Jamie R. Wood, MD

Associate Professor of Pediatrics

Medical Director, Clinical Diabetes Programs

Center for Endocrinology, Diabetes, and Metabolism

Children’s Hospital Los Angeles

Transitioning Your Teen

Outline

• Definition of Transition

• Guiding Principles of Transition

• Transition Milestones:

• Transition from middle school to high school

• Transition from high school to college

• Transition from college to adult independence

Definition of Transition

• The movement, passage, or change from one position, state, stage, subject, or concept to another

Guiding Principlesof Transition • Gradual

• Two steps forward, one step back, two steps forward…

• “Diabetes is a team sport”

• The expectation should never be total independence

• Importance of rehearsal and trial and error with a safety net

• Every person living with diabetes is different and will transition at their own pace

• A parent of a child with type 1 diabetes never “lets go”, nor should they

Diabetes Management Skills• Check finger stick BG

• Give insulin injection with pen or syringe

• Count carbohydrates

• Calculate insulin dose based on carbs and BG

• Treat hypoglycemia and hyperglycemia

• Manage diabetes and exercise

• Change pump infusion set

• Manage sick days

• Refill prescriptions

• Make doctor appointments

• Understand diabetes and alcohol

• Get in touch with diabetes team

• Insert/calibrate/use CGM

• Understand diabetes and driving

Transition milestones:middle school

• Checking BG independently

• Counting carbohydrates/calculating insulin doses (often still with supervision)

• Giving own injections/boluses

• Independent outings with friends, sleepovers

• Changing pump infusion set/CGM (often still with supervision)

Transition milestones:High School

• Independent management at school

• Driver’s license

• Dating

• First Exposure to Alcohol and Drugs

• Sick day management with supervision

• Managing diabetes and exercise with supervision

Issues During High School

Make sure student with diabetes is on a flexible insulin regimen:

Insulin pump therapy

Basal bolus therapy with multiple daily injections (MDI) with insulin pens

Continuous Glucose Monitors

If not:

Make an appointment with your diabetes team to discuss changing to a flexible insulin regimen

Allow enough time for student with diabetes to adjust and become comfortable and independent with new regimen

Insulin Pens

Insulin Pumps

CGMs

Issues During High School

During high school allow the teenager to gradually become more independent with their diabetes self-management:

Are they doing their own injections?

Can they do their infusion set changes independently?

Do they have a system to keep track of when to do site changes?

Can they count carbohydrates independently?

If not directly supervised, do they forget meal boluses or blood glucose checks?

Do they know what to do when they are sick?

Issues During High School

First step is to have teenager assume responsibility for diabetes management with direct adult supervision:

During meals have teenager count the carbohydrates independently and determine meal-time bolus and then double check with adult

Have teenager do site changes independently with adult watching

Issues During High School

Second step is to give teenager more independence with indirect adult supervision

Do as many “trial runs” as possible prior to college when there is still a safety net

Allow overnight sleepovers, sleep away camps

Allow teenager to manage diabetes, but review meter/pump to make sure that teenager is staying on track

If blood glucose monitoring declines, glucose average increases, or boluses are being missed, then increase supervision and try again

Talk through different scenarios – what would you do if….?

Issues to Address Beginning of Senior Year

Make an appointment with your diabetes team to discuss college transition:

Will your doctor remain the same for college?

What type of college setting would be best?

Close to home vs. far from home?

Living at home vs. living in dorm?

How will you communicate with diabetes team?

Email? Phone calls? Faxing logbooks? Download devices remotely? Who will make the call?

How does the parent know communication is occurring?

Issues to Address End of Senior Year

Prescriptions

Mail order with supplies shipped directly to student every three months

Transfer prescriptions to local pharmacy on campus

Whose responsibility will this be?

Appointments

Make appointments far in advance when you know student will be home (winter break, spring break, summer vacation)

Who will be responsible for making appointments?

If moving far from home consider having the name and number of a local diabetes clinic on hand

Issues to Address End of Senior Year

Housing:

Dorm vs. apartment, roommates vs. single

Important to try and normalize college experience

Having a roommate to help respond to emergencies may be safer

Consider a suite with private bedrooms but shared living space

Single room or apartment if privacy is important to student

Kitchen to prepare own meals

Request/purchase mini-refrigerator for room

Issues to Address End of Senior Year

Develop a communication plan

Frequent phone calls, emails, text messages will help reassure both student and parent

Discuss frequency of communication and who will initiate

Teach student to download pump to website, so that parent/diabetes team can review from home

Review health insurance plan

Can student stay on parent’s insurance plan through college?

Does student health plan offered through university cover diabetes supplies?

Diabetes and Driving

• Driving Rules:

• Medical alert bracelet, window decal, or wallet card

• Check BG before you turn car ignition on

• Keep rapid acting carbs in car to treat lows

• Check BG at least every 1-2 hours on longer trips

• Pull over to check BG or treat low

Dating with Diabetes Who to tell about your diabetes and when to tell them

are your decisions

Eating on a date – will it be easier to stick to your meal plan if your date knows about your diabetes?

