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Transition Management of the Adolescent with Diabetes Mellitus <ul><li>MARK A SPERLING </li></ul><ul><li>UNIVERSITY OF PIT...
Transition Management of the Adolescent with Diabetes Mellitus <ul><li>1.Adolescence </li></ul><ul><li>Rapid Physical Grow...
Transition Management of the Adolescent with Diabetes Mellitus <ul><li>2. Hormonal Adaptations in Adolescents   </li></ul>
 
GLUCOSE AND INSULIN RESPONSES TO OGTT IN PRE-AND PUBERTAL SUBJECTS <ul><li>  PRE-PUBERTAL </li></ul><ul><li>  GLUCOSE DOSE...
 
 
 
 
INSULIN RESPONSE TO STANDARD HYPERGLYCEMIC CLAMP
CHANGE IN PLASMA BCAA DURING HYPERGLYCEMIC CLAMP
Transition Management of the Adolescent with Diabetes Mellitus <ul><li>3. Microvasular Complications of  Diabetes During A...
Transition Management of the Adolescent with Diabetes Mellitus <ul><li>4. Emotional Adjustments   </li></ul>
Patton GC –Lancet 2007;369:1130-39-adapted from Gluckman P et al Trends Endocrinol Metab 206;17:7-12 Pubertal transitions ...
Management Issues in Adolescents with Diabetes   <ul><li>a). Provider Requirements   </li></ul><ul><li>▪ Understand diabet...
Management Issues in Adolescents with Diabetes <ul><li>b). Clinical Factors   </li></ul><ul><li>▪ Flexible appointment tim...
Management Issues in Adolescents with Diabetes <ul><li>c). Patient Factors  </li></ul><ul><li>▪ Good staff understanding o...
Management Issues in Adolescents with Diabetes <ul><li>d). Regimen Factors  </li></ul><ul><li>▪ A simple regimen  </li></u...
Specific Management Issues in Adolescents with Diabetes <ul><li>a). Insulin   </li></ul><ul><li>▪  Three daily injections ...
Specific Management Issues in Adolescents with Diabetes <ul><li>b). Monitoring  </li></ul><ul><li>▪  Unrealistic demands a...
Specific Management Issues in Adolescents with Diabetes <ul><li>c). Nutrition </li></ul><ul><li>▪ Meal plan tailored to pa...
Specific Management Issues in Adolescents with Diabetes <ul><li>d). Alcohol and drugs </li></ul><ul><li>▪  Use may express...
Specific Management Issues in Adolescents with Diabetes <ul><li>e). Recurrent Ketoacidosis  </li></ul><ul><li>▪  Associate...
Specific Management Issues in Adolescents with Diabetes <ul><li>f).Sex and Marriage   </li></ul><ul><li>▪ Well-controlled ...
Specific Management Issues in Adolescents with Diabetes <ul><li>g). Parental supervision: Evolving independence </li></ul>...
Specific Management Issues in Adolescents with Diabetes <ul><li>f). Sports  </li></ul><ul><li>▪  Safe participation possib...
Summary <ul><li>Accepting the critical role of continued parental involvement and yet promoting independent, responsible s...
Summary <ul><li>Negotiating targets, goals and priorities and ensuring that the tasks taken on by the adolescent are under...
What do Adolescents Seek in Transition   to Adult Care <ul><li>Court J Outpatient –based transition services for youth Ped...
What do Adolescents Seek in Transition   to Adult Care(2) <ul><li>Eiser et al 1993-clinic for <25yr olds-patients indicate...
What do Adolescents Seek in Transition   to Adult Care(3) <ul><li>Pacaud et al 1996 –postal quest. For 135 patients-50% ex...
Principles of Successful Transition <ul><li>Gradual preparation of youth and family </li></ul><ul><li>Choice of “ideal tim...
Principles of Successful Transition(2) <ul><li>Continuum of environment (large group/academic center) </li></ul><ul><li>Go...
OUTCOMES <ul><li>NEGATIVE IMPACT OF  DM ON QUALITY OF LIFE,DISEASE RELATED-CONCERNS AND LIFE SATISFACTION MAY NOT CHANGE W...
