VOL: 96, ISSUE: 45, PAGE NO: 36
Carol Carson, BA, RGN, RMN, diabetes nurse specialist for adolescents, Royal Hospital for Sick Children, Sciennes Road, Edinburgh
Good glycaemic control in adolescent diabetes minimises the risk of health related complications developing in later life (Box 1). You would expect young people with diabetes to want to maintain control of their condition and enjoy a long and healthy life. However, this age group is subject to enormous pressures that influence their acceptance and maintenance of the disease and, as a result, there are many young people who do not manage their diabetes adequately. The reasons for this should be identified and tackled so as to enable clinicians to help patients and their parents avoid being labelled as non-compliant.
When considering compliance in adolescent diabetes the main areas of concern are:
- Insulin therapy;
- Home blood glucose monitoring;
- Risk-taking behaviours.
Studies in Dundee found that insulin omission was common despite it being associated with poor control and contributing to diabetic ketoacidosis (DKA) which can be life threatening (Morris et al, 1997). So why do adolescents sometimes practice insulin omission when it is so dangerous?
In 1993, the diabetes control and complications trial research group, associated improved diabetic control with weight gain. Insulin drives the appetite, therefore the more you have, the more you eat, and the more weight you gain.
Conversely, if insulin is omitted, patients can eat as much as they like and still lose weight. Rydall et al (1997) found that up to a third of young women with type-1 diabetes have eating disorders, which lead to poor control and increase the risk of future complications. Practitioners must help patients in finding the optimum dose that enables good glycaemic control without increasing the appetite.
Fear of hypoglycaemic episodes or ‘hypos’ is another factor associated with insulin omission. The deliberate under-use of insulin is often adopted as a strategy to avoid hypos, and what the adolescent sees as potentially embarrassing behaviour in front of others, such as alteration in level of consciousness or being forced to appear different because they must eat something.
Those young people with diabetes who excel in sport must make efforts to manage their condition.
Consultation with dietitians about the prevention of hypoglycaemic episodes through sensible diet and insulin adjustment is necessary to manage this patient group. Denial of the disease, the need to fit in among their peers and rebellion against their parents are other common factors contributing to adolescents’ insulin omission and mismanagement of diabetes.
Home blood-glucose monitoring
The testing of capillary blood, usually from fingers and thumbs, enables patients to monitor their glycaemic control throughout the day, interpret results and adjust their insulin appropriately. Traditionally, patients record blood results in a diary and discuss these with the practitioner during clinic visits. During these visits the glycaeted haemoglobin is measured which indicates what the overall control has been for the previous six to eight weeks. Results often show a discrepancy between what patients record and what the actual control has been. This makes the validity of the home testing/recording procedure questionable.
Increasingly, newer devices are becoming available that have a facility for downloading information which can then be printed out. This gives a clear and accurate picture of day-to-day control. Adolescents have reported that they find the printouts a tangible outcome of testing and the responsibility of keeping a diary is eliminated.
For young people with type-1 diabetes problems occur when they skip meals or over-eat high carbohydrate foods, which creates the risk of hyperglycaemia. Patients should be supported in adjusting their insulin to manage different eating situations. Fast-acting insulin could be increased before a large celebration meal or insulin reduced before a smaller-than-normal lunch. Flexibility seems to improve with maturity as does the ability to manage a more complex insulin regimen which more closely resembles normal insulin production. It is essential that eating disorders are recognised early and patients are appropriately referred.
Adolescence is a time of experimental behaviour. This is normal but is often considered non-compliant or deviant behaviour by those responsible for adolescents with diabetes. Although health professionals may not condone involvement in risk-taking behaviour, it is foolish to pretend that it does not occur. Patients should be offered an open environment for discussing their behaviour with staff.
Alcohol and drugs
Alcohol has the potential to induce hypoglycaemic attacks. Adolescents with type-1 diabetes should be made aware of this and know how to adjust their insulin or diet to prevent problems. Very little factual information is available on drug use and diabetes, however, we do know that some drugs, such as amphetamines, depress the appetite and encourage huge energy expenditure (Jenks and Watkinson, 1998). In these instances, insulin and carbohydrate are required to allow energy to be expended without risking hypoglycaemia and DKA. Smoking is very addictive and can quickly become a very difficult habit to break. It increases the cardiovascular risks already carried by people with diabetes as well as other smoking-related illness.
Health care practitioners should employ health promotion and risk-reduction strategies to support young people with diabetes (Carson, 1998) and specialised care should be further encouraged among this patient group. Acceptance of a person does not mean acceptance of their behaviour, but in order to influence their behaviour health professionals must work with the young person with diabetes and not against them. Building a positive relationship with the patient at this stage will have a lasting influence on their relationship with the health professionals throughout their lives.
It is important that goals are set between patient and practitioner and reviewed regularly. If there is disparity in their objectives they should discuss them and to reach a compromise. Practitioners must understand the pressures that make it difficult for patients to achieve their goals.
For young people with diabetes and their health care practitioners, compliance and cooperation is a joint responsibility. Good control should be based on education, support, understanding and flexibility. Even when communication is difficult some form of relationship should exist which allows the patient to use the service when they are willing to do so.