Holy @#%&*$% A1C

From the American Diabetes Association's explantation of Estimated Average Glucose (eAG) - check it out!

August is rapidly approaching which can only mean two things around here. The seven year anniversary of Arden's diagnosis, and the sixth anniversary of this blog are both coming soon.

Seven years in dog years is what, 49? Well in A1C years, it's 28. Arden has had twenty-eight A1c tests since she was diagnosed and most of them didn't go too well. As I've shared in the past, Arden's A1c began it's journey above nine and drifted lower over the years as I learned how to better manage diabetes. It wasn't until recently that we've made real strides in decreasing that elusive number.

I spoke in the past about the things that I attribute to helping Arden's A1c to fall. Things like finding the correct insulin for Arden, and technology like her DexCom G4 and OmniPod insulin pump. I recently wrote about Arden's decision to stop eating Fruit Loops and I think that may have put us over the top in this battle against "the number".

One year ago Arden's A1c was 8.1. Nine months ago we made real progress, 7.5 and back in January it was 7.4. I loved that 7.4 because it showed that the reduction wasn't a fluke, we were on to something! Today when we went to her Endo appointment I was certain that we would see another incremental reduction, and I was secretly hoping for 7.1. As I watched the timer count down on the testing equipment, my heart sped up just a bit. The last 10 seconds ticked away slowly, as I hoped to see that 7.1.

I'm not sure how I kept the words in my head when I saw the number, but somehow I didn't say, "Holy F*ck" outloud when the machine displayed Arden's latest A1C.

It was 6.5.

Six point five.

Six and a half.

Arden's A1c had dropped .09 in five months. I must of read that wrong I thought, so I stood up and looked closer and there it was just as clear as day, 6.5. I turned to Arden and said, "We did it Arden!". Then, without missing a beat, Arden warned the nurse that I was going to cry - but I never did. I wanted to cry, I wanted to scream into the air but I just sat back down, smiled, and told the nurse how Arden decided all on her own after our last visit to stop eating cereal for breakfast. "This was all her", I told the phlebotomist, "Arden asked after her last A1C what she could do to help it to go lower and I told her... she did the rest".

Back in February when Arden's A1C was 7.5 I listed a few simple reason that I thought helped the most to decrease her average daily blood glucose. I'm going to post them again here and then add two new ones.

Support - Love and support from family, friends and teachers is huge.

Insulin Pump - Being able to give insulin quickly and unobtrusively for meals, snacks and high BGs.

CGM - Arden's DexCom is a window to the past, present and future of her BGs and I couldn't make the pinpoint adjustments that helped us get to this new level without it. It's sad to me each day that the FDA doesn't approve it's use for young people.

Over night monitoring - Arden is sleeping almost half of each day, if you can control the night then a few bumps during the day don't hit the A1c average so hard.

Apidra - Arden's BGs are move stable on Apidra then they ever were with the other insulin she was using in the past. Make sure you are using the insulin that works best for you... not just the one some sales person gave your doc.

D.O.C. - You all give me strength to do these things when I otherwise feel like I can't. It's knowing that one of you is awake, sad, crying, happy or running around out of your mind like me that makes me realize that I'm doing okay.

new

Aggressively dealing with BG spikes - You know the ones, after a site change or miscalculated meal. In the past I preferred smaller boluses in the attempt to avoid a low but now I lean on the CGM and smack a high number in the face, preferring to catch it with carbs if I've administered too much insulin. The other way always left me bolusing and rebolusing for hours on end. The only thing I was accomplishing was taking five hours to guide Arden's BG back into place. Now, insulin, watch, catch the fall - done.

The new way that we manage BGs during the school day - Arden has four more days of school left this year and she has NEVER been to the nurse for a diabetes related reason, never. Arden and I text and speak by cell phone to manage her moment to moment type I needs. This new plan is one of the keys to her A1C reduction. In the past, I would make insulin and carb decisions only when Arden was with the nurse. This schedule left large gaps of time when high BGs, miscalculated carbs and the other diabetes anomalies would be left unaddressed. Now, Arden can text me if her BG is slightly elevated after lunch and we make small adjustments as we would if she was home with me. Lows are handle in kind, no more big carb intakes because I won't be in contact with Arden for many hours. We bump borderline lows and readdress if that bump didn't do the trick. No longer is the school day an eight hour crap shoot, Arden's diabetes is being dealt with immediately when in acts up. I plan on speaking more about this at length in the coming months.

This seems like a good time to remind you that I am not a doctor and that there is a clear message at the bottom of this page that insists that you never take anything that I say as medical advice because I do not mean these words to be such. I would however suggest talking about these easy adjustments with your doctor...

Update on Tuesday, June 11, 2013 at 2:59PM by Scott Benner

I originally posted an image with this piece that had some bad information on it. Thank you to Sara (@saraknic on Twitter) for pointing it out and leading me to the new graphic from The American Diabetes Association. Please check out their page about Estimated Average Glucose (eAG) and how it relates to A1C. Very cool stuff!

I'll have Two Eggs Poached, Toast and a Scoop of Maturity

How do habits start? Sometimes it's difficult to remember how you got where you are and with each passing day it becomes harder to imagine a life that is different. That sentiment can be applied to so many aspects of of our days, but today it will help me tell a story about breakfast.

Arden was two when she was diagnosed, that was a long time ago. Those beginning years were well before I knew about the glycemic index, before I understood that all carbs weren't created equally. Today I know better but that knowledge still wasn't helping me to break Arden's cereal habit. That girl enjoys a Fruit Loop.

