A1cs under 6...how do you do it?

[Kendall]

I have been a member here for about a week and I'm reading tons of posts and my husband is starting to think I'm getting sucked into some new cult. Okay, not quite, but I've read most of the threads on at least the front page of Type 1, Pumping Insulin, Monitoring, and Carbs/Calories. I have learned a lot and been reminded of a bunch of stuff I had forgotten that I ever knew. I see that several posters consistently have A1cs near or bellow 6. A few are even consistently close to 5.

The reason I even found this forum is because my husband and I are talking about planning our first pregnancy and I also got my recent A1c back and it was 7.3 (one of my highest ever). I knew it wasn't going to be great, but I'm considering it a starting point for improvement. For several years after dx I stayed in the low to mid 6 range, so I know I can do it. Even in the last week I have seen a huge improvement (avg BG down from 156 to 140) just by paying more attention and pre-bolusing for meals.

Anyway, my question is...what are your secrets to getting your A1cs so low? I know that there are no magic bullets or miracle systems. It will always be hard work, but what are the practical things you do to stay in such tight control? I'm sure some of you do things I would never think of on my own. So please share the wealth with the rest of us.

[dbc]

Restricted/low carb eating plan does it for me, & you'll find many people here saying the same. My last A1c was 6.1

Other things are knowing your I:C ratio, tweaking your basal rate just right, and noting the phases of the moon(!!) - that just to say it isn't all science, seems to me there' s an art to it as well!

There are folks here with good control who eat a more "normal" diet, I don't know how they do it! Seems to me there's no linear correlation between my I:C ratio for a lo-carb meal and I:C for a high carb meal, but that may just be me

[matingara]

i agree with the above.

i would also recommend you buy the book by Dr. Richard Bernstein and follow that. just search on Amazon and you should find it easily.

:)

-- Joel.

[Gary_W]

Hello Kendal,

It is possible to get an A1c below 6 without low carbing. I manage to do so (5.8 these days and eat 200-250g of carbs on average). This is less than the ADA standard amount, but still enough to make Bernstein blush... It includes breads, rice, pasta, cous cous, fruit, the occasional cake etc. Nothing is off limits. All ethnic diets greedily eaten...

My secrets (such as they are) are as follows:

Ensure you basal test and get this set up correctly. Nothing else makes sense if your basal is off. It also allows you to go to bed at a low (but safe) number and have the confidence that you'll wake up :D Having your BG between 5 and 6 (90-108) through the night will really help bring the HBA1c down. Too much basal plus the inevitable snack before bed does not help your A1c quest.

Work out your I:C ratios and also your correction factors. Be aware that these may change throughout the day. Be willing to adjust them when your body changes, which it will...

Learn your insulin profile; you need to know how quickly it kicks in, when it peaks, how long it lasts. Only then will you be able to safely pre-inject and correct.

Carb count effectively. Buy some good books, good scales and (at home) weigh everything. I have the Salter nutrition scales and they are great.

Test before each meal and then test 2 hours afterwards. Correct as needed using your ratios and your understanding of what insulin you have on board.

Learn how to inject for different foods. If something that you love gives you grief at the 2 hour mark, try pre-injecting / over inject and then snack at the 2 hour point. But be safe :)

Treat hypos with 15g of fast acting carbs (glucose tabs preferably). Wait 15 mins and test again. Treating with chocolate, cookies etc will not be effective and gives you rebound highs.

Consider pumping if you can get access to it. It adds better overal control and wellbeing IMO. My HBA1c is unchanged from MDI to pumping at 5.8, but I manage it now with far fewer hypos than MDI + many other benefits. My Animas allows 1/20th unit increments for bolus so you can really match the food effectively.


Hope this helps, good luck with the pregnancy.

Gary

[xMenace]

What Gary said.

If your basals are off at all, you'll never get your meal ratios set properly. Once you get your basal rates and meal profiles set, it really is clear sailing.

Every test should mean something to you. For years I never bothered testing much because they didn't tell me anything. Now every one does because I understand my behavior so much better. When I have an off test I can pinpoint the probable cause(s) very quickly and act properly. No or little guessing.

"Think Like a Pancreas" and "Pumping Insulin" should be in your library.

[Eddy]

Basal testing (I'm a bit off right now), meal profiling, insulin profiling...

...and a bit of luck. I'm fortunate enough that insulin works quickly in me. I can correct quickly (even faster if I shoot in the bicep), and prevent large mealtime spikes without prebolusing. That's why I use my insulin cocktails: I often want slower action, without several smaller, fast-and-peaky injections.

[shabbie]

my last 2 A1c's have been 5.7 and 5.6.

my 'secret' is pretty much what gary and xmenace said. i eat a normal diet giving me around apx 180g-200g carbs daily and maintain a normal weight/BMI.

mostly i like to eat low GI foods like beans and veggies etc. but i also have a weakness for daily chocolate. i try and avoid dairy based foods as this just messes with my profile too much!

understanding how everything works for you is the real key ;)

good luck with TTC ;)

[Olidus]

This site is not like a cult more like a support system.
And for me - my secret is this site.
I am on here and learn something new about the D almost every day.
TEST, TEST and more TESTs.
Never guess - and make sure you know where your body is at, and how you react to the food you put in your system.

As Gary mentioned Carb counting helps alot.

[Evermont]

Forgive my T2-ishness... but wouldn't some exercise and focus on nutrient dense low GI carbs (even if low carbing) also be helpful for a T1?

