Making Sense of Glucose During Puberty

Balancing both requires delicate hand.

Theresa Garnero By Theresa Garnero, APRN, BC-ADM, MSN, CDE

Q. My 12-year-old daughter is going through some erratic glucose readings – very high and very low. She might go to bed with a reading of 86 and wake up at 300. She always likes to have a glass of milk before bedtime but is this a good thing to do? When she is high she is afraid of eating and that is not a good thing. She is on an insulin pump and going through the early stages of puberty. Is all of this making things worse?

A. Undoubtedly, puberty adds another layer of complexity to diabetes management. During puberty, growth hormones kick into high gear and begin the process of sexual maturity necessary to transform the body into that of an adult. The associated increase in adrenocortical and gonadal hormones usually cause an increase in insulin resistance and thus, a worsening of metabolic control. Typically, insulin requirements increase and frequently change during puberty. Basal pump rates often need ongoing tweaking during this precious time.

Despite higher doses of insulin, other counterregulatory hormones contribute to fluctuating glucose values, and may be at play with your daughter's situation. For adolescents in a state of hypoglycemia (defined as less than 70 mg/dL, and for kids, lows may be considered less than 100), the fight or flight hormone—epinephrine—reacts to low glucose values earlier and with more force. Epinephrine signals the liver to release its glucose reserves. If you add that to a state of insulin resistance, it's no wonder adolescent glucose levels go all over the place.

In terms of your daughter liking a glass of milk before bed, give her the freedom to enjoy it! Many factors can raise her glucose levels in the morning (see related article on Dawn vs. Somogyi effect).

Considerations:

1. Is it time for some fine-tuning? Your insightful comment that she is afraid to eat when her glucose is high is an opportunity for education. If I can generalize here, kids don't want to hear it from their parents. Get her to see her team of certified diabetes educators. She can learn more about the dangers of not eating (ketones), and how to correct the high and cover her meal by using her bolus wizard function in her insulin pump. The dietitian can take a closer look at her food choices. Did she have pizza the night before her 300? Pizza is the gift that keeps giving and may take 8 hours to digest (nothing her pump cannot handle). How tall is that glass of milk? Do her basal rates need adjusting? The team can work with her doctor to fine-tune her program.
 
2. Has she used continuous glucose monitoring (CGM)? CGM technology allows for minute-to-minute tracking and trending of glucose values. CGMs have three components: the sensor, transmitter, and the receiver. The sensor measures glucose concentrations from under the skin surface via a small plastic tube that stays taped in position for several days. The quarter-sized sensor is typically taped to the arm or abdomen, and sends electronic glucose values via a transmitter to the pager-sized receiver, or in some cases, an insulin pump. The MiniMed Paradigm REAL-Time System is a combined insulin pump and CGM. It has been approved for use for children over the age of 7. The DEXCOM is another popular device, but it has not been tested in children, adolescents, pregnant women, or persons on dialysis. The Abbott Navigator is approved for those 18 and older, although if the provider writes a prescription for it (considered "off label"), the order, training, and customer support will be the same.

Unlike a glucose monitor that gives you a point in time glucose reading, CGM gives a steady stream of glucose levels and may help predict future blood glucose trends, and alarms when the glucose is too low or too high. Over a 3-day period, some devices can store nearly 900 glucose readings. For your daughter, this could help explain the details and patterns of nighttime information. The CGM can help explain why she went to bed with an 86 and woke up with a 300.

3. What about a diabetes camp? It is helpful to have fun and interact with peers in the same boat. Diabetes is frustrating and scary. Many people voice understandable fears over going too high or too low because of how they feel in those extremes, or the horrible complications that can happen with uncontrolled diabetes. I have heard many approaches. Some people avoid going too low (because they feel terrible or had a negative experience) and become comfortable with high readings. Other folks stay too low because of the threat of dangerous highs. Camps are a way to connect with others and learn what is working in their lives and what might be useful to bring home.

Many factors can interfere with diabetes in an adolescent, the hormones of which have been referred to as "anti-insulin". Being pancreas deficient while blossoming into adulthood with other fun glands is a parental recipe for hard work. Your daughter is lucky to have your caring concern.

Read Theresa's bio here.

Read more of Theresa Garnero's columns.

NOTE: The information is not intended to be a replacement or substitute for consultation with a qualified medical professional or for professional medical advice related to diabetes or another medical condition. Please contact your physician or medical professional with any questions and concerns about your medical condition.

Last Modified Date: July 15, 2013

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by Carey Potash
There is a stark difference between my "see ya later" to my camper and other parents' to theirs. "OK, have fun!" one mom told her son. "OK, don't pass out," I say to mine. The mom laughed and said to her son, "I don't want to hear from you until 4:30 pm this time!" Apparently there was a big ordeal with skates that didn't fit the prior day which caused him to miss some of the camp. ...