Seventy to one-eighty -- don't patronize me

Mental and Emotional Wellness
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Can you remember a time as a child growing up, when the neighborhood gang tired to make it easier for you, the younger child, to accomplish something? Perhaps it was the ability to hit a baseball and they slowed down the pitch and gave you extra swings before your chance was over.

I can. And that memory mixes resentment and gratitude in a strange combination that’s hard to portray. It’s the public acknowledgement of your immaturity and the group’s willingness to accept that immaturity, at least for a short time, that makes it unique.

Your sincere and heartfelt desire is to be accepted as part of the crowd without any accommodation. Slowing down the pitch or lowering the goal posts is not respectable from your younger-child point of view because it tarnishes the beauty of the aesthetic. You must face the reality of the game and deal with the failure.

Success needs failure to define itself. Without failure, success is meaningless. Once you accept your failure you can begin to work on the fundamental skills that allow you to climb out of failure and work toward success.

The 70-180 standard that the American Diabetes Association and others use as a blood sugar success standard will never be accepted as Ok by my inner self’s sense of success. Seventy to one-eighty is the grand accommodation made by the older kids to help out the younger ones but is commonly understood to never be the standard of success. That will only come when the pitch speeds up and goal posts are at standard height.

Now I know that The ADA standards of 70-180 and under 7% A1c can be an effective stretch goal to help people progress to better performance. But too many can see this easier standard as a success where people can settle and see the job as done.

The real world, where biology can exact cruel complications for the long-term acceptance of this contrived 70-180 “success” and these complications will eventually make their rude appearance. And all the organizations and doctors’ standards will be nowhere found to console you when that happens.

Just because we have diabetes, the healthy blood glucose range does not disappear. It still remains near 70-120 and doesn’t care that you have been diagnosed with diabetes.

I see the 70-180 standard as patronizing. It offends me! I see its use as simply temporary in the journey to more normal glucose levels. The ADA, JDRF, and many doctor organizations that advocate for this standard without any clear statement that this goal should only be a transient one while moving to embrace normal glucose.

They don’t see it as a transient goal; in their minds it’s a permanent one. That organizational acceptance of this range as the final goal is what I see as patronizing. It insults me.

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Well, for many people in the rest of the world, not necessarily who spend a lot of time on this forum, even 70-180 (3.9-10) is a real achievement. So we need to be careful not to demean folks who have done this or denigrate that accomplishment. I have been gradually tightening up my TIR goals, currently set at 4.0-9.5 (72-170) and almost always at least 70% in that range and am actually am happy to see 80-85% and ecstatic to get the rare 100%.

It’s hard!

Sure, I’d love to have my target at 75-120 (4.2-6.7) and hit 100% all the time but that is very high standard. I do have no functioning pancreas, after all.

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First of all – congrats on your setting increasing goals toward the ideal. I am not interested in demeaning accomplishments of the ADA standards. What I demean is the unambitious institutional settling for their standards as the ultimate goal of blood sugar management.

Yes, it is hard. The difficulty of the goal, however, should not diminish our ambition to set high standards. Accomplishing normal glycemia without a functioning pancreas makes it all sweeter.

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I understand what you’re saying, Terry, but, as MBW stated, it’s very, very hard for most of us to ascertain “normal “ ranges.

The longer I live with T1D, the more I worry about the ramifications of less than perfect control. I have gotten much better recently, but am still a far cry from 100% 70-120.

It takes a mental and emotional toll. I see a wider range goal less as a slower baseball pitch and more as a way to stay as healthy as possible while not spending every waking minute thinking about T1D. If I am going to function like the person I want to be ( full time career, family, friends, etc), I need to forgive myself for the occasional out of range blood sugar.

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Of course. While you may not choose to target or assess your performance to a more ambitious standard, I think it is helpful to understand that your glucose management could improve when the time is right.

Life with diabetes is all about balance and your tradeoff of glucose management with quality of life is understandable. Just don’t be fooled that your level of management is ideal and requires no further effort.

We are all a work in progress and can evolve over time.

By the way, I don’t think metabolically healthy non-diabetics likely achieve 100% TIR 70-120.

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These are organizations speaking for a very large and diverse patient base with significant differences in:

Income levels
Education
Heath Insurance
Acess to healthcare and medical technology

While appropriate for you and the majority on this site, probably not practical for the other 98%.

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I don’t advocate that organizations abandon the current goals it sets for people with diabetes, no matter the education or access to health care and medical technology.

What I endorse is that they acknowledge that normal glucose is the ultimate target and that the org’s current focus on 70-180 is simply a stepping stone to move to normal.

