Giving Context to a Hba1c Result

I really want to get my hba1c done. I have a referral to pathology sitting in my diabetes file at home, to tide me over until my next endo appointment. But I know it’s still a bit too soon. 

I have a pretty good idea of where I’ll be sitting. Yet my deepest, darkest desires are still chasing sight of a number. A scorecard. That stamp of validation, that will tell me how well or not-so-well I have been doing with my diabetes over the past couple of months.

It’s silly, really.

A hba1c is just a number. It’s only one small element in the scope of managing diabetes. In fact, it’s not even the most accurate measure of how I am managing. Although it’s supposed to be a 3 month ‘average,’ around 50% of that result is drawn from the past four weeks worth of blood sugar levels. If there are big variances in my levels, then the result is likely to be less accurate. I was even told that clinic results can vary by as much as 0.5% from pathology!

With holidays and Easter in the rearview mirror, I definitely felt that it was time to sit down and review my data. So over the weekend, I gathered all of my diabetes devices and uploaded their data to Diasend.

Diasend is a brilliant tool for reviewing my diabetes data at home. It’s a web-based software platform, where I can upload the data from my insulin pump, blood glucose meters and FreeStyle Libre. It generates the data from all these devices into one, easy to read report. So for instance, I can see what my reading was at 12pm, the carbs I ate with lunch, the insulin dose I gave for lunch, and the basal rate I had running at the time.

When I review my data, there are five things I like to look at besides from my hba1c, which give me an indication of how I am doing with my d-management.

Obviously, the first thing I want to know is my average blood sugar level over the past 2-4 weeks. I then use this handy tool to convert my average blood sugar level to an estimated hba1c.

The second thing I think about is how often I am checking my blood sugar. I’ve always been in a pretty good habit of checking my levels before and after meals, and before and after significant activity. I also try to check once during the night, if I don’t sleep over my 1am alarm! Checking my blood sugar more than four times a day means that I’m getting a bigger picture of where my levels are sitting through the day, and that my average blood sugar level is accurate.

The third thing I look at is the Standard Deviation in my blood glucose readings. In other words, how high or how low are my blood sugar levels going? How often are these kinds of swings happening? How big is the variability between these kinds of swings? Before I started using an insulin pump and more actively managing my levels, there were big swings. For several years, I was able to scrape together half decent a1c results, but I always knew that they weren’t accurate because of the large deviation. Ideally, my standard deviation should be less than 3 for the hba1c result to be a reliable one.

My fourth consideration is to any significant events that might have influenced my levels lately. I know that I’ve been travelling and eating a lot over Easter. The increased physical activity has produced a few more lows, while the excess of food has produced a few stubborn highs. There’s usually a good reason for everything, and I simply feel so much better about a disappointing couple of days when it can be explained.

Finally, I try to focus on the progress I’ve made since last time. Whether it’s a lower standard deviation, a problem area I’ve been able to fix, or whether I’m simply feeling more comfortable with my management since last time. I constantly remind myself of these victories, to motivate myself going forward.

A hba1c result is an important number. But there is so much more context that needs to be given due consideration, before we begin popping the champagne bottle, or smashing it to pieces.

Review: Think Like a Pancreas by Gary Scheiner

Think Like a Pancreas. My first diabetes educator often reminded me of the job that I was ultimately trying to replicate.

It was also the title of a very useful book that she recommended to me, if I were ever able to get my hands on a copy of it.

I only wish it hadn’t taken me six years to finally shell out and order it from eBay.

For me, this book ultimately reflected much of what I had gone through in my journey with diabetes. From my diagnosis, to getting my head around diabetes, to getting a bit more active in my management with basal and bolus calculations, to finally learning to navigate my way through the daily diabetes challenges a little more smoothly.

Many of the little intricacies and quirky things I’ve learned about my diabetes over the past six years are covered in this book.

Several of the lightbulb moments I’ve had since I started pumping insulin last year can also be found in this book.

Answers to the many questions or musings I randomly have about my diabetes are also tucked away in these pages.

