Insulin, an SGLT2 Inhibitor, and a Friday Deadline

Because two of the three requests are medical acts: adjusting an insulin dose and prescribing a therapeutic diet to treat a diagnosed disease. Neither is within a fitness nutrition coach's scope, regardless of how much the client wants it or how confident you are.

The risks are concrete, not theoretical:

• Hypoglycemia. Insulin glargine plus fasting plus a large training load is a stack that lowers glucose from several directions at once. The shakiness and sweating after last month's ride is a probable hypoglycemic episode that was never evaluated. Unresolved, that is a ride-ending event at best and a road-side emergency at worst.
• Euglycemic diabetic ketoacidosis. Empagliflozin plus carbohydrate restriction, fasting, and endurance exercise is a recognized combination that can produce ketoacidosis with only modestly elevated glucose - meaning the monitor looks reassuring while the client is in trouble. Illness, dehydration, or a long ride can tip it.
• Dehydration and electrolytes during long rides on a very-low-carbohydrate, fasting protocol.

Reframe your position: "I'm not going to adjust insulin - that's your prescriber's job, and I'll help you get the information to them. Here's what I can do this week." Then deliver something real so the referral is not a brush-off.

Assessment and data: a full food and glucose log pairing meals, rides, and CGM traces. That log is the most useful thing he can hand his care team, and producing it is squarely your job.

General sports nutrition education: fueling before, during, and after long rides, hydration, and the fact that a 60–80 km weekend ride needs a carbohydrate plan regardless of what he eats the rest of the week. Carry fast-acting carbohydrate on every ride. Review his care team's existing hypoglycemia plan with him rather than inventing one, and make sure his spouse knows it.

Behavior work: sleep, meal timing around shift or work demands, and a shopping and prep routine he can sustain. Reduce friction on the days that matter.

Do not: set or change insulin doses; approve or design a <30 g carbohydrate diet for a person on insulin and an SGLT2 inhibitor; tell him fasting is safe or unsafe; suggest he stop empagliflozin; or manage the "getting off insulin" goal yourself.

Refer and coordinate: diabetes care team - prescriber or a diabetes care and education specialist - plus a registered dietitian. With his written consent, send your log and your concerns about the post-ride episode and the SGLT2 inhibitor. Then build the nutrition plan on top of whatever the care team decides.

Boundaries hold better when they come with a plan and a date. Use a written coaching agreement that states what you do and do not do, and revisit it in plain language: "I do the training and behavior side. Your prescriber does the medication side. When those two talk, you get the result you want faster."

Then make the handoff easy and time-bound: "Give me until Wednesday to get your log to your diabetes team. I'll ask them three questions: is fasting appropriate for you, how should insulin change if it is, and what should you watch for on long rides. Friday we build the ride fueling plan either way."

Reflect his frustration without endorsing the plan: "You're tired of being on insulin and you want control back. That's a fair goal." Then separate the goal from the method, and note what you can control - training consistency, food quality, sleep, and the ride plan - all of which genuinely move A1c.

Document everything: what he asked for, what you declined, what you referred, and when. If he proceeds with fasting and dose changes on his own, keep coaching the parts you can coach and keep the care team informed within the limits of your agreement.