Flexible insulin regimens for teenagers with diabetes

VOL: 103, ISSUE: 17, PAGE NO: 30-31

Emma Day, BSc, RSCN, RGN; Sara Keay, BSc, RD, ADp

Emma Day is clinical nurse specialist, diabetes home care; Sara Keay is senior dietitian; both at Birmingham Children?s Hospital.

Abstract: Day, E., Keay, S. (2007) Flexible insulin regimens for teenagers with diabetes. www.nursingtimes.net

Abstract: Day, E., Keay, S. (2007) Flexible insulin regimens for teenagers with diabetes. www.nursingtimes.net

This article outlines the patient education programme used to prepare teenagers for switching from a twice-daily insulin regime to a more flexible, modern insulin regimen (multiple daily injections). It also compares the results of using a group education approach with one-to-one training.

There is a large amount of literature that supports education as a cornerstone of diabetes care (Lucas and Walker, 2004), with structured education programmes heralded as not only desirable but also essential (Department of Health, 2005; NICE, 2003). Silverstein et al (2005) concluded: 'Education is best provided with sensitivity to the age and developmental stage of the child - whereas for most adolescents (after consideration of their emotional and cognitive development), education should be directed primarily toward the patient, with parents included.'

International Society of Paediatric and Adolescent Diabetes consensus guidelines published in 2000 state the aims of control for children and adolescents as a pre-prandial blood glucose of 4-7mmol/L, a post-prandial blood glucose of 5-11mmol/L and an HbA1c of <7.6% (ISPAD, 2000).NICE guidelines on type 1 diabetes (NICE, 2004) suggest pre-prandial blood glucose levels of 4-8mmol/L and post-prandial blood glucose of <10mmol/L, with an HbA1c of <7.5%.

Recent audit data showed that 80% of children with type 1 diabetes in the UK were not achieving an HbA1c target of 7.5% (National Clinical Audit Support Programme, 2005). In order to achieve these outcomes injected insulin regimens should mimic as closely as possible the normal action of endogenous insulin in someone without diabetes. In a person without diabetes, the pancreas releases a constant steady flow of insulin into the bloodstream. When food is eaten, digestion begins and the body senses the level of glucose rising in the bloodstream and automatically releases insulin in sufficient quantities to maintain normoglycaemia (Fig 1).

Multiple daily injection (MDI) regimens mimic the normal insulin action with provision of basal insulin and variable (dependent on carbohydrate load of a meal) boluses of insulin being delivered. Older insulin preparations (isophane NPH) used as the basal component had limitations in action as they last between 18 and 20 hours with a peak of action between four and six hours.

Adolescence and diabetes care

Adolescence is the time between childhood and adulthood and is synonymous with a period of great physical, emotional and behavioural change (Skinner, 1997). Living with diabetes during adolescent years puts enormous pressure on young people when they are going through these traumas. Diabetes requires a high level of self-care and self-management. The avoidance of short-term diabetes complications such as diabetic ketoacidosis (DKA) and severe hypoglycaemia is paramount. This is achieved through a balance of healthy diet, exercise, monitoring of blood glucose levels and insulin injections (Schur et al, 1999).

Parents find the transition from childhood to adulthood equally difficult and struggle with striking the right balance between showing an interest and attempting to control self-care activities. Marshall et al (2006) described some of the studies on parental relationships with adolescents with diabetes and the difficulties both groups face. Newton and Greene (1995) suggested that 'normal adolescent behaviour encompassing rebelliousness and experimentation will be reflected in many teenagers as chaotic blood glucose control'. They went on to discuss the need for health professionals to listen to young people and engage with them in teaching self-management skills. Carson (2003) highlighted the importance of building and maintaining relationships with this group of young people and the need for some consistency in the personnel providing and coordinating their care.

The young people attending Birmingham Children's Hospital's diabetes clinics faced all of these challenges, which we were aware had to be met. When a new type of long-acting insulin became available in summer 2002 the diabetes home-care unit (DHCU) teamwas overwhelmed by the numbers of young people who were requesting transfer to MDI regimens. The team believed extra training and support was needed for these young people. This is something that other centres have also perceived as an issue; Robson and Gelder (2006) described the Leeds experience.

Before the launch of long-acting insulin analogues in August 2002, the teambased at Birmingham Children's Hospital transferred very few patients to MDI regimens. This is thought to be due to the fact that the long-acting insulin available had to be injected before bed and was often forgotten.

Before switching, all the young people were using twice-daily insulin mixtures. When using this insulin regimen, insulin must be injected at a regular time in the morning and repeated in the evening, with very little flexibility. Carbohydrates also need to be consumed between every two and two-and-a-half hours to avoid hypoglycaemia and achieve control.

