Any suggestions on how to lower a high A1C?

Hi Everyone

I am a type 1 diabetic and have been for 23 years. I have a pump and usually use a Dexcom CGMS (right now I am appealing the denial of my request for sensors). I just got my latest A1C and it was wayyy to high (10.1 YIKES!). In the last few weeks I have been focusing on having better blood sugar numbers, but it looks like it hasn’t affected my A1c yet. I know it takes time, but my numbers aren’t in the normal range very often.

I exercise a good amount in the evenings (5 mile walk/jog 3 times a week, pilates/strength stuff for 1 hour 2 times a week, in addition to this I walk the dogs a minimum of 1 mile every day) and am a pescaterian, but I mostly eat vegetarian and concentrate on whole foods and try to stay lower carb.

I tend to go to bed with high numbers, take a correction bolus, and wake up with a normal number that just seems to trend up during the day.

Here’s what I have been doing lately to try and figure things out and get things back in line:

  1. I am taking my boluses 15-30 min before I eat,
  2. I have been inspired by the TAG forum and have been taking square wave boluses to cover my fats/protein,
  3. While I exercise 6 days a week (usually in the evenings), I am making a concerted effort to add an additional 20 min of high intensity intervals on the ellip in the mornings
  4. I know I need to test my basal rates, and I am starting that tomorrow morning, since it’s my exercise rest day
  5. I have started logging everything again (food, exercise, blood sugars, temp. basal rates for exercise, etc.)

Here’s the thing I can’t really control - I have a highly stressful job and normally work 6-7 days a week. I work from home and we are in the middle of a remodel so that is just added stress.

If anyone has thoughts about what I else I should/could be doing, I’d love to hear it!



Out of the things you mentioned, I would work on the basal testing first. If your basals are off, then nothing else works well. If you are having highs between meals, at waking and at bedtime than that indicates the basals are too low. If you are high 2 hours post prandial, then you need to look at the I:C ratios for your meals. Do you also correct highs? Knowing your correction factor and testing and correcting highs really helps get those numbers (and hence the A1C) down.

Looks like you are headed in the right direction. Starting is more than half the battle. What were A1c in the past? And the big question…What do YOU think has elevated the bgs the most?

I agree with Zoe…test the basals first. Even if you need to skip a day or two of excercise here or there you need to test the basals.

One thing I did was stop snacking so much between meals. I would bolus for the carbs, but I figured I wasn’t ever giving my bg the chance to come down before the next meal. This helped a great deal.

Hey Honeybear,

You definitely need to get your basal rate set up first. Remember that menses creates different basal rates. I have 3 different basal rates each month. One is for about 3 weeks and then the other two are 3 to 4 days each. Not sure if it applies, but If you have started menopause, I have no advice. Also allergy meds affect my bg so if I take my allergy meds, I have different basal rates than when I don’t. Also, weather affects my bg. These things don’t affect everyone, but some people are affected by them.

To figure out your basal rates and bolus rates, you should probably read the parts of Pumping Insulin and / or Think Like a Pancreas that apply. When I set my goals, as recommended by those authors, I started with evaluating my bg at dinner time and watching carefully so I would have a good number by the time I went to bed. That made having a good morning number easier and made me less likely to have lows during the night.

Remember, an A1c of 10.1 is an average bg of about 243. Don’t start by trying to keep your bg between 80 and 160 all the time, because you’ll probably fail.

  1. Be patient with yourself and take small steps. Remember that every improvement is still a step in the right direction, so even though an A1c of 8 or 9 is bad, they are much better than 10.
  2. Start by trying to keep your bg between say 120 or 160 and 240. If you start dropping too low you will feel low when you are not and that will be discouraging. Also, if your body is used to a lot of sugar, your mind not work as well if you suddenly drop bg levels.
  3. After you feel comfortable with that, try to keep your bg between 100 and 200. Give yourself at least a couple of weeks to get comfortable and consistent.
  4. Keep yourself between 80 and 160.
  5. Consider taking a mulitvitamin, as well as Vitamin D supplements. A study came out a few weeks ago that said if your A1c is above 8, it is likely yoru vitamin D levels are deficient. More than Calcium absorbtion is affected by Vitamin D deficiency.
  6. Don’t get upset if you start to gain some weight. As your bg returns to normal, it is normal to gain a little weight, at least until your body gets used to being able to efficiently absorb the food you eat.

I’m gonna suggest not exercising when you test your basal rates.

When you were using the Dexcom, what kind of trends were you noticing? I use 3 different basal programs, each having 4-5 different basal rates based on my sleep pattern (I work 3rd shift).

