Endocrinology: Differences In Treating Child and Adult Diabetes
My last blog discussed transitioning to college with the exciting changes in routine, independence, and lifestyle. The summer also is a particularly difficult time for those transitioning from college to the "real" world. Many young adults choose to further their education by attending graduate school, while others start their first paying job where workplace benefits are offered in addition to a salary. You must choose a health plan, a vehicle for retirement savings, long-term disability insurance, etc. Welcome to your new world!
These changes also signal that it is time to make the transition to adult medicine and to an endocrinologist who focuses care on adults. Many of my patients are reluctant to leave our practice. You too probably have a certain level of comfort and connection with your childhood endocrinologist and the multidisciplinary team. Each member of the team, including you, know each other's expectations and can probably describe the flow and content of an entire visit in detail (downloading meters, input of insulin doses and other necessary information, discussion of injection sites, negotiated plan, etc.). In addition, there is the emotional attachment that has bonded you to your healthcare provider and team.
Despite these comforts with your doctors, nurses, dieticians, psychologists, etc, it is now time to change doctors. Why is this important? Pediatric specialists are trained to care for infants, children, and adolescents. At the critical age of 21 to 22 years, you have adult issues and needs. Issues such as sexual relationships, birth control, pregnancy, preventive medications for hypertension, and cholesterol become relevant. Now the physical examination plays a greater role in your outpatient follow-up visits.
Adult endocrinologists are trained to monitor physical manifestations of diabetes-related complications, such as peripheral neuropathy (problems with sensation in feet), retinopathy (eye problems), nephropathy (kidney problems), and cardiovascular disease (heart and lipid issues--cholesterol and triglycerides). These endocrinologists often perform monofilament testing on your feet during an outpatient visit to look for symptoms, such as loss of sensation, which signals peripheral neuropathy. Sometimes they will send you to a podiatrist for more specialized testing on your feet. The doctors will monitor your weight and blood pressure, look for skin changes associated with diabetes, continue to examine your thyroid gland, and do a more detailed physical examination. Adult endocrinologists also will continue to perform associated blood work, including hb a1c, lipid panels, tests for celiac disease, thyroid function tests, urine evaluations (checking for microalbumin), and other adult-related blood work. They will be very concerned about prevention of complications and will even be more rigid about tight blood sugar control. If you are not already on an intensive insulin regime, most adult endocrinologists will strongly encourage you to make the transition. Therefore, I recommend consideration of basal/bolus therapy prior to your transition to adult endocrinology.
The other potential difference with a transition to adult endocrinology is that you may be referred outside the endocrinologist's office for diabetes-related education with a certified diabetes nurse educator, dietician, exercise physiologist, perinatologist (if you become pregnant), etc. There appear to be more private internists/ endocrinologists than pediatric endocrinologists. It also is possible that you may be treated (or continue to be treated) by an academic medical facility with a Diabetes Center that cares for children and/or adults. To find an adult endocrinology practice, check the American Diabetes Association's web site, which lists practices/affiliations in your neighborhood. Your healthcare team also may recommend things to help you find the right fit. I highly recommend that you speak to others and learn who they go to for diabetes care. Word-of-mouth is very important because a healthcare provider may be very knowledgeable, but may not have a comfortable bedside manner. Take the opportunity to meet your future endocrinologist to see if he/she is right for you (not your parents). Your new doctor may ask for medical records to be transferred to his/her office. (This should not be a problem. Just call your doctor's office or medical records to have them sent.) Keep in mind that until you make the transition, your pediatric diabetes team will continue to support and help you manage your diabetes.
I want to emphasize that there is no magical change from age 20-21 when you officially become adult; nor is there a sudden increase in the chances of future diabetes-related complications. The factors related to successful management of diabetes are identical--there is just a change in personnel! There should be no radical changes in philosophy, just more opportunities for adult interactions and partnerships and the potential for more involvement in diabetes research.