Would you make this trade?

[Terry4]

Anyone who has lived with treating diabetes with insulin is well aware of the tradeoff that exists between good blood glucose (BG) control and the risk of hypoglycemia. Those who choose to target glucose levels in the normal range risk crossing into hypoglycemia more deeply and more frequently than those who choose to aim for a higher glucose target.

With the emergence of hybrid closed loop technology comes the promise of changing the calculus of that decision. We will still need to face this same tradeoff but we’ll be able to rationally choose a lower glucose level and more aggressive target with less, but still some, risk of hypo BGs.

I offer you two different hypothetical days of blood glucose control. One contains no BG values below range but the tradeoff is that 34% (about 8 hours) of blood glucose on this day exceeds 140 mg/dL (7.8 mmol/L) and the variability, as measured by standard deviation, is relatively high at 39 mg/dL. Time in range (65-140 mg/dl, 3.6-7.8 mmol/L) is 66%. The BG average for this day is 122 mg/dL or 6.8 mmol/L.

Compare that experience with this second day. This BG day shows 96% time in range but with 4% time hypo. The lowest value settled at 57 mg/dL (3.2). This 4% translates to about 58 minutes. On the upside, this day has a normal average of 85 mg/dL and very low variability at 13 mg/dL (0.7 mmol/L).

My question to you is this: Would you, if you could in some ideal world, choose to live with better BGs and less volatility at the price of some hypoglycemia? Or would you be more comfortable with a higher BG experience with zero risk of going hypo?

Here’s a summary of the two days.

Day 1, higher blood glucose, no hypos.

Day 2, normal blood glucose, 58 minutes in the upper hypo range.

I realize that we cannot order up the blood glucose day we want; this is a bit of a fantasy exercise. I’m just trying to gauge the values of the community in this basic tradeoff we each face when we decide what personal target and associated risk is acceptable to us. I would appreciate in the comments about the rationale for your choice. There is no right or wrong answer here. Thanks.

If you could, which day would you choose for yourself or your loved one?

• Day 1, higher blood glucose, no hypos.
• Day 2, normal blood glucose, 58 minutes in upper hypo range.

[Eric2]

@Terry4

Compare that experience with this second day. This BG day shows 96% time in range but with 4% time hypo. The lowest value settled at 57 mg/dL (3.2). This 4% translates to about 58 minutes. On the upside, this day has a normal average of 85 mg/dL and very low variability at 13 mg/dL (0.7 mmol/L).

This choice was very easy for me. I would take the lower one without any question.

[Sam19]

I would also take the second one. I don’t consider a “low” of 57 to be significant, but a 57 and still dropping with bolus on board certainly could be… imo that’s why they tell you to stay above that level… not because the level itself is dangerous… so in your question where the 57 is the absolute minimum— it’s a no brainer for me

[Terry4]

I like the hypoglycemia descriptions used in this table published in the American Diabetes Association 2018 Standards of Care.

I particularly like the term “hypoglycemia alert value” (<= 70 mg/dL, 3.9 mmol/L and > 53 mg/dL, 3.0 mmol/L) to describe this upper hypo range. It’s time to take notice and action, not time to pull the fire-alarm!

[Sam19]

That’s a better description than simply “below 70”

My doctor always puts in my notes “no significant hypoglycemia” which I appreciate

[Willow4]

I checked the lower one (second choice). Why? Because I don’t view a low of 58 to be of great significance. At 58 I would not even treat with carbs but would turn off basal for a period of 1 hour.

Interestingly, I very recently had one of my quarterly visits to the CDE. She questioned my target of 85 mg/dL +/-10%. She wanted me to raise it to 120. I refused (which didn’t earn me any Brownie points) but did agree to raise it to 100 for nighttime.

I do get a fair number of nighttime hypos but have never needed help. I live alone in a remote location and any help would take at least 30 minutes to arrive.

[Terry4]

@Willow4

Interestingly, I very recently had one of my quarterly visits to the CDE. She questioned my target of 85 mg/dL +/-10%. She wanted me to raise it to 120.

