Wait, sorry… just realized I probably chose my words poorly. I didn’t mean “is insulin better than non-insulin” treatments for Type 1s in the long run. I mean from a scientific standpoint: there isn’t a long enough run of studies and cases to compare with outcomes are better for LADA with sufficient initial insulin production and the two different treatment types. I can rephrase my thought a bit better:
Given how rare LADA that doesn’t require immediate insulin therapy is, in the grand scheme of diabetes mellitus, there is likely not enough evidence to compare long-run outcomes of those treated with insulin early vs those treated with orals, diet, and exercise early.
I wasn’t talking about treatment down the road. Obviously, LADA progresses to insulin-dependence if one lives long enough.
This is precisely the situation I’m in. My initial A1c wasn’t borderline (7.5), but I tested antibodies-positive at 4 months post-diagnosis after bringing my A1c down to 5.1 with diet, exercise, and Metformin. So, the matter is pretty straightforward: since I’m an (early) Type 1 rather than a Type 2 as first thought, does that mean I should immediately start insulin therapy, even though lifestyle (largely low-carb eating) and orals are working? My problem is simple: I don’t need the basal insulin, and if I were to use bolus insulin I’d use either microdoses (like, really micro doses as I’m insulin-sensitive and not IR) or have to eat more carbs to cover the bolus, which doesn’t make sense at all.
So, the considered opinion of my medical team, myself, and my wife is pretty simple: keep doing what I’m doing as long as it works. Change what I’m doing (treatment wise) when it no longer works. And pay attention to the signs of DKA, since I have low fasting insulin.
This is exactly the situation I’m in. My last A1c was 5.1, I’m eating low-carb (about 30g net per day), taking Metformin ER, and testing frequently. I’ve been told to watch for signs of DKA, and that when my fasting glucose numbers creep up by 20 or 30 points on average, that’ll be the time to start thinking about insulin therapy. That makes sense to me. My fasting BGs right now are averaging 91 over the last 90 days, so if they were up to 110-120 range, I would know (given my diet hadn’t changed) that I need to think about supplementing insulin.
Also, you aren’t the only one with weight loss issues on low/moderate carb. I upped my calorie consumption by 400 kcal per day last week (all from fats) after realizing I was losing 3 pounds a week. My wife noticed, not me ;/
Pretty sound basic medical reasoning… when the potential harm of an intervention no longer outweighs the potential benefit it is time to go there… and not before.
Yes sound so long as the blood sugar targets are tight. Maintaining a1c in the low 5s with reasonable effort seems good. On the other hand we see people who also maintain such a1c, but barely eat and their drs won’t give insulin, which would have made things much easier for them.
If one waits for an a1c of 6 or 7 or higher (that is the conventional target for diabetics) before starting insulin, that could be a problem.
Right, that is exactly the reasoning we’re operating off of. It’s compounded by the fact that the GP who originally diagnosed me as Type 2 scared the ■■■■ out of my wife when it comes to insulin therapy. So in addition to just not being indicated for me at this point, my wife (and former doctor) are convinced that a deadly hypo is constantly around the corner…neither one of them are terribly familiar with Type 1, and certainly not with successful treatment of Type 1.
For me it’s also just a path of least resistance at this point. If I were on bolus insulin, I could “eat a normal diet,” which I certainly can’t at this point with my own pancreatic function. That’s the only benefit I can see. I have my quarterly tests next week, and I expect my the A1c to be sub 5.0% (if my long-run testing average is accurate). I don’t need to do anything differently than I’m doing it now. Insulin therapy is also expensive. Metformin costs me approximately $3.00 a month for 2,000mg per day.
You just mashed one of my big hot buttons; or, rather, your GP did. Regardless of where you come down in this discussion, playing on people’s fears is reprehensible. Conversations about whether insulin should or should not be used need to be centered on pragmatic medical issues, not scare tactics. And while things are improving every day, far too many HCPs still spread that sort of guff.
