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December 5, 2001

Blood Tests and Insulin Injections

Question from Cayce, South Carolina, USA:

My 11 year old daughter, diagnosed with type�1 diabetes about four and a half years ago, has never been in good control. She has been on an insulin pump for about eight months, and while we have been very pleased, her last A1c was 9.7% while her meter average was 153 mg/dl [8.5 mmol/L]. This situation has repeated itself several times and now her doctor is trying to discover what is going on. He drew another A1c, sent it to a different lab, and the result supported what was found in his office so now he is puzzled. Clearly he has not seen many cases such as this. My daughter seems to be very healthy, she has no eye or kidney problems, and her weight has been appropriate except for the loss of 1 pound recently, which we attributed to increased activity. Both of us daughter and myself are very discouraged because on a day to day basis we seem to be managing very well, and then her A1c is high. I do not want my daughter thinking that her diabetes is beyond her control, which it seems to be at this time. She does everything she has been taught. Her doctor is consulting with other specialists to find an answer. Has anyone on your staff ever encountered this problem? What might be the cause? Where else can I look for information?

Answer:

I can imagine how frustrating this is for you. Maybe it will help to keep in mind that when you measure her blood glucose readings those three to six times per day, you are checking her measurement at that moment in time, while the hemoglobin A1c is assessing that and what is occurring during the remainder of the 1440 minutes of the day over about 10 weeks or so. So, a possible answer is that during times that she does not usually check (e.g. 4 AM) her glucose readings may be higher. Try checking some “off-hour” glucose readings.

I am pleased that she is on a insulin pump, but I have found some folks who get a wee bit lax with meal planning while on a pump — having an extra little bit of cake or pizza or miscalculating their carb intake.

I have also run into this recently: the family uses a glucose meter that measures whole blood glucose but the printout indicates the values as plasma glucose. Plasma readings are about 15% or so higher than whole blood readings. So confirm that.

If the HbA1c has been confirmed as you say, then I think you have to consider a change in her insulin regimen and check those “other” time readings. She may need a slight increase in her basal rates.

DS

[Editor’s comment: Your daughter’s situation might well be clarified by monitoring sugar levels continuously for several days to try to sort out what’s happening in more detail. See The Continuous Glucose Monitoring System and ask her doctor about using it.

Also see a previous question on this topic.

SS]