Hi, everyone. I am a 50-year Type 1 looking for an endo in the Phoenix metro area. I live in Scottsdale, but I know I’ll probably have to drive a ways.
I love Dr. Bernstein and live the low-carb lifestyle. Last A1Cs were 4.9 and 5.1.
My family practice doc treats my type 1 now, but my low A1Cs now have him telling me I have to raise them higher. He bases this on the ACCORD study that came out ten years ago alleging that low A1Cs led to cardiovascular incidents (deaths). I know that’s been refuted in places, but he still believes in it whole hog. He wants me to aim for an average BG of 115. To that I say: No way, no how.
So I want an endo who is much more informed on the Type 1 world and can give me the straight scoop.
I wish you luck in your quest to find an endo who aligns with your treatment values. I share your commitment to a low carb lifestyle but I’ve given up finding an endo match for me. Instead, I have downgraded my expectation of acceptance of my diabetes treatment tactics and mostly view my diabetes doctor as someone who is willing to support my prespcription needs.
My current endo seems to understand and tolerate my treatment methods and goals. Since I share all my CGM data with him, my ability to keep a low average BG without undue hypo risks and relatively low glucose variability measures seems to satisfy his professional responsibility.
This is the best endo relationship that I’ve been able to build, not ideal but mutually workable.
I’m certain that there are endos out there who believe in the ability of a low-carb lifestyle but unfortunately the mainstream of diabetes doctor thinking does not support us. In any case, take comfort in your exceptional ability to control blood sugar levels and be willing to live with an Rx-writing doc who you interact with in a “smile and nod” pragmatic relationship.
I wouldn’t expect that the average endocrinologist will be up to date and up to speed on interpreting CGM data. I’ve been using the CGM since 2009 and I’ve consulted with several endos during that time. None of them were proficient in CGM data analysis.
I’m happy to read that you use a CGM. It means that at least one of your doctors recognizes the utility of the CGM even though they may not be fluent with all the statistical details. Making treatment adjustments without a CGM is possible but much more difficult. Consider yourself lucky to have access to this great tool!
I soon learned that my ability and skill using CGM data to inform my daily treatment tactics exceeded my endo’s by a lot. I suggest that you do some reading to improve your understanding of various CGM reports. Here’s a good resource that has taught me much.
The 14-day ambulatory glucose profile (AGP) is a single page report that concisely shows your glycemia experience and can point the way toward actions you can take to address the weak spots. I’ve yet to experience one of my endos raising this report and using it to make tactical changes. I’m the one who brings that report to the table!
Here’s a more palatable resource to learn AGP report interpretation.
Dr. Richard Bergenstal in the YouTube video is one of the authors of the first link that I provided above. This 2013 report positively influenced my ability to make rational and effective treatment decisions.
@Terry4 I have spent a lifetime of analyzing data for electronic systems. I was not totally clueless in looking at the data from the Dexcom, but this video cleared up some fuzziness.
My time in range is very good, because I never let BG go to 180mg/dl. I never changed the settings, but if I see BG ramping up fast I will do some stationary cycling or a walk if I can’t get on the road bike. Today I did a correction dose because BG was going up and I could not exercise. I was outside in the heat and humidity cleaning the inside of the car which was a mess. Maybe the heat jacked my BG up. I don’t know.
Before I get taken to task for thread-jacking, I’d like to express my thinking. Sometimes I prefer to answer a question that resides “in between the lines” of a post.
The original poster is looking for help to find a doctor more in line with his values. He expresses frustration with his current doctor.
My sympathy with this sentiment motivated me to encourage him to take the lead role in his doctor/patient relationship. I’ve found in my 37 years of meeting with doctors every three months that they did not fully understand my diabetes data.
Instead of searching for and finding the rare doctor who did get the significance of my CGM data, I decided to learn this skill myself. I now benefit from this skill set and I’m relieved of the doctor search. This is the answer that I wanted to give @Type1For48Years.
So yes, I’m guilty of failing to answer the actual question in this thread but I hope that my answer to the poster’s implied question creates some value for him.
I’m glad that you found some value in my indirect answer, @Luis3.
I did watch a couple of YouTube videos a couple of years ago that helped in at least giving a basis for understanding the Dexcom data. But the one you recommend here is far more detailed. Thanks for the link.