Great comments. I did not catch my T1-LADA diagnosis early, though in retrospect I could have a lot sooner than I did, and thankfully figuring it out did not coincide with an ER visit. But it was also my experience, even with a low-carb diet and the sensibility of an adult who knows how to do research, that the first year while I was still producing quite a bit of honeymoon insulin was a complete bear for bg management. I’m sure some of that had to do with learning the ropes of insulin/diet/exercise etc, but there was clearly a complication with getting significant portions of insulin both endogenously and exogenously. This is not to recommend or dissuade exogenous insulin in this specific case (as I’ve said before, if you need insulin, you need insulin, and it has to come from somewhere), just to highlight the complexity of it.
Insulin is actually safe in early diabetes when the user is well trained in its use and given access to strips for frequent monitoring.
Even better if it means beta cells survive much longer.
I’ve been using low dose insulin for nearly 9 years with great success. I have control. I ionly ever had 1 serious low, before I got educated / educated myself (access to quality education and appropriate tools is definitely an issue).
The modern insulins also certainly make things safer and easier.
I agree 100%. That, and his suggestion to “quit exercising” when I had some issues with mid-ride lows, was why I fired him and got a new doctor It’ll still take my wife some time to get over her fear, I suspect. She suffers from anxiety on a good day, and when it comes to my health she can be a basket case.
My problem is simple: I don’t need the basal insulin, and if I were to use bolus insulin I’d use either microdoses (like, really micro doses as I’m insulin-sensitive and not IR) or have to eat more carbs to cover the bolus, which doesn’t make sense at all.
I asked for metformin before being offered Victoza (which is an injectable and without insurance is as expensive as insulin) and was told it would do nothing for inflammation or restoring my first phase insulin response. I asked for it again recently to be the next drug I add and was told the same thing as above, so that’s not an option for me. There was also a study I read, and can’t find now, that mentioned early insulin use not only helping to preserve beta cells, but aids in establishing a type of metabolic memory in the body wherein blood sugar is easier to control after becoming fully insulin dependent and on much smaller amounts.
I take Metformin not because of my lacking first phase response (which is truly, dreadfully lacking), but because I suffer pronounced Dawn Phenomenon and exercise-related highs (before I go low mid-workout). Metformin doesn’t do much, directly, with glucose. But it does keep the liver from dumping glucose into the bloodstream during the morning and when having a stress response (like happens when first exercising). So, along with low-carb diet, it makes sense for me.
I exercise alot, and between that and the Metformin, I don’t really have any trouble staying within my desired BG range (70-120), and my a1c is almost exactly 5.0%. It doesn’t make sense for me to start insulin therapy at this point, because I’d have to eat carbs to match the insulin I’d be injecting. Eating low-carb is somewhat annoying, but not something I find terribly restrictive (not so much I can’t keep my BG between 70-120 mg/dL).
As I said, I don’t know about early insulin being a good thing for (very slow onset) LADA. I can see both sides of the argument. My diagnosis was during an annual checkup, came out of the blue, but had a much higher fasting BG and A1c than yours: 180 mg/dL and 7.5. It appears that almost all of that was from a pronounced Dawn Phenomenon and an insufficient first phase response. Metformin and low-carb diet takes care of that for me, for now. It will change as my immune systems gets better at destroying my beta cells. But for now, the cost of insulin therapy, and the potential downsides (lows, having to change eating habits again) isn’t worth the potential benefit, since I’m already in my ideal BG range.
If you search this forum on half unit or micro bolusing you’ll see lots of comments on delivering very small amounts of exogenous insulin. These days, I manage fine with integer doses, but in the early days I loved my half-unit pen. Of course you can get really tiny deliveries with a pump, but in your case that’s probably for another day.
Yep, I think it’s down the road a ways (maybe next month, maybe two or three years). I don’t think there is any way to tell. What I have noticed is that my fasting BGs were relatively constant once I got under initial control. They were almost 100% between 80 and 90 mg/dL. In the last six weeks, they’ve been as low as 68 and as high as 115 mg/dL, and they kind of fluctuate all over the place. That has me thinking next month might be more realistic than a few years
But, until there is a clear pattern, I’m comfortable with where my treatment is at now. Honestly, since I don’t spike over 126 mg/dL after eating low-carb meals, I just can’t see how even microdoses would be useful without increasing my carb intake!
