Diabetes Care for Emerging Adults:
Recommendations for Transition From
Pediatric to Adult Diabetes Care Systems
A position statement of the American Diabetes Association, with
representation by the American College of Osteopathic Family
Physicians, the American Academy of Pediatrics, the American
Association of Clinical Endocrinologists, the American Osteopathic
Association, the Centers for Disease Control and Prevention, Children
with Diabetes, The Endocrine Society, the International Society
for Pediatric and Adolescent Diabetes, Juvenile Diabetes Research
Foundation International, the National Diabetes Education Program,
and the Pediatric Endocrine Society (formerly Lawson Wilkins
Pediatric Endocrine Society)
ANNE PETERS, MD, CDE1
LORI LAFFEL, MD, MPH2
THE AMERICAN DIABETES ASSOCIATION
TRANSITIONS WORKING GROUP*
During childhood and adolescence,there is a gradual shift from diabetescare supervised by parents and other
adults to self-care management. The ac-
tual change from pediatric to adult health
care providers signals a more abrupt
change that requires preparation by pa-
tients, their families, and their health
care providers. A number of publications
from the U.S. and other countries have
highlighted substantial gaps in care dur-
ing this transition period between pediat-
ric and adult care that often arise in later
adolescence and the subsequent develop-
mental stage of life termed “emerging
adulthood.” This is a critical time when
patients not only assume responsibility
for their diabetes self-care and interactions
with the health care system but when they
become more independent, potentially
moving out of their parents’ home to attend
college or to join the workforce (1). In the
context of these transitions and the devel-
opmental issues of this age-group, gaps in
diabetes care can result in suboptimal
health care utilization, deteriorating glyce-
mic control, increased occurrence of acute
complications, emergence of chronic com-
plications of diabetes that may go unde-
tected or untreated, and psychosocial,
behavioral, and emotional challenges.
With the increasing incidence of both type
1 and type 2 diabetes in childhood, adoles-
cence, and young adulthood, there is an in-
crease in the absolute numbers of youth
with diabetes in this transition period,
highlighting the need for a framework of
care and education for this population
and a call for additional research in this area.
Substantial challenges relating to the
transitional period include the following:
c The dearth of empirical evidence on the
best approaches to the transition process
c Fundamental differences in health care
delivery between pediatric and adult
health care providers
c Lack of well-defined criteria for de-
termination of transition readiness
c The changing social and demographic
characteristics of young adults that may
influence their utilization of health care
c Gaps in health insurance during this
transitional period
c Differences in learning styles between in-
dividuals in this transition period com-
pared with both younger children and
adults beyond the period of emerging
adulthood
c Deficiencies in training of health care
professionals in care delivery for emerg-
ing adults with diabetes
Most of the limited evidence base has
focused on transitions in care for youth
with type 1 diabetes. The recent emergence
of type 2 diabetes in children and teenagers
highlights an absolute deficiency of studies
on transitioning youth with type 2 diabetes
from pediatric to adult care (2). Although
some medical and psychosocial issues may
be different between these groups of youth
withdiabetes,manyare assumed tobe similar.
c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c
From the 1University of Southern California Keck School of Medicine, Los Angeles, California; and the 2Joslin
Diabetes Center, Harvard Medical School, Boston, Massachusetts.
Corresponding author: Lori Laffel, lori.laffel@joslin.harvard.edu.
DOI: 10.2337/dc11-1723
*A complete list of the members of the American Diabetes Association Transitions Working Group can be
found in the APPENDIX.
This position statement was peer-reviewed by members of the Professional Practice Committee in July 2011
and approved by the Executive Committee of the Board of Directors of the AmericanDiabetes Association in
August 2011.
©2011 by the AmericanDiabetes Association. Readersmay use this article as long as thework is properly cited,
the use is educational and not for profit, and the work is not altered. See http://creativecommons.org/
licenses/by-nc-nd/3.0/ for details.
care.diabetesjournals.org DIABETES CARE, VOLUME 34, NOVEMBER 2011 2477
R e v i e w s / C o m m e n t a r i e s / A D A S t a t e m e n t s
P O S I T I O N S T A T E M E N T
In March 2010, the American Diabe-
tes Association (ADA) convened a multi-
disciplinary group of experts and people
with diabetes (see APPENDIX for organiza-
tions and individuals) to review the issues
that confront both youth and young
adults with diabetes and health care pro-
fessionals during this critical transition
process from pediatric to adult care. The
issues that need to be considered to un-
derstand the process of transition were
described and discussed. This resulting
statement provides a framework for
health care delivery during the transition
period and an agenda for future research.
