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What BG's go with an A1C of 5.3%

Discussion in 'Parents of Children with Type 1' started by Darryl, Sep 3, 2010.

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  1. sooz

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    Thank you for your input. I read the thread you provided the link for which I had missed when it was posted and found it very interesting although I was also interested to see Quote: This study was conducted using people without diabetes. Of course we try to keep Hailey in range to the best of our ability but she does experience lows and since we do not have a continuous monitor it is impossible without testing her every hour to know how long she is low. She does feel her lows usually and we correct right away when they happen. We have been lucky that Hailey has not had a seizure (knock on wood) although her non D sister did have one from heat. It must be truly scary to have that happen. It is really hard for me to keep track of everyone on here so thank you for letting me know that Lee's child has had that terrible reaction from a low.
     
  2. sooz

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    Thank you Tammy, I must have missed the discussion of kids with a1cs over 6.0 having complications?
     
  3. momtojess

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    Just search a1c. There isn't a whole thread titled that, but several threads where certain posters drivel about how horrible highs are and that only a having near non-diabetic a1c will prevent complications.

    Honestly, the thing I like to look at the most is Richard's sticky in the general forum. He has had a1c's from 5.5 to 11.8, not to mention the years before they even had such a thing as an a1c test...and 64 yrs later he has no complications. I think there is more to what causes complications than just #s, perhaps things like gentetics, enviroment, etc but that is just my theory and I don't feel like a looking for studies so take it for whats its worth.
     
    Last edited: Sep 5, 2010
  4. StillMamamia

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    This was also on that article

    and

    That's why we have to be vigilant. There are, unfortunately, no certainties with D. We can only do our best and be very proactive.
     
  5. Darryl

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    Here are a few prior posts where I explained how we use the CGM data to keep BG in the nondiabetic range as much as possible

    1) From Sept 2008, this is the basic method
    http://forums.childrenwithdiabetes.com/showpost.php?p=263645&postcount=52

    2) From Sept. 2009 - See post #14 in this thread.
    http://forums.childrenwithdiabetes.com/showthread.php?t=38078

    (Oh, and don't worry about the "never over 240 rule". Someone was worried that perhaps dd would be punished if this rule was broken, but as I explained, it's not that kind of a rule. The rule means simply that we get aggressive, as described in the post, when BG gets that high.)

    Since the time of the 2nd post above, BG control has gotten more difficult as basal needs vary a lot from day to day. We still use the same basic rules when BG is within the normal range. On the days when BG is harder to control, we have to estimate how much additional bolus and basal are needed based on our experience rather than on simple formulas like in post #1.

    As I said earlier, the way you learn to drive a car is to drive a car. Each car handles differently, and each road presents different challenges. Yet we all learn to drive as long as our car handles well and our eyes are open all of the time. The more often you steer, the less you have to turn the wheel, and the less likely you are to over-steer. When the road bends unexpectedly you have to turn the wheel hard, without any kind of system or mathematical formula to help you. Managing D with a CGM has always seemed to be exactly the same.
     
  6. Darryl

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    Leah will bolus for even 1 or 2 carbs, unless she's eating the carbs to raise her BG. It's so quick and easy to do that, it's just in her routine.

    We don't analyze Leah's results at all! All we do is adjust BG up if it's low, and adjust it down if it's high. The graphs, which I run every few months, are just because I find them interesting, and I like to show her what a great job she's doing.

    Reducing A1C has also never been our goal. Our goal is simply to keep her BG in the nondiabetic range because that's what her human body is designed to tolerate. When it's outside that range, she adjusts until it's back in range.

    We do look for trends in carb ratio, and change them when we see a pattern. It's not often, though. We change carb ratios just a few times each year. We also look for basal patterns, and adjust her baseline basal program every few days. Some aspects of the program are consistent, such as needing more basal between 5 AM and 10 AM, and needing very little between 8 PM and midnight. If we get woken up three nights in a row due to a high or low BG at the same time, we'll change her basal program according to how much correcting we needed to do the night prior.
     
  7. momtojess

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    Ah, I didn't realize that your basal changes were temp basals. I guess that makes our regime similar but as not extreme.
     
