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Reactive versus proactive

Discussion in 'Parents of Children with Type 1' started by Lakeman, Sep 3, 2016.

  1. Lakeman

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    I find myself mostly reacting to numbers and as much as I try and want to be proactive the former is more of what we do. So my question for you all is, what do you do and what works for you to be more proactive?
     
  2. wilf

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    We made several proactive moves over the years, and they've paid off big-time:
    - changing the family's shopping and diet habits to get rid of those foods and drinks which were least compatible with good diabetes management
    - stressing the importance of exercise in helping to manage blood sugars, and making sure the whole family got lots
    - really learning and internalizing the math behind the essentials of good diabetes management
    - giving more basal than was needed to keep blood sugars steady, aiming instead for a slow steady drop in the absence of carbs
     
  3. rgcainmd

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    Sugar Surfing per Stephen Ponder, MD. A lot of time and effort, but you somehow get used to incorporating it into your day.
     
  4. jenm999

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    For our family:

    1. Anticipating lows rather than waiting for them (kind of like our own unscientific sugar surfing)
    2. Correcting highs aggressively - every hour if we don't see satisfactory downward progress - and adding extra insulin over 250 (+.5u) and over 300 (+1u)
    3. Aiming for A1c of under 7, not lower. Recognizing that perfect is the enemy not only of the good but also of sanity. :)
     
  5. samson

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    It's a fine line between proactive and responding to phantom trends, we all are just doing the best we can.

    The main things we try to do:

    1. We collect data: how much total insulin did this meal take the past 20 times and over what period of time? We calculate average peak bg, time to peak, time to in range, standard deviation and note typical rise rate. As soon as my son seems to be rising more than is typical -- between 15 and 20 minutes after a meal begins -- I will increase insulin dosing until the curve flattens.

    2. Still not bold enough to aggressively pre-bolus for expected secondary spikes but ultimately this may be the way to reign in his spikes. (Mac n' cheese, pizza, pancakes or other high-fat, high carb meals will typically cause a nasty spike 2+ hours later and the only way to prevent it is to get ahead of it. Typically these aren't healthy meals so we don't eat them often enough to really master yet.)

    3. Adjust pump settings very aggressively, within 12-24 hours of new trends occurring. Write down the current settings; it's easy to change back if they're wrong.

    4. Testing ISF, carbF and other settings while riding the roller coaster. Any low is an opportunity to test Dexcom thresholds for treating with carbs, carbF, the carb absorption rate, and time it takes for a rise to occur. Any overnight high is a chance to test ISF and DIA. Embracing multiple ISFs and CarbFs for different periods of the day.

    5. The hard reset. After a roller coaster day we try to do a zero carb dinner with lots of protein and veggies, mostly unsaturated fat (something like salmon). Once the night is under control, usually the next day goes better.

    6. Setting (realistic) goals for time in range, or average BG for every day, every week, every two weeks, one month, three months. This can be hard: Our child's body will not always cooperate. But so far, setting the goals has helped make improvements even when we miss targets.
     
  6. MomofSweetOne

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    Reviewing data regularly (once a week or so) is huge for me as far as being proactive. If we go longer than that, we don't remember what caused numbers and don't know which ones to dismiss.

    I was much better about reviewing carb ratios, etc. when logging with pencil/paper with MDI, but I try periodically to make sure there are 4 hours between eating sessions, carbs counted accurately, etc. so that I can periodically evaluate whether settings look like they're working together properly. It is definitely not the nightly look that it used to be! (And neither does it need to be.)

    Sometimes I wreck havoc by going "proactive" when I think things are changing and then create lows that get overfed and creates a rollercoaster. I've learned that sometimes being reactive is better. During puberty, though, I went very proactive with basal changes and actually came up with a formula that would tell me how much to increase/decreasing her temp basal by based on the rate at which her BG is climbing or dropping. I don't remember what it was now, but it worked like a charm. I knew when I needed to give two juice boxes right away while dropping basal and then could sleep the rest of the night without alarms. She blew through the growth charts during puberty, climbing from the 25%tile to the 86%tile, and she was never on the same basal rate for more than two days consecutively. She'd stairstep insulin needs daily for about two weeks, go through a fast, sudden drop, and then start climbing again. It was insane, and if I hadn't had the cgm, her A1Cs wouldn't have been anything like what we managed. The "3 days between changes" wouldn't have worked at all, yet we made it through those years safely.

