National Diabetes Month: How Pharmacists Can Serve Impactful Roles in the Lives of Patients with Early-Onset T2DM

November is nationally recognized as Diabetes Awareness Month. The primary goal for 2021 is for patients to become aware of their diabetes status and complete smaller healthy lifestyle changes to make a big difference in diabetes prevention and management.¹ In the United States (US), there are more than 122 million people who have prediabetes or diabetes mellitus. Between 1999 to 2019 diabetes mellitus was the seventh leading cause of death.^2,3 In 2018, the Centers for Disease Control and Prevention (CDC) estimated that 70% of those diagnosed with type 2 diabetes mellitus (T2DM) were 45 years of age or older.⁴ However, increased T2DM diagnoses are emerging among youth and young adult populations in the US with an estimate of around 5000 new cases each year, which warrants an increased need for awareness of early-onset T2DM.⁵

Early-onset T2DM is defined as T2DM occurrence in patients younger than 45 years of age. Its pathophysiology resembles later-onset T2DM with similar non-autoimmune beta-cell failure and insulin resistance; however, early-onset T2DM pathophysiology is uniquely characterized by rapidly progressive beta-cell decline and accelerated advancement of diabetes complications.^5,6 A clinical observation from a secondary care cohort reveals that the early-onset T2DM patients had a substantial increase in diabetic complications like cardiovascular events (37.2%), retinopathy (59.3%), and neuropathy (53.1%) when compared to later-onset T2DM.⁷ Early-onset T2DM is a more aggressive diabetic phenotype with a higher relative risk of cardiovascular mortality.⁸ Furthermore, a study analyzing the outcomes among this age-group concluded that a much higher proportion of young adults with T2DM required insulin treatment (18 vs. 11%, P < 0.001) and that younger adults with T2DM had an eightfold higher overall hazard of developing any macrovascular disease relative to control subjects (HR 7.9, 95% CI 4.8–13.0) compared with only a fourfold increased hazard in the usual-onset T2DM group (HR 3.8, 95% CI 3.4–4.2).⁹ Despite this unique pathophysiology, prevention and management of early-onset T2DM can be successful—especially with the help of health care providers like pharmacists.

Based upon the increased risk of diabetic complications, prevention of early-onset T2DM is imperative in patients who have modifiable risk factors for its development. In adults aged 18-29 years old, there has been a 70% increase in obesity which parallels the 70% increase in T2DM diagnoses among adults aged 30-39 years old.⁹ In addition to obesity, preventable risk factors include a lifestyle of physical inactivity and a diet high in processed fats and carbohydrates.¹⁰ Pharmacists can help modify these patients’ lifestyles by providing patient education on small healthy changes like increased physical activity and more nutritious eating habits. However, there are certain risk factors that put patients at an increased risk for development of early-onset T2DM which are nonmodifiable. Nonmodifiable risk factors include age, gender, race, ethnicity, and family history of disease. T2DM prevalence triples from the ages of 10-14 years to 15-18 years, and adolescent girls have a 60% higher prevalence rate when compared to males.¹¹ Additionally, disadvantaged racial and ethnic minorities are at the highest risk for uncontrolled T2DM among patients under 20 years of age. A cross-sectional analysis of data from a 6-center US study of diabetes in youth indicated that 43.8% of Native American Indian participants, 36.4% of Asian/Pacific Islander participants, and 27.4% of Hispanic participants were classified as having the poorest glycemic control (defined as HbA1C ≥ 9.5%) when compared to only 12.2% of non-Hispanic White participants falling into the same category.¹² Despite the inability for pharmacists to help change these risks, pharmacists can still make an impact in these patients’ lives by identifying these factors, informing the patient, and counseling the patient on the importance of healthy lifestyles based on their increased risk.

Natalie Blanco was diagnosed with early-onset T2DM at 15 years of age. She recalls feeling lost and confused.

“My physician was using big words that I did not understand like ‘monitoring my blood glucose,’” Blanco said. “I was also overwhelmed by all the new information, and I felt like my diagnosis was all my fault due to being overweight.”¹³

Blanco did not know how to manage her new medications or reduce her increased risk for complications until she transitioned through care with various pharmacists whom she recalls as the “most memorable and impactful healthcare provider” during her journey. She credits pharmacists for her continued control of her T2DM.

