Good, bad, or indifferent

Thanks, Mike! It’s true…the living with it bit makes all the difference. His own daughter (now 20) has it, but as he was talking with me, it was so clear that he didn’t know experientially the part that made decision making critical. For example, I noted one particular place when I was stacking with exercise. Exercise most commonly brings a high down for me but often with a significant rebound (40 points). If I’m not prepared to handle that rebound, it makes for a long night. To this he looked downright doubtful and said, “You’re just not normal in anything, are you?” I thought he was joking, so I laughed before I said, wait, you mean that? He went on to explain to me that exercise brings everyone down.


Eric, I’ve replayed this in my head all weekend. Thank you for this. And I find your scripting to be helpful too. I’ll definitely be adjusting (and practicing) my lines before my next visit. Especially your list of things that goes into each decision I make with insulin. And also your bit about the meter being deceptive. As to Afrezza, I have a plan (which includes switching endos if he doesn’t grant my request at the next visit. But thank you. I’m waiting to wean our baby until I try it, so for now I’m doing okay but looking forward to the day. Your offer is so kind!

@docslotnick, your every word was a balm. Thank you!

@mike_barry, not familiar with how this is relevant. Can you enlighten me?

@britt_j, I haven’t. That’s a good idea…and I had wondered about that in the past, but it seems to be tracking fairly accurately, given the A1c—and also when I feel lows, they seem to correspond to the 50s on my meter. If that measure were really low, it would mean I’d be feeling it at 70 or higher, and I don’t think I’m anywhere near that hypo sensitive. But it’s a really good idea. Should do that–would you do that with a blood-draw at your endo?

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THAT is pretty funny. He should know better. Thanks to Eric, we all do :slight_smile:

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@Irish

Due to the long drive and busy schedule, I only see my endo once a year. Alas, I have a standing order which includes, among other things, A1C, fructosamine and random BG every 90 days.

I always run 3 test strips at the same time. This works well for me as it coincides with my 90-day supply (nearly always a new lot) of test strips.

BTW, was there a reason provided for the refusal to prescribe metformin?

Hey, @Irish

I’m sorry that I’m a bit late to the game here. TBH, I’ve been mulling over whether or not I should share my thoughts or not. I realize that you may not be entirely happy with my opinion. But, I’m sharing it because I want the very best for you and your family.

  • First, I will risk being the lone dissenter. Correct me if I am wrong, but I see 5 hypos of <55 in two weeks. If so, you’re having too many moderate lows. (Perhaps I should duck now?)

  • Metformin should allow you to use less insulin – which should translate to a lessened hypo risk from stacking. Thus, I’d press for it.

  • I would consider running a tad higher – reducing your hypos and variability.

  • I’d also consider gathering your thoughts and emailing them to your D team. Ask that it be part of your record…

  • If you’d like to explore the possibility of a glycation gap, you might request a fructosamine test alongside your next A1C.

14 posts were split to a new topic: Hypoglycemia: When Is It Problematic? (How Low Is Too Low?)

This is a GREAT thread and discussion, one of the best I have read: great arguments, and very cogent on both sides. I think we should fork it so as to leave the OP’s thread focused.

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@Irish ,
Hope you don’t feel like you are caught in the middle of a big debate. I love you, and want what is best for you. We all do.

And every single person here speaks to you from their own experience, because that is all we know. I can’t speak from anyone else’s perspective, only my own. And you have to pick things out of our comments and create your own perspective.

I hope your perspective is geared for a long and consequence free life. And - this is the biggest component of MY perspective - a life that is not hindered by diabetes, a life where the disease does absolutely nothing to get in the way of “living”, full and big.

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Sorry I had checked out for some time working on some deadlines, but wanted to chime in briefly before giving a more thorough response to say thank you for these thoughtful responses. My silence only means I’ve been busy. Not the least big offended, @Eric, but thank you very much for your concern!

I’m glad that you chimed in, @britt_j. Adding your voice to @Chris’s has been helpful in reevaluating my blood sugar priorities. I’m still aiming tight but trying to keep some of those lows at bay.

The more I think about it, the more frustrated I grow with the way that appointment went. I’m still aghast that I didn’t walk out of the clinic with a simple prescription for metformin (he says I’m not insulin resistant), which was confusing to me since he didn’t know my I:C ratio when he said that. And while I agree that I could scale back a little…or at least experiment with that…the tone implied such failure. He also said my A1C wasn’t truly 4.7. He said I had skewed that number with having so many lows. Okay, granted it did reflect a lot of lows, but also a lot of work. None of which was commended.

And while I guess I know commendation isn’t what I need to seek from my endo NP (or anyone else), a little encouragement on this road from a care provider could go a long way. Though perhaps not as long as so many of these comments have gone.

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That is a stupid thing to say in my opinion. The lows shouldn’t have any effect on the amount of glycolated hemoglobin (A1c). From my understanding, the higher your blood sugar the more hemoglobin that binds with sugar. A transient low event shouldn’t affect the number at all. I think you are on the right track. Hope your deadlines worked out ok.

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Whoever said that is not very bright nor well informed concerning A1c. A1c is a number depicting your average Bg. If he had a problem with your lows he should have addressed standard deviation and % time low.

