Thanks for all of the responses, though the linked article is sobering to say the least. I’m nowhere near the level of control I asked about, but with a new CGM and now experimenting with Afrezza, maybe I’ll get there, and the theoretical will become relevant.
A lot of good points here, but some thing which has not been stated is many in the professional field are now saying A1C is not the best measure. Time in range is a better measure. For instance a person can have a great A1C and have a LOT of highs and lows. So I feel strongly in the future it will be a measure of time in range for instance a person with a average120 range BG maybe better than person with 90 and a lot of highs and lows.
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I consider time in range or TIR to be the best measure of diabetes blood glucose control. A high percentage of TIR implies lower variability, less time low, and a lower average BG. One number that bundles in three measures. I have four BG goals and the A1c number is not one of them. The A1c may hide extremes and also suffers from false reports due to anemia and other conditions. TIR is the king of diabetes control statistics.
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I agree time in range is a great measure but when I’m really nailing it, I will “score points” in all of the categories. It may not be accidental how I think of diabetes numbers this way, as I was pretty into fantasy baseball, reading BP, some of Bill James’ books about different numbers (WARP, BABIP type of stuff…) so thinking of TIR has been very usable metric. The Medtronic pump/ CGM allows you to select “daily average” for 1-31 days and it’s very easy to see what your TIR is for different ranges and how your current plan is working, If it gets larger for the period, I can go “w00t” and if it’s lower, well, I can think back, do I need to change or not?
I don’t like being dismissive of A1C as a useful tool or measurement. The repeated warnings such as “Low A1C isn’t perfect,it can be an average highs and low rollercoastering”, “we’re more than numbers” etc. are somewhat true but ignoring how improving say TIR might show results in A1C? Feelings of depression, experiential loneliness, etc. seem quite commonly reported in PWD and I have found myself pretty oblivious to them by working to find successes. I think that clinically it may be very useful to have a broader definition of success to pull in people who have had challenges finding feelings of success, make them more due to control and less random.
As you know, I’m a big fan of tactics to control BGs. Some people’s eyes glaze over when the discussion of tactics arises and I get that. We’re not all wired the same regarding thinking in terms of math and graphs. But turning away at the first mention of numbers, I believe, sells yourself short. Understanding how to use a tactic, like effective pre-bolusing, and then employing it and experiencing success is the best antidote for depression that I can imagine.
In my humble opinion, dismissing tactics and math simply because you are not naturally inclined in that direction and instead focusing on cathartic expression will not fix the underlying problem. You may feel better for a while due to expressing yourself well and being heard, but it doesn’t fix the basic problem. Using tactics to spend more time in a healthy range will not only give you a better statistical result, you will feel physically feel better because every cell of your body feels better.
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This is a great discussion, and an issue I thought about a lot back when I was managing my BGs with insulin before my MODY-2 diagnosis last spring. Acidrock23 shared this post on Facebook, which brought me back here.
One thing I’m surprised to see missing from this discussion is an acknowledgement of how inaccuracies in BG measurement relate to the sort of precision folks here are pursuing. Current meter accuracy standards mean that 95 percent of the time, Terry4’s 83 reported BG reflects an actual BG somewhere between 63 and 103 mg/dl (of course some meters are a little more accurate than others), and I believe CGMs should be a little less accurate than this. That’s a severe limitation on the sort of fine-grained BG control Terry and some others are pursuing.
Good points niccolo although I think the actual accuracy statements of meters themselves seems a little bit more complex than is defined by simply “+/- 15%…”
I don’t know if all meters do, but mine came with a graph of controlled tests and the vast majority of them were in a far tighter range than +/- 15%… The 15% I believe is just the regulatory minimum that hey must demonstrate that they meet… If you’re one for analogies-- It’s a bit like the speed rating on a tire…
Agreed, and even if meters only do as well as the regulatory minimum performance, results are still likely to cluster around the mean in a way that makes many individual results more accurate (though that doesn’t tell you whether any individual result is one of those more accurate ones). And all that said, current meters still have significant inaccuracies associated with them that hamper super fine-grained BG control.
Welcome back to TuD, niccolo. How have you been?
Are you aware of the distinction between accuracy and precision?
Thanks, I’m great. Oddly, no longer managing my BGs doesn’t feel like that big a change. The one area that does feel like a big change is athletics, it’s amazing to go for workouts and not have to think about reducing my basal in advance, what bolus I might have on board, managing my sugars during exercise, etc. Also, I’m pleased to report my A1cs off insulin are actually lower than they were on insulin, with effectively the same lifestyle. Since MODY-2 upregulates BGs to a higher setpoint, that’s not all that surprising, but I’m still pretty psyched about it.
