ERIC EJ871120: Role of Health Educators in Assisting Youth and Adolescents with Diabetes

2009·0.16 MB·English

by  ERIC

Feature Article
Role of Health Educators in Assisting Youth
and Adolescents with Diabetes
Gail A. Spiegel, Alison Evert, and Laura Shea
ABSTRACT
Management of diabetes in children requires balancing nutrition, physical activity and medication on a daily basis
in order to achieve blood glucose targets. The health educator can assist children and their families in meeting their
diabetes management goals by better understanding the current recommendations and tasks involved to achieve
them. Whereas children with type 1 diabetes require multiple injections of insulin per day or use of an insulin pump,
children with type 2 diabetes may require an oral medication, insulin or both. Nutrition and physical activity recom-
mendations are similar for children with diabetes as they are for all healthy children. Meal planning for children with
diabetes usually involves a method of carbohydrate counting, since this is the main nutrient that raises blood glucose.
Short term management outcomes for children with diabetes include the prevention of hypo- and hyperglycemia,
while long term outcomes include the prevention of micro and macro-vascular complications.
Spiegel GA, Evert A, Shea L. Role of health educators in assisting youth and adolescents with diabetes. Am J Health Educ. 2009;40(5):264-270.
This paper is part of a sponsored set of papers contributed through the National Institute of Diabetes and Digestive and Kidney Diseases,
National Institutes of Health.
INTRODUCTION MEDICATION MANAGEMENT tance to the successful management of dia-
Children with diabetes need to balance All children with type 1 diabetes must betes: onset, the length of time before insulin
food, medication and activity on a daily take insulin for survival. Children with
basis to keep their blood glucose in, or close type 2 diabetes who require medication to Gail A. Spiegel is a dietitian/certified diabetes
to, a desired target range. This paper reviews control their blood glucose may take either instructor at the Barbara Davis Center for Child-
current medication management, nutrition an oral medication, insulin, or both. Today, hood Diabetes, Aurora, CO 80045. Alison Evert
and physical activity recommendations for new types of insulin and new delivery sys- is a diabetes nutrition educator in the University
children with diabetes. Diabetes management tems help to keep blood glucose levels in of Washington Medical Center, University of
outcome recommendations also are reviewed, the desired range. These options, however, Washington, Seattle, WA 98105. Laura Shea is a
along with ways that the health educator can may require more frequent blood glucose public and professional education coordinator in
assist children and their families to achieve monitoring and more assistance for the child the Diabetes Control and Prevention Program,
their individualized nutrition, physical activ- with diabetes. New York State Department of Health, Albany,
ity and diabetes management goals. Insulin has three dimensions of impor- NY 12237; E-mail: [email protected].
264 American Journal of Health Education — September/October 2009, Volume 40, No. 5
Gail A. Spiegel, Alison Evert, and Laura Shea
reaches the bloodstream and begins lower- on the nutrient requirements for children dren achieve and maintain a healthy weight
ing blood glucose levels; peak, the time at with diabetes.1 include some of the following practices:
which insulin is at its maximum strength in General nutrition recommendations
• Eat a healthy breakfast every day
terms of lowering blood glucose levels; and, from the United States Dietary Guidelines
• Eat low fat or fat free snacks such as fruit,
duration, the number of hours that insulin for Americans and the United States De-
vegetables, popcorn, or yogurt
continues to lower blood glucose levels. partment of Agriculture for all youth 4-18
• Decrease fast food visits
Most children with type 1 diabetes re- year-olds include: 3 to 10 oz. of grains, 1 to
quire multiple injections, or they receive 2.5 cups of fruit, 1.5 to 4 cups of vegetables, 3 • When eating sweets, do so with a small
their insulin through a programmable in- to 7 oz. of lean meats and 2 to 3 cups of milk/ serving at the end of a meal
sulin pump. For children using injections, dairy per day. Recommendations specify that
there are several types of insulin that may at least half of all grains consumed should DIABETES MEAL PLANNING
be used in combination. The different types be whole grains, most dairy choices should APPROACHES
of insulin have been formulated to have be fat free or low fat, and vegetables and To achieve optimal blood glucose con-
immediate (rapid-acting or short-acting in- fruits with a rainbow of colors should be trol, the American Diabetes Association
