The management of adolescent W

diabetes It is generally agreed that the clinical care of the adoles-

cent diabetic patient poses a great problem for the diabetic health care team. Not only do these patients have to deal with all the normal physical and psychological stresses of adolescence but also the additional strain of insulin therapy and dietary restriction. It comes as no surprise, therefore, that less than 2% of children and adolescents have a HbAl level in the normal range and that diabetic children are less well adjusted in the home environment than their contemporaries.

The average NHS diabetic clinic can approach the pro- blem of the management of the diabetic adolescent in several ways. On the one hand, why bother? Why not let the adolescents get over this period as best they can, giv- ing support in emergencies, and allowing their natural rebellion against advice and restrictions to work itself out, and then begin again when they become mature in their early twenties or, in the girls, when they become, or wish to become pregnant. The main objection to this policy is that it is not a good thing for any diabetic patient to have grossly-elevated blood glucose levels (interspersed with fre- quent hypoglycaemic episodes) for 7 - 10 years. Our pre- sent thinking would suggest that such patients are more likely to develop diabetic complications earlier and to a more marked degree than those young patients whose blood glucose levels more nearly approach normoglycaemia.

On the other hand, the diabetic clinic can adopt an ag- gressive attitude to adolescent diabetic patients, reminding them of the importance of blood glucose control to pre- vent complications. This message is reinforced by the com- plications the adolescent sees in abundance at the adult clinic - blindness, amputations, renal failure etc. Com- plicated insulin regimens with frequent insulin injections are devised to avoid hyperglycaemia but hypoglycaemic attacks may occur quite often. The objection to this policy is that it merely frightens the young diabetic patients away. They are then left to their own devices. They particularly dislike hypoglycaemia.

What, therefore, should be the main aims of manage- ment of the adolescent diabetic patient? First, to keep con- tact by any means possible. The best way would seem to be evening diabetic adolescent clinics, run in a relaxed way and without parents being present, in contrast to paediatric clinics where the advice and teaching is given to the parents, rarely to the child. Unfortunately, many clinics

have great difficulties arranging evening (or Saturday mor- ning) clinics. An alternative might be for the diabetic clinic liaison health visitor and/or nurse to be involved with these young people, either in the home or at the Health Centre, and to act as a link between adult and paediatric clinics. A greater emphasis on the social side of the diabetic adoles- cent group or clinic would seem to be important, as well as a clinic policy of keeping an “open door” for these pa- tients. There is some short-term evidence from Birmingham and Oxford that this approach can improve blood glucose control.

The second aim should be to promote the diabetic educa- tion of young patients, if necessary by subtle means. This does not merely mean instruction to increase knowledge about diabetes but education to produce the intended ef- fect of education: increased compliance of the patient with his treatment. The failure of knowledge to improve com- pliance may stem from the view taken by the adolescent of his diabetes. Often the mere fact of an adult suggesting to an adolescent what he should do induces the patient to do the opposite. To overcome this, it has been suggested that the adolescent diabetic patient will take advice and instruction more successfully from a peer. Clearly, the Young Leaders Scheme pioneered in Scotland may be of great importance in the future. An adolescent and/or adult clinic which has an “open door” policy can give necessary advice and instruction immediately and with much greater impact when the patients are at their most receptive.

There is not much evidence to suggest that adolescent diabetic patients require any special forms of therapy in the technical sense and indeed few seem good candidates for SCII. It is easy to become preoccupied by technical pro- blems in these patients, as a substitute for understanding their social and psychological problems. However, it seems irresponsible to assume that because these young patients rarely have diabetic complications in adolescence, they can be allowed to maintain marked hyperglycaemia without problems in later life. All members of the diabetic health care team have to “run scared” throughout this period, maintaining a delicate balance between hyper- and hypoglycaemia, keeping contact with the patient, teaching whenever possible, hoping that as adults our young patients can enjoy a long, fruitful, happy life with as few diabetic complications as possible.

J K Wales

Practical Diabetes at the IDF Congress - Madrid, 23 - 28 September 1985

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