Original Article

Management Strategies for the Adolescent Lifestyle

Barb Schreiner, RN, MN, CDE, Shannon Brow, RN, BSN, CDE, and
Monica Phillips, MPH, RD, LD, CDE

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How much more complicated can life be than for adolescents with diabetes? The demands of diabetes often pull teens in different directions as they struggle through the normal developmental challenges of the age.

For teens, it is typical to feel self-conscious about personal appearance. Yet diabetes demands visible ID tags. It is normal for teens to practice becoming independent. Yet diabetes demands a degree of dependence on parents and health care professionals. And it is common for teens to stay grounded in the present. Yet diabetes and its potential long-term complications serve as a constant reminder of an uncertain future.

Diabetes and its demands can affect teens' sense of self and security and can challenge budding independence and decision-making. In addition, physiological changes that occur during adolescence promote insulin resistance,¹ making diabetes control even more difficult. At best, the daily demands of the adolescent lifestyle make for interesting problems. Tables 1 and 2 summarize the impact of diabetes on adolescents.

Diabetes professionals who work with adolescents typically serve as coaches, providing the five Cs: contact, consistent message, caring, correct tools, and creative approaches. This article explores through case studies management approaches to meal planning, exercise, and insulin therapy for adolescents with diabetes.

Case #1: "Life's a Party"
Marta, age 16, has had type 1 diabetes for 7 years. Her weekly schedule includes school club meetings, work as the school yearbook editor, weekend dates, and volunteer activities. She has few meals at home and is usually with friends from morning until night. In her list of priorities, diabetes care frequently falls well below her social plans.

Marta needs a flexible but effective and safe management approach. An intensified insulin program might be ideal for Marta. With such a program, teens have much more latitude with meal timing and amounts of food consumed.

An intensive insulin program using long-acting and rapid-acting insulins affords flexibility in schedules and meals. However, teens must commit to additional monitoring and thoughtful decision-making. Intensified programs² often require calculating the amount of insulin needed for an amount of carbohydrate consumed and the amount of insulin needed to return a high blood glucose level to the target range. Clearly, math skills and accuracy in judging carbohydrate content of foods are mandatory.

Intensified insulin programs can become even more convenient with the portability of insulin pen devices and small blood glucose meters. A pen carried in a purse, hip pack, or back pack promotes convenience that, in turn, can promote blood glucose control in a busy and unpredictable schedule.

Very busy teens such as Marta will also need help with restaurant choices and general nutrition. Meal planning for teens should include the use of food models to help estimate portion sizes and carbohydrate choices. These can help prepare teens when eating at restaurants. Menu selection can also be taught using food pictures. Commercially available fast food guides are good tools for helping teens choose healthy foods at their favorite drive-throughs.

In addition, teens like Marta often need help juggling the demands of their daily lives. The routine and discipline required for diabetes care can often serve as a model for the skills needed for studying. Time management and stress management are supporting skills that benefit diabetes self-care. Grey³ and others have demonstrated that such skills training can enhance diabetes control at least for a short time.

For adolescents, diabetes information should be delivered in the context of anticipatory guidance. Issues about alcohol,⁴ relationships, and sexuality⁵ are all compelling topics for adolescents, especially for very social teens such as Marta. Education must include information on how diabetes affects these typical adolescent life issues.

Case #2: "More is Better"
Miguel, 17, has had diabetes for 10 years. He is a good student and is planning to go to college next year. He approaches his diabetes care as he does most things of his life: with drive, energy, and focus. His life is tightly scheduled, and he places a great deal of pressure on himself to succeed. On a recent visit to his diabetes care provider, it was noted that Miguel's blood glucose levels were very high. During the assessment interview, the diabetes educator sensed that Miguel was becoming bored and frustrated with the diabetes management routine.

Teens such as Miguel thrive on routine, precision, and organization. They are often interested in the complexities of diabetes care. Tools for these teens could include continuing education about diabetes care, meters that download to computer analysis programs, insulin infusion pumps, and sophisticated carbohydrate counting methods.

Diabetes software is an attractive tool for teens such as Miquel. Handheld nutrient calculators, for instance, are available to track carbohydrate intake. This type of information is useful in calculating insulin boluses for meals.