I took a good look at my AGP report after watching the videos. Very interesting.
My data looked good in all areas – meeting his suggested percentages and targets – but not in one area. I show too high a percentage in the “low” range. The doctor sets a target of 4% or below for low/very low, and my number is 11.8%. (I have been having nighttime lows. I attribute this to taking too much basal, trying to get that *#@! dawn phenomenon number down.)
I’m going to very slowly lower the amount of long-term Tresiba and see if I can’t get that low/very low percentage within 4%. Even a unit up or down seems to make a big difference for me.
One nice thing – if I can get my numbers within these suggestions – time in range at > 70%, CoV at < 36%, low/very low < 4%, it will give me a “flat, narrow, and in range” graph to show my doctor. (Mine is pretty flat and narrow now, but I have those troubling lows.)
Too much Tresiba could very well be the source of your trouble. Personal experimentation, which you seem comfortable with, will help you discover an optimal dose. Just be careful to not draw any conclusions about Tresiba dose size too quickly. Give a few days between changes to make judgments and adjustments.
Also consider splitting up your Tresiba dose into 2x/day. I’ve read reports of people overweighting the bedtime dose to battle dawn phenomena. Again, your own experimentation will serve you best. Some people do fine on one Tresiba dose/day and sometimes experiment with changing that time of day. It’s all about finding your optimal plan. Until that “optimal” changes and then you need to adjust!
Many of us here also battle dawn phenomenon and something we like to call, “feet on the floor” syndrome. It seems to be triggered by physically climbing out of bed and not the clock. While the basal insulin can play a role in overcoming high morning glucose, many people add bolus insulin to mitigate these daily glucose elevations.
I add 1.5 units bolus right when I get up in the morning. That usually takes care of things but sometimes I’ll even need to add an Afrezza dose (inhaled powder insulin) to bring things back into range.
Don’t be discouraged if you bring to your doctor some highly persuasive statistical evidence to support the treatment changes you made only to receive a tepid response from the doctor. This is attributable to the doctor’s ignorance and inexperience rather than the value of your tactics.
You are the patient outlier in this doctor’s practice. You need to remain secure in the fundamental value of your glucose goals and not require the doctor’s endorsement to feel OK. It’s always nice to hear a doctor affirm your choices but that can take some time and the doctor witnessing that you are doing better than his typical diabetic patients.
Or he may never give that affirmation or simply say, “keep doing what you’ve been doing.” But you still get to live with less volatile, more in-range glucose levels – something I call metabolic sanity. And that is reward enough!
I split up my Tresiba doses about 2 years ago, I think through info gathered in this forum.
6 a.m. - 7 units
6 p.m. - 7 units
8 p.m. - 7 units
I know, sounds nuts. I will take the 6 p.m. dose down to 6 and do that for a week to see how it works out.
I do take fast-acting upon awakening. If my BG is 75 or below, I’ll take a half unit. Up to 110, I take 1 unit. Above 110, I take 1.5 units. And so on.
I wonder if they’ll come up with a true closed-loop artificial insulin system before I kick the bucket? Sure would be nice.
I always split Lantus, but I thought splitting Tresiba wasn’t really recommended. I assume the desire to split doses is only if you are dropping too low at night or having problems with morning highs? I do have to make sure that I am over 100 before bed, so that I don’t drop too low at night. I give my Tresiba injection when I get up in the morning. I don’t tend to rise in the morning.
My only problems with Tresiba is that at times it loses efficiency and the fact that that the pen doesn’t come in half doses. I loved getting rid of the second dose of Lantus, but would split Tresiba if it would do anything for me.
Dr. Andrea Firenczi of EndoAssociates of Arizona is very good. I’m not sure what your A1C is but I’ve had several seizures (full Grand Mal) from low blood sugar, so I wouldn’t try what you’re doing. However, if it works for you, I think she will work with you.
I’m wondering which PCP you see? I’ve been trying to get my PCP to treat my diabetes, so I can cut down on the ridiculous amount of doctor visits but mine won’t do it.
I should mention that although Dr. Firenczi is very good, if you’re not having any issues, she may assign you to one of her PA’s or NPs and that hasn’t worked out well for me.
I would suggest Dr. Bithika M. Thompson at Mayo Clinic. I do not know her opinion on low carb but she is diabetic so she totally understand what we go through.