[davef]

Another T2 sneaking in behind Keith, I've gotten down to 6.2%, for me it's been two things, 1.Being on this forum 2. Testing and striving to make sure what I eat keeps me on target (Less 110 FBG and less than 140 after 2 hours after first bite)

Not sure if that helps,

[Olidus]

Forgive my T2-ishness... but wouldn't some exercise and focus on nutrient dense low GI carbs (even if low carbing) also be helpful for a T1?

So true - The exercise and focus on nutrient shoudl apply to everyone be it Diabetes or not.

I was always told the better shap you are in the less resistance your body builds up to insuline.

[matingara]

yeah. i know tis was asked as a "Type 1" question. and i as a "Type 2" (i think) answered with my opinion.

But on this difference, Bernstein is very clear. small inputs are best. the effects of carbs cannot be exactly predicted all the time.

so, Bernstein basically believes that low carb means that less insulin is needed for both T1 and T2.

this avoids mad swings in BGLs.

it makes a lot of sense if you read the book. i am not an expert.

:)

-- Joel.

[Kendall]

Well, I think I am on the right track then. I have been doing tons of basal testing this week. My doc helped me tweak a few things already. Once I get that set, I was planning on checking my I:C ratios and correction factors. I am on the pump already so I think I might need to have different I:C ratios at different times of day. Dinner always seems to need more.

I have been testing a ton and the pre-bolusing for meals seems to make a HUGE difference in my 90 min - 2 hour post readings.

Thanks Gary for the reminder about 15g glucose and then retesting when low. That is something I used to do religiously but have slacked off on and it does mean I've had a lot more rebound highs.

Because of this forum I have also been looking into low GI foods and how they can help. I need to do a little more research on this. I also need to get "Think Like a Pancreas" and "Pumping Insulin". I keep hearing good things about them.

All of these tips along with support from all of you and some dilligence on my part and my A1c should be headed down under 6 soon. Thanks all!

[MJM]

No one thing will get you right. It's the whole package that will make it work correctly. The package would, in my opinion, start off with having correct basal rates. Carbohydrate Ratio is also important. Exercise is also important. The correct food is also important. In other words the whole package.

[Gary_W]

Forgive my T2-ishness... but wouldn't some exercise and focus on nutrient dense low GI carbs (even if low carbing) also be helpful for a T1?

What you say is absolutely true, but I'd add a little T1 footnote... Excercise can really severely affect the way that insulin works in a person. If you understand its effects then fine. If not, it can really cause peaks and troughs in the glucose levels that can rather spoil your day. It is, of course, vital to long term outcomes (says he sitting on his rear end yet again) so it is worth learning how to do it...

As for low GI stuff, yes I agree in principal BUT if you ONLY eat low GI then you can get the unfortunate situation that the insulin beats the food. You are then left with an evil hypo at the 90 min post prandial mark, a belly full of food and the prospect of having to eat something to treat the hypo that won't work quickly due to already being full. Been there, bought that T-shirt and it really isn't much fun. Same goes for low carb food. In me, I can cope with 'regular' food (by which I mean a bit of carbs from all GI groups but more brown than white, a bit of protein and a bit of fat). It's the high fat, high protein stuff with minimal carbs mixed in that gives me the most grief in terms of getting my levels right at 2 and 4 hours post meal. For some people's metabolism, low carbing may well be for the best as far as their BG goes but it's not a blanket rule whatever Bernstein says.

Both of the above are really covered by my point about knowing your insulin profile. Once you understand how your rapid insulin works in your own body with certain life factors / foods then life gets a fair bit simpler. It is a real shame that doctors often talk in terms of amounts as opposed to telling patients how it absorbs over a period of time. An obvious point once understood but it drives you nuts until you 'get' it.

And I wouldn't say you were T2-ish. Tee Tootal? As opposed to me who is clearly an insulinholic :D

Gary

[viranth]

My last A1C was 5.3%, I'm very pleased with that result.

I don't really know how I got it, I just tested, tweaked my doses and everything worked great.

The basal is very important though, like everyone else says. When I was sick, with fever, for the first time since I got DX'ed, I really saw that the basal is almost everything.

My first night time low (short time ago) was my own mistakes that got me.

I guess the trick is to learn from your mistakes, eat healthy right food, keep a log of what you eat and test test test!

[art]

Beats me. I sort of cruise between 6.0 and 6.5.
If I go lower I feel like ****.
Have the baby. It's worth it.

AFS

[Eddy]

What you say is absolutely true, but I'd add a little T1 footnote... Excercise can really severely affect the way that insulin works in a person. If you understand its effects then fine. If not, it can really cause peaks and troughs in the glucose levels that can rather spoil your day. It is, of course, vital to long term outcomes (says he sitting on his rear end yet again) so it is worth learning how to do it...


Ohhhh yeah. Just a little walking can make a huge difference. And I've tried some jumping around "one-person moshing", which I found also drops me with quickness.


As for low GI stuff, yes I agree in principal BUT if you ONLY eat low GI then you can get the unfortunate situation that the insulin beats the food.


Pumpers can use a different bolus shape. MDIers can split boluses or use slower-acting insulins.

[Evermont]

Thanks Eddy and Gary for confirming my hypothesis. I'm starting to get just how tricky managing insulin is - hats off to all of you who manage to figure it out!

So now I understand that extra precautions are needed for a T1 who wants to do the right thing and exercise and eat well, but they should do it for the same reasons that everybody else should do it - plus helping with long term control of BG.

So it's strategic but with tactical implications. :)

[viranth]

Start lifting weights and interval training on bicycle and running.

On my diet and exercise I've dropped 13-14 cm (5-6 inches) around my waist, I'm stronger than ever and the sixpack is almost there.

