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. **