HbA1c to low?

[Benny G]

I wouldn't say it's easy to maintain this level of control. I'm no longer 'honeymooning', but instead I follow the Bernstein regimen, which I attribute to tight control. I also treat BG levels >6.7mmol/L. My daily basal (Tresiba) requirements are 24 Units. My daily basal/correction requirements vary day to day due to carb intake. Today I consumed 21g Carbs and required 2 Units for breakfast, 2 x 2 Units for lunch (2 to cover the carbs, then 2 2 hours later to cover the protein spike), and then 6 Units for dinner (2 to cover carbs, 3 2 hours later to cover the protein spike, and then 1 more an hour after that to 'kill off' the tail of the protein spike). I then took 3 units to correct 'highs' (1 unit mid afternoon, and then 2 units after evening exercise).

I'm in regular contact with lots of others who follow Bernstein's regimen (mainly in the US) who've had T1D for 10, 20 or 30 years or more who have HbA1cs which are lower than my predicted result. For example, one guy who has really helped me out with insulin dosage and exercise has had T1D for 17 years, has been low carb for 8 years, and his HbA1c has been consistently below 29mmol/L (4.8%) for over 5 years. His most recent HbA1c was 26mmol/L (4.5%).

That's interesting, we don't have many type 1 Bernstein followers on this forum, perhaps you can walk us through your regimen in a bit more detail. I think it would be informative to show what is involved and the results that can be achieved.

When my honeymoon ended, 20 years ago, I read Dr Bernstein's Diabetes solution, and went high protein, very low carb for a full 2 years. It was difficult as I did not inject the very small amounts of insulin suggested by Bernstein. (He provides instructions to dilute insulin to allow tiny doses, a third of a unit of insulin, a quarter of a unit.) Switching from a single unit pen to a half unit pen was the best I could manage.
My consultant could not be persuaded to prescribe 'regular' insulin for high protein meals.

I used to do a lot of distance running and cycling, and things got complicated.

5 years ago I discovered the freestyle Libre, and once again pursued low carb. This time as a kind of 'soft' Bernstein. More high fat and moderate protein. I think my best year was 2019 when my libre suggested an HbA1c 38 for the entire year. I was tested twice that year, the lowest result was 50. My libre HbA1c estimate is always 10 or 20 lower than the lab result.

 

[helli]

I am sorry to say I was put off Bernstein when he suggested all women with T1 should go on the pill to avoid the impact of our hormones.
It is too common to ignore what makes half of the population different.
Putting my monthly cycle on hold suggests diabetes is controlling my life more than I am willing to accept.
Without following the Dr B approach, I am happy with an hba1c consistently in the 40s with no complications after nearly 20 years.

 

[Jacen017]

Such great, easy control, (no doubt on low insulin doses) shows you are enjoying the benefits of your honeymoon. CGM use currently helps you to keep very tight control, which may provide a respite for your ailing pancreas and even extend your honeymoon, but type 1 diabetes is autoimmune, and destruction of the remaining beta cells is relentless. The honeymoon will eventually come to an end.

I was diagnosed in my late 20's, had great control for the first couple of years which tapered off as my honeymoon ended. Throughout the past 20 years, (the last 5 using libre), my best Hba1c has been 50.

Prepare yourself, diabetes progresses over time.

Just as a matter of interest, what would be classed as low insulin doses?

I'm curious as to how much more insulin I'll probably need to be taking in the future.

I'm currently using 20 units Toujeo a day and a ratio of 1:10 for my Novorapid.

 

[nonethewiser]

Just as a matter of interest, what would be classed as low insulin doses?

I'm curious as to how much more insulin I'll probably need to be taking in the future.

I'm currently using 20 units Toujeo a day and a ratio of 1:10 for my Novorapid.

No idea & as said it doesn't really matter as you need what you need.

Don't know if own doses are high or low & couldn't care less, take 4u for breakfast 5u for lunch 5 sometimes 6u for tea, basal is currently 18u using pump.

 

[Proud to be erratic]

Just as a matter of interest, what would be classed as low insulin doses?

I'm curious as to how much more insulin I'll probably need to be taking in the future.

