Monthly Archives: November 2009

End of the Daily Posting

What a trip this last month has been. To be honest, the last week has been a bit of a struggle to find something interesting to say. In general, I found it difficult to write on demand. But it’s done. The daily updates and the eleventh hour races to post are over.

I’ll keep writing, of course. I feel like I’ve learned a bit about myself along the way, and I hope that I’ve taught a few people something new about diabetes. From time to time you’ll see more on that subject here. And there are still many things on all manner of subjects that I intend to write about; but they’re longer, and twenty-four hours just wasn’t enough time to get them finished — or even started.

So you can expect to see more frequent posting than in the pre-November, haphazard past, though most likely not daily updates. Until next time. . . .

What? Were you expecting more? Just wait for it. I’m watching television now. :)

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Snowshoes

Winter — usually my least favorite five month-long season — has been slow coming this year in Massachusetts. For that I’m quite grateful. If I hadn’t been sleeping off the jet-lag after staying up way too late watching AMC’s remake of “The Prisoner,” I would have gone for a nice warm ride. Oh well, there’s always next weekend. Our tulip bulbs have even started sprouting.

I don’t really like the cold, but I don’t really mind it either. It’s the price we pay for the pleasantness that is the other half of the year in New England. But I miss doing a bunch of things on account of snow, which makes it inconvenient to run, ride or hike.

But not this year! I just ordered a pair of snowshoes as part of an early Christmas gift from my mom. I’ve never snowshoed before, but it looks like fun, and my coworkers have been talking it up on the occasions that I’ve asked about it. And Lisa says she would like to get a pair, too.

So the great outdoors may continue to beckon after all. I’ll post pictures once it actually snows.

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A Different Kind of Reading

Lisa and I made it home from Wyoming to find the house still standing, the heat still working, and the kitty still happily away at his little resort until tomorrow afternoon. We have completely unpacked, and Lisa even set out all of the Christmas decorations. That’s a little easier to do this year, since we aren’t decorating a tree. We love getting a Christmas tree, but it doesn’t make sense to put one up just to let it dry out while we’re spending the week around Christmas in Oregon.

I was a bit nervous about today’s journey. Casper was forecast to have two inches of snow, starting right around the time this morning that we were to leave. And somehow I got us a the Casper to Denver to Chicago to Boston itinerary with tight layovers of less than an hour at each stop. But after the frustrating travel experiences we had last month on our way to and from Kansas, we had good travel karma today. We even walked out the door at baggage claim just as the Logan Express to Framingham rounded the corner. That never happens.

We very much enjoyed spending time with my mom and seeing friends in Wyoming, but it’s nice to be home. Nice to be back to sea level. To be back to my pile of reading.

While my two shelves of books will persist into the new year, my periodicals stack won’t. At the beginning of the year I set myself a goal of cleaning up the big shipping box full of various magazines and issues of the New York Times Book Review that I had amassed over the two and a half years that I was in grad school. What I haven’t finished at the end of the year goes into the recycling. “Out with the old” and all that.

Sadly, I haven’t made much progress throughout the year. But I did manage to read a bunch of magazines on the flights last Sunday and today, so maybe there’s hope after all. The Runner’s World article on 1980′s hurdling phenom Danny Harris, who destroyed his career with cocaine, and the National Geographic Adventure feature on a new hiking trail across Nepal were my favorites. The Scientific American article from last year about how the Large Hadron Collider will likely reshape physics reminded me that when I was younger I wanted to be a particle physicist. Oh well, something more to read about next year.

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Postcards from The Equality State

What’s it like in Wyoming? Let us show you.

Kitty couldn
Kitty couldn’t care less whether we’re going on vacation or not.

Happy holidays from the Tate Mineralogical Museum.
Happy holidays from the Tate Mineralogical Museum.

Casper
Casper’s one and only cape buffalo.

Mmm...moose.
Mmm…moose.

What
What’s a diorama?

The world
The world’s smallest carnivore.

Blinky, the three legged pronghorn.
Blinky, the three legged pronghorn.

The owl says, "I will f-ing cut you!"
The owl says, “I will f-ing cut you!”

Like a deer in the headlights. (Hunting that way is illegal, by the way.)
Like a deer in the headlights. (Hunting that way is illegal, by the way.)

Caribou!
Caribou!

I bond with the statues everywhere I go.
I bond with the statues everywhere I go.

Oh, what a feeling!
Oh, what a feeling!

