For those of us who practice persistent glucose management, as in 1440 minutes of every day and 8,760 hours of every year, we watch our numbers with hope. We often aspire to reaching management goals that are long-term and difficult to reach.
It might mean breaking below a 7.0% A1c or even below 6.0% and lower. Of course we are painfully aware that our number ambitions are tempered by respect and fear of severe hypoglycemia. It seems strange to me that a non-diabetic doctor can appreciate why those of us who live with diabetes for decades are often much more fearful of long-term hyperglycemia than we are of short episodes of hypoglycemia.
I visited my endocrinologist this week, in-person for the first time in a year. The medical assistant poked my finger using a “point of care” A1c meter. I hold more respect for time-in-range (TIR) and glucose variability statistics that the CGM produces than the A1c number. My current TIR for the last 90 days or more rest at 90% 65-130 mg/dL.
I was still curious about my A1c. My last one was a year ago.
When the results came back with the lowest number I’ve seen in my 38 years with diabetes, I felt elated as my doctor, with a furrowed brow, couldn’t hide his concern. It was a weird moment.
I’ve noticed that my glucose management performance varies over time. I drive between excellent TIR while holding urgent lows (< 54 mg/dL) down to 0.1% of the time to 1.0% of the time. That means my severe lows vary from about 1.4 minutes average per day to 14 minutes average per day. I consider this entire range of hypoglycemia acceptable.
My doctor does not seem to recognize that my low glucose variability offers a lot of protection from sustained severe hypoglycemia. Even if I trend toward significant hypoglycmia (<54 mg/dL), my rate of descent is very shallow with almost zero units IOB when it does occur. This gives me more time and opportunity to address the hypo.
I use a CGM 24/7 and it has reliably, as in 100% of the time, alerted me to my low sugar status in time to prevent that condition from lasting very long or going any lower.
Doctors are much more willing to risk periods of hyperglycemia. I know the acute risk of a hypo is worth considering but I fear most the effects of longer term hyperglycemia. Things like blindness, heart disease, kidney failure and peripheral neuropathy all motivate me more than it does my doctor.
I know that I am not a typical patient for my doctor. Yet he cannot help himself from issuing a concerned warning to me. I told him that I hear him and acknowledge his caution, but things look differently from my point of view. With a low glucose variability (<= 20 mg/dL standard deviation and <= 21% coefficient of variation), I am not powering into lows with a steep angle and a large IOB head of steam.
I accept that we play a dangerous game. We must choose everyday between the acute danger of severe hypos and the much more damaging effects of chronic hyperglycemia. I choose a solution that means my glucose sometimes skips along close to the danger zone and means I avoid almost all hyperglycemia (<6% > 130 mg/dL and nothing above 250 mg/dL).
This is a basic philosophical choice that I make with my eyes wide open. It’s not perfect and not without any risk. Yet the doctor’s choice of hypers over hypos seems much less desirable to me.
Of course, I’d love to just spend 100% of my time between 65-130 mg/dL but I’m not capable of that for any time more than a day or so. Ninety percent TIR feels acceptable to me.
Doctors use population statistics and guidance from professional associations about population statistics to inform their advice. But I am a unique individual not looking for population advice from my doc; I want advice tailored to my unique situation.
And it’s not like I can’t give my doctor plenty of data to relax a little. My CGM collects as many as 288 data points per day or 25,920 data points for 90 days. But even the heft of all that real-world data unique to me does not apparently persuade him.
I appreciate the doctor’s concern but my perspective, one informed by my skin-in-the-game, is the one that takes precedence. There is no ultimate safety in life, just safer. I like the balance of risk that I’ve chosen to live with. It appears that part of the price I’ll need to pay for that choice will be hearing and acknowledging my doctor’s concerns. I can do that.