Chapter 20 Diabetes Type 2
Non–Insulin Dependent
PATHOPHYSIOLOGY
Type 2 diabetes, previously called non–insulin-dependent diabetes, or adult-onset diabetes, is considered a chronic disease in which hyperglycemia results from insulin deficiency or hyperinsulinemia. Type 2 diabetes is associated with children who are overweight, a positive family history, and insulin resistance. Insulin resistance occurs when fat, muscle, and liver cells resist the insulin molecule both on the cell membrane and inside the cell. This results in the usual enzymatic reaction within the cell. Eventually beta cells are unable to meet the insulin demands of the body. As with Type 1 diabetes, Type 2 leads to hyperglycemia. This occurs as a result of insulin resistance and decreased insulin secretion. The pancreas does not produce enough insulin.
Insulin is necessary for the following physiologic functions: (1) to promote the use and storage of glucose for energy in the liver, muscles, and adipose tissue; (2) to inhibit and stimulate glycogenolysis or gluconeogenesis, depending on the body’s requirements; and (3) to promote the use of fatty acids and ketones in cardiac and skeletal muscles. Insulin deficiency results in unrestricted glucose production without appropriate use, which leads to hyperglycemia and increased lipolysis and production of ketones and, in turn, to lipemia, ketonemia, and ketonuria.
INCIDENCE
1. Girls have a higher prevalence than boys.
2. The onset most commonly occurs around puberty (ages 10–14 years).
3. Type 2 diabetes occurs disproportionately in American Indian, African American, Mexican American, and Pacific Islander youth.
4. Type 2 diabetes accounts for up to half of all diagnosed cases of diabetes in children and adolescents.
LABORATORY AND DIAGNOSTIC TESTS
For the individual newly diagnosed with diabetes, the following tests are indicated:
1. Randomly determined plasma glucose level—200 mg/dl or higher
2. Fasting plasma glucose level—higher than or equal to 126 mg/dl
Prediabetes is diagnosed for children with fasting glucose levels of 100 mg/dl to 125 mg/dl
MEDICAL MANAGEMENT
Children with the initial diagnosis of Type 2 diabetes do not require insulin injections, because the pancreas is still producing insulin. The focus of therapy is to decrease insulin resistance. This is done through increased exercise and healthier eating. Should this therapy regimen prove to be ineffective, then medications and/or insulin therapy may be needed. At this time, the only approved oral medication for children aged 10 years and older is metformin (Glucophage). If ineffective to reduce glucose levels, insulin may be used. The management of these children requires a multidisciplinary approach for lifestyle changes. Hypertension is managed with weight management, reduced sodium intake, and increased intake of fruits and vegetables. If unsuccessful, blood pressure medications are used. Hyperlipidemia should improve with increased exercise, weight loss, and glucose control. Additional serum lipid screening is done at diagnosis and every 2 years afterward. The goal is keep atherogenic LDL cholesterol below 100 mg/dl, protective high-density lipoproteins (HDLs) above 35 mg/dl, and triglycerides below 150 mg/dl. The child and family need ongoing education and support regarding nutrition, exercise, and daily diabetes self-management. To evaluate the effectiveness of the necessary lifestyle changes, blood glucose levels are monitored regularly.
NURSING INTERVENTIONS
CLIENT OUTCOMES
1. Child will achieve normal growth and development.
2. Child will maintain normal serum glucose levels.
3. Child and family will demonstrate care required at home and have support system in place.
4. Child will have minimal complications: hypertension, hyperlipidemia, neuropathy, nephropathy, and retinopathy.
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Law T. Type 2 diabetes mellitus in youth. Adv for Nurses. 2006;7(8):13. (Florida edition)
Scott LK. Insulin resistance syndrome in children. Pediatr Nurs. 2006;32(2):119.
Thomassian BD. Type 2 diabetes among youth reaches epidemic proportions. Nurs Spectrum. 2004;14(24):22. (Florida edition)
