Blood Glucose Targets

i have consistently[over about 5 years] hadA1cs in the 5s

I keep trying for 4s, but haven't managed it yet. I do this by controlling carbs and minimal metformin. I'm fit[resting pulse rate 57] and rarely even catch cold.

My doctor and my nurse both think it's good. Neither has ever suggested I try to raise my numbers. I know it's absurd for someone like me who doesn't use insulin or insulin stimulating medication to worry about bg levels of 4. I'm in NO danger there. My T1 husband often records numbers below 4 and also functions perfectly well down to about 3, which he does correct with Lucozade..

I think this subject is something only Bernstein followers and WELL CONTROLLED diabetics understand. Textbook learners don't, because they never experience it. I think more diabettics should have the knowledge to protect themselves in this way.


I maintain my 5%s without hypos.


I think too that they feel the obligation to say something since, after all, your insurance is paying them a couple hundred bucks? If your A1C is ok, they can't discuss your horrible control, if you don't have complications, they can't' discuss that or refer you to a specialist so they talk about your lows? What do you talk to your doctor about then? Mine says 'great A1C, are you ok w/ these lows?' and I explain 'well, I was running and, for some reason, my BG was in the toilet so I checked and it was 39 so I sprinted 2 blocks as fast as I could, ran another 1/2 mile and tested again and it was up to 85 from the hormones so I ran another 5 miles" and she says 'be careful'? I dunno what else she is supposed to say?

Since "non-diabetics" with higher than average A1cs are at risk of problems usually associated with diabetes, I don't think the benefits of NORMAL bg are "minute". It seems to me that too many health care professionals are lacking sufficient knowledge and understanding.AND don't keep up with literrature. They should know it's the blood glucose levels NOT the diagnosis of diabetes that brings the dangers.


Believe it or not Hope Warshaw told me the same thing, and with a straight face. We had her come talk to my support group. This is part of the reason that I think some of the NHS doctors will remain employed.

ps. I won't tell you who she is, google on your own and don't miss her famous debate on dlife with Bernstein.

If you don't take insulin and tx T2 w/ Metformin, I would think your risk of hypos would be considerably lower? I don't know anything about Metformin but a quick glance @ the Wikipedia page shows that hypoglycemia isn't listed as an adverse affect?

Not sure about the adult targets. Not sure about targets for Type 2s (I believe Type 2 targets should be lower). Targets for children, however, are based on age and sensitivity to insulin. Bedtime targets for toddlers could well be 150 to 180. If your child has a lot of exercise that day, bedtime target most definitely will be raised to 150, and most likely you will see a steady drop within two hours, necessitating juice in our case. Tight control is important but it matters little if your child has a seizure or does not wake up in the morning because of a low blood sugar that was not caught in time. Adult Type 1s also may have severe episodes of hypoglycemia. Targets should be decided by the endocrinologist and the individual or parent/caretaker in question. It goes without saying that you need to choose an endocrinologist that shares your philosopy on D management. I can say that while I am amazed at some of the success I have seen re blood sugar targets and D management by some members on this board, there is no way I can duplicate it. Even as an adult Type 1 the targets of say, never having a postprandial blood sugar over 140 and, indeed, never having any blood sugar over 140, and never ever seeing a blood sugar over 200 is totally unrealistic and impossible.... yes, impossible... to achieve. I am very happy with her A1cs in the low to mid sixes; would love to get it lower but she has Type 1 diabetes. It is not possible for us. As far as the postprandials, never having high blood sugars. Impossible. Unrealistic.

I think that as scientifically trained people, doctors would be aware that their patients with lower A1C results would be less likely (although, of course, not guaranteed...) to have complications if they treat them for a long time.

