Got diabetes questions? You came to the right place! Ask D'Mine is our weekly advice column, hosted by veteran type 1, diabetes author and educator Wil Dubois.

This week, Wil gets a direct ask on how he feels about a controversial but well-known voice in the D-Community: Dr. Richard Bernstein, who preaches ultra-low-carb lifestyle as a "solution" to diabetes management. Opinions may vary, but Wil lays it out there... Read on at your own risk!

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Chris, type 1 from Ohio, writes: I really enjoy your columns and find you to be one of the few people willing to engage in straight talk while still providing very useful information. I really liked your article on food published in dLife. I must say the most challenging aspect of my diagnosis has been figuring out what I can and can't eat, and how certain foods impact my blood sugars. Making matters a bit more complicated for me is that I read Dr. Bernstein's Diabetes Solution book and actually visited him in his private practice for 3 days. I am sure you are familiar with his teachings, but he is a staunch advocate for a very low-carb diet (less than 36 grams per day) and those carbs can only come from a very select list of veggies. Absolutely no fruit or breads, etc. I tried that for about a month and almost lost my mind! However, he did put a huge fear in me that if you don't keep your A1C in the 4.5 % range and if your BG spikes above 100 then you are headed for the nasty complications world.

So, my question for you is... what do you personally feel is a good post-meal target range for blood sugar? What is a reasonable spike? What is a good target A1C range for a 41-year-old male? I know there is plenty of stuff published on this, but I am wondering what you think on this. Please know I am not looking for formal medical advice. I am just looking for straight talk from you, a person whose column I read very regularly and whose opinion I highly respect.

Wil@Ask D'Mine answers: I regard Dr. Bernstein as a fanatic. And in my vocabulary that's no insult. It's actually a compliment. I like fanatics. I respect fanatics. I often wish I had the energy to be fanatical about my own views. But I'm one of those people who prefers to be in a comfy chair with a nice cigar and a smooth Whiskey, reading about exploring the wilds of Africa, rather than actually going out slogging through some mosquito-infested swamp myself. I'm too old, too lazy, and too comfortable to really go out on a limb about anything. So fanatics are great people. Or at least people to be greatly admired, if not necessarily emulated.

Or followed.

I'd sum up Bernstein's approach to diabetes control as perfectionism. And the problem with this, in my view, is that while Dr. Bernstein's methods can and do work, it's too hard a climb for most people. You, yourself, said that after one month on Bernstein's Rx you "almost lost your mind."

You are not alone.

I share your feelings. While I know that super-low-carb diets work, especially for type 1s, and while I know that this kind of diet reduces insulin requirements, and while I know that it reduces spikes, and while I know that it reduces complication risk—I still can't do it.


Because I live in a Gingerbread House in Candytown in the State of Carbachusetts in the Land of Plenty, otherwise known as Everywhere in America. Because it's easier to change your gender than your diet. Because I'm comfortable in my comfort zone. Because, despite my name, I have very little Wil-power. Because those other humans who live with me are not going to follow the Bernstein diet no matter how good it will be for me. And because I suspect dietary dichotomy is the leading cause of domestic violence in diabetes households.

And I'm not the only one who has these problems.

I don't know how many PWDs I've met or worked with in the last decade, but it's a lot. And very few of them are Navy SEAL tough when it comes to diet. Hell, I'm not even sure most Navy SEALs could stay on the Bernstein diet long-term. And, in my book, that's the whole problem with his approach. Diabetes is long-term in the biggest sense of the word. I don't believe in fairies, unicorns, elves, or the cure anytime soon. We are in this for life.

So to my cynical but humanistic eye, a diabetes therapy that technically works, but is not achievable by most people, is a failure. No. Wait. That's not right. It should be an option, of course. Because for those tough enough, zealous enough, fanatical enough to keep it up for their entire lives, it will work. But it's not for everyone, so it should only be one of many options. We need to accept that not every diabetes solution will be the right choice for every person with diabetes.

So what's my approach? I guess my theory of diabetes treatment could be called Sustainable Therapy. That's not as sexy as a Diabetes Solution, but we've already covered my lack of motivation, and sitting around coming up with a better name for my theory of diabetes treatment takes away from my cigar and Whiskey time.

