VOLUME 11 NUMBER 3 • SEPTEMBER 2014
109
SA JOURNAL OF DIABETES & VASCULAR DISEASE
REVIEW
Self-monitored blood glucose has also evolved with new
technology from colour-coded glucostix to glucometers with
downloadable memory and graphic data analysis, and now to
continuous glucose monitoring sensors that can give you a more
complete picture of glucose kinetics with more than 250 readings
a day. This has helped improve understanding around several
aspects, such as nocturnal hypoglycaemia, the ability to assess
glucose responses, and specific diets, activities, and more.
Objective monitoring of glycaemic control with three-monthly
HBA
1c
tests remains the standard of care. Comparisons between
clinical symptoms and signs, self-monitored blood glucose readings,
and HBA
1c
levels are an important aspect of ongoing, long-term
care, especially during adolescence. There are also several newer
oral hypoglycaemic agents on the market for adult care, with ISPAD
guidelines suggesting the use of metformin and sulphonylureas.
This is best done by a paediatric endocrinologist/diabetiologist. A
detailed discussion of these aspects of care is beyond the scope of
this review, but we would like to focus on diet and psychosocial
factors.
Dietetics and diabetes
8
The involvement of a specialist paediatric dietician is important in
the comprehensive management of diabetes in both childhood and
adolescence. It is important that patients understand the relationship
between the food they eat and the insulin they require, and for the
MDT to understand the foods available to the patient. In South
Africa, the presence of both ends of the economic spectrum means
that MDTs have to be well prepared.
Prevention of obesity is a key strategy for optimal glycaemic
control, especially in type 2 diabetes. Furthermore, body image
issues among adolescents may play a large role in compliance,
as insulin can increase weight, while hyperglycaemia can cause
weight loss. While strict dietary control is desirable for optimal
glycaemic control, this must be approached with care and respect
for the adolescent patient’s needs, as disregarding them may
lead to rebellion and poor compliance. Matching insulin to food
intake may be taught as a strategy to overcome occasional dietary
indiscretions. Health professionals should be aware of the possibility
of eating disorders, however, this is rare in our setting.
Dietary recommendations need to be practical and achievable
and based on cultural beliefs and family traditions. Dietary advice
needs to be adapted to suit the economic availability of foods in the
household and focus on healthy eating for all, not just the diabetic
teen. Advice should include the amount, type and even distribution
of carbohydrates as part of a healthy balanced diet. Excessive
restriction of carbohydrates should be avoided. Insulin regimens can
be adapted to suit the dietary patterns of the adolescent, which can
often be erratic. Carbohydrate counting may be a complex concept
for some patients, however, adolescents and caregivers, even with
lower levels of education, can be taught the carbohydrate content
of foods using exchanges and the skill of balancing carbohydrates
throughout the day.
We have found that the majority of our diabetic patients have
a predominantly starch-based diet (maize meal and samp), limited
dietary diversity, and quantities vary with resources; adequate at the
beginning of the month but less or non-existent towards the end of
the month. In this situation, a fixed dose will result in erratic glucose
values, while adjusting the dose according to the carbohydrates on
the plate may produce better control.
A large portion of our children rely on a school feeding-scheme
meal, which is high in starch and fat and is often received at 10:00
rather than at lunch time. Health professionals need to be aware
of this and not withhold this vital meal, but rather adjust the
insulin regimen to allow for the meal. Active adolescents will need
additional dietary advice to support their sporting aspirations, while
maintaining blood glucose stability.
Child and adolescent diabetes: psychosocial factors
Adolescence is generally considered a time of change, with often
stressful adjustments for adolescents and their families in meeting
new developmental demands, such as neurocognitive, social or
physiological changes.
9
It is well known that due to the physiological
changes of puberty, and social and developmental adjustments,
metabolic control is typically less effectively achieved in adolescence
than in other phases of the life span.
10
Repeated incidents of hypoglycaemia, especially with early-onset
diabetes, is associated with significant cognitive impairments, which
in turn affect school performance and diabetes self-management.
11
Neuro-maturational impulsivity during adolescence is a particular
challenge, especially given the normative social pressures for
independence, risk-taking and self-assertion at this stage.
12
Researchers have identified a range of cognitive and emotional
factors affecting diabetes outcomes among adolescents. These
include negative affective experiences, such as health anxiety
and fears of complications, frustrations with the complexity of
diabetes self-care, the difficult task of balancing necessary self-care
behaviours with perceived independence, and peer acceptance.
13
Studies show that although positive caregiver involvement is
consistently associatedwithbetter outcomes, for the adolescentwith
diabetes there is a dilemma between the developmental needs, such
as independence and peer identification, and the need for ongoing
caregiver support. The kind of positive caregiver support required in
adolescence also differs from the close, supervising presence of the
caregiver with the child, to a collaborative, motivating involvement
between caregiver and adolescent; additionally depending on
cultural, contextual and social variations in parenting styles.
14
From the age of 13 years onwards, individual self-management
and adherence plays an increasingly important role in positive
diabetes outcomes, with acquiring skills for active problem solving
being valuable for adolescent diabetes self-management. As self-
management increases, the role of caregivers also shifts towards
less direct supervision and support.
15
Research into stress has identified the considerable demands
placed on the adolescent and caregiver in coping with the multiple
tasks required in diabetes self-management in addition to the burden
of adaptation to chronic disease. Secondary negative associations
with parenting stress, including lower family cohesion, higher
psychological maladjustment, and lower rates of school completion
are all multivariate contributors to negative diabetes outcomes.
16
Levels of perceived stress among adolescents with diabetes are
associated with lower regimen adherence, psychological distress
and poor metabolic control, all of which highlight the importance
of stress management skills as part of support programmes.
17
Unified goal setting between adolescent, caregiver and the health
provider team have been found to improve diabetes outcomes
among adolescents with diabetes.
18
Recent studies from developed world settings have explored
the promising role of communication technology and the internet
