I am a teacher of an adolescent girl who uses an insulin pump, and her diabetes is currently out of control (reaching levels above 400 mg/dl [22.2 mmol/L]). She falls asleep in class and has a hard time concentrating and staying focused. I understand this can be normal for a 13 year old girl, but I am concerned because she literally eats anything and everything she wants, whenever she wants. Today she ate a huge piece of pizza, a chocolate candy, a cookie and a bowl of ice cream. (No exaggeration — I watched her closely today during school and that’s what I saw her eat.) Shouldn’t she be at least attempting to follow a meal plan? She insists that the pump allows her to eat whatever she wants and that her current control problems are solely hormonal. Even if the pump offers flexibility and freedom, it seems unwise to eat inappropriately on a regular basis. I want to talk to her mother, but I don’t want to seem like I’m trying to “rat ” her out. So I thought I’d try to learn more first. Hope you can help.

You are correct, and so is this young lady. Although her reasoning is true, she is not using the insulin pump optimally.

The advantage of “pump therapy” is that it allows a mimicking of normal physiology to a great degree. People who do not have diabetes essentially always make some insulin from the pancreas all the time in what one refers to as a “baseline” or “basal” amount. When that individual eats, then additional insulin is made to cover the amount of calories (especially carbohydrates) that her body metabolizes. This additional meal-time insulin is called the “bolus.”

With insulin pump therapy, the pump can be programmed to provide a basal rate amount of insulin but the patient must then bolus herself the extra insulin at meals. This does indeed allow her to “eat whatever she wants” but she must, in fact, estimate the calorie needs completely correctly and calculate the correct dose of insulin coverage, based on a plan that her doctor has advised.

However, it is really not free reign to do whatever, whenever. While the pump can try to mimic the natural insulin secretion pattern, it is not the same. She should still eat wisely and make good decisions. Sure, there may be days that she splurges and the pump can handle that.

She is kidding herself, at least, if she thinks the rest of her high glucose readings are simply “hormonal.” I don’t think you’re ratting her out; you may be saving her kidneys, or her eyesight, or her life.

DS