Got diabetes? Need advice? Of course you do! And you came to the right place: Ask D’Mine, a weekly Q&A hosted by veteran type 1, diabetes author and community educator Wil Dubois. 
{Need help navigating life with diabetes? Email us at AskDMine@diabetesmine.com}
Wil goes deep this week on blood sugar control issues. Enjoy!
Liz from Oklahoma, type 2, writes: I get lightheaded and shaky even after eating a good meal. My blood sugar is around 118 before the meal—my primary doctor insists on this and feels I don’t yet need to go to the Joslin Center. I have been told these episodes may be “false lows.” I’d like your input. Thanks!
Wil@Ask D’Mine answers: Your blood sugar is OK before the meal, but what’s your blood sugar after the meal, when you start feeling shaky? Common wisdom holds that after-meal numbers are generally higher, but that’s not always true. You need to test after a meal to find out what’s really going on.
Here’s why: early in the course of type 2 diabetes, your body is totally freaking out. Nothing is quite working to design specifications. In some cases the pancreas over-reacts to food. It produces a huge wave of insulin and can actually cause a low. This is particularly common with high-carb meals. Picture the pancreas getting a telegram that a Grand Slam Breakfast is on the way. Lights flash. Alarm bells ring. In commmmming!
In fact, episodes of hypoglycemia are one of the warning signs that can lead to a diagnosis of diabetes. So you need to check your blood sugar when the lightheaded shakies hit to see if you are actually going low after meals. If so, use the speed-dial to call your doc.
As to the issue of you having “false lows,” I doubt it. The term false low, in med-speak called “relative hypoglycemia,” is something that happens to people who have been high for a long time, once their blood sugars start to normalize.
The human body is a real champ at adapting to its environment, both external and internal. If your blood sugar has been at 350 night and day for months your body starts to think that’s normal. If you take a med that quickly lowers you to, say 200, your body flips out. It only knows you just dropped 150 points and that can’t be a good thing; it’s forgotten it was too high to start with. All of the hypo warning signs and symptoms are triggered, even though you are still critically high.
So you can feel like you’re hypo even if you are nowhere close to it.
But I doubt you are experiencing this because you told me you are running 118 before meals. Relative hypos really only happen when your blood sugar has been elevated all the time for an extended period of time. Ups and downs between normal readings and higher readings won’t trigger the effect.
Still, something is causing your symptoms. Check your blood sugar after eating. If nothing unusual crops up, look next to your blood pressure… then your vitamin B or D… then your thyroid… and then…
I hope when they dx’d you they remembered to tell you that having diabetes is like playing a supersized version of Clue… only with higher stakes.
Natalie from Nevada, type 1, writes: My BGs are usually in a reasonably good place — running around 120 fasting and overnight, and 140-180 postprandially. I average about 35u of insulin a day, with 18u of that as basal. I’ve had diabetes for 20 years, and have no complications. My A1Cs are usually in the 6s. My BMI is 24.0. I do have some insulin resistance, though apparently mild. My question is, is it worth the extra insulin to try get my fastings lower, say in the 80-100 range, and PP’s below 140 (per the AACE)? Is there any solid evidence that hyperinsulinemia contributes to cardiovascular disease? Is it better to run somewhat higher than normal BGs or to use more insulin to get them lower?
Wil@Ask D’Mine answers: Now wait a cotton pickin’ minute.
You have a perfect A1C… for two decades.
Your insulin usage is nearly perfectly split at 50% basal and 50% fast-acting.
You have a trim and sexy Body Mass Index.
Your postprandial numbers are nothing short of totally astounding.
Are you really sure you have diabetes?
I’m not convinced.
At the very least, you’re making the rest of us look bad. If you keep this up, we may have to kick you out of the family.
So, yeah, OK, your fasting numbers could, in theory, be a little lower. But if the sign says “Danger: thin ice” would you go skating? Frankly, for type 1s, a fasting of 80 makes me queasy. Don’t forget that AACE guidelines are for all people with diabetes: both type 1s and type 2s. They are blanket guidelines to cover all the bases. You need to individualize these targets for both you and your diabetes. For T1s like us, 110 or 115 fasting is considered golden. You’re pretty darn close.
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In terms of complication risk, average blood sugar and blood sugar variability are
both major players. And both are arguably equally damaging. On top of that, recent research, like the ACCORD study, is beginning to point fingers at hypos possibly causing more longer term damage than previously believed.
Why am I blathering on about this? Well, shooting for a fasting of 80 ups the ante on your hypo risk. Given your low average and tight range in the first place, I don’t see any significant benefit to you in trying to get it even better.
But of course, that didn’t really answer your question, which is about whether hyperinsulinemia, a.k.a. high levels of insulin, might be damaging to your heart. You asked if there’s any solid evidence.
(Insert sound of person laughing hysterically to the point of passing out)….. Let me refer you back a few weeks to this column where we discuss that fact that “solid” evidence doesn’t exist for anything in medical research. I can’t even find any solid evidence that medical research even exists in the first place.
Anyway, forgetting the whole concept of solid evidence for the moment, the role of high insulin levels as a risk factor in cardiovascular disease is one of those things that scientists politely call “controversial.” Some studies have shown no link at all. Some studies have shown there’s a link. Some studies show maybe there’s a link sometimes, in some cases, but a small one.
But a link is only an association. Association doesn’t necessarily imply a cause.
