What is Type 1 Diabetes?

Day 2 Prompt: Introduce your condition(s) to other Health Activists. What are 5 things you want them to know about your condition/your activism? 

When people learn that my 12 year old son has type 1 diabetes, the usually make certain assumptions about that the disease is, or where he "got it" from. Sadly, misconceptions are rampant when it comes to type 1 and the volume of incorrect information floating around is abundant. Sometimes it seems easier to tell people what type diabetes IS NOT, rather than what it is. 

It is NOT:

• caused by eating too much sugar, either as a child or adult, or by sugar at all
• caused by any lack of care or neglect on the part of a parent or caregiver 
• a casual disease that comes and goes. It is 24/7/365.
• a result of being obese or overweight, nor does it have anything to do with weight at all
• contagious, meaning you can't "catch" it from someone else
• a disease with diet restrictions. My son can eat chocolate, sweets, starchy foods, and sugar, just like your child (though when eaten in excess it WILL cause cavities, and lead to obesity and other health issues, just like in your child). We just need to balance his carbohydrate intake with insulin.
• curable.

Type 1 Diabetes is an autoimmune disease in which the insulin-producing beta cells in the pancreas are destroyed, causing the body to stop producing insulin, and blood glucose levels to rise. Without insulin, the body cannot survive, so type 1 diabetes IS fatal if untreated. Fortunately, it is treatable with insulin, which can be delivered either via syringes or subcutaneously using an insulin pump. While insulin therapy is far from a cure for type 1 diabetes, it provides patients with a tool with which they can live a long and healthy life.

It is a disease that never sleeps. It IS manageable, but with vigilance and constant care. Blood glucose levels must be checked throughout the day and night, and insulin must be given multiple times per day to keep blood glucose levels within an ideal range. Variations in blood glucose levels throughout the day are to be expected, but readings outside of the target range (highs and lows) should be treated immediately. Food intake must be closely monitored (carbohydrate intake causes a rise in blood glucose), as do activities that burn carbohydrates, such as exercise. Other factors that can, and do, affect blood glucose, include temperature, stress, illness, and hormones.

There is no cure for type 1 diabetes, so utmost attention to diabetes management is critical and lifelong.

Ok, so that's a few more than 5 things. It is what it is.

What Does 7 Years with Diabetes Look Like?

I'm deviating from the NHBPM prompts today because it's Dylan's 7 year anniversary of the day he was diagnosed with type 1 diabetes.

7 years ago today we found out that Dylan has type 1 diabetes (his diagnosis story can be found here).  That's significantly more than half of his lifetime. And while we're not big on celebrating his diaversary, this is how 7 years with diabetes breaks down, from a basic care standpoint:

15,340+ finger pokes

2190 injections (pre-pump)

609+ infusion set changes

1092 lows (avg of 3/week)

4 hypoglycemic seizures

3 hospitalizations

Approximately 63,800 units of insulin

$55,000+ spent on diabetes supplies

2557 days of worry

1 still-broken pancreas in a child only 11 years old

Diabetes is 24/7/365. Imagine what these numbers will look like after 20 years, or 40, or 80...

Talking to the Doc

Day 3 of NHBPM asks about a conversation with the doctor. It's a topic I've been considering writing about for a couple of months now, but haven't. Why am I avoiding it? Fear.

Rewind to spring of 2011. Dylan had been experiencing some edema (swelling/water retention) in his face, hands, and feet, and I was a bit worried about what was causing it. From what I could find, there didn't seem to be any correlation between diabetes and edema (though if I'm wrong, please let me know), so we asked our GP about it. Our GP (family doctor) thought maybe Dylan had developed an allergy, so he referred us to the allergy clinic at Children's Hospital (where we were added to the bottom of a 18 month waiting list). He didn't seem concerned, so I decided to let it go and wait for the clinic appointment.

At our next quarterly DEC (diabetes education centre) appointment, I mentioned the edema to our endocrinologist. She agreed with the GP.

Fast forward to August 2012. We finally received our appointment at Children's Hospital for the 28th. After a full medical exam and history, followed by a series of scratch tests for animal, plant, and environmental allergens, the allergist had no idea what Dylan was allergic to, if anything. He had no reaction to any of the scratch tests, and because the edema was constant, the doctor ruled out a food allergy. He gave us lab forms for celiac testing and Angioedema and sent us on our way. A 2 hour waste of time in my opinion, but at least we were one step closer to figuring out what WASN'T causing Dylan's inflammation.