sulin), intermediate, or long (basal insulin) included.2,3 recommends monitoring carbohydrates by
onset and duration of action. A coordinated Total fat intake should be 25% to 35% of carbohydrate counting, exchanges, or expe-
combination of different types of insulin a child’s calories per day, mostly from poly- rience-based estimation as a key strategy.8
is used to allow for adequate treatment of unsaturated and monounsaturated sources Carbohydrate counting is the main form of
diabetes at meals, snacks, during periods of such as nuts, fish and vegetable oils. Less than meal planning prescribed for children with
physical activity and throughout the night. 10% of calories should come from saturated type 1 and type 2 diabetes. In the past, meal
For children using an insulin pump (a com- fats (mostly found in animal products such planning for diabetes was much less flexible,
puterized device), a small amount of rapid or as beef, cheese and butter) and trans-fatty and children often were prescribed a rigid
short-acting insulin is programmed to infuse acid (found in fried foods such as French meal plan to match insulin dosing. Today,
24 hours per day (basal rate) and additional fries and baked goods like crackers, cookies the prevailing approach is to match insu-
doses (boluses) of rapid or short-acting in- and other processed foods); consumption lin to the child’s nutrition (carbohydrate)
sulin are programmed before eating meals should be kept as low as possible. Sodium intake. because carbohydrate is the nutri-
and snacks or when high blood glucose levels intake should be 1900-2300 milligrams ent that the body converts to blood sugar,
are attained. by being aware of how medica- per day or less (depending on age) to help families of children with diabetes who take
tions play an important role in managing prevent hypertension.2 insulin are taught how to balance their insu-
diabetes and the challenges that a child Studies indicate that children and adoles- lin with the amount of total carbohydrates
faces everyday, the health educator can help cents with diabetes fail to meet their nutri- that their child is eating.
to provide a supportive atmosphere for the tion goals. They are eating more total and To count carbohydrates families first
child to handle this complicated disease. saturated fat than recommended and many need to learn which foods contain carbohy-
have inadequate intake of Vitamin E, fiber, drates. Sources of carbohydrate that convert
DIABETES NUTRITION fruits, vegetables and grains.4,5 Encouraging to blood glucose include starches (grains,
RECOMMENDATIONS children and families to meet dietary recom- starchy vegetables, beans and lentils) and
The American Diabetes Association mendations (increase fruit, vegetables, whole sugars (fruits, milk, yogurt and sweets). Fi-
(ADA) states that nutrition recommenda- grains) and to decrease their intake of fats ber is also a type of carbohydrate that is an
tions for children and adolescents with and sweets will help them stay at a healthy important part of any healthy food plan, but
diabetes should focus on achieving blood weight, and obtain the nutrients they need does not significantly contribute to blood
glucose goals (without excessive hypogly- to achieve optimal growth. glucose. Non-starchy vegetables such as
cemia), lipid and blood pressure goals and The prevalence of childhood obesity is broccoli and lettuce contain a small amount
normal growth and development.1 Today, increasing rapidly worldwide, as is diabetes.6 of carbohydrate, yet are typically an excellent
meal plans for children with diabetes are This phenomenon appears to be caused by source of dietary fiber. Whereas children
individualized to accommodate food a combination of over-nutrition and insuf- with diabetes can eat foods that have added
preferences, cultural influences, physical ficient physical activity. For children with sugars, those foods should be included in
activity patterns and family eating patterns diabetes, other contributing factors may moderation, as recommended for children
and schedules. Nutrient recommendations be over-insulinization, snacking and excess without diabetes. Regular sodas, juices and
for children with diabetes are based on calorie intake to avoid or treat hypoglyce- other sugary drinks contain large amounts
requirements for all healthy children and mia.7 In addition to the nutrition recom- of carbohydrates, raise blood sugars quickly,
adolescents because there is little research mendations above, strategies to help chil- are low in nutrition and are difficult to bal-
American Journal of Health Education — September/October 2009, Volume 40, No. 5 265
Gail A. Spiegel, Alison Evert, and Laura Shea
ance with insulin. Most diabetes health care style flexibility. These children will have for school lunch and breakfast, or it can be
professionals recommend that children with an individualized insulin-to-carbohydrate obtained through the food service director.
