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Does tight control mean lots of lows?

Discussion in 'Parents of Teens' started by mariaweber, Sep 30, 2010.

  1. kiwiliz

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    I think a bit of a carrot and stick approach might work here. Carrot - She will perform better if she is within range, maybe having to take a little time to have a juice if she is going low ( but you might mention to her that it is much quicker to get up from a low than down from a high - another carrot). I would also reassure her that because of the cgms she does not have to be worried about going really low without warning (unless the batteries dislodge in the receiver!!!) (Nav problem).

    Stick part - not allowed to do so much sport unless she makes a little more effort and keeps in range.

    My educator did once tell me that teens compliance with diabetes care has to be treated like homework. If you don't do it there are consequences. Find the things they love the most and withhold them for non-compliance. Sport in this case. This is a hard line but would work - and she is old enough to catch on quickly.;)
     
  2. StillMamamia

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    You know how tone sometimes doesn't come across as we intended on the forums? Well...this is one of those times.;) The assumption that D shouldn't be that hard to manage, especially when using a pump and a CGMS, well...you know...

    I think there may be other issues here and a good talk with your child may be helpful. Perhaps taking over some of the daytime responsibilities would be good?? Also, do you take a look at the daytime BGs from the meter?? What is the average BG for the past 7, 14 or even 30 days??

    I'd look into Sarah's question about a possible letting herself run high. Or could there be (and please don't be offended) some tampering with the meter??

    To go back to what Wilf was trying to say;), the A1c is not reflecting what you think is happening. But maybe, just maybe, a bigger issue is at hand?? Can your D team help you figure this one out??

    Oh, one more thing - do you see a lot of spikes even with the CGMS?? Could this be the problem??

    Hope I didn't offend you in any way.:cwds:
     
  3. Flutterby

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    Yeah, because its just sooooooo easy. :rolleyes: Judgemental much?

    This is not the attitude someone needs when reaching out for help. criticizing someone over their A1c is completely wrong. She asked a question, she didn't ask for you to pick apart her post and judge her.

    It sounds to me like she wants tighter control be she's afraid it'll bring to many lows.
     
  4. Flutterby

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    The teen years are hard (I'm NOT looking forward to them AT ALL!).. she's probably doing most of her own stuff right now and taking on more responsibily. Tighter control means lower numbers, but not necessarily more lows. With a cgms she can set her predicted low or low alarm a bit higher, so instead of having it set at 70, have it set at 90, so she can treat before getting low. What cgms system does she use? Does she pre-bolus for meals?

    Honestly, if it were me and my daughter was at the age of where she's starting to take more control and was worried about lows I'd sit down with her, with her log book and talk about numbers.. pick out patterns and talk about how to change things. Since she is worried about going low during practice, I would start off with little changes, slowly bring things down.. Does she snack before practice? If not, a small snack will keep her bg from falling.
     
  5. wilf

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    It may be an issue of better training being needed on how to use the available technologies. It may be an issue of neglecting the D management while at school. If she's had bad lows, there may be an associated phobia about experiencing those again.

    Certainly there is room to improve control considerably without getting into lots of lows.
     
  6. Ronin1966

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    Hello wilf:

    <<There is an issue here, but it's not that "tight control means lots of lows". It's that there is little control during most of the waking hours when DD is in charge.

    Tighter control guarantees lows. It is causal. The DCCT trial was dangerously explicit on that very point.

    I propose this "higher" which receives a really "bad rap" among some has some serious and tangible benefits, a safety buffer & mental health both.

    There is a serious difference between observation, a passive detachment and compulsive (belief ?) re: "active control". Consider what happens when that vaunted control does not achieve the advertised result? Or what happens when watching for say for a decade for example.... that you get completely fried by watching too hard, too long... keeping the vigil

    Perhaps a "lighter touch" is not the boogey-man so many consider it :D
    No disrespect intended...
     
  7. wilf

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    It's not that a "lighter touch" is a boogey-man, it's that at some point you cross the line from "lighter touch" to having lost touch and that's what the A1C is reflecting. There's room to get back to having a "light touch" with a better A1C without having constant issues with lows, which is what the OP was originally asking about.
     
  8. Heather(CA)

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    I always say that "Highs and lows are part of it" I just checked Seth's PDM. The 14 day trend for lows is 9%. The thirty and sixty day trends for lows were both 7%. His last A1c was 7.4. The one before that was 7.0. He is paying football right now and has been since mid summer. She doesn't have to run that high to exercise. Have you tried Gatorade?:cwds:

    If I thought that Seth had an A1c of 8.6 because of how he was taking care of himself at school..I would have him go to the nurse everyday at lunch and call me with his blood sugars.