While that ultimate target may not be achievable by a high percentage of the population, it should be acknowledged as desirable and possible. Omitting this higher goal unfortunately communicates that this goal is not possible and targeting that better performance is just not possible. I disagree.

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Yes, I never thought that.

I have and continue to do better. The last couple of years have seen a marked improvement (thanks in large part to the Dexcom) and I am thrilled with that. That being said, I think it’s unhealthy to obsess and beat myself up over some missed targets.

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Good for you! This you should celebrate whenever possible.

I wholeheartedly agree. Balancing healthy goals with acceptance of real world performance is not always easy. I just don’t think aiming at mediocre goals as an ultimate target without a nod to healthy normal glycemia is short-sighted.

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Although a bit different perspective, @Terry4 , you may consider advocating for some of the organizations mentioned here. Lack of awareness and access to care is also a key issue.

https://www.cdc.gov/diabetes/disparities.html

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You are a superstar, @Terry4, and you know that I cherish our friendship. But every time you write stuff like this post, I share my blogpost from a year ago questioning how good do we have to be. For sure I don’t know but I do know that my mental health is better with a high TIR of 70-180 than a lower TIR of 70-120 or 70-150. And I strongly believe that I shouldn’t consider numbers in the 60’s to be an acceptable target. My A1c’s would indicate that I am doing fine and my endo is convinced that at my age, a 70-180 range is appropriate and I am doing great.

I am fine with diabetes most days and my mental health is okay. Except I have times (like Day 1 of Dexcom sensors) when I have incredible rage and frustration. Yes, I have definitely thrown and broken things….

I basically can’t ask myself to do better and I am not sure that I need to. I will continue to pat myself on the back for a high TIR of 70-180. And I will try not to let diabetes social media make me feel guilty about that. And I will continue to be glad to know people like @Terry4 who are pushing the boundaries of what is possible with Type 1 diabetes. :heart:

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I just don’t agree @Terry4 . I think if you are driven to do better, you start looking or joining groups and will inevitably run into people that do better. Then you strive for better goals if you are inclined. Most people don’t even reach the 70-180 goals, which seem to basically be a fairly safe goal. I realize it’s obvious that if a “normal” BG is lower, it is more likely to be better to stay lower. But it is the people that don’t reach the recommended range, which is a majority of people , where there is a huge problem. Pushing an even stricter goal for those people, for all sorts of reasons seems unwise. And if it’s a trade off of being happy and not stressed and staying in 70-180, which seems to be a reasonably safe range, then let that recommendation stand. Most people are not avid about spending more time, on something we have to spend so much time on anyways.

I think the loop systems, even without a lower BG aim is a great thing for many, As it is refined it looks like we might be able to get a lower BG aim out of them. But for many even calculating the right amount of insulin, in variable circumstances is hard enough without having to aim for a lower or narrower range. We personally might strive for tighter control and more of a normal range, but no matter how much we strive for that, we are not normal and as it stands we have a disease we have to learn to live with and stay happy.

Given that I am forever grateful for sites like this and all the people on them. It helped me significantly to strive to do better. There was and is a wealth of information for those that look or need help. Because there is a big lack in being able to access that information in the medical field. I’m not sure that can easily change considering the variability of Endos, DE’s and Doctors out there.

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Good post Laddie and you express a lot of the same thoughts I have. Since going to CIQ my average BG is higher but my time in range is real good and I feel real good. I think I probably spend less time bouncing around chasing the perfect BG.

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While I enjoy coming to this forum occasionally to be inspired by the many who are able to achieve higher BG goals, the range of 70-180 with an A1c between 5.5 and 6.3 is quite acceptable for me. In fact, at the moment I’m feeling a little down because the endo I’ve been going to for the past nine years is retiring and my diabetic care will from now on be supervised by my PCP, a doctor of internal medicine. My endo has for the most part praised the heck out of me for the levels I have reached and has said I could be teaching the majority of his other patients. My time in range is usually 92-95 percent. I can already see that my PCP is going to push me a lot harder, and I don’t know that I’m up for that.

Part of my reason for not really caring if I reach higher goals is that I didn’t become diabetic until age 70. Although at age 80 I already do have some diabetic neuropathy, I just am not likely to live long enough to face the decades of damage people who become diabetic younger typically face. So my level of fear is not as great as it might be for many. And at this age quality of life means something different than it did when I was younger. Most of my life I was very underweight. Until I retired I was only of normal weight for a couple of short periods. Mostly I was too stressed from work to eat much and I frankly wasn’t all that interested in food. But after a medical problem four years ago that took me down to 101 pounds, I had to work very hard for a couple of years to get back to normal weight. But in the meantime, I learned to like food. So now I have disabilities that prevent me from being able to do some of the other hobbies and activities I used to enjoy, but I’ve learned to really like food. (And unfortunately I am now up to 145 pounds, 15 more than I’d like.) But since food is now one of the only joys I have left, I’m simply not willing to restrict my choices too much for a diabetic range that will likely only provide nominally better health outcomes.

