Tuesday, July 30, 2013

Diabetes: How to Cheat

A1C's don't lie.

I don't personally use this statement when talking to patients because I find it a little too harsh. The second you offend a patient is the second they stop listening to you, so I always choose my words carefully in the office.

But the truth, though harsh, is that A1C's really do not lie. The problem is that they do not tell you the exact truth.

We see patients every 3 months for routine diabetes visits. Many patients modify the truth of exactly what went down during those 3 months. Modification runs the spectrum of simple omission, to sugar-coating (the irony), to flat-out fabrication. Parents are sometimes the offenders, but more often than not it is the teenagers. Teenagers long for independence with everything and then quickly find complete diabetes independence to be too overwhelming. But pride/embarrassment/immaturity often prevent them from coming clean and asking for help, so instead they simply lie.

Blood sugars - how does one lie about thee? Let me count the ways!

Some simply write down false numbers into a log book and then conveniently "forget" their BG meter at home. Others have parents who check their BG meter but do not actually SEE them doing the BG check, so those kids have to get craftier. They find out that they can dilute their blood to lower the BG numbers, whether it be with a generous swab of an alcohol pad or simply mixing their blood with water.
Others don't bother to prick their fingers, so they just check blood sugar levels with anything other than blood. They use regular soda, juices, and my personal favorite -- control solution! Because who really uses control solution for it's true purpose? Who even knows what control solution's real purpose is?! The beauty of "checking your BG" with control solution is that you'll get a perfect number every time. It also makes it one of the easiest tricks in the book to sniff out, because we all know that diabetes isn't that perfect.

But I saw a teenage girl and her father for a routine diabetes appointment over a month ago and am still impressed by her method. It's completely novel and she almost - almost - got away with it.

The suspicion started when her father anxiously asked what her A1C was at the beginning of the appointment. I first asked him what their expectation was based on the numbers they were seeing - and he answered "something in the 7's." My insides seized up when I saw that the the result was 10.9%.

I am extra sensitive about how I approach potentially untruthful teenagers because of my own nightmare experiences when I was a teenager and in poor control of my diabetes. So I carefully broke the news as gently as possible and then asked her and her father their feelings about it.

The girl was silent and looked nauseated. The father's mouth hung open in utter shock. He incoherently started sputtering that he uploaded the numbers from her meter every 2 weeks for the last 3 months and how her numbers were all under 160 mg/dl. He proclaimed that he sees her prick her finger almost every time!

I waited for the girl to speak but she remained silent and I thought she might vomit on me. Red flag #1.

I looked over the BG print-out. A standard day's worth of numbers included a 133 mg/dl at breakfast, 136 mg/dL at lunch, and 131 mg/dL at dinner, with a rise all the way up to 142 mg/dl at bedtime. What kind of pattern is that? A false pattern. Red flag #2.

I went over questions about snacking without bolusing, injecting insulin after eating instead of before, use of control solution to calibrate the meter to ensure accuracy, and even raised the possibility of a meter malfunction. I tried desperately to uncover a reason for the 10.9% other than manipulation.

Uncovering nothing, I transitioned to the physical exam. The girl's skin was clammy as hell and she had a tremor. Red flag #3? Perhaps. But first I had to be sure she wasn't going hypo on me.

"You're very clammy. Why don't you test your BG now to make sure you aren't going low?" I suggested. "And we can also see if there is a problem with the meter."

She silently went to her purse and took out her meter. Her hands would have broken the Richter scale the way they were shaking, and I knew in my heart that I was about to catch her in her lie.

The 5 second count-down to the result felt like 5 years. 289 mg/dL. According to her logs, she hadn't been over 200 mg/dL in 3 months. Her father almost fell out of his seat when he realized she had been duping him all that time.

So how did she do it?

She figured out that if your OneTouch bottle of strips says Code 25 but your meter is programmed to 24, it will give you falsely low readings. She burst into tears during her confession. My brain burst at the news of it all. No one in our diabetes office had ever witnessed this trick and we were dumbfounded.

We hugged her and thanked her for being honest. We set her up with counseling services and talked about the burden of diabetes. I hope that this was a big step toward coming clean and starting a new, healthy life with diabetes for her.

And I'm really glad that we were able to see the truth through the smoke and mirrors.


** DISCLAIMER: The tricks listed in this post are not meant to help anyone lie about BG numbers, but instead to help raise awareness of what can and is being done in order to recognize these cover-ups earlier. **








37 comments:

  1. Wow! It's almost hard not to be impressed by the craftiness of it, right?

    I sure did my fair share of these sorts of things when I was a teen. It's hard not to feel judged, especially by our care teams. With that perceived pressure, it creates some pretty interesting methods of fudging the numbers.

