Youth with T1 Diabetes Not Meeting A1c Targets: What Can Nurses Do?

By Jeniece Trast, MA, RN, CDE, clinical research nurse manager, certified diabetes educator, Children’s Hospital at Montefiore, Montefiore Medical Center, Bronx, NY

Diabetes Care recently published an article showing that our youth with type 1 diabetes, especially those in adolescence, are not meeting glycosylated hemoglobin (HbA1c) clinical guidelines. The HbA1c is a blood test done every two to three months that shows how well controlled the glucose levels were over that time period. As much as this news is disappointing, I am not shocked by it. Type 1 diabetes is a challenging disease to live with at any age; however, the adolescent years definitely intensify the challenge.

As a nurse and certified diabetes educator (CDE), I take on many roles when caring for a teenager with type 1 diabetes: educator, team member, moderator, blood glucose assessor, advocate, cheerleader, and even role model (yes, I have type 1 diabetes also).

Challenges and responsibilities. When caring for these patients, keep in mind that type 1 diabetes is a difficult disease to live with on a day-to-day basis. People with type 1 have lots of important responsibilities just to stay alive: multiple insulin administrations each day; constant blood glucose checking; understanding the effects of exercise on glucose level both during and after exercise; balancing exercise, stress, food, and insulin; providing sick day care; assessing for and treating hypoglycemia; troubleshooting when things go wrong; carrying supplies at all times; and worrying about the disease’s future possible complications—just to name of few!

Particular stresses for teens. These obligations require education, clinical and psychological support, and motivation. Nurses can play a vital role in all of that. Additionally, teenagers want to feel “normal,” puberty occurs, growth spurts happen, peer pressures influence them, erratic lifestyles dictate their lives, they long for independence, and many other potentially difficult situations occur during adolescence. All of this contributes to the fact that these teens are not achieving optimal control.

What can nurses do? There are many things we can do with our teenage patients to help them achieve both their goals and our goals.

• Education. Nurses need to be knowledgeable and ready to provide not only diabetes education but also education to both the family and the teenager on puberty, growth, and their effects on diabetes and glucose control. During times of growth and pubescent transformations, insulin requirements change. The nurse should educate them on how to notice these changes and what to do. It is also imperative that nurses be aware of and proactively educate their teenage patients about other things they may be exposed to, such as alcohol and the effects it may have on diabetes management.
• Assess blood glucose. Recommend to your patients that they use log books or a meter that allows you to download glucose information stored within the meter. This will be very helpful for reviewing glucose information. By assessing blood glucose records and patterns, nurses and their patients can recognize when there is a need for change and encourage communication between appointments.
• Diabetes self-management strategies and troubleshooting. A nurse can also offer ideas and strategies for making diabetes self-management easier during these years. Ideas may include setting reminder alarms, learning about the insulin pump (a device that continuously infuses insulin through a catheter in the subcutaneous fat), making a reasonable and acceptable plan with the parents, texting between health care providers and parents, and making use of the many technological advances available, such as smartphone applications. As a nurse you can learn from your other patients to find out what works and what does not. This way you can pass along useful information to those looking for help.
• Make referrals. Health care providers, including nurses, must always assess for depression, eating disorders, or other mental health problems. These issues may present themselves during adolescence. Making referrals to mental health specialists such as social workers, psychiatrists, and psychotherapists, or even to support groups, is something that should be considered. Find out about diabetes support groups or volunteer opportunities that exist in your area. It may be beneficial for some patients to get involved in these types of activities. The teenage years can be difficult ones and extra support and friends who understand may be helpful.
• Motivation, support, compassion, and understanding. As we all know, nurses often provide support and compassion to both patients and their families especially during tough times. Let them know you are there for them, as a cheerleader or just to listen and help out where possible. If the teenager feels supported by you and knows you are on their team, it may help them communicate better to you and reach out to you when they are having trouble.If the teen and parents are not communicating well, the nurse may have to act as a moderator during the appointment in order to design a plan that works for everyone. Tell the teenager what is expected of them but also tell them you understand that it is hard. Each patient is different and will require different care plans and strategies, so be sure to personalize their plan. As a member of their health care team, make sure that you are managing their diabetes appropriately and check that the entire team, including the physicians and specialists, is aware of any issues.

Nurses can take a major role in taking on the challenge of achieving clinical guidelines for our adolescent patients. With the extra care and compassion a nurse can provide, diabetes management in the adolescent can be made simpler and more successful.