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
Adolescence
“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.”
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

How does this affect Diabetes?
changing hormones
Differences
from adults
rapid growth
(and younger children)
psychological
aspects
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
Stage I
Stage II
Stage III
Stage IV
Stage V
Boys
around 0.7
0.8 – 1.0
1.0 – 1.5
1.5 – 2.0
1.5 – 2.0
Girls
around 0.7
1.0 – 1.2
1.2 – 1.9
1.3 – 1.9
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
– These regulate emotions, influence planning and
organisation

Not just mini-adults

Heightened emotional sensitivity

Three problems for you!!
– Recognising emotions
– Planning ahead
– Risk

Not their fault
Normal frontal lobe development throughout
childhood and adolescence:- EEG changes
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.
Gibbs et al. Electrophysiolog Clin Neurophysiol 1949; 1:223-9
Developing Resilience in
Teenagers

“The capacity to recover quickly from difficulties”

Supporting mistakes.

Developing responsibility along a continuum

Providing opportunities for making choices and
decisions and solving problems

Helping develop self-discipline by limit setting
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
Sharing Responsibility

Who is in charge of diabetes care?

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

Who keeps the Diabetes ball
in the air?
Parents
stress
knowledge
friends
too difficult
variability
Young People
anxiety
Practical Tips

Discuss sharing out the ‘diabetes jobs’
– Carb counting
– Packing kit for school/clubs


Notice and authentically 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. Especially first questions…
Keep on top of dose changes so your teenager feels
that there efforts are worthwhile
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
What we know..



Diabetes is hard work (average 35 contact points a
day)
They don’t get a day off
Diabetes ‘punishes’ young people
–
–
–
–
–
–

It hurts
It is unpredictable
It gets in the way of stuff
It cam make them feel physically rubbish
They have to come to hospital for appointments
It can create family conflict
So, it is about minimising this ‘punishment’ as much as
possible
Connection is Key

Encourage independence and staying connected

Strengthen relationships so that limit setting works

Listen and acknowledge (limit advice)

Notice negative V positive interactions (need 5x more +)

‘Let it go’ (take a parental time out)

Schedule in ‘connection time’ (top tip: don’t call it that)
Talking to Teenagers
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!
Mum, my
blood sugar
is 22.5
I’m glad I told Mum.
Now we can do
something so I can
feel better.
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?
Top Tips for “Involvement”

Listen – no phones, no TV, complete focus

Try to suspend judgement and just comment or ask
questions

Present a united front.

Go through book and meter with your young person each
day, or at least once a week

Remember that difficulties with diabetes often appear
when something else is wrong...school/friends/family
Chance to talk to Young
Person and Parent
(who have been through it already!)
Blood Glucose and HbA1c
targets: ambitious goals




pre-breakfast BG
after food
bed-time BG
during the night
4 – 6.9 mmol/l
5 -10 mmol/l
4 – 6.9 mmol/l
Ok to be above 3.5 mmol/l
(frequency of BG testing directly correlates with control)


HbA1c 48 mmol/mol (new NICE guideline)
But best you can get for child/young person
Relative Risk of Complications
DCCT RESULTS
HbA1c and Relative Risk of Diabetic
Complications
15
13
11
9
7
5
3
1
Retinopathy
Nephropathy
Neuropathy
6

6.5*
7
8
9
HbA1c
10
11
12
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.
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
How to stay safe with Diabetes






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
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 lines of communication open at all
costs!

Website - http://oxchilddiabetes.webeden.co.uk/