Nina, let
Nina, let’s meet!

Nina and Rachel.
Nina and Rachel.

Nimmi.
Nimmi.

Simon and Kyle.
Simon and Kyle.

Kyle just cannot believe that. No way!
Kyle just cannot believe that. No way!

I like the Tin Man.
I like the Tin Man.

Lisa wears safety orange.
Lisa wears safety orange.

The fence didn
The fence didn’t wear saftey orange.

Thumbs up!
Thumbs up!

How
How’s that “milking” going?

Prairie.
Prairie.

My mom.
My mom.

Merry Thanksmas.
Merry Thanksmas.

I have a little teapot, short and stout... and ready for backpacking.
I have a little teapot, short and stout… and ready for backpacking.

Prezzies!
Prezzies!

Holiday cheer!
Holiday cheer!

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On “Struggling”

My mother — whom I love dearly and who made a delicious Thanksgiving dinner today — read about a billion pages of this here weblog last night. That’s great! She’s more-or-less the person I have in mind when I write about diabetes for people who don’t have it.

Imagine my surprise, when this morning over breakfast she said, “You’re really struggling with your diabetes, huh?” I have had my struggles and frustrations with diabetes recently, but I don’t feel like I “struggle” with it.

I asked Lisa about this. “Well, you have had a lot of frustrations with it recently. And you’ve been writing about them.”

It seems like all of this writing about diabetes and my process of trying to get my blood sugar to do what I want may be giving you, my dear non-PWD readers, the wrong impression. While I get frustrated when I do something and it doesn’t work, resulting in high or low blood glucose readings, I don’t feel like I’m struggling. I try to be pragmatic and learn something from the experience so that it doesn’t happen the same way next time. And although I’ve been known to wonder whether I’m ever going to be done with these teachable moments, I’m trying to maintain my charming stoicism and faith that there are solutions to my pancreas/paperweight-related issues.

Lisa is undoubtedly correct that it may seem like I’m struggling with diabetes more these days mainly because I’m writing about it more. In that case, perhaps I’ve missed the mark a bit. I was hoping (a) to humanize my illness a bit, to show that diabetes self-management is not mired in old one-size-fits-all rules, to get across the fact that people with diabetes can have as normal lives as anyone else and (b) to present useful information for other people with diabetes, to add to the repository of what works and what doesn’t, to teach what I know and what I’ve learned through experience and second-hand.

With all that said, I did want to share more successes with you than I have been able to present. I was kind of expecting that by this point in November I would be able to tell you that I have all of my basal rates and bolus ratios and sensitivity factors sorted out. And in particular, I was really hoping that I could show y’all what I do with exercise that leaves my blood sugar where I want it. But, while I’m making progress, it’s coming quite slowly. (Although, I feel happy to share that the last couple of times that I’ve gone for a run in the morning, my readings have stayed almost exactly unchanged. More about that later.)

So as I finish up this Thanksgiving dispatch, I want to say that I’m thankful for my Mom and all of her love, friendship, and maternal concern. And I’m thankful for Lisa, the best wife and friend I could ever hope for, who decided to love me even more after I was diagnosed with diabetes and who has helped me through the actual struggles and frustrations with it. I’m thankful for all of my friends and coworkers who enrich my life and treat me like just another person and yet have shown remarkable interest in my illness. And I’m thankful for you, my readers; without you these would just be self-indulgent ramblings.

See y’all here again tomorrow.

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Thanks, peeps!

Well, dear readers. I’m almost done with this entire month of posting here, and I’m kinda glad that it’s almost over. It’s a bit like having homework again. Although, I have to confess that it’s been a good exercise in writing again.

Lisa and I are in Wyoming. We’ve been here since Sunday evening and are having a good time. I like visiting Casper, seeing my mom, and meeting up with high school friends again. (Although in the background now, someone is telling me all of the reasons why Casper is no good. Anyway.)

Tomorrow is Thanksgiving, which promises to involve lots of food. Diabetes-wise, it hasn’t been a great few days. All of these highs tend to suggest to me that there’s still a lot of tweaking I should make with my pump settings and food estimation and whatnot. But tomorrow is another day. That doesn’t make it less stressful, but it does help with perspective.