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  2. Wow. I'm speechless. That kid's a genius. Glad you caught her, for her own sake.

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  3. Wow. That's a new one! When I lied about my BGs I never had to fake my numbers on my meter. My mom never checked my meter, just asked me what my BG was. That all changed after my A1C was 10.8. I changed and I hope this girl does too!

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  4. I'm with the above thee commenters, and probably everyone else who has read this post. WOW! I'm glad you hugged her. I wish I could too!

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  5. I've seen all of these in real life. Sometimes in teens. Many times in adults. I knew about the code trick because I've seen it happen on accident before instead of on purpose. There are several other tricks or habits, too. Thank goodness for A1C's and open, delicate, creative communication and providers who continue to work with challenges for the sake of helping people with diabetes live better emotionally and numerically.

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  6. Holy WOW. Have never heard of that, and I wonder HOW she figured it out. Amazing. And what a great approach to dealing with these issues, Shara. Can I go back in time, and have you as my endo? Seriously.

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    1. Let's go back in time and not get diabetes! If only!

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  7. What a blessing you are to your patients. It's helpful to hear as my son progresses toward his teen years. And helpful to consider how I present his care to his doctor. Do I unintentionally try to cover up things? I'll have to think on that.

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    1. I think it is human nature to minimize things that we are not proud of; I find myself doing this when I meet with my own endo.

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  8. Wow, I always wondered what would happen if one mismatched the code! lol It's so great that you don't get all judgmental with your patients about their numbers (well, I guess having Diabetes yourself helps :). There are waaay too many doctors out there who are insensitive (about D and other things), glad to hear your dedication to sensitive bedside manner!

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  9. WOW - And I agree with all of the above. Thank you for being sensitive and thank you for talking with her and setting her up with a therapist. Way back when, when people still tested urine and meters were something new and incredibly expensive 7 required whole families to spend the afternoon at the pharmacy learning how glucose meters worked, I used to be that girl.
    I was burned out and scared and I just wanted to be normal - And my Dr told me the same thing: A1Cs don't lie.
    Diabetes was and still is so hard sometimes & having a Dr like you who talked with her and not at her makes such a huge difference.
    Thanks for being awesome and thanks for hugging her!
    Kelly K~

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  10. Amazing! I had no idea of this. Poor girl. I feel so sorry for her (having been a teen w/ T1 at one time myself). I hope she reaches out to others and that sh gets the help she needs. Diabetes is a HUGE burden. Especially for a teen.

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  11. What a caring bedside manner you have, Shara. I'm going to share this with a local group for Parents of CWD and I think they'll really feel enlightened.

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    1. Thank you in advance for sharing it - and for your kind words!

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  12. I was diagnosed with T1 at age 21, so I actually felt lucky that I didn't have to deal with this disease during my teenage years. I can only imagine what I would have done, or how badly I would have treated my body (and lied about it to doctors, I'm sure.) Seriously, thank you for treating this girl like a human being, and for understanding (in ways many other doctors wouldn't.)

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    1. But there are also plenty of 20-somethings doing the same things. So who knows how you would have handled your teens -- maybe you would have been fine :)

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  13. Unless things have changed you have to miss code the hell out of it. We did experiments when the kids were little ( and kicked out do school for having diabetes and the school were incomplete snots) we did a science test to see how much difference miscoding made. What we found was not a big difference.

    We found that the average difference was about 1 point on the meter for every code number off. So a 7 vs a 20 is about a 13 point difference.

    http://diabeticdoc.blogspot.com/2013/07/diabetes-how-to-cheat.html

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    1. I don't know if it's different for different meters, but there was a HUGE difference between the two codes for her. Wouldn't have believed it unless I saw it with my own eyes. But I'll have to experiment with my own meter, now...out of curiosity :)

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    2. I don’t really follow the logic here. why even poke yourself for false data? what purpose does the calibration code even serve bc it has been speculated that code chips for the precision and accu check are just to enforce the expiration date and in the uk accu check has released a universal code

      I think more has to be made public about how the calibration codes work, and what purpose the calibration codes serve

      This sounds like a defect in the device, if there is so much room for user error than something needs to be changed with how the device functions

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  14. Wow. Just Wow. Thank you for sharing this. I'll be heading into the teenage years with my son soon and want to do it with my eyes wide open. :)

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  15. You're a really good story teller.
    I was thoroughly enthralled with this. It makes me feel pretty bad on so many levels. Most importantly, why did she feel like she had to lie? Not enough support in her life? I hope she is doing better.