    One thing I'd highly recommend is reading "Think Like A Pancreas" and taking T1U together with the kids during middle school. They need the basis of understanding, but the high school years are so crazy with activity that the focus is less. They need to be familiar with adjustments, etc. before. But, the flip side is they still need lots of support because all those normal activities take lots of brain activity and energy.

    For laughs (and seriousness): My daughter told me this week that we are programming a profile that is for the endo appointment, that the endo can tweak things on that profile to her hearts' content, and as soon as we exit the office, she'll switch back to the "real" profile. I laughed at the brilliance of her proactiveness; she was dealing with several mornings of highs that it took us a few days to remember her carb ratio had been changed at her appointment the week before. But, I'm also glad that she knows and values the tweaking sessions we do with basal testing and ratio testing, that she definitely sees the advantage because diabetes is so much harder when things aren't accurate and she doesn't feel as well.
     
  7. sszyszkiewicz

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    So since CGM, we react more than being proactive, because we can. I have a 14 year old T1D son. I do not believe T1D in a teenager (hormones, massive growth spurts, sports, they want to eat when they want to eat, emotions, etc....) follows any specific kind of quantifiable/repeatable rule. I have two rules. if you are high you need more insulin (or more than likely a new set). If you are headed low you need less. I have a mindset that everyday is a new day. If you have no expectation of continuity, in some ways it takes the pressure off. We set the low and high alarms so we head problems off at the pass. (80 and 180). If we are routinely out of range that doesnt have something to do with pizza or soccer I make a change to the basal profile. Once a week i will look at his Dexcom charts (particularly the chart that shows the percentile data by hour of day) to keep me honest.

    Also if we are high we go low carb for the next meal. No need to throw gas on a fire.

    If you think about it, the artificial/bionic pancreas people dont necessarily care about anything except a few things:
    - what is the number now
    - what direction is the # heading
    - how much insulin have we administered.

    It then makes a decision.

    If they can do it, i can do it. I am trying to approximate that in my head without the regression equations etc..
     
  8. jenm999

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    In fact, an AP/BP doesn't even "care" what the real number is. It's just a set point and it's constantly making micro adjustments to bring you back. That's why the actual number accuracy of the CGM is not really critical so much as verifying drift from the set point.
     
  9. samson

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    None of the AP algorithms have done a great job of meal bolusing, so while being reactive after a meal to keep numbers in range makes sense, it still seems prudent to proactively gather as much data as possible on how to bolus for meals.
    If our son never had to eat, I have no doubt that, with AP or without, his numbers would be in range almost all the time. But the big wildcard, at least for us, is eating.
     
  10. wilf

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    Very cool. Glucose surfing.

    If my daughter ever gets a CGM or equivalent then she would be on this in no time. :cwds:
     
  11. Lakeman

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    Great ideas everyone. Thank you all
     
  12. Ali

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    Hello
    It is really hard. I am a T1 of over 40 years and it is still very hard to be proactive. I do think with basals the programs can really learn to adjust and come up with a really good middle ground of basal rates. The bolus for meals and adjusting for variations in exercise and absorption and the clogged sets gets tricky. But, I would love a better basal pattern that for me, even after forty years, is hard to see the patterns, just too much data for me to absorb. It would be great to have a system that responded to the at the moment data instead of "you parents" or "you" the T1 at 3AM. Oh my lord the improvement in your health from the better sleep is huge. So at this point I often run high at night just to sleep for more than 6 hours. I am desperate for an overnight system, and any help in the day is huge. Believe me, no matter how "not" proactive or "super accurate" any system is, anything that buys you time from thinking about your disease is huge over 80 years:). Perfect would be wonderful but any help is huge! Ali
     
    Last edited: Sep 8, 2016
  13. andiej

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    Well that very much depends what equipment we are using. When we moved to Dexcom we found being reactive worked brilliantly. To give you a bit of back story. Jack diagnosed aged 10 2.5 years ago. First year honeymoon and all hba1c's were under 6.5, we used a pump and pricks. As honeymoon ended we moved to the libre, around the same time puberty kicked in and he started high school, hba1'c's increased to 6.9 - 7.3 using the libre we did a combination of reactive and proactive. just after the 2 year mark when puberty was driving me nuts we moved to Dexcom, alarms allowed us to be reactive but to be reactive quickly...hba1c came down to 6.4...though now he's a teen he doesn't want to wear dex anymore so we are back to pricks so now i have to work at spotting patterns etc and sure we correct each prick but nowhere near as often as we did with the libre and definitely not as often as with Dex. I dread to think what our a1c will be this time :(
     

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