The “diabetes online community” (D-OC) has been wonderful with giving me some perspective. I was part of a diabetes support group for a few years after being diagnosed, but I found that I needed a different kind of support experience. This ad hoc online community makes it easier to find and share the kind of information that’s important to me as a someone with type 1 diabetes. Beyond that, though, my fellow type 1 writers are so wonderful to read because they help remind me that we’re people, not just patients. We have happy diabetes moments. We have total WTF? moments. We have moments that would be almost impossible for people without diabetes to really get — not that we wouldn’t trade those in for non-diabetes lives.

There are lots of diabetes peeps out there, and I feel funny singling out anyone by name. But there are a few people who I just really love to read:

If you have a favorite which you think I should read, let me know in the comments. And have a happy Thanksgiving.

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A Visitor’s Guide to Casper, Wyoming

Lisa and I are in Casper, Wyoming. It’s not the place that I was born, but it’s the place where I grew up. It’s a nice little city of between 40,000 and 55,000 people depending on the combined price of oil, natural gas and uranium.

I was once asked as a teenager, “What do people do here for fun?” And, to my great discredit, I answered truthfully and correctly: “They get drunk or they get out of town.”

To be fair to me, it is a great place to get drunk, I am told. You can “go sneakin’ to the Beacon” Club, which is not nearly as ghost-town chic as it used to be. Or you can go to the World Famous Wonder Bar. Just forget about bringing your horse inside and ordering something from the saddle at the bar; that’s already been done. And, of course, you can always go through the drive-thru liquor store, get a bit to share with friends (or not), head out of town, and get ginned up before shooting guns at road signs or whatever. It’s your business, and Wyoming is very much an “It’s your business” kinda place.

And, when the weather is nice, there are a large number of things to do outside of town. A half-hour southwest of town, there’s Alcova Reservoir, where we go to hike around on the rocks or go sailing or dive into the deep water from the rocks or stir up the rattlesnakes or go drinking or whatever. Nearer to town, you can put your inner-tube or raft in the North Platte River and slowly float your way back to Casper and inebriation. A bit farther down the road is Independence Rock, where “Immigrant Pioneers” wrote their names in the 19th century on the way to Oregon. Fifteen years ago it was possible to clamber all o’er it, but “they” don’t allow that any more. Across the road you can pretend you’re a different kind of pioneer, and push a handcart along the Oregon/Mormon Trails.

Just outside of town to the south is our mountain, Casper Mountain. In the summer, it’s a great place for hiking — the Rotary Park hike around Garden Creek Falls is very nice — and short mountain bike rides. In the winter there are some excellent nordic ski trails and a somewhat rocky downhill ski area, which the Locals seem to like for that midweek and busy weekend ski fix. And Casper makes a great base of operations for summer day trips to trailheads on BLM land or in the Medicine Bow National Forest. It’s also popular pastime to get into the 4×4 and just drive for hours on the dirt roads that cross the range and mountains.

If you’re lucky enough to be here in the first or second week of July, you should definitely stay in town a day or two and have a “rip-roarin’ good time” at the Central Wyoming Fair and Rodeo. You can watch barrel racing, bull riding, calf roping, and bronco busting from the grandstands with real cowboys. And you can enjoy the midway rides and food. (Casper also has the state’s best hospital. So don’t worry if you eat too many funnel cakes. You will get excellent care before, during and after your bypass surgery.) Casper’s fair and rodeo may not draw the same crowds and riders as Frontier Days in Cheyenne or the Wyoming State Fair in Douglas; but it’s probably better, because you’re in Casper and it’s in Casper and those other fairs and rodeos aren’t.

But what if you visit during one of the shoulder seasons? Say, November? Perhaps around Thanksgiving time? It’s not snowy enough to ski. It’s not warm enough to hike. There’s no fair or rodeo. Many of the backroads are impassable. You can’t go to Alcova or float the river. Basically you can’t do much without eventually involving Lunchbox, The Cadaver Sniffing Dog.

(By the way, when a Wyomingite tells you something isn’t a good idea, you should listen. We know lots of stories about people who have died or almost died doing the thing you’re contemplating. You just might be the lucky one who lives, and we’ll help you if we find you. But there are only 400,000 people in Wyoming’s 100,000 square miles, and 1/4 live in the two largest cities; so you do the math on the chances that someone other than Lunchbox will happen across your frost-bitten/sun-stroked/dehydrated/malnourished/rattlesnake-bit/drug-runner-shot/logging-truck-smashed/roughneck-mugged/drunken-cowboy-assaulted self. It’s your business, but I’m just saying. . . .)

