A1C Work In Progress

by Leighann on July 22, 2010

Last week I told you about the disappointing endo appointment we had in the spring (read A1c Ugh!). We had been pumping for a few months and our BG average was looking pretty good. I was perplexed that her A1c came back with an equivalent average BG of 200!

As we were questioned about our practices, we were pretty much by the book as far as counting, weighing, measuring.

She had to have been going high at times that we weren’t seeing in our logbook.

When it came down to it, there were two areas that we decided to look at: postprandial spikes and overnight basal testing.

Let me tell you we weren’t looking forward to the extra BG checks, logging, and most of all lack of sleep!

I really have to thank my Twitter friends for advice, encouragement, and talking me through the process. I even had offers of borrowing CGM’s.

Postprandial Spikes

Post what, you say? Exactly! Postprandial hyperglycemia or spike is the peak in blood sugar after a meal is consumed.

Several people pointed me toward Gary Scheiner‘s article “Strike the Spike.” This article is a must read. (Gary Scheiner is the author of Think Like a Pancreas, which I recently purchased and read.)

A week of checking BG’s one hour and two hours after her meals showed us that she was definitely spiking, but coming back down within range by the next meal (which is why we never noticed the spike). Because she is young and because how much she eats is so variable, we had been bolusing after her meals until this point. This was especially the case when she was on MDI. When she began pumping we started correcting before the meal and bolusing after. But this was not enough to prevent the spikes because that insulin was working on her blood sugar and not the food. The food was peaking before her insulin was peaking.

From Strike the Spike: “In most cases, blood glucose levels peak about an hour after finishing a meal or snack. Ideally, the blood glucose level at the peak should be below 180 mg/dl, or less than 80 mg/dl higher than it was before the meal. With children, after-meal peaks can be a bit more liberal. Teenagers should try to keep peaks below 200 mg/dl, school-age children below 225 mg/dl, and pre-schoolers and toddlers below 250 mg/dl.”

After seeing the spikes we changed our M.O. We began correcting and giving a partial bolus (for 20-30 grams carbs) before the meal. And if she eats more, we give additional boluses. This is made very easy using the pump (and even more so since we started using the OmniPod’s bolus calculator!). This obviously isn’t practical for kids on MDI because you don’t want to give multiple injections at each meal.

Also note that if she is low when we check her blood sugar before a meal, we treat the low appropriately and have her begin eating, waiting 15 minutes to check to make sure she’s back in range before giving the mealtime bolus.

Overnight Basal Testing

She was waking up in range most mornings so we didn’t think she was staying high for too long overnight.

Though using the iPro CGM would have been the easiest way to check her BG’s overnight, it wasn’t practical for us. It would have involved another trip to the endo’s office to the tune of 400 miles traveled and 8 hours in the car.

So we decided to do three nights of overnight testing. Note that these do not need to be consecutive nights. In fact we skipped a night because my husband was exhausted. He does most of the overnight checks because I don’t fall back asleep easily.

Bedtime12:00 AM2:00 AM4:00 AM6:00 AMBreakfast
Friday19436429323115990
Saturday91339299226187126
Monday187304349218167110

As you can see she was in range before bed most nights (100 to 200) and back in range before breakfast in the morning. But she was above 200 and even 300 for part of the night.

Per our CDE’s advice, we increased her basal rate from 0.25 to 0.30 from 10:00 pm until 2:00 am. I was afraid that this would make her go low by breakfast but it didn’t.

Proof is in the Sugar-Free Pudding?

So did it work? You’ll have to come back next week to see how these two changes (giving a partial pre-meal bolus and a small increase in overnight basal rates) affected her A1c.

Please read the disclaimer. Of course none of this constitutes medical advice and you should consult your physician or CDE if you have questions.

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{ 4 comments… read them below or add one }

1 Penny July 22, 2010 at 6:31 am

Great article by Gary. We work with him and he is wonderful in person – so very knowledgeable and keen on kiddos and their T1 management. He has helped us tremendously.
Glad to see that the overnight testing revealed some highs. I think there is nothing like basal testing to reveal the basal rates. Seems like you made some great changes and gained some great knowledge. Now I have to wait until next week to see the results? :0)

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2 Mike July 22, 2010 at 6:37 am

Wishing you the best of luck. It’s hard enough looking after yourself if you have diabetes and it is hard enough looking after kids.

Hope the nights go according to plan!! {fingers crossed} 【ツ】

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3 Heather July 22, 2010 at 7:17 am

Thank you for this post!!! This is exactly what we have been dealing with! We didn’t notice it until my daughter started on a CGM. Our daughter is also doing the exact same thing at night. We however have had to increase her basal rate a couple times. It is still too high at night so I have a feeling we will be increasing again soon.

I will also be getting that book so I can read more about it.

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4 KristinD July 22, 2010 at 7:39 am

when my daughter was on shots I always wondered what was going on inbetween testing..her A1C was around 8..since being on the pump it’s been easier to see what is going on..we did test at night for about 6 months, but stopped from sheer exhaustion..and were told we didn’t have to test at night..but from time to time we need to, just to see what is up..haven’t done the post meal spike thing..although we were told that it works best if the insulin bolus is given about 20 minutes before a meal..doesn’t always work for us, but at least my daughter eats all her meals..will be checking out the dual wave feature on our pump next..gives some insulin at the beginning, then some later.

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