A week later (early Sept 2012) we were back at the DEC for a check-up and this time it was anything BUT ordinary. After doing the routine weighing and measuring, evaluation of pump data, and quarterly A1c test, we sat down with the endocrinologist. As soon as she looked at Dylan I knew something was wrong. She was surprised he was still suffering from such severe edema. She had copies of the reports from both the GP and allergist, but had assumed the swelling had decreased since she had last seen him. She was noticeably worried.

There are not a lot of things that cause edema in the extremities in children and we had already eliminated the less severe causes. Her first suspicion was kidney failure, or a thyroid problem, so she ordered more lab work. At the top of the lab forms she wrote a message to the lab technicians asking to rush the tests and call her immediately with the results. She then told us to go straight to the hospital. Do not pass go, do not collect $200. Now I was panicking.

We live a block from a hospital, so we the lab work and went home. 2 hours after leaving the DEC clinic, I got a text from the endo stating that all the test results were normal. Dylan's thyroid and kidneys were functioning perfectly and all of the other bloodworm was also normal.

A wave of relief flooded over me, but again, it was temporary. We still didn't know what was wrong. The endo suggested Dylan go for an echocardiogram to make sure the swelling was not a result of a heart defect. Wtf? Are you eff'ing kidding me? Could this possibly get any more frightening? I was told to wait for Children's Hospital to call me with an appointment time.

Fast forward again, to last week, when we finally got a date for the echo. It's this coming Thursday. I'm emotionally torn, to say the least. My fingers are crossed that the echo reveals everything with his heart is normal, but a part of me is thinking, what else could it be?

Tweak, tweak

Last week I wrote about the problem we were having with Dyl constantly running slightly high (Trends Don't Lie). As a result, we upped a couple of basal rates in the hopes that it would at least curb the 2 daily spikes he was experiencing. And we were right, it did combat the spikes. However, it still left him elevated throughout the day, all day.

Fast forward to today, when we were back at the diabetes education center for a check-up. In addition to doing Dyl's quarterly A1c, weighing and measuring him, and talking about changes and updates in diet and exercise routine, the endocrinologist took a really hard look at Dyl's pump data and decided to make some pretty substantial changes. In fact, she increased every single basal rate. Background note: Dylan has six different basal rates which vary considerably at different times of day. For example, because he is prone to hypoglycemic seizures in his sleep, he takes less insulin at night. For some reason, which we really have no idea, he requires more than twice the amount of insulin between 2:30pm and 6:00pm than he does at any other time of day. The other 4 rates fall somewhere in between. (This ability to vary insulin delivery over a 24 hour period is one of the MANY reasons I love pumping over MDI.)

I've said this before, and I'll say it again and again: I love our endo and I trust her explicitly. So when she says increase all the basal rates, I do it. And I did, but not without fear. This is, by far, the most drastically we have ever altered Dylan's settings, and a couple of the settings were increased by as much as 0.2 units per hour. In an MDI user that injects insulin two or three times a day, 0.2 units may not seem like much, but in an 11 year old pumper, who boluses additional insulin for food, it's a lot. Fingers crossed that these changes get his bg levels back into ideal range, at least most of the time.

Evaluating the Numbers

Diabetes is a numbers game. We are forever chasing the elusive bliss of bg perfection, a better A1c, or day of spot on carb counting. Some days the planets align and all seems okay; other days we chase highs and lows via the diabetes roller coaster. But how do we evaluate success? And failure, for that matter? For many the quarterly A1c test is the ultimate report card, for others reporting is a daily process.

I fall somewhere in the middle. I look forward to (or dread) the quarterly A1c because I like the overall picture it presents. It gives us a "big picture" idea of how Dylan is doing, and while I try not to take it as a reflection on my ability as a d parent, let's face it, it's pretty hard not to. My problem with the A1c is that it doesn't take into account what is going on in Dylan's body each and every day. It's doesn't identify areas in which pump settings need to be adjusted, or carb ratios altered.

For this information I turn to the pump data itself, and while I have heard from countless people that they hate the Medtronic CareLink reports, I quite like them. I upload pump data every 2 weeks (or that is the goal anyway) and I go through the numbers with a fine toothed comb, looking for patterns, problems, or anything out of the ordinary. Without fail, I always learn something new; no 2 uploads are ever the same. In fact, that seems to be the rule with diabetes - as soon as things start to make sense, they change.