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Just want to point a few things about the A1C. First of all, the A1C is not a measure of average BG. It just measures the amount of glycated hemoglobin.

When your BG is high, the glucose molecules attach to the hemoglobin in red blood cells. Longer and higher periods of high blood sugar cause more glucose to bind to the hemoglobin in the red blood cells, and thus results in higher levels of glycated hemoglobin, and a higher A1C test.

The “average BG” is really only an extrapolation of the result. The A1C is not telling you average BG, just how much glycated hemoglobin you have, but it is an incredibly useful marker. It is a very good and useful test.

Since your red blood cells usually don’t live longer than 120 days, the test is only said to give a “3 three month average”.

Here are a few problems with what you may hear, and with the test.

If you have a 4.7, and they say it was “too low”, you tell them that the A1C does not measure lowness. It measures the amount of glycated hemoglobin, and nothing else.

@Irish
Say to them, “Mr. Snooty Endo, if someone’s blood sugar was 83 for 3 straight months, but never dropped below 83, and they had an A1C result of 4.7…would you tell them they had too many lows? If you did, you’d be wrong, and you’d only be demonstrating your lack of understanding about the test. Nothing in the test determines a low or an absence of a low.”

Additionally, RBCs do not have the same life span. Your more recent BG levels will be weighted more in the test result than the ones from 3 months ago (because there are more of them alive from a few days ago than from months ago). So recent BGs will always weight the result more.

Finally, there is a possibility that a low will cause your body to strip away the glucose that has bound to the RBC in an attempt to use it. That would lower your A1C result. So a severe low BG can lower the A1C a bit. This may seem contrary to what I said earlier, that the A1C does not measure lowness (and the comment to Snooty Endo). But it is not really contradictory. The A1C does not “measure” lowness. There is no marker in the A1C that tells you lowness, so what I said above is accurate. However, BG lowness can lower the A1C, but the Endo can NOT make that assumption. There is no valid marker in the test from which they can make that assumption.

Rushed through typing this, hope I did not confuse anyone with my last paragraph, which might seem contradictory. If I did, let me try to do better with an explanation.

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@Eric Thank you for clearing up my oversimplification.

The fact is, however, most doctors (gp, endo, and others) tend to use my oversimplified explanation that A1c depicts average Bg, more often than not . Likely due to the fact that most diabetics do not control their Bg as well as most around here, so in their minds the only way that a low A1c can occur is with an untoward number of lows.

Like it or not, diabetes care is rarely individualized to the extent that it behaves so differently among the affected population.

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Thankfully our last endo didn’t treat us with oversimplified A1c explanations. He did say that above 180 mg/dl the rate of glycolation of hemoglobin increases dramatically. I can’t find a reference for this, has anyone come across a table that shows glycolation rate at different bg’s?

I always heard that same thing too! For years and years I heard that. But it was only through research that I found out some more information about the A1C. And now it’s fun to be able to correct Endos!

It is probably a reasonable assumption for the most part to say that a low A1C came about because of too many lows. And it’s fine if they want to say that to people. But when they mess with my buddy Irish, it kinda got me…hmmm…what’s a good phrase…

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What would you think about putting this type of info on the page for newly diagnosed? Maybe too much, too soon for them to take in? Possibly hearing something contradictory from what an endo tells them would be confusing.

Maybe hearing A1C is an “average” is ok for a newbie, and later on they can get into the finer points of it?

That’s what I am thinking. What do you think?

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I like this idea.

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I think we can have a page that discusses A1c and glycolated hemoglobin in detail within a wiki, but yeah I wouldn’t put it in the newbie list. It really is a fine point, but important as you and I have pointed out. To get to the bottom of things you really need to understand what you are measuring to determine the pro’s and con’s of that measurement. As we have mentioned A1c is a great measure, but isn’t perfect. It’s just the best/easiest we have now, and has been proven over time.

In my course of learning it wasn’t until 6+ months in that I had a handle on what we were doing, and could think about things like this.

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So, I think that on average you can’t gauge how often a patient is low just by A1C. *But, when our son was first diagnosed I asked our endo if it was possible for him to attain a non-diabetic A1C. She said she had a few patients in her practice with A1Cs of 5.8 or 5.9 but they were having tons of lows as evidenced on their CGM data, without really eliminating the highs. So I took that to mean a lot of lows can affect A1C although exactly how I don’t know.

It’s not accurate to say that @Irish does not have an A1C of 4.7 – her A1C is whatever it is. It’s just that it may reflect some lows. Maybe without any lows her A1C would be 4.8 or 4.9. Big deal!

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I think that control to a newbie (and to some of us old timers) can be boiled down to percentage of normal/high/low. I use boundaries of 70-140, I’m sure some of you use narrower parameters.

At that level I run about 3.5% low (below 70). This results in A1c’ s at 5.5-5.8. I have had endos tell me this is not healthy, that I should be low no more than 2% of the time, and that A1c should be about 6.4.

I personally think this recommendation is B. S., and can actually be pretty dangerous for some PWD’s. The key here is YDMV.

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What would you think of this as a description for the A1C test?

“A measure of the average number or high blood sugar values believed to have occurred over the course of a 3 month period.”

Do you think this description is a little more accurate, but does not get into the weeds so much as to overly confuse people? I just kinda put that one together. Certainly people could refine it more and make it better.