Patients were asked either in diabetes clinics or during arranged home visits whether they wanted to be on the new MDI regime. The advantages and disadvantages of the MDI regime were highlighted. The main advantages of the MDI regime for the young people appeared to be:

• The potential for reducing weight, thus obtaining a lower body mass index (BMI);
• Having the option to give long-acting insulin at any point over 24 hours;
• Improved diabetes control;
• Having the option of getting up late in the morning;
• Flexible mealtimes and sizes of meals and the ability to miss snacks.

The disadvantages appeared to be:

• The need for four or more injections per day;
• Having to gain a greater knowledge of the carbohydrate (CHO) content of foods and to inject appropriately;
• Increased amount of blood glucose monitoring to optimise control.

It was at this point that the team considered a fairly radical approach - certainly in terms of paediatric care. We considered bringing our patients together in small groups to initiate the training and education needed for them to embark on this new treatment plan. This would also take advantage of the opportunity to bring young people together and teach them other self-care practices and offer support.

Starting people on insulin in a group and other organised approaches to educating people about their diabetes - including Dose Adjustment for Normal Eating (DAFNE) by the DAFNE study group (2002) and Diabetes Education for Ongoing and Newly Diagnosed (DESMOND), as described by Davies et al (2005) - have been 'in vogue' for some time. These programmes are designed to empower adults with diabetes to look after their condition as advocated by standard three of the National Service Framework for Diabetes (DH, 2001). Over a five-day intensive period the programme leaders teach patients to count carbohydrate, adjust their own insulin doses and generally understand more about their condition and successful management of it.

Development of the programme

Without exception, young people were changing from mixed insulin given twice a day before breakfast and before evening meal (bd). Some young people were unsuitable for or either unwilling or unable to attend the group sessions. This process is called 'self-selecting': the young people expressed their reluctance to join in with the group approach and so were seen on an individual basis either within their homes or in the diabetes centre at the hospital. The team considered grouping certain individuals together, possibly based on their age, sex or cultural background.

Patients were identified as being suitable (and willing) to change their diabetes treatment regime. During a hospital outpatient visit or a home visit the paediatric diabetes specialist nurse (DSN) and/or dietitian discussed the advantages and disadvantages of the new regime and answered any questions as they arose.

An education programme was designed for use with groups of between two and six individuals aged 13 years and over. The programme was designed by paediatric DSNs and paediatric diabetes dietitians. It goes some way to meeting the criteria of the NICE technology appraisal (2003), which states all people with diabetes should be offered structured education. Some of the criteria are more difficult to achieve when working in very small teams providing care for children with diabetes.

Switching regimens

When the decision to change over from bd to MDI had been made the patient was invited to the group session by letter. Their GP was asked to prescribe the requisite insulin and also at that time the particular pen needles that the pens required.

Dose calculation

Before the first long-acting insulin analogue was introduced, as a team our only option when changing from bd was to change to a basal bolus regime using soluble insulin (short-acting insulin) and Neutral Protamine Hagedorn (NPH) (long-acting insulin). The action of the soluble insulin is 5-8 hours with a peak at 2-4 hours; NPH insulin's action is 12-24 hours with a peak at 6-10 hours (Swift, 1995).

When we changed from bd (a mixture of soluble and NPH) to basal bolus, traditionally the dose was calculated by giving 40% of total dose as NPH once a day and the remaining 60% split equally between three mealtime boluses (fast-acting). This took no account of carbohydrate intake. Out of 400 young people under our care we only had 14 patients on a basal bolus regime. This is probably because of the peak of action - nocturnal hypoglycaemia was common and young children found delaying their once-daily NPH to 11pm most difficult. There was also a need to continue snacking, which for many meant there were too few advantages for the change to basal bolus to be a positive one.

When glargine was first introduced we took advice from its manufacturer and our adult DSN and consultant diabetologist colleagues, and then developed a protocol for calculating dosage. Glargine is described as a 'peakless' insulin (it has no peak of action) and its action is 22-24 hours. It is given once a day, usually in the evening, and the patient can choose the most suitable time for themselves; however, it is essential it is given at the same time each day. The evidence that this new insulin caused less nocturnal hypoglycaemia (Rosenstock et al, 2000) was very positive.

The NPH component of the total dose (bd) was calculated (usually 70-80% of the total dose); this 70-80% was reduced by 10-20%, depending on the control of the diabetes. This was given as glargine and the remainder of the total dose was divided by three and given as mealtime boluses. It soon became apparent that this made the basal insulin dose too large for most children and hypoglycaemia was reported in many cases. Reducing the glargine dose rectified this.