I am aware of the accuracy/precision distinction. In fact, I thought you might bring it up. But it’s not clear to me it changes the point in any fundamental way. When your meter gives you a certain result, your actual BGs could be significantly different. Often they won’t be too different, but you won’t know whether any individual result falls into that category. And although a pattern of results, and other datapoints like how you feel, all help, I don’t think they entirely ameliorate the challenge of fairly inaccurate meter technology. Do you feel differently?
I suppose if your meter is precise, experience might teach you that it mostly errs in a particular direction, and you could adjust your interpretation of its results–but in practice, it would have to be pretty consistent for this to make a difference. And if your meter is accurate, then on average your results would be very good, but that doesn’t help you much if you don’t know whether any given individual result is above or below the mean. Is this what you’re getting at?
I compare my fingerstick meter against lab results. The inaccuracy is not as wide as the standard allows and the precision is fairly tight. I often fingerstick twice and take the average for treatment. Look, I realize that the system I’m playing with has a lot of variability including the rate of digestion, the absorption of sub-q insulin, and the effect of exercise. I know that this game is not a precise science. Just because there’s inherent variability and imprecision doesn’t mean I can’t make some educated guesses about how to dose.
This month marks the start of my 33rd year of poking my fingers and dosing insulin. That’s over 280,00 hours of living and observing this condition in me. I’ve learned a few things. I share my story here in order to help others.
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I think the meter limitations are somewhat overblown, and I feel pretty confident that between my meter and CGM, unless my BG is in a period of transition, I get a fairly accurate idea of where it is. Besides, it’s the best technology we’ve got, so living by it not only makes sense it’s the only logical strategy, IMO. My CGM has not only been enlightening, it’s a motivator. I’ve become rather averse to risking that nice, in-range flatline by having a cookie that I really don’t need anyway. I find it easier to ignore mild hunger pangs if I know that I’m not really going low like my stomach sometimes tries to fool me into believing.
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As much as I talk about “numbers” I am not actually a “math” person at all and pretty regularly talk about how it’s been a great advantage to me to get things set to run smoothly, because I’m totally lazy and ends up being less work.
I agree with @Jim2 about the overblownness of meter inaccuracy. Mine have always been accurate enough for me. +/-20 mg/DL is close enough for me. A couple of mg in a DL of blood seems hairy sometimes- “eek, 47, what if it’s 27?” but, most of the time, 85 vs. 105 isn’t going to skew an insulin dose calculation or other treatment plan. In some of my running antics, I’ve sailed pretty close to the edge, kept nudging my BG to where I want it and finished some pretty long runs where I wanted to be, to drink beer and eat potato chips at the finish line! Neither of which are, of course, recommended by doctors…
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@acidrock23, I can see that I was wrong in seeing more likeness in our control philosophies than really exists. We each have distinct methods that are indeed very different. I prefer to look at all the numbers and take guidance from them, whereas you prefer a more intuitive approach based on the your long history in dealing with D and the wisdom that accrued. Neither method or philosophy is wrong, just something different that works for each of us.
Does that make sense?
Absolutely! D-iaversity! I mostly meant to point out that sometimes, people are inclined to overlink math with success, which has not always been my experience. But I don’t take any notes and am thus useless for anything but N=1 war story type of reporting…
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It’s interesting that we both are attracted to the sugar surfing concept as we come from different quarters of d-management philosophy. As I’ve said elsewhere, calculations can only place you in the right BG-neighborhood. Then you need to nudge things one way or the other. D-management, like clinical medicine, depends on both science and art.
I hear you, @Terry4 . And having interacted with both of you, I’m super impressed by how both you and @acidrock23 manage your BGs (with somewhat difference approaches but in pursuit of effectively the same goals). It wasn’t at all my intention to cast doubt on your good work. But I have been struck that some of the blood sugar micromanagement folks on this forum describe–for example, correcting a “high” just above 90 to try to bring it to 83, to use your example above–seems tough given current meter capabilities. But I suppose it doesn’t matter whether those sugars are actually 83 all the time as long as whatever they are doesn’t risk too many hypos.
Hope all is well on your end!
@niccolo, thank you for your response and well-wishes.
What we’re faced with here is either steering our BG ship peering through a foggy windshield (inaccurate meters) or with a bag over our heads (dismissing or discounting the only meter we have). Now I may be trusting these readings beyond their empiric capability to resolve but it’s the closest thing I have to a clear view.
And I’ve made hundreds, probably thousands, of these navigation decisions based on imperfect information and I didn’t sink the ship. There comes a time when you trust your sense of the waters ahead because you’ve sailed there before. Besides, I can always correct later if my imperfectly informed decision needs a compensating nudge in the other direction. You trust your gut instinct because that’s the best tool at your disposal. It’s literally been honed by hundreds of thousands of hours at the helm.
Here’s today’s line:
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