RATES OF DIABETES DURING
THE TRANSITION YEARSdThe
SEARCH for Diabetes in Youth study has
estimated that about 15,000 youth are
diagnosed annually with type 1 diabetes
and about 3,700 are diagnosed annually
with type 2 diabetes (3). In 2001, SEARCH
estimated that there were approximately
154,000 youth under the age of 20 years
with diabetes (3,4), and in 2010 the esti-
mated number of youth with diabetes was
215,000, representing 0.26% of individu-
als in this age-group (5).
Worldwide, the prevalence of type 1
diabetes in children and young adults
has doubled in the past 25 years and is
expected to double yet again in the next
15–20 years, a phenomenon not observed
several decades ago (6,7). The epidemic of
childhood obesity has lead to an increased
incidence of type 2 diabetes being diag-
nosed in children and teenagers (8). Type
2 diabetes remains relatively uncommon
in children under age 10 years, with the
majority of cases identified in youth dur-
ing the 2nd decade of life and affecting
predominantly those from racial and/or
ethnic minority groups, namely American
Indians, blacks, Hispanics, Asians, and
Pacific Islanders (9–13). Furthermore, al-
though the incidence of type 1 diabetes de-
clines toward the middle to the late 2nd
decade of life (age 15–19 years) from the
peak rates observed during puberty in early
adolescence, the incidence of type 2 diabe-
tes continues to increase with age.
There are limited epidemiological data
that span the age range from late adolescence
through young adulthood (18–30 years
of age), although there are data that pre-
cede and follow this key developmental
period. The SEARCH study provides
prevalence estimates for 15- to 19-year-
olds in various racial and ethnic popula-
tions (9–13). Prevalence of type 1 diabetes
for this age-group ranges from 0.43 per
1,000 in Navajo youth to 3.22 per 1,000
in non-Hispanic whites, while the preva-
lence of type 2 diabetes ranges from 0.29
(non-Hispanic whites) to 2.36 (Navajo) per
1,000. In a survey of 11,855 young adults
(41% response rate), ages 18–29 years, at-
tending 2-year and 4-year postsecondary
educational institutions in Minnesota,
0.55% of students reported having a diag-
nosis of type 1 diabetes (E. Ehlinger, per-
sonal communication).
The size of the young adult popula-
tionwith diabetes is difficult to knowwith
certainty. The overall numbers of chil-
dren, adolescents, and young adults with
diabetes in the U.S. in 2007was estimated
at close to a million in a study of diabetes
costs including the age-groups ,18 and
18–34 (14). Given the current estimates
of the prevalence of diabetes in youth, one
can expect that each year there are tens of
thousands of emerging young adults with
type 1 or type 2 diabetes who will be tran-
sitioning from pediatric to adult care.
EMERGING ADULTHOODdFor
the purposes of this statement, we have
chosen to focus on the age range of 18–30
years. The preceding period of adolescent
growth and development is a stage of tre-
mendous physical, social, and emotional
change that challenges diabetes manage-
ment for both youth and health care pro-
viders. During this stage of adolescent
development, there is a need for ongoing
family involvement in diabetes manage-
ment in order to reduce the risk of dete-
rioration in glycemic control that often
accompanies adolescence (15).
In contrast to the views of traditional
developmental psychology, contemporary
thinking is that young adulthood does not
immediately follow adolescence, but be-
gins when youth are in their late 20s or
early 30s and that the developmental stage
between ages ;l8 and 30 years defines a
period called emerging adulthood (16). Re-
cent cultural trends in America suggest that
young people in their 20s delay assuming
adult roleswith respect tomarriage, parent-
ing, andwork comparedwith young adults
in earlier generations. Contemporary de-
velopmental theorist J.J. Arnett (16) sug-
gests that the postadolescent period is
subdivided into an early phase correspond-
ing to the years immediately after high
school (;18–24 years) and a later phase
when more traditional adult roles are as-
sumed (;25–30 years). Thinking about
the postadolescent period as consisting of
two phases provides a valuable framework
when considering diabetes management
and may help to ensure that the clinician’s
approach and focus are appropriately
matched to the emerging adult’s life cir-
cumstances and readiness to become an ac-
tive participant in his/her own diabetes
management.
During the early phase of emerging
adulthood, the person may be transition-
ing geographically, economically, and
emotionally away from the parental home.
