Growing Up with Diabetes

The impact of diabetes during childhood can be psychological as well as physical. Diabetes and its demands can affect teens' sense of self and security, and can challenge budding independence and decision-making. The physiological changes that occur during adolescence promote insulin resistance, making diabetes control even more difficult. At best, the daily demands of the adolescent make for interesting problems.

Here are specific concerns that typically arise as kids with diabetes grow older.

11-14 Year-Olds

General Characteristics	Impact of Diabetes	How to Approach
Worry about appearances/self-conscious	Not wanting others to see fingersticks, injection sites, or medical bracelet Worrying that hypoglycemia will happen around friends or during sports	Offer alternatives to traditional ID tags (like shoe tags) Use self-consciousness as a motivator to rotate injection sites Use hypoglycemia as a motivator for proper blood glucose testing
Hormonal changes	Having blood glucosefluctuations Increasing insulin resistance Mood changes can mimic hypoglycemia	Using pre-loaded insulin pens or pre-mixed insulin to deal with rapidly changing blood glucose levels Modify sick day rules Monitor blood glucosemore often
Assert independence from family	Skipping insulin shots Ignoring meal plan Not ready for independent self-care Being upset with overprotective parents	Use “experiment” approach: teens test out behavior with support and guidance from team Have teen see diabetesteam alone Modify/simplify meal plan Counseling for parents on changing roles
Are rebellious and defiant	Refuse diabetes self-care Hate reminders Take out anger on parents or school teachers	Provide counseling Teach how to deal with anger
Place importance on peer relationships	Peers take priority over self-care Child hides diabetes Child uses diabetes to establish role within group	Discuss setting priorities Plan for when diabetescare comes first
Question why things happen	Ask “why me?” May experience depression	Offer counseling or find peer support Look into diabetescamps
Aren’t thinking about the future	Don’t think about long-term complications of diabetes Focus on immediate concerns	Avoid scare tactics
Are aware of emerging sexuality	Wonder if they are more at risk for STDs or AIDS Wonder if they will be able to have children or be good parents	Health care provider should talk with child

Schreiner et al. Diabetes Spectrum 13 (2): 83,2000

15-16 Year-Olds

General Characteristics	Impact of Diabetes	How to Approach
Have increased ability to compromise	Can make more decisions about diabetes care	Include teens in decisions Negotiate and use behavioral contracting
Are more independent	Can better understand the relationships between exercise, diet, and insulin	Give more advanced diabetes education
Feel stressed by social, school, and family responsibilities	Stressed teens may eat more, which can result in weight gain or less controlled blood glucose Teens trying to manage stress with physical activity may have low blood glucose events	Teach stress management Assertive communicating training
Test boundaries and take risks	May try drugs, alcohol, smoking, unprotected sex May skip medication	Educate on teen issues Discuss logical consequences
Are figuring out what’s important to them	Are determining how diabetes fits into their life	Meet with a life coach or diabetes coach to help child clarify values
Are learning to drive	Can experience low or high blood glucosewhich may impair driving ability	Educate on safety: checking blood glucose before driving, having fast-acting glucose sources in the car Drive with someone else in case of emergency

Schreiner et al. Diabetes Spectrum 13 (2): 83,2000

Diabetes in Youth: The Basics

Glucose is a type of sugar that comes from food containing carbohydrates. Everyone has blood glucose. A certain amount is needed to provide energy to all your cells. Diabetes is a disease in which the glucose in the blood is higher than normal. High blood glucose is called hyperglycemia.

The body usually keeps blood glucose within a certain range by storing any extra glucose in other tissues. It does this with the help of insulin. Insulin is a hormone that is released by the pancreas when blood glucose begins to rise.

In diabetes, blood glucose levels are too high. However, there is more than one type of diabetes.

