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Teenagers with Diabetes

There are many biological changes during the teen years. This happens along with physical, mental, and emotional development. During this time, there may be a growing desire to fit in with friends, to experiment, to test limits, and to seek independence from family. Self-image changes when a teen’s sexuality starts to emerge. This experience may be difficult and even frightening for some. Diabetes can affect these processes in different ways.

With or without diabetes, all teenagers develop differently. Once teenagers can start to reason and think about their future, they will understand the implications of diabetes and its management. There are many factors such as peer pressure, parties and other social events, part-time jobs, and a busy life in general that may interfere with the teen’s ability to translate this new awareness into good self-care.

Even though it may seem that these young people should be more responsible, more able to achieve good blood sugar control, adolescence is often the time when healthy blood sugar control is most difficult.

Normal developmental patterns during adolescence

Early adolescence (ages 12 to 14)

  • places enormous importance on body image and is intensely self-absorbed
  • seeks reassurance more and more from peers rather than family

Mid-adolescence (ages 14 to 17)

  • struggles for autonomy and control of personal destiny
  • can be involved in teen-parent conflict stemming from relatively trivial issues such as hair length, clothes, and curfew, as well as more serious issues such as smoking, alcohol, and drug use
  • may indulge in other risk-taking behaviours

Late adolescence (ages 18 to 21)

  • becomes increasingly stable (true of many but not all teens)
  • begins to shape long-term plans such as career and personal goals

How diabetes affects adolescents

Diabetes management needs a degree of responsibility and behavioural control that is not typical in many adolescents. The daily demands of the disease have an impact on the personal and public lives of these teens. It affects important developmental stages including independence, body image, identity, sexuality, responsibility, and self-esteem. Parents worry a lot about the teenage years, and perhaps more so when their teen has diabetes. Yet recent research suggests that most adolescents get through this period without too much disruption, and that they are, in fact, quite well adjusted.

Coping strategies

  • Stay involved in your child’s diabetes care, at some level, right through their teen years. Diabetes management is a heavy burden to carry alone.
  • Let go gradually. Make sure your teen is ready, willing, and able to take on the parts of diabetes management you are ready to give up.
  • Praise your teenager freely. There is no danger of giving her an inflated ego. Positive reinforcement will only result in more of the desired behaviour.
  • Parents, teens, and the diabetes team must all have the same expectations of the teen and of each other. Is everyone aiming for the same blood sugar targets? Can everyone agree on how often blood glucose monitoring will be done? Can everyone agree about who chooses what foods at mealtime? Goals and expectations should be reviewed together, on a regular basis, to be sure they’re still appropriate.
  • All teens hate to be nagged, but most don’t mind a little help. You can help get the monitoring equipment ready for a check, instead of simply saying: “It’s that time again.“ Similarly, you can offer to keep the logbook, instead of worrying or complaining that you don’t know what’s going on because the numbers never get into the book.
  • Be prepared to get involved again as necessary. Even the most independent teen is going to need back-up during particularly stressful periods, such as a crisis in a relationship, an illness, or during a time of too many competing priorities. This is not a step backward. It’s just evidence of the family working together to ensure that the teen’s health is kept up at all times.
  • Teens should be encouraged to develop their own relationships with members of their diabetes team. Let your teen have private time with the doctor or nurse at each clinic visit. It’s natural for parents to want to stay informed, discuss issues, and be part of developing the plan for the next phase. However, teens should be able to expect confidentiality in certain aspects of their health care.

Teens and blood sugar checks

Many teens do not like checking their blood sugar levels and avoid doing it. There are a lot of reasons why teens hate doing this:

  • It’s inconvenient and time-consuming. To a teen, losing a few minutes of sleep or party time means a lot.
  • Each check is a reminder that they have diabetes and they are not the same as their peers.
  • They feel accountable for each blood sugar result. Parents often demand explanations for high or low readings.
  • The results may make them feel guilty. They may know why their blood sugar is high but may be unwilling to do anything about it. It feels better not to check.
  • They don’t understand the purpose of checking because they don’t know how to make use of the results.
  • They feel discouraged by the results, which don’t reflect their efforts to manage their diabetes.

It’s worthwhile having a discussion with your teen in an attempt to discover what the issues are in her particular case.

Healthy living in the teenaged years

It’s not unusual for some teens to try risky behaviours, such as smoking, drug or alcohol use, or unprotected sex. In girls, unplanned pregnancies and eating disorders may occur. For teens with diabetes, these behaviours can be extra hazardous to their health.

Using alcohol, for example, increases the risk of severe low blood sugar. Smoking greatly increases the chance of early stroke, heart attack, and other diabetes-related complications. It’s important to talk to teens about the risks associated with these behaviours. It’s impossible for them to make wise choices without the right information.

