ISSUES FACING ADOLESCENTS WITH DIABETES

Adolescence can be a difficult time in the best of circumstances, and for those with diabetes, it can be especially challenging. Issues can arise related to independence and “becoming one’s own person”; the hormonal and maturational changes that occur at puberty; and concerns about peer relationships. For instance, worries in some young people about how friends perceive their diabetes can lead to diminished adherence to diabetes management, erratic metabolic control, and diabetic complications (Justus, 2018). Or young adults may become distressed upon the realization of what a chronic, life-long condition means, and clinicians must be aware that these patients are at high risk for diabetes burnout and depression.

Positive communication between parents and adolescents is important to navigating these issues. Clinicians can support parents in meeting the challenges of relinquishing responsibility for care to their adolescent child and evolving into the role of “coach” (ADA, 2017a). Likewise, adolescents can be educated in ways to “vent” their anger and frustration and assisted in developing a plan to better manage their condition.

Being Diagnosed with Diabetes during Adolescence

The reaction to a diabetes diagnosis is highly individualized. However, a broad distinction can be made between those adolescents who were diagnosed with diabetes as children and those who are newly diagnosed in their teen years. A 15-year-old who was first diagnosed with diabetes as a 4-year-old will likely have a much different mindset about the condition than a 14-year-old who was diagnosed three months ago. For instance, the former may think that “diabetes sucks,” but they will not remember a life without diabetes and are accustomed to it as part of their day-to-day existence.

The newly diagnosed adolescent may experience an acute sense of loss, seeing their choices curtailed, their independence restricted, and spontaneity of actions reduced. A sudden diagnosis of a life-long chronic condition can be devastating for an adolescent. Research has shown that such a diagnosis can produce emotions akin to grief, negatively impact the individual’s self-concept, and evoke a significant feeling of being different from one’s peers. The strong desire for acceptance can cause adolescents with diabetes to deny their condition, neglect diabetes management, and skip insulin injections. The consequences of this behavior can be serious, such as recurring hospital admissions with diabetic ketoacidosis (Robinson, 2015).

An important goal of care is to help such an adolescent accept a new normal in their lives and develop the belief that it is possible for them to manage diabetes. Research shows parental participation and support of family and friends to be the primary source of positive adjustment to diabetes among adolescents. Conversely, a lack of or limited parental involvement correlates with poorly controlled diabetes. Participation in support groups for young adults with diabetes is also linked to positive outcomes for adolescents with diabetes.

The healthcare team also plays a critical role in the adjustment process for adolescents diagnosed with diabetes. How an adolescent is informed of the diagnosis of a chronic health condition is vitally important. Sensitivity, caring, and a patient-centered approach are key factors in how well the young adult begins to process what is happening. Adolescents with diabetes have reported a positive impact of having choices in setting treatment goals and of regular appointments with the same members of the diabetes healthcare team (Robinson, 2015).

Puberty and Diabetes

The physiologic changes of puberty may be impacted by diabetes. Uncontrolled diabetes can delay the onset of puberty. Insulin resistance will increase, and more frequent blood glucose checks are required. This can be a further source of frustration for the adolescent and a source of worry for the parents (ADA, 2017a).

Girls with diabetes have a higher prevalence of weight gain during puberty than their peers who do not have diabetes. They are also at a higher risk for polycystic ovary disease (Justus, 2018). Patient education for young girls and their parents includes a discussion of how blood glucose levels may increase in the days preceding menses and decrease in the days immediately after menses. This requires more frequent blood glucose checks, adjustments in insulin dosage, and possible changes to the meal plan. Hormone fluctuations in the early stages of puberty can also make it more difficult for adolescent girls to maintain optimum glucose control (ADA, 2018).

For adolescent boys, blood glucose control is more difficult in the later stages of puberty. Research shows that one fourth of adolescent males with T1D have diminished levels of testosterone. Poorly controlled diabetes can also result in lower-than-normal weight, height, and BMI in young males (Justus, 2018).

Sexual Counseling

Sexual activity, contraception, and pregnancy should be discussed openly and nonjudgmentally. This is a conversation that most young people will not initiate, whether out of embarrassment, fear, or simply not knowing how to begin. It is up to the clinician to include these topics as part of the overall education plan for the patient with diabetes. It is important to assure the young person that their privacy will be respected. It may also be an opportune time for a clinician to introduce to parents the need for private conversations between their adolescent child and healthcare providers without parents being present.

