Saturday, November 1, 2014

October 2014 results.

If you had asked me, a few years ago, about the voluntary public sharing of health related data, I would have responded that complete secrecy was essential. This is, in fact, still how I feel about most conditions: no one should know that you have high blood pressure, a bad lipid profile or a sexually transmitted disease.

Type 1 Diabetes changed my perception. For two reasons:
  1. every friend or person you interact with will ultimately know that you have T1D anyway. This is sometimes a good thing: friends can keep an eye on you and remind you to treat a low you might not be aware of. Partners or opponents in sport will be aware that you might need a few minutes to check and/or correct your blood sugars. This is also a bad thing: your bank will overcharge your mortgage. Uneducated people will think you have an unhealthy life style. Uber-idiots might think you are contagious. Trying to hide your diabetes will lead to sub-optimal treatment: skipping injections, trying to drive through a severe low. Information will leak whether you want it or not.
  2. when Max was diagnosed, the only resources that I could think of were books. There are some very good ones - Ragnar Hanas Type 1 Diabetes in children, adolescent and young adults is a must have. I learned a lot from them but I learned a lot more by looking at what experienced diabetics were sharing on the internet: movies of their sensor or pump insertions, sharing of their data pre or post exercise, how they handle potentially dangerous situations in the most practical way, how they tackle the myriad of daily issues a T1D faces. Information helps.
This is why I now believe that sharing T1D data is useful and will share more of it in the coming months, including full training and exercise data.

So, putting my money where my mouth is, here's our October summary as seen by our Dexcom CGM and a small discussion of it. Max is almost 14 and on MDI therapy (Novorapid and Lantus)

Mean glucose was reported to be 98: that's quite good, but not totally accurate. A statistical analysis of our Dexcom and Glucometer data has shown that our CGM is systematically running a bit low, underestimating results by 6 or 7 mg/dl. In addition to that, we still have too many lows, mostly during and post exercise. Since the CGM bottoms at 40 mg/dl and the Dexcom tends to recover slowly from lows, we are biasing the average lower. My guesstimate would be that we are running at a still decent 110 mg/dl average.

Standard Deviation remains one of the best indicators of blood glucose variability despite the near monthly appearance of new estimation methods (publish or perish), stands at 33 md/dl. That is very good given the mean glucose value. It shows that we aren't frantically over-treating lows and aren't driving our G levels all over the place. But let's not forget that the rule of thumb endocrinologists often quote "SD must be below 50% of MG" should be taken in the context of good control. A mean glucose of 250 and a SD or 120 is not good. 110 and 33 is.

Hypos: I still feel we have too many of them, but they are extremely hard to eliminate when one continues to be very active. This is a work in progress. Our rule for treating lows is to aim for 110 mg/dl based on a gram of carb per kg of weight calculation. After each correction, we wait 30 minutes before adding additional carbs as sugars need about that time to be absorbed. This is of course more tiring and work intensive than taking "a juice", but this also the only way to avoid over correcting highs.

In target: around 80%, and even around 90% if we consider lows to be on target. Well controlled lows don't hurt long term, highs do. On certain days, we can hit 100%, but then there is always an issue that disrupts that dream landscape.

Hypers: at 8% are a bit too high for my taste (who knows a diabetic who is happy with any highs anyway?) but could be worse. However, and that is a big issue, keeping the number of hypers below 10% is a lot of work, including a frequent corrective dose of insulin given at 4 or 5 AM. On the positive side, the total absence of hypers above 240 mg/dl is, in my book, the best part of this report. I am a bit anxious by nature and, whenever sugars are high, I can't prevent myself from picturing evil glucose molecules cooking themselves in my son's proteins and cells. The less that image is present in my mind, the better it is.

Profile: the average profile clearly shows the pattern we are battling. As discussed in a previous post, the current Lantus injection has been causing early night lows and is unable to control our current dawn phenomenon. It is not a huge issue medically speaking, but is becoming very tiring in practice. In some cases, the dawn phenomenon starts around 3 AM and the rise can be as big as 30 mg/dl per hour. At that point, an additional dose of 5U of Novorapid may be barely sufficient to keep the BG below 160 mg/dl at wake up time (the typical dose is 2-3U of Novorapid). If Max was using a pump, a solution would be to program a higher rate during that period, except that in about 1 night out of 4, we see no increase. Higher insulin deliveries could then create lows. The current strategy is to try to address those morning increases through a bit of standardized exercises.

That's all for today folks!

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