diabetes avoid these “liquid carbs,” unless ratio and blood glucose correction factor
they are used to treat a low blood sugar. for dosing of their rapid-acting insulin. PHYSICAL ACTIVITY
There are two main methods of meal basal-bolus insulin management includes RECOMMENDATIONS
planning using carbohydrate counting: fol- giving multiple daily injections (MDI) of Children with diabetes are encouraged
lowing a consistent carbohydrate meal plan rapid acting insulin with a basal insulin, or to participate in the same forms of physical
or using an insulin-to-carbohydrate ratio to using an insulin pump. The child’s diabetes activity as children without diabetes. Cur-
adjust insulin for variable carbohydrate in- health care provider determines how much rently, it is recommended that children and
take. Which method a child uses will depend rapid-acting insulin the child needs to cover adolescents participate in at least 60 minutes
on the insulin regimen the child uses and the carbohydrates (insulin-to-carbohydrate ra- of moderate intensity physical activity most
family’s skill level. Many families start with a tio) and how much rapid-acting insulin he days of the week, preferably daily.2 Children
consistent carbohydrate meal plan. needs to lower blood glucose to the desired and adolescents with diabetes should stay ac-
On a consistent carbohydrate meal plan, range (blood glucose correction factor). tive for many reasons: to maintain a healthy
the child with diabetes eats a set amount Insulin-to-carbohydrate ratios vary from weight; feel stronger, healthier, and more
of carbohydrates at each meal and snack. child to child. For example, a five-year-old positive about themselves; sleep better; and
This amount is individualized to the needs may use an insulin-to-carbohydrate ratio of experience less stress.
of the child. The amount of rapid acting 1 unit per 30 to 45 grams of carbohydrate, To ensure that children get the daily rec-
insulin (meal insulin) that the child takes whereas teenagers may use 1 unit for each ommended amount of physical activity, the
only changes for the blood glucose level. This 7 to 15 grams of carbohydrate. Exhibit 1 whole family is encouraged to participate.
method of carbohydrate counting often is contains a case study with a dosing calcu- There are many activities that can be a part
used with children with type 1 diabetes who lation using an insulin-to-carbohydrate of spending time together as a family, even
are on fixed dose regimens, or with children ratio and blood glucose correction. With if members have different levels of expertise.
with type 2 diabetes who take only oral med- MDI and pump therapy, children do not For example, families can walk, hike, or bike
ication. With fixed-dose insulin regimens, it have to follow a fixed schedule for meals together. Children can be taught to start out
is important to maintain consistency in the and snacks. slowly and to advance to the full 60 minutes
timing and content of meals and snacks. The To count carbohydrate amounts accu- per day.
student should eat lunch at the same time rately, children and their families are taught Physical activity should be enjoyable, and
each day. Snacks often are neces sary and how to read the “Nutrition Facts” on food it is helpful to include children in planning
must be eaten to balance with the peak times labels for total carbohydrate grams. Families the activity and where it takes place. If a child
of insulin action and with physical activity. should measure or weigh foods periodically has a particular interest, he or she should be
Sample carbohydrate ranges for meals and to estimate portion sizes and carbohydrate encouraged to pursue that interest. being ac-
snacks are listed in Table 1.9 content accurately. Families also should have tive does not have to be expensive. Activities
Insulin-to-carbohydrate ratio, which a book or reference list that they can refer such as playing tag, throwing a ball, jumping
is part of a basal-bolus regimen, is more to for unlabeled foods. Many schools now rope and walking are inexpensive ways to get
physiologic and gives the child more life- are providing carbohydrate information kids moving.
Table 1. Meal Carbohydrate Amounts by Age
Age: 5-12 years old Age: Teens
Boys 45 to 60 grams of carbohydrate at each meal 60 to 75+ grams of carbohydrate at each meal
Girls 45 to 60 grams of carbohydrate at each meal 45 to 75 grams of carbohydrate at each meal
Carbohydrate amount must be individualized based on caloric needs, preferences, and activity levels. Snacks, if needed
usually are 15 to 30 grams of carbohydrate. The child’s diabetes health care provider helps to determine the amount of
carbohydrate that is right for each child at each meal.
266 American Journal of Health Education — September/October 2009, Volume 40, No. 5
Gail A. Spiegel, Alison Evert, and Laura Shea
Many children spend much of their time
watching television and playing video and Exhibit 1. Case Study
computer games. The American Academy
of Pediatrics recommends that children limit Carlos is on MDI and he needs to calculate how much rapid acting insulin to take
screen time to ≤2 hours per day.10 Decreasing for his school lunch. Below are his dosing recommendations for carbohydrate in-
sedentary activities will lead to an increase take and blood glucose, along with the carbohydrate content of his meal, pre-meal
blood glucose level, and dosing calculations.
in physical activity. Encouraging children to
increase their daily activity level by taking
the stairs instead of the elevator, walking the Recommended rapid-acting insulin dose:
dog, or helping around the house also can
Insulin- to-carbohydrate ratio = 1 unit of rapid acting insulin per 15 gm carbohydrate*
help them to stay at a healthy weight.