So what can you do more-or-less year-round in Casper?

Casper started as a fort town. Wait, let’s back up. Casper started as a convenient place for covered wagon trains and Mormons with pushcarts to cross the North Platte River and head overland to South Pass and freedom Oregon. So you can get your Old West history on at Fort Caspar, which has reconstructed buildings and exhibits, and at the National Historic Trails Interpretive Center. The latter is new and quite good.

While you’re getting your “Old West” on, you should definitely stop into Lou Taubert Ranch Outfitter, the best western store anywhere. You want boots? Try on one of 10,000 pairs. You want buckles? Yup, they have those too. Need tack? Wanna rope indoors to try out your new lariat? Need chaps? Yup. Yup. And yup. You can even decorate your home in the Western style and find John Wayne lunchboxes for the little buckaroos.

The rest of downtown is fun and quirky, too. It’s compact and walkable. The shopkeepers are friendly and helpful. There aren’t chain stores downtown, but if you aren’t into interesting things, you can head out to big box stores on the eastern side of town for the same stuff you can find in whatever medium-sized town is near the town where you live. Casper does have one of the three — count em, three! — malls in Wyoming; you won’t go wanting.

Casper has three small museums that are worth a visit. Two of them — The Tate Mineralogical Museum and the Werner Wildlife Museum — are part of Casper College, the Harvard on the Hill. And downtown is the Nicolaysen Art Museum, which has several special exhibitions every year as well as a permanent collection specializing in Western regional art.

And that’s pretty much what there is to do in this modern-day Deadwood. Of course, I’ve left things out. During these energy boom times, Casper seems to have an improving restaurant and bar scene — especially near downtown and on the east-side, where you can eat at chain restaurants after shopping at chain stores. In the summer you can watch a Casper Ghosts baseball game. (We did this last year, though it was postponed due to wind.) And you might consider a short drive outside of town to the east or the northwest to see some of the oil services companies and refineries. (But you probably saw those on your way to or from Yellowstone anyway, right?) And you can drive by Natrona County High School, where Dick Cheney and I went to high school. But now we’re kinda scraping the bottom of the barrel, aren’t we? So let’s just stop there.

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It’s Coming Right at Me!

OMG! Dead stuffed things!!!

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Like No Place on Earth

We made it to Wyoming. Here’s the plane we took:

I read a lot on the plane. Saveur — which is written for people with a lot of money and “refined” tastes, but I found it free at work, and it was all about cheeseburgers . . . mmm . . . cheeseburgers. And I “read” Runners World, Bicycling, New York Times, MATLAB News & Notes. It was the first time, I read the Times in a long, long time, despite the fact that it’s delivered every Sunday. I really should cancel our subscription. It feels like charity, to be honest.

My mom said Sen. John Barrasso (R-WY) was on our flight. Who knew? If I had, I probably would have harassed him about his “No” vote yesterday on the healthcare bill. “I may be a so-called bleeding heart liberal; but you’re a doctor, man. You know better than to do that shit. But from what I’ve heard your patients are happier now that you’re in politics and out of the office. Etc.”

I don’t know how long we’re going to be on the Internets . . . They turn it off here at night. Honest.

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It’s official…

. . . I’m old.

Look what I bought today so that I didn’t have to carry big bottles of vitamins and pills on our trip:

Oy.

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National Parks and Other Treasures

Lisa and I just finished watching the fourth episode of Ken Burns’ six-part documentary The National Parks: America’s Best Idea. I love visiting national parks, and we’re enjoying learning about the history of our parks and the National Parks Service while seeing lots of pretty scenery.

I remember visiting my first national park with my family twenty years ago. My first park was America’s first park: Yellowstone. It was the most beautiful place I’d ever been. (Of course, I’d never really left Iowa in my first fifteen years; so that statement doesn’t really do any justice to the place.) It was also the trip where I appropriated the family’s SLR camera and began a hobby.

After I graduated from college, I started seeking out the solid green blocks on the maps in the atlas, yearning to go to the national parks and monuments in the US and Canada. I assumed these were the most beautiful and interesting places. (Like I said, I may have been a bit provincial in my outlook.)

