Ideal a1c and "time in range"

#1

Did the A1C target shift back to 7? My NP said my A1C was too low today, at 6.3. She wanted it to be over 6.5. I thought under 6.5 was ideal, but maybe that risks too much hypoglycemia? I asked my sister because she did a nutrition internship at Harold Hamm Diabetes Center in OKC last year and she confirmed, the target was 7 at HHDC.

So my in range time was 74%, my low time was 4%, and my time above was 22%. She wanted me to shift to an active insulin time of 3 hours and increase my insulin to carb ratio by 2g. From 1:8 to 1:10. Ok, that’s fine, I don’t want to have hypoglycemia.

However, I think the time below range is not an accurate number because of the lag time on the interstitial blood glucose readings with the sensors. I went slightly low this morning. I tested and was 65, ate some Easter candy. Waited 15 minutes, still felt dizzy, ate a bit more candy… drove to the drs office. At that point, it had been nearly an hour since the initial low. I tested and my blood glucose was 168, but my CGM still said, 72. It finally started climbing while we were changing rates. I was’t low for an hour though, only 15-20 minutes. So if that extrapolates accurately, I’m really only experiencing mild hypoglycemia (nothing below 65) for about 1% of the time.

Based on my initial settings from this fall, the 1:10 carb ratio and 3 hour active insulin time gave me no lows, but only 60% time in range and 30% above, 10% extremely above. I’m not okay with the time above range. I shouldn’t spend 40% of my time feeling sick while using automode on a 670G.

I’m just going to watch it carefully and download data reports weekly. I’ll adjust on my own if I think it’s necessary and sneak it back to the NPs settings before my next appointment.

I mentioned the lag time for my sensor catching up after lows and she said it was because I wasn’t eating fast enough sugar… but I think that will make my rates not aggressive enough.

Thoughts? I’m thinking aloud and would love confirmation or negative feedback if I’m incorrect. I want consensus from DOC because we are the on-top of it crew!

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#2

This particular statement makes no sense. If your bg was 168 and the sensor showed 72, then the sensor was incorrect- point-blank. Eating faster-digesting sugar would only raise your bg value more. It would have no effect on the accuracy of the sensor.

I find her reaction exceptionally annoying and would be unlikely to take any advice from her given some of the statements you mentioned. Spending 40% of your time in the high range to reduce the low range past 4% (with a portion of that time being a false low) is illogical and sounds very unhealthy. As long as you’re not having severe lows, then I think your low range goals are very reasonable. If you want to reduce the low percentage further that’s reasonable too, but it shouldn’t be by shifting that time into the high range.

I think recent guidelines specify that the A1c and “time in range” targets should be individualized.

My goals are similar to yours in that I am trying to reduce my time spent in the low range and increase my time spent “in range”, but I also strive for an A1c as close to “normal” as possible. An A1c above 5.7% is considered pre-diabetes (or a transition period to diabetes), so I have a goal to stay below that level without having frequent bouts of hypoglycemia. A low/normal A1c is my best chance of reducing my likelihood of developing complications- as long as I’m obtaining that A1c without hypos.

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#3

Thanks for responding.

I’m going to sound grumpy now, but I ate lunch at 12:30 and now at 3:25 my blood sugar is 325. That’s just not ok.

Should I make them look at my cgm reports in 3 days or just change it back and not bother messing with convincing them that I’m right? There are other endocrinologist options in our area.

(I think the trying to accomodate the false sensor data will make the settings not aggressive enough… was what I was trying to say before.)

#4

I guess it just depends on how much effort it would be to find a new one. If this one gets you all the supplies you need, then maybe it’s not worth the effort? It probably depends on how much the doctor is going to push you to increase your A1c level.

If you decide your A1c goals before your next appointment and are willing to defend your position, then the doctor may be willing to listen. Depends on the doctor.

Edit: Whether you keep the doctor/NP or not, I would change your settings to what you’re comfortable with. You decide the settings. Not the doctor.