So here’s my secret, backup plan: I can use bolus insulin on Thanksgiving, Christmas Eve and Day, my birthday, my anniversary, and every leap-Day. I’ll eat whatever I want on those days, bolus appropriately, and the rest of the year I’ll continue eating low-carb and taking my metformin
Or maybe ten or twenty or maybe never… (that’s the whole point of the trialnet study of which both my children are participants.). to really get to know what antibodies / combinations of them actually mean in regards to developing “full blown” type 1 diabetes. That entire concept is in its infant stages and very little is truly known or understood.
Sure! I’ll explain my entire process of weight management:
The problem with low-carb diets is that it’s very easy to eat (unintentionally) at a caloric deficit (eating fewer calories than I “burn” during a day), because fat and protein are both very satiating. I feel fuller when I’m not eating very many carbs.
So, when my wife realized I was losing weight, and I got on a scale and realized I was going to look like a 22 year old beachbody model in another six weeks, I recalculated how many calories I need to eat during a day, given my age, height, weight, body fat percentage (estimated), and daily energy expenditure (I bike or hike to work sitting in an office, and exercise 5-7 days a week). I personally use the calculator at ketogains.com.
So, I realized I was running about 400 kcal per day below maintenance (the level I have to eat to maintain weight, on average). Realizing you probably know all of this, these are the foods I added to my daily routine (which is fairly varied) in order to get 400 extra calories:
An extra tablespoon of extra-virgin olive oil on my salad or when cooking a sauce (120 calories of very healthy fat)
An extra two eggs during the day (boiled or in an omelette or poached, whatever works)–143 calories on average, 10g fat and 13g protein
A tablespoon of coconut oil in my coffee (bulletproof coffee!) (120 calories of MCT rich fats)
A tablespoon of Kerrygold grass-fed butter in my coffee or when cooking an omelette (100 calories)
28g (one US ounce) of macadamia nuts (196 calories, 22g of fat, only 4g of carbs).
So, basically, I track my calories to make sure I’m right at 2,250 kcal eaten per day (or within a percent or two). That requires adding two or three of the options above to my “regular” eating plan.
Other options I’ve found good are adding butter and macadamia nuts to Chia-seed pudding. Sounds disgusting, and probably is, but it’s a great breakfast for me (doesn’t spike my BG, high in fiber) that I learned about on this forum, and it is very filling and high fiber. Coconut cream is another item I like adding to dishes: today I made a chicken curry soup with a can of coconut milk. It was very low-carb, but high in fats and proteins. And yummy.
The real key to this whole question is, how slow is “slow”? Up to a certain point, insulin may redundant or even needlessly complicating. Past that point, it becomes a necessity. YDMV.
P.S. With half unit marked syringes, dosing down to ¼ unit is really no great trick. And with a pump, you can get much finger granularity than that.
It’s all relative as is everything else in medicine and physiology. If a heart transplant or a pacemaker was immediately recommended for every arrhythmia ever detected-- we’d no doubt have a lot of bad outcomes. If intensive insulin therapy was immediately recommended for every abnormal glucose situation we ever saw, I have no doubt we’d have the same. In some cases it’s very clear when the potential rewards vastly outweigh the risks and it’s obviously the only reasonable option. In other cases it’s much less clear… in some of those cases the patients that spent a long time in those fuzzy areas wish it had been more clear earlier…
My advice will always be find a doctor whose expertise you trust 100% and if you can’t feel that way then they don’t deserve your money. Communicate clearly with them, see them often enough to have all of your concerns addressed-- and follow their guidance 100%
It’ll still take my wife some time to get over her fear, I suspect. She suffers from anxiety on a good day, and when it comes to my health she can be a basket case.