At the same time, doctors are also forced to participate as 'employees' of a health care system that obligates them to work to their industry's 'standards' which are set through reasearch studies. I don't think that there's any sort of big study about people with 5% A1Cs because the medical industry is too chicken to try it. In the US, I would think that attorneys would have a field day suing any doctor who would try to have ALL of their patients pursue 5% A1Cs because 1) it is not the standard and 2) it is challenging. To me, it makes sense to go for it because it's still challenging to NOT go for a good A1C score but I can't tell anyone else they have to because it's not the 'standard'.

I would also presume that they are supported in their squeamishness by the insurance industry (or government if you are somewhere like the UK where it's on their dime...) since they don't want to provide every T1/T2 450 test strips/ month or various other pricey goodies to support a lower A1C goal across the board. If you can cajole enough supplies out of your insurer, you can do whatever the hell you want but all your doctor can do about your desire to park it in the 5s or strive for a 4 is do it on your own because your doctor will not be able to support you, except surreptitiously or with encouragement and, of course, prescriptions.

I rarely have 'high' blood sugars, > 160 or so and that's usually only a couple of times/ week? I aim for 120 after meals but don't beat myself up if it drifts to 135 or so. It's not impossible *at all* for me to see BG > 200 for 2-3 weeks at a time, occasionally I 'oops' but, w/ the CGM, most of the time, if it hits 140, I start whaling away w/ CB before it gets too high. And most of the time, those peaks are the peak and it turns around on it's own, you can kind of see the 'delta' between the numbers getting smaller as it gets ready to drop. Perhaps its OCDiabetes but it seems to work and I feel very good about my health in general.

I think that it *is* however impossible for me to find an endocrinologist who will go along with that because they won't say 'your goal should be <5.0 A1C.'. They can say 'good job' on a 5.5 or 6.0 or whatever but they can't tell you to get it, particularly in the US, they would likely be liable for malpractice allegations? It would be an interesting case, that seems to me that it would have all sorts of interesting ramifications particularly "is the health insurer complicit in the negligence of a doctor rx'ing 7 strips today? We need copies of all of your files on this case, all your other diabetic insureds and any documents dealing with test strips...or would you like to make us an offer to settle" ha ha ha!

I think that this 'doctor problem' is the biggest barrier towards aiming at lower targets. I would like to see organizations step up and push for reform of these targets somehow but, unfortunately, I am not going to be a lot of money on that happening any time soon w/ the pressure the health care systems seem to be under?

Carb 101's daughter Clara's A1c's (from her home page). Clara is almost 11 years old.

6.0 (previously 6.5, 6.4, 6.0, 6.3, 5.9, 6, 6.1, 11 and 14 at dx)

Boy did you hit the nail on the head! When I was first diagnosed with diabetes, I was put on sulfonylureas, and sent to a diabetes education class. They served the meals there, and we tested only before the next meal. Well, I had been testing at home previously, and I knew I was going into the mid-200s 2 hours after meals, even with the sulfs, but I still had enough insulin secretion to bring my BG down before the next meal. So they told me I was doing fine, and even tried to reduce the dose of the sulfs, not that it was making any difference. They wanted to get me off meds, and onto diet only. This just plain didn't work!

Well, I KNEW that peaks of 250 or so weren't acceptable, and not long after that, I asked my doc to put me on insulin. Well, great, NPH at night REALLY helps with after meals highs, doesn't it?? It took a long time and lots of struggle before I finally got on R at meals and NPH at night, and I still had to be careful of nighttime lows.Now I have a pump, and life is a LOT easier!

This all occurred because I was supposed to be a Type 2 -- I DO have metabolic syndrome, but I also have Hashimoto's Thyroiditis which, as you probably know, is auto-immune. So I'm a mixed bag, and it has been very difficult to get appropriate treatment. But I found the internet a long time ago and educated myself, and I have been able to get what I needed, even if I had to struggle for it. I'm sorry your brother isn't proactive like I had to be.