I'm currently using 20 units Toujeo a day and a ratio of 1:10 for my Novorapid.

For your curiosity, keeping in mind I have no pancreas so no honeymoon interruptions:

I take 10x Tresiba daily; previously was taking 10 or 11 x2 daily Levermir. I know at least one person with total panc'y is on 22 Tresiba daily, so pretty different.

Novarapid:
b'fast ratio 1:8 for 96 or 104 gms carbs, thus 12 or 13 units;
lunch ratio 1:10, not always taken, typically 50 gms carbs;
dinner ratio now 1:10, typically 70-80 gms carbs.

With odd snacks, no bolus, my total carb intake c.230-250 gms on lunch taking days. If no lunch some extra snacks usually.

 

[Wolder]

That's interesting, we don't have many type 1 Bernstein followers on this forum, perhaps you can walk us through your regimen in a bit more detail. I think it would be informative to show what is involved and the results that can be achieved.

When my honeymoon ended, 20 years ago, I read Dr Bernstein's Diabetes solution, and went high protein, very low carb for a full 2 years. It was difficult as I did not inject the very small amounts of insulin suggested by Bernstein. (He provides instructions to dilute insulin to allow tiny doses, a third of a unit of insulin, a quarter of a unit.) Switching from a single unit pen to a half unit pen was the best I could manage.
My consultant could not be persuaded to prescribe 'regular' insulin for high protein meals.

I used to do a lot of distance running and cycling, and things got complicated.

5 years ago I discovered the freestyle Libre, and once again pursued low carb. This time as a kind of 'soft' Bernstein. More high fat and moderate protein. I think my best year was 2019 when my libre suggested an HbA1c 38 for the entire year. I was tested twice that year, the lowest result was 50. My libre HbA1c estimate is always 10 or 20 lower than the lab result.

For those who aren't familiar with the Bernstein regimen, it involves following a low carb, moderate fat and high protein diet. The few carbs I do consume are typically nuts (almonds, macadamia and pecan nuts are favourites), and mushrooms and green leafy vegetables, which ensure I get phytonutrients. I don't eat bread, biscuits, milk chocolate (although I do enjoy the occasional cube or two of Lindt 90% dark chocolate), crisps or pasta - almost all processed carbs are a 'no-no'. I don't eat starchy carbs either, such a rice, potatoes or grains. I hardly eat any fruit either - I occasionally have raspberries or blueberries.

Most mornings I'll eat a 4 egg omelette with mushrooms and spinach, which I'll have with 30g of almonds on the side. Lunch is a bit more varied. Yesterday I had four slices of bacon, sauerkraut (which I appreciate isn't for some people, but I love the stuff), a few cherry tomatoes and some slices of cheddar. Not sure what I'll eat for lunch today - perhaps a couple tins of sardines in olive oil, a couple of scrambled eggs with some courgette and mushrooms.

Evening meals are typically the largest of the day for me - a big piece of meat with a lot of low carb veg. Last night I had one and a half bacon wrapped chicken breasts, some brussels, kale and a few green beans.

I only use Tresiba and NovoRapid, although I would like to add ActRapid, which is a regular insulin, to my arsenal. It would, I hope, reduce the necessity of injecting for carbs and protein seperately.

I am a Libre 2 user and it was quite accurate at predicting my most recent A1c. The Libre 2 predicted 40, but it was in fact 41.

If anybody has any questions, I'd be happy to answer.

 

[helli]

Just as a matter of interest, what would be classed as low insulin doses?

I'm curious as to how much more insulin I'll probably need to be taking in the future.

I'm currently using 20 units Toujeo a day and a ratio of 1:10 for my Novorapid.

There are many things that dictate how much insulin we need.

• Typically, smaller, lighter people will need less insulin.
• Those who are more active will need less insulin.
• It depends how much carbs you eat - if you eat low carb, you will need less insulin.
• A pump needs less insulin.
• If you are ill, you need more insulin.
• Then, there's the "whatever" factor - some people are just more sensitive to insulin and some are more resistant.

