Dear Jane:

This is Oliver! I no longer live in Hawai but I got your letter and I will still talk to you about how I feel about being a dietbetic. It is probably the most stressful medical problem a 14 year old could have. Because everybody will always be on your tail so that you will do what is proper. One way I think will make a dietbetic's life easier is for a cure, but it won't happen soon. But to me the best treatment for dietbetes is having friends, parents, doctors, and even strangers supporting you, helping and always being there for every little thing. But this disease has brought frustration, stress, anger, and lots of problems for me. It is like having a parol officer on your tail. You know what I mean checking in at a certain time just to put a shot on, check your blood sugar, and trying not to cheat on your diet by eating delicious looking foods. And another way people can help make a dietbetics life easier is by making more sugar free selections that taste good and don't cost a fortune. And put more organizations for kids, teens, and adults in more states. Well, hope you have a successful career. And don't forget these are my opinions only. I only talk for myself not others, Bye!

Your Friend,

Oliver says that these are just his opinions, but we know that he is not alone in his description of what it is like for him to live with diabetes. His consistent (mis)spelling of the word "dietbetes" is very telling. As health care providers, we dictate a very regimented life and lifestyle at a time when risk-taking behaviors and rebellion are very much part of normal adolescent development.

The life of a teen is complex, and the complexities increase exponentially when a teen has diabetes. Adolescents struggle with tremendous adjustments as constant changes and challenges occur in all aspects of life. These include physical growth, surges and fluctuations in hormones, changes in sexual development accompanied by changes in body image, peer influences, school and social pressures, family conflicts with the struggle for independence, and many other aspects that are a normal part of the teen years.^2-4 By the time they have reached adolescence, young people are struggling with the Who am I? and the Why? of life, basic identity issues so important for continued development into healthy adulthood. For teens, diabetes is a developmental journey, a journey through the ages and stages of adolescent growth and development and a journey through the constant changes and never-ending adjustments over the trajectory of the disease.

After years of controversy, in 1993 with the release of the results of the Diabetes Control and Complications Trial, it was finally proven beyond a doubt that metabolic control matters. Intensive therapy and tight control of blood glucose has an overwhelming impact on reducing the onset and progression of the long-term microvascular complications of type 1 diabetes.⁵ From the Kumamoto Study, in 1995, Ohkubo and colleagues reported similar findings on the effects of intensive therapy and improved metabolic control on people with type 2 diabetes. This was further confirmed by the larger United Kingdom Prospective Diabetes Study (UKPDS) in 1998.^6,7 All of these studies demonstrated that long-term control of blood glucose is possible, and the result is a significant decrease in complications.

Yet, while diabetes is a "controllable" condition, achieving consistent control requires a tremendous amount of education, motivation, self-discipline, and emotional, social, financial, family, and health care system supports.^4,8,9 With every fingerstick, there is that underlying worry that complications, disability, and death may occur if the result is not "normal" or "good." Diabetes during the adolescent years takes its toll on the individual teen with diabetes, on parents and other family members, on school systems, and on society.¹⁰ The health care team is also challenged.

During the past two decades, we have seen tremendous changes in diabetes care as numerous technological advances and scientific breakthroughs have occurred. Improved technology has resulted in many new products, such as newer and smaller meters with computerized capabilities to download patterns of results, "painless" devices to obtain blood samples, a variety of new oral medications, new insulins and insulin analogs, insulin pens, expanding capabilities of pumps, new devices to detect hypoglycemia, new foods, and many other means of improving diabetes control, largely through diabetes self-management. However, in-spite of the research findings and the continued advances in technology, day-to-day challenges of the treatment regimen, social and emotional issues, and worries about a healthy and productive future abound.

A growing body of scientific evidence and the explosion of new products, medications, and technologies have prompted us to revisit diabetes and adolescents. This From Research to Practice section of Diabetes Spectrum presents the current state of our expanding knowledge and understanding surrounding three teen issues: choosing management strategies for varied lifestyles; developmental and psychosocial considerations with intensive therapy; and the present state of our knowledge and growing concerns about type 2 diabetes in teens. In each of the papers, our distinguished authors have provided new insights into management options in our clinical practices as we attempt to strike the delicate balance between normal adolescent lifestyles and behaviors (including risk-taking behaviors), relationships with parents and peers, quality of life for the present and the future, and, of course, HbA_1c levels.

