Insights on improving A1C to 7

Never asked for help before, but I finally realized I could use it. Just joined up. Here goes:

Have always had a problem getting A1C below 8.4 Last A1C was 9.2 in November.
Diagnosed 15 years ago. Started Type 2, then migrated to insulin about 12 years ago.
Been on Minimed pump for 5 years now (moved to Revel 523 last year) using Novolog insulin. Running CGM about 1.5 years. Find that my insulin peak time is hours 2-3 post bolus.
Test myself many times per day (8-12) depending on physical activity, pump readings, etc.
Am physically fit (workout 5-6 times per week cardio running, biking and elliptical) and understand carb counting, proper nutrition including low glycemic carbs and portion control.
See Dr and CDE in NYC regularly, plus work with another CDE remotely who is also a type 1 pumper.

Honestly, besides convenience, being on the pump has not improved my BGs.
Despite my best efforts, vigilance and intense focus on trying to control my diabetes, I still cannot find the right handle on getting consistency in my BG readings to the point where my A1C shows it. So far, being on the pump is like my golf game. Flashes of brilliance, but consistent mediocrity!

Does anybody have insights based on personal experience how to turn this around. It am frustrated and not sure where to go from here. Tx

I used to have an A1c of 9.3 but with testing at least 6 times a day and doing all of the things that you are apparently doing, I managed to get my latest A1c down to 5.7. You don't mention whether or not there's been any tweeking of your settings based upon your numbers throughout the day. This is what helped me.

I've been a diabetic for 21 years, on the pump for 12, and CGM for 3. My 5 year old was diagnosed about 30 days ago. Every once in a while, I find I have to "start over." I start over by first figuring out if my basals are correct by doing 4 to 5 hour fasts and just watching my basal rates. However, I don't rely on the CGM for my basals, I actually check my blood sugar with a finger prick during the fasting. For example, I wake up, don't eat (pending a decent blood sugard when I wake up) and just check my blood sugar every hour until lunch when I do my usual food/bolus. The next day, I may decide to eat breakfast but check my post lunch basal rates by not eating lunch, etc. I make sure to check my basals as long as I have not eaten and have not taken a corrective bolus. If I am checking my nightime basals, I do not eat dinner and set the alarm every hour. Once I am confident that my basal rates, including nightime rates are good, I then start checking my ratios to determine if those are correct. I have found that if I don't fast, I have a hard time making sure my basal rates are correct.

BGs are up and down.
Dr (CDE really) makes some tweaks to basals and suggests giving them a try. I always feel like its hit or miss then back to the drawing board for another cycle of the same.

Wow. Congrats on the latest A1C! Lots of tweaking to basals across the day, but still not seeing the desired results.

You must upload your pump readings at least every two weeks and allow your doctor or educator to access your account. He or she can then analyze your readings and then tell you how to modify your basal and bolus infusions to correct the problems you are having. You should also keep a diary of your food intake and send that to your doctor or educator every two weeks to match with your pump readings. Once, you are back under control, you should not have to keep the food diary anymore, but you should still keep uploading your pump readings and have them analyzed every two weeks. This is what I do and I have been very successful in keeping at my target goal for HbA1C.

David is correct! If you have a smart phone, download the App "Glucose Buddy." You can then have your logs emailed to you, print them out and take to your doc/educator. I'm finally getting back on track after the holidays and it shows: BG mostly in the 100s. I note carbs and meal on the notes part of the App, so doc has the information he asked me to keep. I've been T1 35 years; on pump 15 years, but my A1C still hasn't gotten below 6.9. I also workout at gym (Anytime Fitness) and follow a sensible 1200 calorie eating plan. Good luck!!

I have been on the pump for 15 years, type 1 diabetic for 27 years. I also test 10 to 12 times a day. Since being on the pump I had the same issues - A1C hovering around 7.9 and 8.2. Not much luck getting a handle on my blood sugars. I felt that I had been given a lot of hype about being able to control my sugars so much better on the pump. Recently, (in April 2011) I read Dr. Bernsteins book The Diabetes Solution again and started following his recommendations about eating low carb. I have been able to improve my blood sugars so much that my last A1C was 6.4 (never had this low a number) Lately, I do not even have to take a bolus when eating breakfast and lunch. I eat about 20 grams of carbs a day. I have reduced my total daily insulin usage by 50%. This is the only time since I have been diabetic, that I have had this much success.

Because you are using the revel pump, you can upload directly from the pump with the carelink usb tool which you can get from minimed.

By the way, endocrinologists today want you to keep your A1c at 7 because lower readings show increased danger of hypoglycemia

The first concern that my endo had was the number of lows that I had experienced. I've been fortunate in that I usually only experience lows when I sleep in or delay a meal for an unusually long period of time. I've had a couple of 48s in the past 4 months but I'm rarely below 70.

First things first, best of luck with the transition for your little one. On the positive side, he/she has seen you taking care of your diabetes forever so a lot of it will hopefully seem normal. My younger brother was diagnosed with Type 1 at 8 yo over 35 years ago and my parents were clueless, let alone the limited technology that was available to support being diabetic that makes our lives easier (imagine sterilizing needles or peeing on a stick for an ball park BG test).

