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I think my results are not pleasing my nurse (diabetes practitioner)

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I am a 70 years old female with type 2 diabetes for last 25 years. I have been on long term insulin and rapid insulin for the past 8 years and I started Victozoa 1.2 from the last 2 months. My carbohydrates ratio is 6:1. And it goes like as follows: breakfast- 24 carbs, lunch - 30-45 carbs and dinner – 45-60 carbs. But my nurse seems not to be impressed or satisfied with this.  My A1c changed from 9.3 to 7.3 in the last 2 months. She is not satisfied with my sugar levels at bed time. They sometimes range from its lowest 123 to 225. I usually don’t eat snacks. I live on just 3 meals as I told before. Today, being the grandparents’ day, I had my usual Slimfast for my breakfast and drove to the program venue 50 miles away. There I had a donut snack and a half cup of cider. After having all these, my sugar level went to a high 223 instead of the usual 120. Can you suggest me anything to lower sugar levels? 

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Category: Internal Medicine Specialist
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Thank you for the question. First of all, as a diabetes nurse, I would like to congratulate you to decrease A1C levels from 9.3 to 7.3 in just 2 months. It is really a great achievement. Also congratulations for checking your blood sugar in regular intervals. According to American Diabetes association A1C should be under 7% and according to American Academy of Endocrinologists, it should be under 6.5%. Anyway, A1C goals should be mended according to the factors including risk of low blood sugar levels. Unfortunately, you haven’t mentioned anything about low blood sugar. So, here I would like to advise you to work on your NP in changing insulin dosage you take. It seems that your bed time sugar readings are on the higher side. So, you have to tweak your bed time carb intake a little or adjust your bed time insulin a little. A combination of both can also be tried.  It is recommended to check blood sugar levels in every two hours after meals and see whether things have changed or not. It is advised to take a generally similar carb diet every day. Please consult with a dietician who is specializing in diabetes for more detailed diet planning. Being your bedtime carbs are over twice in count than that of morning, it is recommended to change it a bit.

Your breakfast before a 50 mile drive is also a matter of concern. It is strongly recommended to check blood sugar level before a long drive to prevent you from going to a low sugar level while on drive. Ask your NP about your required pre-driving sugar level. Better keep some snacks and treatment facility for a low blood sugar level, stocked in your car itself.

Spike you saw with sugar levels is not to be surprised. Both the foods you took: cider and donut hole contains simple sugary carbohydrates which tend to increase sugar levels to spikes of heights. This is more evident when you eat these alone without other heavy snacks. Half a cup of cider can also be used to rapidly increase sugar level when one is in a low sugar level. If you wish to eat these again, ask your NP and dietician for diet plan and insulin coverage. A rapid acting insulin coverage will allow you to eat all these without much hassle. Alternatively, you may limit amounts of these foods you like to take.

Stay healthy. Wish you good luck.

Dr. Steve Merris
Category: Internal Medicine Specialist
Medical School - New York University
Internship in Internal Medicine - Beth Israel Medical Center
Residency in Internal Medicine - Beth Israel Medical Center
Fellowship in Pulmonary and Critical Care Medicine - Columbia University Medical Center
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