Louise DeRiso, MSN, CRNP, CDE, Mehry Safaeian, MS, RD, CDE,
and Sue Challinor, MD

MMF is a 22-year-old Caucasian female who was diagnosed with type 1 diabetes in 1991 shortly after being diagnosed with hyperthyroidism. During a routine physical exam for a driver’s license, an enlarged thyroid gland was noted.

Thyroid function testing revealed an elevated T4 and a nondetectable TSH. Therapy was initiated with the antithyroid drug methimazole, 30 mg per day.

During this evaluation, MMF was noted to have glycosuria, with a plasma glucose of 227 mg/dl. In addition to her hyperthyroid symptoms, a review of systems revealed a 3-week history of polyuria, polydipsia, and nocturia. There was no weight loss during this period.

MMF was admitted to the hospital for the initiation of insulin therapy. At discharge, she was referred to the pediatric outpatient clinic for continued follow up of her presumed type 1 diabetes and hyperthyroidism.

Methimazole was continued for 4 years before initiating definitive therapy with radioactive iodine in 1994 and again in 1995. She failed to return for any further follow-up to the pediatric clinic after her second radioactive iodine treatment at the age of 20. She continued her previously prescribed insulin regimen.

MMF was referred to our center on the recommendation of the director of the University of Pittsburgh’s nurse practitioner program. Her first visit to the adult diabetes center was in December 1997, 2 years after her last appointment in the pediatric clinic. She was 5940 and weighed 111 lb., with a body mass index of 19 kg/m2.

Her insulin regimen consisted of 8 U NPH insulin before breakfast and supper, with a sliding scale of 1–4 U regular insulin at those same times depending on home glucose monitoring values. She monitored her blood glucose twice a day, obtaining readings that ranged between 215 and 549 mg/dl. She described hyperglycemic symptoms of fatigue and polyuria. For the past 2 years, MMF had been exercising aerobically (treadmill, stairmaster, and weight training) for 2 hours, 3 days a week at variable times.

MMF is single and in college in the School of Social Work. She is currently in her fifth year on a clinical rotation at several social welfare agencies. She reports a hectic schedule, often skipping breakfast (especially if her blood glucose level is high) and eating lunch only when it can be fit into her schedule.

Laboratory testing (nonfasting) in our center at the time of her first visit is listed below. 

Nurse Practitioner Assessment/Plan
When asked the reasons for the absence of medical follow-up for 2 years, MMF expressed frustration with the care provided at her visits at the pediatric clinic. She felt she was "being told what to do," and was afraid to return for appointments because she did not do what was recommended. Also, the clinic she was attending rotated physicians, and she said she was tired of having to repeat her history and management plan. She now wanted to have one clearly identified health care provider who would address all of her health care needs. MMF expressed a desire to be treated as an adult and not to be told what to do. She did not seek any medical follow-up for a while, just choosing to "take care of myself."

There are many barriers to the transition of care from adolescent to adult health care in those with a chronic disease.¹ The transition from adolescence to adulthood is generally a period of challenge. The individual is trying to become independent while physical and emotional changes are taking place. Thinking ability evolves from concrete to abstract during this time. Adding to the stress of adolescence are the changing expectations at home, at school, and with peers. Adolescents with a chronic disease face even more stress at this transitional stage since the natural progression towards independence conflicts with the need for continuing adult supervision and support.

In addition, when medical care has to be transferred from a pediatric to an adult health system, additional stress occurs. Many barriers have been identified in the transition from pediatric to adult medical care. These include a change in the type and level of support, a change in decision-making and consent processes, a marked reduction in family participation, reduced tolerance and sensitivity of health care professionals to psychosocial issues, and the lack of insurance coverage and other financial considerations.1 Organized transition programs have been limited and require ongoing interest and commitment for collaboration between pediatric and adult teams.

