When I started using an Omnipod pump last May my initial blood glucose target was 100. After a couple of months using the system my average blood sugar (according to Dex) was 113 SD 35 and 5% hypos but my A1C increased from 5.8 to 6.2. At that time I lowered my target blood glucose to 85 and changed my correction factor. None of these manipulations had much effect as today my average blood sugar continues to be 113 SD 31 and 4% hypos but now my A1C is 6.4. I realize an A1C is not a good indicator of control and I know a lower SD and fewer hypos are good things. But I'm beginning to think it doesn't really matter what number I put in for my target blood sugar the pump and all the math that goes in to it are designed to avoid hypos and not to achieve a target below 100
This is brilliant! I love my pump, but I have never thought it to be the reason for me achieving my targets. It is just a tool. You are so right about that A1c not being a good indicator of control, that is what I have been saying for years. Pumps are amazing but we are the real math wizards in the use of them.
Well since I have an insulin sensitivity issue my CDE put my targets a lot higher than they were for my mdi targets. I'm assuming not because they want me to lose control, but this is a better way to avoid hypoglycemia. I think that's the big goal to pumping to have some more flexibility and also to avoid hypoglycemic episodes and provide for the best control you can do when you use it right.
I think it really depends on your personal habits, for example how promptly you correct. If for example you put in a target of 100 but eat lots of carbs and continually spike and don't test very often so don't correct very often (exaggerating to make the point) you will not be achieving 100 very often. And of course even doing so presumes a perfectly calculated ISF and duration and a bunch of other mystical variables. It's just a machine. How you use it is the determinant of results. And there are plenty of variables we don't even recognize let alone control that go into the mix as well!
Clare - Let me first say congratulations on your excellent control. Your low BG variability, in my opinion, is a greater indicator of you overall metabolic health.
I get an A1c test about every three months. A few years back my A1c series was 6.8, 6.7. 6.6, 6.0, 6.8, 6.8. The 6.0 number was an outlier. I learned that the A1c has flaws. Doctors have told me that the two weeks to one month immediately before the blood draw have a greater influence on the result.
I got my latest A1c result a few days ago. I had numbers very similar to your SD, average, and % hypos. But I did have a few hyper BG excursions overnight that lasted 6-8 hours during the two-week period just before the blood draw. My A1c came in at 6.3%. I was expecting <= 6.1%. No big deal. I place much more value in BG variability, average BG, % time in target, and % time <= 70.
Also keep in mind the data flaws in the CGM. I'm sure you've observed discrepancies with your fingerstick BGs actually lower and higher than the CGM peaks. I also have seen a lot of bad data in the first 24-48 hours of my Dex readings. The last 6 or 8 sensors have performed poorly compared to previous sensors. I've not had one of the last 6 or 8 make it to 14 days. I have much more data dropout. I remember when I consistently got 288 readings every day.
I don't think that the pump algorithms skew insulin doses in favor of avoiding hypoglycemia. My correction doses seem to usually perform as expected. While I shoot for 85, I often end up in the 90s, not a bad outcome given all the variables in the equation.
The A1c is just a number. I truly beleive that it doesn't correlate 100% with my actual BGs. You're doing a great job. Keep on keeping on!
For me with MDI it was interesting to see that if I set my target to 100 I had much worse control with much wider variability in BG numbers. Using the same dose calculator I had much better control if I set the target to 85. I achieved my "real" target of 100 with a much lower SD.
Once moved to the tslim the same effect applied. Pump target 100 wild swings and average BG 120 or higher, set target to 85, average BG 100 with SDs in the 25% range.
Don't know if it's just my own personal response to insulin but for me it did not matter if the delivery method was a pump or MDI, but it did matter where I set my target.
It did not seem to matter if I dosed from my G4 or from my meter most of the time. With extreme physical activity I rely on the meter but for most meals I use the Dex. For me I find when in steady state on the G4 my numbers are reliable. As always YMMV.
I, too, target 85 for BG corrections. I've only been doing this for a few years but it works well. Why shoot for 100 when your real target is 85? I understand that the standard medical advice usually sets the target at 110 or 120. It's weird but my corrections rarely take me to 85; a landing spot in the upper 90s is common.
The higher BG correction target makes sense for most people that have higher variability. If your standard deviation is 50 and you aim for 100 then you risk sinking to 50 for some of the time. A standard deviation of 30 lets me, like you, to safely fly much closer to the danger zone.