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Transcript of "Growth Hormone Therapy Place Holder"

  1. 1. Transition Management of the Adolescent with Diabetes Mellitus <ul><li>MARK A SPERLING </li></ul><ul><li>UNIVERSITY OF PITTSBURGH, </li></ul><ul><li>CHILDRENS HOSPITAL of PITTSBURGH </li></ul><ul><li>DIVISION OF ENDOCRINOLOGY </li></ul>
  2. 2. Transition Management of the Adolescent with Diabetes Mellitus <ul><li>1.Adolescence </li></ul><ul><li>Rapid Physical Growth – Hormones </li></ul><ul><li>Turbulent Emotional Adjustments </li></ul><ul><li>Independence </li></ul><ul><li>Indestructibility </li></ul><ul><li>Immortality </li></ul><ul><li>Risk Taking Behavior </li></ul><ul><li>Sexual Maturation </li></ul><ul><li>Sexual Activity </li></ul><ul><li>Pregnancy </li></ul>
  3. 3. Transition Management of the Adolescent with Diabetes Mellitus <ul><li>2. Hormonal Adaptations in Adolescents </li></ul>
  4. 5. GLUCOSE AND INSULIN RESPONSES TO OGTT IN PRE-AND PUBERTAL SUBJECTS <ul><li> PRE-PUBERTAL </li></ul><ul><li> GLUCOSE DOSE </li></ul><ul><li>1.75 g/Kg 55g/M 2 </li></ul><ul><li> ( N=9) (N=8) </li></ul><ul><li>Fasting Blood 82.0 ±3.1 75.6±4.1 </li></ul><ul><li>Glucose (mg/dL) </li></ul><ul><li>Peak Blood 151.6 ±8.5 143.3±7.5 </li></ul><ul><li>Glucose (mg/dL) </li></ul><ul><li>Area Glucose </li></ul><ul><li>mg/dL x 4hr 409.5±16.3 421.1 ±17.0 </li></ul><ul><li>Area Insulin 118.5±17.3** 115.4±16.5§ </li></ul><ul><li>µU/ml x4hr </li></ul><ul><li>PUBERTAL </li></ul><ul><li>GLUCOSE DOSE </li></ul><ul><li>1.75 g/Kg 55g/M 2 </li></ul><ul><li>(N=10) (N=9) </li></ul><ul><li> 84.3 ±3.0 83.2±3.7 </li></ul><ul><li>152.2±7.9 148.8 ±11.5 </li></ul><ul><li> </li></ul><ul><li>432.7±17.9 429.1±22.9 </li></ul><ul><ul><li>299.1±77.6** 365.4±114.8§ </li></ul></ul>
  5. 10. INSULIN RESPONSE TO STANDARD HYPERGLYCEMIC CLAMP
  6. 11. CHANGE IN PLASMA BCAA DURING HYPERGLYCEMIC CLAMP
  7. 12. Transition Management of the Adolescent with Diabetes Mellitus <ul><li>3. Microvasular Complications of Diabetes During Adolescence </li></ul><ul><li>Microalbuminuria </li></ul><ul><li>Retinopathy </li></ul><ul><li>Neuropathy-Gastroparesis </li></ul>
  8. 13. Transition Management of the Adolescent with Diabetes Mellitus <ul><li>4. Emotional Adjustments </li></ul>
  9. 14. Patton GC –Lancet 2007;369:1130-39-adapted from Gluckman P et al Trends Endocrinol Metab 206;17:7-12 Pubertal transitions in health-
  10. 15. Management Issues in Adolescents with Diabetes <ul><li>a). Provider Requirements </li></ul><ul><li>▪ Understand diabetes management and normal adolescent development </li></ul><ul><li>▪ Consistent care provided by a single physician or team </li></ul><ul><li>▪ Enjoy working with adolescents </li></ul><ul><li>▪ Confidence in diabetes management skills </li></ul><ul><li>▪ Willing to compromise on aspects of diabetes care </li></ul>
  11. 16. Management Issues in Adolescents with Diabetes <ul><li>b). Clinical Factors </li></ul><ul><li>▪ Flexible appointment times </li></ul><ul><li>▪ Convenient clinic location and facilities </li></ul><ul><li>▪ Staff sensitivity toward patient-parent interactions </li></ul><ul><li>▪ Consistent use of appointment reminders </li></ul>
  12. 17. Management Issues in Adolescents with Diabetes <ul><li>c). Patient Factors </li></ul><ul><li>▪ Good staff understanding of patient-parent conflicts and patient interests </li></ul><ul><li>▪ Clearly written, easily understood instructions </li></ul>
