Adolescents with Diabetes: Management from the Teen’s Perspective

Kirsten Bennett PhD RDN LD

June 4, 2021

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Key questions:

1.How would you incorporate the unique nutrition needs of youth/adolescents when managing diabetes?

2.What factors impact eating behaviors of youth/adolescents?

3.How can you incorporate creative ways to support healthy food choices and positive eating behaviors for youth/adolescents managing diabetes?

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Adolescence!Growth and Physical Development

!More rapid than at any other time except infancy

!Puberty and progression through it defines changes

!Three stages !Early (11-14 years)

!Onset of puberty: increased growth, secondary sex characteristics observable

!Concrete thinking !Expanding social relationships

!Peer influence important !“junk” food vs. “healthy” food perceptions

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Stages of Adolescence-continued

!Middle (15-17 years) !Completion of puberty with functional

maturation of reproductive organs and secondary sexual characteristics

!Peer groups define behavior !Family values persist, but some conflict !Developing abstract thought

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Stages of Adolescence-continued

!Late (18-21 years) !Adult physical maturation complete !Identity and body image established !Emancipation nearly complete !Cognitive development complete !Functional role in society beginning to

be defined

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Fig. 14-1, p.326

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Puberty!Females

!Increased hip width with broadening of the pelvic girdle

!Increased fat deposits !Increased linear growth and weight gain

!Males !Increase in shoulder width !Increased leg length !Increase in muscular strength !Increased linear growth and weight gain

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SMR: Sexual Maturity Ratings (Tanner Stages)

!Stages 1-5 in both males and females !By stage 5, puberty is complete !Assigned by assessing primary and

secondary sex characteristics !Useful in assessing growth parameters as

expectations for growth at each stage are different

!40% of skeletal mass gained between SMR 3 and 4 in males and in SMR 2 for females

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Fig. 14-2, p.328

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Fig. 14-3, p.328

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Skeletal Growth!Males have a longer prepubertal growth

phase so that final height is on average 13 cm (5.2 in.) taller than girls

!Peak height velocity occurs ~1 year after onset of breast development and ~1 year before menarche in females

!Menarche signals deceleration !Girls that mature later have a greater

final height !Peak height velocity is higher in males

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Skeletal Growth (continued)!Final stage of skeletal maturation

!Almost half of adult peak bone mass accrued

!By age 18, 90% of adult skeletal mass is formed

!Adequate intakes of bone building nutrients crucial and reduction in behaviors that decrease/limit bone mass development

!Skeletal age !Radiologic examination and comparison to

a standard (bone age) !Skeletal age and chronological ages don’t

always match and this is used as an assessment tool

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Skeletal Growth (continued)

!Peak bone mass !Critical in puberty

!Sets the stage for continued increase through the 3rd decade of life

!Through age 16 there is modeling and growth of bone !After peak bone mass is achieved then

remodeling and bone mass declines !Achievement of maximum bone mass is

considered the best protection against age related bone loss and fracture

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Weight Changes

!Weight increases parallel increases in stature in both males and females

!As much as 50% of adult IBW is gained during adolescence

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Body Composition

!Until adolescence and puberty, LBM is similar between males and females

!LBM increases in males !LBM decreases in females !LBM related to height, so taller

individuals have increased LBM

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Body Composition (continued)

! Body Fat ! Males 4-11% ! Females 15-27%

!17% may be required for onset of menarche !25% may be required to maintain regular

ovulation

! Body Water ! As a % of body weight, water decreases ! Muscle has a high intracellular water content ! As LBM increases, so does intracellular water ! 16 year old has 58% body water (66% of it is

intracellular)

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Assessment (continued)

!Focus is on change in growth parameters

!Incremental changes in height might be the best marker of anabolism

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Adolescence: Nutrient Needs! DRIs (Dietary Reference Intakes)

!Divided by gender and age into 4 groups !9-13y, 14-18y, 19-30y

!Energy !Calorie needs vary with stage of puberty

!Peak growth usually corresponds with greater need and intake

!Height important determinant of adequacy !Can be used to estimate needs

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Adolescence: Nutrient Needs (continued)

Energy Kcal/cm

Protein g/cm

Protein (2005) RDA g/kg

males9-13 11.6 0.24 0.94

14-18 13.3 0.30 0.8519-24 14.4 0.30 0.8females9-13 10.6 0.24 0.9214-18 10.6 0.28 0.8519-24 11.9 0.28 0.80

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Adolescence: Nutrient Needs (continued)!Protein

!Use growth pattern rather than range of intake to estimate needs !RDA (2002 DRI) 9-13y, 0.95 g/kg and 14-18y,

0.85 g/kg !g/cm probably the best

!Most exceed estimated needs !Groups that may not

!Low income !Self restriction !vegetarians

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Adolescence: Evaluation of Needs Estimates

!Extremes of the spectrum !Sedentary life styles with poor food

choices !Self restriction of food or energy !Participants of highly competitive

sports

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Macronutrient Needs

!Proportion of carbohydrate (45-65%), protein (10-30%), and fat (23-35%)

!Watch the percentage of carbohydrate from simple sugars (soda, juice drinks)

!Watch the fat sources (fast food or highly processed foods)

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Micronutrients of Concern Needs

! Calcium !Deficient intake may impact peak bone mass !Studies have shown enhanced bone density

when targeting those with deficient intake, but effect was lost when intake was reduced

!Accumulation best when threshold calcium balance met or exceeded (vit. D, Ca/P 1:1)

!Low intake reported in 40-50% adolescent females.

