On FB the topic of A1c levels, and dropping them, came up. I realized that many people have fantastic A1c goals, but aren’t always sure where to start to attain those goals. It’s no easy process, that’s for sure! I’m a walking example.
As a child my A1c levels were always just ‘ok’. Not horrible, but certainly not great. As I moved out on my own my A1c levels skyrocketed. I didn’t have the right knowledge or tools to do what I needed to do to keep things under control – and add a crazy college and work schedule, a social life, and wanting to ‘feel normal’ to the mix and you get bad results. I had years where my A1c levels ranged from 10.5 to over 14. No, that’s not a typo. I was so overwhelmed by that point that I didn’t even bother trying to fix things – I figured it would be way too much work and I just didn’t think I needed to care so early in my life….I thought complications wouldn’t hit me anytime soon.
Then in 2007 I was diagnosed with proliferative diabetic retinopathy, began an intense battle to keep my eyesight, and I realized I was in really deep – I needed to make changes and I needed to make them immediately.
The first choice I made was to ask for a pump. I had known for a while that MDI wasn’t cutting it for me, but I’d also had no interest whatsoever in a pump. After my diagnosis with PDR I did some research and realized that my first step towards better control needed to start with trying a pump.
My endo said no. He said I needed to have an A1c under 7 for him to recommend me for pump therapy. I tried to argue – my necessary basal rates at that time were far too variable for the Lantus I was using to work well – I was hitting super lows and super highs daily. He still said no. I ended up in DKA several times that year and on one occasion a CDE at the hospital came in to talk to me. I explained my frustration with my endo and his lack of support. The CDE immediately called the clinic where I see my endo and arranged for me to be transferred to the care of a new endo. Two weeks later I was in seeing him, asked for a pump, and was told that I was a perfect candidate.
I had to meet with several CDEs and a dietician first, but eventually I got my pump in the summer of 2008 – already a year into my battle with PDR.
In the next three months I managed to drop my A1c from 10.5 to 6.5 – the lowest it had ever been in my life. This was due in large part to being able to get the basals I needed when I needed them.
Since that time I’ve done well and have no plans to ever return to MDI – it just doesn’t work for me. Since December of 2010 I’ve kept my A1c levels under 6. Is it easy? Hell no. Is it something I can just do on auto-pilot now? Hell no.
I have learned how to make smart adjustments to my ratios and how to bolus in different ways. My top recommendations for someone looking to lower their A1c are:
1. Invest in a good kitchen scale – and weigh as much of your food as you can in grams. Even prepackaged foods labeled as one serving are often larger or smaller than one serving – and this make a difference in how much insulin you need!
2. Learn how early you need to bolus for a meal or snack to avoid a huge post-prandial spike in BG. For some people it’s 30 minutes before eating, for others it’s 2 minutes. For those with gastroparesis it might even be AFTER they’ve eaten. Experiment with it. Keep a record. Find what works best for you. The more you reduce those spikes, the better your A1c will be.
3. If you use an insulin pump, learn how to give extended boluses. If you find that bolusing normally for something high in fat like pizza results in death-defying lows followed by rebound highs then you need to investigate extended boluses. Each pump handles this a little differently – check your pump manual if you aren’t familiar with how to do this on your particular pump. Then start experimenting with HOW to break apart and extend those boluses. You won’t get it right the first time, and over time you may find you need to change your method. But this can help level you out a lot better than a standard bolus can.
4. Figure out your basal rates through basal testing. If your basal rates are not set correctly you are going to be chasing highs or lows all day. This in turn makes it really hard to know if your correction factors and insulin:carb ratios are correct or not. If you are new to pumping then getting appropriate basal rates established should be one of your top priorities.
5. Talk to others. Find new ways others are handling D and managing their BGs. Not everyone follows the same rules and procedures. Find what works best for you. For example, I use something called TAG (total available glucose) quite often, in which I give extended boluses for a small percentage of the protein and fat in a meal. This works for me because I find that protein and fat spikes my BG levels. For other people this doesn’t occur and they don’t use a TAG approach because this would cause them to have a low. Just because I do it doesn’t mean it’s what others have to do – we are all different.
If you use any of these suggestions please speak with your endocrinologist about it – especially bolusing early, TAG, or extended boluses. What works for me is not appropriate for everyone else and I certainly want you to take this list with a grain of salt. I’m not giving anyone medical advice – just giving some ideas for options you may want to explore through research and good discussions with your doctor.