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February 14, 2003


Question from California, USA:

My teenaged daughter, who was diagnosed with type 1 diabetes about six weeks ago, has times when she has to eat continually to keep her sugar up past 45 mg/dl [2.5mmol/L]. Sometimes, she gets zero response from the food she eats and then other times her body reacts from the same food and bounces up into the higher range. This is a frustrating, scary and exhausting situation. She has to continually monitor her sugar because of her sugar instability. She has missed a lot of school because of the lows, and, when she does make it to school, she seems to drop low and often is not able to get it raised up. Her specialist says she is in her honeymoon period, but he has no explanation as to why she has extremely low blood sugars. It just seems that at times her body is in full force to not allow absorption of sugar and carbohydrates. If this continues, it will be a very long and dangerous honeymoon period. I am curious if there are others out there that have the same problems.


I think there are a couple of possibilities that you can explore with your pediatric endocrinologist or your other diabetes team members.

First of all, the likely possibility is exactly what you’ve been told: She’s in the honeymoon. Perhaps it is helpful to think of things this way: The pancreas is a “furnace” that produces insulin (instead of heat). Her pancreas doesn’t work very well. If you had a poorly functioning furnace, you might start to light a fire in the fireplace or put space heaters in the rooms to give off extra heat to allow the furnace to last a little longer. For your daughter, you are giving her extra insulin to supplement her pancreas, but we can’t give insulin precisely the way the pancreas would like, so when she eats, she can produce a small amount if insulin still. If the balance of food and insulin and exercise don’t match well, that can lead to hypoglycemia.

Not uncommonly, the amount of short acting insulin (Regular, Humalog, or NovoLog) can be cut back, sometimes significantly, during the honeymoon. Certainly, you need to review her meal plan and actual food intake with your diabetes team and especially the nutritionist. The longer acting insulins often need only little, if any, changes during the honeymoon.

Certainly, your thoughts about how well she is absorbing her nutrients are good and logical points. If she is not having abdominal pain or diarrhea, however, I think it less likely that there is also an underlying intestinal worry. However, an important consideration is a condition called celiac disease which is associated with an inability to best digest certain grains, notably wheat and barley. There is a moderate (and increasingly recognized) association between type 1 diabetes and celiac disease because both have an autoimmune basis. Celiac disease can be screened for with a blood test, but a definitive diagnosis requires an intestinal biopsy.

Similarly, other hormonal imbalances with autoimmune origins can also have effects on insulin sensitivity — notably adrenal insufficiency and thyroid disease. Ask your daughter’s diabetes team if there is reason at present to screen for these.

While hypoglycemia can be frustrating and very scary, the honeymoon phase for most is actually the easiest time to control blood sugars! In general, pediatric endocrinologists want the honeymoon to last a long, long time.