A presentation given by Julie Edge and Anna Disney on caring for children with type 1 diabetes in Year 8. This is meant for parents, carers and children and other practitioners

1. Year 8 Teenagers with Diabetes
Julie Edge and Anna Disney

2. Topics
Oxfordshire Children’s Diabetes Service
Early Adolescence and Diabetes
What happens in a teenagers brain…
Communication
A young person’s and parent’s experience
BG and HbA1c targets
Some practical issues:
–Sport and Exercise
–Alcohol
–Smoking
–Exams
–School

3. “Our adolescents now seem to love luxury.
They have bad manners and contempt for
authority. They show disrespect for adults
and spend their time hanging around places
gossiping with one another…… they are ready
to contradict their parents, monopolize the
conversation in company, eat gluttonously and
tyrannize their teachers.”
Adolescence
Socrates

4. Adolescence
Transition between childhood and adulthood.
From onset of puberty to the establishment of adult identity and behaviour.
A developmental stage rather than a chronological age.
“Adolescent” behaving in an immature way.

5. Puberty
Physical changes which occur in
–Genitalia
–Bone structure
–Height and muscle bulk
–Hairiness
–Spottiness, greasiness of skin
Starts at age 8-13 in girls
Starts at age 9-14 in boys
Periods start at any time from 11-16

6. Differences
from adults
(and younger children)
changing hormones
rapid growth
psychological
aspects
How does this affect Diabetes?

7. Growth
 During pubertal
growth spurt
– 28 cm added to
height in 4 years
 Doubling of lean
body mass
– from 30 to 60kg

8. Effect of Puberty on Insulin Dose (units/kg)
Puberty Stage Boys Girls Stage I around 0.7 around 0.7 Stage II 0.8 – 1.0 1.0 – 1.2 Stage III 1.0 – 1.5 1.2 – 1.9 Stage IV 1.5 – 2.0 1.3 – 1.9 Stage V 1.5 – 2.0 0.8 – 1.5

9. Features of Adolescence
having to be “one of the crowd”
variable maturity
mood swings/emotional upheaval
experimenting with adult behaviours and risk taking
–smoking, alcohol, drugs
worries
–about friends, body, sex etc etc

10. Adolescence and the Brain

13. Brain development
Frontal regions of brain mature slower
Not just mini-adults
Three problems for you!!
–Recognising emotions
–Planning ahead
–Risk
Not their fault!

14. Normal frontal lobe development throughout
childhood and adolescence:- EEG changes
Gibbs et al. Electrophysiolog Clin Neurophysiol 1949; 1:223-9
The solid circles represent
pooled EEG data at the ages
stated at the LHS of the
Figure. The size of the circles
indicate the relative
abundance of high and low
frequencies waves throughout
the first 2 decades of life.

15. Developing Resilience in Teenagers
Developing responsibility along a continuum
Provide opportunities for making choices and decisions and solving problems
Helping develop self-discipline by creating guidelines and consequences
Helping children feel OK about mistakes – learning opportunities!

16. Sharing Responsibility
Who is in charge of diabetes care?
Changes over time
Developmentally appropriate parental involvement affects BG control
Age 12-15 hardest time to manage diabetes: 13 year olds don’t have ‘emotional muscle to manage diabetes 24/7
Responsibility too early leads to burnout
Be proud for any diabetes care that they do
There are 35 contact points a day with diabetes…that is a lot for a young person!

17. Responsibility for Diabetes Care?
anxiety
variability
knowledge
too difficult
Parents
Young People
stress
friends

18. Practical Tips
Discuss sharing out the ‘diabetes jobs’
–Carb counting
–Packing kit for school/clubs
–Remembering BG tests
–Writing in the diary
Notice and praise any diabetes self-care
Make things as simple as possible
–Set alarms on meter/phone for BG tests
Set times where talking about diabetes isn’t allowed (so it doesn’t take over) and times when it is the focus of conversation
Keep on top of dose changes so your teenager feels that there efforts are worthwhile

19. Developmentally Appropriate Responsibility
Early responsibility associated with poorer blood glucose control & diabetic ketoacidosis
•(White et al 1984, Chase et al 1985, Skinner 2000)
Disagreement on responsibility associated with poor self-care & blood glucose control
–(Anderson et al 1990,96,97,98, 2000, Skinner et al 2000,05)

20. Hvidoere Childhood Study Group

21. Communication

22. It’s so easy to be the owner of a dog. You feed it, train it, boss it around, and it puts its head on your knee and gazes at you as if you were a Rembrandt painting.
It follows you around, chews the dust covers off your Great Literature series if you stay too long at the party and bounds into the house with enthusiasm when you call if from the yard.
Around age 13, your adorable little puppy turns into a big old cat.
When you tell it to come inside it looks amazed, as if wondering who died and made you emperor.
Instead of dogging your footsteps, it disappears. You won’t see it again until it gets hungry, when it pauses in its sprint through the kitchen long enough to turn its nose up at whatever you’re serving.
It sometimes conks out on the couch right after breakfast.
It might steel itself to the communication necessary to get the back door opened or the car keys handed to it, but even that amount of dependence is disagreeable to it now
When you reach out to ruffle its head, it twists away from you, then gives you a blank stare as if trying to remember where it has seen you before

