Although diabetes is incurable at present, blood-sugar levels can be managed through diligent monitoring, exercise and balancing medication along with diet. In the wake of a diagnosis, parents need to impress upon their youngster that adhering to the four-prong program will help him to sidestep not only acute adverse effects like elevated blood sugar (hyperglycemia) and ketoacidosis but serious long-term consequences. Ketoacidosis may occur when there is not enough insulin to handle the glucose that is present; fats and proteins are used and there is a rise in fatty acid metabolites, called ketones, which may be detected in the blood and in urine. Ketoacidosis can be a life-threatening condition that must be corrected immediately.
Diabetes is the sixth most fatal illness in the United States. Years of elevated blood sugar damage blood vessels; later in life, that may come back to haunt patients in the forms of cardiovascular disease, kidney failure, vision problems (diabetic retinopathy, the leading cause of acquired blindness in this country), lack of sensation (diabetic neuropathy) and poor blood flow to the lower legs.
Conversely, diabetics who keep their glucose levels within a normal range as much as possible significantly reduce their odds of developing lifethreatening complications. In a government-funded study called the Diabetes Control and Complications Trial (DCCT), patients with type 1 disease received either standard management or more aggressive care. At the end of nine years, the latter group had a 62 percent lower risk of eye disease than those treated less aggressively; their progression of kidney impairment and nerve damage was approximately 60 percent lower as well. A few years later, a British study of type 2 diabetics yielded similar results.
Hormone Therapy
All adolescents with type 1 must learn to give themselves subcutaneous injections (in the fatty tissue beneath the skin) of insulin two, three or more times a day. Type 2 patients, on the other hand, control their disease through diet and exercise, and possibly the oral medications described below. Although formerly referred to as “non-insulin-dependent diabetes,” type 2 diabetes may eventually require insulin because the pills used to control blood sugar may eventually lose their effectiveness in about one-third of all patients.
Insulin administration must be timed with eating, so that the hormone reaches the circulation around the same time that glucose from food makes its arrival. This task has been simplified somewhat by the introduction of different types of insulin programmed to commence working, achieve their maximum effect, and then subside at various times. Standard therapy calls for two shots a day. In the more aggressive approach, patients self-administer three or four doses of various insulins.
Most insulin-dependent youngsters soon become quite proficient at wielding the needle syringe. However, many are now switching to an external insulin pump, which administers a continuous dose of the hormone at the same rate as a healthy pancreas. The programmable device, about the size of a pager, can be slipped into a pocket. A thin catheter tube delivers the insulin into the tissue below the surface of the skin.
Drug Therapy
The current drug regimen for type 2 diabetes combines the biguanide agent metformin with a sulfonylurea (chloropropramide, glimepiride, glyburide, glypizide, tolbutamide, tolazamide). Biguanides prevent the liver from producing glucose, while sulfonylureas work by prevailing upon the pancreas to secrete more insulin. A third type, glucosidase inhibitors (acarbose), inhibits a key enzyme that reduces the intestines’ absorption of carbohydrates. Side effects such as flatulence and bloating make this drug less than popular with the teen set.
Dietary Measures
Virtually all endocrinologists have a dietitian on staff to counsel teenage patients and their parents on making necessary changes in the diet. Current recommendations are for food intake to be at or under 30 percent as fat, 50 to 60 percent as carbohydrate and the rest protein. The teen should check with his physician and dietitian to work out a specific meal plan that is right for him.
Blood-Glucose Monitoring
This simple blood test, performed several times daily, measures the concentration of sugar in the circulation. Based on the results, which are logged on a chart, the drug dosage and/or diet may be adjusted in order to help patients maintain control of their blood-glucose level. Most young people with diabetes are taught “carb counting” at mealtime and snack time, so that they can become adept at balancing the carbohydrate content of the food they eat and the amount of insulin they must take.
Controlling diabetes can be akin to piloting a ship between two icebergs. Veer off course in one direction, and your blood sugar rises alarmingly high. Stray too far the other way, and you’re confronting an equally dangerous situation: blood-glucose deficiency, or hypoglycemia, the most common acute complication among young persons with diabetes. Even the most conscientious patients overshoot or undershoot their marks now and then, due to their own miscalculations of how much insulin to take or to complicating factors like physical illness, exercise or emotional stress.
Ironically enough, both insulin and oral diabetes medications can perform too well and bring about hypoglycemia, which is defined as a blood-sugar level below 40 to 50 mg/ml. These insulin reactions can be serious, so an endocrinologist deciding on a target blood-sugar range for an adolescent usually builds in margins for error at both ends.
When Symptoms Point to High Blood Sugar (In a Person With Diabetes)
If the teen feels ill, contact your pediatrician or endocrinologist immediately for instructions. Otherwise, step one is to test the blood-glucose level.
If the concentration of sugar in the blood is higher than normal but under 240 mg/ml:
- Drink at least eight glasses of water a day.
- Eat according to the prescribed treatment program.
- Continue to check blood glucose four times a day until it returns to a safe level.
- Take extra short-acting insulin.
If blood sugar regularly exceeds 239 mg/ml, the teen is at risk for ketoacidosis and should:
- Test a urine sample for excess ketones (ketonuria). Testing strips are available over the counter in most pharmacies.
- If the urine tests negative for ketones or contains only a trace amount:
- Repeat blood and urine tests.
- Drink at least eight glasses of water a day until the urine is clear of ketones.
If the urine tests positive for ketones:
- Call your pediatrician or endocrinologist right away.
- Keep drinking plenty of water.
- Do not exercise. In this state, physical activity can nudge blood glucose higher still.
When Symptoms Point to Low Blood Sugar (In a Person With Diabetes)
Hypoglycemia, though usually mild, comes on suddenly. As with hyperglycemia, the blood should be tested at once, because the symptoms of low blood sugar mimic those of other medical conditions. Report repeated episodes to your doctor, who may need to adjust the dosage of insulin or oral diabetes medication.
If blood sugar is below 60 mg/ml, indicating hypoglycemia, and the teen is alert, he should:
- Eat or drink one of these rapidly digested starches, such as:
- glucose tablets
- orange juice
- non-diet soda
- grape jam, honey or sugar
- If the symptoms do not improve after fifteen minutes, call your pediatrician or endocrinologist for instructions. Continue feeding the teen sweets every fifteen minutes until the blood sugar climbs back up to at least 70 mg/ml.
- Once he is out of danger and feeling better, give him something more substantial to eat, such as bread or crackers with peanut butter or cheese, or a bowl of cereal with milk.
If the blood sugar is below 60 mg/ml and the teen is convulsing or too drowsy to swallow safely, or unconscious:
- A family member or friend should inject him with the hormone glucagon.
- Alert your pediatrician or endocrinologist immediately.