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#5

I have kept my A1c in the non diabetic range under 5.7 for over 20 years. I have no diabetic complications and have been a diabetic for 60 yrs. I am alarmed by what your NP is telling you. I have always figured that I am the boss of my disease and understand my illness better than any doctor ever could. Don’t let doctors bully you. You are correct that your glucose levels are too high. I understand why you don’t want to have episodes of hypoglycemia, but high levels are dangerous too. Never having used a pump or a CGM I don’t completely understand what is going on in your situation, but I find high numbers very alarming. I am glad that you have other doctors you can interview and choose to help you.

Marilyn
Type 1 dx 1959

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#6

No way would I want my target to be 7. It is six, and I generally am around 6.1 with a lower reading last time of 5.4 which blows my mind. It may even have been wrong. I get tested again in 2 days and as long as it’s under 6, I’m golden.

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#7

My understanding is that there is no way to get an A1c under 6% with a 670g in auto mode.

That said, your goal is not to please the NP but to conserve your health in the best way possible. If you change the settings to what you feel you need, leave them there and do NOT let her bully you. You know best what your need is.

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#8

I just saw the nutrition and diabetes educator who is also a type 1. She said under 6.5% is great (I’m 6.4) that it’s actually considered to be non diabetic readings, although a type 1 is always a type 1. I was at 93% in range, 5% over (my DP causes most of this) and 2% under, (her top range being more liberal than mine and the bottom less so).

She was more concerned about the under saying 2% was on the border of being acceptable, I told her I wasn’t as these were all in the 60’s and I could just eat something. I suppose I could set my warning at 80 and treat before I reached 60? But I don’t mind hitting 60’s some of the time to have tighter control. She said with tight control comes the more possibility of lows I should ease up. Okay this is the standard give on I’m sure medical protocol, they worry about anything lower. She didn’t try to say anything about changing settings, just told me I should ease up on being so aggressive about trying to keep lower so much. And that she hadn’t seen anyone with so many different settings before but I was doing good. I personally am not worried about hitting in the 60’s, I don’t like how I feel, but I am not worried about it. I don’t plan on changing anything except to always refine my settings for better control.

My old endo who was also a type 1, she just would check my readings and she would study them uninterrupted for about 5-10 minutes and just say doing good, a few lows, a few highs, but she could see I took care of it and made adjustments. Ask if I had any questions and tell me about any new equipment/technology coming out. But she was always pro lower A1C, I don’t know how low, but since she had started voluntary group type 1 meetings monthly and had started low carb classes, I bet she wouldn’t blink at lower readings, I am guessing at that though.

I can’t see letting anyone do adjustments on my equipment except me, the one time the new endo tried I spoke up about her not doing it and she hasn’t tried since. She just commented she saw I made adjustments as needed so she didn’t have to.

The very first endo I saw was a jerk and I refused to go back to him. I found an internist as my pcp until they hired a new endo. That was before I was diagnosed as a type 1.

But I hate how we are “beholden” to a doctor/endo for prescriptions we need. So you have to find your own path, but if you can get a second opinion at least I would do so.
But they could be worse or better.

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#9

That’s but just one of many reasons my current pump, a 530G will be the last Medtronic pump for me, unless they seriously step up their game.

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#10

This AM I was talking with my Endo and CDE about upcoming Control-IQ from Tandem and their excitement about it. She said something to the effect that the 670 in Auto mode makes it tough to get below 7(?) because the target is set at 120 (?). Some of their patients are disappointed about this. Sorry or the “?” in my answers but I’m not on the 670 so wasn’t paying close attention

I wouldn’t be comfortable with the targets your doctor set. 4% of the time below range doesn’t seem bad to me. I would be more focused on the 22% above range. But it’s really a personal preference.

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#11

Agreed. I’m only above range 8% of the time, and my upper limit is set to 150! I need to get as many years out of this body as I possible can, and having an A1c over 6 just isn’t the way to do that.

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#12

One more voice for the consensus.

I don’t think there is any reason to raise a 6.3 A1c. Spending an hour a day in the 60s with an occasional dip in the 50s seems OK to me although I try to spend less time than that below 70. If you need an adjustment to limit your hypos buying jelly beans and eating one or two when you hit 80 is probably all you need.