Here’s the problem with trying to figure out if insulin screws up your heart or not: High levels of insulin are most commonly found in only one place in nature: early-to-mid stage type 2 diabetes where the pancreas is working triple time and nights and weekends to try to overcome the disease’s signature insulin resistance with wave after wave of insulin. The problem is, and please don’t take offense all you type 2s, there’s also a whole lot of other metabolic dysfunctions taking place at the same time. It starts to get very chicken and egg trying to sort out the complex interrelationships between the various markers, much less assign cause and effect to any of them.
And even if it eventually turns out to be true that hyperinsulinemia is a cardiovascular risk factor, it would be a moot point for you. You’re literally sipping insulin—35u really isn’t that much. A frickin’ vial is lasting you a whole month, for crying out loud. Even if you were inclined to fine tune your fasting numbers (a modest increase in your basal would do the trick), I doubt you’d be taking more 45u per day.
Consider that many type 2s use 100u to 150u per day.
You, my dear, don’t even qualify to enter the hyperinsulinemia marathon.
And making it double moot is the following: even if hyperinsulinemia is a cardiovascular risk factor, and even if you injected at ton of insulin, you’re still talking cats and dogs, apples and oranges. Taking a lot of insulin isn’t really the same thing as being hyperinsulinemiaic. If anyone has actually studied the role of injected insulin as a possible cardiovascular risk factor, I’m unaware of it, nor have I been able to find any trace of it on the internet.
The bottom line for everyone is: even if in the future solid evidence for hyperinsulinemia causing heart trouble is discovered, I think it would still be a hell of a stretch to apply that discovery to injected insulin as well.
Bottom line for Natalie is: I don’t think more a little more insulin would put your heart at any more risk; but at the same time I think your blood sugar control is already beautiful. I don’t think it matters much which way you choose to go.
Disclaimer: 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.
Thanks will for your lighthearted advice! Thanks Amy for your work! I am a pediatrician, hacker, iOS developer and also mom of newly diagnosed Kennedy 11 with type 1. We are 44 days out from diagnosis (but who’s counting?)
Just want to let you’all know the significant contribution that the doc has made for me as a new parent dealing with this disease.
Amy and I spoke at a recent mayo clinic transform symposium about our unusual roles in creation of healthcare value through web content and community. The value creation of the doc is undeniable.
Anywho, thanks again and look forward to seeing my crazed and somewhat forward thinking posts reflecting on the era of diabetes management that my daughter is entering… One of patch pumps, accurate cgm, and promising pediatric open loop trials, truly an exciting time! That is if my kid doesn’t die in her sleep tonight from hypoglycemia… Sigh…
Best, Natalie
http://Www.Personalmedicine.com
http://Www.personalmedicineofkentucky.com
I wish the ACCORD study had never existed. The results have been spun out of control so bad, there seems to be no end to the confusion.
And again we have another example. The ACCORD did not find that hypos (or insulin use) were related to excess mortality. Here is a discussion from the principle investigator:
Endochrine Today “ACCORD: Intensive glucose control not to blame for excess mortality”, June 10, 2009 on the ADA 69th Scientific session (http://www.endocrinetoday.com/view.aspx?rid=40829).
“HbA1c was associated with hypoglycemia but not in the relationship we expected,” said Denise Bonds, MD, MPH, project officer for ACCORD at the National Heart, Lung and Blood Institute, National Institutes of Health.
Severe hypoglycemia was associated with higher risk for death in both treatment groups but a lower risk in the intensive group vs. standard group (HR=1.28 vs. HR=2.87). Further, risk for hypoglycemia was lower in the intensive control group who achieved the target goal faster compared with the standard group (HR=0.86 vs. HR=0.72). Importantly, hypoglycemia did not account for overall mortality findings.
“Hypoglycemia was felt to play no role in most deaths,” Bonds said. Few deaths occurred within 90 days of a documented episode of severe hypoglycemia.
I have long suspected that the excess mortality in ACCORD could be attributed to the extensive use of AVANDIA which was used in the majority of patients in the intensive arm. AVANDIA has been implicated as causing heart problems and will be removed from the market in November (http://www.fda.gov/Drugs/DrugSafety/ucm255005.htm). The inability of the study team to “prove” that AVANDIA was not the cause of excess mortality says reams about the situation.
And remember, the AACE suggests for healthy people getting your A1c “in general < 6.5 for most; closer to normal for healthy." Closer to normal means lower. If you have other problems and are less healthy you should consider a more lenient control. But for many of us, higher blood sugars are "not better."
just another Riddle little update on your ACCORD info:
“The answer was no. People who rapidly lowered their A1c didn’t have excess deaths,” Riddle said. In fact, “it was the ones who couldn’t bring their A1c’s down that had increased mortality.”
http://www.diabetesincontrol.com/index.php?option=com_content&view=article&id=9287-tight-blood-sugar-control-may-not-harm-diabetes-patients&catid=1&Itemid=8
Thank you, Wil, for your response. Since I don’t have access to Diabetes Education (my insurance has a grand lifetime benefit of $50, which didn’t even cover one hour), it is nice to be able to ask my weird questions!
The reason I have been able to achieve such good control is that I am limiting my carbs to those found in vegetables and occasionally small portions of fruits and dairy. No added sugar (read the label), and minimal high-carb, low nutrition foods like bread, rice, potatoes, pasta, cereal, etc. For me, it works.
I went to the AADE convention last week, and heard some really interesting presentations called 1) Food, Fat and Satiety, explaining about all the hormones involved, and 2) Fructose and Cardiovascular Disease, a not so sweet connection. I don’t know if you have access to the Power Point slides, but they are very worth viewing. I learned a lot, but no one answered my question like you did!