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February 10, 2006

A1c (Glycohemoglobin, HgbA1c)

Question from Newton, New Jersey, USA:

My 12 year old son has had type 1 for two years. This past July he went on a pump, which we love. However, his A1cs are still hovering around the low 9s and I can't seem to get them down. The doctor doesn't seem too worried, but I am and don't know what else to do. I send in his numbers and meals all the time, but my nurse has told me she doesn't know why he does what he does or how to fix it. My regular pediatrician called them to mention my unhappiness, but I never heard from them. They are the only specialist around my area and they are still one hour away. I don't know what else to do for him. He is very good about testing frequently to monitor closely but we can't figure any of his numbers out. Do you have any suggestions?

Answer:

One my problems with teens is the concept of living on basal: too many do it. The pump runs and they just let it. The EuroDiab group looked at the A1c as related to number of boluses. Not surprisingly, the more, the better. One really should give a bolus for the glucose before the meal and a bolus for the food right after the meal. A correction in between isn’t a bad idea. I’m now up to seven or eight boluses a day. Have you thought about the dual wave? Many use it with success. The pump just helps; it isn’t the answer.

Look at the daily totals. If they are a lot different, why? Is it really that much difference in food or missed boluses? Are there lots of fixed units of insulin meaning no calculations, just guessing? The latest pumps will tell you the proportions of boluses that are to food, to sugar and manual guessing. They also tell the ratio of basal to bolus; mostly basal means no meal insulin. Even with a pump, great diabetes control is hard work.

LD