Competing academic, economic, and so-
cial priorities often detract from a focused
commitment to chronic disease manage-
ment. Even as young adults face these
competing demands, most do not believe
that they have achieved all of the skills
necessary to remain independent and ac-
cept these responsibilities on their own
(16). Therefore, it may be unrealistic to
expect the person with diabetes in the first
phase of emerging adulthood to make ma-
jor changes in their diabetes management
strategies, or even to transition to a new
adult diabetes health care provider. Con-
versely, for many this early phase is
marked by feelings of invulnerability
and a tendency to reject adult control,
which may further limit receptiveness to
recommendations for diabetes treatment.
During the second phase of the young
adult period, the 25- to 30-year-old often
has a maturing sense of identity and as-
sumes adult-like roles in society, such as
entering into stable intimate relationships
or full-time employment. This phase,
when the individual starts making plans
about his/her future life, is often accompa-
nied by a growing recognition of the im-
portance of striving for better glycemic
control and receptiveness to improving
self-care behavior. Life partners can be
important supports and agents for change,
and a shared sense of investment in the
future will often catalyze this change in
self-care behavior. This period, when life-
long patterns of behavior are likely es-
tablished, can be a critical window of
opportunity for health care interventions.
ISSUES IN THE TRANSITION
BETWEEN PEDIATRIC AND
ADULT DIABETES CAREdThe
transition from pediatric to adult diabetes
care represents a high-risk period for
a person with diabetes, a perfect storm
during which interruption of care is likely
for multiple reasons. The young person
is leaving what has often been a long-
term, comfortable relationship with
health care providers, sometimes without
preparation or ready access to a subse-
quent provider. There are also multiple
2478 DIABETES CARE, VOLUME 34, NOVEMBER 2011 care.diabetesjournals.org
Position Statement
psychosocial adjustments during the
postadolescent period of emerging adult-
hood that can be confounded by financial
stressors. Poor glycemic control, the
presence of risk factors for complications
(hypertension and dyslipidemia), high-
risk behaviors (cigarette smoking and
drug and/or alcohol abuse), and emerging
complications may further increase the
difficulty of this period. The period of
emerging adulthood may be accompanied
by uncertainty regarding health insurance
coverage upon completing education or
leaving the parental home. Given that
individuals in this transition period have
had the highest rates of uninsurance or
underinsurance in the past, the reforms
of the Patient Protection and Account-
able Care Act in the U.S. should be of
particular benefit to emerging adults
with chronic conditions such as diabetes.
The following sections elaborate on
eight areas of particular relevance for the
emerging young adult with diabetes: differ-
ences between pediatric and adult care,
poor glycemic control, loss to follow-up
care, acute complications, psychosocial is-
sues, reproductive health issues, substance
use and abuse, and chronic complications.
Differences between pediatric and
adult care
There are fundamental differences in the
approach and delivery of diabetes care
between pediatric and adult patients. Di-
abetes care for pediatric patients requires
involvement of the family in order to be
successful. Young children do not have the
cognitive ability to master diabetes man-
agement, and teens often donot possess the
emotional maturity to sustain the tasks of
daily therapy. Although health care deliv-
ery varies by system and access, in the
pediatric health care setting, visits tend to
be family-focused, holistic, and centered on
management approaches that fit diabetes
into the child and family’s lifestyle. Diabetes
visits and management approaches include
parents/guardians as well as the youth.
In adult care, the focus is more on the
autonomously functioning individual pa-
tient, who can be informed or counseled
but then is expected to make his/her own
choices about behavior or treatments.
Adult visits tend to be substantially shorter
and focused on medical problems. Adult
patients choose who they do and do not
want to have access to their health infor-
mation and are largely considered indepen-
dent consumers of health care. Whereas
individuals change gradually from child-
hood to adulthood, the change in health
care provider can be abrupt and unsettling,
suggesting that a more gradual transition
may be preferable.
Poor control of glycemia and other
risk factors
There remains a considerable gap between
the recommended glycemic control levels
and the levels actually achieved in clinical
practice, especially for older teens and
young adults. The SEARCH for Diabetes
in Youth study showed that only 32%
of youth with type 1 diabetes aged 13–
18 years and 18% of those aged $19
years achieved ADA-recommended
A1C targets (17). On the other hand, Na-
tional Health and Nutrition Examination
Survey data reveal that 56% of adults ach-
ieve target A1C values of ,7% (18). The
greatest proportion of youth with type 1
or type 2 diabetes in poor glycemic con-
trol (A1C$9.5%) were teenagers; one of
every four patients aged .12 years had
such elevated A1C levels (17). Others
have documented poor glycemic control
during the older teen and young adult
years (19,20). Those in the poorest glyce-
mic control are at high risk for both acute
complications and chronic microvascular
complications (20,21).