A nurse practitioner who is a certified diabetes educator (CDE) can provide holistic health care in a cost-effective manner in the absence of an organized program during this transition phase.² The Diabetes Control and Complications Trial serves as a model for an effective team approach.³ A nurse practitioner CDE may be able to provide many of the skills of the study team. The combination of a basic nursing background and advanced nurse practitioner skills for assessment of physical and psychological status, together with diabetes education skills, allows for the provision of comprehensive diabetes care. Fragmentation of care is reduced using this approach, and patient satisfaction may be increased.

MMF was relieved to know that a nurse practitioner would be the main provider of care and education. A registered dietitian is available in our clinic for nutritional education, but in the absence of this team member, a nurse practitioner can also provide general dietary counseling to people with diabetes. Based on MMF’s initial lab work and home glucose monitoring results, a conservative goal for home glucose measurements of 100-200 mg/dl was established. The goal range was made with MMF’s active participation, thereby reducing her perception of "being told what to do."

Her current split/mixed regimen of NPH and regular insulin did not allow for flexibility in mealtimes or for unexpected or unplanned meal portions. The nurse explained the rationale of using ultralente insulin combined with regular insulin at each meal, and MMF was anxious to try this method, which would allow for flexibility of mealtimes. A dosage was established of 15 U of ultralente in the morning, combined with 5 U of regular with each meal, along with an algorithm for adjusting the dose of regular. The sliding scale developed involved subtracting 1 U of regular for blood glucose values <100 mg/dl and adding 1 U for each 50-mg increase in blood glucose level above 200 mg/dl.

Based on her lab results, MMF was found to have two additional intercurrent illnesses, hypothyroidism and a urinary tract infection (UTI). After consultation with the attending physician, MMF was started on 0.075 mg of levothyroxine every day for post-ablative hypothyroidism. She was also started on a 10-day course of sulfamethoxazole/trimethoprim for the urinary tract infection.

MMF’s exercise schedule was discussed at the initial visit. She decided to try to exercise for 1 hour a day, 5 days per week in the morning in order to the reduce potential fluctuations in blood glucose due to varying exercise times. She agreed to check her blood glucose level three times a day and to call in blood glucose values on a regular basis until glycemic control was established. She was instructed to check for urine ketones when glucose measurements were above 240 mg/dl for two consecutive readings.

Nutrition Assessment/Plan
At the initial visit with the dietitian, MMF expressed a desire to keep her weight between 117 and 120 pounds. She also stated "I need to learn how and what to eat on the run."

According to diet recall, MMF eats 2–3 meals per day at irregular times and with variable portions. Her diet was assessed as being low in protein and fiber and high in carbohydrate.

At the initial assessment, the dietitian discussed the nutritional objectives of diabetes management: 1) appropriate blood glucose level, 2) appropriate blood fat/cholesterol level, 3) balanced nutrition, and 4) reasonable weight.⁴ The dietitian also discussed the basics of diet and diabetes, which included the roles of carbohydrate, protein, and fat in human nutrition and blood glucose control.

Using the USDA Food Guide Pyramid, the dietitian discussed the concepts of balance and variety.⁵ MMF was encouraged to include a source of protein at each meal to help curb the blood glucose peak. The dietitian and MMF discussed a variety of easy-to-obtain protein sources to accommodate her busy schedule. Given MMF’s work and eating schedule, the dietitian also discussed the causes, signs, and treatment of hypoglycemia.

We try to discuss different meal- planning approaches with our clients and let them weigh the options, choosing the one they feel they can employ. Therefore, in addition to the information above, MMF was made aware of other meal-planning approaches, such as carbohydrate counting (premeal regular insulin given per specific grams of carbohydrate consumed), if the desired outcome was not reached.

Follow-Up
MMF called in blood glucose values 2 weeks after her initial visit. Her glucose level was now ranging between 250 and 380 mg/dl, an improvement from the values of 400–500 mg/dl. The decision was made to increase the ultralente to 20 U.