Over the past few months, one trend emerged over and over in the reports - Dylan was not testing enough. This has been an ongoing problem for us, and the one things we are continuously working on. Dylan is amazing about testing when he's at home, but regular testing at school has always been an issue, more so as he's gotten older.

The most recent upload, however, showed quite an improvement in testing, and more tests means a more accurate picture of what is really happening inside his body. So what did I learn this time? I learned that we need to up his basal setting almost across the board. In the 2 weeks of data, only 3 days did his average bg fall into the ideal range. The remaining 11 days it was just above normal. Was I surprised? At first, but then I took into account a number of things. First, it's been a couple of months since we made any pump adjustments. Second, he's growing, and has been eating a lot more lately. Third, hockey season is over, so his activity level has decreased a bit. Each of these factors, or all three, could be causing his bg to rise.

Without the reports, or a log of some kind, I would have to wait until our next quarterly A1c test and endo visit to find out this info and to make pump adjustments. But our next appointment isn't until the end of July, so that's a full month in which Dylan's bg could be running higher than it should, wreaking havoc on his body and making him feeling like crap unnecessarily.

So now what? We tweak. We increase basal rates a bit here and a bit there, and maybe increase carb ratios a tad. And we fire the data over to the endo for any additional changes. Then in 2 weeks we repeat the process. And we do it again, and again, and again, every couple of weeks, to ensure that Dylan's pump is giving the ideal amount of insulin to his body throughout every day.

Diabetes Time Capsule ~ HAWMC, Day 1

Today is the first day of WEGO Health's 2012 Health Activist Writer's Month Challenge. Yup, 30 posts in 30 days, so let's get this party started.

Today's prompt asks bloggers to pretend they are making a time capsule of their health focus that won't be opened until 2112. What's in it? What might people think of it when the find it?

Seeing as we keep all of our household diabetes supplies in a rubbermaid box, I think it's fitting that my time capsule be in the same. Its contents would be:

-insulin pump with instruction manual

-vial of insulin

-sample infusion set and reservoir

-blood glucose kit

-bottle of strips

-handful of lancets

-bottle of dextrose tablets

-couple of syringes

My guess would be that people opening my time capsule would be shocked that we even used such things. Hopefully that would be because diabetes had either long since been cured, or because the technology to control it was so far advanced that our pumps looked to them as the first insulin pump looks to us now. 

Technological development moves exponentially fast, so I find it unfathomable to even imagine where we might be in 100 years. After all, 100 years prior to now, there was NO treatment for diabetes whatsoever. Insulin has only been available for 90 years, and the first insulin pump wasn't invented until just over 30 years ago, at which time it was the size of a large backpack and looked like this

Can you imagine wearing one of these bad boys around?

**Don't forget to enter the Blood, Sweat & Carbs giveaway for your chance to win a $200 prepaid credit card. For full info, click here.**

Oddity

I don't know how many infusion sets I have changed over the years. A lot. Once every three days, for four and a half years (Dylan was on MDIs for his first two years with diabetes), would mean somewhere around three hundred and fifty site changes. It's basically always the same thing - disconnect tubing from Dyl, peel off old set, rewind pump, dispose of old reservoir, fill new reservoir, attach new tubing, insert in pump, prime, insert new cannula in Dylan, attach pump, fixed prime. Good for another three days, assuming nothing plugs, falls off, gets kinked, infected, or runs out batteries. It's become routine. So routine, in fact, that I rarely need to think about it; I move in an almost robotic state, much like when tying my shoes or brushing my teeth.

But today, for some bizarre reason, something was different. As I popped the new reservoir onto the top of the insulin vial and pulled back the plunger to fill the reservoir with insulin, I found myself struck by the oddity of it. I watched as the life saving serum slowly filled the tube-shaped reservoir, the liquid creeping up the marked plastic: 50 units, 100 units, 150 units. As it neared the 180 unit mark (Dylan will only use about 120 units over 3 days, but I always add a little extra), I released the plunger and removed the reservoir from the insulin vial.