Years later, the national parks I’ve visited are some of my favorite places, but they aren’t the only ones. Since you asked, here’s my list:

  • Zion NP — This Utah park is probably the most beautiful place I’ve ever been. Simply perfect scenery, if a bit crowded. . . .
  • Grand Canyon NP, Arizona — Nothing can really prepare you for the first time you see it. It makes a mockery of any possible description.
  • Baxter SP, Maine — I’m going to keep this park’s secrets to myself. At least I told you about it.
  • Jasper NP, Alberta
  • Kings Canyon NP, California
  • Rocky Mountain NP, Colorado
  • The Beartooth Highway, Montana/Wyoming
  • Cloud Peak Wilderness, Wyoming
  • Paris
  • London
  • San Francisco
  • Museum of Fine Arts, Boston
  • National Gallery of Art, DC
  • Musée d’Orsay, Paris
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The Odometer Rolls Over

I went to the hospital lab this afternoon to get blood drawn for my HbA1c test, anticipating my endocrinology appointment in a couple weeks. (We’re going to Wyoming next week, and I hate having to rush the results.)

For those who don’t know, blood glucose sticks to red blood cells. The more blood sugar there is, the more of it will stick to the hemoglobin. That blood sugar makes the red blood cells bigger and can cause damage as they flow through the blood vessels, scraping as they go. So, the lower the A1c — which measures average glucose over a three to four month period — the better.

I’ve had a bunch of high readings over the last six weeks as I’ve gotten used to my new, correct basal rates and figured out exercise. The good news is that I think I’m almost there, but I fully suspect that this A1c will be higher than the last.

While the prospect of an A1c result that’s worse than my previous test is disappointing, the test is done and the next three to four month test period has started. My diabetes odometer has rolled over, and I can try for a better A1c in February or March. The worst thing about diabetes is that it’s always with me, but at least I can wipe the slate clean a few times every year and try to improve.

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A Day in the Life

Bilingual people do something called “context switching,” when they change from one language to another. It’s kind of fascinating to watch. I think we people with diabetes perform our own form of almost seamless context switching as we go through our day. Diabetes isn’t always on my mind, but it’s never far away; and frequently I switch from thinking about whatever I’m doing to “thinking in diabetes” and then switch right back.

If you look at today — a rather boring day — you can see this happening all the time.

5:25 AM: Throw the cat out of the bedroom, which is sadly part of our daily ritual.

5:45 AM: Wake up again, test the blood glucose — 118 mg/dL — which made me feel very good. I have an appointment with my endocrinologist next week, and I need to have my blood drawn for my A1c. Contemplate going to the hospital lab this morning on my way to work.

6:15 AM: Make a sandwich for lunch. Weigh everything so that I know how many carbohydrates I’ll have to bolus for later: 56 grams.

6:30 AM: Kiss Lisa goodbye. Drive to work, listening to pop music.

6:45 AM: Decided to wait to go to the hospital despite good numbers. Breakfast wins.

7:15 AM: Now at work. Grab some breakie (a small butter croissant and a small chocolate chip muffin) and guess that it’s 60 grams of carbohydrates. Enter all of the values into my pump and bolus 6.0 units.

8:00 AM: Grab a little more breakie while buying a Diet Coke. (It’s Wednesday after all. Free breakfast day. And the mini chocolate croissants are out.) Guess that it’s 25 grams. Bolus another 2.5 units.

8:00 – 11:30 AM: Sit at my desk, doing very important work — gathering requirements for a new infrastructure feature in MATLAB.

11:30 AM: Test again — 219 mg/dL. Wish it were lower. Ask my pump what correction I should give myself to lower my blood glucose. Survey says: 0 units. Well, that seems fishy, but I’m trying to do better at trusting what my pump bolus wizard suggests and fixing the settings when they’re wrong. Eat my sandwich (56g) and yogurt (19g). Bolus 7.5u.

12:00 – 1:00 PM: Training at lunchtime. Ooh, GlowCode!

1:00 – 2:00 PM: Planning meeting.

2:00 PM: Test — 129 mg/dL. That’s more like it. The pump was right after all.

2:00 – 4:00 PM: Sit on my butt, continuing that important work. Those requirements analysis documents aren’t going to write themselves.

2:30 PM: Hungry . . . I’m trying to avoid bolusing for a few hours before I exercise, so that I can limit my active insulin. So why did I buy that cookie at 1:00? I’m a masochist.

3:45 PM: Test — 124 mg/dL. Woo hoo! My afternoon exercise experiments starts with eating about 30g of carbs, lowering my basal rate to 0.2 u/hour, and then exercising an hour later. I eat that cookie which has been staring at me for about three hours.