By this time other paediatric centres were gaining more experience in using this new insulin regimen and further advice was sought.

Our team decided to use a protocol that proposed 50% of the total daily dose (reduced by either 10% if HbAic is greater than 8.5% or by 20% if HbA1c is less than 8.5%) given as basal insulin. The remaining 50% is given as rapid-acting insulin analogue, usually aspart or lispro (Humalog), split over three doses and given with food. We continue to use this approach with success.

Patient case study

Jenni (HbA1c 7.5%) was receiving 60 units of human biphasic isophane insulin (Mixtard 30) (30% soluble and 70% NPH) insulin as a bd regimen of 40 units in the morning and 20 units at teatime. She was changed to 24 units of glargine at 6.30pm with the remainder split over three mealtime doses and given as as Novarapid.

The programme

The monthly MDI group training was arranged into two sessions. The aims of the education sessions were:

• To begin the education of adolescent patients wanting to commence MDI;
• To assess food intake and the insulin needs of the individual;
• To enable patients on MDI to estimate CHO in food in relation to insulin dose;
• To encourage peer-group support and to answer questions.

Before the meeting, young people completed a three-day food diary with parental support. The amount of CHO in the foods was assessed and a fixed insulin dose suggested, using the calculation equation of one unit of insulin for 10g CHO as a baseline.This remains unchanged for the first 5-7 days.

Module 1

During the meeting several procedures take place:

• Insulin and pen supplied by GP is checked by nursing staff;
• Using insulin profile charts the different actions of bd and MDI insulin are discussed;
• The timing and a single site for glargine (as per manufacturer's instruction) are chosen;
• The young people inject their first dose of glargine with the support of the nurses;
• The patients give themselves (with nurse supervision) a mealtime (fixed) dose of bolus insulin with a packed meal brought from home. The dietitian takes this opportunity to discuss the content and advise on the CHO content of this meal.

Before going home the young people were instructed:

• To start looking at CHO labelling on food packets;
• To weigh CHO-containing foods (for example, cereals, potatoes, rice and pasta) to assess their own typical portion size of these foods;
• That any food that contains CHO will require insulin. Initially it was said that small snacks containing &le;10g CHO did not require insulin, but current practice is to inject for any CHO food, however small;
• The importance of healthy eating was emphasised to achieve an appropriate BMI;
• That three or four blood glucose tests are required both before and after eating. This is to help assess whether the dose of insulin is correct;
• To self-adjust glargine dose by increasing by two units each day until morning/fasting blood-glucose levels are <7mmol/L;
• To call 7-10 days after starting to review blood-glucose results.

These instructions and initial doses are given in a written format as an aide-mémoire.

It has been suggested that parental influence and support should not be underestimated in this age group (Silverstein et al, 2005) and it was with this in mind that a parent teaching programme was designed to run alongside the young people's programme.

Module 2

The objective of this module was to teach more about CHO counting and to help young people gain confidence in this area. A large part of the module is dedicated to:

• Assessing CHO in food:
  - Visualising the difference in appearance between cooked and uncooked foods that are high in CHO
  - Looking at hidden sources of CHO in foods, for example, sausages, beef burgers;

• Managing eating outside the home environment;
• Sports management;
• Illness management;
• Alcohol management;
• Basic maths.

The young people discussed many challenges when assessing CHO in foods - bread in the form of rolls and loaves that do not come with the nutritional information was mentioned, in particular. They also discussed pasta (cooked and uncooked) and potatoes (mashed, chipped, baked and boiled). Calculating the CHO content of cakes and sweet desserts also caused some confusion for young people.

In order to meet its objective, module two was made up of mainly practical sessions. A quiz was used, which involved the young people being presented with examples of foods and food models (specific foods and prepared meals) and having to assess CHO content. Food labels and scales were available, as were CHO-counting literature produced in house as well as examples of commercially available literature.

Using food models and real food, this module comprised four areas:

• Prepared meals - various meals were presented to assess CHO content, for example, sausage, mash and vegetables; spaghetti bolognaise;
• Portion size - assessing their own typical portion size of cereal by weighing and measuring;
• High CHO foods - estimating the CHO in different types of bread;
• Snacks - measuring the CHO in different snacks.