I found myself overwhelmed in a way I cannot even explain. How can something so small be responsible for so much? This tiny amount of simple, watery-looking substance gives my son life for three days. Without it, he would die. I am well aware of this fact, and I am eternally grateful to Frederick Banting for his miraculous discovery over ninety years ago. I am in awe of the advances in the field of medicine, that enable my son to wear an insulin pump, essentially a mini-computer, that continually injects him with one of six different preset amounts of basal insulin, specific to his body weight, activity level, and the time of day.

And yet today, for the first time, I was genuinely struck with a feeling of surprise at how readily we accept and embrace this blend of nature and technology. Pumpers are not alone in their use of health technology; the addition of man-made materials to the human body is widely used, ranging from braces to pacemakers, to prosthetic limbs, to breast implants, to wheelchairs, among other things. Each device serves a purpose, and many are brilliant inventions that not only enhance lives, but save them, each and every day.

With the exception of insulin itself, an insulin pump is the greatest advancement in diabetes care to date. It has changed diabetes itself, enabling it to become an easily manageable disease with fewer side effects and a longer life expectancy than ever before. I love Dylan's insulin pump and I am so thrilled the technology is available. Yet it is still a machine, and for today I found that odd, that's all.

Take that Diabetes!

The search for a cause of Dylan's headaches has now brought us full circle. We have gone from blaming diabetes, to questioning his eye sight, and back to diabetes as a cause again. When I first thought diabetes was the culprit, I assumed it was high blood sugars that were giving Dylan headaches, but when we tracked the headaches, there was absolutely no correlation with elevated blood sugar so we eliminated D as a cause.

Then this past Friday, Dylan had his quarterly checkup at the Diabetes Education Center of our local hospital. After speaking with his endocrinologist about the headaches, she thinks that they may, in fact, be a result of D. Her belief is that they are an after effect of low blood sugar. When I heard this, it sounded vaguely familiar. I remember reading some comments from type 1 adults that compared the feeling of over-treating a low to a hangover. Does treating, or perhaps over-treating, a low result in a headache? And if so, is there any way to avoid this?

On a separate note, Dylan did a victory dance for his endo at the appointment Friday. His last A1c was in early December of last year and we were both very upset to see a result of 8.7. It was the highest he had even been and I felt like a complete failure as a d-mom to let his A1c get that high. The 8.7 was the direct result of Dylan being very nonchalant about his testing. He was great testing at home, but was neglecting to test at school, resulting in too many highs. His endo wanted to see a reduction of a full point, bringing his A1c into the upper 7's by the next appointment. A tough task indeed. We both vowed then and there to be more vigilant about testing, determined to bring that 8.7 down to a healthier level.

So were we successful? Not only did Dyl get his A1c into the 7's, he got it down to 7.1!! Personally, I would still like to see it lower, but we are celebrating this victory nonetheless. Take that diabetes!

"See"king Answers

Headaches can be quite a nuisance, and trying to identify their cause can be equally annoying. As I posted yesterday in Blame Diabetes, Dylan has been getting frequent headaches for the past few months and we have been unable to figure out why.

Originally I assumed they were blood sugar related, but after some simple tracking I quickly ruled out diabetes as a source. My next thought was that they were an allergic reaction to something. We saw our family doctor and he gave us some suggestions on how to check for a food allergy, but so far we've come up empty-handed. Dylan is currently on a waiting list to see a pediatric allergist, but the wait is almost a year, so it will likely be autumn before we get in.

Then Dylan came home from school a few weeks ago complaining that he was having difficulty seeing the overhead projector screen from his desk, leading me to think he was straining his eyes and needed glasses. He was due for his annual eye exam anyway, so we went in yesterday to see the optometrist. Another strike-out. Dylan's eyes are close to perfect, and while he has a -.25 in each eye, it is not enough to warrant glasses or to cause headaches. The optometrist was not at all concerned, and informed us that vision can fluctuate a little bit during growth spurts, and with diabetes. He expects it will stay the same or return to normal by next year's appointment.

I'm happy for Dylan that he doesn't need glasses (he really didn't want them), but I'm frustrated that we still have no idea what is causing his headaches. He has his quarterly DEC appointment (A1c test and visit with the diabetes team) tomorrow morning, so maybe his endo will have some answers.

And for the record, the results of his pupil dilation test (to check to any signs of diabetic retinopathy) were perfect. His eyes show no signs of any problems whatsoever.

