Psychosocial Aspects of Diabetes

Children, Adolescents and Their Families

Christie Deborah, Clarissa Martin

• Publisher: CRC Press
• Year: 2021
• eBook ISBN: 9781000477078
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

Part of the Paediatric Psychology series Children and young people are increasingly among those being diagnosed with diabetes. However in the UK only 1 in 6 children succeed in controlling their diabetes successfully, despite support from parents and professionals. This enlightening new book is a comprehensive account of diabetes and the complex medical and psychosocial factors that influence metabolic control in children and young people. It presents a series of evidence-based and accessible educational, psychological and social approaches to increase specialist knowledge, promote positive attitudes, enhance patient care and create appropriate healthcare environments. The book offers an easy-to-comprehend approach to clinical care and includes practical tools for assessment for all healthcare professionals throughout the text. Featuring contributions from a number of international experts in the field, this thorough and wide-ranging guide is informative reading for all students, academics and professionals with an interest in paediatric psychology and health.

PART I

Understanding Diabetes

CHAPTER 1

A global perspective on childhood diabetes: worldwide prevalence and incidence

Ragnar Hanas

INTRODUCTION

Diabetes mellitus is a group of metabolic conditions characterised by chronic hyperglycaemia (high blood glucose) resulting from defaults in insulin secretion, insulin action or both. Insulin allows glucose in the bloodstream to enter into cells in order to be converted into energy. When there is insufficient insulin, the cells start to produce ketones, ultimately causing ketoacidosis. This can cause coma and, ultimately, death. The abnormalities in carbohydrate, fat and protein metabolism found in diabetes are due to inadequate action of insulin on target organs (Craig et al., 2009). Diagnostic criteria for diabetes are based on blood glucose levels and the presence or absence of symptoms (see Table 1.1).

TABLE 1.1 Criteria for the diagnosis of diabetes mellitus (ADA, 2010; WHO, 1999; reproduced from Craig et al., 2009)

1. Symptoms of diabetes plus casual plasma glucose concentration ≥ 11.1 mmol/L (200 mg/dL).* Casual is defined as any time of day without regard to time since last meal. or 2. Fasting plasma glucose ≥ 7.0 mmol/L (≥ 126 mg/dL).** Fasting is defined as no caloric intake for at least 8 h. or 3. 2-hr postload glucose ≥ 11.1 mmol/L (≥ 200 mg/dL) during an OGTT. The test should be performed as described by WHO (86), using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water or 1.75 g/kg of body weight to a maximum of 75 g (65).

* Corresponding values (mmol/L) are ≥ 10.0 for venous whole blood and ≥ 11.1 for capillary whole blood and

** ≥ 6.3 for both venous and capillary whole blood.

Prevalence and incidence figures vary across countries. For example, in the United Kingdom there are at least 20 000 children under 15 years of age with diabetes of all types (Jefferson et al., 2003). In the United States, approximately 13 000 new cases of diabetes are diagnosed in children every year (Klingensmith et al., 2003). Some 154 000 US citizens under the age of 19 years have diabetes (one out of every 523 young persons), making this the second most common chronic disease in school-age children – the first being asthma (Liese et al., 2006).

This chapter introduces diabetes and the different types from a global perspective. World prevalence and incidence figures for diabetes are presented and discussed, as well as the different resources that countries may employ in its management.

DIFFERENT TYPES OF DIABETES

Type 1

Mankind has known diabetes mellitus, usually referred to simply as ‘diabetes’, since ancient times. Diabetes means ‘flowing through’ and mellitus means ‘sweet as honey’. Egyptian hieroglyphic findings from 1550 BC illustrate the symptoms of diabetes. In the past, diabetes was diagnosed by tasting the urine of the patient. No effective treatment was available. Before insulin was discovered, type 1 diabetes always resulted in death, usually quite quickly.

In type 1 diabetes, an autoimmune process destroys the insulin-producing cells of the pancreas. When tested, most children with new-onset diabetes are positive for pancreatic autoantibodies. This eventually leads to a total loss of insulin production. Type 1 diabetes is insulin-dependent, meaning that treatment with insulin is necessary from the time the disease is first diagnosed. Insulin is given by injection, with syringes increasingly being replaced by insulin pens. Twice-daily injections have for a long time been the traditional method of treating diabetes. To provide a more physiological insulin profile, short-acting insulin needs to be given with each meal, and there is also a need for a long-acting insulin (basal insulin) to be given once or twice daily through multiple daily injections (MDIs). In many centres, it is routine to begin with MDIs at the time of diagnosis. Most school-age children learn quickly how to give themselves injections. The average age for learning how to self-inject is around 8 years old (Wysocki et al., 1996). However, for some children and adolescents, injecting insulin remains unbearable even after many years of living with diabetes. In one paediatric study, 8.3% of subjects scored themselves as having a pronounced needle phobia (Hanas and Ludvigsson, 1997).

