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September 12, 2010

A1c (Glycohemoglobin, HgbA1c), Hyperglycemia and DKA

Question from Istanbul, Turkey:

My son has had diabetes for five and a half years. For the last four and a half years, he has been on a pump. Since last year, it has been hard to control his diabetes. His last HbA1c was 9.6, the highest since diagnosis, so we tried to get more control, monitored his blood sugar more often, did basal/bolus corrections. His rates in the summer were between 60 and 250 mg/dl [3.3 and 13.9 mmol/L], never going over 300 mg/dl [16.7 mmol/L] until three days ago. Three days ago, there was an error related to his pump. My son was high at night, 520 mg/dl [29 mmol/L] at noon. After we corrected his pump, his blood sugar returned to normal. Today, we went to get an HbA1c, which the Diabetes Foundation tests by a finger prick. They indicated my son's A1c was 10.6, which I know is too high. I suspect they made a mistake. Should we go to a hospital to have the A1c checked with a blood draw? Could the one day with high blood sugars have affected his HbA1c?


The HbA1c determination reflects overall (“average”) blood glucose values over the preceding two to three months, with the more recent weeks being more heavily influencing. But “one day” of poor glucose control would not account for the values that you have seen.

There is something not right going on. I suspect that there is either miscommunication (or outright deception) regarding your child’s daily glucose values and his reporting it and taking steps to correct them. Are YOU in charge of his daily glucose checks and correction boluses? Are YOU in charge of his taking insulin with meals/snacks? Or, is the child in charge of these important considerations? Do you have a meal/snack time insulin-to-carbohydrate ratio? Do you find that when you do a correction for a higher glucose, that the follow up glucose (checked one to two hrs later) is, in fact, close to your target glucose value? In other words, are you documenting that the correction boluses are working?

When diabetes management is not on track, I think it is helpful to go back to basics and double check EVERYTHING regarding insulin (how old is it? how is it stored? who administers/doses the insulin? how is your son supervised?) and exercise (what type? how often? when in relation to meals?) and meal planning (counting carbohydrates? dosing appropriately? all meals/snacks accounted for? straying from the diet?).

For a young person who has been pumping almost all their time into their diabetes, and who is now a teenager, perhaps your child “needs a break.” Perhaps they don’t like being attached to a machine all the time? What about switching to an injection regimen? This could be done INSTEAD of pumping. It could be done IN CONJUNCTION with pumping (see The Un-Tethered Regimen).

You really should be talking frankly with your child’s diabetes consultant. The values you point out are BIG warning signs.

As an aside, many of the fingerstick HbA1c determination machines are quite good!