What happens if you get low while with your date?

How will you check your blood glucose and bolus while on a date?

Will the date involve physical activity like hiking or walking? Be prepared with extra snacks.

Most people figure out that discussing your diabetes before hand avoids awkward moments later

Alcohol

“All young adults face challenges and have to make decisions about dating, driving, and alcohol. Teens with diabetes face the same choices as their friends. But having diabetes complicates the choices you make.”

http://www.diabetes.org/for-parents-and-kids/for-teens.jsp

Alcohol (1)

Drinking is illegal until your are 21!

Metabolism of alcohol uses the liver enzyme that is also responsible for maintaining blood glucose overnight or raising blood glucose during hypoglycemia

Alcohol can be dangerous for a person with diabetes for various reasons:

Alcohol can cause hypoglycemia

Alcohol can impair your ability to recognize hypoglycemia/hyperglycemia

Alcohol can impair your judgment and ability to make good decisions

Alcohol (2)

If student makes the choice to consume alcohol, they need to know

how to do it safely:

Check glucose very frequently

Moderation (1-2 drink maximum)

Avoid sugary drinks and hard liquor

Always eat before, during, and after drinking

Do NOT cover carbohydrates in alcohol with insulin

Wear your medical I.D.

Tips for Parties

• Go with friends who know you have diabetes and know what to do in case of an emergency

• Rehearse a couple of lines to politely say “No thanks” to a drink offer

• Have confidence that most friends will respect your decision to not drink

• Offer to be the designated driver or sober monitor

• Carry a half-full “drink” around with you to avoid being asked if you want another – nobody needs to know it is only diet coke

• Alternate alcoholic drinks with non-alcoholic drinks or water

A Few Words About Recreational Drugs

• JUST SAY NO! Extremely dangerous even without diabetes

• Gateway drugs – use of one (e.g. marijuana) often leads to use of more dangerous and addictive drugs

• Dangerously impair your ability to feel lows

• Dangerously impair your ability to make good decisions

• Will often result in forgetting to take your insulin resulting in DKA (diabetic ketoacidosis) and in overeating (highs)

Transition Milestones:College

• Independently manages diabetes, but knows how to call for help and seek advise

• Has a method to keep track of numbers (BGs, carbs, insulin doses)

• Download pump/CGM to parent(s) or diabetes team for review

• Established agreed upon communication plan with parents

• Can independently manage sick days and exercise

College “The task of letting go is a major

developmental milestone for both the child and family members, especially parents. This transition is exceedingly tough and emotionally stressful. It is hard enough to send your child to a new environment away from the nest, but it is even harder to leave your child with diabetes in the midst of a bustling college dormitory!”

Dr. Fran Cogen, MyDiabetesCentral.com

What You Need to do Before Classes Start (1)

Find Your Campus Health Center

Ask what resources are available for students with diabetes

Ask if you can empty your sharps container at the health center

Ask about prescriptions and pharmacy locations

Ask about support groups on campus or in area

Find the Dining Halls/Cafeterias

Is nutritional information available or can it be provided?

Ask for the weekly menu so you can plan ahead

What You Need to do Before Classes Start (2)

Form a relationship with your school’s Office of Disability Services or Office of Student Services

They will help you avoid academic problems arising from your diabetes (high or low blood glucoses, ketones, doctor’s appointments)

Universities are legally required to make reasonable accommodations for students with diabetes (Section 504 of the 1973 Rehabilitation Act and 1990 Americans with Disabilities Act)

Contact office to see what they require – many will ask for a letter from your doctor stating that you have diabetes

What You Need to do Before Classes Start (3)

What accommodations should I ask for?

Option to reschedule exams for episodes of hypoglycemia or hyperglycemia

Extra time to complete exam to allow for blood glucose monitoring, eating a snack

Excused absences for sick days or medical appointments

Allowances to bring food/water into class

What You Need to do Before Classes Start (4)

Prepare backpack with diabetes supplies to carry to class (glucose source must always be with you!)

Pack a sick-day kit for dorm room

Obtain a medical alert bracelet and wear it

Go through checklist of diabetes supplies

Put together emergency contact information:

Phone number for RA, health center, doctor, pharmacy, parents

List of medications and allergies

Copy of insurance card

Who Needs To Know You Have Diabetes?

Your Housing Resident Advisor and Resident Coordinator

Your Roommates/Friends

The University Health Center and Office of Student Services

Professors

What do they need to know?

Diabetes overview

Signs/symptoms of hypo and hyperglycemia

How to administer glucagon

When to call for help and who to call

Teaching Glucagon

• Save expired glucagon kits for teaching/demonstration

• Download app:

How To Break The News

It is hard to explain diabetes to a person without diabetes

Assure the person that you have control of your diabetes and the information you are sharing is for emergencies only

Show the person:

How to use Glucagon - this can be overwhelming to a stranger of diabetes, try to answer their questions and concerns

How you use your glucose meter

Your pump and how it works

It may be easiest to tell your roommate about diabetes through a written letter

Thank you!!!Questions???