23. How do you Respond ?
Continue to behave as if its a dog. When you call it or tell it to stop digging up the rose bushes, you still want it to obey you, and pronto
It pays no attention now, of course, being a cat. So you toss it onto the back porch, telling it to stay there and think about things, mister, and it glares at you, not deigning to reply.
It has a new nature, and it must feel independent, or it will die.
Only now, you’re dealing with a cat, so everything that worked before produces the opposite of the desired result. Call it, and it runs away. Tell it to sit, and it jumps on the counter. The more you reach out, wringing your hands, the more it moves away
So try behaving like a cat owner. Put a dish of food nearby, and let the cat come to you. If you must issue commands, find out what the cat wants to do, and advise it to do that (and help it to).
But remember that a cat needs love and affection, too. And your help, once in a while. Sit still, and it will come, seeking warm, comforting lap that it has not entirely forgotten. Be there to open the door for it

24. 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

25. I’m glad I told Mum. Now we can do something 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

26. Ideas?
You can try to explain how you feel
–I feel …….. when you .………… because..
–How do you think……was feeling?
If angry your words actually count for very little
–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?
You can LISTEN and not try to judge or fix
Communication - you need to work together as a team

27. Top Tips for “Involvement”
Listen – no phones, no TV, complete focus
Try to suspend judgement
Ask questions
No accusations
Present a united front. (Discuss differences of opinions behind closed doors)
Go through book and meter with your young person each day, or at least once a week
Schedule discussions when BG not high
Remember that difficulties with diabetes often appear when something else is wrong...school/friends/family

28. How do you see Parenting?
Definition: “difficult work, taking great skill”
Diabetes in your family doesn’t allow as many mistakes
Consistency is the key
Don’t be afraid to gather information
–Books, other parents, diabetes nurses, you tube, websites

29. How to support your young person with diabetes
Principles –
–DO NOT expect them to be independent until around 17-18
–they need your help (like shopping, cooking, cleaning)
–they can’t do the strategic thinking so don’t blame them
So what does this mean?
–Sit and do BG tests and injections with them when you can
(nurses double check doses, and everyone makes mistakes)
–Make sure they inject BEFORE meals
–Use that opportunity to get them to write results in the book, especially from lunch-time
–Why a book??
–Look through the book with them once a week so they learn how to adjust doses

30. Chance to talk to Young Person and Parent (who have been through it already!)

31. Blood Glucose and HbA1c targets: ambitious goals
pre-breakfast BG 4 – 6.9 mmol/l
after food 5 -10 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 control)
HbA1c 45 – 57 mmol/mol
But best you can get for child/young person

32. 1
3
5
7
9
11
13
15
6
7
8
9
10
11
12
Retinopathy
Nephropathy
Neuropathy
HbA1c
Relative Risk of 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.
DCCT RESULTS HbA1c and Relative Risk of Diabetic Complications

6.5*

34. Sports

35. Types of 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.

36. 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

37. 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

38. Smoking

39. Smoking is Important
•It burns a hole in your pocket: if you smoke just 10 a day, that’ll cost you £15 per week, £67 per month, and a huge £803 a year.
•It’s addictive. Just think how much cash cigarette manufacturers and advertisers pour into getting you to dole out your wages - millions of pounds.
•It is not easy to give up – even for a young person
•It doubles the risk of getting some of the small blood vessel problems of diabetes eg kidney problems, eye changes etc
•It increases by 4 times the chance of getting large blood vessel problems when older.

40. Alcohol

41. Parents are Important
Age of first drink mainly between 13 and 15
A third of young people cited peer pressure as their main reason for having drunk alcohol in the last week.
But the majority (61%) only occasionally or rarely drink
Almost ½ said their parents were the first port of call for information about alcohol (as opposed to 8% friends).
Family members are the main suppliers of alcohol to young people; 2/3 15 to 17 year olds had been given alcohol by someone in their family last week to drink at home
43% said their family had given them alcohol for house parties or birthday parties in last week
88% 15-17 year olds have drunk alcohol
You have a role in shaping attitudes and responses
www.drinkaware.co.uk

42. Alcohol can cause hypoglycaemia and will prevent recovery from hypos by preventing glycogen release
ALWAYS eat extra carbohydrate before, during and after drinking alcohol
Take your 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.
Always go drinking with someone who knows you have diabetes and knows to treat a hypo if you behave oddly
How to stay safe with Diabetes

43. Exams

44. Be vigilant
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
Make sure BG is between 5 and 10
–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

45. School in general

46. Support at School
New care plans in development
Hypos – should always be allowed to test and treat WHEREVER THEY ARE
Must always have somewhere safe and secure to inject (if they want it) at lunch and break times
Should do PE / sport like everyone else
Should not be excluded from any activities
Can even go on World Challenge to outer Mongolia!
All secondary schools now have a school nurse
There is a legal requirement to make adjustments for disabilities and medical conditions

47. Finally
We are always here to help
Do keep in touch with your nurse
Keep listening!!
Website - http://oxchilddiabetes.webeden.co.uk/