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

Mail

Britain tops teen drugs

league

Children's plastic surgery epidemic

by JENNY HOPE and ROGER DOBSON, Daily

Mail

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

http://vimeo.com/81492863

Empathy

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…