July 12, 2005
A1c (Glycohemoglobin, HgbA1c), Hyperglycemia and DKA
Question from Kansas City, Missouri, USA:
My daughter is 14 years old and has had type 1 diabetes for five years. We have always had A1cs below 7.0 until the last nine months. I have been concerned as she has gained about 22 pounds in the last year while also growing about three to four inches. She is now 5 feet, 7 inches and weighs 141 pounds. She has not started menstruating and she will be 15 in November.
The endocrinologist recently screened her thyroid and hormone levels, which were okay. He also screened for celiac disease. Her recent A1c was 9.7, which didn’t surprise us as her blood sugars have been horrendous in the last few months. My daughter is extremely compliant and we just can’t figure out what is going on. Her blood sugars now seem to increase drastically (even 500 to 600 mg/dl [27.6 to 33.1 mmol/L]) with sports or stressful events, such as school dances. We are concerned both about her blood sugars and the fact that she just keeps gaining weight especially in her trunk area, despite cutting her carbohydrates by 45 grams in the last six months. Will her weight decrease at all once she starts menstruating? Will her blood sugars become more predictable? Can you give us any advice on any further testing, etc.?
Answer:
Celiac disease typically leads to weight loss, rather than weight gain. I’m reassured that her thyroid levels are normal.
To better answer your concerns, it would be more helpful to know what type(s) of insulin your daughter receives and by what method (basal-bolus by injection or pump or split fixed doses of intermediate and short-acting insulins, etc). Does she dose based on her carbohydrate intake? Are you quite confident in her abilities to count carbohydrates? Any “extra calories” going in to which you aren’t always privy?
In and of itself, puberty is a state of insulin resistance. Estrogen and other hormonal changes during puberty lead to changes in body composition and fat distribution. So, it is not uncommon to see insulin requirements and weight changes during this time. It may be helpful, although I’ve not always seen this successful, to switch to a basal-bolus insulin plan, if she has the capacity to do so and is not already doing this. The addition of metformin might also assist in matters, even though it is more often used in type 2 diabetes.
Finally, of course, it still emphasizes the need to count those calories carefully and have ready an exercise plan.
DS
