So following on from my piece on what classifies as a hypo (you can read it here) – and the addition of the word “waffy” to the worldwide vocabulary - I thought I’d develop the idea that the patient with diabetes and the medical professionals have different opinions on what is good and what is bad. Again I’ll be basing my thoughts on my slightly messed up thinking following 30-odd years of varying control levels and judgement. I could use medical research and qualified expert opinion but why should I start doing that now?
Before we start I’ve a simple question for the fellow Ds reading this. For the non-Ds don’t give up; hopefully the rest of this piece will give you a delve into the brain of one person with diabetes – as always your diabetes may vary, so this isn’t guidance or the opinion of everyone but it’s mine and the one thing writing down my random thoughts has proven is that others think the same as me. Maybe. Sometimes.
Anyway I promised you a simple question so here it is:
What is better to be slightly low / waffy / hypo (4mmol/L or 73 mg/dl) or to be slightly high (10mmol/L or 180mg/dl)?
OK, you don’t have to tell anyone your answer but I’ll guide you through mine. I’ll preface this by saying that I have relatively good hypo awareness and no noticeable complications.
For me it’s going to be the low every time - apart from when driving, operating heavy machinery, unicycling across the grand canyon etc. For years the one judgement of ‘success’ of my 24/7 ‘management’ – lol there’s another lose term, was the score returned by a simple blood test that takes a mean average of my BGs for a long period. HbA1c measures your average BG for the previous eight to twelve weeks. That’s perfect you might think. Surely it’s the easiest way to look at what my ‘normal’ BG is. So for years when looking at the results Consultants (Endos) would look over their glasses at me and say “Hmm, that’s a little high, you need to bring that down”. Simple English you might think but the use of the word high when discussing HbA1c has had a huge influence on my opinion on whether it’s better to be serially-waffy or ‘high’. If I have to bring down my average then I need to get as low as I can reasonably be for a long as I can and also try to reduce the number of ketone-inducing hypers to lift the average to a more normal level.
This sat well with me as a logical practice for years before the huge head-mess from my diabetes specialist nurse who suggested that the best way to bring down my high A1c was to reduce the number of hypos and aim to lift my target BG levels. What? How? Yes, again, I know the logic is there but it’s erm, wrong. You can’t tell me for years my BGs are too high and then ask me to fix it by reducing the number of lows and lifting my target levels. Malfunction, brain does not compute!!
So after picking me up off the floor and explaining the logic we agreed that my high levels were due to over-treating of hypos and therefore if I had less hypos I would drink less Coke and there’d be less of a rebound. Perfect. Then I had to glide through meetings with my local GP’s Diabetes Nurse who was still in 1986 in her thinking (that was similar to mine) that if my A1c was high then I wasn’t having enough insulin. Thankfully she was happy that maybe my DSN was the one I should check anything with first.
So me and the DSN have treated the cause of the high average but she’s still contrary to me on what a dangerous level to run at is. I’d prefer to bounce along at between 4.5 and 6 (81 and 108) in my perfect D dreams, but this is ‘not good’ in her world of being trained that any hypo is evil. I’ve got relatively good hypo awareness so any waffy moments can be helped with a couple of Fruit Pastilles (3g of carbs in each) to lift me gently out of head-fuzzines.
And so we sit at seemingly opposite sides of the same desire to improve my overall control and bring my average BG to a figure that can sit comfortably on their trained measure of what will prevent ‘complications’ in the near/far future. If my BGs are high I know that blindness and imminent death will be around the corner. The proof of this conflict is when I borrow a CGM for a week. I have one coming up and once again look forward to the background trending analysis it can provide. Going off on a tangent slightly the CGM benefits this time won’t be useful in measuring a normal day as we’re off to the London 2012 Olympics for a few days on the day after I have it stuck in. Obviously when we applied for tickets we went for the high profile sports to see the world’s most talented and most famous athletes. Hence why we now will be watching the group stages of women’s basketball and women’s hockey. Hey ho, we’ll be there and I’m still pretty damn excited.
Where was I? Ah, yes. CGM analysis. When we sit down and analyse my BGs her eyes will zoom in to anything marked red as a hypo and mine will go straight for anything in double figures. In her defence she’ll also look at those in the middle and compliment me on any that are in range; whereas I’ll ignore those and just look at the failures. She’ll come out with statements such as “Oo, you were a little low all day that day” while I’ll be looking at the same figures of between 4.2 and 5.8 (76 and 104) and think “Wow, you got it spot on that day Dave”. For me low is good because I'm now at a stage where I'm relatively comfortable how much treatment I'll need to bring it up. Treating a slight high is more of a black art with correction doses frequently ending in lows.
So who needs retraining; me or my DSN? I know I can't be alone in my thinking but going back to the previous blog how do I persuade my healthcare professionals that all hypos aren't evil?
I absolutely love the psychology that comes with being a person with diabetes and how much of a factor in a someone's treatment it can be. As our day to day management is in our hands, it is a foolish Health Care Professional who thinks that by telling us what is 'correct' it will be enough to get us to buy into the principle. I know there are some HCPs out there who do know all this but for them to understand why takes time and reprogramming of their mind too.
To conclude what is best waffy or high? I know the real answer is that neither are good and perfect control is what we must strive for but for as long as we are told that complications (there’s that word again) arrive because of bad control which is judged by highness on the A1c scale, I think I’ll stay tending towards the low side. DSN; I’m sorry.
PS. I hope everyone in the UK has now completed their feedback to the government on food labelling. If not, why not? Go here. Now. Thanks :)