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I think how tight you need to have your ranges depends somewhat with how long you will live with diabetes. I had no serious complications of diabetes until I had been a type 1 diabetic for 51 yrs. I definitely thought that I was one of the lucky ones who would escape serious complications, but I suddenly needed 2 heart stents. I had an A1c of 4.7 at the time.

I developed retinopathy 61 yrs after being dx.

During my first 22 years living with diabetes my care wasn’t good. The next few decades my A1c was under 7 and I ate whatever I wanted. The last 17 yrs my diet has been strict and I have stayed in the non diabetic range. I low carbed for 11 yrs and ate no more than 30 carbs daily until my body rejected the diet.

Now I try my best to stay between 65 and 130. I eat a plant based low fat diet with plenty of very healthy carbs, so that hopefully I won’t have a stroke or a heart attack. I also make exercise a big part of every day. With diabetes one never knows when a complication will suddenly surprise you. I am trying my hardest to live as long as possible.

I am 71 now, and would like to live well into my 80’s if possible. I really like the food I eat and that certainly helps. At this point I am thankful for every day that I am alive.

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@Uff_Da I am really surprised that you think your internist is going to push you harder. And very curious. Most internist just don’t know as much about diabetes and want a higher A1c. I mean I think it is pretty standard they go by the 70-180, 70% in range…but are really pushy about not less than 4% low and preferably staying less than 2% low. Your 92-95% TIR in between 70-180 is doing great by most doctors standards. Unless there are more lows.

So what are they saying that you think they are going to push you harder? Is it because of lows?

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Marie20- The reason I think the internist is going to push me harder is because he already gave me instructions on the records he wants me to keep even though I asked him to take over my care regarding diabetes only after my endo retired, which isn’t until the end of this month. I haven’t kept written records of BG before each meal and at corrections, BG at bedtime, etc. for years. Since my overall control is good, I don’t know that all the extra work is going to accomplish anything. I’ll be seeing him early next month, so I may have a better idea of whether my fears are real.

It could be that he is mainly concerned about the possibility I’m having more lows or worse lows than he likes, since my last A1c was 5.9 and that was what he saw at our first meeting. But the records he’s asking me to keep don’t really indicate that as the concern. Will see.

Okay, I just checked my Dexcom clarity to see what the internist will likely see at our next meeting. He hasn’t seen one of my reports yet, since as far as I was concerned he wasn’t handling my diabetes yet when I saw him. As of tonight by the last 30 days report I’m sitting at less than 1 percent very high, 3 percent high, less than 1 percent very low, 3 percent low. Most of the very low is typically when a new sensor thinks my BG is 50-100 points lower than it really is. Happens about half the time with a new sensor.

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@Uff_Da I get that low after starting a sensor, it drives me nuts so I am ready to hit it with a calibration right away to make it go away when it happens. I hate things like that play with our TIR. But I will calibrate a new sensor several times anyways to get it more accurate.

I am wondering if the written records is because the Internist is unfamiliar with a Dexcom? Internists mostly see type 2s and most probably don’t have a CGM? So maybe it’s standard to ask for written records early because to be able to look at written records, people have to keep them beforehand? Maybe call the office and tell them you have a Dexcom, can you just copy your Dexcom records and is that good enough?

The 4% total that you have, a lot will not like it at all. The endo probably understood more about a certain amount being from sensor error. If a bunch is from starting a sensor, you might try the immediate calibration, or soaking before you start it so it doesn’t start so low. I once let one sit saying I was low for hours as an experiment to see when it would go up and then I realized it was really mucking with my numbers and going to be reading as low for a good percent of time and really ruining my TIR…never again lol!

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Thanks for the link, @MM1. It serves to remind just how big and diverse the world of diabetes is. And it suggests my concerns are small by comparison!

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I agree. The point that seems to be getting lost here is that I am not advocating that the 70-180 target range be replaced by something else.

I certainly don’t think that “pushing an even stricter goal” for people who struggle to meet the 70-180 time in range target is a good idea. Instead, what I propose is an acknowledgement that normal glucose is the ultimate goal and those who easily meet the 70-180 target should consider a lower range.

Thank-you for your thoughtful comment.

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