Blame Diabetes

Suffice it to say I do this far too often. Diabetes is on my mind for such a large proportion of each and every day that I tend to hold it accountable for any problem in Dylan's life. Sure, a lot of the time it's warranted because diabetes is the culprit, but from time to time there are other factors at play. After all, he is an 11 year old boy. He CAN and WILL get sick, scraped, scratched, bruised, banged up, and heartbroken as he grows up, and many of those times it will have nothing to do with diabetes.

On and off for the past few months, Dylan has been battling headaches. Some are minor, some more intense, and some even causing nausea they are so powerful. At first, I wrote them off as normal, stress related aches and pains, but their persistence has me concerned.

My immediate reaction was that they were blood sugar related; that he was getting headaches when his blood glucose level was high. In fact, I was positive this was the cause (always quick to blame diabetes). So we started tracking patterns. Every time he had a headache we'd test his blood sugar, but we quickly learned that there was absolutely no correlation between his sugar levels and headaches.

Back to the drawing board we went, unable to figure out the cause of his discomfort. Fast forward to a couple of weeks ago when Dylan came home from school and told me he had been having trouble seeing the overhead projector screen from his desk in his classroom. As the metaphorical lightbulb flashed in my brain, I wondered, "Could it be that simple? Does he need glasses?"

He is due for his annual eye exam (the one with the pupil dilation) anyway, so I called the optometrist and made an appointment for Dylan to have a full eye exam. We see the doctor this afternoon, so hopefully I'll have some answers soon.

"Excuse Me, Where is the Banting & Best Museum?"

Until recently, this questions went unanswered, as there was no museum dedicated to Banting & Best, the Canadian researchers who discovered insulin and forever changed the lives of millions of people around the world.

This week, however, that finally changed. The exhibit, entitled "Insulin: Toronto's Gift to the World," opened yesterday at the MaRS center in Toronto, Canada. It not only shows how the scientists discovered insulin, back in the summer of 1921, but outlines the continuing legacy of their work both in Toronto and around the world.

Those visiting the permanent exhibit can see a video, plus items from Banting and Best's laboratory, including scientific equipment used by the pair, as well as a collection of photographs, letters, and documents. There is even a selection of vials of insulin dating back to the 1920's.

Insulin vials from the 1920's to now

Banting and Best's discovery is one of the most important medical advances in history, and remains today one of the "most spectacular therapies that medicine has in its arsenal." (Bliss, The Discovery of Insulin). \

Banting won the Nobel Prize in October of 1923 for his incredible contribution to medicine, but creators of the exhibit hope that it will inspire a new generation of diabetes investigators to help find the ultimate grail: a true physiological insulin replacement.

For complete article, visit http://www.healthzone.ca/health/article/1076505--exhibit-celebrates-insulin-toronto-s-gift-to-the-world.

"Mom, What's Wrong With Having Diabetes?"

Watching "Biggest Loser" is a longstanding Tuesday night tradition in our household. My husband and I have faithfully watched the show since its early days with Bob Harper and & Jillian Michaels, through Jillian's departure after Season 2, her return for Seasons 4 to 11 (and corresponding rise to "fitness diva" as I like to think of her), and her departure again at the end of Season 11, to the current Season 12 with new celebrity trainers. It is a weekly family event in our house; sometimes our kids watch the first hour with us and then my hubby and I watch the second hour after putting the kids in bed. Other times we tape the entire 2 hour episode and watch it later in the week. The kids love to witness the contestants' extreme transformations and I love the healthy lifestyle message promoted by the show and its trainers.

With each new season we watch the new contestants face the grueling workouts, the dramatic weigh-ins, and the before and after health evaluations. Early in each season, all of the contestants undergo a full medical exam by "Biggest Loser" doctors, and some of the findings are shared on the show. Most, if not all, of the men and women are told that they have some kind of health condition as a result of their weight; for some its high blood pressure, for some its early signs of heart disease, for some its asthma. There is usually at least one contestant who is told they have diabetes (or that they show early signs of diabetes and will develop the disease unless they make some major changes to their diet and lifestyle).

Don't get me wrong, I love the show and I have the utmost respect for the colossal challenge that its producers and trainers have taken on. Obesity has reached epidemic proportions in North America and if a big television network show with celebrity trainers and Cinderella-style weight loss stories can motivate people to make positive changes in their lives, then power to them! After all, every little bit helps, right?