Sex is a physical activity, and similar to all other physical activities, it can impact a patient with diabetes. Lower blood glucose levels may occur during and following sexual activity. Therefore, preventing hypoglycemia associated with sex is part of an adolescent’s self-management plan (ADA, 2020a).

Girls with diabetes are educated that pregnancy during their teen years can result in serious health problems related to their age and to diabetes.

PRECONCEPTION COUNSELING

Many young people may have concerns that diabetes will prevent them from having a normal pregnancy and a healthy baby. The clinician can assure them that once they are ready to have a baby, a healthy pregnancy is possible and that the key to this is preconception counseling (ADA, 2018). Female adolescents with diabetes can also be referred to OB/GYNs, since these professionals provide in-depth preconception counseling. Preconception counseling begins as soon as a girl starts menstruation and continues as an ongoing conversation at every visit with the diabetes management team.

Awareness of the importance of the consistent and correct use of contraception in the prevention of unwanted pregnancies is something that must be re-enforced with adolescents who have diabetes. Recommendations for contraceptives include the use of long-acting reversible contraception (LARC) such as intrauterine devices and subdermal hormonal implants. However, studies find that healthcare providers infrequently provide counseling on LARC use.

Clinicians must also discuss the importance of planned pregnancies and achieving and maintaining optimal blood glucose levels prior to becoming pregnant in order to decrease the risk of adverse outcomes for the mother and baby. Unplanned pregnancy, especially if blood glucose levels are not well controlled, can put the expectant mother at risk for several complications, including pre-eclampsia (a condition characterized by hypertension and leading to damage to organ systems, most notably the kidneys and liver). Preconception counseling therefore focuses on ensuring the patient has attained optimal glycemic control and overall good health prior to becoming pregnant (Disney et al., 2020).

Although the ADA recommends preconception counseling as part of the education process for all adolescent girls with diabetes, studies indicate that this may not be happening. As advocates for their patients, clinicians can be instrumental in incorporating preconception counseling into the diabetes management program. Other considerations for preconception counseling include expanding the program to include adolescent males and ensuring the program is sensitive to cultural and religious values (Peterson-Burch et al., 2018; ADA, 2020a).

Driving with Diabetes

Driving with a low blood sugar increases the possibility of having an automobile crash. While having diabetes does not preclude an adolescent from obtaining a driver’s license, under the law, all drivers can be held accountable for keeping their blood glucose at safe levels while driving (ADA, 2017a; ADA, 2020a). Therefore, part of responsible behavior for an adolescent with diabetes is to ensure that their blood glucose level is within a set target range prior to driving.

Driving education for an adolescent with diabetes includes the following points:

• Check blood sugar levels prior to driving, every time.
• Treat a low blood glucose level even if it means being late to one’s destination.
• Do not start driving until blood glucose is within the target range. (It is okay to call a friend for a ride or to tell others that one is going to be late.)
• Keep a supply of nonperishable snacks and fast-acting sugars in the car or carry some along if traveling in a friend’s car.
• Never leave insulin and test strips in the car; hot and cold temperatures damage them.
• If beginning to feel unwell or noticing that blood sugar is dropping, pull over immediately. Do not tell yourself, “I’m nearly there; I can make it.”
• Once pulled over, check blood glucose, treat a low level, wait 15 minutes, and then recheck.
• Never leave home without a medical alert ID bracelet or necklace.
  (ADA, 2017a; ADA, 2020a)

Alcohol, Smoking, and Recreational Drug Use

Although the legal drinking age in most jurisdictions is 21 years, a conversation about alcohol, smoking, and drug use must begin during adolescence. Using alcohol and drugs can have an instantaneous effect on blood glucose levels. These substances can also adversely impact an individual’s awareness of and capacity to treat a low blood glucose level.

ALCOHOL AND DIABETES

Knowledge that drinking alcohol can be dangerous to those with diabetes may not prevent an adolescent from this activity, particularly in the presence of peers who are drinking. The clinician must educate the adolescent and their parents on its safe use.

