5 - 6 % A1c

I'm hoping to hit 6% hbA in the next month. I have been trying pretty hard, compared to what I used to do. What do I need to do to get a hbA of 5 or 6%. I know its a big question but fire away. Average bg according to GLUCO meter 6.2 which is about 108 or so. Still having some highs and lows, so this is far from ideal.

I'd suggest getting away from thinking "lower" and think "smoother" which is, of course, easier said than done? One of the many things I've noticed about the pump is that very small adjustments in rates and ratios, that would be sort of impossible to manage with injections.

It may be that the easiest way to change a carb ratio might be to make small food adjustments, either up or down, to get a ratio +/- .3G/U. If you can count carbs precisely (which I've sort of realized I actually suck at, because I bolus more for "chunks of food" that are wildly estimated a lot of the time...), then you can modify the ratio and perhaps nudge your BG to the spot you want it to be. I also think that if your ratios re set really precisely (again, easier said than done...), it will help eliminate a lot of upsiedownsies. Small proteiny snacks, I like cheese more than peanut butter, which has more carbs but sees to be popular with folks here, can also serve to "boost" BG a shade when you need it and, if you anticipate a low with something more "food" than "candy," I think it also helps to smooth out your BG a bit, which it seems like is what you are looking for!

First a BG average of 108 is great, congratulations! 108 mg/dL should correlate to an A1C of 5.4. I have kept detailed records for a bit and found that my A1C is 8% higher than my average BG so if my data holds true for you, then you may score a 5.8 or 5.9. You very may well have reached your goal.

The things that really helped me lower my A1C below 6% are a lower carb diet. I eat about 100-120 carbs per day and try not to go over 40 grams a meal. Certainly not Bernstein low, but it is low enough for me to not have as many highs and lows. Testing. I am testing 12 times a day on average. I believe you need quite a bit of accurate data to be able to achieve near normal A1Cs. CGM. CGM helps me catch highs much faster and earlier. CGM also helps tremendously with adjusting my ever fluctuation basal rates. I believe these ongoing adjustments are quite important to achieving optimal control.

Consistency. While my consistant diet and timing may seem like management style from the 1980’s, I find it very benifical. I eat the same breakfast and lunch at about the same time every workday (5 days a week). I look at it as eliminating variables as in unknown carbs, glycemic indexes, etc. and increase my chances of staying in my target range.

My average is always between 110 and 122 and I have not had a A1c over 5.7 in over 5 years. I have been as low as 5.0 but never have had one in the 4's. Distribution is the key....My Bg is between 70 and 140 between 85% to 92 % of each day, I still have BG lower than 70 and higher than 140 but my goal is to not stay there for long periods of time and I make predictions based on my CGM and correct as soon a possible. My diet is only a small part of my success, my CGM and my life style are 90% of what enables me to get low A1c results...if I see that my BG is going to drift out of my target range I will stop what I'm doing and fix the problem (walk the dog, get on treadmill, what ever it takes) I don't just give a correction bolus a wait it out.. When I was younger I did not have this luxury, my job and family where my #1 priority's...but I have plenty of time now...;-)

I'd really love to get the pump, going to ask my D team about this in Dec. Yeah I think my carb counting needs a good kick. Sometimes I eat an extra slice of bread if I anticipate a low and it has worked. I messed up today because I ate out and had no idea what was in the soup, went low about 3pm. Would love to get a CGMS, hopefully 2013. Thanks for replying AR. Hope you're getting out in the fresh air still.

Aw thanks Cap, I seriously hope I've made it. The prob is keeping it there. I'm testing more than 12 times per day, the chemist think I've lost the plot, its the only way I know what is going on. I think I have an 1980's approach most of the time, same b/f, same lunch, same tea all at the same time for most of the month. I guess to achieve this A1c we need to give over this amount of dedication 24/7. Very long sighhhhhhhhhhhhh

I really would love a CGM John, hopefully sometime in the new year. Does it get easier or do we ALWAYS need to keep adjusting ? I'm usually running around but I have now put my bg above nearly everyone else.

My BG never stops changing it's ether going up or down and is never stable it's like driving a old car with lose steering, you are always correcting and can never take your eyes off the road...My problem for many years was I thought I could adjust to everyones schedule and sometimes I had no choice but now that my children are out of the house I can just tell my wife to find a girl friend to go with her to dinner if I'm having a BG event we are both happy with this arrangement I try to never eat when my BG is out of my target range and if I do I'm just going to worry and the meal is ruined anyways.

If you eat 3 meals a day and space them apart far enough so you will not have any active insulin left between your meal bolus then you will have a better chance of keeping your BG in target range. I'm not saying I never snack...:-)... but it's rare.

I think we always need to adjust. I probably change my pump settings every couple of months to try a new angle. It was really cranked up before the marathon. Maybe I was eating more or something like that but, after the race, I sort of crashed in a number of ways, including my BG which, unfortunately, I only recently made adjustments for so I gained 5 lbs. Fortunately, I have this week off and things are falling into place once I've turned things down. But, next week, maybe something will happen and I'll turn it back up? Who knows!?

I am adjusting a basal rate every 2-3 weeks. I have a large and ever changing DP. It also seems that if I lose or gain a pound then I need to adjust. I feel like I am aiming at a moving target!

It can be a bit exhausting at times but seeing good results will spur me on. I hope all this work reflects in the next hbA. Read that vit C can give false results, so there goes the vit C.

Couple of things to keep in mind.

The correlation between A1C and average BG is just that, a correlation, There is not an absolute relationship between the BG averages and A1Cs reported on those charts. There is a lot of variation around those averages for individuals and your A1C most likely reflects a lower or higher average BG. My A1Cs have been between 5.6 and 5.8 over the past two years but my meter averages have been between 92 and 102. That's about 10 to 20 points off what my A1C says my BG average should be.