It is very hard to compare one person's dose with another or to suggest how much you will need.
It is even hard to compare one day to another: my highest total insulin in a day this year is 50% higher than my lowest total daily dose. The highest was when I was unwell and not exercising. The lowest was towards the end of a week of walking every day.
My lowest dose last year was even lower and I had loads of hypos - that was the day I had my covid jab.
I am small and active. After nearly 20 years, my dose is similar to yours, on an "average day".

As @nonethewiser says, it doesn't matter - the correct amount of insulin is the amount you need to keep your levels stable.

 

[johntheterrier]

Thanks for posting this Jacen its a very good question, I was wondering the same thing as my libre is saying 90 day average is 34mmol/mol but not sure how reliable the A1C is on the libre. like you I dont have many hypos the libre sometimes goes off in the night but it always seem to be from laying on it.

I don't think the A1C prediction on the Libre is very accurate at all, my last 2 blood test Hba1c's have been 10 points higher than the Libre prediction, which is very disappointing.

 

[johntheterrier]

Me too!

And me!!

 

[Ian68]

I don't think the A1C prediction on the Libre is very accurate at all, my last 2 blood test Hba1c's have been 10 points higher than the Libre prediction, which is very disappointing.

Yes that must suck , I imagine the lows it picks up from sleeping on it must bring the average down, saying that I would be happy with 44.

 

[nonethewiser]

I don't think the A1C prediction on the Libre is very accurate at all, my last 2 blood test Hba1c's have been 10 points higher than the Libre prediction, which is very disappointing.

Interesting, never checked but will do next time have bloods taken, 10 points seems fair whack.

 

[trophywench]

I rarely seem to either lose data or have compression lows. Bit like pumping really - people say they get occlusions. I remember I had one once, the first pump I had. Now on pump 3 for 2 years and all Roche so approx 12 years ago. Even so - as you say - roughly 10 too low.

 

[everydayupsanddowns]

Well done @Jacen017 - great to have such positive reaction from the emergency-panic-Consultant

Prior to my most recent HbA1c result I was told by one DSN that a HbA1c of >48 was dangerous, and another told me to go as low as possible without experiencing regular hypos. My TIR (4.0mmol/l - 7.8mmol/l) is 96% and the remaining 4% is >4mmol/l unfortunately, but I've never experienced a severe hypo. I once got as low as 3.3mmol/l, but it only took me 3/4 of a Lift tablet to climb back up to 5.4mmol/l within an hour.

I find the International Consensus on Time in range very helpful as far as this goes - the range they suggest is 4-10mmol/L (so I suspect your TIR would be even higher!)

Time In Range - useful for Libre / CGM wearers

I've been meaning to post this for ages, but kept forgetting! At the ADA this year the international consensus paper on TIR (time in range) was published by a panel of experts with a huge amount of knowledge and expertise in supporting people to use continuous data to help manage their...

forum.diabetes.org.uk

By that reckoning 4% below 4.0 is a little more than ideal (but only just). But 96% is impressive. In your shoes I think I would feel. ore comfortable with a more even split between above and below range. It’s perfectly possible to spend 25% of time above range, and still have an HbA1c that evidence shows reduces risk of long-term microvascular complications. But a higher proportion of time spent below 4.0 is associated with a reduction in hypo warning signs, and associated difficulties.

 

[everydayupsanddowns]

Just as a matter of interest, what would be classed as low insulin doses?

I'm curious as to how much more insulin I'll probably need to be taking in the future.

I'm currently using 20 units Toujeo a day and a ratio of 1:10 for my Novorapid.

The general rules of thumb I’ve come across include estimating basal by bodyweight

40-60kg 3-3.5 units/kg
60-85kg 0.5 units/kg
85-100kg 0.7-1.0 units/kg
>100kg 1.0-1.5 units/kg

Basal would usually be expected to be around half TDD

I think DAFNE ‘defaults’ are 1:10 insulin to carb ratio, and 1unit lowers BG by 3.0mmol/L, so your insulin seems pretty standard to my meddically untrained brain

And of course any of these are only average starting points - people’s actual requirements can be very different. At the end of the day you need what you need 🙂