Research shows that it takes the liver between one to one-and-a-half hours to process a single drink, and it is during this time that those with diabetes are most at risk for developing low blood glucose levels (Demitz, 2017). Consuming two alcoholic drinks prolongs the risk of hypoglycemia for two to three hours, and the more alcoholic drinks consumed, the greater the amount of time one is at risk for hypoglycemia.

Actions to keep safe when drinking include:

• Eating before taking the first drink and eating carbohydrate snacks such as chips while drinking
• Remaining in the company of a reliable friend who is aware one’s diabetes and who knows how to treat hypoglycemia if it occurs
• Between alcoholic drinks, consuming water or a sugar-free drink to prevent dehydration
• Testing blood sugar at least every hour, or having a friend test it. If the blood sugar level drops and one starts vomiting and cannot keep anything down, have someone call 911. Ensure that there is at least one friend with you who knows what to do in these circumstances because it is an emergency.
• After a night of drinking, eating a meal that contains both fat and protein. Since alcohol remains in the body for a period of time after one stops drinking, it is possible that hypoglycemia can occur while sleeping.
• Since the symptoms of hypoglycemia mimic those of being drunk, always wearing a diabetes ID necklace or bracelet so that, in the event of a hypoglycemic episode, others will not presume the individual is merely drunk.
  (Demitz, 2017)

SMOKING AND DIABETES

Smoking rates are considerably higher among youth with diabetes than among their peers without diabetes (ADA, 2020a). Education for adolescents with diabetes regarding smoking includes the fact that nicotine damages small blood vessels and can result in kidney and nerve disease. Smoking also heightens the risk for albuminuria.

The best advice a clinician can give to an adolescent with diabetes is: “If you haven’t started smoking, don’t. And if you have, we can work together on helping you stop.” Advising against cigarette smoking also includes advising against the use of e-cigarettes (ADA, 2020a).

RECREATIONAL DRUGS AND DIABETES

Substance abuse and nonprescription drug use can lead to impaired judgment, irregular diabetes management, infrequent blood glucose checks, and erratic insulin administration. This puts the adolescent at risk for short- and long-term complications. Adolescents with diabetes are taught that this is a dangerous and possibly lethal practice (Yale School of Medicine, 2019).

Different types of illicit drugs can affect people with diabetes in the following ways:

• Marijuana is the most commonly used substance by youths with T1D. Those with diabetes consider marijuana to have fewer negative consequences when compared to drugs such as cocaine or heroin. However, the impact of marijuana on cognitive and physical functioning can lead to grave problems for those with diabetes. Negative effects include:
  • Greater appetite, which can cause overeating, and hyperglycemia
  • Short-term memory problems, which can lead the individual to forget to take insulin or diabetes medications
  • Impaired hand-eye coordination, which can lead to incorrect administration of insulin or diabetes medications
  • Symptoms of depression with regular use
  • Severe damage to the kidneys and heart when combined with alcohol
• Stimulants: Those who take stimulants frequently experience low blood glucose levels due to stimulants breaking down carbohydrates at a faster rate than normal.
  • Ecstasy is a stimulant drug that may contain poisonous substances. It can be particularly hazardous for persons with diabetes. Serious side effects of ecstasy use include kidney damage leading to kidney failure and an irregular heartbeat, which can prove fatal.
  • Cocaine is an extremely addictive stimulant that can cause hypertension and a subsequent heightened risk for strokes and heart attacks. Cocaine use also leads to loss of appetite. Those who use cocaine on a regular basis are predisposed to eating fewer balanced meals and an increase in the intake of fatty foods. Irregular eating habits and poor food choices can be damaging to those with diabetes.
  • Methamphetamines are extremely dangerous for those with diabetes. They interfere with the activity of insulin and hormone production, causing the release of excessive glucose and subsequent high blood glucose levels. If taken consistently, methamphetamines can cause decrease in appetite, depression, and memory problems.
• Heroin is a very dangerous, highly addictive depressant. It causes erratic eating patterns and hormone production, impairing the person’s ability to maintain blood glucose levels within a set range.
• Hallucinogens (PCP, LSD, ketamine, mescaline, “magic mushrooms”) result in hallucinations, which can lead to paranoia, bizarre behavior, and panic attacks. These behaviors can decrease awareness of fluctuating blood glucose levels and the need for interventions to stabilize blood glucose levels.

