I just saw the results of my latest test results. A1C is 8.3. I am happy with this considering that that my first 2 years, I never saw one below 10. In my 3rd year now I see progress in the right direction, down for 9.2 in May. Even though this is better I was expecting something lower. Accu-Check has an A1C calculator, that I put my average glucose over the last 2 1/2 months, and it calculated my A1C at 7.5.
I wanted to find out why there is a difference, and what I needed to do to get it better. I think I have the right idea, but want to check.
A1C is an average glucose over 2-3 months, calculated from glycated hemoglobin. Glycated hemoglobin is in red blood cells, produced by a reaction with glucose in the blood, the more glucose in the blood the more glycated hemoglobin in blood cells.
My average glucose takes in to account both the highs and lows (I test about 5 - 6 times a day). Most of the day I test between 70 and 140 mg/dl. But in the evenings, it is not uncommon for me to see between 180 - 250 mg/dl. What I think, is during those high times, the levels of glycated hemoglobin is elevated, and adding to the average A1C. Even though it is for a shorter period of time compared to the more normal tests. It is like the more lower tests lowers the median compared to fewer higher tests when averaging glucose readings. At the same time, the higher tests, produces more glycated hemoglobin, raising the median compared to less glycated hemoglobin that is produced during the lower glucose readings.
Don't numbers just boggle the mind? :)
So, for me to get a better A1C, is to reduce or eliminate the highs (over 200)and try to keep the normals the same.
Just wondering, Eric, since you're on a pump, if you've thought about tweaking the basal rates for those evening hours when you are between 180 and 250 to bring down those numbers? I have found that having different basal rates for different "time zones" is what allows me to utilize the pump for those problem times.
Your Meter average will probably never convert to your A1c. Your meter average is influenced by your red blood cell count and Hematocrit value at the time of each test and if your Hematocrit is on the low side of 40% your meter will overstate the test value and if Hematocrit is higher than 40% the the meter will understate BG. Remember A1c is just the percentage of Glycated hemoglobin at the time your blood is drawn.
Most meters overstate my BG so my A1c is always lower than the number calculated from my meter average. And most meters can be off buy as much as 20% when close to 200mg/dL and get a little better with lower numbers around 100mg/dL.
You said you test about 5-6 times a day - that works out to about every 4 hours. The A1c takes into account every minute of that 24 hours, not just every 4 hours. When I was using a CGMS, it recorded a BS every 5 minutes so there were 12 numbers every hour or a total of 288 times a day. The CGMS reports were more reflective of a real day than my meter because it was testing every 5 minutes as opposed to every 4 hours. Don't forget, most of us don't test 5 minutes after a meal (unless we are actually testing a new food). If you don't test until 1 or 2 hours after you eat, you miss the after meal high. You didn't say when the 200 in the evening comes down, but if you are high before going to bed, it might be on the side most of the night and then you wake up with a good number.
Basically, the more you test, the closer you can be to your A1c number. I test 18 times a day (literally every hour), but it is still a little off. If I test and am over 200, I will wait longer to retest after a correction than if I test and am low.
My understanding is that most of us spike from our meals between one and 2 hour point, which is why we're taught to test at two hours.
Also the A1C is not a true average of 3 months, but is slanted towards the latter part of the period. I never have the breakdown in front of me when the topic comes up.
Thanks Zoe, Yes, before I left the Doctor's office, we did make changes to the evening settings, so far it is more inline with the rest of the day. This is the beginning of the 3rd month on the pump, I am sure there will be more tweeking.
My endo is great, she scheduled a phone appointment for 2 weeks, for a follow up. I am sure she will also email any changes that needs to be made as well.
So far the latest settings are working better so far. Still a little high compared to the rest of the day, but not as much of a big difference between after lunch and after supper, 20 - 30 points higher now, compared to 50 (or more) points higher before the change.
True Zoe, but I check at one because of gastroparesis and chances of going low. I think from reading in the Dexcom group when I was using it, a lot of people don't realize how big of a spike they have until they see those double arrows going up so that is why I wanted to mention the after meals.
Ah, that makes sense; I know gastroparesis changes the digestion timing. Yes, we all have our own spike points. I spent some time checking at various periods after my meals and found that I generally spiked around 1 3/4 hours so the 2 hour test works for me.
I am sure 2 hours works for most people. I forget to say why I do it at one hour!
I want a CGM. I had one about a week after I started on the pump, but I think it was used more to "fine tune" the initial settings for the pump. I forgot to talk to the doctor about that this time.
My doctor showed me the graphs from 3 days of the CGM. It was way different than the meter readings.
