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About That A1C

What is an A1C test?

A1C is shorthand for "HbA1C" or glycated hemoglobin. It is a blood test, usually done by finger prick at modern clinics and hospitals, used to diagnose diabetes and asses how well someone is managing their disease. The A1C value is a number that reflects your average blood glucose (BG) over the course of three months - which is why most patients see their endocrinologist every three months. More importantly, red blood cells typically live over the course of 2-3 months, so the A1C measures the hemoglobin's exposure to glucose over that period. This amount is reflected as a percentage (for mg/dL metrics) or ratio (for mmol/mol metrics). Glucose is a sugar that enters your bloodstream from the foods you eat. In short, the higher your A1C, the more glucose is attached to your red blood cells.

Coral in her T1d Truth t-shirt available on Zazzle.com/t1dlife
Why is this number important?

It's important to set some guidelines or goals, but the A1C does not paint a whole picture. For example, someone with frequent hypoglycemia or low BGs, will likely have an average of 90-120 mg/dL over a 90-day period. This may seem favorable to them, but with that many lows, how truly happy or healthy are they? If Coral were to have many frequent hypo's at such a young age, it would be detrimental to her health, growth, and damaging to her brain cells. The same goes for if she were constantly averaging over 200 mg/dL for months and years. She would likely have such diabetes complications as eye retinopathy, neuropathy, and kidney or liver failure before she's 30 years of age.

Good-Glucose-tshirt-zazzle

What is Coral's A1C?

We literally just had her latest endocrinologist or "endo" appointment today, Tuesday May 15, and I'm proud to say she has been cruising in the low six percentile for the past 12 months! Despite stubborn high BGs over 250 mg/dL on multiple occasions during our Oahu Trip, we managed to get back on track these last couple weeks to receive some good news, it's 6.3! It was previously 6.2 at her endo appointment end of January. We're not even eating super low carb (less than 5-10g carbs) during lunch and dinner anymore either. Everything in moderation balanced with fun activities and exercise. If a particular food makes her BG spike and keeps her "high," then it isn't worth the bolus. We always try to find healthier substitutes for snacks like those listed here.

How did you achieve this?

DEXCOM CGM: Coral was diagnosed at 15 months old on March 11, 2016 with an A1C of 11%, finger prick was around 450 in the ER. By the sixth month post-diagnosis, I believe her a1c went down to the seventh percentile. We started using a Dexcom G5 continuous glucose monitor or CGM on April 2016 which gave us great insight as to where her BG was trending, allowing us to prevent highs (with correction boluses aka fast-acting insulin) and/or lows (with fast-acting carbs). We later discovered this technique was known as Sugar Surfing. Honestly, we had been sugar surfing before reading the book. We made sure to set the Dexcom's "high alert" setting to no more than 200 mg/dL and the low alert setting to 70 mg/dL. She's still hypounaware or not able to feel and/or verbalize low symptoms. If the high alert setting is too high, it's more difficult to prevent a spike in BG whether two hours post-prandial (after a meal) or just fasting. If I had just given her a bolus, but Dexcom shows she's still trending up past 200, I'll set the high alert to what I think she'll "flatten out" (straight arrow on Dexcom) to which is about 220-250 depending on the circumstances and what kind of carbs she ate. Once she's back in range (80-180), I'll reset the high alert back down to 200 mg/dL.

PUMPING: We started Coral on the Animas One Touch Ping insulin pump in April 2017. The first 10-12 weeks were like starting "new" and a huge pain in the okole [oh-koh-leh] or butt. The main reasons being - no more Lantus or slow-acting insulin, just fast-acting insulin (Novolog at the time) placed in the pump reservoir to act as both. There's a steep learning curve to making pump settings for I:C or Insulin to carb ratio, ISF or Insulin Sensitivity Factor and BG target in addition to basal profiles and/or time settings. These may vary depending on her growth and amount of physical activity that day. Basically, I don't usually make any changes except to her basal settings because of said activity and foods. I'll wait until I notice a pattern of either high or low BG occurrences at the same times, usually overnight based on her Dexcom graphs. For example, if she's consistently high between the hours of 1am to 4am, regardless of what she ate for dinner, then I will increase her basal from say 0.075 to 0.1 an hour prior to the noted rise in BG. We have about ten basal time settings on a single profile on her pump. We've always made our own pump setting changes since we got the hang of it after May 2017.

I am reluctant in lowering her daytime basal settings where the lowest is currently set at 0.175 for various reasons like change in eating habits or activity. For this, I am grateful for the Ping's Temporary Basal setting where I can decrease it from 10-100% (or completely off) for intervals of 30 minutes at a time. I use the temp off setting for when she is running around non-stop at the park, parent and me class, gymnastics, or fasting overnight and slowly dropping from 90.