Ultimately, this book would have saved me so much time and frustration in the last year or so!

Think Like a Pancreas is a book for anyone with diabetes who uses insulin, whether on multiple daily injections or an insulin pump. Author Gary Scheiner is a longtime type 1, diagnosed back in 1985 at the age of 18. Gary starts his book with the very basics of what diabetes is, and talks us through many of the common insulins and insulin regimens. I felt that in this regard, the book would also be easy for a family member or loved one without diabetes to read.

Gary talks us through some of our common motivations for reading this book, and some of the advantages we can expect to see from seeking out better control. He also highlights some of the tools that we will need in order to succeed in our quest for better blood sugar levels – our healthcare professionals, our diabetes tools, glucose monitoring, record keeping, data analysis, and the right mindset, to name a few.

As we head into the meatier part of the book, Gary highlights the importance of setting a well tuned background rate of insulin. I know that a well tuned basal rate will keep my blood sugar levels steady while I’m fasting, and generally easier to manage the remainder of the time. A not-so-well tuned basal rate will leave me feeling like I’m walking through quicksand.

Gary gives practical, actionable tips for setting a background rate of insulin – a chapter I feel would be highly advantageous to a new insulin pumper trying to figure out basal rates. There’s a very useful table in this chapter where Gary gives suggestions for tweaking basal rates based on the current rate, and the magnitude of the rise or fall while fasting. For those on multiple daily injections, Gary sets out the conditions for conducting an overnight fasting basal test, and advises how to go about adjusting long acting insulin doses.

Gary then proceeds to talk about calculating bolus, or mealtime insulin to cover carbohydrates, and insulin to correct blood sugar levels. Ever correct a high blood sugar level during the night, only to wake up low soon after? One of my lightbulb moments in this chapter was the confirmation of greater insulin sensitivity that seems to occur in the wee hours. There are more useful tables in this chapter giving tips for bolus timing to minimise post meal spikes in blood sugar, and adjustments for post-meal exercise. 

Welcome to the real world. Gary proceeds to talk through the many other elements that tend to affect blood sugar levels. Caffeine, stress, illness, travel and pregnancy, to name a few – with tips for dealing with them. There are also tips for dealing with protein when consumed in the absence of carbohydrate. And have you ever gone out for dinner, only to find yourself correcting resilient blood sugar levels well into the night? One of the lightbulb moments for me in this section of the book, was Gary’s suggestion of using a temporary basal rate for several hours to combat the insulin resistance that typically follows a larger, restaurant, or higher fat meal.

This is the best book I’ve read about diabetes, ever.

I loved that it didn’t tell me that I was doing anything wrong, or that I needed to change something about myself. It simply helped me to better utilise my insulin regime, so that I would be able to get more out of it.

It went so much further than simply talking about diabetes. It gave me practical, actionable tips to better navigate my way through the daily diabetes challenges, helping me to ultimately see more in range blood sugar levels.

Today, Think Like a Pancreas sits within reach on my bookshelf, for easy reference. It’s kind of like having my diabetes educator’s advice handy when I can’t get to her. Whenever I sense that something’s a little bit off, I’ll pick it up and revisit the relevant sections of the book.

A must read.

P.S. I’m more of a hard-copy kind of guy, but if that sort of thing doesn’t bother you, you can grab a digital copy from Amazon and start reading on your iPad/tablet/device today. I swear I wasn’t paid to say any of this – it’s just a really good book! 

“How Do You Manage Sweets With Your Diabetes?”

My red, plastic plate was piled high. I’d grabbed a scoop of hot apple crumble topped with Connoisseur ice-cream, a Cherry Ripe chocolate cupcake and a slice of liquor sponge cake from the desert table at our family get together over the weekend.

Get togethers in our family are all about the food. I spent most of Thursday telling Mum that she’d prepared way too much for our get together that evening, and the remainder of the weekend saying I told you so. Nonetheless, you still want to try and have a little bit of all the deliciousness.

