Achieving optimal diabetic control in
adolescence: the continuing enigma
E. M. McConnell
R. Harper
M. Campbell
J. K. Nelson*
Diabetes Unit, Ulster Hospital,
Dundonald, Belfast, Northern Ireland
*Correspondence to: Dr J. K. Nelson,
Ulster Hospital, 700 Upper
Newtownards Road, Dundonald,
Belfast, Northern Ireland
BT16 1RH, UK.
E-mail:
susan.williams@nda.n-i-nhs.uk
Summary
The transition from childhood through adolescence to adulthood is a dif®cult
stage, particularly for patients with type 1 diabetes. The yearning for
autonomy and independence, as well as the hormonal changes around the
time of puberty, can manifest in poor glycaemic control. The focus on diet and
weight increases the prevalence of eating disorders, compounding the
dif®culties in supervising diabetes patients. This can be exacerbated by the
realisation that hyperglycaemia induces weight loss and the use of this
knowledge to further manipulate diabetes control to gain a desired body
image. The management of adolescents with type 1 diabetes is therefore
challenging and requires close collaboration between psychological medicine
and diabetes teams. This review describes the dif®culties frequently
encountered, with a description of four cases illustrating these points. Case
1 demonstrates the problem of needle phobia in a newly diagnosed patient
with type 1 diabetes leading to persistent hyperglycaemia, the recognition of
weight loss associated with this and the development of bulimia. The patient's
overall management was further complicated by risk-taking behaviour. By the
age of 24 years, she has developed diabetic retinopathy and autonomic
neuropathy and continues to partake in risk-taking behaviour. Case 2
illustrates how the lack of parental support shortly after the development of
type 1 diabetes led to poor glycaemic control and how teenagers often omit
insulin to accommodate lifestyle and risk-taking behaviour. Case 3 further
exempli®es the dif®culty in managing patients with needle phobia and the
fear of hypoglycaemia. Case 4 adds further weight to the need for parental
support and the impact of deleterious life events on glycaemic control by
manipulation of insulin dosage. Copyright # 2001 John Wiley & Sons, Ltd.
Keywords adolescence; diabetic control
Background
Type 1 diabetes mellitus is a serious disorder of childhood and is managed by
a complex and invasive treatment regimen aimed at maintaining good
glycaemic control to minimise the risk of long-term complications. It is well
documented that during adolescence, a particularly stressful time for the
normal healthy teenager, there is deterioration of glycaemic control in
patients with type 1 diabetes. This may be related to hormonal changes
around the time of puberty but is also related to the individual's desires for
independence and control over their own life. A number of problems can arise
during the management of the adolescent diabetic patient as illustrated by
four case reports from our local diabetes clinic, demonstrating the dif®culties
with treatment encountered on a daily basis and possible management
strategies that can be adopted.
The deterioration in glycaemic control during adolescence has been widely
documented. Females in particular appear to have a signi®cantly higher level
CLINICAL CHALLENGES
IN DIABETES
DIABETES/METABOLISM RESEARCH AND REVIEWS
Diabetes Metab Res Rev 2001; 17: 67±74.
Copyright # 2001 John Wiley & Sons, Ltd.
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