Despite numerous different changes in my 12 year old daughter’s regimen (she was diagnosed at age four and half), her A1c remains elevated. Her last one was 7.3%, and her highest was about 11%. The doctors tell me it’s because she sneaks food so this last year I have been “the food police” big time. She carbohydrate counts, checks her blood glucose every time she eats any little thing, and she takes insulin every time she eats.

She also has hypothyroidism treated with levothyroxine, but has not grown very much over the last 18 months. Her weight is about 68 pounds, and her height is about 4 feet. Could she have a problem with her pituitary gland or her adrenal glands? I’ve been reading the pathology books (I’m a nurse) and wondering if she could have something else going on, also. One of her pediatricians thinks she might have the Somogyi syndrome, and I’m wondering about an elevation in her cortisol levels. She’s going to the doctor, so I’d like to have a better idea of how to present my case.

You sound like you are really trying to be proactive. It sure is easy for folks to resort to the “sneaking food” retort. I have a couple of things that you and your daughter’s diabetes team may want to think about:

First of all, a hemoglobin A1c of 7.3% is pretty darn good (assuming the normal value in your reference lab goes up to about 6% or so). So perhaps you are being overly concerned about this right now. However, I would expect her to gain weight a bit better than 68 pounds and certainly expect her height better than “4 feet” at age 12 years! A pituitary growth hormone issue is a possibility, but one would expect enhanced insulin sensitivity and therefore lower insulin requirements. I presume that with her diagnosis of hypothyroidism and treatment thereof her thyroid levels (T4 and TSH) are normal.

As for her apparent higher insulin requirements, that also is not usually a problem: she needs what she needs. It is not uncommon to see insulin doses that approximate up to 1.5 units or more of insulin per kilogram body weight in a teenager. Has she demonstrated any signs of puberty?

The Somogyi Effect is a process in which after a (usually) unrecognized low sugar, there is a “rebound” high sugar. This doesn’t sound like Somogyi to me.

Low adrenal cortisol levels could also have issues with control and growth, but I would expect a generalized darkness to the skin (even areas where the sun doesn’t get a chance to tan) and also relative diminished requirements of insulin.

These issues of thyroid disease and adrenal gland problems do sometimes affect people with type 1 diabetes because they all have an autoimmune basis as to the mechanism causing the disease. There is an intestinal disorder called celiac disease that has a higher incidence with autoimmunity.

If your daughter has not been followed by a pediatric endocrinologist, it may be time to do so to be certain the puberty hormones are appropriate, the “correction factor” for highs, the growth and weight gain, etc are addressed now.

DS