Type 1 diabetes is a common childhood condition. However, type 2 diabetes has been in the spotlight lately due to the increase in childhood obesity, as the two conditions are related. Both types of diabetes result from the shortage of proper amounts of insulin. The body needs insulin to use energy from food. Without insulin, cells cannot work the way they are supposed to. The energy comes from glucose that comes from food (carbohydrates). Insulin helps the glucose into the cell. In this way, insulin helps keep blood sugar (blood glucose) at a certain level in the blood. Blood glucose levels need to stay within a very narrow range or there can be harmful effects on one's health.

Type 1 Diabetes

Type 1 diabetes (sometimes called juvenile onset diabetes) is one of the most common chronic childhood diseases. About one in 400 children and adolescents has type 1 diabetes.

The disease starts when the body destroys its own cells that make insulin. This is an autoimmune process, meaning that the body no longer recognizes certain cells as its own. The immune system starts to attack the cells the same way it attacks viruses and bacteria.

Type 2 Diabetes

Type 2 diabetes is becoming more common in children. Fifteen years ago, type 2 diabetes accounted for less than three percent of new diabetes cases in children, but now it is closer to 45 percent of all cases!

Type 2 diabetes (sometimes called adult onset diabetes) happens when cells in the body become less responsive to insulin over time. This is called insulin resistance. Pre-diabetes (impaired glucose tolerance) can begin before a person fully develops type 2 diabetes. Pre-diabetes means that cells are already starting to be less responsive to insulin. More and more insulin needs to be released in the body to have the same effect as before.

Maturity Onset Diabetes (MODY)

This is a rare form of diabetes. It is caused by a single gene problem that leads to faulty insulin secretion. Unlike type 2 diabetes, there is no problem with insulin's ability to work – insulin secretion from the pancreas is not consistent. This type of diabetes usually becomes apparent before age 25.

Genetic testing can be used to diagnose youth with MODY.  If someone in a family is found to have MODY, all family members should be screened to see if they also carry the mutated gene. Since the gene can be passed down to future children, a person with MODY needs to make decisions about whether they want to have genetic counseling when trying to get pregnant. Treatment of MODY depends on the cause and the severity of the high blood glucose, or hyperglycemia. For instance, about two-thirds of those with MODY diabetes do not require hypoglycemic medications, and diet therapy is usually enough to help control blood glucose levels.

Related Conditions

People with diabetes may have other related conditions at the same time.

Type 1 Diabetes

Celiac Disease

About five percent of people with type 1 diabetes have celiac disease. Celiac disease happens when the body reacts to gluten. Gluten is a protein found in wheat and foods containing wheat. Symptoms may be ignored or blamed on other causes. They may be mild or they may be triggered by other stressors. Symptoms of celiac disease vary greatly from person to person, but often include complaints about gastrointestinal distress. For example, diarrhea, stomach pain, and bloating may be reported.

Thyroiditis

Thyroiditis is an inflammation of the thyroid gland. The thyroid problem most commonly seen in people with diabetes is called Hashimoto’s Thyroiditis. Symptoms include weight gain, fatigue, hair loss, abnormal menstrual bleeding, dry skin, inability to concentrate, and depression. Thyroid problems can develop quickly or slowly. They are often overlooked as a possible reason for the complaints about weight gain, lethargy, and slow thinking.

Type 2 Diabetes

Polycystic Ovary Syndrome (PCOS)

PCOS affects about 6-10% of the female population in the United States. PCOS is a metabolic disorder that results in a hormonal imbalance. Females with PCOS have too much testosterone and not enough estrogen and progesterone. This can lead to excess facial hair, infertility, menstrual irregularity, acne, and wart-like growths. Ovarian cysts are often found in PCOS and can contribute to the hormone imbalance.

Insulin resistance, impaired glucose tolerance (pre-diabetes), or type 2 diabetes can occur along with PCOS. A patient diagnosed with PCOS will have blood work done. Metformin or other diabetesmedications may be used to control blood glucose levels. Being overweight or obese can worsen the imbalance between hormones, so a primary treatment for PCOS is weight loss. About 50% of females with PCOS are not obese, but following a healthy diet and exercise routine can help alleviate PCOS symptoms, regardless of weight.