“They continuously educate and empower me to successfully manage my diabetes, which is why I pursued a career as a pharmacy technician,” Blanco said.¹³

Blanco is just one of many patients for whom pharmacists play an irreplaceable role in the advocacy for and management of early-onset T2DM. Moreover, pharmacists can continue to be impactful providers for this patient population through recognizing risk factors, providing proper medication management, aiding in transitional care, identifying support groups, encouraging healthy lifestyle changes, and spreading awareness of early-onset T2DM for the month of November as well as every day beyond.

REFERENCES

1. National Institute of Diabetes and Digestive and Kidney Diseases. [Internet]. National Diabetes Month 2021. U.S. Department of Health and Human Services; [cited 2021Oct2]. Available from: https://www.niddk.nih.gov/health-information/community-health-outreach/national-diabetes-month
2. National Center for Chronic Disease Prevention and Health Promotion. Diabetes and Prediabetes [Internet]. Centers for Disease Control and Prevention; 2020 [cited 2021Sep21]. Available from: https://www.cdc.gov/chronicdisease/resources/publications/factsheets/diabetes-prediabetes.htm
3. Centers for Disease Control and Prevention, National Center for Health Statistics. Underlying Cause of Death 1999-2019 on CDC WONDER Online Database, released in 2020. Data are from the Multiple Cause of Death Files, 1999-2019, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program; 2020 [cited 2021Sep1]. Available from:
4. http://wonder.cdc.gov/ucd-icd10.html
5. National Diabetes Statistics Report 2020 [Internet]. US Department of Health and Human Services; 2020 [cited 2021 Aug 3]. p. 6. Available from: https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf
6. Nadeau KJ, Anderson BJ, Berg EG, Chiang JL, Chou H, Copeland KC, et al. Youth-onset type 2 diabetes consensus report: Current status, challenges, and priorities [Internet]. Youth-Onset Type 2 Diabetes Consensus Report: Current Status, Challenges, and Priorities. American Diabetes Association; 2016 [cited 2021Oct2]. Available from: https://care.diabetesjournals.org/content/39/9/1635
7. Gungor N, Arslanian S. Progressive beta cell failure in type 2 diabetes mellitus of youth. J Pediatr. 2004 May;144(5):656-9. doi: 10.1016/j.jpeds.2003.12.045. PMID: 15127006.
8. Song SH, Hardisty CA. Early onset type 2 diabetes mellitus: a harbinger for complications in later years--clinical observation from a secondary care cohort. QJM. 2009 Nov;102(11):799-806. doi: 10.1093/qjmed/hcp121. Epub 2009 Sep 4. PMID: 19734298.
9. Song SH, Hardisty CA. Early-onset Type 2 diabetes mellitus: an increasing phenomenon of elevated cardiovascular risk. Expert Rev Cardiovasc Ther. 2008 Mar;6(3):315-22. doi: 10.1586/14779072.6.3.315. PMID: 18327993.
10. Hillier TA, Pedula KL. Complications in young adults with early-onset type 2 diabetes [Internet]. Diabetes Care. American Diabetes Association; 2003 [cited 2021Sep21]. Available from: https://care.diabetesjournals.org/content/26/11/2999
11. Type 2 diabetes in children [Internet]. Mayo Clinic. Mayo Foundation for Medical Education and Research; 2020 [cited 2021Oct2]. Available from: https://www.mayoclinic.org/diseases-conditions/type-2-diabetes-in-children/symptoms-causes/syc-20355318
12. Dabelea D, Mayer-Davis EJ, Saydah S, Imperatore G, Linder B, Divers J, Bell R, Badaru A, Talton JW, Crume T, Liese AD, Merchant AT, Lawrence JM, Reynolds K, Dolan L, Liu LL, Hamman RF; SEARCH for Diabetes in Youth Study. Prevalence of type 1 and type 2 diabetes among children and adolescents from 2001 to 2009. JAMA. 2014 May 7;311(17):1778-86. doi: 10.1001/jama.2014.3201. PMID: 24794371; PMCID: PMC4368900.
13. Petitti DB, Klingensmith GJ, Bell RA, Andrews JS, Dabelea D, Imperatore G, Marcovina S, Pihoker C, Standiford D, Waitzfelder B, Mayer-Davis E; SEARCH for Diabetes in Youth Study Group. Glycemic control in youth with diabetes: the SEARCH for diabetes in Youth Study. J Pediatr. 2009 Nov;155(5):668-72.e1-3. doi: 10.1016/j.jpeds.2009.05.025. Epub 2009 Jul 29. PMID: 19643434; PMCID: PMC4689142.
14. Blanco, Natalie. Personal interview by Rachel Friend. 9 August 2021.