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Managing the teenager with diabetes

Carol Carson
BARGN RMN DipRHV
Diabetes Nurse Specialist for Adolescents
Royal Hospital for Sick Children
Edinburgh
E:carol.carson@talk21.com

Childhood and adolescent diabetes is common. The annual incidence of type 1 diabetes in Scotland is 25 per 100,000, almost triple what it was 30 years ago.(1) This has increased the need for resources to address the problem.
The teenage years are the most difficult time to manage diabetes. Insulin sensitivity decreases during puberty, the body undergoes changes in energy intake, and there are both physical and psychological developments and an increase in the level of growth hormone.
However, the most influential factors that affect the young person with diabetes can be attributed to normal adolescent behaviours and lifestyle.(2) Risk-taking behaviour in adolescence is common, but these behaviours can lead to long- and short-term complications in those with diabetes. It is our role as health professionals to support young people through this difficult time and try to ensure that they minimise the risk of complications.
Diabetes UK (formerly the British Diabetic Association) recognises that adolescents are a special group who require specialist care,(3) which is provided by specialist centres. However, it is only by primary and secondary care working together that we can offer holistic care to this vulnerable group. This article will focus on health risk behaviours common in adolescence and how they affect the young person with diabetes. It will also look at how the primary care team can support these vulnerable young people.

Risk-taking behaviours

Smoking
Most teenagers are exposed to or become involved in experimental health risk behaviours, and smoking is one of the most common. At present 15% of 15-year-old males and 13-14% of 15-year-old females smoke regularly in Scotland.(4) However, evidence suggests that there are small decreases in the number of young males smoking, and it is hoped that this decrease continues.
Smoking is associated with an increased cardiovascular risk in people with diabetes. Young people with diabetes need to be given the clear message that smoking and diabetes together are a lot more dangerous than either one on their own. Strategies must be in place to support those who want to stop smoking. Primary care is the ideal setting for supporting groups of people who want to stop smoking and for prescribing replacement therapy if appropriate. In addition, school nurses can be very effective in helping teenagers in school to improve their health outcomes by organising peer support opportunities.

Alcohol
Alcohol use among young people is common.(4) In the person with diabetes alcohol inhibits glucogenesis and can lead to delayed hypoglycaemia. This is often experienced by those who are unaware of the risks associated with alcohol use. Both primary and secondary care professionals must reinforce to young people with diabetes that alcohol should be used with caution and that extra carbohydrates must be taken before, and/or during, and/or after alcohol intake.
It may also be necessary to reduce the insulin dose, especially if there has been a high energy expenditure associated with alcohol intake, such as energetic dancing. When trying to identify the reason a young person with diabetes has a major hypoglycaemic episode, it may be helpful to ask about alcohol use.

Drug use
Illegal drug use in teenagers is becoming increasingly common.(5) The prevalence of drug use is variable throughout Europe; unfortunately young people in the UK are among the highest users.(6) While there is no research showing the effects that drugs have on ­glycaemic control, plenty of evidence exists indicating how different categories of drugs affect behaviour and how, in turn, this behaviour can affect diabetes self-management.(7)
Professionals working in the field of diabetes must address this issue at annual review. They should be nonjudgmental when dealing with teenagers who are engaged in this activity. Teenagers should be given relevant information to make informed choices about their behaviour. Professionals working in primary care are aware of the environment and culture of their patients and may be the first to identify an adolescent involved in drug or other substance use.

Contraception
If glycaemic control is poor at the time of conception there is an increased risk of congenital malformations, spontaneous abortion, fetal death and macrosomia.(8) It is essential that young women know the importance of contraception, how to get it and how to use it, before they become sexually active.
Again primary healthcare staff are in an ideal position to influence sexual health through health promotion within schools and the community. There is a long-held belief that the combined oral contraceptive pill is not suitable for women with diabetes. However, low-dose combined oral contraceptives can be used with routine monitoring if there are no complications present. It is also important for young people of both sexes to protect themselves against sexually transmitted diseases by using condoms.

Diabetic ketoacidosis (DKA)
DKA is the most dangerous short-term complication of diabetes and can lead to cerebral oedema and death. In adolescence it is usually associated with poor insulin compliance,(9) weight control, particularly in young women with abnormal eating behaviours,(10) and poor self-care following drug or alcohol use. DKA may also be present at diagnosis.
It is important that all healthcare professionals are aware of the presenting signs of diabetes (dehydration, weight loss, polyuria, polydipsia, lethargy, poor concentration, ketonuria and glycosuria) to ensure that it is promptly diagnosed and insulin therapy commenced.

Conclusion
While secondary healthcare professionals may have expertise in adolescent diabetes it is primary healthcare professionals who are in an ideal position to get to know their young patients well. They have local and family knowledge, which can have a huge influence on glycaemic control, and they may have a greater understanding of particular patient's needs than secondary healthcare staff. Regular prescription requests give primary care staff the opportunity to have regular contact, and the school nursing service is ideally placed to get involved in health promotion and peer education. By working together and liaising closely, primary and secondary care staff can optimise the care given to this vulnerable group of patients.

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References

  1. Scottish Intercollegiate Guidelines Network. Management of diabetes: a national clinical guideline. Edinburgh: Scottish Intercollegiate Guidelines Network; 2001. (www.sign.ac.uk)
  2. Carson CA, Kelnar CJH. The ­adolescent with diabetes. J R Coll Physicians Lond 2000;34:24-7.
  3. British Diabetic Association. Recommendations for the management of diabetes in primary care. London: BDA; 1997.
  4. Scottish Executive. Smoking, drinking and drug use among young people in Scotland in 2000. Edinburgh: Scottish Executive; 2001.
  5. Todd J, Currie C, Smith R. Health behaviours of Scottish schoolchildren: Technical Report 1: Smoking, drinking and drug use in the 1990s. Edinburgh: Research Unit in Health and Behavioural Change, University of Edinburgh; 1999.
  6. European Monitoring Centre for Drug and Drug Addiction. 2001 Annual report on the state of the drugs ­problem in the European Union. Available at www.emcdda.org
  7. Carson CA. Risk-taking behaviour in the teenager with diabetes: the norm, not the exception. Modern Diabetes Management 2001;2:22-4.
  8. International Society for Paediatric and Adolescent Diabetes (ISPAD). Consensus guidelines for the management of type 1 diabetes mellitus in children and adolescents. Zeist: Medical Forum International; 2000. (www.diabetesguidelines.com/health/dwk/pro/guidelines/ISPAD/ispad.asp)
  9. Morris AD, Boyle DI, McMahon AD. Adherence to insulin treatment, glycaemic control, and ketoacidosis in insulin-dependent diabetes mellitus. Lancet 1997;350:1505-10.
  10. Rydall AC, Gary MS, Rodin M, et al. Disordered eating behaviour and micro-vascular complications in young women with insulin-dependent diabetes mellitus. N Engl J Med 1997;336:1849-54.

Resources
Diabetes UK
W:www.diabetes.org.uk

Further reading
All of the issues here are addressed in a leaflet written by young people with diabetes for young people with diabetes, entitled From Glucose to Ganja.This is a very useful leaflet for both ­professionals and patients. Copies of the leaflet are ­available from Diabetes UK
T:0207 323 1531

Forthcoming event
25 April 2002
Delivering the Diabetes NSF:Abolishing the Boundaries
Central London
Contact:Harrogate Management Centre
T:01423 506611
F:01423 531166
E:info@hmc.co.uk
W:www.hmc.co.uk