December 21, 2006
Daily Care, Insulin
Question from Kansas City, Missouri, USA:
My 16 year old daughter has had type 1 since she was nine. She was using an insulin pump with Humalog for about the last one and a half years and prior to that Lantus and Humalog. Her basal rate was 1.9 to 2.1 from 8:00 a.m. to 10:00 p.m. and 1.5 during the night. We recently returned to injections as she is very active and it just seemed like we had a great deal of difficulty regulating her blood sugars with the pump. She was tired of all the highs every time she disconnected despite bolusing before disconnecting. She is a cheerleader, plays soccer, and does gymnastics. Her A1c was below 7 until she hit puberty and, since then, it has been so difficult to control her sugars. It has been in the 8s for the last two years. She is very responsible with checking her blood sugar, etc., but her sugars seem to be so erratic, which I've heard is very common through the teenage years. I feel I have had no success discussing this subject with our endocrinologist. My daughter has gained 40 pounds through this difficult period, despite cutting her calorie intake to about one-third of what she ate before, eating about 1200 to 1500 calories per day and doing some form of exercise every day for 40 to 60 minutes. She has really tried to "diet" and has not lost any weight. When we returned to her injection routine, it was alarming to realize she is on 50 units of Lantus and about 15 to 20 units of Humalog. She takes one unit of Humalog per 7 grams of carbohydrates. She is 5 feet, 7 inches and 165 pounds. She has had her thyroid levels checked and she has also been checked for Cushing's disease. It concerns me terribly that she requires so much insulin. I feel her inability to lose weight is tied to her being insulin resistant. Are there any other options for her? Would she be a candidate for metformin or other medications to decrease her insulin requirements? At what insulin levels is a person considered insulin resistant? Her endocrinologist has said you are only insulin resistant if you have high morning blood sugars and that is usually not the case for her. My daughter also has not had a regular menstrual cycle, so he put her on Premarin and Provera, which quickly initiated a regular period. She did not have her first period until she was 15 1/2 years old despite her physical development. You would have thought she would have started when she was 15. I also wonder if this absent cycle could be tied to her insulin resistance although he says they are unrelated. She had a three to four pound weight gain with the Premarin/Provera, which we realize is typical. Her endocrinologist continues to say it is "calories in/calories out" despite the fact that no one in our whole family has any weight issues at all. Will her insulin resistance decrease as she finishes puberty or will this always be a concern? I am wondering if I should seek out a second opinion for her as I know she is very frustrated and has felt her endocrinologist has no solutions for her. Are there any further tests or medications that could be initiated or are there no solutions for this problem?
She is significantly overweight and this obesity is at least a likely contributor to some insulin resistance. Has she ever had a formal check for polycystic ovaries or endometriosis? Has she had a pelvic ultrasound? Metformin is a possibility, also Atkins-like restriction of carbohydrates, so that you could cut her insulin requirement and therefore assist with weight loss. The good news is that post-puberty, this type of high insulin dose usually comes down significantly, but this too would depend on how obese she remains and for how long this obesity persists. I would tend to agree with your endocrinologist that such weight gain coupled with high A1c levels usually indicates significant excess caloric intake and your description of her food and activity is not consistent with the high A1c and weight. A few days with using the continuous glucose monitoring systems may help provide some more information.