Year 8

Teenagers

with

Diabetes

Julie Edge and Anna Disney

Topics Oxfordshire Children’s Diabetes Service

Early Adolescence and Diabetes

What happens in a teenagers brain…

Communication

A young person’s and parent’s experience

BG and HbA1c targets

Some practical issues:

– Sport and Exercise

– Alcohol

– Smoking

– Exams

– School

“Our adolescents now seem to love luxury.

They have bad manners and contempt for

authority. They show disrespect for adults

and spend their time hanging around places

gossiping with one another…… they are ready

to contradict their parents, monopolize the

conversation in company, eat gluttonously and

tyrannize their teachers.”

Adolescence

Socrates

Adolescence

Transition between childhood and adulthood.

From onset of puberty to the establishment of adult identity and behaviour.

A developmental stage rather than a chronological age.

“Adolescent” behaving in an immature way.

Puberty

Physical changes which occur in – Genitalia

– Bone structure

– Height and muscle bulk

– Hairiness

– Spottiness, greasiness of skin

Starts at age 8-13 in girls

Starts at age 9-14 in boys

Periods start at any time from 11-16

Differences

from adults (and younger children)

changing hormones

rapid growth

psychological

aspects

How does this affect Diabetes?

Growth

During pubertal

growth spurt

– 28 cm added to

height in 4 years

Doubling of lean

body mass

– from 30 to 60kg

Effect of Puberty on Insulin

Dose (units/kg)

Puberty Stage

Boys Girls

Stage I around 0.7 around 0.7

Stage II 0.8 – 1.0 1.0 – 1.2

Stage III 1.0 – 1.5 1.2 – 1.9

Stage IV 1.5 – 2.0 1.3 – 1.9

Stage V 1.5 – 2.0 0.8 – 1.5

Features of Adolescence

having to be “one of the crowd”

variable maturity

mood swings/emotional upheaval

experimenting with adult behaviours

and risk taking

– smoking, alcohol, drugs

worries

– about friends, body, sex etc etc

Adolescence and the Brain

Brain development

Frontal regions of brain mature slower

Not just mini-adults

Three problems for you!!

– Recognising emotions

– Planning ahead

– Risk

Not their fault!

Normal frontal lobe development throughout

childhood and adolescence:- EEG changes

Gibbs et al. Electrophysiolog Clin Neurophysiol 1949; 1:223-9

The solid circles represent

pooled EEG data at the ages

stated at the LHS of the

Figure. The size of the circles

indicate the relative

abundance of high and low

frequencies waves throughout

the first 2 decades of life.

Developing Resilience in

Teenagers

Developing responsibility along a continuum

Provide opportunities for making choices and

decisions and solving problems

Helping develop self-discipline by creating

guidelines and consequences

Helping children feel OK about mistakes –

learning opportunities!

Sharing Responsibility

Who is in charge of diabetes care?

Changes over time

Developmentally appropriate parental

involvement affects BG control

Age 12-15 hardest time to manage diabetes:

13 year olds don’t have ‘emotional muscle to

manage diabetes 24/7

Responsibility too early leads to burnout

Be proud for any diabetes care that they do

There are 35 contact points a day with

diabetes…that is a lot for a young person!

Responsibility for Diabetes

Care?

anxiety

variability

knowledge

too difficult Pa

ren

ts

Yo

un

g P

eo

ple

stress

friends

Practical Tips Discuss sharing out the ‘diabetes jobs’

– Carb counting

– Packing kit for school/clubs

– Remembering BG tests

– Writing in the diary

Notice and praise any diabetes self-care

Make things as simple as possible

– Set alarms on meter/phone for BG tests

Set times where talking about diabetes isn’t

allowed (so it doesn’t take over) and times

when it is the focus of conversation

Keep on top of dose changes so your teenager

feels that there efforts are worthwhile

Developmentally Appropriate

Responsibility

Early responsibility associated with poorer

blood glucose control & diabetic

ketoacidosis • (White et al 1984, Chase et al 1985, Skinner 2000)

Disagreement on responsibility associated

with poor self-care & blood glucose

control – (Anderson et al 1990,96,97,98, 2000, Skinner et al 2000,05)

Hvidoere Childhood Study Group

Communication

It’s so easy to be the owner of a dog. You feed it, train it, boss it around,

and it puts its head on your knee and gazes at you as if you were a

Rembrandt painting.

It follows you around, chews the dust covers off your Great Literature

series if you stay too long at the party and bounds into the house with

enthusiasm when you call if from the yard.

Around age 13, your adorable little puppy turns into a big old cat.

When you tell it to come inside it looks amazed, as if wondering who died

and made you emperor.

