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Teenagers – living with diabetes Rachel Besser and Mary Owen
Background about BG and HbA1c targets
Recap of the teenage brain and how parents can support
Some practical issues: Alcohol
Smoking
Driving
Exams
Sleep
Contraception
Sports
Topics covered
Blood glucose and HbA1c ‘targets’
pre-breakfast BG 4 – 6.9 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 HbA1c)
Target HbA1c 48mmol/mol (6.5%)
But best you can get for child/young person without significant hypoglycaemia
Blood glucose and HbA1c ‘targets’
DCCT Results: HbA1c and Relative
Risk of Diabetic Complications
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.
42 53 64 75 86 97 108
Teenagers
https://www.youtube.com/watch?v=dLuEY6jN6gY
Changes in all areas- bodies, emotions, social lives and relationships Can’t always ‘see’ the changes
Can begin as early as 10 and keep going until early 20’s Variable maturity
Emotional rollercoaster mood swings worries about friends, body, sex etc having to be “one of the crowd” experimenting with adult behaviours smoking, alcohol, drugs
Features of adolescence
Adolescents in the media
One in four adolescents is a
criminal
by MATTHEW HICKLEY, Daily
Britain tops teen drugs
league
Children's plastic surgery epidemic
by JENNY HOPE and ROGER DOBSON, Daily
Sexting is 'increasingly the norm' among
teenagers
Britain’s teenagers are stressed,
drink too much and think they’re fat
Teenagers struck by depression
‘epidemic’Oliver Wright, Policy Editor
August 22 2016, 12:01am,
The Times
Brain development
Frontal regions of brain mature slower (involved in planning and decision making)
Not just mini-adults
Three abilities that are affected:
Recognising emotions (when a parent is upset)
Planning ahead (packing for school, trips etc)
Risk (judging balance of risk and reward)
Related to brain maturation
What does this mean? Increased risk taking
behaviour
Decision-making in emotional contexts is difficult
Brain regions involved in empathic responding not mature until adulthood
Brain changes increase vulnerability to stress
Pre-frontal cortex – planning, decision making, moderating social behaviour - keeps developing until mid 20s
Limbic system – emotional responsiveness and motivation - are well developed from birth. But they don’t have neurological maturity.
Dopamine is the ‘YES’ chemical
Adolescents reward system will often over-ride inhibitions or judgement
Risk taking with friends – greater activation in the reward system.
Brain development
Teenagers are wired almost perfectly for the job of moving from the safety of home to the complicated world outside
When flying the nest they need the courage and confidence to take risks in a ‘leap of faith’
Increased risk taking
Reduced ability to judge – impulsive and emotional
Reduced understanding of social cues.
Social development
Parenting
Definition: “difficult work, taking great skill”
A young person having diabetes means parenting is taken to a higher level
Parenting roles change:
Parent
Cheerleader
Teacher
Safety Net
Advisor
Consultant
Team-mate
Variables • Growth • Exercise • Stress • Illness
Life events Struggles with • Independence • Identity • Responsibility
Perceived or actual social pressure/ expectations
Day off???
Simple model of treatment adherence
Dilemmas Visible Invisible
Want to have a ‘normal BG’
Please my parents
Don’t get told off in clinic
Have a good HbA1c
Test BG
In a rush to get to school on time
What to do before sport? Nobody else has a bag
Give insulin
My friends have already gone off at lunch
I don’t want to look different
Never-ending tasks that provide little sense of achievement and often provide a sense of ‘failure’
Control passes from adult to teenager often leading to increased conflict and decreased adherence Identified barriers
Brain development Forgetfulness and distraction Hard for them to plan, organise and schedule Difficulty swallowing pills Worried what friends think Voluntary resistance e.g. trying to be more like friends Find it harder to take other people’s perspectives Inclined to take risks Find it hard to look into the future and understand long term
risks
Adherence in adolescence
Who keeps the Diabetes ball
in the air?
anxiety
variability
knowledge
too difficult Pa
ren
ts
Yo
un
g P
eo
ple
stress
friends
Evidence suggests:
Early responsibility associated with poorer blood glucose control
Disagreement on responsibility associated with poor self-care & blood glucose control
How can we help:
Understanding the skills needed for ‘responsibility’ (a gentle ‘hand-over’).