Boy being shown insulin injection device

Managing insulin delivery

There is a wide range of devices that have been developed to help improve the experience of injecting insulin. For example, indwelling catheters (Insuflon, I-port) may be used to help decrease injection pain for those who are new to injections, and they can be especially useful when multiple injections are used from the onset of diabetes (Hanas et al., 2002). Insulin pens, often used for MDIs, deliver insulin more accurately (Lteif et al., 1999) and are easier to handle than syringes (Graff and McClanahan, 1998), while injection aids (PenMate) for pens insert the needle automatically (Diglas et al., 1998). Two pens have a memory, which can be used as a reminder that insulin has been injected (or forgotten): the HumaPen Memoir has 16 memories and the NovoPen Echo has one. Parents can check the memory and help their child or teenager find strategies to remember their doses. Forgetting only two doses of insulin per week has been found to raise glycated haemoglobin (HbA_1c)¹ by as much as 0.5% (Burdick et al., 2004).

An alternative to injections is the use of insulin pump therapy, also called continuous subcutaneous insulin infusion (CSII). This is increasing in use in developing countries. A small pump (about the size of a pager) delivers a continuous infusion of short-acting insulin via an indwelling subcutaneous catheter. With this type of therapy, no long-acting insulin is used, as the basal infusion rate can be adjusted to match the individual’s varying needs during the day and night. The pump can deliver extra insulin (bolus) when eating or when the blood glucose is high by pressing the pump buttons. Parents report that their children achieve CSII skill mastery at a mean age of 12.5 years (Weissberg-Benchell et al., 2007). The use of insulin pumps in very young children has become established in many centres, and many now begin with insulin pumps from the onset of diabetes (Phillip et al., 2007). All insulin pumps have extensive memory capabilities, and it is possible to download details of previous bolus doses and basal rates for more than a month. This is very helpful during consultations, and it creates opportunities for discussions about how a young person or parent is managing the diabetes regimen. Using insulin pumps from the onset of diabetes in the age group 7–17 years has been shown to give better scores on the Diabetes Treatment Satisfaction Scale (Bradley, 1994), but has not shown improvement in glycaemic control (Skogsberg et al., 2008). Parents whose children are younger than 12 years of age have reported more freedom, flexibility and spontaneity in their lives, as well as reduced parental stress and worry regarding their child’s overall care, when switching from MDIs to CSII (Sullivan-Bolyai et al., 2004).

TABLE 1.2 Different modes of insulin delivery

Frequency	Consists of	Type of delivery
Twice-daily injections	Mixture of regular short- or rapid-acting insulin and intermediate-acting basal insulin	Mixed in syringe or premixed in an insulin pen
Three times daily injections	Morning injection of mixture of regular short- or rapid- and intermediate-acting insulins before breakfast; rapid-acting or regular short-acting insulin alone before afternoon snack or main evening meal; intermediate-acting insulin before bed	Mixed in syringe or premixed in an insulin pen in morning Syringe or pen for the other injections
Multiple daily injections	Basal insulin once or twice daily and rapid- or regular short-acting insulin before each meal	Usually insulin pens, but syringes can also be used
Continuous subcutaneous insulin infusion	Only rapid-acting (or short-acting) insulin is used in the pump The basal rate used in the pump substitutes for injection of basal insulin Bolus doses of insulin are given before each meal Rapid- or regular short-acting insulin is used	Insulin pump, bolus doses are delivered by pressing the buttons on the pump

A little girl plays happily in the sunshine: her insulin pump is visible at the neckline of her dress

Managing diabetes in school

MDIs and pump therapy both require an insulin dose to be taken when the child has lunch at school. Whereas older children should be able to manage this by themselves, younger children need help, both with taking insulin and with measuring blood glucose. Children who have adequate support from their school are reported to have a better quality of life and to...

Table of contents

• Cover
• Title Page
• Copyright Page
• Table of Contents
• Series introduction
• Dedication
• Foreword
• About the editors
• List of contributors
• Introduction
• Part I: Understanding Diabetes
• Part II: Management and Intervention
• Part III: Tools for Clinical Practice
• Index