My son entered puberty a few months ago, right after Xmas, and the consequences have been difficult to adapt to. We now see sudden hormonal peaks at some time of the day or the night, most every day, at least once or twice, springing straight up, out of nowhere, and reaching 200-400 in a half hour, before any insulin can be brought to start squashing the peaks.
I made some math calculations and figured that, if you want to remain below 6% A1c, you can’t afford puberty peaks AND postprandial peaks AND upward drifts.
We can’t do anything about hormonal peaks – they come when they come, and we can only squash them as quickly as we can. So we have focused on postprandial peaks and BG drifts.
Postprandial peaks
We now try to totally eliminate post-prandial peaks, particularly for dinner. When I say that, I mean we don’t want anything to go above 130 at any time after a meal. We are successful about 80% of the time. The way we now do it is:
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of course, we bolus ahead, approximately 40 minutes before a meal
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we wait until the BG has “turned the corner” to eat
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we stage a part of the meal for later. For instance, we plan on a certain amount of desert, but we don’t eat desert until he is almost low. That’s when we eat desert carbs. Dinner typically takes 1.5 hours before he has eaten everything, but it is staged, really. He will be doing his homework after the bulk of dinner, then, when he gets an alarm at 75, that is when he eats desert.
Drifts
We aggressively dose for upward drifts. We make 1/2 unit corrections often, and attempt to aim to be under 100 rather than 120. So, if a 1/2 correction is good for 20 mg/dl, we will correct at 120 to go back below 100.
Hormonal peaks
While we know we can’t suppress them, we have also been aggressive in bringing them down. We are still in the process of learning how to deal with them best. What we typically do is to catch them right above 130 (with an alarm at 130) and dose immediately, with a formula that depends upon the slope of the peak – the steeper, the higher the correction. It is not always possible to do so in the way I just explained, in particular if you are not 100% sure that you are facing a hormonal peak vs a food peak.
The results
So far, we appear to be holding steady on A1c. Our last A1c two months into puberty was actually a little better than before, 5.3%. But we see these peaks getting steeper and more frequent every week, and we don’t think we will be able to hold these numbers forever.
As we know, though, the A1c is not the only thing to look at. Every other metric is worse than before. With such frequent peaks, SD has worsened a lot. it was around 25 “before”, now it is typically around 35. Time In Range has also worsened - it used to be around 95%, it is now typically between 80 and 85% (we use 70-140 for time in range stats). Finally, time in hypoglycemia has also worsened, going from 2.8% average to close to 5%.
So you may ask, with all the metrics going south, how are we able to maintain good A1cs? The only way that has worked for us is to essentially lower our averages, when we have no peaks. Beyond getting rid of most postprandial peaks, we run lower than we used to. Not ideal – but, worse, it is not clear that it really helps: with such a high SD, probably getting worse, it is not clear that a low A1c is any better than letting him run a little higher on average. It is possible that the peaks are what damages him, in which case what we are doing (outside of reducing postprandial peaks and aggressively going after hormonal peaks) may not be improving outcomes.
Still, since nobody knows any better, we figure we might as well optimize all the metrics we can. There is, of course, one potential drawback: running lower, we risk more hypoglycemia, in part because we are willing to dose higher rather than lower on insulin, and catch the fall of the curve with carbs.
There is one more negative consequence that I was not expecting. With some many peaks day and night, it has become harder to get good calibration for his CGM. There are just not that many flat sections on the curve.
So, as you see, puberty is a bear 
We are learning as we go, and are getting better – but I can see that the next four years are going to be a tough fight: the enemy’s tactics have developed into new directions that we are not able to control as well as we used to.
Still, I am optimistic. Surprisingly, my son is not getting frustrated, I think in great part because we treat every day as a scientific experiment. Conditions are so hard (and becoming harder) that whatever we learn now will give him really good control after puberty is passed.
Eventually, it will get easier!
Just funnin’ you of course. Any sharing of thoughts is good stuff!!