Provide logical opportunities for making choices and decisions, getting it wrong and solving problems.
Help to develop ‘self-regulation’ through discussion, connection and clear expectations. In many ways this is like scaffolding.
Helping teenagers feel OK about mistakes – “learning opportunities!” NO CATASTROPHISING
Negotiating responsibility
Discuss sharing out diabetes ‘jobs’
Carb counting
Packing for school
Talking to school about exams
Putting meter/pens next to meal on table
Notice and specifically praise effort (not result)
Ensure diabetes isn’t spoken about all the time
Practical tips
Adherence
• Do you eat at least 5 portions of fruit and vegetables every day?
• Do you brush your teeth twice a day and floss once a day?
• Do you take 2 hours and 30 minutes of moderate-intensity aerobic exercise e.g. cycling or fast walking or 1 hour and 15 minutes of vigorous-intensity aerobic exercise e.g. running, tennis each week?
• Do you do weekly gratitude/mindfulness exercises?
• Do you consume –men- less than 21 units, Women - less than 14 units of alcohol per week?
• Do you keep up New Year’s Resolutions e.g. The plank challenge?
• Diabetes: only 7% of patients adhere fully to all aspects of their diabetes regimens;
• 30-70% do not adequately monitor blood glucose levels
• 20-80% do not correctly administer insulin;
• 70-80% do not adhere to exercise guidelines
• 35-75% do not follow dietary guidelines
Communication
Diabetes is hard work (average 35 contact points a day)
Your children don’t get a day off
Diabetes can sometimes feel like it is ‘punishing’ young people It hurts
It is unpredictable
It gets in the way of stuff
It can 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
What we know…
Try not to connect emotions to BG numbers
Instead of bad/good you can use low/in range/high, and ‘check’ not ‘test’
Predict that mistakes will happen and enable solution-focused talk (e.g. a mini-debrief).
Notice the behaviours that your teenager is doing (there will always be something!) that are positive
Keep meal times/family time where possible
What might help…
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 together 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
Conflict resolution
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
You can try to explain how you feel
I feel …….. when you .………… because.. To me …… to you……
How do you think……was feeling?
If angry your words actually count for very little (take a time out) 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?
Practical tips
The balance of encouraging independence and staying connected
Strengthen relationships (e.g. trips to cinema, meal times) so that limit setting works
Listen and acknowledge (try to limit advice)
Schedule in ‘connection time’ (top tip: don’t call it that)
Connection is key
Listen
Try to suspend judgement
Ask questions
No accusations
Present a united front if you co-parent (discuss differences of opinions behind closed doors)
Schedule discussions when BG not high/low
Remember that difficulties with diabetes often appear when something else is wrong...school/friends/family
Don't answer a feeling with a fact. E.g. If they’re saying “I hate my diabetes”: then, “Tell me more about that”. NOT “it’s the best its been for ages, I’m not sure what you’re fussing about”.
Top tips for involvement
Find some alone time with each child.
Make the implicit, explicit “if you needed to go to the doctor, I would take you too” and “I love you”.
Normalise difficult feelings
Parenting other siblings
Stuff that sucks: Accepting what you can’t change and committing to what you can – Ben Sedley.
A good read…
Alcohol
Alcohol can cause hypoglycaemia and stop recovery from hypos
- liver can’t make new glucose (it’s too busy breaking down alcohol)
- liver can still break down glycogen stores but risk when glycogen stores are empty
- lower cortisol and growth hormone levels
= hypo risk often several hours after alcohol consumed
Alcohol and 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 slim-line mixers if drinking spirits.
How to stay safe with diabetes
ALWAYS eat extra carbohydrate before, during and after drinking alcohol
Take 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.
Smoking
• Cost if you smoke just 10 a day, that’ll cost you £15 per week, £67 per month, and a huge £803 a year.