My glucose control is very good as long as I work out, when I can't work out, for example when sick, then glucose control is much harder.

So, work out, there is absolutely no reason why you shouldn't. It'll only take you an hour or two (if you're into it), and what are you missing out on? Watching TV or playing games or being online? It's not like you haven't done it before, and you know it's going to be there when you get back.

[Gary_W]

Thanks Eddy and Gary for confirming my hypothesis. I'm starting to get just how tricky managing insulin is - hats off to all of you who manage to figure it out!

So now I understand that extra precautions are needed for a T1 who wants to do the right thing and exercise and eat well, but they should do it for the same reasons that everybody else should do it - plus helping with long term control of BG.

So it's strategic but with tactical implications. :)

That's about the size of it. The bell curve of insulin needs to match the bell curve of the food. If it does, you avoid spiking post meal and avoid hypo later on. Get it wrong in either direction and one or other happens. Eddy alters the shape of his insulin bell curve by mad chemistry and mixing various types of insulin. I just use Apidra and slow it down using the pump's extended bolus facility for the higher fat foods. But I'm still at the early stage of the pump learning curve and it's not as reliable as regular carbs without the extended bolus. Extending really does help me with mild excercise after eating, though, which was often a quick trip to hypo city on MDI :(

[LancetChick]

For me, the biggest things are testing and logging everything that affects my BG. When my A1c's were in the 6's my blood sugars were really all over the place, and my only goal was to reduce the variation and strive for stability. I started testing roughly every hour, and documenting it all, and my A1c's just "happened" to plummet..... I'm now hanging pretty steady at 4.8%.

As others have said, getting the basal rate exactly right is a key element. Also, understanding how long foods take to digest, and matching with an appropriate bolus duration is important, as well as understanding the nature of various foods and how they respond to insulin. For example, in me, a 150g carb hot fudge sundae will take 4 hours to digest, whereas a plate of baked French Fries with 1/3 bottle ketchup and the same # of carbs will take 6-7 hours to digest. Protein begins converting to glucose in me from 1 1/2 - 2 hours after eating, and this lasts up to 6 hours. I do not count carbs, unless the exact info is right there on the box, nor do I weigh anything..... I just test every hour, sometimes more often, sometimes less, and if my BG is starting to rise or fall, I nip it in the bud immediately. I find that higher carb meals match insulin action more exactly than lower carb meals, and if I dose correctly I don't ever get BG higher than the 90's.

If there is no food digesting, I'll correct a BG of 95 so that my meter averages stay in the 80's (pumps are great for that). Mind you, I do make mistakes, and get surprised by hormonal insulin resistance, which will give me high blood sugar, but I figure if I correct it quickly, then I'm a little like a non-diabetic who will have elevated BG after a carby meal, but not otherwise. Different reasons for the highs, but overall, similar results.

Having written all this out, it sounds as if diabetes is a full-time job for me, but it really isn't. Testing frequently is certainly inconvenient, but only takes a minute per test, and I eyeball foods to come up with an insulin dose rather than calculating carb content, protein content and bolus duration, which I consider too time-consuming for me. It generally takes a second to come up with an insulin dose, and if I've made a mistake (which I do), then it won't have become too apparent when I test an hour later, and I can correct before anything too out of hand occurs.

I'm still learning, and next endo visit I'm going to ask for metformin, since I find insulin management much easier the more sensitive I am to insulin, and the less my liver acts up.

[Ailsa]

What a great question Kendall


Learn how to inject for different foods. If something that you love gives you grief at the 2 hour mark, try pre-injecting / over inject and then snack at the 2 hour point. But be safe :)


Gary I would be interested to know what sort of bg you are aiming for at 2 hrs?
I use novorapid which does not fit my digestive profile very well.
I find I am hitting 9-10 (160-180?) at 2 hours. but down to 4-6 (70-100) after 3 hours. if I Have more insulin I am hypo after 2 1/2 hours & have to clock watch to avoid it.
Apidra is not available where I live.

Would be interested in your thoughts on this thanks.

[pegasus]

I recently asked my endo about below-6 A1cs, and his immediate response was, "they must have a lot of 30s-40s BGs." I asked what he meant, and he said, regardless of how well controlled one is, the instant a diabetic takes in food, there's an immediate--however temporary--spike, could be 500-1000 BG. Could come down within seconds, but it's there each time nonetheless. So one would need 30s-40s to average out to a <6; which, he says, the brain/body can adjust to, but isn't necessarily ideal. So, he says, the generally recommended diabetic A1c would be ~6.5, to avoid those extreme lows.

Thoughts?

[Scratch]

I recently asked my endo about below-6 A1cs, and his immediate response was, "they must have a lot of 30s-40s BGs." I asked what he meant, and he said, regardless of how well controlled one is, the instant a diabetic takes in food, there's an immediate--however temporary--spike, could be 500-1000 BG. Could come down within seconds, but it's there each time nonetheless. So one would need 30s-40s to average out to a <6; which, he says, the brain/body can adjust to, but isn't necessarily ideal. So, he says, the generally recommended diabetic A1c would be ~6.5, to avoid those extreme lows.

Thoughts?
Get a new endo? He doesn't seem to have that all good a grasp of mathematics and digestion rates which I would find very troubling for someone of his specialty.

He's right that we would all do well to avoid extreme lows but either he is misinformed some, or he's misinforming you some, and that's troubling, IMO.

[xMenace]

Thoughts?

Your endo is full of ****!