Sustainable Therapy is a softer approach, something maybe not a good as a Solution, but more attainable. I'm a big believer in Le mieux est l'ennemi du bien (perfect is the enemy of good). I personally believe that for most people, striving for perfection is a recipe for failure. And in diabetes, failure is measured in blindness, amputation, dialysis, and death. But I also believe we can avoid failure by simply being good enough. Not perfect. Good enough.

So how good does good enough need to be? Well, first off, I think the notion that any blood sugar spike over 100 is dangerous is just ridiculous. We know that sugar-normal people commonly rise to 140 mg/dL when subjected to a glucose challenge. That's why the American College of Clinical Endocrinologists chose 140 as the postprandial glucose target. Because it's normal.

But it's also ambitious. True, it's easier to try to stay under 140 than to always stay under 100, but even staying under 140 is damn hard to achieve. At least in my real world. For reasons I've already forgotten, the International Diabetes Federation likes us to be under 160, and the American Diabetes Association picked 180. As no one really "knows" what's dangerous, what's good, and what's good enough, we are clearly free (at some risk to our hides) to define the numbers ourselves.

Personally, I use under 200 most of the time. Why'd I pick that number? Because my wife says I get "pissy" when my blood sugar goes north of 200. She's talking about my mood and attitude—not urinary function—that goes awry north of 300. So figure if that level of sugar is changing my behavior, it's probably not good for my body either.

Why most of the time? Because I live in the real world where 88% of the population does not have diabetes. Because ice cream socials happen. Birthday parties happen. And there's this frickin' anti-diabetes holiday ironically called Thanksgiving. Yeah. Right. Thanks. And because, unlike Dr. Bernstein, I have great faith in the toughness of the human body. I think it can take a licking and keep on ticking. Our biology is engineered to roll with the punches. We shouldn't abuse that engineering, but we shouldn't live in fear either.

For fasting blood sugar, I personally like a target of 100, as that's the highest fasting level we see sugar-normal people at, so that makes sense to me that this would be a safe starting point. It's also achievable, with a little effort, and the ice is thick enough for errors. And by that I mean that I feel a fasting target of 80 is dangerous for most insulin users. Our insulins are not that good. Hypos happen. If you shoot for 80 and miss, you can get into a world of hurt very easily.

How well do I do at that? Not too well. My body tends to park itself at 120 despite my best efforts, and I'm too lazy to try to force it down that extra 20 points.

So to answer one of your questions, using the math between my typical fasting and my pissy level, I find an 80-point spike to be reasonable.

Now, as to A1C, that's a little easier than understanding what postprandial glucose targets should be. Pre-diabetes is defined as starting at 5.7%. Bernstein's 4.5 would translate to an average night and day blood sugar of only 82 mg/dL. For people on very low-carb diets, this might be OK, but for most people it's simply damn dangerous. When I see A1C's south of 6.0 there's almost always a great deal of hypoglycemia.

Let's not forget that hypos can kill you dead.

Dead really isn't good control.

On the top end, we know that at an A1C of 9.0, or an average blood sugar of 212, blood becomes cytotoxic—it kills cells. So for safety, you need to be between 6 and 9. But where? I think part of that depends on age; after all, blood sugar damage is slowly corrosive (which is also why I don't fear brief excursions, I believe that damage takes time). Younger type 1s should shoot for the lower end, older ones might as well loosen up a little and enjoy their Golden Years. I'm fifty-something, yes, I'm too lazy to look up my actual age and I've forgotten what it is, and low sevens work for me. My body seems happy there and I don't have to work too hard to maintain that. You're a bit younger than I am. In my opinion, high sixes sound sensible, and more importantly, doable, for you.

It is sustainable. It is achievable. And it's not perfect.

And that actually makes it perfect, because what could be more perfect than good enough control that doesn't drive you mad?

“This is not a medical advice column. We are PWDs freely and openly sharing the wisdom of our collected experiences — our been-there-done-that knowledge from the trenches. But we are not MDs, RNs, NPs, PAs, CDEs, or partridges in pear trees. Bottom line: we are only a small part of your total prescription. You still need the professional advice, treatment, and care of a licensed medical professional.”