Working on the A1c

I was really early for my endocrinology appointment this morning. It was one of those “arrive really early or struggle to make it on time” choices that had me sitting around in the hospital cafeteria, leisurely eating a muffin and reviewing my diabetes data. The hospital has free Wi-Fi, so I uploaded my data from my pump and meter into CareLink and then exported it from there back to MATLAB. (It’s an inelegant process, but it’s the best I can do . . . for now.) My endo’s staff was going to download all of it again when I got to her office, but I wanted to look it over myself so that we could talk about what’s going on.

My last couple of A1c blood draws have been near all-time (that is to say, “post-diagnosis”) highs. My endo is remarkably judgement-free, and she’s really eager to help me figure out what’s going on and what changes to make. It’s a partnership, and we both bring our own perspective and fresh ideas. I have the context behind the numbers, and she has experience with other type-1 patients.

For this visit, I decided that Saturday and yesterday were two good case studies that we might investigate.

Saturday was a typical weekend day: sleep in a little, clean house a bit, have lunch out, do some shopping, etc. The thing that made it interesting was that I slid into lunch a bit low and then I had a lot of trouble getting myself out of the hypoglycemic zone. We decided that it may have been because my Indian food lunch was rather “complex,” causing the carbohydrates to take longer to get absorbed into my bloodstream. She also noticed that I have a lot of “bolus stacking” going on, which I had also seen from my graphs. (She observed a lot of stacking on Halloween and the day after, too. “Yeah, you can see when the Tooth Decay Fairy showed up,” I said to much amusement.) The stacking isn’t a problem per se, but it does make digging myself out of an insulin hole harder.

Yesterday was typical of some of the other issues I’ve been having. I had good BGs overnight and before swimming. I ate a little bit before heading to the pool and finished my swim an hour later at about the same place I started. So far, so good. But then I didn’t bolus enough for the extra muffin at breakfast. I knew the amount was probably too little, but even with all those carbs it just felt like a lot of insulin. I was going to be walking around the campus a fair bit, going to meetings and preparing for a very important meeting of my own later in the day. I didn’t want to go high, but I also couldn’t afford losing time to the lows. Not surprisingly, I went way up before lunch and then really had to work to bring it back down. By dinner I was in a happy place, except (once again) I was worried about lows, so I delivered less insulin than required. This time it was totally the right thing, since I kept sliding lower throughout the evening, and I ended up in the low 60s (3.3 mmol/L) twice overnight.

That story garnered some more suggestions, and I have a bolus test or two to do. In a couple weeks I will send her more data.

The interesting thing, we both thought, is that if you look at the last two weeks (and take out the 24 hours after the trick-or-treaters left) my BGs look pretty good. We think that with a few changes, my next A1c will be much better. Let’s hope so.

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