[Lloyd]

I limit my carbs to 80 g per day
I test 6-8 times
I use an insulin pump

[LancetChick]

I recently asked my endo about below-6 A1cs, and his immediate response was, "they must have a lot of 30s-40s BGs." I asked what he meant, and he said, regardless of how well controlled one is, the instant a diabetic takes in food, there's an immediate--however temporary--spike, could be 500-1000 BG. Could come down within seconds, but it's there each time nonetheless. So one would need 30s-40s to average out to a <6; which, he says, the brain/body can adjust to, but isn't necessarily ideal. So, he says, the generally recommended diabetic A1c would be ~6.5, to avoid those extreme lows.

Thoughts?

TOTAL BS! That's the kind of thinking that prevailed when I was first diagnosed over 20 years ago. It's funny being a type 1 diabetic, because we are in a position where, at least the more veteran of us, know more than the doctors about insulin management, and we are able to see how these doctors treat this disease. I have seen and heard ignorance beyond belief spewing from the mouths of "professionals"..... to the point where the advice they give is downright dangerous. I use my docs for prescriptions and lab tests and THAT'S IT.

[xMenace]

TOTAL BS! That's the kind of thinking that prevailed when I was first diagnosed over 20 years ago. It's funny being a type 1 diabetic, because we are in a position where, at least the more veteran of us, know more than the doctors about insulin management, and we are able to see how these doctors treat this disease. I have seen and heard ignorance beyond belief spewing from the mouths of "professionals"..... to the point where the advice they give is downright dangerous. I use my docs for prescriptions and lab tests and THAT'S IT.

:stupid1:
.

[Scratch]

I just ate a rice cake and my blood sugar spiked up over 500 mg/dl!

[viranth]

I just ate a rice cake and my blood sugar spiked up over 500 mg/dl!

Why would you do that? Rice cake is very high GI ...

[Lloyd]

I recently asked my endo about below-6 A1cs, and his immediate response was, "they must have a lot of 30s-40s BGs." I asked what he meant, and he said, regardless of how well controlled one is, the instant a diabetic takes in food, there's an immediate--however temporary--spike, could be 500-1000 BG. Could come down within seconds, but it's there each time nonetheless. So one would need 30s-40s to average out to a <6; which, he says, the brain/body can adjust to, but isn't necessarily ideal. So, he says, the generally recommended diabetic A1c would be ~6.5, to avoid those extreme lows.

Thoughts?
My only 40's were when I had a A1c in the 7's and was on glypizide.

I've been in the 50's twice in 15 months on a pump, with an A1c of 4.9 for the last 8 months.

The doctor has no clue.

-Lloyd

[Evermont]

...his immediate response was, "they must have a lot of 30s-40s BGs."...Thoughts?

My most recent A1c was 5.7. I've never been under 86 and never over 220 in almost a year of testing 5-7 times per day. I don't understand your guy at all.

[Scratch]

Why would you do that? Rice cake is very high GI ...
I was just joking.

The rice cake itself is 11g of carbs, I was 73 mg/dl and had about 1u of bolus insulin remaining. Works for me.

But according to that one endo, I momentarily saw a high spike of blood sugar.

Last time I saw a blood sugar up over 300 mg/dl was the time I forgot to bolus for lunch a few months ago. And I had probably eaten up around 90g of carbs.

[Real4]

Anyway, my question is...what are your secrets to getting your A1cs so low? I know that there are no magic bullets or miracle systems. It will always be hard work, but what are the practical things you do to stay in such tight control? I'm sure some of you do things I would never think of on my own. So please share the wealth with the rest of us.
One think that works. test often, correct often. I correct with as little as 1/2 a unit of insulin.

[xMenace]

My most recent A1c was 5.7. I've never been under 86 and never over 220 in almost a year of testing 5-7 times per day. I don't understand your guy at all.

You're not injecting insulin either. Non-IDDs have more of an intensity problem, not a timing one. It's much tougher for us to synch the insulin troughs with the sugar humps.

[Gary_W]

What a great question Kendall



Gary I would be interested to know what sort of bg you are aiming for at 2 hrs?
I use novorapid which does not fit my digestive profile very well.
I find I am hitting 9-10 (160-180?) at 2 hours. but down to 4-6 (70-100) after 3 hours. if I Have more insulin I am hypo after 2 1/2 hours & have to clock watch to avoid it.
Apidra is not available where I live.

Would be interested in your thoughts on this thanks.

Hello Ailsa,

I try to be <7.5 at the two hour point and if I'm eating at home and therefore able to weigh out the portions then I achieve this pretty consistantly. This works for MOST foods, and means that I'll be down at a 5.5 by hour 3 and then stay somewhere between 4 and 5.5 until I eat again.

If I am higher at the 2 hour point, I'll put the number into my pump and go with its suggestion UNLESS I know that the meal I ate was correctly counted but evil in terms of GI. If that's the case, the high is deserved and will come down by itself. I'll just leave it and test at hour 3.

If I am down at a 5 or so at the 2 hour point, I'll think carefully about what I ate. If it was all low GI / high fat etc then again I'll leave well alone. If I feel that I'm down there because I messed up the carb counting then I may eat or drink a little something (small amount of juice, some apple etc) to stave off the inevitable hypo at hour 3...