Bernstein tries to have all of his patients with A1cs in the high 4's. I don't know what his percentages are, but I do know he is very rigorous about his treatment. A group of diabetic list-mates and I had a telephone consultation with Bernstein many years ago, and he even keeps his patients with kidney damage on a low-carb diet. Since they can't tolerate protein, they eat mostly oil (which kind, I don't remember). I don't think I could stand that, but that's what he said.

Very true, acidrock. Doctors (& the ADA) are a barrier, regarding targets & patient education. Having received enough arrogance, apathy & misinformation from endos & a CDE, I nicely stated my goals to the last endo & asked if he could help me reach them. He kind of sputtered & turned the question on me by asking why those were my goals. Well, duh, because I'd like to avoid complications. I'm now going to my PCP for diabetes care. His son was recently diagnosed T1 & he's reading everything.

Dear Jan,

I totally hear where you are coming from! All it takes to push me past a PP 140 is 15g of carb. I once even hit 180 PP after a small zero carb meal. I feel so dispirited when I read the advice of diabetes writers I otherwise trust, saying you should *never* go above 140. For me, that's virtually impossible and unrealistic. And nobody seems able to tell me if I'm doing harm to myself with these excursions (it always comes back down again 4-5 hours later) even though my overall A1C is ok.

I don't think anyone really knows the answer to that. However, I do know that glycation of hemoglobin takes several hours, and is partially reversible. So if a peak is short-lived, then it shouldn't contribute much if anything to glycation. However, I don't know if that applies to other tissues or not.

I forgot -- are you on insulin? I also experience 2-hour peaks higher than 140 (usually 160-200) when I consume even a small amount of carbs, but I'm on insulin, and they come down within 4 hours. If your excursion is lasting that long, maybe you need insulin?

Absolutely right! acidrock

Metformin DOESN'T cause hypos [the best thing about it is that it suppresses gluconeogenesis,hence Dawn Phenomenon]. However the point I was making was that you don't need VERY LOW readings to keep in the 5s. You just need to be consistently in the lower range. I rarely see a number above 6 [108], or below 4 [72] . 6 only happens if I eat too much carb. Haven't seen a 7 [126] for many months. a 7 freaks me out, because I've gone so far off the path. Yet DUK recommends a 2hour PP of up to 8 for T2. Doubt if 5% is possible with that.

Although I'm fairly disciplined, I do fall off the wagon occasionally. If tempted, I try to make do with"a tiny bit". That way, I don't feel deprived. Also I don't eat to fullness. Small portions of nutrient rich food make life easier.


Hi Natalie, yes I am on insulin. My Novorapid does absolutely nothing in the first 2 hours. But I am usually back to a normal range 5 hours after insulin. I have tried injecting earlier and that works some of the time; however sometimes that gives me hypos.It also isn't always possible to inject 2 hours before eating - plus it makes carb counting even more difficult.

I brought up this issue at my last meeting with the diabetes nurse and they are so terrified about people getting hypos. Their official advice is not even to test after meals 'because of course it'll be high' but only to test before the next meal and do the adjustment then. This makes sense as it would be 5 hours later in most cases - I have had pretty nasty hypos from insulin stacking up.

Irl Hirsch is actually kind of an interesting guy. My impression is that throughout the first part of his career and rise to the top as an endo, he was strictly a "party member." He advocated the ADA party line and was very prominent in spouting the ADA message. However in the last few years, he has had what appears to be an enlightenment. He has recently helped found Beta Cells in Diabetes, arguing for early and tight control and in positions much more consistent with DeFronzo and even his nemesis Bernstein. It sounds like Dr. Hirsch is a keeper.;

Ok, you didn't hear this from me and you are not advised to do this, but intramuscular insulin injection can improve the rapidity of insulin action. Here is Dr. B on the technique although he advocates it for correction Dr. B on Intramuscular Injections. There is potentially more variability in action ( Oh, and you didn't hear it from me.

I have actually had 2 doctors tell me that also. Didn't seemt to matter to them that I was T1!