• Addiction - it is not easy to give up – even for a young person • Health - doubles the risk of getting some of the small blood vessel problems of diabetes eg kidney problems, eye changes - increases by 4 times the chance of getting large blood vessel problems when older. Parental modelling
Why smoking is important
Complications
Long term complications:
Eye problems
Kidney problems
Nerves
Large vessel disease – coronary artery disease
Probability of developing complications:
HbA1c
Duration of Diabetes
Puberty (rare before puberty)
Smoking
Pancreatic reserve (C-peptide)
?genes
Driving
The law now says that you MUST inform the DVLA if you:
Have 2 or more episodes of severe hypoglycaemia which require help from another person within 12 months, even during the night.
Completely lose warning symptoms for the onset of hypoglycaemia.
New hypos rules
Driving safely Always check your blood glucose before you set off on a trip.
You need to be 5 to drive! If you are involved in an accident, the evidence of your glucose levels will help to show that you have been looking after yourself, even if the accident had nothing to do with your diabetes.
Always check that you have a “hypo kit” in the car. – rapid and longer acting carb
If you feel that your blood glucose is low while driving, stop as soon as is safely possible.
Get a Medicalert bracelet or something similar
Libre and driving: 4mmol/L or less – do a finger prick check
Sex and contraception
Festivals, drugs, tattoos & piercings
Exams
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 Ideally BG is between 5 and 10 (4-15mmol/L effect on learning)
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, but only up to 5% exam grade taken into account
Be vigilant
University, leaving home & transition
Sleep
Solidify and consolidate memories.
"consolidation “ = overnight, bits and pieces of information are transferred from more tentative, short-term memory to stronger, long-term
after people sleep, they tend to retain information and perform better on memory tasks.
grow muscle, repair tissue, and synthesize hormones (eg growth hormone)
In adolescence, the body clock shifts forward
Sleep
Slow wave (deep) sleep is important for the brain to shut down, using less glucose, decreasing the body’s cortisol levels and increasing growth hormone
Poor sleep affects the body's hormone levels and ability to regulate and metabolize glucose.
eg healthy adults asked to sleep 4 hours a night for 6 nights. Following this, the glucose tolerance (their ability to break down glucose) was 40 percent lower. When fed a high-carbohydrate breakfast, their glucose levels stayed significantly higher than when they were well rested
Other health risks: heart disease, low mood, weight gain, poor memory and performance
Why is sleep so important?
How much do you need?
Age Recommended May be appropriate Not recommended
Newborns 0-3 months
14 to 17 hours 11 to 13 hours 18 to 19 hours
Less than 11 hours More than 19 hours
Infants 4-11 months
12 to 15 hours 10 to 11 hours 16 to 18 hours
Less than 10 hours More than 18 hours
Toddlers 1-2 years
11 to 14 hours 9 to 10 hours 15 to 16 hours
Less than 9 hours More than 16 hours
Preschoolers 3-5 years
10 to 13 hours 8 to 9 hours 14 hours
Less than 8 hours More than 14 hours
School-aged 6-13 years
9 to 11 hours 7 to 8 hours 12 hours
Less than 7 hours More than 12 hours
Teenagers 14-17 years
8 to 10 hours 7 hours 11 hours
Less than 7 hours More than 11 hours
Young Adults 18-25 years
7 to 9 hours 6 hours 10 to 11 hours
Less than 6 hours More than 11 hours
Good sleep habits
Avoid physical exertion late in the day
Consistent daily bedtime.
Last drink 1–1.5 hour(s) before bed
Avoid stimulating food and drink (eg, sugar/caffeine)
Wind-down time in the hour before attempting to settle to sleep
No screens (television, phones, tablets) for 2 hours before bed
No TV in bedroom
Low light during settling; red coloured light if night light is needed (does not interfere with natural melatonin production).
Tinted (orange) glasses
Parental modelling
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.
Types of exercise
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
We are always here to help
Do keep in touch with your nurse
Keep the communication open
Look out for support
Finally…