As I wrote this post, I wondered to myself what our diabetes medical providers would answer to the question I posed. I think they’d overwhelmingly vote for the higher glucose, no hypos choice.

This highlights the major difference in perspective between the person with diabetes (PWD) versus the person giving medical advice to the PWD. As a PWD we must balance the short term consequences with the long term ones. The provider giving medical advice, I believe, significantly underweights the importance of long-term complications when compared to hypoglycemia. I also think that providers see all hypoglycemia in the same light and make no distinction between alert hypoglycemia and serious, clinically important hypoglycemia.

[John58]

I vote for the second, with a few contingencies:

1. A Dex CGM or equivalent is on me,
2. My age…61 right now. My endo and I have had deep discussions about this question, and I have developed the attitude that a deep hypo will be a greater risk to me down the road when I finally reach the status of “old geezer” and is a minimal risk right now while I am on top of things and can treat those developing hypos before they knock me over.
3. My finances: it’s not cheap to manage BG and if I ever hit a rough patch without access to my preferred brands of modern insulin or a good CGM I would probably revert to #1, higher BG goals.
4. Similarly, it takes time and mental focus to maintain a low BG. When I have a hectic string of days and am not able to devote those snippets of time each day I inevitably end up closer to #1 than #2. I think my A1c reflects that, always in the range of 5.9 to 6.3. When I look at 90 day sequences in Clarity, I see 2-3 week stretches similar to #2 mingled with short bursts of #1 or higher lasting 3 days to a week or so.

[MM1]

@Terry4

One contains no BG values below range but the tradeoff is that 34% (about 8 hours) of blood glucose on this day exceeds 140 mg/dL (7.8 mmol/L) and the variability, as measured by standard deviation, is relatively high at 39 mg/dL. Time in range (65-140 mg/dl, 3.6-7.8 mmol/L) is 66%. The BG average for this day is 122 mg/dL or 6.8 mmol/L.

I consider this a pretty perfect day. This will not lead to increased risk of complications. Personally, 140 is not my upper limit goal. I set alerts at 140, so I can check and possible correction. Need to balance with enjoying life !

[Sam19]

I think healthcare providers aren’t as foolish as sometimes you think. They know the difference between significant and serious hypoglycemia and mild inconsequential hypos… these aren’t dumb people, it’s just a different perspective. I suspect if you and I were giving professional medical advice for a living we would be more aligned with their perspectives ourselves. As a professional, if you advise someone that it’s ok to have a blood sugar of 57, and they get it slightly wrong and end up in the icu or dead, you have given them willfully negligent advice that has caused them harm… it’s not fair but that’s how the world works.

That is a very paradigm from you and I having the conversation above where we both agree that there’s no harm in a bg of 57 a few minutes of the day that doesn’t go any lower…

[Sally7]

I also would go lower. But I have always thought this way much to the dismay of my medical teams. From the time I was diagnosed, highs scared the heck out of me. I never wanted to feel like I did when I went into that coma. I was also scared to death of the horrible stories that were told back then.
So have I over the years stacked more than I should, sure. Over the years have I tested more than I really needed to and struggled with the results, sure. All I can say now, is thank goodness for my CGM! As I try and stay on the high wire tightrope, it has saved me more times than I care to admit when I am more aggressive than I should be. As long as I have those alarms to alert me, I can be more aggressive now.
But I also don’t live by myself, I don’t have and heart conditions that could make severe lows life threatening and I review my reports each week to see how things are going.
So for me, I would prefer low vs higher any day!

[Terry4]

@Sam19

I think healthcare providers aren’t as foolish as sometimes you think.

I don’t see their position as foolish but I think as patients we need to realize that our interests can and do diverge from the provider. I agree that I would likely fall into the same mindset if I were a doctor, but I am not.

I can see from my personal history with doctors, that I was not always cognizant of this divergence of interests, and I made medical decisions, weighted primarily by advice from the doctor, where I suffered significant harm because of that. We each need to honor our own interest.

