New foster mom to 9yo with Type 1--lower A1C?

Type 1 and LADA
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Hello! I’m new here and looking for advice on transitioning a child to a healthier diet and lowering her A1C.

We are long-time foster parents but are new to parenting a child with diabetes. Our 9 year old foster daughter was placed with us about 6 weeks ago, and she has Type 1 Diabetes (diagnosed 8/16). Before being removed from her home, her diabetes management was very poor. She apparently ate a lot of fast food and high carb/sugary snacks, her mom counted carbs inconsistently, and they apparently missed doses of insulin frequently. She was hospitalized twice in the last six months for DKA, and her A1C at her latest hospitalization (just before she was placed with us) was 12.1%.

We are working very hard to feed her a healthy diet, count carbs, test her BG frequently, and help her to dose her insulin properly. She’s very compliant and responsible about much of the process. At her last endo appointment (when she had been with us for 3 weeks), her endo was thrilled to see that her average BG over those three weeks was 127, with only one spike over 200 and only a couple of lows under 70.

Our big struggle now that the honeymoon period of a new placement is over is that she’s starting to become more resistant to choosing snacks that are low carb or to taking insulin to cover higher carb snacks. For example, she constantly wants apples for snacks, but doesn’t want me to cut the apple and give her an amount that is under her threshold (her ratio is 1:12), nor does she want to take insulin to cover that 20 carb apple. We give her the choice between the two, and encourage her to eat her apple with PB (as an example) so that she’s fuller and doesn’t want another apple an hour later and we go through the same struggle again. We don’t budge on this, and are kind about it and give her choices of things she likes, but her response is usually, “Well, Mommy let me have an apple without insulin, and I was fine.” Except, she obviously wasn’t fine…

She does pretty well at meals, especially because there are 4 other kids in the house (including her bio sister) who are all eating the same healthy meal. And she’s fine with dosing appropriately for meals, most of the time.

Additionally, we are struggling because she has twice weekly supervised visits with her mom, and they just got approval to leave the visitation facility (with a supervisor) during visits. After her visit on Thursday, she came home with a 32 oz soda in hand, and had eaten Panda Express (chow mein, teriyaki chicken, and orange chicken with white rice), as well as frozen yogurt. Her BG was over 250 when she got home, and then we struggled with lows all through the night (my husband and I took turns checking her BG in her sleep and giving her juice and glucose tabs throughout the night). Her BG has been like a roller coaster since that evening, and she still seems to be dealing with the effects of that visit. Luckily, her social worker agreed to tell mom no more eating out in future visits, once I told him what was going on.

Any ideas from those of you who have been managing your or your child’s diabetes for longer and have more experience here? Also, any advice on lowering her A1C? We go back to the endo next week, and I am hoping to spend more time with the diabetes educator and dietician at that appointment as well. If you’ve read this far and have any advice for me, I greatly appreciate it!

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Wow. First off, WELCOME TO TUD! This has been a powerful source of information and support for many people, myself included, so I hope you stick around. You sound exceedingly articulate and well organized, and for someone who is dealing with the arcane and unpredictable world of T1 D for the first time—lows, highs, carb-counting and all—you sound like you’ve educated yourself amazingly well. I’m seriously impressed!

It sounds like the biggest problems are emotional ones, partly on the bio mom’s side and partly on the girl’s side. Clearly the mom doesn’t “get it” nearly as well as you do. Making the restriction about taking her out to dinner stick would help, both in terms of keeping her from skyrocketing after her visits (Chinese is the worst, even for those of us who know what we’re doing, and clearly that is one clueless mom–does she really have no idea how much carb she was pumping into her kid with that stuff???), and in terms of not reinforcing the pre-adolescent “but my MOM lets me!” stuff. That sounds like a trickier problem to resolve than the T1 itself, which you seem to have a remarkably good handle on. Just keeping her more in range may have a side benefit in the fact that big BG swings can screw with a person’s emotional responses.

One question though: you didn’t actually say what treatment regimen the girl is on. Reading between the lines, I’m guessing basal-bolus MDI, not a pump, but it’s just a guess. Always good to know these details so we can be of more help.

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I agree with DrBB, and am also impressed with how well you are managing and coming up to speed.

One suggestion might be to check with Dr about getting a Freestyle Libre continuous glucose monitor. There is a Pro version, where only the Dr gets to see the data, and can send info, or review at next visit. The personal version was recently approved in the US, although I’m not sure if available. But it would help give more visibility to how her BG responds to food, insulin, and activity.

