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Risk Taking Behaviours in Adolescents Living with Type 1 Diabetes

INTRODUCTION

The organ responsible for producing insulin is call the pancreas when the immune system begins to destroy cells within the pancreas called betta cells the hormone responsible for converting carbohydrates into energy no longer exist and a chronic autoimmune condition call Type 1 diabetes (T1D) is established. The daily regime of someone living with T1D involves the management of multiply daily, blood glucose monitoring, insulin injections and dietary management. Those living with T1D need to be attentive of hyperglycaemia which is when you experience particularly levels of high blood glucose or low blood glucose levels known as hypoglycaemia. The serious long term health complications associated with TID are hard to comprehend as a teenager as quite often they are living for the here and now. Many trials have been conducted over the years by the Diabetes Control and Complications Trial research group (DCCT) and have been able to establish that with intensive management complication such as; retinopathy (blindness) kidney disease, heart disease, neuropathy and vascular disease can be reduced (DCCT/EDIC Research Group, 2016).

This report will outline evidence to support the importance of providing ongoing support for adolescents in their diabetes self-management in relation to risk taking behaviours. A session plan has been developed addressing the information for adolescents providing outcomes appropriate diabetes self-management. Although research, clinical management, technology, psychosocial and behaviour of diabetes has improved diabetes care these factors are less documented. During the teenage years they are trying to negotiate many changes including physical, cognitive and psychological, it is at this time that the susceptibility of engaging in risk taking behaviours such as alcohol and other drug use is increasing, this for some will lead to developing mental health problems (Schreiner, 2017).

Even though the threat of risk taking behaviours has been similar to adolesces without those living with T1D has been seen to be comparable in teenager with and without T1D, poor self-care and metal health conditions have been a higher for those diagnosed with T1D (Moore et al, 2013).

NEEDS ASSESSMENT

At diagnosis most education and management is directed to the parents and it is not until the child is older that the responsibility/focus of self-management is placed on the child, for some teenagers they can understand the clinical processes of giving insulin and blood glucose monitoring but not understand why these things are done. The DAWN youth study looked at some of the goals identified by adolescents along with the unique challenges of childhood diabetes (DAWN study, 2007). Some of the goals identified included: improving access to education, psychosocial support, age appropriate care, and, improved peer support with better educational and psychosocial support for parents and families (DAWN study, 2007). The DAWN Youth programme aimed to assist advocacy and action while improving the lives of children living with diabetes and their families, while particularly focusing on disabling psychosocial barriers through the use of the DAWN call to action goals. Being able to provide ongoing education in a trusting environment for your patient is essential in the long term for their development in self-management. Goal 3 in the DAWN study was defined by offering individual assistance to manage a healthier and more active self-management lifestyle.

The success of reaching a supportive and motivating diabetes care team is essential when trying to achieve effective care and good outcomes when establishing an active diabetes self-management result (Betschart Roemer, 2016). When creating a treatment plan health care professionals need to take into account the patient’s individual needs, circumstances, issues and resources, because if the plan is to be followed effectively it is essential in the management of their diabetes. When encouraging/fostering diabetes self-management for all patients it can be challenging, before considering the other demands of teenage life in an adolescent with T1D. As changes to their bodies are happening being able to maintain blood glucose levels can be increasingly challenging, adolescents are often expected at this stage to take on more accountability in the management of their diabetes. At the same time, the increasing demands of school, the possibility of getting part-time employment, and diabetes management can become increasingly less important with an evolving social life in the mind of a teenager. Some teens find it easier to quit taking care of themselves due to the competing pressures and demands (Betschart Roemer, 2016). Evidence by Moore et al 2013, found that during adolescence adherence to your diabetes self-management is particularly poor. Not only can peer pressure and the normal changes of teenage development cause conflict let alone living with a chronic condition and trying to manage it, this strain alone can form a platform for major personal, family stress and even mental illness. Part of the makeup of an adolescent is that they do not recognise that harmful things can happen to them and therefore cannot foresee potential negative consequences of their actions. Teenagers have a difficult time deciding whether to doing something or not doing something. Sadly when already confronted with T1D some risk-taking behaviours engaged in today will have an effect on them in the future. Teenagers are risk-takers and it has been shown through research by developmental experts that risk-taking behaviours are a big part of adolescent behaviour (Moore et al 2013).

