In addition, clinicians should be alert to conditions that affect their patients’ mental health. Look for signs of eating disorders and insulin manipulation to induce weight loss, particularly in young women, as these can be fatal.2 Younger men who experience erectile dysfunction may feel great social and emotional distress. Routine screening for psychosocial distress and mental well-being should be incorporated into the care of patients with diabetes. Comorbid conditions of anxiety, depression, disordered eating, and fear of hypoglycemia are significantly correlated with nonadherence, suboptimal glycemic control, reduced quality of life, and increased acute and chronic diabetes complications.5 It is important to explore the support systems in place for such individuals, including family, friends, and support groups. 

Preconception care and counseling for both males and females with diabetes within this age group is an important aspect of diabetes management. For individuals contemplating parenthood, the predisposition for diabetes and risk of birth deformities in the offspring can be an important factor to consider. For males with type 1 diabetes, the risk that their offspring will also have diabetes is 1 in 17. For females with type 1 diabetes, the risk that their offspring will also have diabetes is 1 in 25 if they give birth before age 25. If they give birth after age 25, the risk that their child will have diabetes is 1 in 100.


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Comparably, the risk for patients with type 2 diabetes to have an offspring with diabetes is 1 in 7 when the parent is diagnosed before age 50. If the patient is diagnosed after age 50, there is a 1 in 13 risk that their offspring will have diabetes. The increased risk for diabetes among offspring of parents with type 2 diabetes compared with parents with type 1 diabetes appears to be partly attributed to familial lifestyle habits.6

Diabetes during pregnancy bears significant risks for both the mother and fetus. There are different risk stratifications for women with preexisting diabetes compared with pregnancy-onset (gestational) diabetes. Gestational diabetes has a prevalence of 9.2%, according to the CDC .7 Women with pre-existing diabetes have a higher risk for miscarriage, preeclampsia, and preterm labor. In women with pre-existing diabetic retinopathy, the condition can accelerate rapidly during pregnancy. Risks to the fetus/neonate born to mothers with pre-existing diabetes include stillbirth, congenital malformations, macrosomia, birth injury, perinatal mortality, and postnatal adaptation problems (such as hypoglycemia).8 Comparably, women who develop gestational diabetes have a significantly decreased risk for birth defects. 9

The teratogenic effects of hyperglycemia primarily occur in the yolk sac during early pregnancy. Maternal hyperglycemia leads to excess glucose metabolism in the developing embryo, resulting in changes in cell lipid metabolism, excess generation of reactive oxygen species secondary to mitochondrial dysfunction, and activation of programmed cell death or apoptotic, signaling cascades.9

In a study comparing congenital birth defects of offspring born to women with type 1 diabetes compared with offspring born to women with type 2 diabetes or without diabetes, the rate of birth defects was five times higher for offspring of mothers with type 1 diabetes compared with mothers with gestational diabetes. The risk of major birth deformities was proportional to the extent of maternal glycemic control during the first trimester.9 The key to preventing/minimizing maternal fetal complications is through preconception counseling and stringent glycemic control prior to conception and throughout pregnancy.5

Women with a history of gestational diabetes have an increased risk of developing gestational diabetes during subsequent pregnancies. These women will also require a lifetime of screening for type 2 diabetes, even long after the birth of their child. Their risk for development of type 2 diabetes is 50% over 7 to 10 years. Women who are overweight can reduce their risk of developing diabetes by 60% through losing 7% of their pre-pregnancy weight.10

Conclusion

Younger adults with diabetes have different healthcare needs than their young or elderly counterparts. Clinicians need to account for their unique developmental characteristics, milestones, and psychosocial challenges when individualizing a plan of care for a patient in the younger adult population.

Annie D. Lu, ANP-BC, ADM-BC, practices at the NYULMC-Hospital for Joint Diseases Diabetic Foot and Ankle Center.

References

  1. Centers for Disease Control and Prevention: National diabetes statistics report: estimates of diabetes and its burden in the United States. Accessed Oct. 19, 2015. http://www.cdc.gov/diabetes/pubs/statsreport14/national-diabetes-report-web.pdf
  2. Garvey KC, Wolpert HA. Identifying the unique needs of transition care for young adults with type 1 diabetes. Diabetes Spectrum. 2011;24(1):22-25.
  3. Saint Edward’s University. Hypoglycemia and alcohol intoxication. Accessed Oct. 19, 2015. www.cs.stedwards.edu/chem/Chemistry/CHEM44/sebesta/ohgly.html
  4. Centers for Disease Control and Prevention Office on Smoking and Health. Accessed Oct. 19, 2015. http://www.cdc.gov/tobacco/data_statistics/sgr/2012/index.htm
  5. American Diabetes Association. Standards of medical care in diabetes 2015. Diabetes Care.  2015;38(1):S1-S94.
  6. American Diabetes Association. Genetics of diabetes. Accessed Oct. 19, 2015. http://www.diabetes.org/diabetes-basics/genetics-of-diabetes.html
  7. American Diabetes Association. What is gestational diabetes? Accessed Oct. 19, 2015. http://www.diabetes.org/diabetes-basics/gestational/what-is-gestational-diabetes.html
  8. National Institute for Health and Care Excellence. Diabetes in pregnancy: management of diabetes and its complications from pre-conception to the postnatal period. 2008. Accessed Oct. 19, 2015. https://www.nice.org.uk/guidance/cg63
  9. Reece AE. Diabetes-induced birth defects: what do we know? What can we do? Curr Diab Rep. 2012;12(1):24-32.
  10. Joslin Diabetes Center. Accessed Oct. 19, 2015.  http://www.joslin.org/info/Gestational-Diabetes.html