  8. momtojess

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    What is her i:c ratio? We wouldn't be able to cover just 1 carb for Jess because the animas only goes as small at .05 for a bolus.
     
  9. Lee

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    Yes - my child does have lows. And my child has had three seizures based on these overnight lows. And our endo has set 3 as the magic number for seizures and prolonged physiological effects of lows.

    I now have the PLEASURE of sitting through every freakin appointment and listening to an endo or/and a CDE touting the risks of bad lows- strokes, brain damage, permanent nerve damage, what have you...

    I am not saying that our kids do not experience lows, and I am not saying that they do not experience highs - I am just saying that prolonged lows lead to as much physical and mental harm as prolonged highs. And I would rather run my kid at 100 then run them at 70 to prevent this harm.

    Once your kid has three seizures, and once you see you child looking like she had a stroke, unable to talk, seeing one side of her face sagging, pissing herself, well - go right ahead and tell me that lows blood sugars can't cause harm - until them, remember - you haven't walked a mile in my shoes yet. Until you are in a ER, wondering for hours if your child will ever be normal again, well, than you can be nonchalant about lows...

    I feel just as strongly about the health risk of lows as Darryl feels about the health risks as highs - and that is my damn right.
     
    Last edited: Sep 5, 2010
  10. Darryl

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    I'm not sure where the concept of "sustained and repeated lows" is coming from but would like to make two comments:
    • The NIH defines the normal fasting range to be 70-99, and hypoglyemcia to be "a blood glucose level below 50 mg/dL".

      So, just for the heck of it, I re-ran the Carelink graphs with the hypo threshold set to 50, for the same week of crazy BG numbers (July 1-8) that we were looking at earlier. And guess what the data shows? In the entire 7-day period, there was exactly *1* hypo excursion, and the total time spent in hypo (when rounded to the nearest digit) was 0%. The graph is below.

      Now, I know that endo's call a 70 a low, but actually it's the low end of normal and certainly does not cause brain damage or most of the people in the world would be brain damaged. Below 70 is low. Below 50 is a cause of concern. In D management, we always treat a 70 because of the risk that it might go much lower, but not because 70 is, on its own, damaging.


    • Do we really believe that any D child here does not have similar lows? Or worse lows? Or even, god forbid, hypos by the NIH standard - 40's, 30's, or 20's?. Or do our particular CGM plots simply provide a window into what is typical but goes undetected in children who are not using a CGM? We do know that rebounds happen in many children, and rebounds are a epinepherine response to a bad low. Some people see rebounds "all the time." Yet despite Leah's "sustained and repeated lows", she's never experienced a rebound. Or a seizure, loss of conciousness, inability to treat herself, or symptoms worse than "I feel a little low." I think some perspective is in order here, as well as recognition that not everyone has yet to post 8 weeks of CGM plots and disclose what's really going on ;).


      [​IMG]
     
    Last edited: Sep 5, 2010
  11. Darryl

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    Yes, temp basals. Currently we limit temp basals to 2 hours, then see if more time is needed.
     
  12. Darryl

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    Becky,

    I hope you know that neither you, nor I, nor anyone here believes that lows are good, or even acceptable. That is why Leah has a device which alarms when her BG is below 80, and she begins treating the BG with carbs and reduced basals until it comes back above 80. She is never "run" at 70, her target is 90.

    I think the main point we're really discussing is whether a higher target, or higher A1C, would prevent lows. I don't think so. In our experience, unless we ran the BG's really high, lows will happen.

    Should Leah ever experience a serious or symptomatic low, you can bet that we'd re-evaluate her alarm thresholds, and raise that 80 to provide earlier warning and more time to treat.
     
  13. MamaC

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    And this is where I will weigh in. Admittedly, I do not strive for control as tight as Darryl is able to achieve (although I wish I could, but I cannot deny my almost adult son his freedom and his own responsibility for self-care). Even without that level of control, my son has had about a half dozen hypo seizures. And what Lee describes, quite accurately, I might add...the vacant stare, the combativeness, the loss of function, the aftermath, one near death...this is a place no parent wants to go, and a place no parent I know would be able to leave totally behind.

    Given the number of seizures Tom has had you may ask if they are neurological in origin. That has been ruled out via EEG and neuro consult.
     