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  16. I really hope she's okay and free from any additional issues as a result of this. Because I kind of want her to look back and laugh at being a rebellious teenager, and use it as a springboard to go on to greater things. It's great that you handled things the way you did, giving her support and getting her help. Hopefully, the story will have a very happy ending.

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  17. We can learn a lot from teens. Thanks for being such a caring endo, and thinking about ways to break the bad news. And thank goodness for auto-coded test strips.

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    1. Thanks, Bernard! And it's interesting that you mention auto-coded strips. Our CDE actually recommended switching to a code-free meter after we discovered that this was going on.

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  18. My daughter began faking lows in 4th grade with the wet finger trick, to get out of math class. She was dx'd at age 6. She is now entering 7th grade, and I cringe knowing that she is struggling with D and her teens, she just doesn't want to check anymore! Luckily she knows that my biggest thing is, bolus, bolus, bolus for what you eat. Hoping she continues to do so, even if she isn't checking as much as she SHOULD be. It's so hard!

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  19. This is awesome, hearing it from the Endo's point of view. I love the story of the lie, and equally as much love that you don't care about control solution!

    I never understand how to get it, when to use it, who has it.

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  20. There's a deeper underlying issue that isn't really touched upon though and that's why so MANY people feel the need to lie about their bsl numbers. I believe the messages consistently sent out to type 1 diabetics (by d orgs, DNEs, some endos, GPs the media etc) lead to false expectations. I was 30yrs old (and had d for 28.5yrs) before I realised I wasn't the only diabetic who's sugars fluctuated wildly even for no reason. If only I'd been taught that the bsl CHECK is just a call to action rather than an evaluation of your effectiveness as a human being. The mere fact that people cheat with control solution tells you that their beliefs about how they can control their diabetes are wildly unrealistic. People are trying to please, so they think this control solution BS is what they're expected to come up with. Proof to me that it's a failure of d education as much as "cheating" by the diabetics.

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  21. You're on Best of the 'Betes Blogs today, Doctah:

    http://bigfootchildhavediabetes.com/2013/08/05/best-of-the-betes-blogs-july-edition/

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  22. Wow! I never even thought about using the wrong code-never to "trick" my numbers nor what it would do if I had the wrong code-good to know! I think you deserve 100 high fives for dealing with teenagers. I don't know how I got through my teenage years but I do know that I didn't test very often so I have no idea how my endocrinologist even helped treat me. Thanks for sharing!

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  23. "An evaluation of your effectiveness as a human being." Yes, this. For some kids, the parent-child relationship is NOTHING but this. Failure is not an option. I got this message very early from two very ambitious parents, and only realized lately (almost 50 years later) how fluently I learned to lie. I might add that my parents also lied about my diabetes - my mother watched me fill in my "test results" in the waiting room. My Dad insisted (with no evidence whatsoever) that I had a "low renal threshold" - to explain all those +2 urine tests. They still cannot face the truth that my diabetes was thoroughly out of control all through my childhood and teens (I broached the matter recently and got short shrift - what do I know?). My mother used to take me to my appointments and complain bitterly all the way that it was her responsibility. Once, at the age of 17, I hauled my little scale out from the back of the cupboard to check if I was still estimating my carbs properly, and my mother exploded with fury: "You don't need that! Put it away now." I could go on. My mother was a school principal. My father an engineer.

    My mother betrayed me more times than I count in terms of lack of support, undermining treatment, etc, etc.

    There was no counselling in those days and since my mother was always sitting next to me in the consultation, what could I say? Only once the hospital caught her out, the ward sister realized what she was doing, and kept me in for an extra week. Blessed relief. I LOVED my annual check-ups when I was a kid. Three days away from my mother and surrounded by a bunch of nurses who apparently cared about me. To this day I find people weird when they say they hate hospitals. But I like nurses more than doctors because nurses don't believe the BS.

    When PWDs react strongly against mild criticism from doctors, I think it's because we are reliving those early years, "We thought we would be proud of our kids but now maybe not so. We will love you, if you are good, but if you're a bloody nuisance......".

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  24. This comment has been removed by a blog administrator.

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  27. Okay. I feel really guilty now, being 18 and this struggle. But I swear. Its not easy. And blood glucose is reaaaaaaaaaally unpredictable at so many times. Its hard at this age trying to eat less and keep those sugars without getting too low or too high. You know, fit in with all the other girls who are pale and thin. And I think most of us fear low blood sugars more than we fear high blood sugars. I sit in class sometimes and have panic attacks where I think I have a low blood sugar, but it ends up being fine. I think we've all been there, and done that. Here's to being honest!

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    1. I hear ya. Good luck with the honesty thing -- it is tough, but worth it in the end!

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