    He had been forgetting to bolus sometimes recently..He now has to text me every day at lunch to tell me his number and that he bolused. He has been informed that if this doesn't work, he WILL be going to the nurse's office at lunch. I know that he is not forgetting on purpose, so I am helping him remember.

    Sports other then PE are usually after school. Is it different for your daughter? Also, I have found that if Seth starts playing a sport high, he will stay high, not go low. He almost never goes low when he is exercising intensely, only when playing around in the backyard for example. The Gatorade is actually for keeping him from going high, not dropping. Does that make sense? :)
     
    Last edited: Oct 17, 2010
  9. sarahspins

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    From my perspective, tight control means it's EASIER to go low (obviously, starting from a normal BG of 90-100, it takes much less of a drop to hit 60 than it does from say, 150, or even 200), but that doesn't necessarily mean that it always results in more lows.. at least my experience is that lows when tightly controlled are much milder, not as severe as they can be when you're bouncing around from really high to really low. As a result, I find that they're much simpler to manage, as long as you can resist over-treating.

    Matching insulin (in the form of a reduction, OR an increase in some cases) and carb to activity is KEY however, to preventing lows and maintaining a more normal BG during activity. It's not always easy, but with experience you begin to learn how much works, and how much doesn't, and what is normal for "your" body.
     
  10. chbarnes

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    Okay, if I recall correctly, in the DCCT "tight control" meant testing at least 4 times a day, bolusing for each meal, and giving corrections when necessary. The average person on this routine had a low so severe that they "required the assistance of another person" about twice a week. That means they were too weak to get their own juice - or worse.
    That was published in 1994.
    We do a lot better now. The average person on this site checks 7 times a day.
    Checking even more frequently during sports with fingersticks or GGM, can usually avoid lows, and when they do occur they are usually of the sort the athlete can manage on their own.
    One Team Type 1 member told us he always carries gummy worms.
    The long and short of this, is we can achieve better A1c's with far fewer severe lows than were achieved in the DCCT, by testing more frequently.

    Chuck
     
  11. sarahspins

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    Yes, something else to consider is that there were NO analog insulins (commercially available) in 1994.. which meant that everyone in the study was still dealing with Regular. Humalog came out in 1996 and Novolog in 1999. I'm pretty sure that aiming for tight control on Regular (and whichever basal insulin was chosen.. be that NPH, Lente, or Ultralente). almost always results in lows... because of the limitations of those insulins and the much longer DIA that regular insulin has, combined with the "peaks" of the basal insulins of the time and how much easier it is to "stack" insulin and end up much lower than you meant to.

    I spent 9 months on R and N, during my first pregnancy and the few months afterward, and I remember it well.. and not in a good way. Lows in the 30's were common for me if I lost track of time and forgot to snack at the right times (which happened a lot since I had a newborn to care for - which made it just that much scarier). It was like a miracle when I was finally given Humalog and Lantus... control was so SIMPLE compared to the balancing act that R and N were, and not being tied to a set schedule of meals. Not to suggest it's always easy, but we do have much better tools NOW than just 10 years ago. Lantus hit the market in 2001 and changed everything... since then Lente and Ultralente were discontinued, and Levemir came out. There are other long-acting insulins being developed.

    I am quite thankful for the new analogs - it's almost impossible for me to "stack" insulin with Apidra because of how quick it works for me.. it is all but GONE in 2 hours.. I have my DIA set to 2.5 hours more as a visual reminder that I recently bolused (so that some IOB shows up in the bolus calculator, which I usually ignore). By the time I am thinking "Hmm, maybe I needed more bolus" it's all but done working for me.. and I can bolus again without much concern for a low. On regular, that was absolutely not the case (and I have recent experience there, having recently tried pumping both regular insulin, and U500 regular at the urging of my endo and allergist - both of which offered many more downfalls than benefits).
     
    Last edited: Oct 17, 2010
  12. chbarnes

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    Excellent points, Sarah. I wasn't closely involved with diabetes at that time, so I don't have the same appreciation for the insulin analogs that you do. It really is amazing how far we have come in the past few years.

    Chuck
     
  13. wilf

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    It is impressive to think how far D management has come - even in the past couple of decades.. :)

    Pumps, CGMs, ketone meters, and all the new insulins! For those who haven't tried it, Apidra is a stellar insulin that we've used to improve control and avoid both spikes and lows.
     
