Beyond Blood Glucose: Addressing Adolescent Diabetes Challenges

Pharmacist interventions have a great impact on patients with diabetes, but young people living with the disease present with unique challenges. During a time of rapid emotional growth and physiological changes punctuated by important individuation processes, managing diabetes as an adolescent can be difficult, isolating, and embarrassing. Socialization plays a crucial part in human development, with peer interactions helping teenagers explore their identity, develop self-esteem, and learn to navigate social situations. What's more, one's social rating can significantly impact their well-being.¹

Adolescent with diabetes / Dragoljub - stock.adobe.com

But at a time in life when making friends is already fraught with challenges—such as those stemming from social anxiety, pressure to conform, or bullying—checking a continuous glucose monitor or taking a finger prick in a public setting may not exactly be perceived as cool. Adjusting insulin doses to prevent hypoglycemia while playing sports, ensuring access to refrigeration for a sleepover, or even discussing diabetes with a new partner are all considerations adolescents with diabetes must face that their unaffected peers do not.

Other hallmarks of the teenage years make diabetes management harder, including characteristics of spontaneity, a sense of invincibility, and personal exceptionalism.² For adolescents who may not be as affected by social pressures, believing that youth equals good health may lead them to neglect proper diabetes management.

This is particularly relevant to the burden of care associated with diabetes self-management. Appropriate daily insulin treatment, regular blood glucose monitoring, physical activity, a healthy diet, education, and support are all necessary to prevent complications. Juggling these responsibilities can lead to diabetes burnout, characterized by feelings of being overwhelmed, frustration, and a loss of motivation to manage diabetes effectively—especially for adolescents who may not feel inclined to do so in the first place.³

Diabetes burnout further exacerbates stress, anxiety, and low self-esteem, which are already common in adolescents. Studies have shown that adolescents with type 1 diabetes (T1D) are nearly twice as likely to experience depression as their peers, which becomes especially concerning given that depression has been shown to impact metabolic control negatively.⁴ Additionally, depression has been linked to decreased adherence to treatment and, consequently, higher hemoglobin A_1c (HbA_1c) levels. The combination of puberty, body image concerns, and societal pressure in adolescence, along with the intense focus on food intake and exercise required for diabetes management, can make adolescents with diabetes particularly prone to disordered eating as well.²

Physiological changes during adolescence can also disrupt diabetes treatment. Glycemic control deteriorates during adolescence, with higher HbA_1c levels than at any other life stage; in addition, hormonal and body composition changes may affect insulin sensitivity.⁵ These changes necessitate adjustments in medication or lifestyle to maintain effective diabetes control, further complicating self-management.

Managing diabetes in adolescents presents unique challenges that may be unfamiliar to health care professionals who primarily work with middle-aged and older patients. Nonetheless, it is essential to prioritize diabetes management for adolescents. It becomes even more so when considering the projected increase in the incidence of the disease: According to a study published in Diabetes Care, if the rate of new diabetes diagnoses in adolescents continues to increase, T1D and type 2 diabetes cases will rise by 65% and 673% by 2060, respectively.⁶

Experts have suggested multiple interventions to help adolescents manage diabetes, including structured interventions, encouraging nonjudgmental family support, and utilizing technology. Here is how pharmacists can help.

Meeting Adolescents Where They Are

There is no one-size-fits-all approach to addressing diabetes management in adolescents, given the challenges that vary from one young person to another. Therefore, tailored approaches that consider the unique circumstances of each adolescent are essential for optimal outcomes.

Something as simple as the context in which a child measures their blood glucose can significantly impact feelings surrounding diabetes self-management. As highlighted in a study published in Current Opinion in Pediatrics,² “For some kids, advising a child to measure their blood glucose in a private setting like a nurse’s office could make the process feel private, but for others, it could contribute to feelings of isolation.”

Although blood glucose control is a primary concern for pharmacists, it is important to recognize that other outcomes are also meaningful to young people with diabetes. Understanding which outcomes “matter to teens with [diabetes] could support successful interventions to optimize their health care and also improve their engagement in managing their diabetes,” wrote investigators in a study published in Diabetes Educator.⁷

In the study, investigators analyzed the content of 2 popular diabetes forums in which adolescents asked questions and wrote about their experiences. This online anonymity allowed researchers to gather authentic perspectives from the demographic. Then, investigators coded user data from 50 posts that described diabetes outcomes that mattered to teens and organized them into 8 categories.

Of these, the most mentioned were interactions with peers, emotional well-being, and blood glucose management. An important subtheme of the “interaction with peers” category included advice seeking. In an example post, one adolescent asked for advice on obtaining a new insulin pump and whether it was painful. The emotional well-being category included subthemes related to having a depressed mood and desire to be normal. Analyses of this theme revealed that most commonly, adolescents felt embarrassed and stressed by diabetes management. On par with pharmacist concerns, blood glucose control was also shown to be a top concern for adolescents, with many expressing anxieties about addressing high blood glucose.

These results have important implications for providing diabetes counseling in the pharmacy. First, they emphasize the importance of prioritizing patient well-being: Pharmacists should promptly address emotional well-being with screening and referrals to appropriate care, especially as feelings of depression and isolation were prevalent among adolescents.

Further, by exercising empathy and understanding through motivational interviewing techniques, pharmacists can foster a support environment where adolescents feel comfortable discussing their concerns and gaining a deeper understanding of self-management. Motivational interviewing involves asking open-ended questions, encouraging patients to reflect on their thoughts and feelings.⁸ This approach can help build intrinsic motivation to enact positive behavioral changes and help adolescents overcome the external pressures of diabetes neglect.

