Argument with Endo over good A1C of 5.2

First off he thought my A1C was too low. I told him my method and he totally disapproved, but I don’t care. I will keep doing it.



To avoid spikes I give myself larger boluses so I peak at around 120-130 or so. Then knowing at the 2-hour mark I will be low because of the extra insulin I always have a snack - an apple, an orange, crackers, rice cakes.



He thought that wasn’t a good method and its ok to hit 160-180 at the 1 hour mark as long as long as I am below 120 before the next meal. I don’t agree. Now I go to the doctor only for bloodwork and prescriptions.



He was more worried about hypos but I am more worried about hitting 180 everyday, hence the reason for trying to avoid high spikes after meals. I’d say I hit 60 maybe twice a week but with the CGM, I can see if I am crashing too quickly so there isn’t much of a problem.

I disagree with your doctor, but I also wouldn’t choose your method. I think 5.2 is an amazing A1C, but if it was achieved with lots of lows, not so good. No, being at the 160-180 mark for any length of time is too high and complications can accumulate. Doctors in general worry more about lows than highs, and their emphasis is pretty unbalanced, because both are to be avoided as much as possible, though as Type 1’s “stuff happens”.

But I don’t think overbolusing and then having to snack to prevent lows is a good approach. This is known as “feeding the insulin”, you are eating to support the dose of insulin you are taking, rather than the reverse. That can lead over time to weight gain and development of insulin resistance, so it might seem successful in the shortterm but cause more problems in the longterm. The goal is to take as litle insulin as possible to achieve the desired effect.

Instead if you are spiking too high at an hour than something needs to be altered: A tad more insulin could be the answer, but you are taking too much if you crash at two hours if you don’t eat more. How much are you increasing the insulin? I didn’t check your profile, but if you are on MDI, obviously you can only increase by whole units (unless you have a 1/2 unit pen) and so it may be hard to find a happy medium, especially if you are insulin sensitive and the difference between 1 and 2 or 2 and 3 units is severe. You might want to consider a pump. Another option is to vary how much ahead of time you bolus to prevent the peak, or if you are on the pump, to do some form of extended bolus so you take more now and less later. Lots of possibilities to play around with.

Hi Rich. I do the exact same thing in the morning when I drink my mocha latte. The caffeine in the coffee causes a spike so I bolus an extra unit for it; about two hours later my body seems to realize there really weren’t any carbs for that unit. In the meantime I don’t spike, and have a little breakfast/brunch in two hours. The time works out just fine since about that time I’m hungry and need something to eat.

Are you testing to make sure the 60 on your CGM isn’t really a 30 or 40? That would be my only concern.



I too wish docs would pay more attention to the post meal spikes and offer better advice there. When you have a teen T1 that eats often it can’t be healthy to spike into the 200’s every time they eat/snack. Instead they tell teens to eat whatever they want and dose for it, don’t worry about the 2 hours after you eat. Talk about out of touch. Unfortunately, your approach would be too risky for my daughter to use.



Are you eating low carb?



I love our doc but decided long ago we are really on our own for the the day to day stuff.



I am pretty envious of your A1C - especially if you are only having a couple lows per week.

I think the question is, why do you get higher than 120-130 if you don’t “over-bolus”. Are you bolusing 30 min before eating? Is your baseline set right? If you are taking your bolus the right way at the right time, you shouldn’t even be as high as 120 2 hr later.
Your method is OK, nothing really wrong with a snack, that’s exactly how people on MDI do it, but if you are on the pump, as I assume you are if you’ve got a CGM, then you don’t need to.

My doctor told me that this is exactly how they manage diabetes when pregnant b/c “keeping the numbers that much lower, are that much more important, and in order to only spike at 1 hr at 120ish, inevitably with how insulin works, you’ll have to have a snack at the 2hr mark, or you’ll go low.” So… I’d say if it works for you, and you aren’t concerned with gaining weight or anything, then do it! And 60 twice a week with a CGM isn’t so bad…I mean what diabetic ALWAYS has perfect BG’s. None, obviously :slight_smile: Great job! 5.2 is phenomenal!

I don’t think 5.2 is too low per se, but I think that I would be extra careful that you are not having repeated hypos that diminish your ability to function and feel well. My endo (who I like a lot and who has a sterling research/clinical reputation) is of the opinion that 5.8-6.2 is the “sweet spot” for T1 and that once you are in that range your risk of severe, irreversible long-term complications is as low as you can really hope for, and that the marginal returns of lower A1c diminish rapidly beyond the high 5’s. I think your method is probably fine with a CGM (because you can get a sense of the real-time rate of change) but I would not recommend it without.

When I clocked in with a 5.5 and was quite proud of myself, my internist did that “that is too low” – I gave serious thought to doing serious bodily injury as she kept talking. When I can, I like to keep myself not much higher than 120. But you aren’t going to do any appreciable damage by getting up to 180 after a meal, so long as you are staying high. I have a CGM but it consistently misses my lows. If it wakes me up at night with a 64, I’m probably 40 or less.

Today, however, has been one of those not matter what I do I’m staying high. I had to do a pod change and it is 4 hours after lunch and I’m 248. I can hear my 5.5 shattering.