Parents also need to understand that diabetes routines may become a target for risk-taking behaviours. Teens may skip blood sugar checks or meals. They may not wear their MedicAlert bracelet, which could alert help if anything went wrong.

The teenaged years can also be stressful, with all the changes, peer pressure, and school pressures. It’s important for teens to try to have a positive attitude, and keep stress under control.

For teens who are injecting insulin, risk-taking behaviour can seriously affect diabetes control. The result can be missing lots of school, hospitalization (due to diabetic ketoacidosis), or poor growth or weight loss. In this case, parents will need to start giving the injections and doing the blood sugar checks, regardless of the teen’s age. Parents have to keep doing this until there is proof that it’s safe to allow the teen to manage on her own once again.

Smoking

One of the best things your teen can do for her diabetes, and overall health, is to not start smoking. Or, if she has already started, to stop smoking. We all know that smoking increases our chances of getting many kinds of cancers. However, smoking also increases the risk of blood vessel damage, heart attacks, and strokes. People with diabetes already face these risks.

If your teen has diabetes and smokes, every puff of a cigarette increases his risk of these serious health problems even more. If you as a parent are a smoker, your child with diabetes is being exposed to your second-hand smoke. Quitting now will not only improve your own health, but will improve the air your child is breathing.

Quitting smoking can be difficult. Teens who really want to quit will succeed with will power and help from others. Your doctor and diabetes health care team have experience helping other teens break the habit. Ask for their help. There may be a smoking cessation program your teen can take. Here are some points to keep in mind about smoking.

  • If you are a non-smoker, don’t start!
  • If you smoke, quit now.
  • Get help from your doctor or health care team. There are proven ways to help people quit.
  • If there are other smokers in your house, quit together so you can give each other support.
  • Ask friends and family to help and to be supportive of your teen’s efforts.
  • Don’t give up the struggle to quite smoking! It may take several tries, but keep at it.

The day your teen stops smoking, his body will start repairing the damage done and he will be on his way to leading a healthier life.

Alcohol & drugs

It’s not unusual for teenagers today to be offered alcohol or drugs, and to have to decide whether they will try it. Teens with diabetes have to think about these decisions extra carefully because diabetes and alcohol or other drugs are not the best mix for their health.

Alcohol

Alcohol has no nutritional value (except calories), but it does have a powerful effect on blood glucose control. Alcohol is processed in the liver. It blocks the liver from releasing sugar into the bloodstream. This can lead to low blood glucose levels.

If your teen is also taking insulin or pills to lower his blood glucose, the risk of low blood glucose becomes more serious. If your teen takes diabetes medicines, it is very important to eat when he drinks alcohol to prevent low blood glucose.

Also, a teen who is under the influence of alcohol may miss the early warning symptoms of low blood sugar. Things may move quickly to a severe episode. Others who have been drinking may not recognize the problem. Or they may smell alcohol on the teen’s breath and think he has passed out from being drunk.

Another issue to think about is drinking and driving. We all know the dangers involved. Many teens do experiment with alcohol. If your teen has diabetes, he will need to think carefully about drinking and take the necessary steps to drink safely and responsibly if he chooses to do so.

Marijuana and other drugs

Pot may increase the appetite and get in the way of trying to lose weight. It can also affect judgement about how much food has been eaten, food choices, and balancing food with medications. Also, a teen who is under the influence of marijuana may miss the early warning symptoms of low blood sugar.   

The direct effect of other street drugs on blood glucose levels is not well known. They may do other damage and may also contribute to poor judgement and risky behaviours such as unprotected sexual intercourse.

Ideas for talking about alcohol and drug use with your teen

As a general rule, it’s better to teach teens with diabetes about safe alcohol use rather than forbid it. You can’t assume that your teen won’t try a drink at some point. 

Here are a few tips that your teen should know about to drink safely and responsibly:

  • Wear a MedicAlert bracelet. If anything does happen, the medical information is available.
  • Too much alcohol use is very risky – drink in moderation.
  • Choose light beer and dilute white wine with club soda. Liqueurs, fruit drinks, and drinks mixed with regular soft drinks have more calories and more sugar.
  • Never drink on an empty stomach. Eat when drinking.
  • Drink slowly and don’t have more than 2 drinks. Have water or diet pop instead.
  • Test blood glucose before, during, and after drinking.
  • Stick with a friend who knows about the diabetes and can recognize a low blood glucose reaction.

If your teen decides not to drink, it can sometimes be hard to be the only one not drinking. He may feel peer pressure to drink even though he doesn’t want to.

