Argument with Endo over good A1C of 5.2

Hi Rich, An interesting topic that I expected to get a larger array of opinions. By my math an A1C of 5.2 equates to an average BG of 105ish. Congratulations, that is outstanding!

If you are observant with your timing and monitoring your CGM, then I see no problem with you bolus stradegy. Be careful because this stradegy sounds like using R and N and can lead to crashes if a snack is late or carbs are overestimated.

I may be having a very similar conversation with my endo next month as well. If my A1c is 5.2 I would be more concerned about the few 60s, rather than the 180s. Your A1C shows that your red blood cells are barely affected by you BGs (little glycosilation). You may be in the range on a non-diabetic with that A1C and this means little/no organ or tissue damage. Again, kudos!. You may want to focus on your few hypos to limit any complications associated with LBS since your A1C is so desirable.

You seem to be saying that you are your own Dr. and you will take care of yourself as you see to be best. If so, we are in agreement. Afterall it is you that may develop complications from diabetes, not your endo. Keep up the great work

Low blood sugars will “kill” highs will not. That is my endo’s motto and I tend to agree with him. The CGM can be very inaccurate so be careful…always double check with your meter…180 is not a bad number. I have found, with 57 years of experience under my belt it is OK to be 180 after food AND yes bolusing with too much insulin is definitely weight gain.
Chasing insulin with food is not a good idea.
Sheila

Hello Rich:

What you are doing won’t be a problem until someday it kills you… Too low runs that serious potential risk.
But this generation of technology COULD produce a brand new approach to getting “testbook” results. Time will write that script.
Are you still getting clear signals when you are low whether severely or just technically low? That is another very serious issue to at least consider…

I look forward eagerly to hopefully being wrong ; ).
Stuart

I wouldn’t say that. Given a dx about a year ago, I’d say it’s pretty sharp to have figured out a good way to maintain a good average blood sugar. It’s still useful to look for room to improve. I wouldn’t agree w/ the doc or you that it “sucks” or is dangerous or whatever the doctor’s arguments may be. I’d characterize insulin as a “hard” drug in that it can kill you so of course it’s dangerous but hyperglycemia is also dangerous, if slower. I don’t ever feel like I’m “set” and ready to just sit back. I’m constantly fiddling around, noticing a high (like 120…) here or a low (whatever…) there that I want to clean up. Part of it is that I think that I could benefit from .5U increments w/ carb ratio that aren’t supported by my pump as I’ll go up to 8 and down to 7 and pretty much get to choose between low and high. Small, incremental improvements are very useful and I think that’s what the original poster needs to get. I don’t think it’s productive of his doctor to advocate completely abandoning the strategy. I think that a better approach would be to reduce the angle of the downward BG drop so it doesn’t drop as rapidly. It might work to add some fat/ protein to the meals before the drop to slow things down a bit? That way the “average” would be about the same but not as much delta-ing.

For those of you who are saying this strategy is bound to lead to deadly hypos, what evidence is there of this? Hitting 60 twice a week does not indicate a propensity for horrible, fatal hypos; it indicates that you have excellent control. At least one endo has said the following to me: “If you don’t drop into the 50s or 60s a couple times a week, your control isn’t tight enough.” I think there’s a lot of merit to that, especially because it’s very hard for a hypo to kill you unless you are asleep or behind the wheel of a car.



Anyways, a CGM makes all the difference in the world for this strategy. The trend is far more important for this strategy than the actual number, and the trends tend to be more accurate than the readings themselves. Being able to see a real-time rate of change (even if the results are 15 minutes behind) and understanding how to react to different patterns solves most of the problems y’all describe.

I don’t know what kind of insulin you are using, but how about considering Apidra if you are not using it? Quicker peak and shorter tail. Maybe you can help to avoid your situation.

A better approach would be calculating more accurate insulin doses & fine tuning timing. Over-doing insulin & filing in with carbs isn’t a strategy for long term BG control or weight control. There are enough problems & variables with ever changing results without intentionally throwing more variables into the mix. Agree that 180 isn’t acceptable. There are other ways to avoid highs than this method which is risky. Nothing healthy about taking higher doses than are needed. No one should be eating for the insulin. Insulin should be calibrated for the meal.