MMF returned to the clinic 1 month after the initial visit and was happy to report less fatigue, depression, and urinary frequency. She had completed her course of antibiotics and was now taking the levothyroxine sodium as prescribed. She currently weighs 118 lb., a gain of 7 lb. since the first visit. Her home glucose values range between 156 and 350 mg/dl.

At this time, her ultralente insulin was increased to 22 U, and regular insulin was increased to 6 U at lunch and supper. Because her glucose levels decreased overall throughout the day, a decision was made with MMF to change her goal range to 100–150 mg/dl. MMF chose an insulin pen to help simplify her diabetes regimen. Plans were made for preventive health visits to an ophthalmologist and gynecologist. Labs drawn on the return visit revealed a random glucose of 154 mg/dl, electrolytes within normal range, and a normal urinalysis.

MML returned 10 weeks after the original appointment and reported home glucose values between 112 and 170 mg/dl. She reported eating meals at regular times, including a protein source at each meal. Her weight was stable at 117 lb., within her target range. Labs drawn at this follow-up visit revealed the following:

T4 (Thyroxine):
    8.7 µg/dl (normal 5–12 µg/dl)
Thyroid Binding Ratio:
    1.09 (normal 0.8–1.2)
Free Thyroid Index (FTI):
    9.5 (normal 5–12)
TSH (thyroid stimulating hormone):
    4.789 (normal 0.3–5)
Glucose (nonfasting):
    338 mg/dl
HbA_1c:
    15.5%
Cholesterol:
    219 mg/dl

Conclusion
In the 2 1/2 months since the initial visit, MMF made two follow-up visits to the diabetes center and one phone follow-up and demonstrated good adherence to directions. She no longer complained of symptoms of hyperglycemia, had gained weight, had been successfully treated for a urinary tract infection, and was now euthyroid on replacement hormones. Because the HBA_1c levels had not decreased, plans were made for the next visit to assess glucose meter technique and accuracy by comparing with a lab glucose.

The HBA_1c levels had not have decreased during this time period because there has not yet been a 3-month interval between testing. This will be reevaluated in 2 months, and if no improvement is seen at that time, additional factors such as nonadherence and eating disorders may be considered.

The patient will also be requested to check 2-hour postprandial blood glucoses. Lispro insulin will be considered if these levels are elevated. In order to rule out that the patient is falsifying her glucose results, her glucose monitor’s memory will be reviewed.

The transition from pediatric to adult care can be challenging. It is important for health care providers to try to reduce barriers to adherence to the diabetes regimen and to involve patients in the decision-making process. A nurse practitioner CDE can successfully provide a holistic approach to managing diabetes patients during this time of transition.

References

¹Rettig P, Athreya BH: Adolescents with chronic disease transition to adult health care. Arthritis Care Res 4:174-80, 1991.

²Nettles AT, Kreitzer MJ: Trends in advanced nursing practice and implications for care of diabetes patients. Diabetes Spectrum 7:344-49, 1994.

³The DCCT Research Group: The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 329:997-86, 1993.

⁴American Diabetes Association: Position statement: Nutritional recommendations and principles of people for people with diabetes mellitus. Diabetes Care 21 (Suppl. 1) :S32-35, 1998.

⁵U.S. Department of Agriculture: The Food Guide Pyramid. Hyattsville, MD, USDA’s Human Nutrition Information Service, 1992.

Louise DeRiso, MSN, CRNP, CDE, is an adult nurse practitioner at the University of Pittsburgh Center for Diabetes and Endocrinology and an adjunct instructor at the University of Pittsburgh School of Nursing. Mehry Safaeian, MS, RD, CDE, is a dietitian at the Center for Diabetes and Endocrinology of the University of Pittsburgh Medical Center. Sue Challinor, MD, is an assistant professor of medicine in the Department of Medicine, Division of Endocrinology, at the University of Pittsburgh and director of the Diabetes and Endocrine Center at St. Margaret’s Hospital of the University of Pittsburgh Medical Center.