In Control, On Average, and Under Water

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I finally got down to the lab to get my blood tests done the other week. The last one was about four or five months ago, so this HbA1c is an important measure of my progress and control over the past few months. (For those of you unfamiliar with HbA1cs, it is a test of longterm plasma glucose concentration that serves as a measurement of average blood sugar over a three to six month period. For more information, see Wikipedia or the NIH’s medical encyclopedia.)

I got the results about a week and a half ago; I’ve been delaying writing about them since then, mostly because I’ve been delaying thinking about them since then.

In other words,
“‘The time has come,’ the Walrus said,
‘To talk of many things:
Of shoes–and ships–and sealing-wax–
Of cabbages–and kings–‘” (Lewis Carroll, 1872)

This is me stalling for time.

Ok– deep breath; it is better if I just dive in, so the water doesn’t feel so cold.

My HbA1c was 6.3%. For those of you unfamiliar with HbA1cs, that means that on average over the past few months, my blood glucose has been about 145 mg/dL. For those of you unfamiliar with me, that means I feel like I’ve failed.

(And there’s that moment where I hit the water and it is under and over and all around and it is cold. Instinct and panic push against the roof of my mouth, and all I can do is fight the temptation to breathe in the cold water.)

Let me explain myself: for the past few years, I’ve had HbA1cs of 5.9 and 6.0%. This translates to an average blood glucose of about 130 mg/dL, and sits just above the cusp of non-diabetic values, which range from 4.0 – 5.9%.

In other words, on average, from the outside, I was almost normal. That must be success, right?

The problem is, averages are deceptive. Truth of the matter is, for the past few years, I spent way too much time hanging around a blood glucose of 50 or 60. I woke up in the middle of the night with measurements below 45 at least once a week.

Why? Why couldn’t I see those lows coming, bolus less, eat more?

Good question. Here is me being honest (bear with me now; the cold of the water slows my limbs and severs my toes as I kick upwards): I did see it coming. I could have bolused less, and I should have. But, despite my better sense, and my years of education, and the concerned admonition of my husband, and the oh-shit warnings of my doctor, being low was less scary than being high.

Being low is less scary than being high.

It shouldn’t be. If I stop and think, or if I’m explaining diabetes to the unacquainted, I know full well that extended periods of high blood sugar are indeed damaging, but severe lows even for a short time can lead to comas, fainting, or horrid accidents. As if that’s not enough, my doctor informed me recently that new studies imply that extended incidence of hypoglycemia can cause debilitating mental degradation over time.

Yes; I know all that; I see all that. Yet all I can feel is: high blood sugar is failure. Failure to plan, failure to anticipate, and, most tellingly, failure to control. High blood sugar felt like loss of control, and so I would push ever lower to avoid the possibility of being high.

Why doesn’t low blood sugar feel equally out of control? I don’t know; I’m not a psychologist and do not understand all the emotional and psychological mechanisms at play, but I presume my feelings are similar to the kind that drive anorexia: an expectation reasonable in moderation (controlled blood glucose/controlled weight), taken to one extreme (severe hypoglycemia/starvation) in order to avoid the emotional impact of another (hyperglycemia/obesity). Initially, external indicators feel like success (“Your HbA1c looks great!”/”You look great! Have you lost weight?”), until things move too far to one end of the spectrum. And my friends and family purse their lips with worry. And it’s 2 AM and my husband says in exasperation– “You’re 33. How many times do we have to do this?”

So. I am not aiming for a blood glucose of 70 anymore. I’m aiming for 130. I suspend my basal and eat corrective carbohydrates when I’m 100 now, so I can stop myself before I reach 50. I write down the factors and variables I am considering when I bolus to make sure I am not over accounting or adding in extra units arbitrarily. I make a conscious effort to think to myself: do not overbolus; better to be 150 in thirty minutes than 50.

(And the water thins out and I can feel the light, press against the tension of the surface.)

I see the fruits of this labor; being low feels physically awful, and not being low all the time means I think more clearly and I panic less. I miss 130 at times, and end up hyperglycemic, or hypo, but less often than before.

And my HbA1c is 6.3. This is progress. This is good, I tell myself. This is not failure.

And as I continue to get more involved in the diabetic community here and see the promise of better care through thought and science, I can almost convince myself to believe that.

(And I reach air and breathe is relief, safety in the expansion of molecules. And I pause, treading water, waiting for my blood to catch in the wind and accept the cold.)

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Jessica Apple

Mike and I often talk about the fact that if a type 1’s a1c is unusually good, it probably means he’s spending a lot of time way too low.  The lows are miserable, and though I am someone who is horrified at anything over 129 on the glucometer… I’ll take a 180 over a 40 any day.
Sounds like you’re doing a great job!

Sally
Sally

I think you are swimming, not treading water, already.
I like the paragraph that starts “So.” best of all because you are strong and totally committed.

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