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August 17, 2000

Other Social Issues

Question from Leeds, West Yorkshire, England:

My nine year old daughter has type 1 diabetes. Neither we nor the hospital are able to get a regular blood sugar count and she always has ketones. So, the specialist at the hospital has involved social workers to find out if she is under a lot of stress at home to see if this is the cause. Is this possible?

Answer:

Yes indeed. In the past, a term, “brittle, ” was used when a person’s blood glucose (sugar) level often was swinging quickly from high to low and from low to high. This term no longer is used much because there has been such a debate over what it means (also called labile and unstable diabetes ).

In essence, someone who has lots of admissions to hospital with hypos and/or ketoacidosis would be labelled “brittle”. However, in itself, this is a useless label because it tells us nothing about the cause. There are many potential problems that can lead to blood sugar instability including poor injection sites, missing insulin, poor diet, etc. the quality of diabetes education, the availability of home blood glucose monitoring, the understanding of factors other than diet in blood sugar levels and the important role of psychosocial factors in maintaining control. Nowadays, poor control, as defined by a high A1c level, calls for a much more specific definition as to where the problem lies.

In my experience, the first step is to identify the individual issues then to get help in unraveling them. This usually involves a social worker, or, better yet, a psychologist or psychiatrist with a special interest in diabetes. This is often a very tense and difficult time but the good news is that the majority of such patients eventually settle down. In the interim, the most important thing is to keep your daughter attending the clinic.

As I say to my patients, type 1 diabetes, except in cases of severe psychological/ social distress interfering heavily with diabetes control, is, by nature, “brittle.” Everyone has difficult periods, but most people can prevent hospitalizations and frequent severe hypoglycemia.

MS