It seems to work well. Apidra helps; it is about 65-70% gone after 2 hours so it's excellent at dealing with that post-meal spike. The other thing that has helped with spikes is the super bolus on the pump. I super bolus every single morning. For those not in the know, you 'steal' some of your basal and give it up front at the same time as a food bolus. My morning basal varies a touch, but between 7.30 and 10.30 am I have a grand total of 1.65u of basal insulin trickling in. If I get up and eat 40g of carbs, I need 4u of insulin. I actually inject 4 + 1.65 = 5.65u of insulin, then I set a temporary basal rate of 0 for 3 hours. In this way, my post-breakfast spike will be minimised and I won't go hypo later on. Museli, cereals and toast are all do-able with a 2 hour BG of 7-8, which is pretty good as far as I'm concerned. Especially as I have a gradual drift down to a 5 and it stays there. Lunch time for me is anywhere between 11.30 and 3pm, so it needs to :)

And Pegasus - that is a typical outdated comment. Yes, you can lower your A1c with persistant hypos. But to suggest that this is always the case is just not true. It is the spike duration that does you in, and IMO if you can get the spike to be reasonable at hour 2 without going hypo at hour 3 or 4 then your job is well done. This is achievable by dietary choice, correct insulin use and many other ways of which regular hypos is the least desirable ;) I have around 1 mild hypo per week these days. At some points with MDI I was up to 3 per day. I still had a great A1c but that was the bad way of doing it. Not intentional I hasten to add....

Gary

[Gary_W]

One think that works. test often, correct often. I correct with as little as 1/2 a unit of insulin.

You've got to love the pump. I did a correction shot of 0.05u of insulin earlier because the pump suggested it.

Did it make a blind bit of difference? No. But it felt cool in a weird kind of way. Yes, I do need to get out more.

Gary

[birdyland]

I'm T2, but on insulin....

I test test test and test again... and I LOG everything via spreadsheet.

Good luck TTC, I sent you a PM ;-}

[Kendall]

Apparently I started a little bonfire of activity on this one. I seem to understand the importance of getting the basal correct first. I think I have that pretty well set. A few more minor tweaks maybe but I'm so sick of fasting I'm taking a break for a day or two. From what I've heard, I think carb ratios are next along with correction factors.

I think the post meal spike is where I keep getting stuck. I have a very difficult time keeping my post meal BGs from going over 150. Sometimes I skyrocket up to the mid 200s and stay there. I pre-bolus by about 15-20 min, more if I start out high. I don't seem to be going low at 3-4 hours usually. Does that mean my carb ratio is off? I seem to need a correction almost every meal.

Do I just change my I:C ratio and see what happens? Or is there a more scientific way of testing it? Thank you all for your input.

[pegasus]

Apparently I started a little bonfire of activity on this one.

Me too! ;)

I clearly have a bunch to learn about this. In a minidefense of my doc (you should hear him go on about the corrupt drug industry, and how bad so much science is because of control by industry, etc.--sentiments I think would get support here:) ). I think his comment was meant a bit hyperbolicly--not that people w/low A1cs are constantly getting 30s and 40s, but that all Ds have even nanoseconds worth of extreme highs when food hits our systems because we simply don't have the same ongoing and automatic physical functions as non-Ds, and so there must be similarly momentary lows to balance.

But as I say, I have a lot to learn.

[shiftzor]

Guys just remember it’s easier to stay in a small bg range than it is to stay in a wide range. Concentrate on lowering your Standard Deviation which will help your A1c. Typically you should be under 10mmol/L or 180mg/dl after a meal but I would aim for the same bg as you started with ideally. The key to all of this is to not stop learning and to keep testing. We should make a sticky with all of this useful information so many people ask.

Diabetes Monitor - standard deviation buzz (http://www.diabetesmonitor.com/m57.htm)

[cheryl]

I have learned a few things along the way, and am still learning i am nowhere near five a1c, but keeping only basal testing is effective if it's your same set routine daily....

I have a very very off schedule, I get stressed, I went from loosing massive amount of weight to finally not....

One thing, never test basals if your are around your monthly HORMONES do throw it off a bit....Test a week after you get your monthly this gives us girls less time to get it so.....

I was all gung ho to retest here after I got a root canal that was making my sugars wacky, Had to wait for the monthly then my job did something awful to me, took me off the schedule, I am working different hours different time frames don't know WHAT to do, was high from stress last week, got resolved at work, but working 12-8 one day, 9-5 the next, cannot basal test on these days. I decided for now to do it on days off, and if I am willing when it's over night....

I tell you, I had everything set back in from DEC-March, poop hit the fan and I have not been level since....I don't know when it will all settle, but now, since this last stressful event and actually seeing a 308 because of it, never do I ever hit that high, unless set faliure...that I am done, I am not stressing, so now, I am dropping again...

STAY AWAY FROM STRESS, that is the key to finding your true rate....and do the testing on your normal avg routine days, never on a different day...

Cheryl

[LancetChick]

Guys just remember it’s easier to stay in a small bg range than it is to stay in a wide range. Concentrate on lowering your Standard Deviation which will help your A1c. Typically you should be under 10mmol/L or 180mg/dl after a meal but I would aim for the same bg as you started with ideally. The key to all of this is to not stop learning and to keep testing. We should make a sticky with all of this useful information so many people ask.

Diabetes Monitor - standard deviation buzz (http://www.diabetesmonitor.com/m57.htm)

That's exactly it. As I said earlier, my only goal in testing every hour and logging the results was to narrow my standard deviation, and having my A1c drop over an entire percentage point was merely icing on the cake. Narrowing the deviation is healthier, too..... developing 3 complications with A1c's in the low 6's seems rather unusual, but it wasn't my average blood sugar that caused the complications, it was the fluctuations. Wide fluctuations = Damage, no matter what your A1c is.

