead to life-long health complications and premature mortality (Temneanu, Trandafir, & Purcarea, 2016).  For this reason, it is necessary for early identification of patients at risk for T2DM so that a diagnosis can be made,  and treatment can be implemented. Proper education should be provided to patients and caregivers in an effort to prevent or reduce complications associated with this disease. 

 The purpose of this health literacy project is to assist patients and caregivers in the primary care setting with understanding the risks and diagnosis of type 2 diabetes mellitus through the use of educational materials.  The adolescent patient and caregiver are the targeted audience for this project. This paper will discuss the exploration of the evidence base for type 2 diabetes mellitus, the health literacy for patients and caregivers, provide an educational outline, and an educational pamphlet to be distributed to patients and caregivers in the primary care setting. 

Exploration of the Evidence Base for Diabetes Mellitus Type 2 in Adolescents

The family nurse practitioner (FNP) plays a pivotal role in the assessment of risk, diagnosis, treatment, and education of adolescents with T2DM.  In order to properly provide care for these individuals, the nurse practitioner must have a full understanding of the disease. In this section the pathophysiology, clinical manifestations, and treatment of T2DM will be discussed. Type 2 diabetes mellitus currently affects about 25,000 adolescents, with an increased prevalence amongst children from a poor socioeconomic status and ethnic backgrounds (Nadeau et al., 2016).  The rates have continued to rise since the year 2000, placing an increased burden on the health system (Mayer-Davis et al., 2017), as many body systems play a role, and are affected by T2DM. As this threatening disease increases in children, so does the prevalence of chronic and long-term comorbidities. The earlier youth develop T2DM, the earlier damage can occur to other body systems (Kao & Sabin, 2016). This correlates with increased medical expenses among those diagnosed with T2DM (American Diabetes Association, 2018).  In an effort to reduce the onset of long-term health issues connected with the disease, education and treatment should be provided when risks for the patient become evident. 

Pathophysiology

Type 2 diabetes is a multisystem metabolic disorder characterized by insulin resistance and reduced beta-cell function (McCance, Huether, Brashers, & Rote, 2019).  Several factors play a role in the development of insulin resistance including diet, lifestyle, genetics, environment, and obesity (Temneanu, Trandafir, & Purcarea, 2016).  Insulin resistance occurs as a result of insufficient insulin responses from the muscles, liver, and adipose tissues (McCance, Huether, Brashers, & Rote, 2019). Obesity is one of the most common contributors to T2DM in children as it affects many of the insulin pathways. White adipose tissue, associated with obesity, leads to increased levels of the hormone leptin and decreased levels of adiponectin, both of which result in insulin resistance (McCance, Huether, Brashers, & Rote, 2019).  Obesity further causes elevated levels of inflammatory cytokines in the body, promoting atherosclerosis and fatty liver (McCance, Huether, Brashers, & Rote, 2019). Obesity can occur for a number of reasons. Research points to poor diet, lack of exercise, stress, environment, and genetics as causes of obesity, thus contributing to T2DM (Temneanu, Trandafir, & Purcarea, 2016). While obesity plays a major role, other body systems contribute to hyperglycemia. Hyperglycemia is the term given for elevated blood glucose levels. Irregular function of the liver, digestive system, kidneys, pancreas, muscles, and brain  can be conducive to T2DM. Increased gluconeogenesis in the liver, decreased ghrelin secretion from the stomach, increased reabsorption of glucose from the kidneys, decreased insulin sensitivity from the muscles, increased secretion of glucagon from the pancreas along with decreased beta cell-function, and altered insulin- signaling pathways and dysfunction of neurotransmitters in the brain contribute to and result in hyperglycemia (McCance, Huether, Brashers, & Rote, 2019). Elevated blood glucose levels are indicative of insulin resistance and is a necessary criterion for the diagnosis of T2DM. The long-term effects of hyperglycemia lead to an abundance of comorbidities and health issues that can be detrimental to the patients’ overall health. Comorbidities associated with T2DM include neuropathy, retinopathy, heart disease, hypertension, liver disease, immunosuppression, increased infections, chronic kidney disease, and increased risks for stroke, myocardial infarction, and cancer (McCance, Huether, Brashers, & Rote, 2019).