Blood glucose correction = 1 unit of rapid acting insulin per 50 mg/dl over 150
before starting a new program of physi-
mg/dl blood glucose*
cal activity, the child’s parent or guardian
should be instructed to check first with their
School Lunch Carbohydrate Content
diabetes health care provider. There may be
6 baked chicken nuggets 15 grams
adjustments to a child’s meal plan and/or
½ cup mashed potatoes 15 grams
medications that need to be made to prevent
½ cup green beans 5 grams
hypoglycemia. Often it is recommended that
½ cup canned fruit in natural juices 15 grams
the child’s blood glucose level be monitored
1 carton 2% white milk 12 grams
before, during, and after physical activity,
Total 62 grams
especially when first beginning a program.
Pre-meal Blood Glucose = 250
SHORT-TERM DIABETES MANAGEMENT Total Carbohydrate Intake = 62 grams
OUTCOMES—DAILY CHALLENGES
Hypoglycemia Dosing Calculations:
In the 2005 position statement by the
Insulin needed for carbohydrates = 62÷15= 4
American Diabetes Association, near-nor-
Insulin needed to lower blood glucose to target level= 250-150 (target) = 100 ÷ 50 = 2
mal glucose control was recommended for
Total Dose= 4 (Insulin needed for carbohydrates) + 2 (insulin needed for high blood
children with diabetes.1 However, achieving
glucose) = 6
optimal glycemic control is not without
risks, the greatest being hypoglycemia (low
* Insulin-to-carbohydrate ratios and blood glucose corrections are individualized for each child. This
blood glucose). On a daily basis, parents
example should not be used as a recommendation for dosing.
and caregivers must carefully balance their
child’s glycemic control with their child’s
sciousness and convulsions, which can be life hyperglycemia can impair cognitive abilities
unique vulnerability to hypoglycemia.1
threatening. One of the greatest frustrations and affect academic performance. Over a
Young children have difficulty recogniz-
for the child, caregiver, or school personnel long period of time, even moderately high
ing hypoglycemia and as a result, parents and
can be the occurrence of hypoglycemia de- blood glucose levels can lead to serious
other caregivers, including school personnel,
spite scrupulous efforts to maintain optimal complications such as heart disease, stroke,
must be educated about signs and symptoms
glycemic control13-15 (Table 3 and Table 4). blindness, kidney failure, and amputations.
of this acute diabetes complication. To ad-
dress these unique needs of the developing Hyperglycemia Blood Glucose Self-Monitoring
child, the ADA has developed age-specific Hyperglycemia, also called “high blood Parents and caregivers can evaluate their
glycemic goals that can be used together with glucose,” is a result of too little insulin or child’s blood glucose control by reviewing
the health care plan provided by the child’s glucose-lowering medication, illness, infec- the daily blood glucose monitoring results
health care team1 (Table 2). tion, injury, emotional stress, ingestion of on an ongoing basis. Weekly or periodic
Hypoglycemia usually can be treated food that has not been covered by the ap- review of the child’s blood glucose data
easily and effectively. Early recognition of propriate amount of insulin, or decreased can help the caregiver and the health care
its symptoms and prompt treatment are physical activity. provider, including diabetes educators, to
necessary for preventing severely low blood Symptoms of high blood glucose include make treatment decisions. The child’s in-
glucose levels. Severe hypoglycemia that is increased thirst, frequent urination, nausea, dividual response to their meal and snack
not treated promptly can lead to uncon- blurry vision and fatigue. In the short term, choices, medication and physical activity
American Journal of Health Education — September/October 2009, Volume 40, No. 5 267
Gail A. Spiegel, Alison Evert, and Laura Shea
Table 2. Blood Glucose Goals for Children
Age Before Meals Bedtime Goal HgbA1C
Toddlers and Preschoolers (< 6 years) 100-180 mg/dl 110-200 mg/dl < 8.5 (but > 7.5)%
School-age (6-12 years) 90-180 mg/dl 100-180 mg/dl < 8%
Adolescents and young adults (13-19 years) 90-130 mg/dl 90-150 mg/dl < 7.5%
Source: American Diabetes Association: 2009 Clinical Practice Recommendations
Note: Individual goals may be different than the ones shown. Obtain specific guidelines from the child’s diabetes health care provider.
insulins; test at least four times a day; and
Table 3. Management of Hypoglycemia periodically test two hours postprandial (i.e.,
after meals), before and after exercise and
Teach causes of hypoglycemia:
between 1:00 AM and 3:00 AM.