Adolescents such as Miguel are also likely to understand their individual sensitivities to food and to feel comfortable knowing how to modify their intake to achieve blood glucose goals. Learning mathematical formulas, such as insulin-to-carbohydrate ratios and insulin sensitivity factor calculations for correcting high and low blood glucose values, empowers many teens and families.

An insulin pump may be exactly the "hi-tech" device to help Miguel control his blood glucose values. Young people who are attentive to details and have both good problem-solving skills and good math skills can easily learn how to use this device.

Teens using intensified insulin management can achieve the same level of control as those using insulin pumps, although they may be more limited by the number of injections needed to do so each day. An insulin pump may provide Miguel with the confidence that when he tests his blood glucose level, he will be able to quickly respond. When his blood glucose values are evenly mildly out of target, Miguel can make an adjustment by even 0.1 U at that moment. Motivation can come from something as simple as seeing one's desired results on the meter.

Sometimes, these teens follow a very rigid approach to meal planning and would benefit from updated nutritional information. Children who were diagnosed at a younger age may be operating on information provided at the onset of their diabetes. A refresher course with information targeting adolescent concerns may pique Miguel's interest.

Education should also include vocational counseling topics. Although employment barriers are beginning to ease, there are still several jobs not open for people with diabetes. Exploring career options and planning further education are developmental tasks for teens. In addition, some states have scholarship programs for teens with diabetes through the state vocational rehabilitation department.

Teens who transition to college will need additional information and assistance. Issues to explore include:

• How do you maintain a reasonable blood glucose level while studying all night?
• How do you safely and responsibly party with your friends?
• Who needs to know about your diabetes, and how do you tell them?
• How do you build your own diabetes team while at school?

Miguel and his parents have already been discussing how he will handle his diabetes next year, when he moves away to college. He is confident that his pump will give him the flexibility to get through unpredictable days, all-night study sessions, eating pizza at 2:00 a.m., other rigors of university life.

Case #3: "Diabetes in the Back Seat"
Saru, 14, has had diabetes for 3 years. She has begun skipping insulin doses and rarely checks her blood glucose. Her friends are supportive, and her school grades are good. She has simply lost interest in her self-management.

Of course, most health professionals would like to have all of their adolescent patients maintain the gold standard of control defined by the Diabetes Control and Complications Trial.⁶ However, there may be several reasons why this treatment goal is difficult, if not impossible, to obtain for some teens.

Achieving diabetes control requires a delicate balance between self-management demands and lifestyle desires. For teens, the balance often swings in favor of the activities of living. Adolescents often lose interest and motivation for self-care. Often, this is a signal that the management plan has become too complicated. This is not the time to make the management plan more cumbersome by tightening control. Tightening control and increasing care demands often leads to further rebellion, including falsification of records and skipped insulin doses.⁷

Simplifying the treatment plan and providing additional external support are key interventions. The goals for care may have to been adjusted for a time. Simplifying the plan may include changing the insulin program from three or more injections per day to two injections per day. Making diabetes care more portable, with insulin pens and smaller meters, can help as well. Although not ideal, occasionally using pre-mixed insulins may be necessary to keep teens metabolically safe. Simplifying the meal plan may mean changing from carbohydrate counting to the food pyramid or plate method. In these approaches, teens focus less on carbohydrate amount and more on overall amount of food consumed.

Parents and professionals sometimes need to step in when teens take a break.⁸ Parents may need to occasionally draw insulin and give injections. Physicians or nurses could provide additional phone support or office visits to encourage and monitor progress. Other support is found through peers in camping programs, youth support groups,^9,10 books for teens with diabetes,¹¹ and safe Internet chat groups.

Cautiously lowering expectations for diabetes care can be tremendously freeing for adolescents. However, teens and their parents must understand that this level of care is not optimal and should not continue long-term. Education at this time should include a discussion of decision-making skills and logical consequences. Scare tactics are usually ineffective, so a discussion of overall goals for management is important. The plan should include strategies for transitioning back to more acceptable, tighter degree of metabolic control.

As teens demonstrate more maturity, moving back to intensified insulin programs, will be important.