Clinical Manifestations

With T2DM in youth, clinical manifestations and comorbidities are known to progress at an accelerated rate (Nadeau et al., 2016). Common clinical manifestations of type 2 diabetes mellitus include excessive urination (polyuria), excessive thirst (polydipsia), increased appetite/hunger, fatigue, blurred vision, rash, weakness, and headaches (McCance, Huether, Brashers, & Rote, 2019).  Patients may further experience delayed wound healing and increased infections due to immunosuppression (Zao & Sabin, 2016). These symptoms are a result of multiple body systems malfunctioning leading to hyperglycemia. An elevated fasting blood glucose level is generally noted when these symptoms are present. It is important to note that adolescents with diabetes may be asymptomatic, therefore suggesting an increased need to screen patients for risk factors (Temneanu, Trandafir, & Purcarea, 2016). The diagnosis of T2DM requires one of the following criteria: a hemoglobin A1c (HgA1c) greater than 6.5 percent,  a fasting plasma glucose (FPG) greater than 126 mg/dL, a two hour plasma glucose of greater than or equal to 200mg/dL, or a random plasma glucose above 200 mg/dL in any patient that exhibits the presence of a hyperglycemic crisis (McCance, Huether, Brashers, & Rote, 2019). Type 2 DM has disproportionately affected adolescents with an American Indian ethnicity, followed by Asians of the black race and individuals from Pacific islands (Temneanu, Trandafir, & Purcarea, 2016). Although rates have been lower among non-Hispanic whites, there is still an association of increased T2DM in individuals from a poor socioeconomic status. This plays a critical role in the management and treatment of T2DM in the primary care setting.

Management/Treatment

Management and treatment of children and adolescents with T2DM starts with identifying causative factors.  The family nurse practitioner needs to assess the patient for factors that play a role in the disease. One factor is a predisposed genetic factor, if diabetes runs in the family. Children with familial history of DM have a 10 to 15 percent increased risk of developing the disease (McCance, Huether, Brashers, & Rote, 2019).  Due to the major role of obesity among children with T2DM, lifestyle should be evaluated. A poor diet high in processed foods and fast foods coupled with lack of exercise promotes increased adipose tissue and obesity. Modifications to lifestyle are critical in the management and treatment of diabetes in youth (Kao & Sabin, 2016).  This is often the first step of treatment and can result in decreased blood glucose levels through a reduction in carbohydrates, empty calories, and exercise. Socioeconomic status should also be recognized as a contributing factor in DM among adolescents. Patients living in poverty may have difficulty eating healthier foods and obtaining needed medications. Individuals from a poor socioeconomic status  may have difficulty accessing adequate health care, further increasing the risk for health disparities. Medications may be needed to treat type 2 diabetes mellitus in children if diet and exercise are not enough to reduce elevated blood glucose levels (Zao & Sabin., 2016).  

 There are two main medications utilized in the treatment of T2DM for adolescents and children.  Metformin, also known as Glucophage, and insulin are the safest known medications for use in youth (St. Onge, Miller, Motycka, & DeBerry, 2015).  Metformin is known to promote insulin sensitivity and decrease the production of glucose from the liver (McCance, Huether, Brashers, & Rote, 2019).  Insulin can be rapid-acting, regular-acting, intermediate-acting, and long-acting. Insulin is generally utilized in combination with metformin to treat adolescent T2DM(St. Onge, Miller, Motycka, & DeBerry, 2015).  The use of insulin can result in other complications such as hypoglycemia. While there are many other medications presently used for the treatment of diabetes in adults, there have not been sufficient studies to assess risks to children resulting in the lack of use for adolescents (St. Onge, Miller, Motycka, & DeBerry, 2015). 

