Sharing Experiences

By Susan C. Conrad, MD, and Stephen E. Gitelman, MD

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Melissa, 17, has had diabetes since she was 3 years old. When she was young, her mother took care of her diabetes management, and Melissa’s A1C’s were usually under 8 percent.

When Melissa became a teenager, she began to take more responsibility for her diabetes care. She took glargine once a day and lispro before meals. She based her mealtime doses on how much carbohydrate she planned to eat. She also added a correction factor if needed, adding 1 unit for every 50 mg/dl above 100 mg/dl.

At a recent diabetes clinic visit, Melissa said that she was satisfied with her blood glucose control. When her meter memory was downloaded, it showed at least three or four blood glucose checks a day, and almost all were in the 70-180 mg/dl range. But her A1C was 9.4 percent. That meant that Melissa’s average blood glucose level over the past two to three months had been over 250 mg/dl.

Possible Reasons:

There are many reasons an A1C may not agree with home blood glucose checks.

If you check your blood glucose levels only before meals, you catch only the lowest values of the day. By checking two hours after meals, you may catch some high glucose levels that would otherwise be missed.
Glucose meters need to be calibrated with a code from the test strip. If the wrong code is entered, the results may be wrong.
Test strips need to be protected from light. If they aren’t, they may give incorrect results.
Some medical conditions can affect A1C.
But in teens, a surprisingly common reason that an A1C does not agree with the blood glucose log is that the numbers in the log aren’t true. Some teens simply make up numbers without checking blood glucose. Others report numbers that are “better” than what the meter showed.

“Exhausting”
After a lengthy discussion, Melissa admitted that she had used the meter’s control solution for most of the checks. She said she was tired of dealing with her diabetes, and she found it “exhausting” to meet the expectations of her family and diabetes team.

Her mother, who always came with Melissa to her clinic visits, was surprised to find out that Melissa had used the control solution. She said she had little involvement now with Melissa’s diabetes care. Melissa seemed to want to be more independent, didn’t want her mother to “nag” her, and seemed to have things under control.

Caution: Teen Years Ahead
The teen years are rough, for teens and their parents. Diabetes adds another area for conflict.

In many children, blood glucose control worsens when they hit their teens. Part of this is biology: Growth hormone, testosterone, and estrogen make their bodies less sensitive to insulin. Part is social and psychological: Teens want to be to be like their peers. They want to be independent. They test limits.

When out-of-range blood glucose numbers start coming up, parents may get upset or angry, and may nag or punish. Or at least, this is how the teen sees it. So the teen may become secretive.

It’s tempting to think that this is “just a phase” and that diabetes control will get better again after high school. But recent research suggests that poor coping habits now may continue into adulthood. It’s important to break this cycle now.

Your teen is not mature enough to handle all his or her diabetes care alone and still needs your help with this complicated, frustrating, never-ending task.

What You Can Do

Get help from your diabetes care team. Extra sessions with the diabetes educator may be needed. It may help to see a social worker or psychologist, who can teach your teen coping skills.
To keep from “nagging,” try having a set time every evening to review your teen’s blood glucose results.

- Keep in mind that the numbers on the meter are neither “bad” nor “good,” they are information.

- Your job could be to simply record the numbers from the meter’s memory. Or you might help your teen look for patterns: highs or lows at certain times of days, or on certain days. Talk to your diabetes educator about how to adjust the insulin plan when you see these patterns. Your teen may need to take a break from diabetes care, and you could do all the tasks that day.

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Susan C. Conrad, MD, is a pediatric endocrinologist at Children’s Hospital and Research Center at Oakland in Oakland, Calif. Stephen E. Gitelman, MD, is a professor of clinical pediatrics in the Department of Pediatric Endocrinology at the University of California, San Francisco.