• Eating too little or delaying a meal
• Diabetes medications LONG-TERM OUTCOMES –
• Insulin REDUCING RISK OF COMPLICATIONS
• Oral diabetes medications IN THE FUTURE
• Unplanned or extra physical activity
Hemoglobin A1C
• Unknown
Lowering hemoglobin A1C (HgbA1C) to
Teach symptoms of hypoglycemia: an average of ~7% has been shown to reduce
micro-vascular and neuropathic compli-
• Feeling shaky and/or sweaty
cations of diabetes and possibly macro-
• Nausea
vascular complications.11 However, as stated
• Extreme hunger
previously, less stringent HgbA1C goals may
• Heart pounding or racing
be more appropriate for children due to
• Blurred vision
their difficulty in being able to recognize the
• Confusion and/or inability to concentrate
symptoms of hypoglycemia by themselves.
• Impaired judgment
The American Diabetes Association’s 2008
Teach the “Rule of 15”: standards of care recommend performing a
HgbA1C quarterly with children.11
• If blood glucose level is:
• Less than 70 mg/dl – treat with 15 grams of carbohydrate* Growth
• Less than 50 mg/dl – treat with 30 grams of carbohydrate Medication and food plans for youth with
• Check again after 15 minutes diabetes must be updated continually. Grow-
• If still less than 70 mg/dl, repeat treatment ing children will need to have adjustments
• If next meal is not within 1 hour, eat a small snack with protein, such as cheese to therapy made from developmental and
and crackers, or a small peanut butter sandwich physical assessment data (height and weight
plotted on a CDC growth chart), laboratory
* See Table 4 for examples of 15 grams of carbohydrates. and blood glucose meter data, as well as life-
style factors (changing food preferences, fluc-
tuating levels of physical activity and school
can reveal an ongoing pattern of highs or medication and food plans are also missed.1 schedules).1,12 Parents may restrict food at
lows. There are many reasons that blood Youth with diabetes should follow these meal time or at snack time in an attempt to
glucose levels can vary, including inaccu- guidelines for blood glucose self-monitor- achieve desired glycemic targets, when all that
rate meal insulin dosing due to inaccurate ing:1 use glucose levels to make insulin dose is needed is an adjustment in oral diabetes
carbohydrate counting. If results are not re- adjustments for rapid-acting or short-acting medications or insulin doses. Insufficient ca-
viewed frequently, patterns are easily missed insulins and after observing patterns over loric intake, as well as glucosuria, can impair
and opportunities for changes in diabetes several days to adjust doses of long-acting the child’s normal linear growth.
268 American Journal of Health Education — September/October 2009, Volume 40, No. 5
Gail A. Spiegel, Alison Evert, and Laura Shea
Table 4. Sources of Carbohydrates
Grams of
Carbohydrate Source Amount Calories
carbohy-drate
Glucose Tablets
3 to 4 tablets 15 60
1 tablet = about 5 grams carbohydrate; check the label
Fruit Juice ½ cup 15 60
Soft Drinks
½ can 20 70
(not diet or sugar free)
Sugar
1 tbsp. 15 60
1 teaspoon = 4 grams of carbohydrate
Sport Drinks 1 cup 15 60
Milk, Non-fat 1 cup 12 90
Milk, 1% 1 cup 12 105
Fruit Roll-Ups
1 12 to 15 50 to 75
1 roll = ½ ounce; check label
Raisins 2 tbsp. 15 60
Source: Evert Ab, Hess-Fischl A. Pediat Diabet. Chicago, IL: American Dietetic Association; 2005.
Role of the Family: Transitioning medication management, health educators Geil Pb. Choose Your Foods: Exchange
Self-care Behaviors can assist children and families better to Lists for Diabetes: The 2008 Revision of Ex-
Ongoing involvement of the family or achieve optimal blood glucose control in change Lists for Meal Planning. Alexandria,
caregiver is a crucial component in achiev- children with diabetes. VA: American Diabetes Association, 2008.
ing optimal glycemic control. The level Spiegel G, Penkilo M. Carbohydrate
and amount of parental involvement will RESOURCES Counting for Children with Diabetes. India-
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Websites
and ongoing communication with all the (free resource)
CalorieKing Wellness Solutions. Avail-
individuals in the youth’s life will help to Warshaw HS, Kulkarni K. Complete Guide
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and consistent manner. Diabetes medication American Diabetes Association, 2004.
National Diabetes Education Pro-
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270 American Journal of Health Education — September/October 2009, Volume 40, No. 5