Where I do take offense is when the show promotes incorrect and/or insufficient messages about diabetes. At least two contestants in this week's episode were informed by "Dr. H" that they had diabetes. There was no mention of what kind of diabetes, not even a brief explanation of what diabetes is. The doctor presented the information to the contestants as if it was a death sentence and with each diagnosis the receiving contestant began to cry. My son, upon watching the scene, asked, "Mom, what's wrong with having diabetes?" My heart broke at his question and my eyes welled with tears. Yes, diabetes is a scary, unpredictable, life-threatening disease. But there is nothing "wrong" with it, and there is nothing "wrong" with someone who has it. It is a manageable disease that does not prevent a person from doing anything. Furthermore, my type 1 diabetic son (as with all type 1's and many type 2's) does not have diabetes because of obesity, lack of exercise, or poor lifestyle choices, and there is nothing he, or I, can do to change it. And I know that Dr. H is referring to type 2 diabetes, just as I'm sure he knows he is referring to type 2 diabetes, so WHY CAN'T HE SAY THAT? Why promote ignorance when this show has the ability and the reach to educate millions of viewers? This is a great teachable moment that "Biggest Loser" has simply let go to waste.

Okay, end of rant for today.

For full info about the show, visit their website.

Unsupervised BG testing

While I was away last week for the Cyclebetes national relay, my son was home with his older brother and my husband, which meant I wasn't here to keep him on top of his bg testing. And frankly, I find the idea of him taking responsibility for his own diabetes care is both exciting and frightening.

Dylan has always been mature for his age, especially when it comes to looking after his diabetes, but he is 10 after all, and is apt to make mistakes. Nonetheless I left him in charge of his testing I was gone for exactly 1 week and I uploaded his pump data when I returned last weekend. 

Results: I was very pleasantly surprised to see that he tested an average of 4.8 times per day. No, this is not the 6+ times he SHOULD be testing daily, but it's still pretty good. There was just 1 day that was scary. On the Wednesday he didn't test at all - NOT ONCE between the time he woke up and the time he went to bed (which also means that his average was better than 4.8 times per day because this big "0" certainly lowered the daily average). He also changed his own infusion set not once, but twice, all my himself!!

So overall, I can't complain. While the one missed day is scary as hell, he did a pretty darn good job looking after his own diabetes care. Way to go Dyl!

It's Not About the Numbers

Last Friday was Dylan's quarterly diabetes checkup with the team of caregivers. I've often wondered how diabetes checkups are done with other endocrinologists; ours has kind of a different approach I think.

Every 3 months we see the endo at what our local hospital calls the "Diabetes Education Center," which is essentially a wing of the hospital comprised of a large classroom and a few smaller, private rooms. Our stay lasts anywhere from as little as 45 minutes to as long as two hours and in that time we meet with at least 3 different individuals. A dietician is available to weigh and measure Dylan, take his blood pressure and talk about any changes in diet and/or activity level; a diabetes nurse does Dylan's A1C test, uploads Dylan's pump data to a software program to evaluate the numbers, and answers general health questions or issues; and the endocrinologist evaluates the numbers, both from the pump and the A1C, talks to us about changes, both good and bad, and adjusts Dylan's basal rates, carb ratios, or insulin sensitivity factor, if needed.

After we see everyone, there is always an educational session led by one of the individuals from the medical team. Topics vary from advanced pumping, to traveling with diabetes, to what to do when sick, among other topics. And then there are always a few other people there too. Last week our medtronic rep was there, as well as a medical student from the local university.

Together this amazing medical team provides a well balanced approach to diabetes that covers all aspects. But I think everyone's favorite part of the quarterly visit is the chance to sit and talk with other parents of type 1's. The appointments are scheduled by sex and age, so when we go, any other type 1 patients who are boys between the ages of 9 and 12 are also there. This is such a great opportunity not only for me to talk to other parents, but for Dylan to talk to other kids his age who have diabetes, an opportunity he doesn't get too often.

For the record, his A1C was 7.8. A bit higher than I would like, but an improvement over his previous one of 8.2, and the best A1C he's had in almost 2 years. The endo was happy to see it moving in the right direction, and it long as it continues to go down over the next few visits, I'm happy with it too.

So how do diabetes checkups work where you live? Do you see the endo alone, or is this team approach the norm?