Cardiovascular Disease and Metabolic syndrome

High blood pressure, large waist circumference, low high density lipoproteins, and high triglycerides may be present in teens with diabetes. Together these make up a disorder called metabolic syndrome. Guidelines for treatment of high blood pressure and lipid disorders with medications are well-founded for adults, but not so much for youth. This is because the long-term effects of medications in youth with diabetes are unknown. Primary treatments for metabolic syndrome in youth with type 2 diabetes include a loss of body weight and increase in physical activity.

Is MyPlate Okay If I Have Diabetes?

For people with diabetes, it is important to understand what foods are made of so that blood glucose levels can be more easily controlled. Remember, carbohydrates are the main source of glucose in the blood. Memorizing the exact amount of carbohydrate in all the foods that we eat would be almost impossible and impractical. Fortunately there are six main food groups that have similar carbohydrate content (see What Foods have Carbohydrates?):

• The Starch and Starchy Vegetables Group
• The Fruit Group
• The Vegetable Group
• The Meat, Meat Substitutes, Eggs, and Cheese Group
• The Milk and Yogurt Group
• The Fats and Oils Group

It is important to eat foods from each group every day. The type and the amount of food that you chose to eat can have either positive or negative effects on your health. These food groups are included in MyPlate, except for Fats and Oils.

The same foods will be important whether you have diabetes or not. However, the amounts may be different from MyPlate to whatever food tracking system you are using. One of the most popular is the carbohydrate counting system (carb counting).

In the carb counting system, for instance, raw vegetables are not counted as long as the total number of carbs eaten are less than 20 from this food. In one cup of raw vegetables there is 5 grams of carbohydrate. If you ate this five times in one day, or ate two cups of raw vegetables three times a day, that would add up to more than 20 grams, and would have to be counted as part of your carbohydrate allowance.

In MyPlate, the recommendation is to eat 4 to 5 servings of vegetables per day. This may not be what your meal plan tells you to eat. So, while MyPlate can be used by those who have diabetes, the diet plan discussed with you by your dietitian should guide your food choices. If you haven’t talked to a dietitian, ask your doctor at your next visit, or go to http://www.eatright.org/Public/. At the far right of the green top bar, click on “Find a Dietitian”.

Energy Needs

An important part of managing diabetes in youth is finding the right energy balance. We want to make sure the child gets enough calories for growth but not so much that they gain a lot of weight. Physical activity also plays a role in how much energy is needed.

Energy needs depend on age, size, activity, and growth factors. Appetite is an important indicator of immediate calorie needs in children. Some children seem to eat more than they need, and some children may seem to eat less than they need.

High blood glucose levels can make all of these a challenge, where appetite might be very high or very low. A child with high blood glucose may not have much energy to go out and play, and may not be very hungry.

The equations listed below are often used by health professionals when figuring out how many calories are needed. These take into account age and gender as well as physical activity.

Estimated Energy Requirements for Children and Adolescents
3 – 8 yearBoys Girls	88.5 – (61.9 x age [yrs]) + PA x (26.7 x weight [kg] + 903 x height [m]) + 20 kcal 135.3 – (30.8 x age [yrs]) + PA x  (10.0 x weight [kg] + 934 x height [m]) + 20 kcal
9 – 18 years Boys Girls	88.5 – (61.9 x age [yrs]) + PA x (26.7 x weight [kg] + 903 x height [m]) + 25 kcal 135.3 – (30.8 x age [yrs]) + PA x  (10.0 x weight [kg] + 934 x height [m]) + 25 kcal
PA = physical activity coefficient	if sedentary 1.13 if low active 1.26 if active 1.42 if very active

Another way to estimate the number of calories a child needs is to use these guidelines from the Joslin Diabetes Association.

