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Thank-you
for your comprehensive article that highlighted the potential
complications of pregnancy in teenagers with type 1 diabetes (T1DM).
We were surprised at your findings that “chronically ill
adolescents are less likely to receive contraceptive counseling and
sexual education than their healthy counterparts”.1
The clinical practice guidelines in Canada and the United States
clearly require that adolescents with T1DM receive counseling on
contraception and sexual health to avoid unplanned pregnancy.2,3
Given that adolescents with T1DM see a physician 3 to 4 times per
year, there is much more opportunity to discuss sexual health and
birth control issues compared to adolescents without chronic disease.
We
are a multi-disciplinary team in a pediatric diabetes education and
care program for children with diabetes. Pediatric endocrinologists,
a masters-prepared social worker, nurses, and dietitians make up our
team. As a quality assurance activity, we surveyed adolescents age 12
to 18 years with diabetes in our program from January to August 2001
to determine rates of smoking and sexual activity and their recall of
teaching on these subjects.4 We found 11.8% of adolescents
with T1DM were sexually active compared to the Canadian national
average of 44% for females age 15 to 19 years.5 Only 5.9%
of our adolescent males with T1DM reported sexual activity compared
to 43% of Canadian boys age 15-19 years.5 Sixty percent of
adolescent girls and 40% of adolescent boys in our clinic reported
having being involved in a discussion about sexuality in the previous
year. We understand that our rates may be low due to reluctance of
the patients to divulge this information and because we included
younger adolescents in the survey.
Our
team begins education about adolescent issues including sexuality,
birth control, and preconception counseling at approximately age 12
years. Oral contraceptives are encouraged as well as barrier methods
to prevent sexually transmitted diseases. We know of only one
pregnancy in more than 500 females with T1DM in our program since
1985. Our concern lies in the difficulties that adolescents face when
they are transferred to adult care at age 18.6 The rate of
dropout of diabetes care in young adult years has been found to be
25%,7 and this is alarming considering the risk of
pregnancy without early care, as you clearly state in your paper. Our
focus needs to be on supporting young adults through the stress of
transition while remaining ever vigilant in the care of our
adolescents in preventing pregnancy.
Sincerely,
Gillian Toth, RN, CDE
Heather Dean, MD, FRCPC
Elizabeth Sellers, MD, FRCPC
Janet Grabowski, MD, FRCPC
Louise Rawluk, RN, CDE
Nicole Aylward, RD, CDE
Norma VanWalleghem, RD, CDE
Gen Henderson, MSW, CDE
Catherine MacDonald, BFA(H)
Diabetes Education Resource for Children & Adolescents
Departmentof Child Health
Winnipeg, Manitoba
Author’s Response: We
appreciate your letter and kind words concerning our review on
pregnancy in adolescents with T1DM, and we are grateful to learn of
your comprehensive care program for adolescents with diabetes.4
Such programs are ideal and hopefully will translate into a decrease
in the rate of pregnancies in diabetic adolescents. You are correct
in quoting the guidelines in Canada and the United States that
mandate education on contraceptive counseling and sexual
education.2,3 Unfortunately, these guidelines are not a
guarantee for appropriate contraception. The quality assurance
activity that you reported4 may not reflect the true
prevalence of sexual activity among T1DM adolescents. Your comparison
group of non-diabetic adolescents (1994−95 National Population
Health Survey) reported an estimated 43% of girls aged 15 to 19 years
had at least one sex partner in the previous year. In addition, among
sexually active 15- to 19-year-old adolescents, 51% reported having
sex without a condom in the past year and less than 50% of the
adolescent females who admitted to sexual activity reported using
oral contraceptives.5 These surveys are not available for
comparison in T1DM.
You
reported that 69% of adolescent females in your clinic have been
involved in a discussion about sexuality in the last year. The impact
of these discussions to lower the pregnancy rate in T1DM patients is
yet to be shown. Intensification of methods that prevent pregnancy in
this high-risk population need to be implemented. Offering effective
contraception, even without consent of the parents, may be the only
means to decrease the pregnancy rate in adolescents. Hopefully, your
program will provide the evidence and strategies that are applicable
to diabetic adolescents and thus spur increased efforts to focus on
pregnancy prevention.
Lois Jovanovic, MD
Director & Chief Scientific Officer
Sansum Diabetes Research Institute
Santa Barbara, California
References - (linked to  )
1. Brindley
B, Jovanovic L.Growth Genet Hormon 2004;20:49-55.
2. Canadian
Diabetes Association Clinical Practice Guidelines Expert Committee. Can J Diabetes 2003;27(suppl 2): S84-S90.
3. Silverstein
J, Klingensmith G, Copeland K, et al. Diabetes Care 2005;28:186-212
4. Toth
G, Dean H, Deatrich J. Can J Diabetes2002;26:269 [abstract].
5. Statistics
Canada:Sexual activity and contraceptive use. Accessed: January 15,
2002.
6. Whittaker
C. Diabetes Quarterly.2004; Spring:10-14.
7. Frank
M, Perlman K, Hamilton A, Small M. Can J Diabetes. 2002;26:254.
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