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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