It's strange to some degree because Arden isn't a junk eater, doesn't like candy and other sweets. She's the kid that goes trick-or-treating to dress up and run around, not for the candy. Yet every morning she has one cup of Fruit Loops with fat free milk - and her BG's take a hit because of that choice. It's a choice that I sanctioned many years ago, and one that I regret now but all of the talking in the world wasn't getting Arden any closer to eating something different. At some point I gave up on trying to get her to change and set out to try and defeat her spikes as best as I could. I did that with a combination of pre-bolusing, temp basals and shear will. I learned how to defend against spikes and create boluses that didn't cause a low, all because of my battle with Toucan Sam. I guess that I should be grateful for that lesson, and I am. None of that however could make me feel any less like a drug dealer when I handed Arden her cereal in the morning.

But then something wonderful happened...

Arden got tired of the spikes. She began to pay attention to her health in a way that I found astonishing, I did not expect her to make this leap so soon and it all started at her Endo appointment. Arden's A1c experienced a significant decrease about six months ago. Her NP made such a great celebration of her achievement and gave Arden a huge hug as she told her how happy she was for her. As much as I believe that her encouragement got the ball rolling for us... it wasn't until Arden's next Endo appointment that she decided to take her fate into her own hands. Three month later Arden's A1c decreased again by .01, an accomplishment for sure, but it apparently didn't hold a candle to the previous decrease, at least in Arden's mind. 

As we were driving home Arden asked me how she could get her A1c to go even lower, I could see that she was feeling competitive with that number and also beginning to think about her health in a different, perhaps more mature way. I didn't want to make too big of a deal about our conversation and so I offered a few small suggestions. We spoke about being a bit more patient before eating an unscheduled snack to give a bolus more time to work, (we pre-bolus meals but small unexpected snacks not so much). I suggested that we could exchange a grain for another vegetable at dinner and then I slipped in that making different breakfast choices would definitely help. The conversation turned to her CGM graph and I explained about how the prolonged spikes from the cereal raised her A1c. It all may sound like too much as I explain it here, but this was an easy and quick conversation in our car, nothing heavy.

One week later Arden approached me about finding new options for breakfast and she hasn't had a bowl of Fruit Loops since. She is growing up, understanding more, and I am proud to be able to say that I can see her wanting good things for herself.

I don't remember thinking even once about my health when I was eight.

Why does basketball make Arden's BG rise?

Arden brings the ball down the court, passes and looks for a rebound.

Last week during Arden's quarterly Endo appointment I brought up an issue that I had identified but couldn't figure out. I explained to our nurse practitioner that when Arden exercises her BG falls. Riding a bike, running around, recess at school, really all of the her physical activities decrease her BG... except sports.

I, of course, am aware that activity can cause a decline in BG but our issue didn't seem to be following that "rule". It took me a while to be able to see past the expectation that physical exertion would decrease Arden's blood glucose level. Inexplicably, I was having trouble with her BGs actually going up during basketball games and practices this winter. When I finally thought back, I realized that I saw similar BG trends last summer during softball.

Our NP asked about Arden's level of competitiveness, as she spoke I began to understand what she was getting at...

Arden is a very competitive little girl, when it counts. That is to say that if she goes out back with her brother to shoot baskets her BG falls from the activity as you may expect but when she is in a game, when there is a score being kept and winners and losers are recorded - Arden's BGs go up.

I explained to our NP that Arden entered her last basketball game with a BG of 125 and that by the end of the game, just one hour later with no food or carbs in her system, her BG was 220 and climbing. I was bolusing during the game, which was nerve wracking when you consider that the expectation is that there will be a fall from the activity.

The NP described to me that this is a phenomenon that they generally see with boys, then she turned to Arden and said, "so, you like to win huh?". Apparently it's common for very competitive people to access their flight or flight response (also known as 'the stress response') during a sporting competition. Their desire to win is so strong that they feel the game on a different level. Adrenaline is released and their body prepare to battle as if they are fighting for their lives.

Next week when we arrived at the gym. I am going bolus as if Arden was about to consume a 15 carb juice box (the ones we use for low BGs). I'm confident that the insulin begins to act it will find a rising BG to tussle with, if I'm wrong... we'll just drink the juice. I'll report back and let you know what happens... Never a dull moment with type I diabetes.

The lowest A1c ever

Yesterday was Arden's quarterly endo appointment and it could not have gone any better! At her last appointment her A1c was in range but a bit higher then usual, though still at the high end of acceptable for her age. Arden's A1c is always very stable and in range but never as good as it could be. Our endo likes that it's steady, I am usually unhappy with the number and trying to make it lower.

I don't know about your endo's office but Arden's does her A1c test on site. Today, I was just too on edge to wait for the nurse to bring the news, so I snuck back into the lab just as the test was finishing...

10, 9 ,8, it counted down, 7, 6, 5, I actually said, "c'mon be lower", 3, 2, 1... Test complete. It wasn't just lower then last time, it was .7 lower! Almost a full point! I held in my excitement and made my way back to the exam room (where Arden was blowing up a sterile glove for our now traditional game of VolleyGlove). I told her how far her A1c had fallen, she smiled coyly and offered a high five or three. Then we volleyed that glove like it was our first time.

The NP came in a few minutes later and she began asking the standard questions but I just couldn't wait. I said, "did you see her A1c yet?", she replied, "no". I responded, "Well I have and it's amazing!".

She asked me what it was (I don't share Arden's exact A1c here) when I told her she began clicking furiously on Arden's file and found a list of past test results.

"I thought so" she said... "lowest EVER!", she congratulated Arden and then me. I found myself thinking that my smile must look ridiculous because my face felt like it was about to break. As soon as we got into the car I called Kelly to share the great news and we celebrated all over again.

It's ten hours later and I'm still as excited as I was in that exam room. Even when things are going well with diabetes it can still feel as if they aren't. Yesterday was a much needed and well deserved chance to celebrate and feel accomplished. I hope everyone gets a day like this very soon, it was reinvigorating.