Overall, both the Dexcom and pump have given us more control and flexibility over the years. We will be looking into upgrading to the newly approved Dexcom G6 and switching to the Tandem Tslim X2 pump most likely before the end of June. We have decided to go with this pump versus Medtronic or Omnipod since it is a) easier to update software than entire hardware, b) will feature an Auto-Suspend mode before end of 2018, and c) awaiting closed-loop system or CLS by early 2019. It is not worth the time and effort to make our own CLS with her Animas Pump and we will most likely no longer need or desire a remote function once it becomes so.

TIMING IS EVERYTHING: We are able to enjoy carbs in moderation with proper timing of insulin. Her pre-meal BG will determine how soon in advance we will give her a bolus via pump or even a syringe (as needed, for example: if over 200 mg/dL and nagging to eat right away). Simple carbs like fruit or ice cream cause BG to rise quicker than complex carbs like starches. Therefore, if she's 90 trending downwards, I bolus at first bite. If she's 180 steady, I pre-bolus about 10-15min ahead of eating anything over 6g carbs. Everyone's timing varies per individual and same goes for how certain foods affect their body. Use good judgement and always consult your doctor for medical advice.

KEEP RESEARCHING & LEARNING: Both my husband and I have read many books on Type 1 diabetes and managing with a pump and CGM after Coral was diagnosed. I highly recommend every T1d, especially parents of T1d's, to do the same if they wish to take control of this disease. For those using a CGM and/or insulin pump, "Pumping Insulin," 6th edition, by John Walsh and Ruth Roberts is a technical must-have book. Nurse's looking to get their diabetes educator certification also reference that book. It's best read from start to finish and then used as reference for specific topics much like what I've discussed in prior paragraphs. In fact, this book can replace an endo except for the prescriptions needed [if you know how to utilize the information accordingly]. Haha.

As previously mentioned, "Sugar Surfing" by Stephen W. Ponder, is useful until it simply just becomes entertaining. I preferred "Think Like a Pancreas" by Gary Scheiner over the former. During the month of November, aka Diabetes Awareness Month, I constantly referred to Pumping Insulin and Think Like a Pancreas for posts on Instagram. I also enjoyed reading "Taking Control of Your Diabetes" by Steven V. Edelmen, MD who's conference was very informative, per my Hubs.

"Diabetes Solution" by Richard Bernstein is not likely suited for Type 1 toddlers and best for an audience older than five years old due to the strict low carb belief. As with anything you read, including this blog, take what you want and leave the rest so that you can find a solution that works for you in accordance with your primary care giver and/or endo.

Why does Dexcom Clarity show a higher average than my A1C result?

This may likely be due to Dexcom's algorithm and use of data over the course of 90 days. Also, the Dexcom sensor or any other CGM sensor has a wider range of mean absolute relative deviation or MARD versus fingerstick values on a glucose meter. Dexcom Clarity is a tool to give you a general idea of where your average BG may lie, give or take 10-20 points off. It is not a definite number. Do not let it discourage you or affect your mindset and performance. Coral's Dexcom Clarity and the Sugarmate app (uses it's own prediction algorithm in addition to Dexcom readings) both showed her average was between 141-145 mg/dL. However, her 6.3 A1C would be an average BG of 134 and is categorized with "pre-diabetic" individuals (see A1C infographic chart).


Something to keep in mind

Staying in-range is just as important as allowing Coral to "be a kid." She can't very well enjoy what she's doing if her BGs are on a constant glucoaster every day. That lack of stability would ultimately be her demise. We simply won't allow any chance of any type of diabetes complications to threaten her livelihood. We like to enjoy things in moderation and try our best to achieve balance in our lives. Anyone who has met Coral can clearly see how happy she is, singing and dancing most places we go, saying "Hi" to random people, and smiling from ear to ear. We will keep on thriving because we know it is  possible to still live a happy life while managing this disease.
Just remember, you can do anything you set your mind to, but it takes action, perseverance, and facing your fears.
- Gillian Anderson 
Mahalo for reading,
Shelsea

REFERENCES:
The A1c Test and Diabetes. National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/diabetes/overview/tests-diagnosis/a1c-test. Accessed May 15, 2018.

Performance Evaluations of Continuous Glucose Monitoring Systems: Precision Absolute Relative Deviation Is Part of the Assessment. US National Library of Medicine National Institutes of Health. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3879746/. Accessed May 15, 2018.


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