My A1c’s have been in the 5.4-6.4 range for almost 20 years. My internal med doc wanted me in the 5.5-6.0 range, and he wanted me to avoid lows. That is impossible, but I never convinced him. Then I started seeing endos in 2007. They wanted me in the 6.0-6.5 range, without lows. That is certainly more feasible, but I still have some lows. My previous doc does not like the A1c’s now being greater than 6.0. My endo likes my current A1c’s, but she thinks I can avoid lows. I cannot satisfy either doctor. I just sit there and smile. They smile back at me, and write my prescriptions. Then we wish each other well, and that is how all my office visits go. I have been my own doctor for many years.
If doctors could be required to live with type 1 diabetes for a week before being licensed to practice, the whole field of diabetology would be revolutionized. An endocrinologist I had had for many years was professor of endocrinology at the local medical school, and he gave me similar trouble to what your doctor did. Eventually he married a type 1 diabetic, and after he had finally seen how type 1 diabetes really operates in everyday life, he had the decency to apologize me and his other patients for “how stupid he had been,” as he was actually willing to put it.
A large part of the disease of ‘doctor dumbness’ in treating type 1 diabetics is that 90% of their patients are type 2 diabetics, in whom control is easier, so they are induced to make false assumptions. Another source of their stupidity is the association between insulin deficiency disease and diseases involving other forms of inadequate hormone production, where you just titrate the dose of supplementary hormone to get the ‘right’ amount, and then that solution is fairly stable for the patient. It is easy for doctors to assume from that experience that dosing should also be stable in diabetics, which it is not.
The real dumbness in diabetology is that since the disease begins as an insufficiency of insulin producing hyperglycemia, doctors tend to continue viewing the disease in those terms, even though treated diabetes is an entirely different condition. The disease we all have now is not primarily insulin insufficiency or hyperglycemia, but insulin requirement instability, and the means we are provided with to address that are inadequate to control it.
A normal beta cell makes a million measurements a day to put out a million microdoses of insulin in response to fluctuating blood sugar levels, and the body also releases glucagon as the ‘brakes’ to moderate the effects of the ‘gas pedal’ of insulin. Nature would not have expended all the evolutionary effort to produce that if that degree of sophistication were not necessary, and so, lacking that, we cannot imitate nature’s effects.
Instead of accepting doctors’ criticism of our performance, we should criticize them for not having come up with a cure nearly a century after Banting and Best developed what was immediately recognized as an inadequate treatment for the disease.
Some doctors make the assumption that the A1c can be precisely and willfully produced. I think the difference in the effort between an A1c of 5.5% and 6.0% is nil. We try our hardest to do our best and the number just appears.
My A1c is always about 0.5% above the average blood glucose measured on my CGM and fingerstick meter. I used to think that this variance was the result of my red blood cells living longer than the assumption embedded in the A1c assay.
I now believe that I am a “high glycator,” and this is what drives up my A1c result. This experience is what drives me to look to time-in-range and other measures as more usable goals to help guide my daily efforts.
Exactly: since H1c varies with hemoglobin levels, you will have artificially lower levels if you have anemia, and artificially higher levels if you are blood-packing for the Olympics. Since men have an average hemoglobin level of 140 and women’s average is around 120, diabetic men will no doubt look more ‘guilty’ to their doctors than women.
This is really well explained
WE also lack Amylin, also produced by beta cells which puts the brakes on glucagon.
I’ve never had an endo want me to increase my a1c.
We also lack c-peptides. What else we lack is unknown to me but there are probably quite a few other hormones that are out of whack that emanate from the pancreas.
It has just dawned on me that the greatly larger numbers of T2s are such an enticing market for pharmaceuticals that very little T1 research is ongoing. That’s what happens when profits are the moving force in health care.
To Willow 4: There has been a lot of research, especially by Professor Wahren in Sweden, about the possible role of c-peptides, which are produced along with the body’s production of insulin, in preventing the development of diabetic complications. It is important to remember that we lack not just insulin, which causes hyperglycemia, but also c-peptides, and if c-peptides block the complications, then this may explain part of the coincidence between hyperglycemia and complications.
Are researchers working on giving us makeup C peptides?
There was a company in Sweden that produced a c-peptide that could be given by injection. I think the funding ceased and the company moved to California. Progress continued until human trials were scheduled. The trials failed, and whole project was discontinued.
Hi Richard: I split off this topic and continued it on a separate thread on c-peptide. One study seldom conclusively establishes anything in medicine, so I think c-peptide may still have some possible therapeutic uses, especially if newly-diagnosed patients are given it and no time is allowed for hyperglycemic memory to get a foothold. Even the Ersatta study showed some benefit, so a more optimistic approach would have said, “That’s a start,” rather than “Well, let’s just forget about it.”
Maybe you already use it but the Medtronic 670G absolutely reduces lows by stopping delivery because it can see them coming with the CGM sensor. If you’re not using the 670 you may want to consider it.
@thoffmanjr, I have been using CGM’s off and on for many years, but I have never had consistent accuracy. I always do finger sticks before meals, at bedtime, and before driving my car. I can have serious problems if I don’t. The 670 is a great pump for some users, but I cannot trust a pump to decide when I need extra insulin, I must do that myself. My Dexcom 5G is a wonderful device for trends, and alarming at night when I am having highs or lows, but my meter frequently disagrees with the CGM, sometimes by as much as 30 points.
So beautifully stated!! Are you by chance an English professor?
Hello @MKSSS. I taught math at the college level for many years. I wanted to write and speak like an English professor, so I kept trying. I improved, but I never came up to that level.
I get into a similar battle over calcium/vitamin D intake between my endo and nephro docs. Finally asked endo to contact nephro, and I would abide by their agreement. End of confusion.
Turned out that each specialty had their own standards, so neither was “right” or “wrong”.
Might work with your docs!
Mine has—she was positively gleeful when I went from 5.7 to 6! “Not as many hypos, right?!”
I have less hypos at 5.7 than I did at 6.1. And that’s because I’ve reduced my carb intake and therefore, insulin usage.
Many clinicians believe that the lower the A1c, the more hypoglycemia. But this is not necessarily true. I know for a fact that with reduction of glucose variability in combination with BG average drops enables a lower A1c without undue hypo risk.
Those of us who have the data via the 288 data points/day that CGM supplies should push back at any appointment where the doc warns about hypos yet is looking at a patient who spends less than 5%, on average, of his/her time hypo.
This is a pernicious critical thinking lapse that we should not allow our doctors to make unchallenged. I keep thinking about the chart that shows that non-diabetics spend, on average, more than 70 minutes per day under 70 mg/dL (3.9). That’s more than 5% every day. Tell me how any clinician can righteously challenge a diabetic patient for living with 5%, on average, of their day hypoglycemic.
Only 10% of T1Ds use CGM. It is an empowering technology. I think every person who lives with glucose disfunction should have access to a CGM. When you have this data, the docs have to respect what you’re saying. The numbers don’t lie; A1C’s do!