Instead of dogging your footsteps, it disappears. You won’t see it again

until it gets hungry, when it pauses in its sprint through the kitchen long

enough to turn its nose up at whatever you’re serving.

It sometimes conks out on the couch right after breakfast.

It might steel itself to the communication necessary to get the back door

opened or the car keys handed to it, but even that amount of

dependence is disagreeable to it now

When you reach out to ruffle its head, it twists away from you, then gives

you a blank stare as if trying to remember where it has seen you before

How do you Respond ?

Continue to behave as if its a dog. When you call it or tell it to stop digging

up the rose bushes, you still want it to obey you, and pronto

It pays no attention now, of course, being a cat. So you toss it onto the

back porch, telling it to stay there and think about things, mister, and it

glares at you, not deigning to reply.

It has a new nature, and it must feel independent, or it will die.

Only now, you’re dealing with a cat, so everything that worked before

produces the opposite of the desired result. Call it, and it runs away.

Tell it to sit, and it jumps on the counter. The more you reach out,

wringing your hands, the more it moves away

So try behaving like a cat owner. Put a dish of food nearby, and let the cat

come to you. If you must issue commands, find out what the cat wants

to do, and advise it to do that (and help it to).

But remember that a cat needs love and affection, too. And your help,

once in a while. Sit still, and it will come, seeking warm, comforting lap

that it has not entirely forgotten. Be there to open the door for it

Mum’s really mad

at me! She’d be

happier if I told her

my blood sugar

was 7.5 or if I

didn’t check at all!

Mum, my

blood sugar

is 22.5

22.5! Why so high?

What did you eat?

That scares me! A

high blood sugar

like that could

cause problems!

Talking to Teenagers

I’m glad I told Mum.

Now we can do

something so I can

feel better.

Mum, my

blood sugar

is 22.5

That happens sometimes.

It’s good you checked

because now we can

adjust your insulin dose

before dinner!

That’s pretty high.

But the diabetes

team said to expect

some out of range

blood sugars

Ideas? You can try to explain how you feel

– I feel …….. when you .………… because..

– How do you think……was feeling?

If angry your words actually count for very little

– Facial Expression = 55%

– Tone of Voice = 38%

– Words = 7%

Experimentation is normal

– Especially with diabetes

– With other “adult” behaviours

Teenagers watch and listen. Think about your own relationship with

diabetes. If two parents involved…are you parenting with the same

message?

You can LISTEN and not try to judge or fix

Communication - you need to work together as a team

Top Tips for “Involvement”

Listen – no phones, no TV, complete focus

Try to suspend judgement

Ask questions

No accusations

Present a united front. (Discuss differences of

opinions behind closed doors)

Go through book and meter with your young person

each day, or at least once a week

Schedule discussions when BG not high

Remember that difficulties with diabetes often appear

when something else is wrong...school/friends/family

How do you see Parenting?

Definition: “difficult work, taking great skill”

Diabetes in your family doesn’t allow as

many mistakes

Consistency is the key

Don’t be afraid to gather information

– Books, other parents, diabetes nurses, you

tube, websites

How to support your young person

with diabetes

Principles –

– DO NOT expect them to be independent until around 17-18

– they need your help (like shopping, cooking, cleaning)

– they can’t do the strategic thinking so don’t blame them

So what does this mean?

– Sit and do BG tests and injections with them when you can

(nurses double check doses, and everyone makes mistakes)

– Make sure they inject BEFORE meals

– Use that opportunity to get them to write results in the book,

especially from lunch-time

– Why a book??

– Look through the book with them once a week so they learn

how to adjust doses

Chance to talk to Young

Person and Parent (who have been through it already!)

Blood Glucose and HbA1c

targets: ambitious goals

pre-breakfast BG 4 – 6.9 mmol/l

after food 5 -10 mmol/l

bed-time BG 4 – 6.9 mmol/l

during the night Ok to be above 3.5 mmol/l

(frequency of BG testing directly correlates with control)

HbA1c 45 – 57 mmol/mol

But best you can get for child/young person

1

3

5

7

9

11

13

15

6 7 8 9 10 11 12

Retinopathy

Nephropathy

Neuropathy

HbA1c

Rela

tive R

isk o

f C

om

plic

ations

Adapted from DCCT Research Group: N England Journal of Medicine. 1993;329:977-986

*Endocrine Practice 2002, 8 (supp 1), pg. 7. AACE recommends less than or equal to 6.5 HbA1c.

