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Question:

From Mexico:

My son is now 16 years old and has had Type 1 diabetes since he was 7 years old. His doctor feels his control is very good but I would like to check about the test we do every three months. His glycosylated hemoglobin results are always over the test standard range, e.g., if the range for that test is reported as being 4-8, his results was 9. Can you enlighten me as to the "normal" variance in a teenager. He tests with a blood glucose monitor about twice a day. His readings fluctuate quite a bit but only very rarely do they reach 300. He has more trouble with unexplained lows. We has lived in Mexico since he was born so I often feel a bit out of touch with what might be the best care for him. Thanks for any help you can give us.

Answer:

This question was referred to several members of the Diabetes Team, who have each given an answer:

Answer from Dr. O'Brien:

It sounds as though your son is doing a splendid job of controlling his blood sugars. There is very little data on optimal A1c levels at this age; but in one study that was published about seven years ago in a group of 220 young Type 1 diabetics aged less than one year to 18 years, it was shown that there was a direct relationship between elevated A1c levels and their duration with eye and kidney problems after age 15. In that study an A1c of less than the upper limit of normal for the method + 10% was considered excellent control. That figure for your son would be 8.8%; but remember that the confidence limits for this test are +/- at least 10% so your son ought perhaps to start thinking of using a pump or going on to what is called 'intensive insulin therapy' which would mean three before meal shots of regular plus a long acting shot that might be combined with the morning or evening Regular insulin. When he next sees his doctor he should talk about the possibility of switching to the new more precisely acting Lispro insulin, which can be given after the meal. Later on in a few months time he might also consider changing to a new long acting insulin which is very evenly released over the 24 hours; but is not yet available. These newer developments do ask a certain expertise on the physicians's part which may not be easy to find in Mexico where the incidence of Type 1 diabetes is a good deal less than in the U.S.

DO'B

Additional comment from Dr. Lebinger:

Although I agree completely that everyone with diabetes should aim for as close to normal blood sugars as possible, I think it is important to keep in mind that completely normal blood sugars are rarely possible with the present methods of diabetes care after the remission or honeymoon period. It is also important to remember that if you try too hard, you may experience severe low blood sugars.

It is important to remember that children and adolescents cannot achieve as good control as adults because their insulin requirements are continuously increasing with growth. The only way you will know that your child needs more insulin is to see some high blood sugars. Even in the Diabetes Control and Complication Study, only 4% of the adults in the "intensive treatment" protocol were able to maintain their HgbA1C in the high normal range. The average HgbA1C in the intensive treatment protocol in the adults was 7.1% (non-diabetic < 6.05%) The adolescents in the intensive treatment group averaged 8.06%. 63% per of the adolescents in the intensive treatment group experienced at least one episode of seizure or unconsciousness due to a low blood sugar. 82% of the adolescents in the intensive treatment group had at least one episode of low blood sugar severe enough that they required assistance from someone else to treat the low blood sugar. This demonstrates the frustrating problem that if you try too hard for normal blood sugars, you may overshoot and experience a severe low blood sugar.

HgbA1c is a test which gives a rough measure of "average" blood sugar over the past 2 to 3 months. It tells you nothing about the range or pattern of blood sugars. I personally find that an accurate record of blood sugars evaluated several times a day tells me much more than a HgbA1C and gives much more information to help me work with my patients to obtain the best blood sugar control possible while avoiding serious lows. It takes a lot of patience and work to obtain the best blood sugar control possible, but it's worth the time and effort.

TGL

Original posting 21 Feb 97

  
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Last Updated: Tuesday April 06, 2010 15:08:54
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