At 9 yo, probably not much impact from monthly hormones changes, but that can have a big impact for girls/women. (and some endos don’t think it is significant). But emotional stress, hard times, etc can also make it very challenging, and need to understand there is more than just food/carbs and insulin that impact BGs.

As for the situation with the apple, you can check with the endo about pens with 1/2 unit dosing to give her more choices. Adding PB is great, to slow down the BG rise, and I love apples with PB !!

I was diagnosed at age 5, 50+ years ago when things were much different. I had high BGs most of the time until 1980s with improved insulins and BG testing. But took another 10 years to get A1Cs in range, with an insulin pump. (insulin pens were not available yet, so most doctors thought it best to do morning, dinnertime and bedtime injections).
I felt fine most of the time, so it’s hard for a child to understand that keeping BG close to normal range now is better for their long term heath. I have several diabetes complications, including some vision loss. I wish I had listened more to my doctors back then.

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As mom to a 14 year old T1, I really applaud the way you have taken on this challenge. I find listening to my daughter is the best way round food disputes. The more loved and safe and heard she feels, the easier she finds it to take care of herself and make good decisions. There are so many complicated issues you are dealing with - just wanted to send my best wishes to you and the family.

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I don’t have any specific advice for the OP. So apologies.

I just want to say, that I see how easy it is for a young diabetic person to get seriously messed up when they are told, or maybe a little later figure out on their own, how bad it is for them to eat a whole apple.

It shouldn’t be surprising at all that diabulemia and other eating order variants are so common.

I myself skirt around this issue every day. No, I don’t have diabulemia, but this constant thinking - in my case it’s not being told - does to me. I think “don’t eat that apple it’ll mess up your bg”. But that’s just bonkers and seriously messes me up to the point that I make other even less healthy food choices, because the apple seemed just as bad and evil as the other food choices.

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Did your daughter get any diabetes education classes? You could offer to attend one with her so “she can help YOU understand” all the ins and outs of managing T1D. You could both learn at the same time. From my childhood experience, missed bolus, skipped meals, and sneaking crap on the side were daily occurrences. Best of Luck…every kid ever diagnosed wIth T1D does stuff every single day that would make their parents feel faint then angry if they knew.

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Hi Type1Foster,

It does sound like you’re doing a fantastic job - achieving an average of 127 in a child isn’t easy!

With regard to the issue of your daughter resisting lower carb food choices and not wanting to take extra insulin to cover extra carbs: I would suggest encouraging the endo to congratulate your daughter directly for her improved blood sugars. If she feels ownership of the results, she may be more willing to make small sacrifices for the process.

When I was a kid, a certain amount of congratulations from doctors and parents eventually caused me to view blood sugar management as a valuable skill and even part of my identity. When I became proud of what a good job I was doing and felt a sense of agency more than imposition of rules, I was also more willing to tell other people that I couldn’t eat much rice or needed to drink diet soda.

I was a bit older than your daughter when I reached this point, but I think that it could have started sooner if I had been given a little more ownership of dosing and food decisions. (Even a child who can’t do all the math can read from a sliding scale or look up carb values.)

Even as an adult, my experience is that it’s difficult to continuously regulate my behavior based on fear of complications or adherence to “rules.” I do best when I view blood sugar management as a challenge or a game with the goal of minimizing or eliminating blood sugars outside of a certain range.

The success of this strategy may depend a lot on your daughter’s personality. I’ve read that many people with diabetes consider it unfair or bad for morale to “judge” numbers as “good” or “bad.” On the other hand, focusing on an ability to achieve results can provide a greater sense of agency and optimism than a focus on conformity to limitations that most other people don’t have. (For morale’s sake, though, it is important to acknowledge that challenges such as hormones, stress, and illness can interfere with control and that it can be an achievement just to reduce the effects of these.)

Finally, I’d be interested if you’re able to tell us a little bit about what strategies work for you. I’m not at the parenting stage of my life yet, but I’ve sometimes considered whether my experience with diabetes would someday make me a good foster/adoptive parent to a diabetic child. One of my concerns is that the significant role of diabetes in my life combined with a child’s resentment of his/her own diabetes might stress such a relationship.

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I just want to clarify that I’m definitely not telling her she can’t have a whole apple. That’s totally fine–but her threshold is 12 carbs, so she either needs to eat under 12 carbs of the apple or take insulin for the larger amount of apple. She just wants to eat the whole thing with no insulin, which she cannot do. I definitely don’t want her to grow up with disordered eating. We are trying really hard to walk the line of lots of choices for her, but healthy diabetes management.