DCCT RESULTS

HbA1c and Relative Risk of Diabetic

Complications

6.5*

Sports

Types of Exercise

Aerobic exercise (which uses oxygen) will usually lower your blood

glucose during and after exercise, examples include running, swimming,

cycling

– if your exercise lasts longer than 30 minutes you will probably need to reduce

your insulin and/or have extra fast acting carbohydrate

– for exercise that lasts for less than 30 minutes you may not need to lower

your insulin but you may need a little extra carbohydrate

Anaerobic exercise (does not need oxygen) may make your blood

glucose rise during the exercise and fall after the exercise. Anaerobic

sports are usually short, sharp & fast or strength and power sports.

Examples include sprinting, basketball, weight lifting.

Some sports will be a mixture of aerobic and anaerobic exercise, e.g.

football and team sports. Mixed exercise may produce steady blood

glucose levels.

Practical Points If doing aerobic exercise – running, cycling, swimming

– you may need to reduce short-acting insulin by 25-75%

– but not if you are exercising more than 2 hours after a meal

– try to use the same injection area for regular training

– not leg if running

If doing anaerobic exercise – sprinting, basketball

– don’t reduce insulin doses, but check BG levels

If BG levels are high before exercise, take a small amount of

insulin and delay until BG 7-8 mmol/l

Long acting insulin doses will need to be reduced

– when you are going to be active all day

– when your activity is strenuous and

– if you will be exercising again the next day.

Background insulin may need to be reduced by 25-50%.

Testing BG before, during, after and later after sport will give you

the answers

What to eat and drink

Carbohydrate

– Most children who do serious sport don’t eat enough

carbohydrate (CHO)

– May need to take CHO before, during and after exercise

Rough rule 1g glucose/kg/hr aerobic exercise or if anaerobic lasts

more than 30 minutes

Example – Mark weighs 60 kg and exercises for 60 minutes.

– So takes 20g at start, 20g at 30 minutes and 20g at end

Water

– roughly 100 ml every 10-15 minutes ie ½ litre over an hour

– can make up correct dilute solution of Lucozade sport

Smoking

Smoking is Important

• It burns a hole in your pocket: if you smoke just 10 a day,

that’ll cost you £15 per week, £67 per month, and a huge

£803 a year.

• It’s addictive. Just think how much cash cigarette

manufacturers and advertisers pour into getting you to dole

out your wages - millions of pounds.

• It is not easy to give up – even for a young person

• It doubles the risk of getting some of the small blood

vessel problems of diabetes eg kidney problems, eye

changes etc

• It increases by 4 times the chance of getting large blood

vessel problems when older.

Alcohol

Parents are Important Age of first drink mainly between 13 and 15

A third of young people cited peer pressure as their main reason for

having drunk alcohol in the last week.

But the majority (61%) only occasionally or rarely drink

Almost ½ said their parents were the first port of call for information

about alcohol (as opposed to 8% friends).

Family members are the main suppliers of alcohol to young people; 2/3

15 to 17 year olds had been given alcohol by someone in their family

last week to drink at home

43% said their family had given them alcohol for house parties or

birthday parties in last week

88% 15-17 year olds have drunk alcohol

You have a role in shaping attitudes and responses

www.drinkaware.co.uk

Alcohol can cause hypoglycaemia and will prevent recovery

from hypos by preventing glycogen release

ALWAYS eat extra carbohydrate before, during and after

drinking alcohol

Take your usual insulin for meals before drinking alcohol

DO NOT take extra insulin with the snacks you have whilst

drinking.

If your blood glucose is high after drinking still have a snack

before you go to sleep but DO NOT give any insulin for the

snack or to correct your blood glucose at this time. If your

blood glucose is still high in the morning you can correct this

with your breakfast insulin dose.

Always go drinking with someone who knows you have

diabetes and knows to treat a hypo if you behave oddly

How to stay safe with Diabetes

Exams

Be vigilant

Stress can do odd things

– mostly BG goes up, but can go down

– so try to get to know how you react

Test before you go in

Make sure BG is between 5 and 10

– you can’t concentrate if it is low OR HIGH

– so you may need a small amount of insulin

We have a letter to show your invigilator

– so you can take in dextrose tablets/drink/test kit

– and can be allowed extra time if low – need to wait at least ½

hour

Failing all else, if there are problems we can write to the exam

board if a low BG has affected your exam

School in general

Support at School

New care plans in development

Hypos – should always be allowed to test and treat

WHEREVER THEY ARE

Must always have somewhere safe and secure to

inject (if they want it) at lunch and break times

Should do PE / sport like everyone else

Should not be excluded from any activities

Can even go on World Challenge to outer Mongolia!

All secondary schools now have a school nurse

There is a legal requirement to make adjustments for

disabilities and medical conditions

Finally

We are always here to help

Do keep in touch with your nurse

Keep listening!!

Website - http://oxchilddiabetes.webeden.co.uk/