[Sam19]

Also, and this is somewhat morbid, br accurate I believe, but it speaks to your point about healthcare providers valuation of long term consequences vs short term…

Healthcare providers understand (as professionals) that their patient have a lifecycle, eventually every human will have health problems and will ultimately succumb to them. But their job is to give the best advice they can to ensure a full life.

Consider this hypothetical to help understand what I’m trying to say. You are a doctor and have magical powers. You are given a terrible choice, but have to decide. You have to decide between one of your patients who is 10 years old having a cancer diagnosis that has a 70% chance of survival. Your other choice is, instead, a 75 year old patient having a diagnosis with only a 10% chance of survival. Which would you chose? Why?

I guess the point I’m trying to make is that they don’t give advice that keeps people alive forever, because that’s not possible and they know that. They strive to give the advice that keeps people out of crisis.

[Terry4]

@Sam19

They strive to give the advice that keeps people out of crisis.

I understand and agree. I think I answered the gist of your question in the answer I posted just above. I am aware of the burden doctors feel, but I am not fully sensitive to it since I don’t shoulder it – similar to the case where doctors don’t fully appreciate what it feels like to live 24/7 with the burden of insulin dependent diabetes. We each need to honor the rightful role we respectively play and make the best decision possible.

Too many patients put doctors up on a pedestal, including me earlier in my life, and that situation is not good for either the doctor or the patient.

[Jim26]

We have to remember that for 95% of PWD are not as motivated as the people on this site. If the doctor advocated for the lower BS, would more than likely put that 95% at increased risk of a severe hypo event and put himself at risk of an event that would risk his career.

[Jen]

I used to get quite frustrated with “conservative” advice from healthcare professionals. Then I myself became a professional in a field where my advice and recommendations would hold life-or-death consequences for the client I was working with. Suddenly, I found myself giving conservative advice and taking no risks with the recommendations I made. Making decisions that affect only you in situations where you have direct control at all times and making decisions that affect others who you do not have direct control over are two very, very, very different things. In my role, I was very acutely aware that a client could get seriously injured or worse if I gave them them incorrect or incomplete advice…or even if I gave them correct and complete advice if they misunderstood it, misinterpreted a situation, or forgot part of what I said. I actually had to get out of that full-time, front-line role after a very short time because I couldn’t handle the stress of giving life-or-death recommendations in that type of service delivery model (although I’m still using my certification in an auxiliary role in my current job). After that experience, I have a lot more respect for what doctors and other healthcare professionals deal with on a day-to-day basis.

The problem with lows is that, while there are people on this site who can maintain extraordinaryily tight control, that is not the case for the vast majority of people with diabetes, for a variety of reasons. I would ideally pick the second day if the low of 57 mg/dl was a line that could never be crossed. But the reality for me is that the first scenario is a normal day for me, and even with that, I regularly drop well below 57 mg/dl—last night I woke up at 2:00 AM to my CGM alarming to a very sudden and rapid drop to 45 mg/dl (thank you, hormones decreasing basal needs by 20%!)—despite efforts to reduce hypoglycaemia, such as frequent testing, wearing a pump and CGM, and being very engaged in diabetes management every day. I have very good diabetes control compared to a majority of people with Type 1 diabetes. So, given this, I can totally understand why healthcare professionals may recommend the first sort of day to a patient who may be only minimally engaged in managing their diabetes and may have a limited understanding of the actions that may increase or decrease the risk of serious lows.

[beacher]

@Jen

I can totally understand why healthcare professionals may recommend the first sort of day to a patient who may be only minimally engaged in managing their diabetes

Not just to prevent serious lows or too much time below the low threshold, but to prevent hypo-unawareness that follows from those, even in patients who are 100% engaged in their management.

[lumi73]

I chose #2. I feel like crap when I dip below 80 mg/dl and it takes ages for me to feel better again.

[Terry4]

Seems like the “Day 1, higher blood glucose, no hypos,” would then be your preference. Maybe I misunderstood your words. Or perhaps the poll software displays the two options out of sequence to the original display. I clearly understand your sentiment. Day 1 is your preference, right?

[lumi73]

Haha that’s what I meant!