Being able to provide ongoing support and education to adolescents in the prevention and guidance in risk taking behaviours may provide some insight into what can occur when consuming alcohol, taking drugs, unprotected sex and driving. Betschart Roemer (2016), reports that, risky behaviours are common among adolescence such as tobacco use, drug use alcohol consumption and unprotected sex. Adolescence don’t consider the potential consequences for their actions and those living with diabetes will often test the boundaries or are preoccupied with something else therefore skip blood glucose monitoring or insulin injections (Betschart Roemer, 2016) . The education session plan that will be covered in this assessment will look at adolescents living with T1D, focussing on education on risk-taking behaviours. Research has shown us that adolescence is naturally a time of increasing independence and self-assertiveness, but also of risk-taking (Moore et al, 2013). Therefore, determining the appropriate extent of parental involvement can be challenging. Although adolescents should be responsible for the day to day management of their diabetes, minimal or no parental supervision has been known to results in poor glycaemic control (Schreiner, 2017). While shared management between the adolescent and parents is associated with better glycaemic control, parent-child conflict over daily management leads to poor control, and adolescent depression of even a mild degree can interfere with family involvement and diabetes control (Schreiner, 2017). Levisky and Misra 2018 found that by providing family-focused teamwork sessions focusing on parent child responsibility and strategies to avoid conflict showed an overall improvement in the care of an adolescent with diabetes. The trial looked at children ranging from 8-17 years, they changed the practice in how they managed diabetes by making it more family focused compared to the normal standard multidisciplinary approach by establishing a responsibility for both the child and the parent/carer to be more involved in establishing an active family discussions resulted in increased family involvement and better glycaemic control down from 93% to 8.8% (Levisky & Misra 2018). Developing a session that can provide strategies for adolescents to understand what is happening to their bodies and provide them with options of what they need to consider before initiating drinking, drugs, blood glucose monitoring, insulin omission and sexual activity will hopefully decrease some risk-taking behaviours associated with long term diabetes complications and establish open and active family discussions.


Presentation Plan


Topic:

Risk taking behaviours in adolescents living with T1D

Date:

21/07/2018


Learner Profile:

­To support adolescents living with type 1 diabetes in developing the appropriate knowledge and skills in understanding the effects that risk taking behaviourshas on their body.

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PROGRAM OBJECTIVES / LEARNING OUTCOMES:

Being able to identify risk taking behaviours

Short-term implications – here and now

Recognise long term complications associated with risk taking behaviours

Be able to plan/prepare for risk taking situations

Be able to communicate appropriately with educators and parents regarding risk taking behaviours

Be able to self-manage their diabetes whilst continuing an open relationship with parental support


LESSON STRUCTURE:


Time


Beginning / Introduction:

Why is this included?


0830

Introduce myself and role

So that the group has a understanding of who you are and your role within the session


90 sec

Assess any prior knowledge

So that you are aware of any learning issues in case you need to change your learning style to meet the needs of the participants in the session.


Hand out questionnaires

(Appendix A)

So that the session is interactive and you can have a feel of what the participants are wanting to learn & their current behaviours.



Time


Middle / Main Content:

Why is this included?




50 sec


Alcohol:





Effect of alcohol on BGL





Preventing hypoglycaemia (eg. Importance of eating too)





Frequency of testing (eg. Before going out, before bed)


The buddy system (make sure close friends know what to do if you have a hypo and how to know it’s a hypo)

When drinking alcohol you can have decrease in blood glucose levels, alcohol works by blocking the production of glucose which is stored in the liver. When you blood glucose drops the emergency stores of glucose that are stored in your liver assist by raising your blood glucose levels. Once these stores are used up of glucose are used up a person who is under the influence of a lot of alcohol cannot make more straight away, this can lead to a dangerously low blood glucose level (hypoglycaemia) or even mortality (American Diabetes Association, 2017). Turner et al (2001), claims the insulin will continue to have an effect and drop the blood sugar unless you are eating. This action can happen very rapidly if no action is take.

The effect of the alcohol consumption the following morning has been associated as one of the recognised risk factor for hypoglycaemia in people with T1D. Approximately one in five are estimated to have a severe hypoglycaemic episodes are attributed to alcohol consumption (Tuner et el, 2001).


50 sec


Illicitly drugs & risks associated with diabetes





Effect on BGL





Preventing hypoglycaemia/ hyperglcaemia





Frequency of testing

Although illicit drugs are less common than alcohol a study by Jaser, Yates, Dumser & Whittmore ( 2011), found that 40% of students admitted to using illicit drug and more often marijuana. Although marijuana may not have a direct effect of your blood glucose level, it is known to affect you judgment increase your appetite which will in turn have a negative effect on how you manage you diabetes management such has counting carbohydrates and insulin blood glucose corrections. Diabetic Ketoacidosis and been reported to be associated with drugs such as ecstasy are taken.


50 sec


Smoking





Long term health effects





Increase in AbA1c

Although tobacco smoking is not an illegal drug it has also been known to be the leading cause of preventable deaths worldwide. Adolescent living with T1D who smoke have a greater risk of having a higher HbA1C levels compared to those who are nonsmokers. Tobacco has been known to increase the abnormal secretion in the pituitary and counter regulatory hormones, from this you will get an increase in growth hormone and cortisol which in turn may lead to an increase in your blood glucose levels and potentially a reason for a higher HbA1C level. Further studies have shown that adults who continue to smoke have an associated with microalbuminuria, diabetic nephropathy, and retinopathy. (Hofer, Rosenbauer, & Grulich-Henn, 2009).


50 sec


Insulin omission





Long term health effects





Peer pressure





Diabetes burn out

Eating disorders are common among adolescents, particularly girls. In a study conducted by Eaton et al (2010) it was reported that

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45% of high school students reported trying to lose




weight, 41% restricted their diet. 11% went for 24




hours without eating, 5% reported taking diet pills.




