TEENAGERS with
Diabetes
Julie Edge and Anna Disney
Summary
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Background about BG and HbA1c targets
Recap of the teenage brain and how parents
can support
Some practical issues:
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Alcohol
Smoking
Driving
Exams
Contraception
Sports
Blood Glucose and HbA1c
targets
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pre-breakfast BG
after food
bed-time BG
during the night
4 – 6.9 mmol/l
5 – 9 mmol/l
4 – 6.9 mmol/l
Ok to be above 3.5 mmol/l
(frequency of BG testing directly correlates with control)
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Ideal HbA1c 48mmol/mol (6.5%)
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.
Features of Adolescence
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changes in all areas: bodies, emotions, social lives and
relationships
can’t always ‘see’ the changes
having to be “one of the crowd”
can begin as early as 10 and keep going until early 20’s
variable maturity
mood swings
experimenting with adult behaviours
– smoking, alcohol, drugs
worries
– about friends, body, sex etc etc
Adolescence and the Brain
Brain development
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Frontal regions of brain mature slower
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Not just mini-adults
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Three areas that affect them:
– Recognising emotions
– Planning ahead
– Risk
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Related to brain maturation
Parenting and Diabetes
How do you see Parenting?
Definition: “difficult work, taking great skill”
 A young person having diabetes means
parenting is taken to a higher level
 Roles change
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– Cheerleader
– Safety Net
– Consultant
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Teacher
Advisor
Team-mate
Who keeps the Diabetes ball
in the air?
Parents
stress
knowledge
friends
too difficult
variability
Young People
anxiety
Appropriate
Responsibility
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Early responsibility associated with poorer
blood glucose control & diabetic
ketoacidosis
• (White et al 1984, Chase et al 1985, Skinner 2000)
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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
Supporting your Teenager
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Developing responsibility along a continuum (a gentle
‘hand-over’)
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Provide logical opportunities for making choices and
decisions and solving problems
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Help to develop self-regulation through discussion,
ground rules and connection
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Helping children feel OK about mistakes – “learning
opportunities!”
Practical Tips
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Discuss sharing out diabetes ‘jobs’
– Carb counting
– Packing for school
– Talking to school about exams
Notice and specifically praise effort
 Make things as simple and neutral as
possible
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– E.g. alarms for BG checks
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Ensure diabetes isn’t spoken about at times
Communication
What we know..
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Diabetes is hard work (average 35 contact points a
day)
They don’t get a day off
Diabetes ‘punishes’ young people
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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
Some ideas?
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Try not to connect emotions to BG numbers
– Instead of bad/good you can use desirable/undesirable
or just low/in range/high
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Predict that mistakes will happen and enable
solution-focused talk (e.g. a mini-debrief).
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Notice the behaviours that your teenager is doing
(there will always be something!)
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
Conflict resolution skills for parents
 Research highlights that managing conflict at home is a large
factor in young people’s diabetes self-care skills:
 Some Ideas:
• schedule arguments (when BG not high)
• stay on topic
• talk in the car (or any other neutral activity that
doesn’t involve eye contact)
• Focus on yourself (I not You)
• discuss after the storm
• Focus on solutions
• Take a non-judgemental stance
Practical Steps?
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You can try to explain how you feel
– I feel …….. when you .………… because..
– How do you think……was feeling?
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If angry your words actually count for very little (take a time out)
– Facial Expression = 55%
– Tone of Voice = 38%
– Words = 7%
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Experimentation is normal
– Especially with diabetes
– With other “adult” behaviours
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Teenagers watch and listen. Think about your own relationship with
diabetes. If two parents involved…are you parenting with the same
message?
Connection is Key
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Encourage independence and staying
connected
Strengthen relationships so that limit setting
works
Listen and acknowledge (limit advice)
Notice negative V positive interactions
Let it go (take a time out)
Schedule in ‘connection time’ (top tip: don’t
call it that)
Top Tips for “Involvement”
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Listen
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
regularly or schedule in diasend download time
Schedule discussions when BG not high/low
Remember that difficulties with diabetes often appear
when something else is wrong...school/friends/family
Understanding and Being Understood
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Do you think people around you understand what it is like to have T1DM?