“How do you manage the sweets with your diabetes?” my Uncle asked me as I sat down at the table with my plate.

After all these years with type 1, you sort of begin to expect these kinds of questions. I mean, even I get a little conscious when I sit down with a piled plate, wondering what others must think.

I went on to explain that I would look at the plate and estimate that I had at least 100g of carbs there.

I went on to say that I would enter 100g into my insulin pump, and that the pump would deliver an insulin dose for me.

I went on to explain that I can technically eat anything, so long as I cover it with insulin.

I went on to explain that I should still be mindful of how many carbs I eat, but that it was Easter and I didn’t care so much today.

I went on to explain that if it wasn’t Easter and I did care a bit more, a back up bolus of at least 15 minutes would also be helpful.

I didn’t explain the months of hard work that went into perfecting my basal rate, so that my mealtime insulin does its job and doesn’t get stuck in quicksand.

I didn’t explain how I weigh all of the food I prepare at home, multiply that weight by carb factors, and then divide it by my own unique insulin to carb ratio.

I didn’t explain how some foods are digested very slowly, while others are digested very rapidly, and insulin needs to be backed up or delayed accordingly.

I didn’t explain that a larger, higher fat or restaurant meal, requires a temporary basal rate for several hours to combat the insulin resistance.

I didn’t explain the importance of checking my blood sugar levels post meal, to ensure that my insulin is doing its job.

I didn’t explain that sometimes I get it wrong, and I end up eating my way out of lows.

I didn’t explain that sometimes I also get it wrong, and I end up shovelling down insulin and bucket loads of water at 3am to bring down the highs.

I didn’t explain the huge investment I’ve had to put into learning, observing and applying, so that I don’t make these errors so often and see more numbers in range.

I know that my uncle wasn’t trying to be rude or judgemental. And it was nice of him to ask. I liked that it opened up the dialogue, and that I could deflate the stigma around sweets and diabetes.

It’s just a shame that despite how simply I’d put it, nobody in that room will remember a word of what I said.

It’s a shame that despite how many times I check my blood sugar or pull out my pump during the day, nobody seems to notice the diabetes.

It’s a shame that I’m only ever asked these questions when I’m seen with a plate piled high with desert.

Easter Holiday Vibes

I was greeted by a beautiful deep blue sky and the fading orange light of the setting sun as I made my way out the doors of Perth Airport on Tuesday afternoon.

The past couple of days back at home have been pure bliss. The early morning silence that hasn’t been interrupted by blaring alarms telling me to get up for work. The comfort of waking up in my own bed, at an hour of my choosing. Getting up and having all the time in the world to sit and savour that first coffee of the day. A welcome return to sunshine, after a few miserable looking days in Melbourne. Making myself a decent lunch instead of the 2 minute toasted sandwich that’s become one of my diet staples lately. Sprawling on the couch in front of a movie in the afternoons, with all the time in the world to do so.

Having this time out over the past week has given me a much needed break.

When I think back on the first quarter of this year, it feels like a blur. I remember lots of rushing, lots of thoughts swirling in my head, lots of grumbling, lots of exhaustion and hardly enough time to just be.

I can’t remember the last time that I haven’t been constantly thinking about work, diabetes, today, tomorrow and all of these things that I haven’t done – and yet this break has given me just that.

My Easter weekend kicked off with far too much food last night when we had Mum’s side of the family over for dinner. Over the coming days, there will be more food, chocolate, espresso and other sweets. While times like these have proven to be a challenge with type 1 diabetes, I do genuinely believe that it’s something that I have become better at navigating my way through over time – without having to give up the chocolate.

Over these past few days, I’ve also been thinking a lot about how I can extend these relaxed holiday vibes into the other 51 weeks of the year. Because all of those other elements that contribute to my mindfulness and wellbeing, are ultimately what I will need in order to continue to manage my diabetes to the best of my ability.

I hope you are able to enjoy some time out this Easter weekend, too.

Wishing you a very happy, and safe Easter break. With lots of chocolate, of course…