Here are some ideas of things for your teen to say if anyone asks why he isn’t drinking:

  • If someone asks if he would like a drink, he could just say, "No thank you!" (Polite and to the point.)
  • If your teen is comfortable talking about his diabetes, he could say, "It’s not good for my diabetes." (Real friends won’t try to force him to do something that could make him sick.)

Birth control

We all know the importance of protection from sexually transmitted diseases (STDs) and unwanted pregnancy. This is especially true for teens with diabetes. Girls can become pregnant, and boys can father a child.

To prevent STDs, condoms are a must for all sexually active teens. To prevent pregnancy, an additional form of birth control, such as the pill or a diaphragm, is needed. In general, young women with diabetes have the same options for birth control as do those without. 

For teens with type 1 diabetes who are sexually active, intercourse should be considered an extra activity that uses energy, requiring a carbohydrate snack afterward.

Pregnancies in teenaged girls are always considered high risk. This means there is a greater chance of things going wrong for both the mother and her baby. But being a pregnant teenager with diabetes adds even greater risk. Babies who are exposed to high blood glucose levels when they are in their mother’s womb have a greater risk of birth defects, difficult deliveries, and a greater chance of developing diabetes when they grow up.

Teens with diabetes should be given information about sexuality, contraception, and pregnancy well before they need it. These discussions should take place with members of the diabetes team and should be confidential. When the time comes to plan a family, they should be reassured that the health care team will be there to help them and their baby get the best possible start.

MedicAlert bracelets

Teens wear MedicAlert identification for all sorts of reasons: because they wear contact lenses, have allergies to foods, medications or bee stings, or have asthma. The bracelet or neck chain gives emergency medical personnel information that could save a person's life. Ask your diabetes educator to show you samples of the kinds of identification available.

Eating disorders

Eating disorders are common among teenage and young adult women. They are much less common among males in the same age group. Researchers believe that eating disorders grow from an obsession about gaining control in a life that teenagers see as being out of control. There are many possible causes of this obsession, depending on the individual’s experience. People with anorexia nervosa try to regain control by denying themselves food. People with bulimia nervosa try to regain control by excessive overeating or binging, then purging by vomiting or with the aid of laxatives. These definitions aren’t cut and dried––people with one disorder sometimes show characteristics of the other. In the long term, anorexia can lead to severe weight loss and can be fatal.  The constant binging and purging of bulimia can result in severe stomach ulcers and can be fatal.

In teenage and young adult women with type 1 diabetes, it is common to have ongoing disturbances in eating attitudes and behaviours. Full-blown eating disorders occur in as many as 1 of every 10 teenaged girls with diabetes, but even milder problems can play havoc with blood glucose control.

Some diabetes-related factors may increase the chances of an eating problem. At the time of diagnosis there has often been weight loss. With insulin therapy this weight is quickly regained. In the vulnerable girl, this may trigger dissatisfaction with her body and the desire to be thinner again. Also, meal planning is a key part of diabetes treatment. Such planning means that there will be some restraints on eating. This is another trigger to disordered eating. Finally, some girls discover that by skipping or reducing their insulin dose, they can lose sugar in their urine and keep themselves underweight. Although this may be an effective way to control weight, it leads to poor diabetes control and, in the long run, earlier onset of diabetes-related complications.

Warning signs of an eating disorder

Eating disorders in people with type 1 diabetes can lead to wild, unexplained changes in blood glucose levels, often outside the safe range. If a teen has many low glucose reactions (insulin reactions) or high glucose reactions (excessive thirst and urination, perhaps leading to urinary ketones), it may be a sign of an eating disorder. Some other signs of eating disorders include:

  • a preoccupation with food and weight, beyond what is needed in diabetes management
  • a stated desire to lose weight beyond what seems appropriate
  • requests for a change to low-calorie, low-fat, vegetarian, or other diets to lose weight
  • binge-eating episodes
  • insulin manipulation

What you can do to help

If you know someone with an eating disorder, there are several things you can do to help.

  • Express concern for the person’s health, while respecting the need for privacy. Eating disorders are usually a symptom of a greater psychological problem. The fact that you are there to help will be appreciated.
  • Avoid power struggles around food. Forcing someone with an eating disorder to eat will probably make things worse.
  • Examine your own attitudes around food and weight. Are you furthering the idea that "thin is in"?
  • Talk about more flexible meal plans with the diabetes dietitian. Perhaps the current meal plan restricts eating too much, and reinforces the idea that the person with diabetes is different and deprived.
  • Avoid commenting on weight, either positively or negatively. This only emphasizes the importance of appearance.
  • Express your concern to the diabetes team and get support for the person.

