Great HbA1c result but got told off for it...

kitedoc said:

So unless the nurse had those parts of the picture

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Like the medical records you mean?

bulkbiker said:

Like the medical records you mean?

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Medical records will not cover eating habits, blood sugar curves and how they correlate.

Hi, @kitedoc , there's a bit of a quantum shift going on at the moment to do with what a safe a1c is.

More and more people are now using cgm. Some areas here are funding Freestyle Libre on the NHS, more areas will hopefully do so after they see how it works out elsewhere, and many people are privately funding it.

Being cautious about a low a1c is perhaps understandable when we're on strips alone. The lack of visibility which strips alone give means that hcps are very often correct when they see a low a1c and assume it's only achievable through lots of hypos.

But it's a completely different picture when we're using cgm. Because we're getting to see a more or less real time moving picture of our levels 24 hours a day, instead of a few momentary strip snapshots, we can be a lot more precise about timing and dosing, see more clearly how we respond to food, and take small steps to keep in range by the odd 1 or 2 u here, or 4g there, just to gently nudge it, without risking crazy lows.

One thing which is sometimes underestimated in getting a low a1c is simply avoiding highs.

I've got a transmitter attached to my libre which turns it into "proper" cgm with high and low alerts.

The low alerts are obviously good for all the usual reasons, but the high alerts are also very useful. I've got mine set to 7.6.

So, if I'm sleeping and it turns out I miscalced the last bolus, or my basal is being temperamental or the hundred and one other reasons why I might trend up during the night, it means I'll be woken up on the first 5 min reading above 7.6, I can then think about whether I need a small novorapid correction to lower it a bit.

Now, if I didn't have this set up, there's a every chance I might have woken up to find that I'd been above 10 for several hours.

Just being able to stitch those above 8, 9, 10 readings before they happen makes a big difference to lowering a1c, and will also give me steers on basal adjustment.

I've certainly had times in the past where docs have said they're worried my a1c was too low, but, more recently, I've showing them the statistics on my cgm and explaining how I'm doing it and why it's safe - it's partly through running at 5 to 7 for a fair bit of the time, but also largely just avoiding above 10, and they're not seeing any major hypos in the figures.

I think some docs are now becoming more comfortable seeing lower a1cs once they see how they're arrived at, but there will likely still be a fair number of old school hcps who stick to the old ways.

My GP is quite accepting of it all - she was joking last time I saw her about 30 to 40 becoming the "new normal"!

Mel dCP said:

If she’d had bothered to look, she’d have seen all my traces on the Diasend system too...

I add all my carb counts and doses to the Diasend system when I upload my scanner too! And I definitely know she didn’t look at those, otherwise she’d have queried the very low carb count too...

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That's true, you can upload better values now, but as we both know carb count is not everything that's relevant to your blood sugar, and there are differences between the different insulin types that fall in the same category.
Also, my estimated A1C according to my phone is 6.3% or 45 mmol/mol which looks good if you're just looking at that number, but if you look at the actual values there are plenty of problems, not to mention most of you would probably be horrified by all the poison I eat.

Mel dCP said:

If she’d had bothered to look, she’d have seen all my traces on the Diasend system too...

I add all my carb counts and doses to the Diasend system when I upload my scanner too! And I definitely know she didn’t look at those, otherwise she’d have queried the very low carb count too...

@kitedoc My big gripe with the whole thing was that she basically called me a liar when I said I wasn’t having hypos. I explained I was using the Sugar Surfing technique, I told her I had a CGM that meant I could glance at my BG every few minutes and that gave me the real time data to nudge it into line with a half unit here or a dextrose tab there. I told her I ran completely steady overnight, and she flat out refused to believe any of it. She said it wasn’t possible, and insisted I made an appointment with my GP to be taught about hypos. I’ve been T1 for twenty years now, including a pregnancy, so I’m used to the changes getting older is bringing, and when I pay attention, I can usually adjust things to deal with it. Luckily my GP is pretty forward thinking, so I think once he sees my data charts, this will go away. Giving the nurse the benefit of the doubt, I expect she just isn’t used to seeing the vast improvements the Libre can give a T1, as far as I know I’m only one of two patients at the practice using it just now. It’s especially exasperating because they have a photocopied black and white version of the chart attached on the wall of every consulting room in the practice. The red bit shows as dark grey; all the other colours are white. So on their own chart, that they refer to at every diabetes consultation, my score of 43 comes up as “excellent”. So I’ve printed (and laminated!) a full colour copy as a little gift

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Mel dCP said:

Doctor’s report!

Ok, he’s happy that I’m not having hypos and apologised for the nurse’s cackhanded way of expressing concern. I was right though, I’m only one of two patients at our practice using Libre, so they really have never seen that control this good is even possible. We had quite a long chat about it, apparently one of the big concerns with people who have been T1 as long as I have is that they lose hypo awareness, but mine is still good. He’s happy that I keep well above legal limits to drive and ride, and that I know that a single dextrose tablet will raise my BG by 0.6mmol, so I can adjust it very quickly if I need to. I left him with a list of the books I’ve been referring to with a brief synopsis of each and how it’s helped. He’s totally behind my low carb eating, too.

Cholesterol - while the nurse had said it was high (6.2 total) he agrees with me when I pointed them out that the total:HDL (3.1) and HDL:triglycerides (0.6) ratios are absolutely spot on perfect. He said he wasn’t going to even think about “inflicting” (his word) statins on me, despite NICE guidelines that all T1s should take them as a preventative because I simply don’t need them. @bulkbiker - thanks for all the papers and stuff you’ve posted about statins, I went in well prepared for the statin battle!

At the end of our meeting he said I should train to be a diabetes specialist nurse and that there was probably funding available for (ahem) mature applicants...

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Sounds like a brilliant meeting and a job offer too!.. what more could you want.. can you send him down south please we could use some here.. Great news for you and well done.

Yay, excellent outcome, @Mel dCP , (age aspersions aside, and I suspect a part of you is mildly disappointed with him not giving you an opportunity to lamp him with the battle handbag!).

It goes to show that libre/cgm is a new thing for docs as well as us and there's a part for well informed patients to play in educating them about it.