Drop it Low.

I’ve been on a mission for the last few months. It’s called Operation Get My Freaking A1c Back Down After Going Up Over a Full Percentage Point While Traveling in Asia a Year Ago (might need to get an abbreviation for this project name…). After struggling much more than I anticipated in the past year with all of our transitions (travel, wedding, new city, new job, you know EVERYTHING), I feel like I am finally actually making some headway in getting my numbers down. But the worst part about tightening up your control is the inevitable fact that more lows come along with it.

As I get more aggressive with preventing and treating highs, the price I pay for it is more lows. In just the past week, as I’ve been tweaking my overnight basals, I’ve woken up between 3am and 5am FIVE TIMES with some serious lows. I’ve since worked out (most of) the kinks on the basals, but it was a rough week of poor sleep and “low hangovers” the next day. I’ve also had some afternoon problems with lows as I try to be more accurate with dosing for lunch. I recently downloaded my CGM to look for any patterns and there they were, all those lows, called out in bright red:

Download of BGs

If you have explored your CGM download before, you will know that the thermograph at the bottom of the patterns shows the frequency, duration, and intensity of the lows (the brighter and larger the red section, the worse and more often they happen). This is just seven days worth of BGs and you can really see where I’m struggling. I still go a bit high overnight, and then correct that with boluses or basals, but pay the price early morning with a low.

Tightening control for me has always meant a consequence of more lows.  Even with a CGM you can’t prevent the fact that you will have some dips – you’re correcting numbers you might not have in the past, stacking doses at times, and experimenting with basals. The goal for me here is to get the overall A1c down, and then troubleshoot the areas where I’m still having challenges. It’s not easy work, but it’s necessary. Which means I’ve kept the GU packs stocked and the can of cake frosting where I can grab it quickly.

Do you all find that when you really tighten up your control that the consequence is more lows? And if so, how do you deal with it? Do you work to bring everything down and then fix the problem areas? Or aim for a higher goal at first and slowly lower it?

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Look at your standard deviation. That will tell you where you are from your average most of the time. So if your average was 7mmol/L(126) and your standard deviation was 3mmol/L(54) you would be from 4mmol/L(72) to 10mmol/L(180).

Your target minus the standard deviation should not be in the lows. So with a standard deviation of 4mmol/L(72) you shouldn’t set your target lower than 8mmol/L(162) or you will be low often.

The key to better A1C is a tighter standard deviation, so postprandial highs and accurate counting.

I’m not pumping, I’m using MDIs. The problem I have is I don’t always know what my activity level is going to be for a certain day, so I often have to readjust with my fast=acting. The problem is, it’s not as effective as having basals right and going from there.

The one thing I know I have a handle on is how much food I should be eating. As an extreme athlete has told us at our quarterly Sports and Diabetes Meeting: get enough fuel first. Without the right amount of energy everything falls apart. Then you can adjust your basals and dose for food.

Sometimes I take a step back and force myself to do the OPPOSITE of what I think I need to do…for instance, with all your overnight lows, you may try more basal and less dinner/correction/boluses to try to level things out (also that could completely backfire)…it’s all about trial and error!

I’ve been in a very similar situation before, and I did exactly what you said at the end of your post – aimed for a higher goal and then slowly lowered it. When I first got my pump I was having too many lows but I’d also set my “goal” a little too low… increasing by just 10 points has made a huge difference. I too am racing after a lower a1c and being patient is the hardest part!

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