The study found that adolescent girls with T1D




were at a 2.4 higher risk than those without T1D to




have some form of eating disorder’.

Insulin reduction and omission has been a common behaviour for those living with diabetes as a way of losing weight. It was reported that 31% to 36% of females living with T1D have used insulin reduction or omission to aid in weight loss (Eaton, et al, 2010). Those who reduce insulin omission place themselves at risk for early complications from diabetes. Risks of microvascular complications, including retinopathy and nephropathy, diabetes ketoacidosis as well as mortality are increase with long term insulin omission/withdrawal.


50 sec


BG monitoring





Keeps you safe





Better glycaemic control





Latest advances

It has been recommended that regular blood glucose monitoring assists patients and medical teams gage therapeutic levels, correct insulin and dose for blood glucose out of range targets, detect and prevent hypoglycaemia (Formosa, 2013). The Diabetes Control and Complication Trail(DCCT) was launched in 1981 and followed people living with T1D who kept their blood glucose levels as close to normal as possible after 6.5 years had fewer diabetes related health problems. With the introduction of the continuous glucose monitors (CGM) a small wearable device that continuously measures your glucose levels day and night. It has reduced the number of finger pricks, will alarm if you are too low or high and has been known to reduce your HbA1c by being able to monitor your blood glucose level more closely.


50 sec


Sexual health





Birth control





Sexually transmitted diseases





Nerve damage ED

It has been reported that 46% of high school students have had sexual intercourse (Eaton et al 2009). Adolescents with T1D where found to have an increased risk of unexpected pregnancies and sexually transmitted disease the study also found that only half the girls who were sexually active used a form of birth control or condoms (Schwartz, Sobota, Charron-Prochownik 2010). Girls with T1D were more likely to have unprotected sex because they falsely believed that due to their diabetes they would have difficulty conceiving (Fennoy, 1989).

Sexual issues are higher in men who have poorly controlled diabetes than those who maintain good control. For men with diabetes particularly those that also smoke this can lead to nerve damage that can cause erectile dysfunction. Snow 2018, found that men who have shown to have erectile dysfunction and diabetes have a higher chance of developing heart disease, as erectile dysfunction carries the same risk factors for coronary artery disease.

CONCLUSION

This report looks at some of the risk-taking behaviours of adolescents living with T1D. Diabetes care today seems far from the norm as what it was in years gone by when one, two or three injections was the management. Today those living with diabetes are expected to self-manage their diabetes at an earlier age and is likely injecting a basal insulin once or twice a day along with fast-acting insulin at meals or use an insulin pump. Even with the advances in technology they are still being asked to check blood glucose level multiple times a day, eat healthy foods, count carbohydrates, carry supplies, exercise, maintain an insulin pump, and keep records of their blood glucose levels, it is understandable that adolescence want to escape from it all through risky behaviours (Schreiner, 2017).

While adolescents live a very active and full life, and tell us they assure us they will abstain from alcohol, cigarettes, drugs, and sex, they may also just as quickly change their minds. The session plan provided evidence why these risk taking behaviors are important in covering whether run in a group session for adolescents so that they can freely ask questions and explore ways of meeting these behaviors. By assessing behaviors regularly in clinic appointment the diabetes educator or provider can report if any risk taking behaviors have been established and ensure counseling and education is provided regularly (Moore et al, 2013). Adolescents with T1D are regularly seen every three months, establishing an open patient/educator relationship by reinforcing positive behaviors for avoiding risk taking activities. Ensuring that you allow for education and discussion about relevant risk-taking behavior appropriate for the age of the adolescent and if concerned about their management to seek the appropriated health professional to assist with ongoing management (Funnell, 2013).

APPENDIX 1

Assessment Questions for Adolescents with Type 1 Diabetes


Time


End/ Conclusion:

Why is this included?


90 sec

Open discussion for any questions

Allow time for any further question they may have

Eating

What do you like about your body?

What do you not like about your body?

Are you happy with your weight?

Has your weight gone up or down in the past year?

Have you done anything to try to manage your weight this year? How? How often?

What do you think is a healthy diet?

How much exercise do you get on an average week?

Have you ever decreased the amount of insulin you’re supposed to take or skipped insulin doses to manage your weight?

Do you ever skip mealtime boluses?

Drugs, alcohol, tobacco

Do any of your friends use tobacco? Alcohol? Other drugs?

Does anyone in your family use tobacco? Alcohol? Other drugs?

Do you use tobacco? Alcohol? Other drugs?

Do you adjust your insulin when drinking? When using other drugs?

Is there any history of alcohol or drug problems in your family?

Sexuality

Do you have a boyfriend or girlfriend?

Have you ever had sex? If yes, how many people have you had sex with?

What does the term safe sex mean to you?

Have you ever been pregnant or worried you may be pregnant?

Do you use condoms every time you have intercourse?

Have you ever been forced to have sex against your will?

Do you disconnect your insulin pump during sexual activity?

(Jaser et al, 2011)

 

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