[Lizzie G]

Forgive my T2-ishness... but wouldn't some exercise and focus on nutrient dense low GI carbs (even if low carbing) also be helpful for a T1?

yes its enormously helpful, but not majorly in reduing your A1C directly...for that you need to get correct basal, CHO ratios, and time your shots depending on what you are eating. doing a lot of exercise also causes the CHO ratio to vary a lot more so you have to be extra aware at all times!

low GI has pros and cons to be honest. i find that rapid acting insulins are only ideal for certain things and anything that sticks around a long time involves splitting shots quite a bit, if i take novorapid with wholewheat pasta for example, and dont split, i tend to go a bit low an hour after food and then keep rising for along long time (maybe 4 to 6 hours) so of course if its the evening it is difficult to go to bed not knowing whether or not you will end up in the right place, and as someone else mentioned nighttime is the crucial time to maintain a steadt 5 to 6 as the backbone of good control! having said that low GI stuff is excellent a couple of hours before exercise with minute amounts of insulin and reduces the need for glucose tabs during your workout. i also adore lentils beans pulses etc and prefer the tastes to white rice and flour and so on.

anyhow, i must go and do some work (groan)....good luck in your A1C quest. my last was 6.6, i hadnt been putting too much effort in, my goal for next time is below 6. we will see. i think it can be done without having to be too limited or obsessive...maybe!!!

[soso]

For me an approach that includes exercise (but not excessive or life interrupting) careful attention to my food choices and insulin use (i.e. lots of testing with new foods) and being prepared to tweak as I go (things never stay the same week in week out)

I get very few high spikes(that I know of..haha) and not many lows (the odd mid 3 and the very occasional mid 2)

I put this down somewhat to eating a lot of fibrous veggies and not much at all in the way of processed or packaged foods. I eat 70% chocolate every day though and once in a while have a carb fest and bolus for it with reasonable success..
IMO it just takes time to work out how your body works..BUT, I think reading the forums and threads like this just give so much info that you do start to absorb and learn and work it into your own situation and that leads to a lot of success.

[orpy]

I recently went from 7.2 to 6.0 and it's because of lantus and humalog...I do eat low carb but always did. I struggled for three years feeling like a failure because no matter what I did, exercise, low carb, oral meds, I could not get my A1C down; in fact it just kept creeping up. I tell newly diagnosed diabetics to not waste too much time; get insulin sooner than later if you are low-carbing and seeing no results.

Along with Bernstein's book, be sure to read Jenny Ruhl's book, recently published.

[metamarty]

I'm constantly around 5.0%, with latest around 4.8%

I don't do low carbing. I've found that good control can be achieved by using two primary rules:

- Don't count carbs. Count glycemic load instead.
- Match action profile of insulin to action of glucose.

I feed all ingredients I use into a program I wrote to come up with the correct insulin action required. Fat slows down glucose uptake, so I look at the total glycemic load divided by the total grams of fat to decide what type of insulin to use (actrapid/novorapid). The lower the value, the slower the glucose will work. I also use this to sometimes delay taking the insulin, or taking it a bit earlier or even to add a bit of olive oil to get the values matched. This ensures the profiles of insulin match the glucose uptake. After about 45 minutes, I measure the glucose level to see if it peaks correctly, or possibly lower or higher to take corrective action.

[Kendall]

metamarty - What kind of a program is it that you use? I am just getting into the idea of GI and glycemic load and don't know a ton yet. I know with the pump I have a lot of flexibility in how I dose the insulin but I haven't yet figured out how to maximize its potential.

[metamarty]

metamarty - What kind of a program is it that you use? I am just getting into the idea of GI and glycemic load and don't know a ton yet. I know with the pump I have a lot of flexibility in how I dose the insulin but I haven't yet figured out how to maximize its potential.

I wrote it myself. Basically it's a webbased food calculator. It contains a database of food with all relevant information including GI. It adds all values for a given meal to provide totals.

GI is sometimes hard to get, so I must guess it sometimes, but even then, glycemic load proves much more valuable than just carbohydrates. Given the total load, it then divides this load by my personal load per IE value, which is roughly your carb to IE ratio divided by 2.

Also, the glycemic load divided by the total fat seems to be a good indicator for the time it takes for glucose to be processed. A pump could use this information to spread the insulin dose over a period of time, instead of giving it all at once. The real values are very personal, but if you happen to notice that your insulin dose works too quickly, while later in the evening, your glucose levels rise, the glycemic load divided by fat was probably too low. Pizza is notorious for this effect.

[dbc]

I'm constantly around 5.0%, with latest around 4.8%

I don't do low carbing. I've found that good control can be achieved by using two primary rules:

- Don't count carbs. Count glycemic load instead.
- Match action profile of insulin to action of glucose.

I feed all ingredients I use into a program I wrote to come up with the correct insulin action required. Fat slows down glucose uptake, so I look at the total glycemic load divided by the total grams of fat to decide what type of insulin to use (actrapid/novorapid). The lower the value, the slower the glucose will work. I also use this to sometimes delay taking the insulin, or taking it a bit earlier or even to add a bit of olive oil to get the values matched. This ensures the profiles of insulin match the glucose uptake. After about 45 minutes, I measure the glucose level to see if it peaks correctly, or possibly lower or higher to take corrective action.

Metamarty - this sounds like the "missing link" I've been looking for. Going by my fasting BG & 2hr PP readings, my A1c should be around 5.5%, but it stubbornly stays at 6 - 6.2. I do lo/restricted carbing & high protein/fat. Seems I should concentrate on the 3,4,5 hour PP reading to understand the glycemic load vs fat effect.

One learns something every day! thanks!