At the end of the group session young people were usually taken out to eat and given the chance to put into practice their new CHO-estimating knowledge. The team organised going out for Italian meals and arranged buffets for the young people to share; both experiences proved invaluable in giving them confidence in different situations. Those patients taken out for a meal after the training session found it difficult to assess CHO in the food served. Many were startled to discover the large doses of insulin needed to balance CHO found in pizza, dough balls and chocolate fudge cake. The confidence to accurately assess and then appropriately calculate the correct amount of insulin bolus for this meal was only achieved by pre- and post-meal blood-glucose checks and expert support in calculating the doses of insulin required. Blood-glucose levels were later reported back to diabetes nurses who discussed this with the young people as an educational tool. Although this type of eating became more manageable, it was not promoted as a regular lifestyle choice.

Following this module regular clinic and telephone contact was maintained.

Comparison of group and individual approach

Results

Some 62 patients were involved in the audit. Of these, 42 of these were taught about MDI on a one-to-one basis and the remaining 20 were taught in groups as described above.

The BMI results (Fig 2) take into account that many of the young people were still growing and should continue to gain weight. One patient lost 8.3kg while maintaining an HbA1c of 7.5%. Others also achieved significant weight loss while improving HbA1c levels.

Our findings showed there was a reduction in HbA1c and BMI when patients were changed to MDI. As shown in Figure 2 those young people who attended the group training sessions demonstrated a greater reduction in their BMI when compared with those who attended the one-to-one training sessions.

Conclusion

There is not enough data to speculate on the reason for the improved results of those attending the group training sessions, however, one of the key differences in the training was the meal out. As mentioned, the self-selecting nature of the groups may be a limiting factor in future work.

Teaching for young people changing over to MDI at Birmingham Children's Hospital is now mainly by group teaching although for some patients individual meetings are still desired and appropriate. Since the audit was completed a further 26 young people have come together in a group to learn about MDI regimens. From a practice development viewpoint the scheme has strengthened the team's resolve to continue to offer this way of educating and supporting young people.

References

Carson, C. (2003) Adolescence to adulthood: how to keep adolescents in the system. Adolescent Services. Journal of Diabetes Nursing; 7: 1, 24-27.

DAFNE Study Group (2002) Training in flexible, intensive insulin management to enable dietary freedom fro people with type 1 diabetes: dose adjustment for normal eating (DAFNE) randomised controlled trial. British Medical Journal; 325: 746.

Davies, M.J. et al (2005) The DESMOND (Diabetes Education and Self Management for Ongoing and Newly Diagnosed) programme: from pilot phase to randomised control trial in a study of structured group education for people newly diagnosed with type 2 diabetes mellitus. Diabetic Medicine; 22: Supp 2, 104.

Department of Health (2005) Structured Patient Education in Diabetes: Report from the Patient Education Group. London: DH.

Department of Health (2001) National Service Framework for Diabetes: Standards. London: DH.

International Society for Paediatric and Adolescent Diabetes (2000) Diabetes consensus guidelines. Oslo: ISPAD.

Lucas, S. Walker, R. (2004) An overview of diabetes education in the United Kingdom: past, present and future. Practical Diabetes International; 21: 2, 61-4.

Marshall, M. et al (2006) Adolescents living with diabetes: Self-care and parental relationships. Journal of Diabetes Nursing; 10: 18-13. [check ref]

National Clinical Audit Support Programme (2005) www.icservices.nhs.uk/ncasp/pages/audit_topics/diabetes

NICE (2004) Type 1 diabetes: diagnosis and management of type 1 diabetes in children and young people.NICE: London.

NICE (2003) Guidance on the use of patient education models for diabetes: Technology Appraisal 60. NICE: London.

Newton, R., Greene, S. (1995) 'Diabetes in the adolescent' In Kelnar, C. (ed) Childhood and Adolescent Diabetes. London: Chapman and Hall Medical.

Robson, F, Gelder, C. (2006) Experiences with flexible insulin regimens for children. Journal of Diabetes Nursing; 10: 2.

Rosenstock, J. et al (2000) Basal insulin glargine (HOE 901) versus NPH insulin in patients with type 1 diabetes on multiple daily insulin regimens. US insulin glargine (HOE 901) type 1 diabetes investigator group. Diabetes Care; 23: 8, 1137-42.

Schur, H.V. et al (1999) The young person's perspective on living with diabetes. Journal of Health Psychology; 4: 2, 259-36.

Silverstein, J. et al (2005)Care of Children and Adolescents With Type 1 Diabetes: A Statement of the American Diabetes Association.Diabetes Care; 28:186-212.

Skinner, C. (1997) Health Behaviour, adolescents and diabetes. Practical Diabetes International; 14: 6, 165-7.

Swift, P. (1995) 'Insulin: types and regimens' in Kelnar.C. (ed) Childhood and Adolescent Diabetes.London: Chapman and Hall Medical.


Useful link
www.leedsth.nhs.uk/sites/diabetes/tips/MDI.php