  13. 18. Management Issues in Adolescents with Diabetes <ul><li>d). Regimen Factors </li></ul><ul><li>▪ A simple regimen </li></ul><ul><li>▪ Emphasis that monitoring benefits the patient </li></ul><ul><li>▪ Well-documented negotiations and parent understanding of management goals </li></ul><ul><li>▪ Short-term compromise for long-term success </li></ul>
  14. 19. Specific Management Issues in Adolescents with Diabetes <ul><li>a). Insulin </li></ul><ul><li>▪ Three daily injections </li></ul><ul><li>▪ Total daily dose 1 – 1.5 U/KG/D </li></ul><ul><li>▪ Intermediate: Short acting insulin 2:1 to 3:1 </li></ul><ul><li>▪ Insulin pumps </li></ul>
  15. 20. Specific Management Issues in Adolescents with Diabetes <ul><li>b). Monitoring </li></ul><ul><li>▪ Unrealistic demands and expectations may lead to misrepresentation </li></ul><ul><li>▪ Glycosylated hemoglobin tests may uncover falsified home records </li></ul><ul><li>Recommendation: </li></ul><ul><li>Carefully confront the patient. Emphasizing importance of accurate records </li></ul>
  16. 21. Specific Management Issues in Adolescents with Diabetes <ul><li>c). Nutrition </li></ul><ul><li>▪ Meal plan tailored to patient with help of dietitian </li></ul><ul><li>▪ Regulate increased caloric needs (100-200 calories/day for each year > 12 years) </li></ul><ul><li>▪ Be aware of body image concerns </li></ul>
  17. 22. Specific Management Issues in Adolescents with Diabetes <ul><li>d). Alcohol and drugs </li></ul><ul><li>▪ Use may express rebellion or peer pressure </li></ul><ul><li>▪ Increased danger of hypoglycemia </li></ul><ul><li>Treatment: Consider referral for counseling </li></ul>
  18. 23. Specific Management Issues in Adolescents with Diabetes <ul><li>e). Recurrent Ketoacidosis </li></ul><ul><li>▪ Associated with poor adherence and psychosocial adjustment </li></ul><ul><li>Treatment: Prompt referral for counseling </li></ul>
  19. 24. Specific Management Issues in Adolescents with Diabetes <ul><li>f).Sex and Marriage </li></ul><ul><li>▪ Well-controlled diabetes before conception </li></ul><ul><li>▪ Ready access to birth control information </li></ul><ul><li>Recommendation: </li></ul><ul><li>Both partners attend clinic and diabetes education sessions. </li></ul>
  20. 25. Specific Management Issues in Adolescents with Diabetes <ul><li>g). Parental supervision: Evolving independence </li></ul><ul><li>▪ Gradual increase in adolescent responsibilities for care </li></ul><ul><li>▪ Inability to take responsibility may lead to poor control </li></ul><ul><li>▪ Link driving privileges to reasonable control and adherence </li></ul><ul><li>▪ Wear Medical identification necklace or bracelet </li></ul>
  21. 26. Specific Management Issues in Adolescents with Diabetes <ul><li>f). Sports </li></ul><ul><li>▪ Safe participation possible with appropriate adjustment of diabetes regimen </li></ul><ul><li>▪ Physician reassurance of school officials often needed </li></ul>
  22. 27. Summary <ul><li>Accepting the critical role of continued parental involvement and yet promoting independent, responsible self-management appropriate to the level of maturity and understanding </li></ul><ul><li>Understanding that knowledge about diabetes in adolescence is predictive of better self-care and (metabolic) control but the association is modest </li></ul><ul><li>Discussing emotional and peer group conflicts </li></ul><ul><li>Teaching problem solving strategies for dealing with dietary indiscretions, illness, hypoglycemia, sports, smoking, alcohol, drugs and sexual health (continued) </li></ul>