Stufffing my face= 4-5X as much insulin as I need! He’s not reporting catastrophic swings although, in my experience, there can be a fine line between +/- 40 points so a planned drop to the 60s, particularly if you have a bunch of IOB (which I would presume from eating an orange as a snack…), seems like an opportunity to make a smal adjustment to perhaps aim for the 70s and to bolus for the orange instead? I don’t suspect anyone using the words “rice cakes” of “stuffing their face”

I see nothing wrong with his approach, if people would actually read what he is saying. He probably has fewer lows than most people do, and he NEEDS to gain weight. What difference does it make how he eats the food. If he added those foods that he is using for snacks to his meals, he would likely spike more. His method is the same one that everyone used before Novalog and Humalog came along. Snacking was essential with the old insulins.
If this is working well for him, then I see no reason not to continue it. Having to eat to the insulin would not be my preference, but if he doesn’t mind it and is achieving great results, then why not?

It’s always my goal to improve something, sort of fidgity I suppose? There isn’t a lot of hay to mow w/ 5.2 so I’d look to try to do less work, which is like getting a “raise” in my big scheme of things!

Basically you are just pre bolusing for your snack. If the snack fits into your alloted calories for the day I think you should be fine with weight gain issues. I may try a bit of this at some. A CGMS makes this all the easier and safer.

I agree with Ressy. Most of us experiment until we find what works for us, probably fine-tuning our method for each meal and time of day, and then those methods become habit and second-nature for us. Learning about different successful methods used in dealing with Diabetes, and discussing them, increases our knowledge. Thanks, Rich, for this discussion.

Thanks for all the great responses and insight. Just a few things I’d like to clarify

a) I am not taking huge boluses or doubling my requirements. If for breakfast or lunch I have a sandwich with 32g of carbs instead of taking 4 units I take 5 units. This prevents a huge spike. I also always wait 20 mins
b) I have a CGMS and have not been in the 50s in about a month. Once I see myself trending downward I test to prevent a low that is coming.
c) I am trying to gain weight so the extra food I have as a snack - rice cakes, yogurt, fruit, crackers aren’t an issue.
d) If I took the required insulin that would get me down to 90 or 100 after 2 hours, I would hit 180 or so. I’ve tried it before. I don’t mind hovering around 80 or so most of the day as I am very diligent about testing.

The foods you are eating are great, but not the best for helping to gain weight. Have you ever tried any of the canned drinks like Muscle Milk to help with that? Maybe some peanut butter on those crackers too.

Muscle Milk is crazy high in fat and carbs, and is more expensive than it needs to be…Optimum Nutrition whey protein is almost 90 percent protein (24g protein/3g carbs per scoop) and is 8-10 bucks a pound on Amazon…mix a scoop with milk and you’re good to go. Plus it comes in virtually every flavor you could imagine, and most are pretty good.

They do have a lite version of MM, and it comes in powder form too. I bought it at Costco for my elderly mother. Her doctor told me to get it for her. They used it to keep weight on people in the nursing home that didn’t have an appetite. Doesn’t matter what brand you use, I just wanted to bring up that those foods would be hard to put weight on with.

I can’t really recommend Muscle Milk. There are lots of bodybuilding drinks that are high in carbs, and I don’t think they are good for us diabetics. I do really like protein shakes, I buy the 6 lb bags of EAS100% whey protein at Costco. It is low carb, 2-3g per serving. If you really want to gain weight (and I presume you mean muscle), then eat more protein and lift weights. Don’t run. Don’t eat carbs. Eat protein and lift heavy weights.

I am on 2.5mg of ramipril since I had an elevated protein number in my urine. My doctors said not to go crazy on protein so I don’t think that would be a good idea for me.

I have had protein in my urine consistently since 2003. After getting a foot wound in 2005 and having pretty low levels of protein in my blood, my doctors recommended using a protein powder. I did that up until 2 years ago then stopped. I am going to add it back again because my nutritional levels are getting low again. Other than the protein in my urine, I have never shown any other signs of kidney problems.

So you were diagnosed a year ago, you have an A1c of 5.2% and your doctor believes your kidneys are already failed? Does something not make sense?

Did you remember to not exercise before your last urine test?