Questions for Endo

I've been D for almost 4 years. In this time, I've seen an Endo. once...and I wasn't too inspired from that meeting. Nice lady, but she thought instead of A1C's in the 6s, I should be shooting for an A1C in the 8's????? She also said I was a "perfectionist" in relation to my eating habits (IF and 20-30 carbs per day) and that I should be eating whatever I wanted, and covering it with insulin, and rather than pre-blousing by 45 mins (which she called "dangerous") I should be blousing AFTER eating!?!?!?! I couldn't believe I went to her for advice...

Anyhow, I've done my research and am planning to see a new Endo. soon. I may keep my eating habits to myself, because I feel I have that part under control. However, what things should I ask to be looked at? One main concern for me is scar tissue on my stomach from only putting my omnipod there (and occasionally on my arms in the winter time).

Any suggestions on other things I should be asking??

Even in the low carb world, 20-30 carbs per day seems insufficient to support metabolism. That by itself, would worry me. Additionally, why bolus 45 minutes pre-meal? I think most of us bolus just before eating. If you are low, blousing 45 minutes prior to eating could be very dangerous.... I used to pre-inject the weirdo old time insulin like Lente 30 minutes pre-meal as it took a while to get working. The new ones are very good and work quickly, if you are taking Novolog, Humalog, etc. Pump or MDI?

I am not always a fan of endos and feel my instincts and knowledge are different--not better--than theirs.

I generally chart everything: BG readings, food, bolus, basal (I am on a pump and CGM, so data is everywhere.) I download all pump, cgm and meter readings online, so the doctors can look at that. If I am having some major problems, I address them.

Sit down and think about where you are, what is happening with the D and what you would like to change. I would encourage you to listen to the endo before rejecting everything said. Changing D habits is very hard, but sometimes, if you give it a chance, your life can improve.

some discussions here on endos:

Searching for the perfect endo

how many time a year do you see an endo

Endo today

Doc says my a1c is too low for a type 1

I so understand. Just try to be open a little. You might find a new idea or philosophy, or nothing at all.

Endos are often pretty good pattern spotters. I would bring a complete log and ask about any segment of the day that you're currently having a problem with. A problem with scar tissue might be better addressed with a Nurse Practitioner who probably has more hands on experience with the nuts and bolts issues.


Diabetes is a chronic condition. It isn't like a broken arm where you just get the arm set, let it heal and you are as good as new. You deal with it everyday and you should be making the decisions about how much effort and compromise you make based on your view of the risks and rewards. We clearly know that keeping your A1c at 8% exposes you to more risks of complications than an A1c of 7%, let alone 6%. If you wish to set a more aggressive goal, that is your prerogative.

Some doctors and endos treat patients with doctor centered care, the doctor makes the decisions and the patient is just expected to "comply." As far as I am concerned, that just doesn't work with diabetes. If you encounter a doctor with this attitude and you want to make decisions and take a path different than the doctors recommendation you are just setting yourself up for conflict. I prefer a patiented centered model, where I ask the doctors advice and I make central goal decisions about my blood sugar targets, my diet and even my cholesterol. If you see a new endo, ask questions that reveal whether they will work with you in a patient centered model.

As someone who follows Bernstein and seeks tight blood sugar control, I've had lots of conflicts with doctors. I have mostly ended up just not discussing my diet other than to say "low carb." And I have done this to diabetes educators and dieticians as well. It is my decision. I'm always pleased to get new information and take that into account, but it is my decision. Which brings me to the second point. Even if you don't agree with the doctor, you should always listen. The doctor is right that pre-bolusing 45 minutes before a meal (even if you use R) carries some risk. Even though I often do the same, I also recognize that it there are risk. If I am going to a restaurant, I won't do this since my meal may be delayed or may be wrong leaving me with a problem. And I constantly get admonitions from my endo about hypos because of my tight control. I listen and we discuss my strategies and my actual risks and typically go over my logs looking for hypos and when we don't find any we move on. And if we continue to disagree, I'll just say "ok, I'll think about what you have said and consider making changes." I keep the ultimate decision in my hands.

ps. With a new endo, I would ask about the scar tissue, but I'd also ask for a fuller workup, including thyroid

I think Brian (bsc) has hit on the approach you should take - patient-centered.

Following that view of YOUR world, I would try and ask questions that address your concerns.

I am concerned about ... scar tissue/A1Cs/hypos/hypers, etc. Can you or the nurse practitioner help me with ways to reduce them?

As far as your 45-minute pre-bolusing (careful with autocorrect here!) goes, that might also be a question to ask. Maybe something along the lines of, "I find that pre-bolusing 45 minutes ahead of my meals gives me the best after-meal BG, and I do not have hypos with this method, but I would like to bolus closer to the meal. Do you have any suggestions?

Then, whatever the doctor says you can make your own decisions. Of course, it always helps if you have some data on your side when you find yourself in disagreement with the endo.

For me, I find it helpful to remember that I am a person who has diabetes, AND I have a life to lead beyond the disease or the visit to the doctor. The endo has expertise in my disease and may not understand my life beyond the disease. I take action accordingly.

I think it is safe to assume he is bolusing when he is in normal range, but I believe it is normal to bolus 30-45 minutes before a meal so that the insulin takes effect as the carbs from the food hits the body. There is some risk of going low, but then you avoid going dangerously high at every meal. Also, with me once my BG goes high, it is harder to get it back down with insulin.

I suppose with someone eating ADA level carbs, the risk of going low bolusing 45 minutes prior would be pretty significant because you have to inject enough to cover 50g of carbs, but not when you are covering less than 10. For me that would be 2 units of insulin, enough to lower my BG 50 mg/dl. If I start out at 100, the chances of dealth from going low is basically nil. Yeah, the protein also has an impact, but that has a slow impact and can be covered with a 2nd injection before eating. Finally, when I am covering 50g of carbs with insulin, BG goes up and down pretty quickly, but when I am eating low carb my BG goes up and down SLOWLY. Plenty of time to eat a glucose tablet as BG starts to decrease.

I'm a big fan of shopping around when it comes to doctors. Keep looking until you find one you are happy with. Many of them give bad advice. A1C in the 8s (183-210) range is simply dangerous and causing damage IMHO. Then what endo wants you to bolus after eating? Newer insulins take 30-45 minutes to work on most people. If I at whatever I wanted and bolused after eating, I'd be hitting the 300s 2-3 times a day and staying in that range for 3-6 hours a day. Yeah, maybe the carbs eaten are a bit on the low side, but far less damage than that endo's advice.