  23. 28. Summary <ul><li>Negotiating targets, goals and priorities and ensuring that the tasks taken on by the adolescent are understood, accepted and achievable </li></ul><ul><li>Understanding that omission of insulin is not uncommon. The opportunity should be grasped for non-judgemental discussion about this </li></ul><ul><li>Developing strategies to manage transition to adult services </li></ul>
  24. 29. What do Adolescents Seek in Transition to Adult Care <ul><li>Court J Outpatient –based transition services for youth Pediatrician 1991;18:15-56. </li></ul><ul><li>100 adolescents-mean 20.5yr (17-27)-left RCH clinic1-5 yr prior- </li></ul><ul><li>70% response rate to non validated questionnaire </li></ul><ul><li>Ideal age for transition-17-20 yrs(53%);up to 25 yr (35%) </li></ul><ul><li>Prioritized privacy, promptness, confidentiality, trust & informality-”care giver you like and get to know” </li></ul>
  25. 30. What do Adolescents Seek in Transition to Adult Care(2) <ul><li>Eiser et al 1993-clinic for <25yr olds-patients indicated helpful if clinic could have been visited before transfer of care-seek co-ordination between pediatric and adult care giver </li></ul><ul><li>Pediatricians emphasize “school progress & family relations” vs.”exercise and blood glucose control” by Physicians </li></ul>
  26. 31. What do Adolescents Seek in Transition to Adult Care(3) <ul><li>Pacaud et al 1996 –postal quest. For 135 patients-50% expressed difficulty with transition due to delay, loss of regular F/U.Concerns at insecurity,less information, less interest, more efficient blood sampling. </li></ul><ul><li>Summary:Paucity of Data </li></ul>
  27. 32. Principles of Successful Transition <ul><li>Gradual preparation of youth and family </li></ul><ul><li>Choice of “ideal time” for transfer may vary e.g choice of college vs work force </li></ul><ul><li>Introduce concept of transition in mid –late puberty to allow sufficient time for concept of eventuality of Tx. </li></ul><ul><li>Personality, independence, physical and emotional maturity rather than age alone must be the determining criteria. </li></ul>
  28. 33. Principles of Successful Transition(2) <ul><li>Continuum of environment (large group/academic center) </li></ul><ul><li>Good working relationship between involved care givers . </li></ul><ul><li>CONSIDER CREATING ADOLESCENT/YOUNG ADULT CLINIC </li></ul><ul><li>PROVIDE INFORMATION ON EMERGENCY/TELEPHONE ADVICE </li></ul><ul><li>ENCOURAGE INDEPENDENCE/AUTONOMY AND RE-INFORCE CONTROL VS. COMPLICATIONS </li></ul>
  29. 34. OUTCOMES <ul><li>NEGATIVE IMPACT OF DM ON QUALITY OF LIFE,DISEASE RELATED-CONCERNS AND LIFE SATISFACTION MAY NOT CHANGE WITH AGE,OR GENDER. </li></ul><ul><li>RELATIVELY FEW COMPLICATIONS ARE NOTED IN EARLY ADULTHOOD. </li></ul><ul><li>INTENSIVE TREATMENT DOES NOT SIGNIFICANTLY CHANGE THESE PATTERNS-DEPRESSED TEENS ARE MORE LIKELY TO BECOME DEPRESSED ADULTS. </li></ul><ul><li>INSABELLA G ET AL Transition to young adulthood in youth with T1 DM on intensive treatment-Pediatric Diabetes –in press </li></ul>
  30. 35. THANK YOU THANK YOU
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