4:00 PM: Drive home. I’m probably going to go deaf one of these days while listening to this Yeah Yeah Yeahs song on my commute. (It’s also good live.)

5:00 PM: Test again — 224 mg/dL. Oh cookie, you’ve made me a little higher than I’d like, but you’re giving me a bit of a buffer in case my experiment goes really wrong. Run a bit more than three miles in a bit less than half an hour. Afterward — 189. Woo hoo! On Friday, I’ll try lowering that pre-run number. The bolus wizard says 0.8u . . . done.

6:00 PM: Dinner of leftovers, which is supposed to contain 33g carbs. I have a bad habit of bolusing after I eat, which means that sometimes I forget to bolus for a bit. I didn’t get my 3.6 units until 6:40, and I think that might have something to do with what happened later.

7:00 – 9:00 PM: Run all over Milford, shopping. Man, we were frightful low on groceries. Mother Hubbard came over to borrow a cup of sugar, and I sent her on her way empty-handed. Thus, sandwich for lunch and leftovers for dinner.

8:20 PM: Test — 295 mg/dL. I felt a bit off at the Stop & Shop, so I tested in the beverage aisle. Mr. Wizard suggests 0 units? WTF, diabetes? I’m going rogue: 1.5 units.

9:30 PM: Test — 196 mg/dL. That’s better. A little rage bolusing wins every time. (Well, not every time. Not even most of the time.)

Now, after watching a PBS travelogue on Paris while writing here, it’s time for bed.

Update: The rage bolusing caused me to be lower than I’d like at bedtime (81 mg/dL) and then low (55) in the early hours of the morning. Sorry for doubting you, Mr. Wizard.

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In the Bag

Thanks to diabetes, I carry around a lot of stuff. All of it is important to have with me, but I never know exactly when I’m going to need all of it. On more than one occasion, I’ve had to leave work for something important that I was missing, so now I just bring it all with me.

A whole bunch of diabetes supplies
My big bag of diabetes stuff (click for larger)

The contents of the bag of diabetes supplies
Stuff in the bag (click for larger)

So what’s in it?

  • Infusion sets and reservoirs (usually at least two of each)
  • Inserter
  • Syringes (just in case I need to give myself a little insulin the old fashion way)
  • Alcohol swabs
  • A spare insulin pump (because a couple have broken, I carry this out of warranty pump)
  • AAA battery for the pump
  • A quarter (to open the pump to change the battery)
  • Glucagon (not that I’ll be able to give it to myself . . .)
  • Timolol malleate eyedrops (for my other, other chronic illness)
  • Moisturizing eyedrops (because sometimes my eyes get dry)
  • Prescriptions (This really helps when traveling)

Some more diabetes supplies
The kit I take with me every time I leave the house (click for larger)

This little kit has everything I need 90% of the time: my Freestyle glucose meter, test strips, BD lancing device, a couple fresh lancets, insulin, a syringe, a tube of glucose tablets, and my prescription eyedrops.

I’ve recently started carrying around a sheet of paper with carbohydrate values for things that I eat when we eat away from home. I don’t know why it took me so long to figure out that I could do this, but it’s quite helpful. It’s too bad that some restaurants have made it so damn hard to find this information.


Exercise update: Over the previous three days of exercise, my blood glucose levels have been much better: The “after” readings have been much closer to the “before” values, which have been much better as well. More details to follow when I’m convinced it’s not a series of flukes.

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What’s the Right HbA1c Target?

In my most recent post I mentioned the matter of an on-going debate over the proper target for HbA1c values. I went back and listened again to the debate at this year’s EASD conference on the “right” A1c target. (You can find it by starting at the EASD webcast page and searching for “Berger”.)

The talks by Drs. Irl B. Hirsch and Andrea Siebenhofer-Kroitzsch are chock full of information, and I’ll summarize them here. I’ve also taken the liberty of including some of their slides. Any mistakes in recapping these presentation are entirely due to my limited knowledge of epidemiology and shouldn’t reflect on the good doctors arguments. Also, there’s a lot of statistics in these presentations; and while I studied mathematics as an undergraduate, I went the abstract math route and am rubbish with statistical jargon.

First, Dr. Hirsch advocated for a target of 6.5%.