Since some adolescents will experiment with illicit drugs, those with diabetes must be educated about their safer use and the dangerous outcomes that can result. Important points to emphasize include:

• Check blood glucose levels every 2–3 hours.
• Check for ketones if the blood glucose level is >300 mg/dL.
• Implement a sick-day plan when needed.
• Work with the healthcare team to eliminate problematic drug use.
• Only take an illicit or new drug in the presence of someone else who knows what the drug is and who knows you have diabetes; this will help ensure that necessary care will be sought if serious complications occur.
• Do not stop taking insulin or other diabetes medications, since this can lead to high blood glucose levels and organ damage.
• Have readily available sources of quick-acting carbohydrates in case symptoms of hypoglycemia develop after taking an illicit drug.
• Avoid mixing illicit drugs or combining them with alcohol, since this can be a deadly combination.
• Always wear a diabetes identification bracelet.
• Develop friendships in which peer pressure to engage in high-risk activities is not present.
  (Yale School of Medicine, 2019; Vieira, 2020)

Privacy about Diabetes Diagnosis

It is an adolescent’s decision about whom to share their diagnosis with. Confiding in close friends usually is not a problem, but sharing this information with someone they start dating and want to impress may not be so easy. Frequently, parents want everyone, or nearly everyone, their child is friends with to know about their condition. Adolescents can find this annoying and may complain about it to members of their diabetes management team. The clinician empathizes with their need for privacy, at the same time explaining that parents are motivated by concern for their child’s welfare. The clinician also explains to parents that it is up to their adolescent child to decide when and whom to tell about their condition.

Regardless of whether an adolescent decides to tell the person they are dating about their condition, they are reminded by clinicians of the importance of wearing a medical alert bracelet at all times. Also, they are encouraged to think ahead about situations such as eating out on a date or playing sports, for instance, what snacks to eat (or avoid) at the movies or how they will manage an out-of-range blood glucose level, either too high or too low, while on a date?

A question the clinician may be asked is, “How do I tell someone new that I have diabetes?” The clinician can suggest keeping it simple and using language that is most comfortable for the adolescent. It is usually wiser to tell a new partner about diabetes early on in the relationship. The clinician can remind the youth that a caring person will be supportive and that someone who does not want to be in a relationship with a person with diabetes is probably someone the youth would rather not be around in any case.

The clinician can also discuss with the youth that it may be awkward for a new or existing partner to ask questions about diabetes. They can be concerned about saying something that sounds foolish or ignorant. The youth with diabetes should not take silence as a lack of caring. For the young person with diabetes, it is a matter of inviting those they care about into their personal space: talk to others about what they experience living with diabetes, what it feels like to have a hypo- or hyperglycemic episode, and what a partner can do to help in these situations (CDN, 2019a).

Disordered Eating Behaviors

Disordered eating behavior (DEB) can be a problem in young people with type 1 diabetes. Research data shows that females with T1D are 2.4 times more likely to develop an eating disorder than females who do not have diabetes. Risk factors for developing DEB among adolescents with diabetes include depression and the desire to curb weight gain. Although eating disorders are more common in females with diabetes, they can also occur in males (Weiner, 2017).

Diabulimia is an eating disorder behavior in which insulin use is intentionally restricted to lose weight. It is estimated that 30%–40% of young females with T1D reduce insulin therapy to lose weight, with the highest incidence of this behavior in those between the ages of 15–30 years (Weiner, 2017; ADA, 2020b). Adverse side effects associated with diabulimia include:

• Dehydration
• Loss of lean body mass
• In severe cases, development of DKA
  (ADA, 2020b)

Eating disorders also occur in young people with type 2 diabetes. In one study, over 50% of the surveyed youth with T2D had an eating disorder, and over 30% were willing to sacrifice diabetes control and insulin dosing to lose weight (Weiner, 2017).

It is vital for clinicians to educate young patients with diabetes that this is both an unsafe and potentially life-threatening practice. Adolescents may have a hard time acknowledging problems with eating to a clinician, including whether they are skipping insulin doses. Clinicians must maintain a nonjudgmental, supportive attitude. Patients with an eating disorder will most likely be referred to a mental health professional with experience in eating disorders (ADA, 2017c).