I wish I could test more often, but I sorta have to ration the test strips right now. That is why I want a CGM, but am having trouble finding out if they are consider durable medical supplies.
Thanks Kelly.
Because I have to ration the test strips, I will usually test about an hour before I go to bed, around 3 1/2 hours after I eat. Most mornings I wake up between 80 - 100, since I started using the pump. I think that this may be part of my answer here. I now test about 2 hours after other meals, so maybe I need to wait an hour or so after those meals as well to get a more accurate post meal reading.... I think I will try that this week. And start working on getting a CGM.
Any way I look at it, it is simply crazy to try and mimic what the body does naturally and perfectly. But I am not going to give up trying. :)
I'm not sure I understand, Eric. Are you saying you want to wait till 3-3 1/2 hours after your meals to test? I understand you are doing that with your bedtime test to save on strips, but if you test 3 1/2 hours after meals you will miss the spike that happens around 2 hours. If you are high you want to correct using your ISF so you don't stay high for too long.
Also, you need to be able to see if a high is due to mealtime issues (which would show up in your 2 hour test) or basal issues, which is what you see at several hours after a meal.
This difference is important you may need to do some tweaking of your basal rates for those evening hours when you are between 180 and 250. If your basals are off, then nothing works well. So if you are in range two hours after a meal more often than not, that's telling you that your I:C ratios are good. If you start to go high say 3+ hours after a meal then you need to tweak the basal rate for that time. You usually change it at least two hours before the period you are concerned with. So if you start hitting the 200s say at 9PM on a regular basis you want to increase your basal a tad around 7PM. Do you have Using Insulin by John Walsh? It really helps with all this. The basal rates are really important to your all around management and the ability to have different basal rates is how the pump helps you to do what your body does naturally!
Keeping on trying is the way to go! If you are "rationing" (good term!) I'd try to lobby for more strips. I have gotten letters from Blue Cross explaining "Medicare provides 4x strips/ day, so that's all we owe you..." but they keep providing me more than that, although the doc has rx'ed 14/ day and, by my count, the last shipment was for 13/ day, which seemed a bit odd.
It may be crazy to work to mimic the body's natural action but I think that's a useful goal to use, rather than the targets used by associations, based on longstanding experience with people who have trouble hitting the targets. The point of a target is to have a challenge, not a "slam dunk". I don't think you or your health care team should beat you up if you miss an ambitious target but my goals are to try to normalize things as much as I can.
Actually Medicare is 3 a day for people on insulin but like with your insurance you can get more - I do. If you want more than 3 a day, your doctor has a write a letter of medical necessity and you have to provide a log showing you are using them.
Maybe your supply company is trying to trick you and if you don't complain, they will continue to give you 13 a day and next time, it will be 12!
Being able to use a CGM really makes you aware of what is going on. A lot of people change their ways after seeing those double arrows going up. It is also helpful treating lows because if it alerts you at 68 but not dropping, you aren't going to be as aggressive as treating a 68 with 2 straight down arrows. That cuts back on rebound highs.
For most insurances, it is considered durable medical.
Is it your doctor or your insurance that won't give you more strips? You shouldn't have to ration them. You can appeal your insurance. You should be checking before & after meals, when you feel low and before you drive. Being on a pump, you need to be careful after putting a new site in. You could come up with a good appeal letter.
That's what Blue Cross said, I'm not Medicare eligible so I don't get anything from them directly, just the BCBS letter, that said 4x/ day. Maybe they are negotiating with them to hagggle us down?
No right now, I test about 2 hours after breakfast and lunch, after evening meal is when it is 3 1/2 hours after eating, or about an hour before bed. I live alone, and when I was in the hospital after diagnosis, I was frequently hypo at night. I can remember that only happening 2-3 times in 3 years (most recently after I started with the pump, but that has been taken care of, lower over night basal rate), but I still worry a little about that happening. My doctor did increase the basal between 4 pm and 12 am, about 4 days ago, so far this is working better, still may need tweeking a bit, but the rates have not went over 190 since then, with 150 the night of the change, 189, 174 and I missed testing last night, don't know how that happened.
I guess I should tell you,as well, I started a vegetarian diet in Jan last year, to help with a 20+ year issue with high cholesterol. I try to stay within 30-35 carbs for each meal. Most days will have a snack of fruit or some nuts. Sometimes the nuts come covered in chocolate, just for a change of pace (smile please). That seems to be about right, as I have energy throughout the day, and have maintained the same weight for over 3 years. BTW the cholesterol is now right in the middle of the recommended level for overall, LDL and HDL and have been that way since May 2011.
They lied to you! They are trying to haggle you down. They hope that you are someone else's problem when the complications hit from not testing.