  14. Ronin1966

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    Hello Chuck;

    Pleasure to meet you.

    Re: the DCCT, "tight control" meant c. 30% of us were taken out by that tight control, and was directly causal eg cause and effect.

    Until the CGM become accurate, providing functional data (no calibration or cross verification mandatory), tighter means lower, and lower guarantees "crash and burn" potential. I will hypothesize that a new standard will someday advocate a higher crusing altitude more buffer than today contends


    <<We do a lot better now.

    Love to see that proof.


    <<by testing more frequently.

    You could be right. Another huge study I want absolute proof of... IMV testing is the Clinistix/Tes-Tape of this generation. Its what we got but, its worthless and harmful on a whole bunch of different levels.

    Ever read-seen the discussion of the March 16-17 2010 FDA meeting in Gathersberg MD re: meter/strip accuracy. :eek:

    Here was Scott Strumello's Blog on that night-terror

    http://sstrumello.blogspot.com/2010/03/tell-fda-20-is-not-good-enough-today.html


    There was an angry Tsunami about that meeting.... and rightly so.
     
    Last edited: Oct 21, 2010
  15. wilf

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    Stuart, lower A1Cs mean more of the numbers are lower - it does not necessarily imply that increased bad low potential is "guaranteed". It all comes down to how the lower A1Cs are achieved.

    If numbers are kept high enough to provide a "buffer" against lows (150 to 300 (averaging 225) with the outliers (spikes and lows) balancing out, then the A1C will be around 8.5. Most endos would say that's too high. I would agree.

    So you aim to get lower numbers. Here's 2 scenarios:

    1) If numbers are lower in a fairly tight band of 100 to 240 (averaging 170) with just a few outliers (brief spikes and short shallow lows) a day, then the A1C will be around 7.

    2) If numbers are swinging like a yo-yo from 40 to 300 (averaging 170) with lots of outliers (even higher spikes and worse lows) a day, then the A1C will also be around 7.

    Scenario 1) achieves a way lower A1C, without inordinately increasing risk of lows. To my mind, scenario 1) is much preferable to the base case with an A1C of 8.5

    Scenario 2 on the other hand has lowered the A1C, but also sharply increased the risk of bad lows. Scenario 2 is problematic, and may be worse than the base case.

    To my understanding of the term, Scenario 2 does not represent "tight control". It is more like "out of control".

    "Tight control" to me represents the lowest numbers that can be reasonably achieved without obsessing about the D management, and without suffering bad lows.
     
    Last edited: Oct 21, 2010
  16. Jordansmom

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    Maybe you should stick to something you have experience with. Regarding CGMS my daughter has never had an A1c over 6.7 through out puberty and non-honeymooning. Because of cgms we have MUCH better capability to keep bgs in range without yo-yoing with large dose corrections and correcting lows with excess carbs.

    Her pumping target bg is 100 day and night. Her CGMS average is 135 and we rarely see numbers under 70. The lowest low she has ever experienced was a 43.

    Tighter bg management with current technology absolutely does not "guarantee a crash and burn". Comparing the DCCT's definition of intensive management to today's diabetes management is apples to oranges. Regardless the study included such a varied level of education, care, and vigilance, the results can't be accurately compared to what many of us on this board do to manage our children's health.

    Our Endo will never "advocate a higher buffer to keep her safe". She currently advocates an A1c under 6.5. My DD is as safe as she can be as a type 1 diabetic. Keeping her bgs high to avoid lows isn't going to keep her any safer. That's ridiculous. And insensitive to the emotions parent's are currently working through.
     
  17. Bigbluefrog

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    I am always working at getting the basals in range. Kudos to you!

    I believe that frequent lows will lower the a1c. My dd was 6.4. and I thought it would be higher because of the 200s thrown in here and there, but I would say a good percentage are in range. It would be difficult to have tight control during the teen years. Growth hormones, female hormones, and teenage diet full of simple carbohydrates...can all make it challenging.
     
  18. momof3sons

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    May not need any more comments and I don't consider myself an expert, but a few thoughts:
    1. Wow! Approaching puberty is tough. I'll bet the teen years are difficult for many reasons.
    2. Running all the miles required for a cross country/long distance track workout would be a challenge in terms of D management.
    3. YDMV- The school nurse accidentally emailed us the wrong student's weekly BS log. I was jealous of those perfect numbers. As our endo says about my son in her strong accident, "he is a little bit tricky." Our last a1c was 8 and I can assure you we are working as hard as we can!
    4. We are all battling this disease, loving our kids, and doing the best we can.
     

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