So as background you might want to read the posts A1c Ugh! and A1c Work in Progress in which we had a rather disappointing endo visit in the spring (the “Ugh” part) and listened to suggestions that the nurse practitioner gave to try to see some improvement (the “Work in Progress” part).
After looking for postprandial spikes (spikes after meals because blood sugar spikes before the insulin peaks) and looking for overnight highs, we decided to make a few adjustments and hope for the best.
Of course the things we did could not have been done if we were still on MDI.
To try to stop postprandial spikes, we began giving the correction and at least a partial bolus before she began eating. Usually this bolus was 20 to 30 carbs (or more) depending on what the meal was going to be. Then we would bolus for more carbs as she ate or when it looked like she would eat everything we had counted/weighed/measured out for her.
Ideally you pre-bolus 15 minutes before a meal and you bolus for the entire meal. This just doesn’t happen for us and may not happen for a while. How much she eats is still extremely variable. And I absolutely do not want to create a scenario where we force feed her (can you say SuperNanny?). People with diabetes have enough food issues. Girls at some point in the tween/teen years develop food and body issues. I just don’t want to go there. (Read more about diabulimia). So for now, she gets insulin for the amount she actually wants to eat and she’s allowed to eat as much or as little as she wants (obviously within reason).
Overnight Basal Rates
When the CDE said to increase her basal rate from 10:00 pm to 2:00 am I did question it a little. I knew we needed to bring her closer to range during those hours, but I thought that that increase would make her be low by morning since she is typically in range at breakfast. Didn’t we need to decrease her early morning insulin?
Well it turns out we didn’t. After making the adjustment she wasn’t as high overnight and her morning numbers were still pretty good.
And the Envelope, Please
Since I was so disappointed at the last appointment I didn’t want to set myself up for a similar sense of failure. These changes had to have helped at least a little, right?
The doctor asked, “Do you want to know what her A1c is?”
I replied, “Um, (pause), yes.”
“It came down 0.9!”
To say I was overjoyed is an understatement. Even though we parents shouldn’t feel judged by that number, let’s face it we do. We all think of it as a report card. We think of it as a measure of success or failure.
Even though some of it is beyond our control. Even though outside factors such as illness and stress can make it higher than we expect. Even though diabetes decides it can change the rules at any given minute and throw everything we thought we knew out the window.
Are We There Yet?
So are we where we need to be? Yes and no. We’ve been struggling for two years to get her A1c below 8.0, which is appropriate for her age. The doctor told us at this visit that she wants to see it between 7.0 and 8.0. This triumph brought us to 8.0, so there is still room for improvement.
Our next order of business is to bring down her dinner numbers which seem to have crept up a little. We are going to start checking her blood sugar before her afternoon snack to see if there is a pattern. Perhaps if her afternoon BG is above a certain number then it is making her dinner number too high. If we can see a pattern, then we may start giving a partial bolus at snack time.
We also discussed the upcoming school year because her schedule will be completely different.
We’re getting there!
Please read the disclaimer. Of course none of this constitutes medical advice and you should consult your physician or CDE if you have questions.