• A child of average weight needs about 1000 calories at age 1
• Add 100 calories for each year up to puberty

Example

Let’s compare the two methods using an active 13 year old boy who is 5’6” (1.68 meters) and weighs 115 pounds (52.3 kilograms).

88.5 – (61.9 x age [yrs]) + PA x (26.7 x weight [kg] + 903 x height [m]) + 25 kcal = ?
88.5 – (61.9 x 13) + 1.26 x (26.7 x 52.3 + 903 x 1.68) + 25 kcal = ?
88.5 – (805) + 1.26 (1396) + 1517 + 25 = ?
88.5 – 805 + 1759 + 1517 + 25 =  about 2500 - 2600 kcal

VS.

Joslin equation:

1000 calories + 100 (12) = 2200 calories

One is a little low, one is a little high. These equations only give an estimate of calorie needs. Remember, the amount of energy needed by a child or teen is usually dictated by their appetite. Growth is the best long-term indicator of the correct calories.

Resources

Resources for Parents, Teachers, Child Care Providers, and Health Professionals

• Helping the Student with Diabetes Succeed: A Guide for School Personnel. National Diabetes Education Program, 2003. Available at http://www.ndep.nih.gov/Diabetes/pubs/Youth_SchoolGuide.pdf

• Diabetes Care Tasks at School: What Key Personnel Need to Know. Alexandria, VA, AmericanDiabetes Association, 2008. Available online at www.diabetes.org/assets/pdfs/schools/forward2008.pdf

• Your School & Your Rights: Protecting Children with Diabetes Against Discrimination in Schools and Day Care Centers. Alexandria, VA, American Diabetes Association, 2005 (brochure). Available online at http://www.diabetes.org/your-school-your-rights

• Children with Diabetes: Information for School and Child Care Providers. Alexandria, VA,American Diabetes Association, 2004 (brochure). Available at http://www.diabetes.org/ assets/pdfs/schools/chren-wdiabetes-brochure-caregivers.pdf

• ADA's Safe at School campaign and information on how to keep children with diabetes safe at school. Call 1-800-DIABETES and go to 
  http://www.diabetes.org/assets/pdfs/schools/SAS-Booklet-2010.pdf

• American Association of Diabetes Educators: http://www.diabeteseducator.org

• PADRE Foundation: Pediatric Adolescent Diabetes Research Education. http://www.padrefoundation.org

• Clarke W: Advocating for the child with diabetes. Diabetes Spectrum 12:230–236, 1999. 
  School Discrimination Resources. Alexandria, VA, American Diabetes Association, 2006. Available at http://journal.diabetes.org/diabetesspectrum/99v12n4/pg230.htm

• American Diabetes Association: Complete Guide to Diabetes. Alexandria, VA, American Diabetes Association, 2005. Call 1-800-232–6733.

• Raising a Child with Diabetes: A Guide for Parents. Alexandria, VA, American Diabetes Association, 2000. Call 1-800-232–6733.

• American Dietetic Association: http://www.eatright.org

• National Diabetes Education Program: http://www.ndep.nih.gov/index.aspx

• National Diabetes Information Clearinghouse: http://diabetes.niddk.nih.gov/

Resources for Youth with Diabetes

• Wizdom: A Kit of Wit and Wisdom for Kids with Diabetes (and their parents). Alexandria, VA,
  American Diabetes Association, 2000. Order information and select resources available atwww.diabetes.org/wizdom.

• ADA's Planet D, on-line information for children and youth with diabetes. Accessible at
  http://www.diabetes.org/living-with-diabetes/parents-and-kids/planet-d/.

• Children with Diabetes: The online community for kids, families, and adults with diabetes. Accessible at http://www.childrenwithdiabetes.com/

• Juvenile Diabetes Research Foundation International. Accessible at http://www.jdrf.org/

• Diabetes Health: Diabetes Support Groups. Accessible at http://www.diabeteshealth.com/archive/psychology/support-groups/

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