[metamarty]

Metamarty - this sounds like the "missing link" I've been looking for. Going by my fasting BG & 2hr PP readings, my A1c should be around 5.5%, but it stubbornly stays at 6 - 6.2. I do lo/restricted carbing & high protein/fat. Seems I should concentrate on the 3,4,5 hour PP reading to understand the glycemic load vs fat effect.

One learns something every day! thanks!

This will be very subjective, but overall, fat reduces glucose uptake speed. If you're doing high fat, you should check your values later in the evening. Chances are you've calculated the correct insulin amount for the first few hours, but glucose is still being absorbed once the insulin has stopped working. In the evening novorapid has this effect for me. Switching evening insulin to actrapid did the trick for me. It might be that you would do better by taking a bit more insulin of a slower acting type.

[Alene]

I'm going to have to go back and read these posts in detail again, but I noticed that a couple people said they use "corrections" after meals to keep their a1cs low. We all do this from time to time, but I've heard it's not good because you don't want to depend on the sliding scale all the time. Once you have your basal/bolus and carb counting figured out, you should be able to assume that your bs will level out after your meals. I especially don't want to have to use the sliding scale method because I can't afford that many test strips as my insurance is going to expire at the end of the summer. I would love to test 10x a day or whatever, but I think that we should all be able to test only 4 times a day. Should....

I also want to mention that I think good a1c results have a lot to do with LUCK. for a while I was leveling out pretty well, and I met another girl with diabetes that always had spikes and drops in her blood-sugar. She tested constantly, used the sliding scale, did everything to try to figure out her diabetes, but nothing worked. I couldn't figure out why she had problems, I figured it was that she was doing something wrong, but I think it was just that her body would basically do what it felt like doing.... be it due to stress or whatever, she just happened to have a really hard time taking care of herself and I just happened to do O.kay with minimum effort. Sometimes when you do what makes sense, it just doesn't work.

[Gary_W]

I'm going to have to go back and read these posts in detail again, but I noticed that a couple people said they use "corrections" after meals to keep their a1cs low. We all do this from time to time, but I've heard it's not good because you don't want to depend on the sliding scale all the time. Once you have your basal/bolus and carb counting figured out, you should be able to assume that your bs will level out after your meals. I especially don't want to have to use the sliding scale method because I can't afford that many test strips as my insurance is going to expire at the end of the summer. I would love to test 10x a day or whatever, but I think that we should all be able to test only 4 times a day. Should....

I also want to mention that I think good a1c results have a lot to do with LUCK. for a while I was leveling out pretty well, and I met another girl with diabetes that always had spikes and drops in her blood-sugar. She tested constantly, used the sliding scale, did everything to try to figure out her diabetes, but nothing worked. I couldn't figure out why she had problems, I figured it was that she was doing something wrong, but I think it was just that her body would basically do what it felt like doing.... be it due to stress or whatever, she just happened to have a really hard time taking care of herself and I just happened to do O.kay with minimum effort. Sometimes when you do what makes sense, it just doesn't work.


It is more expensive on test stips, but testing at 2 hours after a meal is (IMO) essential to ensure good blood glucose control. Whilst in the majority of cases you can safely assume that you got the carb counting right and that your blood will come down to normal at the 4-5 hour mark, that 2 hour test will point out the occasions where you got it wrong so you can do something about it in a timely manner. They also help to point out any problem foods.

As to luck, I wouldn't hold with that. However, it is clear that some people have a much easier time managing diabetes than others. But this is a dynamic process.

This time last year, Lantus used to last almost 24 hours in my body and was a pretty close match to my actual needs. It just worked. By Christmas, it changed and my basal needs would go up and down like a thing posessed. They still do. I started pumping 3 months ago to cope with this nice change. My basal rate goes up and down many times each day and the pump now caters for that. Every 2-3 weeks, my body changes again and I have to adjust the rate at particular times of the day (I have just had to give an extra unit of insulin during the night as my DP seems to have worsened, but to make up for it I've been getting afternoon hypos so I've had to throttle back the afternoon basal...). Were I on MDI, I would indeed now be having a pretty miserable time of it. With pumping, it messes me around for a couple of days whilst I confirm that it is a new trend rather than a temporary blip but then it's sorted out.

Because of my particular body, 4 tests each day just wouldn't cut it. Yes, I'd get by but I don't want to 'get by'. I want to feel well. But if you can get away with 4 tests whilst feeling good and having decent numbers then good for you :) I'd ideally like to stab my fingers rather less but don't see me doing that any time soon.

Gary

[cheryl]

I'm going to have to go back and read these posts in detail again, but I noticed that a couple people said they use "corrections" after meals to keep their a1cs low. We all do this from time to time, but I've heard it's not good because you don't want to depend on the sliding scale all the time. Once you have your basal/bolus and carb counting figured out, you should be able to assume that your bs will level out after your meals. I especially don't want to have to use the sliding scale method because I can't afford that many test strips as my insurance is going to expire at the end of the summer. I would love to test 10x a day or whatever, but I think that we should all be able to test only 4 times a day. Should....

I also want to mention that I think good a1c results have a lot to do with LUCK. for a while I was leveling out pretty well, and I met another girl with diabetes that always had spikes and drops in her blood-sugar. She tested constantly, used the sliding scale, did everything to try to figure out her diabetes, but nothing worked. I couldn't figure out why she had problems, I figured it was that she was doing something wrong, but I think it was just that her body would basically do what it felt like doing.... be it due to stress or whatever, she just happened to have a really hard time taking care of herself and I just happened to do O.kay with minimum effort. Sometimes when you do what makes sense, it just doesn't work.