I think you may be right about pressing the "reset button" on my pump settings. I have done many basal tests over the past several years covering the 24 hour day, but things do change. In fact, I did a basal test yesterday after breakfast. I have been having problems going low 1-2 hours after meals, dinner especially, since I increased the time I have spent working out. I have also been cheating the bolus wizard because my carb ratios seem to be set too low (eg, giving 8 units to cover 45g carb rather than the 10 units the pump calls for,etc.). I set my pump to run 85% of normal basal and tested every hour from 12 noon to 7pm. My BG was really consistent during that time from 97 to 125 while fasting. Only difference is that my CDEs typically want me to eat and wait for the bolus insulin to wear off before basal testing.

Thanks Packers fan.


Take a look at The sessions may seem trite at the beginning but as you progress you may find them helpful in identifying ways to get better results. There is also an "accountability forum" (my term) that helps to keep you involved. There are 10 sessions and it is worth the money-back guarantee.


Thanks Den. Amazing results. Congrats!
I read Dr Bernstein's book during the summer. His approach turns typical medical advice upside down. I eat about 100 - 150g carb per day now (which is about half what an active 6 foot male should take in). I was concerned that his regiment would be very difficult to sustain once you make the transition. How are you finding this part of the program? Also, do you exercise? If so, how do you handle that part? When I workout, I may be riding my bike anywhere between 1 and 4 hours at a good pace or I may be doing interval training on an elliptical machine for 60 minutes. The other day I finished my workout and tested to find my BG at 53. I needed 16g of liquid glucose to bring me up. Thats about what you would consume in a day on his plan. How does this factor in?

One of the other area that was of interest in his book is that people seem to lose weight as a byproduct of following his low carb plan. I have been gaining weight this past year despite watching my intake of calories / carbs and exercising.
Maybe I should re-read his book and start moving in that direction.

I would be curious to know the target settings for your pump.

Aside from what you are already doing, ie accurate carb counting and regular BG tests throughout each day, two things had a big impact on lowering ours son's A1c. The first was to set his daytime target so that all boluses, whether for food or a correction, are aiming to put him at a target of 4 to 5, which would be 72 to 90 during the day time and 5 to 5.5 or 90 to 100 overnight. The second thing was to increase his fixed prime. He wears the silhouette angled set. He often does set changes every other day as he is very sensitive to his sites and they tend to clog, bend or just simply don't work beyond two days. Increasing his fixed prime on each new set insertion from the manufacturers recommended fixed prime to 1.5 units seems to have allowed him to start a new set without going high at the start of each set change.

Keep searching for answers. David is a growing and very active young adult, soon to be turning 19 and is managing to keep his A1c below 6.5.

Thanks for posting this Doug. I have been stuck around 8 for the past couple years with similar effort. I am reading along feverishly. I don't know if I could manage Dr. Bernstein's diet long term, so I'd like to try other approaches first. I have been using the Minimed CGM, but I am going to try the Dexcom because of it's reputation for better accuracy. It'll take time but I will let you know if that helps me.

(Type 1 15+ years, pump 12yrs, CGM 1 year)

I should clarify....the 20 grams of carbs that I mentioned does not include carbs used for correcting lows. I use max 10 grams of liquid carbs to correct my extreme lows (42 has been the lowest). (I use Honest Kids Juice Pouches.) Then I wait and It usually seems to work ok. Otherwise you spend the next two days chasing highs after over correcting. The regimen has not been difficult except at first cause I had a lot of indigestion and stomach issues until my body adjusted. Once you adjust, you really don't crave the carbs anymore. I have been exercising (not as much as you) but only about 20 to 30 min a day on a treadmill or elliptical and doing some weights. What I found when I exercise is that I did not experience huge drops in blood sugar after exercise because I had decreased how much insulin I was using. Dr. Berstein has a chapter in his book where he discuses how to adjust for strenuous exercise. You asked about weight loss. The more insulin I use the more it makes me gain weight (directly tied to how many carbs I eat) . Although I have decreased my insulin usage, I have not been successful with the weight loss issue but I haven't gained and I feel so much better. I do have other issues such as thyroid that are probably working against me. I hope the wieght issue will eventually sort itself out. :-)

I upload my pump and meter to Carelink regularly. My CDE has direct access to my account and goes through both inputs thoroughly before suggesting changes to my settings. He does not usually ask for more than 3 days of food logs. This is something that I find to be a pain to do, but it sounds like it is worth doing (maybe even for a week at a time) from the results you are seeing. Thanks David.

My target settings are 110-110 all day long.
How does your son deal with his targets? Does he have many hypos? Even with my CGM, I find that it often runs 20-30 points higher than actual BG, much more if I am exercising.

I have been toying with the idea of the Dexcom unit as well. But, I am not ready to take up the other front pocket with a second device .. the egg shaped CGM. Besides, I might miss the harpoon sized needle that the Medtronic sensor has (: . Let me know how it goes and if it helps you lower your A1C.

First day here...
So apparently it's not just me that thinks they are doing everything correctly and achieving sub-optimal results. If nothing else, I feel a little better about that.
I've only been at this for 2.5 years but am completely frustrated. Like you, I am in reasonable shape, workout, test like crazy, read everything, have a good Dr., and am frustrated that there seems to be no finding the "sweet spot" for keeping BG under control.