I test up to 20 times a day, overnight, compared my BG readings to my CGM which I wore for awhile, and have checked my meter against lab numbers every time I've had my blood tests. Nothing points ot a 10 to 20 point difference between what my meter says my A1C should be and what I've actually been getting. At this point, I trust my meter a bit more than I trust a chart to tell me what my average BG is.

The other thing is, the thing that affects my average BG and A1c the most is highs. It's pretty straightforward, I cut down on my highs, that brings down my average BG, and my A1c follows.

My data logging sucks. I usually just eyeball the CGM average which, while reasonably close, tends a bit lower, perhaps due to the fact that I ran all summer and would sometimes have lower readings after long runs than what it was actually reading. Then there's the BG Meter Average in the pump, based on what I input. That's a bit higher, closer to the actual reading. But then there'd be the average in the meter as well, as if I don't eat anything, I blow off inputting the BG into the pump. But I never got a cable to link my meter to my computer and the clocks are off on my meters anyway.

Will keep this in mind, I was a bit disappointed with the last A1c, my meter readings were lower. I don't pay much attention to those chart things. Someone here says its really important to have bg perfect at the time of blood withdrawl. I never knew that.
Maybe the meters are just trying to raise our hopes. Fix the clocks AR.

I pay attention to the chart things but only to think “ok, that’s what it is…”. I am comfortable explaining any discrepancies between my meter and CGM with various scenarios like I blathered about but it also sort of doesn’t matter, since all the excuses, reasons, explanations, etc. are in the past. I don’t have a cord to plug my meter into anything so there’s no point in worrying about how different those numbers are from the other numbers. The CGM works pretty well and I probably log enough numbers on the pump to be close. Close is good enough, as long as you keep attacking.

I would recommend to increase your test frequency. The earlier you catch highs the better the A1c. It also gives you the incentive to identify the cause. This will work to some degree. After some fine tuning you will still see spikes of 1 to 2 hours after meals but they will not influence the A1c much. This does not mean that these spikes will not attribute to complications. But the likelyhood will be lowered significantly.

One problem of the average glucose in our meters is that timing is ignored. Let me give an example:

8am: 250
1pm: 100
6pm: 100
11pm: 100
average: 137.5

The big unknown is the time span for the 250. Was it high all night? Was it just caused by dawn phenomenon? Likely the real average was higher like 150. The longer the time span the higher the A1c.

I don’t pay any attention to those different charts on the internet, the ones that correlate bg with A1c, there are too many of them, it has given me a rough guide though. I have three written down charts on the go at the mo, it is starting to level out but it changes from week to week. A lot of my spikes and lows are my own fault in fairness.

See that’s the thing, the D team say that as long as the A1c is good it doesn’t matter about spikes or lows, which is quite ridiculous and they don’t know how tiring it is living with them. I’ve managed to keep my last nightime reading and my 8am reading at between 4-6 mmols. It starts to go up if I don’t take my shot before 9am. Some probs in the evening when I may eat more than I should but that’s my own fault, I correct it then. Not going to expect too much from the hbA but hoping for a decrease and the main thing is to even all bg out. I was going to ask you Hol, should I split my Lantus, I take 8 units at about 11pm, why do people split it ?

I have to tell you, there are some people that may be able to achieve tight control (A1c < 6%) with just routine stuff. Counting carbs, taking bolus and correcting when needed. But if tight control was just about lowering the average, we could all just increase our basal and get that. So I will assume that you are a veteran, that you can estimate your meal and correction boluses properly. So, in order to be successful most of us need to take additional action, but what do we do?

So I embrace several key themes that seem to help me:

1. I calculate my standard deviation (SD) from my blood sugar tests, and I make that my "prime" goal, reduced SD. A lowered A1c is a collateral result

2. I "prevent" highs and lows. I restrict carbs to reduce my sings. I move my testing after meals to 1 hr make adjustments to prevent highs. I use testing to catch my blood sugar swings, not to see if I got the total carb bolus right.

3. I want to never have to correct, you can't "test in quality" and you can't attain tight control chasing highs or lows.

4. I adjust my insulin to match the timing and profile of my needs, not just my total needs. Sometimes I'll bolus my humalog 20-30 minutes before my meal. A slower digesting meal I might bolus after the meal, or even split the dose.

5. I don't really track meter averages, I like to track my fasting blood sugars and try to keep them on target and then I track separately (and calculate SD) for my meal responses. Our fasting blood sugar and postprandial blood sugars are separate things we can track and improve.

I hope these are helpful. I applaud you for striving for tighter control. I think the experience alone can be helpful. Life is of course a balance, the effort it requires is not trivial and in the end you may not feel it is worth it. But I suspect you will learn a lot and you will better off in the long-term even if you choose to not maintain those levels.

RE the splitting the Lantus dose I believe the theory is that while it's supposed to be flat and last 24 hours, some people observe mild spikes in action leading to lows and also that it runs out of gas, caussing a rise at the "tail". By splitting it, even if the action spikes, the spike is less pronounced and it's less likely to run out of gas.

Where you say "A lot of my spikes and lows are my own fault in fairness" I totally agree with too. A lot of times, my approach, which is to not write anything down, can let a repeated low or high go on for some time as I correct them with food (yummy!) or insulin (not so yummy although, of course, if you get carried away, a high can lead to a low...and so on and so on...) but spotting repeated issues can be a big help to smoothing things out. Once the level is smooth, it can be raised or lowered as needed more accurately I think. The time factor of a high or low influencing the next event or events can be an opportunity to realize improvements.