  14. MamaC

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    I must also state my concern about adolescent tendencies to eating disorders, for males as well as females, and the possibility that carb obsession can play into a predisposition to those tendencies.
     
  15. momtojess

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    Sustained or repeated lows....that came from seeing the graph showing 12+ hrs below 70 in a week. In order to have that much time below 70, it is either have bg stuck that low, or repeatedly going low.

    Perhaps, in a non-diabetic, below 50 is need for concern..but as said in another thread today, a diabetic's bg can drop in a way that a non-d person can't. Perhaps, endos like to say under 70 is low because with the 20% meter variation, a 70 could really be as low as a 56.

    Even with your re-run report, she spent 40 mins that week under 50. I can honestly say my child doesn't have similar lows. Rarely do we see anything under 60, and anytime under 70 isn't for hours at a time/day/week...but then again, our a1c isn't in the 5s nor do I want it to be. For us, an a1c that low would be as harmful as an a1c over 9.

    As for recognition that not everyone is yet to post 8 weeks of graphs....umm yea, its a public forum, and this is your kids personal medical information.
     
  16. Darryl

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    Sure, if the low was undetected, and the treatment of the low didn't already start 30 minutes prior, and the too-high basal was left that way... I guess that's why Leah's BG never drops low enough to be symptomatic.

    Not sure what all the fuss is over "private medical information". These are just graphs of blood sugar. Leah is happy that it helps others. Somehow I doubt that's the reason why people aren't posting more real data like this in the forum ;).
     
  17. momtojess

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    Well, speaking for myself, I am not posting my child's blood sugar logs, graphs, a1cs, etc on an open public forum. Next time I download the dexcom I will be happy to email you a copy if you would like. Just to let you know, its gonna be awhile.

    Sure, I can ask my 8 yr old if she is okay with it, but seeing that she is 8, I am not sure she would still be happy with that decision in 20 yrs from now.
     
  18. Midwestmomma

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    Darryl, I have a couple questions if you will...

    Does your daughter play any physical sports ? experience delayed lows from them if she does?

    Does she have a day where she pigs out on whatever she wants...just because she is a kid and wants to be "normal" like her friends?

    Do you have her on a restricted diet/amount of carbs besides the Celiac diet ?

    These are just things that have me wondering...not accusing or being persnickety....just asking.:cwds:
     
  19. swellman

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    Dude, it's a red herring.

    It's an obvious and lame attempt to smear what the creator of these forums and site has already lauded. Screw 'em. Most of us are here to learn and, whether one agrees or disagrees with the premise, rational discussion will certainly benefit everyone. I applaud you for your fortitude to keep addressing pertinent questions while, hopefully, ignoring the obvious self fulfilling prophesy.
     
  20. Diana

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    I cannot do this without CGM, and I have two months worth of data this summer to prove it :eek: It was ugly. Apidra also helps alot because we can correct more often and basal changes have a quicker effect.

    I change the basal rate at some point every single day. If he is really active tomorrow and needs less basal, it will show up on the CGM and I'll change the basal rate. If he is not so active the next day, his numbers will creep up and I'll adjust the basal when I see that happen. If I miscount carbs and he goes low, I'll treat and reduce the basal. Sure, he might not have really needed the basal decrease (because it was actually too much bolus and not a basal shift that caused the low) but I'll eventually see that on the CGM and change the basal back.

    We worked on it alot this summer. You alarm low - eat something, adjust your basal. Since there is only one rate programmed in the pump, he doesn't have to figure out what time of day it is to make sure he chooses the right one. He doesn't have to figure out whether it is a 10%, 20%, or 30% temp change, and he doesn't have to figure out how long to run the temp for.

    I don't use a formula. If he really is shooting up quickly, I will increase the basal 0.10 instead of 0.05. If we are getting really aggressive, I will raise the low threshold so I can back off before he crashes. I haven't taught him any of that though. Right now, he is allowed to increase only 0.05 at a time. Once this becomes routine for him, we'll start working on more sophisticated decisions.

    ETA: My son is on relatively low basal rates, so a 0.05 change is a fairly significant change. A high rate for us is 0.4 units. He often is only getting 0.15 units/hour.
     
    Last edited: Sep 6, 2010
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