What frustrates you most about the way people treat you because you have
T1DM?
Have you asked those closest to you for help to support your diabetes selfmanagement?
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In an ideal world, what would you like to be different about the way those closest to
you help you manage your T1DM?
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What is the one thing you would prefer they did NOT do?
What is the one thing you would prefer they did?
If someone close to you had T1DM:
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If yes – what happened?
If no – why not?
How would you feel?
What would you want to do to support them?
How do you think you could do that?
Do you think they would be happy about the way you went about it?
Think of ONE thing that your family do regarding your diabetes that bothers you.
Think of ONE thing that your family do regarding your diabetes that helps you.
How will you turn the first thing into the second thing?
What would need to happen for you to feel more supported?
Alcohol
https://www.youtube.com/watch?v=h
ZalaE0spRA
Downsides of Alcohol to discuss
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Vulnerability
– Unprotected sex
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Alcohol poisoning
Appearance
Liver damage
Brain development
Drinking later in life
Parents are Important
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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
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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
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43% said their family had given them alcohol for house parties or
birthday parties in last week
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Almost ½ said their parents were the first port of call for information
about alcohol (as opposed to 8% friends)
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Age of first drink mainly between 13 and 15
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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
AVOID
Low sugar beers and lagers have a much higher alcohol content
than the ordinary ones because the excess sugar is converted into
alcohol.
Sweet sherries, wines and liqueurs as they contain a lot of sugar.
BE CAREFUL
With low alcohol beers, ciders and wine
Remember that spirits have a lot of alcohol (40%) in a small volume.
Strong beers, lagers and alcopops have a higher alcohol content,
5%+ alcohol. Cider can be 8% alcohol, much stronger than you think!
Wine has a stronger alcohol content (12 – 15%) and is often served
in very large glasses.
Choose low calorie or slimline mixers if drinking spirits.
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Alcohol can cause hypoglycaemia and will prevent
recovery from hypos by preventing glycogen release
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ALWAYS eat extra carbohydrate before, during and
after drinking alcohol
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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.
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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.
Driving
New Rules re Hypos
The law now says that you MUST inform the
DVLA if you:
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Have 2 or more episodes of severe
hypoglycaemia which require help from
another person within 12 months, even during
the night.
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Completely lose warning symptoms for the
onset of hypoglycaemia.
Driving Safely
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Always check your blood glucose before you set off on a trip. If
you are involved in an accident, the evidence on your meter will
help to show that you have been looking after yourself, even if the
accident had nothing to do with your diabetes.
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Always check that you have a “hypo kit” in the car. You need
a supply of rapid acting carbohydrate (such as mini cans of coke,
lucozade sport or glucose tablets) and some longer acting
carbohydrate such as cereal bars or biscuits.
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Check that you have a glucose meter with you.
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If you feel that your blood glucose is low while driving, stop
as soon as is safely possible. Do not ignore the warning
symptoms
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Get a Medicalert bracelet or something similar
Sex and Contraception
Festivals
Drugs
Tattoos
Piercings
Exams
Be vigilant
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Stress can do odd things
– mostly BG goes up, but can go down
– so try to get to know how you react
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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
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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
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Failing all else, if there are problems we can write to
the exam board if a low BG has affected your exam
University
Leaving Home
Sports
Types of Exercise
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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
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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.
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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
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If doing aerobic exercise – running, cycling, swimming
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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
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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.
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Background insulin may need to be reduced by 25-50%.
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Testing BG before, during, after and later after sport will give you
the answers
What to eat and drink
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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
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Water
– roughly 100 ml every 10-15 minutes ie ½ litre over an hour
– can make up correct dilute solution of Lucozade sport
Possible Long-term
Complications of Diabetes
 Eye
problems
 Kidney problems
 Heart disease
Probability of developing
complications is related to:
HbA1c
Duration of Diabetes
Puberty (rare before puberty)
Smoking
?genes
Finally
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We are always here to help
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Do keep in touch with your nurse
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Keep the communication open
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Look out for support