Family dysfunction leads to a poor quality of life and affects hemoglobin A1c (A1C), especially in children with type 1 diabetes.¹ Choice of insulins in relation to food absorption, activity level, and stress in the family may lead to difficulties in developing a successful diabetes regimen. Lack of education and psychosocial support, especially when the person with diabetes is an adolescent, affects self-management and the cost-effectiveness of a program of care.² The effect of emotional situations pitted against the action of various insulins may have the outcome of “bouncing” blood glucose levels.³ The following case demonstrates such a situation.

Presentation

R.P. is a 13-year-old Hispanic girl with type 1 diabetes diagnosed a number of years ago. Her disease was well controlled for at least a year on a three-injection regimen of 70/30 NPH/regular insulin before breakfast, regular insulin before supper, and NPH at bedtime. During the following 2 years, her glucose control deteriorated, and she required hospital admission twice (April and July of the second year) for re-regulation (Table 1). After the second admission, she was referred to a diabetes specialist.

During her hospitalizations, R.P. was evaluated for the Somogyi or rebound effect (hypoglycemia followed by hyperglycemia due to counterregulatory hormone release), and she was also assessed for the development of insulin antibodies, which were not demonstrated. During the second hospital stay, she was placed on a continuous glucose monitor for 3 days. Her blood glucose patterns were noted (Table 2) and reported later to her family at the time of her first outpatient visit to the specialist.

The patient's medical history revealed that she was the larger of fraternal twins, weighing 7 lb, 10 oz at birth. The pregnancy had …