Exploration of the Health Literacy in Patient and Caregiver

Education to both patients and caregivers is essential in reducing the risk for long-term health complications, comorbidities, and early death among adolescents with type 2 diabetes mellitus. It is important to include patients with their care as it promotes patient autonomy and could be beneficial to adolescents, improving their long-term compliance and health outcomes.  The family nurse practitioner should assess the ability of the patient and caregiver to understand information and education regarding the disease at a basic level, known as health literacy. Health literacy provides insight into the capability of the patient and caregiver to adequately make decisions regarding the patient’s care. In type 2 diabetes mellitus, the health literate patient or caregiver would need to be able to identify risk factors for the disease, understand the role of diet, exercise, and obesity, as well as medications. According to a recent study, about 30 percent of patients in the United States diagnosed with T2DM were not health literate (Abdullah, Liew, Salim, Ng, & Chinna, 2019).  Poor health literacy amongst parents of children with type 2 diabetes poses as a barrier to the management and treatment of the disease. Consequences of low health literacy regarding diabetes can lead to ineffective treatment, medication errors, poor diet, and increased risks for complications and hospitalizations (Morrison, Glick, & Yin, 2019). As noted above, the ability of patients and caregivers to properly identify risk factors for T2DM is important because some children can be asymptomatic for long periods of time, which could delay diagnosis and treatment (Temneanu, Trandafir, & Purcarea, 2016). This can inherently increase the risk for early progression of the disease and comorbidities. Early education, therefore, has the potential for reducing complications related to diabetes through increased adherence to behavior and lifestyle changes (Temneanu, Trandafir, & Purcarea, 2016).

 Morrison, Glick, and Yin (2019) discussed ways in which health literacy can be improved through clear communication and adaptation to the patient and caregiver’s level of functional understanding.  There is further need to engage both the patient and caregiver in different methods of education that can stimulate learning to promote improved health-literacy. Communication is key between the practitioner, patient, and parents to promote optimal health of the adolescent (Morrison, Glick, & Yin, 2019). 

 Family nurse practitioners are uniquely poised to provide and promote education regarding T2DM to patients and caregivers. It is in primary care that nurse practitioners, in accordance with the scope of practice, can formulate a trusting relationship with patients and caregivers, obtaining a complete health history identifying health issues, comorbidities, family histories, and living environments that may affect patient care and adherence to treatment plans (American Association of Nurse Practitioners, 2019).  Because T2DM is complex and associated with many comorbidities, it is necessary for the FNP to deliver education materials that can easily be understood by both patient and caregivers in an effort to increase their health literacy. An educational outline should be utilized to facilitate patient and caregiver learning and include patient risks for T2DM, proper diet, exercise, weight loss, and medications used to treat the disease.

Educational Outline

Zhang and Chu (2018) studied a systematic health education model for patients with type 2 diabetes, noting that the approach resulted in increased adherence to treatment plans and reduced HbA1c. This system takes a multifaceted approach to education regarding T2DM. In this model, visual education materials are provided,  nutrition and exercise are addressed and programs for adherence are offered, patients and caregivers are educated regarding self-monitoring of blood glucose levels, and monthly visits to assess compliance and therapeutic effectiveness is encouraged (Zhang & Chu, 2018). While following this approach to educating patients with diabetes, it is also important for the nurse practitioner to communicate clearly with the patient and caregiver. 

The presentation of educational material by the FNP to patients and caregivers can be done in the privacy of the exam room. If language barriers are present, the presence of an interpreter is necessary to facilitate adequate understanding.  Education of patients and caregivers should occur over several visits to ensure adequate health literacy. Prior to the start of education, it is important for the nurse practitioner to assess both the patient’s and caregiver’s current health literacy regarding T2DM. Goals should be predetermined, measurable, and appropriate to the diagnosis. During the first visit, and subsequent visits, the FNP should spend about 30 minutes providing education and allow time for questions and teach-back of material by patient and caregiver. An educational pamphlet should be provided that reinforces educational information and provides other community resources regarding T2DM. The FNP should take time to speak slowly, calmly, and directly at the persons being educated.  Education should be split up, and learners should have the opportunity to ask questions, clarify concerns, and request additional information if needed. Prior to the end of the visits, the nurse practitioner should identify any new issues, concerns, or decreased understanding of material taught. The patient should further be provided with ways to get in touch with the primary care office if questions or health issues arise outside of the office visit. 