The prevalence of cardiovascular risk
factors is much greater in youth with type
2 versus type 1 diabetes, regardless of
ethnicity (22). However, as the general
obesity rates among all U.S. children
and adolescents increase, youth with
type 1 diabetes have experienced simi-
larly increasing rates and may have addi-
tional cardiovascular risk, partly as a
result of the suboptimal diets reported
in youth with either type 1 or type 2 di-
abetes (23). Studies show higher rates of
dyslipidemia in obese children and ado-
lescents with type 2 diabetes (22,24,25).
Elevated lipid levels in youth with type 1
diabetes appear to be related to level of
glycemic control (26). The rates of hyper-
tension in children and adolescents with
diabetes comparedwith those without di-
abetes are largely related to overweight or
obesity status. Fatty liver disease is also
more common among obese children
with insulin resistance and diabetes,
may precede the diagnosis of type 2 diabe-
tes, and has also been linked to type 1 di-
abetes (27). Progression and optimal
treatment of fatty liver disease is not
known in adolescents, but the disease
can progress to cirrhosis and death.
These risk factors need to be addressed
in the adolescent and transitioning young
adult.
Loss to follow-up
The competing distractions of young adult
life often interfere with the requirements
of successful diabetes management, in-
cluding the need to maintain consistent
medical care. Transitioning older teens and
young adults are at high risk for disen-
gagement fromhealth care and, in turn, the
emergence of complications that may go
undetected without appropriate follow-up
diabetes care and screening. There are
adverse short-term (hypoglycemia, hyper-
glycemia, or diabetic ketoacidosis [DKA])
and long-term (nephropathy and retinop-
athy) outcomes when patients with diabe-
tes are lost to follow-up or have infrequent
encounters (21,28,29). Rates of hospitali-
zation and emergency use and costs of care
are higher when glycemic control is poor
(21). Glycemic control and diabetes out-
comes are also poorer when patients do
not understand or participate in their care.
The relative risk of death is higher for
young adults with diabetes than for those
without diabetes (30). Lapses in care or
loss to follow-up accounts for some of
these adverse outcomes of transitioning
older teens and young adults (31–33).
Older teens and young adults with diabe-
tes, especially those from racial/ethnic
minority or low socioeconomic status
backgrounds, require increased access to
care in order to maintain continuity and
coordination of multidisciplinary support
and to receive ongoing self-management
support. Continuous follow-up helps re-
duce the need for costly, acute hospitaliza-
tions and provides for early intervention of
chronic complications to optimize long-
term health outcomes and functioning.
Increased risk for acute
complications
A variety of factors may increase the risk of
hypoglycemia and severe hyperglycemia
or DKA in transitioning youth, including
loss of parental supervision of diabetes care
and reduced attendance at diabetes med-
ical visits. The challenges of work and/or
school often take precedence over diabetes
care. Other lifestyle changes may include
increases in alcohol consumption, changes
in physical activity levels, varying motiva-
tion for self-care (as emerging young
adults separate from parents), and differing
dietary patterns from a more controlled
family-home environment. Although data
are lacking on the incidence of severe
hypoglycemia and DKA during the early
transition years, in the Diabetes Control
and Complications Trial (DCCT) adoles-
cents aged 13–17 years at study entry and
care.diabetesjournals.org DIABETES CARE, VOLUME 34, NOVEMBER 2011 2479
Peters, Laffel, and the American Diabetes Association Transitions Working Group
20–24 years at study’s end had a higher rate
of severe hypoglycemia than adults (34).
Rates of DKA in older adolescents are asso-
ciated with nonadherence and poorer gly-
cemic control (35).
Recent studies of continuous glucose
monitoring (CGM) have assessed rates
of overnight hypoglycemia in individuals
aged 15–24 years, with nocturnal hypo-
glycemia documented during
本文档为【ADA青少年成人糖尿病护理过渡期指南】,请使用软件OFFICE或WPS软件打开。作品中的文字与图均可以修改和编辑,
图片更改请在作品中右键图片并更换,文字修改请直接点击文字进行修改,也可以新增和删除文档中的内容。
该文档来自用户分享,如有侵权行为请发邮件ishare@vip.sina.com联系网站客服,我们会及时删除。
[版权声明] 本站所有资料为用户分享产生,若发现您的权利被侵害,请联系客服邮件isharekefu@iask.cn,我们尽快处理。
本作品所展示的图片、画像、字体、音乐的版权可能需版权方额外授权,请谨慎使用。
网站提供的党政主题相关内容(国旗、国徽、党徽..)目的在于配合国家政策宣传,仅限个人学习分享使用,禁止用于任何广告和商用目的。