By Guest Writer Evelyn Stinger. (Dr. Cogen's comments are in bold.)
"Evelyn Stinger?" the nurse calls out.
Oh god. It's my turn. In a few seconds, I'll be getting some quality time with Dr. Cogen at my quarterly endocrinology appointment. Last time, my A1C was 9.1- not exactly good (a 3 month estimated blood glucose of 214.47 mg/dl). As I walk to the office where Dr. C awaits, I think back.
I actually was diagnosed with Type 1 Diabetes in fourth grade. Soon after, I found Dr. C and, five years later, in ninth grade, I'm still going to her. I've been using a Deltec Cozmo pump and I love it. But ever since getting diabetes, I've had trouble remembering to check my blood glucose and to bolus. My family and I have tried many things to help me remember. We participated in Children's National Medical Center's Teamwork study, which helps teenagers and their families cope with diabetes. (The Teamwork study is funded by the NIH and is under the direction of Randi Streisand, PhD, CDE, and colleagues in our psychosocial component of the diabetes team.) I tried making signs and setting alarms on my pump, not to mention my parents nagging me ALL the time. But even with all that, I just couldn't get it right. My last appointment, when my A1C was 9.1, we knew something had to be done because it was just not healthy to continue on the path I was headed.
Evie's situation is typical of many of our children and teens with diabetes. Checking blood sugars, one of many diabetes self-care skills, may not be the main priority in the day-to-day life of our patients. As we have discussed in previous blogs, adherence to self-care skills requires the "buy-in" from the child or adolescent to be successful. Nagging or harping about blood glucose monitoring by caregivers or the diabetes team typically brings forth a glazed look on the face of the "naggee." Quite simply, admonishing our patients in this age group is generally NOT successful. Other motivators are required, including creative positive reinforcement techniques. Negative reinforcement is not recommended either; however, there should be consequences for non-constructive behaviors.
One night, my Dad had a brilliant idea. "I have an idea for a system we could use to get you to bolus!" he practically screamed. I was skeptical at first, but once he explained it to me, I realized that for once something my dad said actually made sense! The system he suggested went like this: I put 20 $1 bills in a bowl in my room. Whenever he asks me if I checked my blood glucose or bolused and I haven't, he takes a dollar from the bowl. But, if he asks me if I checked my blood glucose or bolused and I have already done it, he adds a new dollar to the bowl. My Dad and I both think that we've discovered a pretty good system. (BTW, it does not actually have to be dollars- it could be other monetary denominations or other desired small tokens).
During weeks when I am on top of things, I make a few dollars and then my cheap Dad stops asking me about it so much, which I like. But if he senses that I am slacking off, he starts up again. The system then starts to get expensive, so I get back on track.
In present time again, I walk to Dr. C's office. I sit down, she checks my eyes, looks at my infusion set sites, and after some small talk, we look at my current A1C, which is 7.8 ( a 3 month estimate glucose average of 177.16 mg/dl). It dropped 1.3 points (statistically significant)! After a small victory dance (YES, we do celebrate), and a lot of smiles, we tell Dr. Cogen about our system. She really likes it and suggests that I co-write a blog with her about it! She gets more excited as she sits there trying to come up with catchy name. Then, practically jumping out of her seat, says, "I know! Bolusing for Dollars!" She is so excited; I wonder if my Dad offered her a cut of the money from my bowl... (NO, he did not, but....)
Bolusing for Dollars works for me, but what is your system? What do you do to stay on track with your Diabetes? Evie is very correct in her analysis. What works for her, may NOT necessarily work for you. PLEASE send us comments about which reinforcement techniques work for you. We can all learn from each other and apply those ideas that seem promising to improve diabetes control.
Published On: June 29, 2010