Challenges in care28

Puberty is a period of rapid and radical physical, psychological and social change during which a child, in physiological terms, becomes an adult capable of reproduction. Adolescence refers as much to the psychosocial characteristics of development during puberty as to the physical changes. Adolescents with diabetes, who need to adhere to a complex medical regimen based around self-care throughout this period of development, face a series of particular and considerable challenges. In this article, Hala Tfayli and Silva Arslanian look at the hormonal, metabolic and behavioural changes that impact on diabetes care during the years of puberty, and outline strategies that could help young people to achieve good glycaemic control, and thus protect their health and well-being into adulthood. The difficulties involved in maintaining good blood glucose control during adolescence were reflected in the findings of the Diabetes Control and Complications Trial (DCCT). In both the intensive and the conventional treatment groups, adolescents had 1 % higher average long-term blood glucose levels (measured by HbA1c) compared with the adults, de-spite similar therapeutic approaches – and despite receiving higher doses of insulin (units per kg of body weight).1 This worsening in metabolic control is due to both physiological and behavioural changes. Physiological insensitivity to insulin Studies have demonstrated that insulin levels are higher during puberty than they are during adulthood or the years preced-ing puberty.2 The direct evidence of this pubertal insensitivity to insulin became apparent only after experiments which measured in vivo insulin sensitivity.3,4 A decrease in insulin-stimulated glucose uptake in healthy adolescents compared with pre-pubertal children was dem-onstrated for the first time in the 1980s. While this effect is exaggerated in children with type 1 diabetes,3 in children without diabetes, whose pancreatic beta cells function nor-mally, puberty-related insensitivity to insulin is compensated by an increase in insulin secretion.4 The challenge of adolescence: hormonal changes and sensitivity to insuli