I know how you feel on the test strips, but for me with my activity level at work which varies, Ok my point, I was only 80 2 hrs after breakfast on Friday versus, I was 150 two hours after breakfast on Sunday, I ate the same same bolus, same basal rates, same activity....I knew I needed something to snack on at 80.........

Also for me being on the pump, I can pinpoint when there is a clog or set might be absorbing what not.....I have skipped post meal test if I feel ok....but sometimes I just don't....I have to know where I am at...

But it is expensive....honestly though I can probably get away with it at work moreso....

Cheryl

[Gangrel]

The only time i'll correct at the 2 hour mark (if I even do a 2 hour test) is if I'm really high. Like, maybe 12+. In my mind, it just complicates things way too much.

If you correct for a 10 2 hours after you eat, then sit down 2 hours later for your next meal and you're an 8.0, what do you do? Do you ignore it, knowing you still have 2 hours of correction rapid in you? Will it stack up with the bolus you're about to do for what you're going to eat? Is 8.0 too low for that period now, because the correction dose might push you down even further?

I much prefer to take my checkpoints at intervals where I *know* what's happening (well, what should happen anyway). That means my body is free of rapid and I can make a clear headed decision on what to do next.

Am I ever going to have an A1c in the 5's? Most likely not. But I much prefer the relaxed nature of this approach rather then fretting about things, and for the past few years I've managed A1c's lower then 6.5, so that's good enough for me.

[xMenace]

I also want to mention that I think good a1c results have a lot to do with LUCK. for a while I was leveling out pretty well, and I met another girl with diabetes that always had spikes and drops in her blood-sugar. She tested constantly, used the sliding scale, did everything to try to figure out her diabetes, but nothing worked. I couldn't figure out why she had problems, I figured it was that she was doing something wrong, but I think it was just that her body would basically do what it felt like doing.... be it due to stress or whatever, she just happened to have a really hard time taking care of herself and I just happened to do O.kay with minimum effort. Sometimes when you do what makes sense, it just doesn't work.

She's working hard but not necessarily working smart. Using your daily compliance tests is very difficult to identify problems. There are too many variables going on, and single tests cannot identify who did what.

To gain that level of control one has to do controlled testing where variables are eliminated or kept static. Basal testing is the classic example. Eliminate food and extra activity to identify how your basals behave. Once you've done this, and adjusted to ensure your basal dose(s) keep you flat, you've eliminated a big variable from your daily activities, and your tests should now be representing bolus action only. Now eliminate food and activity variations, and titrate until ratios are set. Voila!

Not complete, but 80% so. Enough to get an A1C close to 6. Pumping or MDI.

[xMenace]

The only time i'll correct at the 2 hour mark (if I even do a 2 hour test) is if I'm really high. Like, maybe 12+. In my mind, it just complicates things way too much.

If you correct for a 10 2 hours after you eat, then sit down 2 hours later for your next meal and you're an 8.0, what do you do? Do you ignore it, knowing you still have 2 hours of correction rapid in you? Will it stack up with the bolus you're about to do for what you're going to eat? Is 8.0 too low for that period now, because the correction dose might push you down even further?

I much prefer to take my checkpoints at intervals where I *know* what's happening (well, what should happen anyway). That means my body is free of rapid and I can make a clear headed decision on what to do next.



One of the outcomes of my controlled testing was an expected pattern or profile. I now know at 2hrs pp for breakfast that 8.0 was ideal for me. Anything lower I'd drop my basal rates and anything higher I'd correct.

It works very well for me in the mornings. In the evenings before bed it's not so clear. For some reason my evening variability is much less consistent. And correcting before bed is risky for me where I tend to crash in the night.

I tend to be aggressive during the day and cautious at night. But as Aaron has implied, corrections can backfire. I can attest to that :(

[LancetChick]

I'm going to have to go back and read these posts in detail again, but I noticed that a couple people said they use "corrections" after meals to keep their a1cs low. We all do this from time to time, but I've heard it's not good because you don't want to depend on the sliding scale all the time. Once you have your basal/bolus and carb counting figured out, you should be able to assume that your bs will level out after your meals. I especially don't want to have to use the sliding scale method because I can't afford that many test strips as my insurance is going to expire at the end of the summer. I would love to test 10x a day or whatever, but I think that we should all be able to test only 4 times a day. Should....

Yowza, what can I say in response to this kind of thinking? "Correcting" errant blood sugars is not the hallmark of the Sliding Scale Method; it's just good practice, promoting good health and helping to ward off complications. In addition, some of those "corrections" are, in fact, additional boluses to extend the insulin action after consuming a meal that takes longer to digest than the insulin takes to wear off. If you're happy with having your BG "end up" in normal range, with no concern about what it's doing before then, good for you. I am not so complacent, and that's why my A1c's are so low.

We should all be able to test ONLY 4x a day..... put your head back in the sand, this shouldn't interest you at all. I developed some nasty complications testing that infrequently, and it was only by testing MUCH more often that I was able to reverse them. If I were unable to afford to test so often, I'd get rid of my satellite dish, quit going to restaurants and movies, get a cheaper place to live and get a second job if I had to. Diabetic complications are no fun, and they have an annoying tendency to get worse.

I also want to mention that I think good a1c results have a lot to do with LUCK.

Uh-huh. Testing 4x a day---> retinopathy with recurring blind spot, frozen shoulder, arthritis.
Testing 15x a day---> clear vision, no hemmorhages, no frozen shoulder and no arthritis...... TOTAL COINCIDENCE!