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May 17, 2003

Blood Tests and Insulin Injections

Question from a school nurse in Milwaukee, Wisconsin, USA:

We have a seventh grade transfer student with type 1 diabetes, and in the records from her previous school, it states that she is able to manipulate her blood glucose monitor to give lower blood glucose readings. How could this student manipulate the monitor and results so they are lower than actual?


Children will sometimes try to manipulate results from their meters. What they can do and how they do it is very much dependent on the meter. Here is a common list:

put too small a drop of blood on the test strip
dilute the blood drop with alcohol or water (such as leaving wet alcohol on the fingertip)
using someone else’s blood
using control solution instead of blood
using a check strip instead of blood
remove the battery from the meter for long enough to lose the memory of blood glucose results

It is important to explore these behaviors when children resort to these tactics. There can be many reasons why a child would falsify results. Children often provide us with just what we want to see. They want to avoid hassles and arguments. They want to please.

One strategy to decrease such behaviors is to take the emotionalism out of blood glucose monitoring. Blood glucose checks should be viewed as information gathering. The blood sugar result does not reflect the person’s worth, just his or her metabolic state. The blood glucose result is a piece of information to help decide future actions.

Additional comments from Shirley Goodman, diabetes nurse specialist:

Depending on the meter, there are several ways in which a blood glucose level can be falsified. One of the simplest ways is to report a level different from the one on the meter. If the meter has a memory, this method of falsifying the reading can be detected by reviewing the memory. Not all these methods will work with all meters:

Some of the meters will not differentiate between a testing strip that has been used and a new one. The used testing strips if used a second time will usually have a lower reading.
Applying a sample that is smaller than the recommended sample size will result it in erroneous reading.
Wrong coding on the meter will result in an erroneous readings sometimes.
I had one patient who inadvertently converted the units of measure on her meter from mg/dL to mmol/L which changes the values by a factor of 18.
Applying other substances (such as alcohol used to clean the finger or the control solutions used to test the strips and meter)to the testing strips will alter the readings. In meters that operate by light reflectance, painting the window with clear nail polish or rubbing it with alcohol may alter the readings.

I am sure there are other ways in which an individual will alter their testing to achieve the result that they want. I continue to explore with the young people I work with who also falsify there testing how they were able to achieve the results.

I think it is important that the team working with the child and family seriously grapple with the issues surrounding falsification of the glucose testing. There are many motivating reasons why children (and let’s be honest) adults intentionally alter their testing results. I would hope that a mental health professional is working with this child and family to reestablish the child’s sense of self that is separate from diabetes.

Additional comments from Jane Seley, diabetes nurse specialist:
You need to observe her doing the entire test to make sure she doesn’t dilute the blood sample. I had a child once at diabetes camp that actually licked the blood off the test strip right after applying it to lower the sugar so he could get more snacks!