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Mary, I like the framing of numbers as not good or bad, but as a way to achieve results. Thanks. That’s a good way for me to be thinking of it. I could see a parent who has Type 1 being a great foster parent to a kid who has similar medical needs. You’d already be an expert! If you’re interested in potentially fostering, I’d be happy to chat about that more. My experience has always been that the kids are much easier to handle than the system, if that makes sense!

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We’ve done some one-on-one education at the hospital before she came home with us (we had to be trained before she could leave the hospital, so we had almost a week of training like that. It was SOOOOOOO helpful. I’ll ask her endo about some on-going classes at the next appointment–maybe a nutrition class would be a good thing for both of us, since she’s so new to managing diabetes with GOOD nutrition, rather than fast food and junk all the time. I appreciate the reminder that all kids with T1D deal with this stuff–we are so new to it that it is hard to know what is normal and what is because of her rough background.

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I asked her doctor about a CGM at the last visit, and they’re going to try to get one approved by Medi-Cal (she had one before, but mom lost it). I’ll ask about the Freestyle Libre. I know she liked having the CGM before, and I think it would be super helpful for all of us!

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She uses pens (Humalog and Tresiba)–no CGM or pump at this point. Thanks!

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It’s almost a given that pump & CGM go together but of course that isn’t a necessity. A lot of us would give up the pump before the CGM if it came to a choice. I don’t know that much about the Freestyle Libre, but one advantage of the Dexcom system for parents is that the data can be shared to your own smartphone as well as that of the patient. So you idon’thave to be there to know what’s going on.

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I’m saying this with care and concern for you and your daughter…don’t nag or harp about the evils of junk food. When diagnosed with T1D, crazy cravings and wanting to go back to eating whatever whenever are very difficult for T1s to come to terms with. You don’t want to become the nasty nag about what she eats. For me, my poor worried Mom, became the Wicked Witch of the West who criticized all my food and self care choices. Best Wishes for success.

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I very much agree. I definitely don’t want to be a bad guy to her or control what she eats in a way that is damaging. One thing that is helpful in that department is that I have lots of experience as a foster parent with doing things differently from a child’s bio parents while being careful not to badmouth or shame their parents (because the goal is for the kids to go back to their parents—they need a good relationship!). For her, junk food is intrinsically linked to mom. I can’t badmouth junk without badmouthing her mom, you know? My main goal is for her to know how to manage her own care and know what healthy foods she likes because she won’t always be with me (much sooner than if she were my biological or adopted child).

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One thing you might want to see if you can do to help her with her diabetes is see if you can make a rule that she has to call you before she eats when she is with her bio family. If she is going to eat junk food and sodas then at least you can help her take insulin for those things over the phone? Talk with your caseworker and see if that is something that you all can set up. Before she eats she makes a quick call- you all figure out carbs over the phone and she doses. Maybe that will also help her bio family see that diabetes is a part of her life and she must take insulin before she eats or drinks? Also, it might give her a little freedom and responsibility?

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I was diagnosed when I was 18 months old and from what my mom says at first I was compliant and even learned how to give myself my own injections (I don’t remember this), but when I was about 5 I think I realized that someone was always gong to be sticking me and I started refusing to do any of my own diabetes care. Somebody else had to give all of my shots and that didn’t stop until I was about 8 when I attended a diabetes camp. For the first time in my life I was around other kids with diabetes and even though I knew most of the information the classes and counselors were giving me I finally started to actually use that knowledge. Learning I wasn’t alone and having other kids to compare and commiserate with made a big difference to me, I used to consider it the most fun time of my year.

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Is there any way to include her biomother in the education process with you and her? You are sure that she will eventually get her child back home and she needs to understand how to handle her diabetes. The child will also know that her mother cares… we hope.

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@Type1Foster, you are doing just fine.

I have a 13-year old who was diagnosed at 11. The rule is — he can eat anything he wants, exactly like a normal kid. But he has to dose for it (which means, unfortunately, typically waiting 45 mins for a prebolus).

So don’t worry, But I would definitely mention the mother’s actions to the social worker. She is damaging her daughter in more ways than one.

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Regarding the apple, I do enjoy eating the whole thing myself. I like that crunch of the first bite. So I buy little apples for me - my husband 6’6" gets the big ones. If there is a way to maybe apply for a scholarship to diabetes camp, she could be with others “just like her” and gain a strong sense of support and membership in a pretty awesome tribe. Also check out celebrities with type 1. There are performing artists, actors, athletes the British Prime Minister and a US Supreme Court justice who are achieving great things. They can prove that have T1 isn’t the end of dreams. And some Endo practices/hospitals have mentor programs where kids with T1 are team up with trained older kids - kinda like a big D brother or sister.

By the way, you are doing a wonderful job. A lesser person wouldn’t even consider taking on a T1 child.

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