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• 1. Transition Management of the Adolescent with Diabetes Mellitus
  • MARK A SPERLING

• UNIVERSITY OF PITTSBURGH,

• CHILDRENS HOSPITAL of PITTSBURGH

• DIVISION OF ENDOCRINOLOGY

2. Transition Management of the Adolescent with Diabetes Mellitus

• 1.Adolescence

• Rapid Physical Growth Hormones

• Turbulent Emotional Adjustments

• Independence

• Indestructibility

• Immortality

• Risk Taking Behavior

• Sexual Maturation

• Sexual Activity

• Pregnancy

3. Transition Management of the Adolescent with Diabetes Mellitus

• 2. Hormonal Adaptations in Adolescents

4. 5. GLUCOSE AND INSULIN RESPONSES TO OGTT IN PRE-AND PUBERTAL SUBJECTS

• PRE-PUBERTAL

• GLUCOSE DOSE

• 1.75 g/Kg 55g/M 2

• ( N=9)(N=8)

• Fasting Blood82.0 3.175.64.1

• Glucose (mg/dL)

• Peak Blood151.6 8.5143.37.5

• Glucose (mg/dL)

• Area Glucose

• mg/dL x 4hr409.516.3 421.1 17.0

• Area Insulin118.517.3**115.416.5

• U/ml x4hr

• PUBERTAL

• GLUCOSE DOSE

• 1.75 g/Kg55g/M 2

• (N=10)(N=9)

• 84.3 3.083.23.7

• 152.27.9 148.8 11.5

• 432.717.9429.122.9

• • 299.177.6**365.4114.8

6. 7. 8. 9. 10. INSULIN RESPONSE TO STANDARD HYPERGLYCEMIC CLAMP 11. CHANGE IN PLASMA BCAA DURING HYPERGLYCEMIC CLAMP 12. Transition Management of the Adolescent with Diabetes Mellitus

• 3. Microvasular Complications ofDiabetes During Adolescence

• Microalbuminuria

• Retinopathy

• Neuropathy-Gastroparesis

13. Transition Management of the Adolescent with Diabetes Mellitus

• 4. Emotional Adjustments

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- 15. Management Issues in Adolescents with Diabetes

• a). Provider Requirements

• Understand diabetes management and normal adolescent development

• Consistent care provided by a single physician or team

• Enjoy working with adolescents

• Confidence in diabetes management skills

• Willing to compromise on aspects of diabetes care

16. Management Issues in Adolescents with Diabetes

• b). Clinical Factors

• Flexible appointment times

• Convenient clinic location and facilities

• Staff sensitivity toward patient-parent interactions

• Consistent use of appointment reminders

17. Management Issues in Adolescents with Diabetes

• c). Patient Factors

• Good staff understanding of patient-parent conflicts and patient interests

• Clearly written, easily understood instructions

18. Management Issues in Adolescents with Diabetes

• d). Regimen Factors

• A simple regimen

• Emphasis that monitoring benefits the patient

• Well-documented negotiations and parent understanding of management goals

• Short-term compromise for long-term success

19. Specific Management Issues in Adolescents with Diabetes

• a). Insulin

• Three daily injections

• Total daily dose 1 1.5 U/KG/D

• Intermediate: Short acting insulin 2:1 to 3:1

• Insulin pumps

20. Specific Management Issues in Adolescents with Diabetes

• b). Monitoring

• Unrealistic demands and expectations may lead to misrepresentation

• Glycosylated hemoglobin tests may uncover falsified home records

• Recommendation:

• Carefully confront the patient. Emphasizing importance of accurate records

21. Specific Management Issues in Adolescents with Diabetes

• c). Nutrition

• Meal plan tailored to patient with help of dietitian

• Regulate increased caloric needs (100-200 calories/day for each year > 12 years)

• Be aware of body image concerns

22. Specific Management Issues in Adolescents with Diabetes

• d). Alcohol and drugs

• Use may express rebellion or peer pressure

• Increased danger of hypoglycemia

• Treatment: Consider referral for counseling

23. Specific Management Issues in Adolescents with Diabetes

• e). Recurrent Ketoacidosis

• Associated with poor adherence and psychosocial adjustment

• Treatment: Prompt referral for counseling

24. Specific Management Issues in Adolescents with Diabetes

• f).Sex and Marriage

• Well-controlled diabetes before conception

• Ready access to birth control information

• Recommendation:

• Both partners attend clinic and diabetes education sessions.

25. Specific Management Issues in Adolescents with Diabetes

• g). Parental supervision: Evolving independence

• Gradual increase in adolescent responsibilities for care

• Inability to take responsibility may lead to poor control

• Link driving privileges to reasonable control and adherence

• Wear Medical identification necklace or bracelet

26. Specific Management Issues in Adolescents with Diabetes

• f). Sports

• Safe participation possible with appropriate adjustment of diabetes regimen

• Physician reassurance of school officials often needed

27. Summary

• Accepting the critical role of continued parental involvement and yet promoting independent, responsible self-management appropriate to the level of maturity and understanding

• Understanding that knowledge about diabetes in adolescence is predictive of better self-care and (metabolic) control but the association is modest

• Discussing emotional and peer group conflicts

• Teaching problem solving strategies for dealing with dietary indiscretions, illness, hypoglycemia, sports, smoking, alcohol, drugs and sexual health(continued)

28. Summary

• Negotiating targets, goals and priorities and ensuring that the tasks taken on by the adolescent are understood, accepted and achievable

• Understanding that omission of insulin is not uncommon. The opportunity should be grasped for non-judgemental discussion about this

• Developing strategies to manage transition to adult services

29. What do Adolescents Seek in Transition to Adult Care

• Court J Outpatient based transition services for youth Pediatrician 1991;18:15-56.

• 100 adolescents-mean 20.5yr (17-27)-left RCH clinic1-5 yr prior-

• 70% response rate to non validated questionnaire

• Ideal age for transition-17-20 yrs(53%);up to 25 yr (35%)

• Prioritized privacy, promptness, confidentiality, trust & informality-care giver you like and get to know

30. What do Adolescents Seek in Transition to Adult Care(2)

• Eiser et al 1993-clinic for