Patients may also benefit from receiving practical support. Providing how-to-use demonstrations of diabetes technology, setting achievable blood glucose goals, and connecting patients with resources such as support groups and online communities can help patients feel more empowered, supported, and confident in managing their condition.

Including All Stakeholders

Managing diabetes in adolescents is often a family affair, requiring collaboration and support from all family members. Common challenges families may face include feeling different from other families due to the presence of diabetes, parental overprotectiveness that can hinder independence, a lack of understanding or empathy from family members, and the financial strain associated with managing the condition. Naturally, these challenges shift as adolescents with diabetes grow into young adulthood.

The transition from pediatric to adult care can be a vulnerable time for young adults with diabetes, especially as research indicates that glycemic control declines during this period.⁹ Data have shown that many young adults in their 20s do not fully develop the habits and behaviors necessary to achieve consistent glycemic control until their 30s.⁹ Often, this transition is hindered by a lack of guidance from parents or caregivers and feelings of being overwhelmed by the increased self-management responsibilities.

To address these issues and empower adolescents during this shift, pharmacists can collaborate with parents and young adults to create a personalized and structured transition plan. Providing ongoing support, education, and distributing the burden of care can grant young adults more autonomy in their condition and facilitate healthy self-management habits to prevent long-term health complications.

“By coordinating with pediatric providers, identifying strengths and deficiencies in self-care, establishing rapport with young adult patients, directly addressing prevalent psychosocial concerns, and developing a team-based approach to keep patients engaged, adult care teams can prioritize support for the most vulnerable transition patients,” wrote investigators in a study published in Clinical Diabetes and Endocrinology.¹⁰ “Improved strategies to propel emerging adult patients through the transition period toward habits leading to optimal glycemic control could have a major long-term impact on preventing diabetes-related complications.”

Expanding Support With Technology

The diabetes technology market is saturated with innovative devices that offer adolescents more options for self-managing their diabetes and overcoming related challenges. Adolescents are often more comfortable and proficient with technology than older generations. This technological savvy allows them to integrate these devices seamlessly into their daily lives.

Subcutaneous insulin infusion has been used for more than 4 decades.¹¹ As technology has advanced, insulin pumps have become increasingly compact and user-friendly. Today, models are often no larger than smartphones, making them more convenient for everyday use. Patch-style continuous glucose monitors (CGMs) eliminate the need for painful finger-sticking and manual scanning. These discreet devices can be easily hidden under clothing and provide real-time blood glucose readings directly to a smartphone or smartwatch.

A milestone in diabetes care was achieved last summer when Dexcom’s Stelo, the first FDA-approved OTC CGM, became commercially available on pharmacy shelves.¹² Although intended for adults 18 years and older, the launch of this integrated CGM underscores the rapid advancements in diabetes technology for young people seeking more accessible options for self-managing their diabetes.

Pharmacists should speak with adolescents at length about device options to help them find the best technology to support self-management of the condition. Health care professionals might also consider addressing potential cost concerns with patients, as diabetes can be a significant financial burden. Understanding the costs associated with different technologies can help patients make informed decisions and improve adherence to treatment plans.

READ MORE: Diabetes Resource Center

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References

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2. Borus JS, Laffel L. Adherence challenges in the management of type 1 diabetes in adolescents: prevention and intervention. Curr OpinPediatr. 2010;22(4):405-411. doi:10.1097/MOP.0b013e32833a46a7

3. Kontoangelos K, Raptis A, Lambadiari V, et al. Burnout related to diabetes mellitus: acritical analysis. Clin Pract Epidemiol Ment Health. 2022;18:e174501792209010. doi:10.2174/17450179-v18-e2209010

4. Ye CY, Jeppson TC, Kleinmaus EM, Kliems HM, Schopp JM, Cox ED. Outcomes that matter to teens with type 1 diabetes. Diabetes Educ. 2017;43(3):251-259. doi:10.1177/0145721717699891

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7. Ye CY, Jeppson TC, Kleinmaus EM, Kliems HM, Schopp JM, Cox ED. Outcomes that matter to teens with type 1 diabetes. Diabetes Educ. 2017;43(3):251-259. doi:10.1177/0145721717699891

8. Bischof G, Bischof A, Rumpf HJ. Motivational interviewing: An evidence-based approach for use in medical practice. DtschArztebl Int. 2021;118(7):109-115. doi:10.3238/arztebl.m2021.0014

9. Miller KM, Foster NC, Beck RW, et al; T1D Exchange Clinic Network. Current state of type 1 diabetes treatment in the U.S.: updated data from the T1D Exchange clinic registry. Diabetes Care. 2015;38(6):971-978. doi:10.2337/dc15-0078

10. Iyengar J, Thomas IH, Soleimanpour SA. Transition from pediatric to adult care in emerging adults with type 1 diabetes: a blueprint for effective receivership. Clin Diabetes Endocrinol. 2019;5:3. doi:10.1186/s40842-019-0078-7

11. Becker RH. Insulin pumps. Medscape. Updated January 4, 2023. Accessed September 6, 2024. https://emedicine.medscape.com/article/2139073-overview?form=fpf

12. Meara K. Dexcom’s OTC continuous glucose monitor now available in US. Drug Topics. August 26, 2024. Accessed September 6, 2024. https://www.drugtopics.com/view/dexcom-s-otc-continuous-glucose-monitor-now-available-in-us