Schreiner and colleagues (p. 83, Management Strategies for the Adolescent Lifestyle) present us with four teens, who have very different lifestyles and present different challenges to their health care team. Marta is a busy young lady involved in school clubs, community volunteerism, dating, and other social activities. Miguel, an organized and energetic young man, is high-tech, high-speed, and bound for success. Saru has just become tired of the rigors of diabetes self management and is now skipping insulin and rarely using her meter. And John is an athlete. Recently diagnosed, he is trying hard to fit the diabetes regimen into a lifestyle that includes consuming large amounts of food with his teammates after practice each day. The authors explore varied management considerations and strategies for diabetes professionals who work with adolescents, emphasizing strategies to consider during periods of "sub-optimal diabetes self-management."

The article by Schreiner and colleagues sets the stage for a comprehensive discussion by Weissberg-Benchell and Antisdel (p. 88, Balancing Developmental Needs and Intensive Management in Adolescents) concerning the effects of intensive insulin therapy on the developmental and psychosocial needs of adolescents. With a refreshing reminder that the teen years can be (and are) delightful, the authors look far beyond the frustrations and challenges about which we are so accustomed to hearing. They remind us of the strengths and capabilities of adolescents as they develop through each age and stage, exploring new horizons and redefining roles and relationships in their ever-changing lives.

Weissberg-Benchell and Antisdel discuss the risk behaviors of teens, including the potential risks associated with intensive management. A number of recent studies that include reports on the use of insulin lispro and other recent technologies are cited throughout the article. The authors pay particular attention to the effect of these new management tools on the lives, lifestyles, and quality of life of adolescents.

Ponder and his team (p. 95, Type 2 Diabetes Mellitus in Teens ) provide us with the current state of knowledge about type 2 diabetes in childhood, a growing epidemic in the United States. The authors define the types of diabetes found among children and adolescents and distinguish the often misunderstood differences among them. They present the epidemiology of type 2 diabetes, highlighting a number of societal changes in the lifestyles of youth over the past several decades.

The authors also provide an in-depth discussion of the scope of the problem of type 2 diabetes among teens, including hypertension, lipids, menstrual problems, obesity, sleep apnea, menstrual problems, and acanthosis nigricans. We are reminded that diabetes is only one manifestation of the insulin resistance syndrome.

Goals of therapy and safe, realistic interventions specific to adolescents and their lifestyles are described with an emphasis on medical nutrition therapy and physical activity. This article offers guidance in the use of pharmacological agents for teens in whom lifestyle interventions alone are often insufficient to achieve reasonable metabolic control.

The authors of all three of these articles have presented many recommendations for practitioners, based both on the limited number of studies conducted to date (referenced in their articles) and on their expert opinion stemming from clinical experiences over time. All note that, while evidence is growing, we need to continue to study the effects of new lifestyle, pharmacological, and behavioral interventions for teens with type 1 and those with type 2 diabetes.

Though adolescents are preparing for adulthood, they are seriously struggling with the present. We require them to live a regimented lifestyle at an age when rebellion against authority is the norm as they struggle to be independent and self-directed. We must be realistic as we guide them through the normal developmental challenges of the teen years, compounded by the myriad of day-to-day details and daunting life-long demands of diabetes.

Perhaps Oliver best articulates what it is like to be an adolescent who has diabetes. "It's probably the most stressful medical problem a 14 year old could have . . . it's like having a parol officer on your tail . . . checking in at a certain time just to put a shot on, check your blood sugar, and trying not to cheat on your diet by eating delicious looking foods."

But Oliver also has some suggestions for both clinicians and community health professionals. ". . . the best treatment for dietbetes is having friends, parents, doctors, and even strangers supporting you, helping and always being there . . . " He also suggests that we need more healthy, affordable, and tasty food products and more programs for people with diabetes.

The following articles provide a number of additional recommendations for working with teens who happen to have diabetes.