Conclusion

In conclusion, the current rising trend of type 2 diabetes mellitus among adolescents is alarming.  The complex and chronic disease affects many body systems and can lead to poor long-term health of the patient and early death.  With a noted accelerated progression of the disease among adolescents, it is necessary for early diagnosis and treatment in an effort to reduce complications associated with the disease. The family nurse practitioner, in the primary care setting, has a responsibility to address T2DM and preemptively combat it through adequate risk assessment, education, and treatment.  The FNP should assess health literacy of all patients and caregivers so that barriers to knowledge and care can be identified and reduced. The use of educational materials in a private setting is needed to enhance the health literacy of the patient and caregiver, as well as improve treatment compliance and health outcomes.

References

• Abdullah, A. M., Liew, S. J., Salim, H. undefined, Ng, C. undefined, & Chinna, K. undefined. (2019). Prevalence of limited health literacy among patients with type 2 diabetes mellitus: A systematic review. PLOS ONE. Retrieved from https://doi.org/10.1371/journal.pone.0216402
• American Association of Nurse Practitioners. (2019). Standards of Practice for Nurse Practitioners. Retrieved from https://www.aanp.org/advocacy/advocacy-resource/position-statements/standards-of-practice-for-nurse-practitioners.
• American Diabetes Association. (2018). The Cost of Diabetes. Retrieved from https://www.diabetes.org/resources/statistics/cost-diabetes.
• CDC. (2017). CDC features: Prevent type 2 diabetes in kids. Retrieved from https://www.cdc.gov/features/prevent-diabetes-kids/index.html.
• Kao, K.-T., & Sabin, M. A. (2016). Type 2 diabetes mellitus in children and adolescents. Australian Family Physician, 45(6), 401–406. Retrieved from https://www.racgp.org.au/afp/2016/june/type-2-diabetes-mellitus-in-children-and-adolescents/
• Mayer-Davis, E. J., Lawrence, J. M., Dabelea, D., Divers, J., Isom, S., Dolan, L., … Wagenknecht, L. (2017). Incidence trends of type 1 and Type 2 diabetes among youths, 2002–2012. The New England Journal of Medicine, 376, 1419–1429. doi: 10.1056/NEJMoa1610187
• McCance, K. L., Huether, S. E., Brashers, V. L., & Rote, N. S. (2019). Pathophysiology: the biologic basis for disease in adults and children (8th ed.). St. Louis: Elsevier.
• Morrison, A. K., Glick, A., & Yin, H. S. (2019). Health literacy: Implications for child health. Pediatrics in Review, 40(6), 263–277. Retrieved from https://doi.org/10.1542/pir.2018-0027
• Nadeau, K. J., Anderson, B. J., Berg, E. G., Chiang, J. L., Chou, H., Copeland, K. C., … Zeitler, P. (2016). Youth-onset type 2 diabetes consensus report: Current status, challenges, and priorities. Diabetes Care, 39(9), 1635–1642. Retrieved from https://doi.org/10.2337/dc16-1066
• National Institutes of Health. (2017). Rates of new diagnosed cases of type 1 and type 2 diabetes on the rise among children, teens. Retrieved from https://www.nih.gov/news-events/news-releases/rates-new-diagnosed-cases-type-1-type-2-diabetes-rise-among-children-teens.
• St. Onge, E., Miller, S. A., Motycka, C., & DeBerry, A. (2015). A review of the treatment of type 2 diabetes in children. The Journal of Pediatric Pharmacology and Therapeutics, 20(1), 4–16. doi: 10.5863/1551-6776-20.1.4
• Temneanu, O. M., Trandafir, L. M., & Purcarea, M. R. (2016). Type 2 diabetes mellitus in children and adolescents: a relatively new clinical problem within pediatric practice. Journal of Medicine and Life, 9(3), 235–239. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5154306/
• Zhang, Y., & Chu, L. (2018). Effectiveness of systematic health education model for type 2 diabetes patients. International Journal of Endocrinology, 2018. doi: 10.1155/2018/6530607