Dear Dani, Grace and Jude,
Note: This page is advice for Grace, Jude and John. For any other reader, it’s information only. No therapeutic relationship is formed – read this.
There are so many things you can measure to see how things are going. It’s easy to get overwhelmed because:
What gets measured, gets managed
It’s easy to burn out following ten different things!
I will keep it super simple.
Let’s focus on the three most important measures.
- Percentage time in range (4.0-10.0mmol/L or 70-180mg/dL)
- HbA1c (mmol/mol or %)
- Total daily insulin dose (u/kg)
Time in range (4.0-10.0mmol/L or 70-180mg/dL)
You are familiar with time in different glucose ranges, I have been banging on about them from the start. Here is a graphic from the latest international consensus statement of where to aim for. There is a lot more on the For John – Research page.
I think 70% time in range is a good place to start. However, by following Dynamic Glucose Management, 70% is the basement.
We are going up to the penthouse.
I created this table that allows you to choose what time in range you would like.
The catch is you must set the high alarm accordingly and use the GAME part of Dynamic Glucose Management to achieve it.
Don’t start too fast.
Rome was not built in a day. Take baby steps like I did, improve 5% every two weeks or so.
HbA1c (mmol/mol or %)
This picture explains HbA1c is measuring how much glucose is stuck to your red blood cells. The more glucose stuck, the higher the blood glucose has been for the last three months.
The HbA1c measurement is like a crystal ball. It allows you to see how healthy you will be on the future.
This is a famous graph from the biggest trial ever done on people with type 1 diabetes.
It shows the risk of nasty small blood vessel complications goes up as HbA1c increases.
Aim to keep HbA1c at or below 48mmol/mol (6.5%). If you keep time in range above 80%, this is almost guaranteed.
Total daily insulin dose (u/kg)
If HbA1c tells you the risk of small vessel complications, total daily insulin informs you of cardiovascular disease risk. Cast your mind back to the Bolus Insulin section. Specifically,
Lots of circulating insulin in the bloodstream increases your risk of cardiovascular disease
Insulin is a growth factor.
Having lots of it flowing through the heart and the brains major blood vessels is not good. It gives damaged arteries a catalyst to build blockages. This can lead to heart attacks and strokes.
The blockages develop over a lifetime, so it’s never too late to get the total daily insulin in check.
How much is too much?
It depends on your weight. It’s all about how many units of insulin per kilogram of weight.
You need to do a simple sum.
Total daily insulin / weight (kg) = units per kg
For example, my total daily insulin is 35 units, I weight 100kg, therefore I am on 0.35u/kg.
Here is some guidance to consider.
0.2-0.4u/kg = Very low cardiovascular risk
0.4-0.6u/kg = Low cardiovascular risk
0.6-0.8u/kg = Average cardiovascular risk
08-1.0u/kg = High cardiovascular risk
1.0-1.2u/kg = Very high cardiovascular risk
>1.2u/kg = Extremely high cardiovascular risk
Think back to the Activity and Exercise page. The more active you are the less insulin you need.
Activity and exercise open the side door to the cells,
and increases blood flow to the muscles making insulin stronger and last longer, so you need less.
Quite simply, get active to protect your heart and brain.
What about 0.0-0.2u/kg, that must be better, right?
If you are still in the honeymoon phase or have LADA, it’s ok.
If not, you may be in trouble, why?
Insulin is a growth factor needed for growth, repair and much much more.
A daily insulin requirement of 0.0-0.2u/kg is usual in the following groups, and has the associated issues:
- Over exercisers. Lots of exercise is good, astronomical amounts are bad. It puts too much stress on your heart as you get older. By astronomical, I mean consistently running over 100 miles a week.
- Ketogenic diet. A ketogenic diet might be ok for adults. However, it’s terrible for children. They don’t grow, have awful blood fat levels, and cannot enjoy meals with their mates. Some children with epilepsy have to follow a ketogenic diet as a medical treatment. After three years on it, they all run into problems. I understand the ketogenic diet makes blood glucose control easy. But for children, it comes at too high a price. You can find out more in the Ultimate guide to mealtime insulin. Plus, with Dynamic Glucose Management, there’s no need to be so strict on carb intake.
- Under-eaters. If you eat like a sparrow, there will be little need for much insulin. However, growth and repair stop, all energy is diverted to survival and you become a miserable git! I know this when I dieted down to 5% body fat. You can read about this in the 120-day carb experiment.
I am sure there are exceptions where it’s not detrimental, I just have not seen them yet.
Grace and Jude, here is what we will be aiming for:
- 80% or more time in range (4.0-10.0mmol/L or 70-180mg/dL)
- HbA1c less than 48mmol/mol (6.5%)
- Total daily insulin of less than 0.6u/kg
Dear John, you obsessive man with a family history of heart disease:
- 95% or more time in range (4.0-10.0mmol/L or 70-180mg/dL)
- 75% or more time in non-diabetic range (3.3-6.7mmol/L or 60-120mg/dL)
- HbA1c less than 40mmol/mol (5.7%)
- Total daily insulin of less than 0.4u/kg
CONGRATULATIONS, you have laid very strong foundations.
You are now ready for the game changer.
Next step: Dynamic Glucose Management
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