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August 25, 2007

Behavior, Hyperglycemia and DKA

Question from Illinois, USA:

My daughter has had diabetes since she was two and a half. She is now 16 1/2. I am concerned about her thinking of diabetes. She has always tried for good A1cs. Two years ago, it was 6.8. Iit is now, since high school, 11%. She had a severe low never needing glucagon but, since then, she keeps herself high so she doesn't have to worry of lows. Until high school, she was okay. All of her life she has tested 10 to 15 times in a 24 hour period so she knew if she were low. Now, of course, she is never low and the meter says her average blood sugar is 300 mg/dl [16.7 mmol/L]. I tell her what can happen and she acts like she wants to do better, but mentally can't get over the hump. Our relationship used to be great, but because I am constantly looking at the numbers and trying to talk to her about it, she is getting "annoyed" (her word). She has only been to two diabetes camps in her life when she was younger and never liked being away from us. She is a kindhearted kid who does not drink or do drugs. She is a great kid in a slump. Where do teens go to get help when they are out of control? I was looking at a lifestyle retreat for a family but, really, I could only find one for older adults. I did come across Camp Sweeney for a three week camp in Texas (without parents), but I am not sure she can go until next year anyway. Her diabetes team says it's for kids and highs schoolers. Meanwhile, my child is in a rut and can't pull herself out of. She gets comfortable and doesn't change. She saw a psychologist, but it was no help. We even bought her a MiniMed continuous sensor, but her numbers were off when she first started using it. I think she was calibrating too close to having to take a shot for a high. Now, she says I can't trust it. We will try to use it after summer is over. Because of sweat, she has a hard time trying to keep it on. She also has a pump, but does not use it because the alarm went off at school and embarrassed her. Instead, she takes Lantus. Again, I need to know if there is a good program for teenagers trying to rethink and get their blood sugar under control instead of running it high all the time. Secondly, my daughter has always run sky high after she eats breakfast. She take Lantus and NovoLog. She might be 147 mg/dl [8.2 mmol/L] before breakfast. She eats and doses for all her food. I check sometimes. Her breakfast insulin to carbohydrate ratio is 1:5, while, at other times, it is 1:8. She is 5 feet, 5 inches, 115 pounds. We have been having her wait now 20 minutes and she is still in the high 200s mg/dl [14.4 to 16.6 mmol/L] and 300s mg/dl [16.7 to 22. 2 mmol/L] instead of the 400s mg/dl [over 22.2 mmol/L]. She stays that high until lunch. She takes morning dose of 25 units of Lantus. We are having her fast we don't see that rapid rise only as soon as she eats. How long can one wait to eat after taking a shot of NovoLog?

Answer:

The best book to purchase would be Insulin-Dependent Diabetes in Children, Adolescents and Adults by Ragnar Hanas, M.D. Amazon or other online booksellers will have it and it can also be special ordered at your local bookstore. The bigger problem is that she has “Fear of Hypoglycemia,” which interferes with her taking sufficient insulin to control her diabetes. This is a major problem that requires a team approach – including your diabetes team – plus an experienced psychologist or social worker who can help with the behavioral “blockade.” It will be important to make sure that she does not have diabulimia or any variant eating disorders since this also produces such consistently high blood sugar readings. Whether or not she uses an insulin pump or multidose insulin regimen, if she does not deliver sufficient insulin, she will achieve her goal of avoiding hypoglycemia but have chronic problems of all kinds with such high blood sugars. So, you are wise to be worried and need individualized assistance to help figure out alternatives that will be acceptable. Stay involved and please tell your child that it is your duty and right as a parent to help with this dilemma because of the short and long term severe health consequences if things don’t improve, the dangers of DKA, etc

SB
Additional comments from Dr. Jill Weissberg-Benchell:

I am not aware of any specific family-based or adolescent-focused programs that help teenagers get blood sugars under control. However, there are a number of experienced mental health professionals with expertise in diabetes that can be quite helpful. I would encourage you to ask the member of your diabetes team for referrals. The book by William Polonsky, Diabetes Burnout, published by the American Diabetes Association may be very helpful for you and for your daughter. Finally, I’d encourage you to talk with your daughter about the most difficult time of the day for her – morning?, evening?, and offer to check her blood sugars and administer her insulin for her. That will allow you to know that at least for part of the day, her diabetes is appropriately managed, while she can take a “break” from thinking about it or being “nagged” about it.

JWB

[Editor’s comment: To our knowledge, there is one resident facility in the U.S. that is willing to help teens with diabetes. The Cumberland Hospital for Children & Adolescents is located in Virginia. We recently answered a question about the hospital.

BH]