Hi Everyone. Thanks for the great advice!

Zoe - I do use a correction factor. I have a Minimed Paradigm pump with the insulin wizard, and I have different carb ratios for different times of day, different basal rates, different correction factors, etc. The problem is somethings not right and they just aren’t working for me right now.

Bug - my A1C’s have always been too high, but in the 7’s and 8’s, not 10’s before this. I think what happened is I got crazy with work about a year ago and allowed that to take over and I ended up with some bad habits - one of which was snacking instead of eating real meals (except for dinner) on most days. Right now I have gone back to 3 meals a day. So I think you are right about the snacking. While I bolus for it all, its not the same as eating 3 meals a day. With the snacking I have also let my carbs creep up, so I have recently cut out processed carbs like white bread, crackers, chips, pasta, etc. Instead I am eating quinoa, whole beans, fruits, veggies, and dairy. The closest thing I eat to bread is a corn tortilla once in awhile - which is only 6g of carb.

I also think that when work is crazy I stop focusing on me, and what I have to do to stay healthy as a diabetic, and instead just get caught up in what the daily fire is. I basically stopped paying attention. The other thing that happened was around the same time my PC died and I got a Mac to replace it, and since then I can’t download my Dexcom graphs, so instead of having the weekly over view of what my BS was doing, I was only looking at each number by itself. The return to logging should give me a better concept of trends.

Baby tee - Thanks for the reminder - I’ll go pull out my copy of Pumping Insulin read it again. In terms of vit. D - I do take a supplement every day. I was tested in January and found to be very low. And on the weight gain - I am trying to turn that around as well! I am seriously limiting my food and hoping that this will help me to lose, not gain. My goal right now is: BS under 200. I know that’s not very aggressive, but I think it is more doable. And thanks for the reminder about hormones and the monthly cycle. I do have a different pattern for certain times, but lately I haven’t been using it. Allergies and allergy meds are also a good thought. It has been a bad allergy season here and I have been taking zyrtec every day for as long as I can remember. I am still suffering, even with the meds. I think the immune response to all the pollen may factor into this as well…

I am another vote for getting the basals straightened out first. You can put a nice well-built house on a crappy foundation & it will cave in - your basals are the foundation to your BS control. Once you get that set, you can work on testing your carb ratios & correction rates. Look at the duration of insulin in your pump - we are all different and just because someone else has theirs set at 4 hours doesn’t mean 4 will work for you.

ok. you are doing a lot of stuff. I may sound cliche but, how about things you don’t think about. If you live in a warm environment, maybe your insulin went bad. Also, SOMETIMES exercise causes highs, believe it or not. I usually go into the high 180s, or even the 200s after I exercise. Also, are you having pump problems with the tubing or the cannula not inserting. Just some thoughts, also, I am curious as to what your doctor or nurse says in response to your dilemma.

Another thought, It does seem as though you have a lot of stress in your life. Maybe you can try to incorporate some non-stressful things into your day. For instance, when remodeling, (while doing something like wall papering or painting) play some relaxing or tranquil music. Or, when working from home, every two hours, for 30 seconds to draw a pretty picture or color, some people find coloring or drawing relaxing. If you don’t, choose something else. Maybe lighting candles? Good luck. It IS difficult to get diabetes under control in times of stress.

I am totally lazy about formal “basal testing” but might just turn it up like a notch and see if it helped the numbers improved across the board. If you get your reports, I like the idea of trying to fix a particular timeframe first, often times breakfast is a good one for me as it always seemed to be my most challenging area.

Veteran Diabetic’s comment about exercising is also an interesting observation, particularly since you mention “high intensity intervals”? I think that anything where you are going at or near 100% will cause adrenaline spikes which, since they don’t include carbs, can be challenging to work around. I get rises after I run all the time and correct them but it is a tedious chore. I run pretty regularly but when we got our puppy last August, walking her 4-5x/ day pounded my BG down and seemed to help a lot. When my BG runs up, I like to take a CB and take the dog for a walk. That seems to help more than just walking and I don’t have to do the whole “get ready to work out” ritual that is a pain in the butt for me. Plus it makes the dog happy!

Snacking. Sometimes you have people tell you that it is “better” to eat 6-8 times a day. Well they aren’t diabetic. If you are having frequent bolusworthy snacks during the day instead of eating, it can become impossible to correctly bolus and correct. No pump can properly account for “stacking” of insulin and carbs. Most can take insulin stacking into account for corrections, but that is it.

One strategy that may really help is to eat only three bolusworthy meals, this will give you a good amount of time between meals to see how you are at 2-3 hours, correct if needed and accumulate data on whether your carb and correction ratios need adjustment. You may still feel compelled to have a snack, but try to select one that is very low carb.

