September 17, 2003
Daily Care
Question from Rochester Hills, Michigan, USA:
My 10 year old stepdaughter has had type 1 diabetes for two and a half years and has been using pump therapy for about five months. My husband and I have joint custody (50% of the time), but her mother has primary contact with the endocrinologist, and some of the information she provides to us is very inconsistent with what I know about diabetes. For example, I read that exercise and a good diet maintain good blood glucose control, but when I have asked her mother to get on the same diet program we use, she tells me that diabetes is very unpredictable, and its probably stress levels at our home that creates the lows we experience. I tend to serve a low fat diet, no red meats, strong supplements with veggies and fruits. Unfortunately, based on my knowledge of her diet at her mom’s house, I understand she eats a fair amount of fast foods, over sized bagels, sugary cereals and snacks. Her mother has informed me since my stepdaughter is on the pump, she can eat whatever she wants whenever she wants it. I have even suggested that she schedule a mutual meeting with a dietitian, but her mother has shown no interest from her Is this true? Should I have limits of sugar intake?
Also, my stepdaughter suffers from low blood sugars (particularly through the night) when she is with us. My husband and I typically test her blood sugar two-three times during the night which is extremely draining, and often times we have to wake my stepdaughter up to force her to drink juice or Glucerna. How can we keep her balanced through the night when there are such extremes to her diet? Should we send her to bed with a high reading (200s mg/dl [11.1 mmol/L]) so that as she drops through the night we don’t have to interrupt her sleep to keep her levels up?
Lastly, the other morning my stepdaughter had a blood sugar over 400 mg/dl [22.2 mmol/L] before she played soccer with no ketones. Due to her high levels her mother didn’t want her to play soccer, despite the fact she was going to keep her pump on during the game. I heard that exercise is good to help lower blood sugars. By the way, she was giving chocolate milk before she played which I suspect increased her level to begin with. I guess given a similar set of conditions I would have given her a correction bolus (assuming it had been two hours after having her last snack), and allowed her to play, and checked her sugar levels at half time or other scheduled breaks.
Can you touch upon your thoughts on these topics of diet and exercise?. Also, any recommended reading that may help. Bear in mind that since we only have custody part of the time I can only control diet at my home.
Answer:
You ask many good questions that this forum cannot answer adequately in the time and space allotted. So, let me touch on salient points:
For the sake of the child, given the apparent “mixed messages” that are being received, I do strongly urge your husband and you to attend the next appointment with your stepdaughter’s pediatric endocrinologist. (Hopefully, she is seen by a pediatric endocrinologist.) Bring with you a list of questions for that diabetes team to address: meal plans, activities, assessment and treatment of hypoglycemia, etc. The diabetes team can then have you speak with their dietitian and nurse. In addition, I think that conferring with a social worker (or better yet a psychosocial worker) would benefit everyone. Based on your letter, I think there is a lot of tension between the two households, probably in good part (but not completely) due to the girl’s diabetes, and she is probably conflicted, wanting to please everyone, yet at the same time, “getting away with as much as she can.”
While it is true that insulin pump therapy offers much flexibility in terms of meals and activities, I actually disagree that she can eat “whatever she wants whenever she wants.” That is a common misunderstanding. Yes, she can eat a wider variety of foods and not be restricted to a schedule, but that does not mean that she should, and it certainly does mean that she must give extra insulin for any significant meal or snack, as directed by her diabetes team.
Offhand, I also disagree that “stress” is causing the low glucose in your home, as suggested by the birth mother.”Stress” more typically leads to higher glucose values, not lower. Lower values stem from increased insulin or exersice relative to meals and snacks. Perhaps in your home, the meals are more regulated. Do you know how to carb count? Does her dad?
Given the joint custody, her father has the right, if not obligation to be involved in the care, meet with her doctors and have issues and questions addressed. I actually do not know how much responsibility can be shared with a stepparent. So, the households need to have a meeting of the minds, best with a diabetes professional to guide you through any turbulence. Ask to meet with your stepdaughter’s diabetes team, especially any psychosocial worker or similar professional.
DS