  • An A1c of 6.5% works out to an average of 144 mg/dL or 7.8 mmol.
  • But 6.5% actually has a fairly large overlap with 7.0% if you use the 95% confidence intervals of each.
  • So, there’s not that much of a difference between 6.5 and 7.0%.
  • 6.5% is protective. There’s a small but significant reduction in the risk of complications with an A1c below 7.0%.
  • And there’s an “exaggerated increased risk of hypoglycemia” below 7.0% for type 1.
  • The DCCT (which suggested that there was increased risk of severe hypoglycemia with better A1c) was reported in 1993. It’s a different time now. JDRF continuous glucose monitor (CGM) studies show that risk is way down at all levels of A1c to the same as very high A1c.
  • Lower A1c values are protective for type 2 as well, but treatment is a “moving target.”
  • No matter what you target, the actual is going to be higher (often by as much as 0.5%). — So why not aim lower?
  • Furthermore, doctors have been told “additional action” is required if the A1c is more than 1.0% over the target — so people with diabetes (PWDs) often aren’t getting told to change until well into the danger zone.
  • Does the ACCORD study indicate that trying to achieve normal A1C results in increased mortality? [Yikes!]
  • As in other trials, a higher average A1c in ACCORD is associated with a higher risk of death: +22% for each 1% of A1c.
  • And with intensive treatment, the risk of death continues to decrease below 7.0% — Not so with “standard treatment strategy.” [I believe the "intensive treatment" group aimed at lower A1c.]
  • Moreover, the people with the highest risk of mortality in the study, were the people with the lowest decline in A1c.
  • The causes of death in ACCORD weren’t differentiated, though.
  • Of course, the target value is individualized based on other factors. “Clinical judgement always trumps guidelines.” “If you can’t get there, don’t push it.”

Dr. Andrea Siebenhofer-Kroitzsch used meta-analysis of several different diabetes trials to argue that we can’t tell definitively whether improving glycemic control (as measured by a lower A1c) actually helps.

  • There are many other factors that along with A1c confound what causes improved/worse outcomes. Factors such as social status.
  • So far, there are only seven randomized, controlled trials on A1c (DCCT is by far largest with 1441 patients).
  • The age of people in the DCCT were quite young, so it was hard to see macrovascular complications (such as heart disease) directly from the study.
  • And, the ACCORD study had to be stopped because intensive treatment had a higher mortality for some groups. [Seriously?]
  • Some studies showed more hypoglycemia and more weight gain with aggressive treatment.
  • Other changes are more effective in preventing complications: blood pressure, cholesterol reduction.
  • Don’t confuse intensive self-management with A1c.
  • Tight glycemic control is very beneficial for young people with type 1. Admits that people with type 1 need tight glycemic control because of length of treatment. [But type 2 is occurring much earlier in age, one audience member reminded us.]
  • Lots of open questions about the value of glycemic control.
  • Individualized treatment is more important, almost suggesting letting patients to set their own targets as long as a minimum level of outcomes are met.

Here are my reactions and some questions I had while listening to the session:

  • It’s good to see that the increased use of CGM technology can dramatically reduce the number of severe hypoglycemia episodes. Given what it costs to go to the ER, there’s another argument in favor of covering CGMs and supplies more widely by insurance carriers.
  • The meta-analysis was very . . . meta. Consequently it pushed very hard on the difference between “proof” and “connection.” A lower A1c may suggest better outcomes, but it doesn’t prove that the lower A1c caused it. I get this, but the data are compelling to me.
  • Almost all of Dr. Siebenhofer-Kroitzsch charts suggest favoring more intensive treatment, although that seemed to contradict the core of the presentation. Perhaps I don’t know how to read them correctly? [Mo meta, Mo problems.]
  • Does the fact that clinical trials never met their A1c targets mean that people with diabetes (PWDs) are going to feel even worse about not meeting A1C targets if the target is lowered to 6.5%?

Ultimately, based on the questions and comments from the audience, the debate sounded like a draw. I think I’m in Dr. Hirsch’s camp, and I would ultimately like the lowest A1c I can safely get; but I don’t think I’ve ever really been close to breaking below 6.5%. So maybe Dr. Siebenhofer-Kroitzsch’s camp and the ADA have a point worth considering carefully when looking for a number to cover all of us.

Some of Dr. Hirsch’s slides:

Some of Dr. Siebenhofer-Kroitzsch’s slides:

Posted in Diabetes, Fodder for Techno-weenies, From the Yellow Notepad, NaBloPoMo, NaBloPoMo 2009 | Leave a comment