A doc or NP who is willing to have you high for half the day so that you don’t go a little low may mean well but it is not being helpful.

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#13

The thing about all the advice you hear from “health professionals” is that they’re not going to be around to apologize when you develop neuropathy, circulation issues, amputations, retinopathy and or blindness, hyper-tension and heart disease, nephropathy etc etc.

Their words will echo in your ears as you ask yourself why you ever listened to people telling you to intentionally destroy your own body (temple).

You only get one body and you’re the only person in charge of it. Make your choices wisely :thinking:

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#14

To put it another way, that doc may be thought of as being “short-term helpful”, but long-term irresponsible. That’s my feeling on it, having been high in the past for too many years.

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#15

My wife was in on a surgery today for a patient with a cataract. Type 2, bg 425. They did the surgery anyway–something I find medically sketchy, as does she. doctors just want to make money. You all should see how often 2 rooms are set up for one doctor so they can work like on an assembly line. Makes it difficult for the nurses, but more money per hour in the doctor’s pockets.

#16

I must comment on the “assembly line” comment. I had cataract surgery 3 years ago and I purposefully selected an ophthalmologist who did assembly line surgery. That was because he had the greatest experience in removing cataracts. I have retinitis pigmentosa (tunnel vision) and he took great precautions because my retinas are so fragile. The assembly line may look like a money-making machine, and it certainly may be exactly that, but there were people all along that line who knew exactly what their job was and did it to perfection. Some medical procedures need to be done in assembly line fashion. I would not trust an ophthalmologist who had not done hundreds of these procedures to work on mine.

#17

My doc works much slower than his co-horts but he does a FANTASTIC job and my wife has worked with and known him for many years (which is why he is my doc). he did two cataract surgeries on me and the results couldn’t be better. I have 20/20 vision in both eyes–something I didn’t ever have in my life. He’s a great guy and not so greedy he needs to do the “2-room thing”. I’m glad yours worked out, but I hear all about the doctors, the surgeries, the results, from my wife. I’ll take the doc that doesn’t rush. Being too fast might look impressive to some, but it inspires no confidence in me and my wife who has to work with these guys also doesn’t think much of it although some of the docs are quite skilled. But the amount of rushing some of them do is ridiculous.

#18

I started rereading Sugar Surfing today. I had read “Think Like a Pancreas” and liked Dr Scheiner’s style of writing better. But find the info in Sugar Surfing more relevant for pumpers.

I’m going to try to “surf” better in auto mode. So Scheiner recommends watching the insulin tail to estimate your active insulin time. How long it takes a correction to level out. I’m at 2.5 hours today. I’m going to switch that back.

And then I’m just going to play around with the surfing principles and change accordingly. Can’t be worse than the yo-yo or staying hyperglycemic for hours during the daytime!

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#19

Big discovery for me this past week after a difficult 5-week adjustment period to getting a pump and CGM (Tandem & Dexcom G6). While I am finding that I’m able to get better control than manual injections in general, there are more frequent times when my BG goes on a wild roller coaster. This past week, however, I finally decided to check my BG with my old Freestyle meter and compare it to my Dexcom readings. Here is where it gets interesting. If my Dexcom Reading is in the normal range, the Freestyle meter is in agreement and even the same sometimes. If Dexcom the low, my Freestyle meter displays a number in the low 80s. If Dexcom indicates a BG of 200 or more, the Freestyle meter shows a value far lower (tonight’s was 160, for example).

No wonder my BGs get onto a roller coaster! If I take insulin to correct an exaggerated high BG, I’ll go low. If I eat for an exaggerated low, I’ll end up high. This has been going on for weeks! I guess I’ll just have to use my blood glucometer a whole lot more to double check before I take any actions.

#20

Goldilocks is an apt description of diabetes management. It’s what makes good management difficult. You always have to weigh the secondary effects of any treatment. I know it seems impossible but it can be done. Maybe not every time but you can get better at it.

My best tactics are CGM use, a carb-limited diet and appropriate prebolus times. Well timed exercise is another great tool. I’ve found basal rates set too high to often be the cause of the roller-coaster experience.

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