Case #4: "One for the Gipper"
Josh, 15, has recently been diagnosed with type 1 diabetes. Josh is a superb athlete. He competes on the school wrestling team and enjoys working out with his friends almost daily.

During Josh's initial assessment on the first day of diagnosis, the diabetes team discovered that a typical three-injection-per-day regimen would likely not work for Josh. He usually works out with his coaches and teammates for 3 hours each afternoon. Josh and his teammates have a habit of going for a yogurt smoothie at 4:00 p.m. each afternoon after practice. This drink has 190 grams of carbohydrates. No conventional insulin program would cover such a large carbohydrate load.

Rather than tell Josh that he needed to drastically change his lifestyle, the diabetes team presented a variety of insulin programs, gave him the pros and cons of each, and let him choose. Josh did not want to give up his daily afternoon treat, and he preferred the flexibility of multiple injections, so he chose an intensified insulin program from the start.

Josh keeps a blood glucose monitor and insulin pen with him at all times. Should his day take an unforeseen turn, he can adapt.

Sports can be a strong motivator for some teens, such as Josh. Some will recognize that good diabetes control equates with better athletic performance. Teen athletes can benefit from an intensified insulin plan or an insulin pump. With these approaches, they can more easily adjust to training schedules and competitions.

Nutrition education should include adjustments for energy needs, carbohydrate choices and types for training, amounts of fluids to consume, and attention to nutritional supplements. The ingredients in food and energy supplements also need to be evaluated. Teens should be encouraged to avoid megadoses of protein and other supplements. During exercise, teen athletes need to replace glucose stores regularly. Sugar-free fluids should be consumed during exercise to avoid dehydration, while carbohydrate-containing fluids should be available for treating hypoglycemia.

How blood glucose is managed before, during, and after exercise will depend on several variables including time of day of exercise, duration and intensity of exercise, type of insulin regimen, blood glucose targets, and a teen's typical response to exercise. Guidelines are available to help young athletes compete safely.^12,13

Many teen athletes are quite lean. New, short-needle insulin syringes can be a good choice for them. Consistently injecting in one body location with careful site rotation is also recommended, because insulin absorption can vary when multiple injection locations are used. Changing seasons and ambient temperatures may be another source of variability. Teens need to be cautioned about the effect of changes in seasonal routines. Boland¹⁴ has reported that summer time often means deterioration in blood glucose control.

Anticipatory guidance for teen athletes includes recommendations for recognizing and treating hypoglycemia. Glucose-containing foods must be readily available at practices and competitions. Teens must be educated about prolonged post-exercise hypoglycemia, as well. Precautions include checking blood glucose before bedtime, having a bedtime snack, or adjusting the evening insulin dose. One other precaution is wearing a medical ID tag. These tend to be cumbersome for teen athletes, but there are alternatives. Tags that attach to exercise shoes are a great option.

Just as a teen's athletic coach guides performance, the diabetes team serves a similar role in the teen's diabetes care. Coaching teens with diabetes means making recommendations, guiding behavior, and providing positive and negative feedback. Coaches recognize that peak performance comes from an individual's drive to succeed and an environment that nurtures that drive. The diabetes coach recognizes that teens are often motivated for self-care but may have incredible barriers to overcome.

Summary
The approaches suggested for working with teens such as Marta, Miguel, Saru, and Josh may not be permanent solutions. If a diabetes management plan does not parallel changes in lifestyle and individual needs as teens advance through adolescence, the teens will likely be labeled "noncompliant" or "nonadherent."

Poor follow-through on the part of teens is nothing more than an indication that their self-care strategies are no longer working. It is an indication that both teens and professionals must craft a new plan. Such times often require professionals (the coaches) to provide closer contact, a consistent message, caring, new tools, and creative approaches. Without a doubt, it can take great creativity and patience to develop approaches successful to the care of adolescents with diabetes.

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Barb Schreiner, RN, MN, CDE, is an instructor at Baylor College of Medicine and associate director of the Diabetes Care Center at Texas Children's Hospital in Houston, Tex. Shannon Brow, RN, BSN, CDE, is a diabetes nurse educator, and Monica Phillips, MPH, RD, LD, CDE, is a diabetes dietitian at the Diabetes Care Center at Texas Children's Hospital.