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January 30, 2003

Daily Care

Question from Albuquerque, New Mexico, USA:

My four year old niece has had type 1 diabetes for nearly a year, her blood glucose readings are still bouncing all over, and my sister is having great difficulty in figuring out what factors are affecting them. I am a statistician and have decided to collect data on variables that may affect her blood sugar (food intake (by carbohydrate, protein, fat), exercise, site of injection, illness, time of day, insulin type). I am planning on creating a structural equation model to attempt to isolate the factors that have been impacting her blood sugar in order to gain some understanding of the interaction between these variables. I have researched MEDLINE and several other databases to see if others have attempted this and if so, what sort of model was used, but I have not found any prior research on this topic. Do you know of anyone who has done such research who might be able to point me in the right direction?

Answer:

Although your idea is an interesting one, the problem is that blood sugar is affected by many physical and emotional factors so it is virtually impossible to weigh the impact of one variable over another for each individual. I think it is more important right now to work directly on controlling your niece’s blood sugar through known means such as meal planning, physical activity and the best use of available insulins. Perhaps she is a candidate for an insulin pump or other intensive therapies. Has she been on The Continuous Glucose Monitoring System to find out exactly when these fluctuations occur? I would have her parents go back to the pediatric endocrinologist to find out what else can be done to control her blood sugar now.

JS
Additional comments from Dr. Stuart Brink:

Many people have such information, and there is much published especially with work about artificial pancreases that dates back to the 1970’s. Michael Albisser has worked in this field for many years and also should have several publications from several years ago.

SB
Additional comments from Dr. Donough O’Brien:

Some years ago, there were a number of attempts to devise an equation such as you suggest. So far as I know though, none of them really caught on because of the difficulty in uniformly assessing some of the variables especially those of various kinds of stress and of appetite and exercise.

For those reasons, the emphasis has recently shifted to giving a bedtime injection of a basal insulin like Lantus (insulin glargine) and calibrating the dose to the fasting morning blood sugar. At meal times very a short acting insulin like Humalog or NovoLog can be given just after the meal with the dose adjusted for the premeal blood sugar and the ‘carbs’ actually consumed. This is an approach that your sister should discuss with her daughter’s diabetes team. Since this probably will involve more needle sticks it is important to use UltraFine needles to give the insulin and perhaps one of the essentially painless glucose monitors such as the FreeStyle or One Touch� Ultra for blood sugar assays.

DOB