I don’t have any issue with your A1c, but I do question your approach. While today, you are young. Over time, you are going to find that having to eat to avert hypos is a formula for weight gain. I have to really ask exactly how much “damaging” control you would give up by exactly covering your meals and not requiring carbs to avert hypos. I suspect that some lowering of carbs and reducing of carb bolus would achieve nearly the same control levels without having to chow down on those snacks.

You might want to do something even more clever - like take your bolus a half hour or an hour before your meal, and size it to fit the meal, not “supersize” it. That way you don’t have all the after-meal snacks.



The usual suggestion is that fast acting bolus be taken at the same time as the food but you and me are clever enough to know that’s not always optimal :-).



I don’t think hitting 60 a couple times a week is dangerous at all, BTW. More than that could be a problem.

I sort of freak if my BG makes it to 160 but I sort of agree that overshooting and planning a snack would not be a regular occurrence. A lot of times, if my BG drifts low on the downslope, I will have a small snack, like 2x mini pretzel twists, about 6G of carbs, and see how that does. I figure as much as anything, it sort of means I undercounted the carbs I ate. I still run lowish regularly but I don’t look at it as a plan.

I’d say maybe lowering carbs might help achieve smoother curves but you said rice cakes so maybe you are doing that already? (low-carb humor?) I have not spent a lot of time at that level of control but I think that it’s a good idea to continually look for things to improve? A lot of my focus is on smoother rather than lower so maybe that approach would help? If the insulin doses are ‘correct’, I think that it’s possible to “level out” at 120-130 and then drift down a bit? W/ the CGM, I’ve noticed that if I change my ratio like +/- 1G of carb/ U it will make an appreciable difference in my BG at any given level and to me, that’s a sign I’m pretty flat? Maybe try adjusting a few of the different settings you can “trim” and see if you can find more adjustments and, if nothing else works, maybe eat a bit more protein/ fat w/ a meal, like a hunk of cheese or something, to give you a boost that might help?

Thank you all for your replies, very informative. I am not concerned with weight gain (I am very thin as is and looking to gain 10-15 pounds). However I am concerned with some people saying I could develop insulin resistance with large boluses. What exactly is considered a large bolus? My breakfast is 4.5 units, my lunch is 4.5 units and my dinner is 7 units (with 4.5 upfront and 2.5 extended for 3hrs).

I agree. I definitely go low (like 30s and 40s) for short periods of time nearly every day. Usually for about 10 minutes. My lows are really easy to fix so I wil be at 60-70 in 15 minutes and then stay there. I have severe insulin resistance. So, based on what’s he’s telling us, I’d say he’s doing pretty dang well.

Aw I had one of those days not too long ago. No matter what I did, it hovered at 240 for 4 hours and then plummeted down to 20. It was NOT a good day. But… I increased my basal with the next shot and havent seen another of those since. Hopefully that was the answer.

Definitely. I have a tendency to go from 90 before meal to 130 one hour after meal. And then it stays there for at least 4-6 hours. 7 months pregnant currently, so maybe I’m borrowing some of her pancreas or something. But, I do the bolus injection half hour before meal. And I don’t mind going low because I’m really carb sensitive and insulin resistant, so lows are REALLY EASY to fix for me. Highs aren’t as easy.

To me, That’s not a large bolus. How long you been T1?

Insulin resistance has creeped up on me over the past 13 years. I can do a bolus (I’m on MDI) of 20-30 units of Apidra per meal. My corrections are 1 unit for every 25 points. Carb ratio is 1 unit for every 4 carbs. In the morning, 1 unit for every 2 carbs. I don’t believe my insulin resistance came from doing mega boluses. It’s just in my blood. I used to do tiny boluses to cover meals, but my insulin needs have drastically increased over the past 13 years. I’m taking Metformin in the morning and with dinner to help absorb the insulin I inject. Which helps a little.

I agree with Tim. I am able to get the same results without the snacks by bolusing early.



Currently I am pregnant and the approach that you are using is recommended during pregnancy, but I am eating every 3 hours and at fixed times and checking very often. When I return to my “normal” lifestyle, I will not want to always depend on eating a snack because I know that I will sometimes forget and not eat the snack in time. For me, bolusing early with the correct amount is a safer method.

I would also worry about hypo unawareness over time. I used to think that a few mild lows a day were normal, but I think that they can be avoided without going over 160 (not always, but most days).

Some folks here are extremely insulin sensitive and will tell me that anything above 1.5 units is too large and is sure not to just cause insulin resistance but also indicates I already have insulin resistance :-).

And some endos/docs have looked at my doses and they tell me they are actually on the small side.

Your boluses sound entirely typical to me (meaning my numbers are almost exactly the same, 5 or 7 units at each meal.)

This was me Sunday/Monday. Crazy highs all day Sunday out of nowhere through to most of Monday. Monday am increased the basal by +50%, then things started to come down. Then by 2am this morning, was 30. WTF?! Anyway, I’m glad to be over with that. Who knows where these curveballs come from, but whomever is throwing them had better stop!! :slight_smile:

I do the same thing but I dont tell my doctor. Meanwhile my A1c is lowered than its ever been…Its almost like they are afraid to prescribe anything over the recommended even though each person diabetes is different…