The best way to establish basel rates. Any opinions?

I have been a snackaholic for years but mostly eat cheese these days. I bring along a bag of pretzels in case I have a “tail” sneak up on me and need a couple of carbs but most of the time the 28G serving of pretzels will last for like 2 weeks with a pretzel or two, here and there.

Personally, I’m like AR when it comes to basals. I could tell from the highs or lows at different times of day what times my basals weren’t right, so I just kept tweaking those “time zones” (2 hours before the time needing change) until they were in target. I’m sure formal basal testing works well and probably takes less time and effort than the way I do it, but my way works well for me.

Hi Everyone,

Thanks for all the ideas. I did the first part of my basal rate testing yesterday morning. It was pretty interesting. My blood sugars were fairly stable. When I woke up I was 178 at 9:30 am and was at 155 when I ended the basal rate testing at 2pm. It was trending down at that point but I just needed to eat and had to stop the testing. :slight_smile: I’ll repeat the morning test again, but I was happy to see I was fairly stable for the time period.

I am wondering if maybe I should test the dinner basal next, since my biggest problems are in the evening. The testing kind of sucks, but I do think its worth it.

Veteran Diabetic -yes, I am wondering if the exercise is messing me up. I think I need to finish all of the basal rate testing (without exercise) and then move on to checking my carb ratios and correction factors. My gut feeling is the highs are somehow related to the exercise and all the stress in my life, and maybe my carb ratios are off. Right now my carb ratios are 1:8 for breakfast and 1:10 for the rest of the day.

I also tweak basal rates for my daughter on a pretty regular basis, with no basal testing. Having a CGM is helpful for sure in doing this. Her needs seem to change all of the time, so it just doesn’t make sense for me to try to get her to do basal testing. As soon as I see a pattern, I decide whether her basal or ratio needs to be tweaked for that time of day.
One thing that we try to do if she is running high for any reason, is to bolus for the meal or snack and correction way ahead of time. Sometimes that can be an hour or more. She can watch the Dexcom to see how things are going. Eating with a high bg is just adding fuel to the fire. If you are not sure how much you are going to eat, you can bolus for half of the meal. This really helps prevent spiking.
Honeybear, I am wondering how often you are testing and if you are doing corrections during the day or just with meals? You can set up a temp basal rate or a new basal pattern on your pump instead of changing it right off the bat. If it works out, then you just switch over to it. I have been using temp basals more often to combat higher numbers and they seem to work better than just corrections. I can’t find any patterns right now, so I can’t make any real changes for her.

I’m a little confused, Honeybear. Based on the basal testing you did where you woke up at 178 and then went down to 155, aren’t you going to raise the basals a bit during those time periods? You say you were fairly stable, but the idea is to be stable at a lower number.

Zoe, I agree with you, but the problem with basal testing is that you are not supposed to make changes after just one day of testing. I believe it is supposed to be 3 times for each time period, but many people just do 2.

I have never done the testing myself, Mary, but just like you said, when I see patterns I tweak it. Works for me!

Zoe - the point with the basal rate testing is to make sure your basal insulin is keeping you stable. Your basal rate is not supposed to be used to lower your blood sugar - that is what the correction boluses are for. Your basal rate is just supposed to keep you stable if you don’t eat. Imagine if I had started with a blood sugar of 80 - a higher rate would have been a problem. You don’t want to have your basal rates set so high that they are always pulling your blood sugars down. If you do, you can’t remain at a flat line at a lower number without going low unless you are constantly eating.

Yes, I started with a too high number, so if I hadn’t been testing my basal rate I would have taken a correction bolus, but since I was, I didn’t.

Mary - without my Dexcom I test about 10-12 times a day. I do sometimes take corrections if I think I need them, but I try to do it at times when I not piling insulin on top of itself. If I take a correct and 2 hours later I am high but going down, I need to give the insulin time to work. I don’t want to get frustrated about a high, pile corrections on top of corrections, end up with a low and then a rebound high after that.

As I’ve said, by biggest problem is evenings. I need to have a lower number when going to bed so that I wake up with a good number. If I am high all night, that is one-third of my day!

Well, I think if you’re doing basal testing, and you start at 178, your goal is to end at 178. Ceteris paribus, your basal rate for that time period may be too high. Another issue for some people is the higher the BG, the higher the insulin resistance… so at a lower BG, you would drop even more. Did you exercise at all during that time period?

As far as your evening/morning numbers, do you know if you suffer from dawn phenomenon?