Driving

Driving a car requires sound judgement and responsibility. Young people with diabetes have an additional duty to make sure that their blood sugar is not too low before they get behind the wheel of a car. Low blood sugar can impair judgement. This can increase the risk of an accident. You should be certain your teen is responsible before you allow him to apply for a driver’s license or lend him the family car. Getting a regular driver’s license is not generally a problem, as long as your teen has reasonable blood sugar control and has had no severe episodes of hypoglycemia in the past year.

Employment

There are many examples of people with diabetes who have succeeded in a broad range of careers––doctors, lawyers, nurses, politicians, professional athletes, accountants, teachers, and engineers, to mention a few. In general, young people can be counseled to pursue the career that interests them. However, it is also important to know about certain limitations. Two questions are often asked of the diabetes team: "Are there jobs that are not available to people with diabetes?" and "Do some employers discriminate against people with diabetes?" The answer to both questions is yes.

Some organizations have a blanket rule that prevents the employment of people with diabetes. This includes jobs involving operation of an aircraft and jobs in some military or police departments. These rules are based on the risk of hypoglycemia while on the job. Before applying for a particular educational or employment opportunity, teens with diabetes should find out whether they can be employed in these areas.

Employer discrimination has been documented over many years. There is often a mistaken belief that people with diabetes will come to work less often and do the work less effectively than their peers. Young job-seekers with diabetes should stress their personal qualifications, abilities, and ambitions to potential employers. They should not hold back information about their diabetes, but rather stress the fact that they can perform as well as others. If they believe they are being treated unfairly, they should seek advice through their advocacy group, such as the Canadian Diabetes Association or the American Diabetes Association.

Menstruation

When your daughter begins menstruating, a question that often comes up is whether diabetes will affect her periods. The answer is no. However, the hormonal increase during menstruation can cause blood sugar levels to rise. For women who take insulin, some may need more during their periods. This is checked by observing the blood sugar pattern during the menstrual cycle.

Sleeping in

Staying up late and sleeping in seem as if they would throw diabetes management off track for those taking insulin. Although regular timing of meals and snacks is important, with a little extra effort and caution your teen can make the adjustments needed to sleep in safely. For example, if your teen is going to bed at midnight on Saturday night and wants to sleep in until 10 a.m. Sunday, try this: instead of taking the evening NPH insulin at 10 p.m., take it at midnight, together with a blood sugar check and a little snack. If your teen is on 2 injections a day, it’s advisable to split the evening one: take the rapid-acting insulin before supper and take the intermediate-acting at bedtime, along with an added small snack and a blood sugar check. This will ensure that your teen's sugar doesn’t go low during those extra sleep hours.

If your teen is on an insulin pump, sleeping in is much easier. Just stay on the overnight basal rate and take a bolus with the first meal. The risk of either hypoglycemia or hyperglycemia should be very low.

Positive attitude

It may sound like a cliché, but a positive attitude will go a long way to helping your child or teen manage his diabetes. It is normal for young people with diabetes to feel overwhelmed at times or to feel like no one understands them. But if your child feels angry or resentful about his diabetes, or is sad or having trouble coping, he may find it difficult to make the choices he needs to stay well. Your diabetes health care team is there to help. Talk to them for ideas or encourage your child to talk to them, either with you present or privately. The diabetes team might even be able to put your child in touch with others the same age who have diabetes and who understand just how he is feeling.

A trip out of town: Jackie’s story

Jackie is 14 and has had diabetes since the age of 7. She’s proud of the fact that she manages her diabetes by herself. She checks her blood sugar 3 or 4 times a day, and takes insulin 3 times a day. Already she joins in decisions about insulin dose adjustment. Her hemoglobin A1c checks have been consistently in the 7s, indicating excellent blood sugar control. She’s happy and involved in school and extracurricular activities.

At a recent clinic visit, the doctor discovered that, on one of the few times when Jackie’s blood sugar checks were high, she wrote down a lower result. When this was pointed out to Jackie, she started to cry. With a little prompting, she was able to tell her diabetes nurse that she felt upset because she was looking forward to a youth group trip to Ottawa, and her parents had agreed that she could go if she maintained good diabetes control. She believed that they wouldn’t let her go if they saw the high blood sugar results. Jackie asked her nurse to help her explain the doctor’s discovery and her feelings and concerns to her mother, who was in the waiting room.

After Jackie’s mother heard the explanation, she put her arm around her daughter, saying, "Jackie, that’s not what your father and I meant by good control. We should have been clearer about what we expected." In fact, her parents meant that she should put in a strong effort. Everyone has occasional highs and lows, sometimes for no apparent reason. Jackie’s parents didn’t mean to suggest that they expected checks to be perfect. The misunderstanding gave Jackie and her parents an opportunity to talk about and rework their goals.

Marcia Frank, RN, MHSc, CDE

Denis Daneman, MB, BCh, FRCPC

2/12/2010

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