December 24, 2007
Behavior, Community Resources
Question from Atlanta, Georgia, USA:
I’m a 21-year-old female, a senior in college, and I’m having a couple of issues with my diabetes. I’ve been a type 1 diabetic for 16 years and have had varying levels of control. To cut it down to the years that matter, in high school, I had relatively decent control after getting an insulin pump (A1cs of 7 to 7.5%, down from 10%). I was happy with that, then a sequence of events happened. I went to college, was fine for the first two years (maintaining the 7% A1c), then lost the diabetes team with which I had a 16 year relationship. To make a long story short, they could keep me until I turned 22, but, despite my pleading with them that leaving would be a bad idea at the time, they made me go to an adult endocrinologist when I was 19. I liked the endocrinologist to whom they sent me, but she had scheduling issues (needing flexibility due to my college schedule, I’d call to move an appointment, but they wouldn’t have another until two to three months later, making it a total of six to seven months in between visits when I finally got in). After about a year, I went to another endocrinologist who had great reputation, but I ultimately don’t know if I want to stay here or not, as I didn’t feel the same “click” as I did with the first new endocrinologist.
I once had a serious low in which I didn’t pass out, but needed a massive carbohydrate correction to make it come back up (really needed a glucagon treatment, but didn’t have one on me at the time – wasn’t at home). Ever since then, I have serious issues with a fear of lows (and, therefore, rebound highs). In sum, for all of these reasons, I haven’t seen a decent A1c since I left the pediatric diabetes team (meaning they now range from 8.5 to 10%). I know that I need some help, because the fear of lows/anxiety issues is beginning to compromise my diabetes care. I can’t seem to get motivated enough to change my “fear-driven” ways, but I’m not at the point where I’m comfortable discussing this with my current endocrinologist. Presently, for a low of 65 mg/dl [3.6 mmol/L], I’ll eat a 30 gram snack, maybe 15 grams of juice, then 15 grams of crackers. Then, I’ll wait until my sugar is around 200 mg/dl [11.1 mmol/L] to give the correction, if I do so at all, which I know isn’t good. From another point of view, if my blood sugar is 200 mg/dl [11.1 mmol/L], I’ll let it sit there instead of giving a correction for it. I have mood swings all the time, which I’m almost positive are related to the swinging blood sugars. How would I go about finding a psychiatrist/therapist that works with young adults (and/or possibly a diabetes team that works with young adults)? I’m just really frustrated because this is the first time I’ve felt like I don’t have a diabetes team with which I really feel comfortable and I just feel as though, in combination with everything else that’s happened, it’s beginning to take its toll. I’m becoming worried about it.
Answer:
You are not the only person that has had such a problem. There are marked differences between pediatric and adult care that lend themselves to different kinds of interaction. Adult care is clearly more individualized and patients are expected to be “self-sufficient.” That doesn’t always work if you have problems that need troubleshooting. That is where you do need a team of professionals working together. At my own institution, this is one of my interests. That is, we are interested in the transition of care from pediatric endocrinology to adult endocrinology care. What we have found is that there is a sizable amount of support that has to occur during the years 15 to 25. Some do well and would do well anywhere. Others need additional education and close supervision to work on specific problems. Finally, there is the issue of a “treatment gap” that you identified when you are gone to college and it doesn’t seem like you are accessible to anyone. You might want to see if there is an endocrinologist in the area where you live that is interested in transitional care for patients with type 1 diabetes. This type of clinic might be available at a university-based site or in the community. Such programs are almost always associated with a diabetes care team made up of diabetes educators and physicians. The other choice would be to try another physician. What I have done with my patients is to have a primary endocrinologist that handles all information, even if at college. However, you can have a primary physician or another endocrinologist who sees you while at school.
JTL