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Micronutrients (continued)

! B vitamin needs increase with body size and rapid growth ! Folate

!Women of childbearing age (400 ug/d) !Relationship to cardiovascular health

! Vitamin C ! Increased needs with smoking ! Increased with LBM and menstruation !May have low intake with restricted calories (6

mg/2000 kcal)

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Micronutrients-continued

! Zinc ! Deficiency related to growth failure and

delayed sexual development ! Needs increase ! Teens consuming a vegan diet at risk for low

intakes ! Needs move from about 5 mg/d in young

children to 8-11 mg/d in actively growing adolescents

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Factors Affecting Food Behaviors

! Body Image ! Males

!Anabolic steroids ! Unaware of the risks for CV disease, osteoporosis

and liver tumors !Peer pressure !High risk behaviors

! Alcohol ! Drugs ! Tobacco

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Chronic Disease Prevention

! Obesity ! Three questions to ask that identify risk and offer solutions

! What do you drink when you are thirsty? ! What do you like to do in your spare time? ! How much TV do you watch every day?

! Computer time (not homework) ! Video games

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Eating Dilemmas! Eating and food intake controlled by

many factors ! Voluntary changes in eating behaviors

can become more pronounced leading to disordered eating

! Severe disordered eating can then result in an eating disorder-meeting the guidelines for classification outlined in the Diagnostic and Statistical Manual for Mental Disorders (DSM-IV)

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• What are the priorities of adolescents?

• What are adolescents passionate about?

• How do adolescents approach decision-making?

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• The challenge of intervening…becomes even more daunting with the realization that in children and adolescents, the interplay of economic, social, behavioral, biomedical, and environmental influences must be considered individually at each stage of development (Esposito et al., 2009)

Key Developmental Considerations

! Identity ! Is this __________behavior key to my identity or developing

identity? !May involve adoption or rejection of behaviors

! Relevance ! Is this __________relevant to the world as I see it? Is

_________relevant to my world? !May have to think about this; quick decisions may not occur

! This is potentially frustrating for providers working with adolescents

! Control ! Is this _______ behavior change my decision? If so, can I

sustain it?

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Identity

!Health is part of my identity !Physical !mental

!How will good health help me be the person I want to be?

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Social! How will good health impact my ability to

have friends and partners? !Energy level? !Appearance? !Participation?

! Do I have support from my social network for my health behaviors? !Self-regulatory skills may not be adequate

or well developed (Strong et al., 2008) !Self-monitoring !planning

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Decision Making

! How will I use the information being offered to make an informed choice? ! Arm with knowledge ! Provide opportunities to use knowledge

!Trust! ! Intervention/Education/support may not be

immediately apparent !“Teachers affect eternity; they can never tell where their

influence stops.” Henry Adams

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Relevance! Is my FUTURE health relevant to me now?

!May relate to identity and social considerations !Adolescent developmental patterns include:

!Invincibility !Long term consequences of behavior not

considered !Disease focus typically does not work in

adolescents like it does in adults !Impulsivity

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How can we support an adolescent’s need for exploration and control with regard to healthy dietary, physical activity, and diabetes management practices?

!What would you ask? !How would you start a

discussion with an adolescent with diabetes?

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Break out sessions-10 minutes How would you approach opportunities and challenges ?

! 18-year-old male-Devin (adapted from J. Wick, Pharmacy Times October 2014) ! Type 1 DM diagnosed age 10 ! Mom with Type 2 DM and dyslipidemia ! Weight 200#; Height 6 feet ! A1C 8% ! Dyslipidemia ! Loves movies and TV-no regular planned physical activity ! Has a limited social circle at high school and does not participate in sports or

clubs ! Eats good breakfast at home-prepared by Mom ! For snacks and lunch chooses vending machine and fast- food cafeteria

items (pizza, hamburgers etc.) ! Knows how to adjust insulin based on carbohydrate intake however

sometimes lacks the time and privacy to make adjustments at school ! Devin is concerned about transition from his pediatric care team and what

that means for his care-he feels abandoned

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Family Focused Treatment

!Responsibility sharing !Outline at the end of each visit !Responsibilities change for the

teen as they mature !Manage conflict

!Screen !Behavioral health !Eating disorders

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Creative Strategies-what have you tried

! Fast food and teens ! Choices ! Environment

! Teen Schedules ! School ! Sports ! Jobs ! Social

! Transition to adult care teams

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References

! Brown, K. (2010) RD Coaching: making strides with small steps. PNPG Post, 20(3);1-3, 5.

! https://www.pharmacytimes.com/view/diabetes-dilemmas-potential-interventions-accessed June 1, 2021

! Esposito, L., Fisher, J. O., Mennella, J. A., Hoelscher, D. M., & Huang, T. T. (2009) Developmental perspectives on nutrition and obesity from gestation to adolescence. Preventing Chronic Disease, 6(3); 1-16.

! Levitsky, L., Misra, M. (2019) Overview of the management of type 1 diabetes mellitus in children and adolescents, Up to Date-accessed 4-29-21.

! McNaughton, S. A. (2011) Understanding the eating behaviors of adolescents: application of dietary patterns methodology to behavioral nutrition research. JADA, 111(2);226-229.

! Spahn, J. M., Reeves, R. S., Keim, K. S., Laquatra, I., Kellog, M., Jortberg, B., & Clark, N. A. (2010) State fo the evidence regarding behavior change theories and strategies in nutrition counseling to facilitate health and food behavior change. JADA, 110;879-891.

! Strong, K. A., Parks, S. L., Anderson, E., Winett, R., & Davy, B. M. (2008) Weight gain prevention: identifying theory –based targets for health behavior change in young adults. JADA, 108; 1708-1715.

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