Each developmental stage in the life of a child is fraught with unique challenges. When compounded with a chronic illness such as diabetes, additional concerns complicate normal development. Previous blogs have discussed issues regarding diabetes management throughout the stages of child development. However, the biggest challenge is for the family caregivers and healthcare providers working with children who are on the cusp of emerging adolescence. As our pre-adolescents become full-fledged adolescents, managing diabetes becomes extremely perilous, as the developmental task of the adolescent is to separate and become independent from parents and caregivers. Gentle reminders about diabetes self-care skills become an annoyance to the typical teenager. Much of my clinical time is spent trying to negotiate with unruly adolescents. My goal is to engage them as much as possible by keeping up-to-date on the latest teen fads, fashion, and entertainment. Family caregivers and healthcare providers have always known that the glycemic control of adolescence often deteriorates. However, we now have an evidence-based scholarly paper that further defines the mechanism for glycemic disruption.
In a paper by Rausch, Hood, and Delamater published in Diabetes Care, Changes in Treatment Adherence, and Glycemic Control During the Transition to Adolescence in Type 1 Diabetes, the authors conducted a two-year study in which multiple sites were samples of 225 youth with T1DM between 9 and 11 (beginning of adolescence) to describe the influences of glycemic control (measured by hb A1c), and treatment adherence (measured by frequency of blood glucose monitoring) during the transition to adolescence. According to the authors, no study with pediatric patients who are transitioning to adolescence has evaluated the rate at which management adherence predicts change in diabetes control or if the adherence/glycemic control is according to the authors' bi-directional (involving mutual influence).
What does a bi-directional relationship mean? According to the authors, if adolescents have higher hb A1c values, they may receive more intensive intervention designed to promote adherence. Use of glycemic control data to represent and guide future management of treatment adherence as the potential to mask other contributors to a higher hb A1c such as insulin dosing and glycemic variability.
What were the results?
Hb A1c increased from 8.2 to 8.6 percent (statistically significant: p<0.001) and blood glucose monitoring frequency decreased from 4.9 checks to 4.5 checks per day (statistically significant: p<0.02) during the two-year study period. Changes in the blood glucose monitoring slope predicted changes in hb A1c. An increase in Hb A1c was associated with a decrease in blood glucose monitoring frequency of 1.2 (statistically significant: p<-.001) after controlling for covariates.
What does this study add to our understanding to adolescents and diabetes management?
We can observe that the decline of the frequency of blood glucose monitoring effects glycemic control in pre- and early adolescence and may be even greater than the decrease in monitoring observed in older adolescents. We must pay even closer attention to the frequency of blood glucose monitoring as we manage pre, early, middle, and late adolescence. No longer are we required to use anecdotal evidence to present to our patient population to justify the importance of frequent blood sugar checks.
SBGM is key to optimal diabetes management. However, awareness of this need to check blood sugars does not necessarily lead to action. We must continue to develop strategies to engage this vulnerable population. Our psychosocial colleagues must continue to determine best practices to attract, connect, and maintain the relationship with both the family caregivers and healthcare providers.
Published On: April 20, 2012