It took a little bit of convincing for me to win over my doctor to this point of view. When she and CDE look at the CGM, fingerstick meter, and pump data, they can see that I can set a lower BG correction target as well as a lower average BG target. What that tells me is that very few people with diabetes use these tactics.
exactly! There is a quote that I love - "The music is not in the guitar"! It is true. And so in this case, The control is not in the pump or the algorithms. The bolus wizard has no idea what you did (or did not do) all day long, or if you are feeling bad or have a fever or plan to do cartwheels and aerial flips after you eat.
That's a great point Sugar Bertie. I'll bet that most people here can attest to the fact of giving a second correction to make up for the first one landing too high. I agree that high BGs create insulin resistance.
I wonder if anyone has developed a formula that takes this into account. I think that the pump manufacturers and the doctors that advise them are always building in a safety factor that promotes landing high with a pump-calculated correction dose. If the pump would take into account BG variability, then it could be more aggressive with PWDs that have a low BG variability.
I understand the legal fear that motivates under-dosing. We play a game with a medication that can and does kill.
I love that! I'm in the middle of compiling a list of "morsels", pithy literary quotes to use as prompts in my writing group. I've quoted Tolstoy, Mao and Ursula LeGuin. I think I need to add Karen from TuD! (or do you know the source?)
Zoe, I got that guitar gig from from Life Is Good shirt for my rock star (I love their t-shirts - they are so very positive and promote optimism and the shirts are really colorful and super soft!):
1012-lifeisgoodrakeandremembermusicisnotintheguitar.jpg (149 KB)
And here is the positive message from today:
Remember that happiness is a way of travel not a destination. - Roy Goodman (shared from LIG facebook page).
The LIG mantra is Do What You Like, Like What You Do :)
So you don't know the source of the quote, Karen? (I can always just write "unknown")
“The music is not in the guitar” is from a book called Life is Good by Jake and Rocket (aka, Bert and John Jacobs).
Bert Jacobs and John Jacobs are the people's names? (I have the feeling I'm supposed to know who these people are, but I don't..lol. I just like the quote, especially for writers. I'm more likely to quote dead Russians than Facebook blogs..lol
Zoe, they are not facebook blogs, they are: Bert & John Jacobs. Brothers & co-founders of Life Is Good - 1978, Boston, Ma
The quote is in their book, which is full of upbeat quotes and is written for kids (of which I admit I will always be!).
I don't "know" them. You could look up Life Is Good and read all about them. I have supported them and their causes and company for many years but that's just me. I wear their products myself, and give them as gifts whenever possible.
They are good guys (a good company) and they really do spread good vibes, joy. They are all about their Kids Foundation, and Playmakers. Who knows, maybe they would enjoy making some positive and optimistic product wear for diabetes. I just love them!
ps - Dear Clare, I did not mean to make your discussion and ad for Life Is Good....sorry.
Pumps are amazing things, but the pump controller is the formula maker in my opinion, and knowing how and when to adjust is genius :)
Thanks, Karen!
I was always taught that the target bg set in the pump is not your blood glucose target and I don’t see how it could be enough to affect your overall average by itself. It’s just a number the pump uses when it calculates a correction dose. There are too many other factors that come into play that could offset any changes your target makes. For example basal rates are not affected by the target bg and neither is your insulin to carbohydrate ratio if you eat without a bg check.
I don't bother paying that much attention to the correction factor on my pump. I just sort of let it ride and figure the other numbers will do the trick. If my BG is running high, I figure "not enough insulin" and turn it up, either basal or bolus, depending on how the numbers look. I think the numbers can overlap, if your basal is a bit hot, maybe it will wash out some food for you and you can get away with less insulin/ unit of carbs but the basic question is more insulin or less insulin. I don't think pumps really use algorithms either, I think those are for CGMs, to determine how to convert interstitial fluid into BG, an imprecise science. I've found that the more variables I put into the mix, the harder it is to work on things but, if I do "more" or "less" I can manage things pretty well.
I use 85 for a target. If it's not 85, I think about what I might do to get it there or whether or not I really want to get it there. To me, that's a useful tool.
Clare, were you calibrating your CGM with the Omnipod...maybe the discrepancy has to do with the 'bad' POD test strips and our needing to change or increase the coding on the POD? Just a thought. I just had my A1C done too, it was 6.7%, the highest I've ever had..since a few months after Dx..ugh!