Diabetes Care: New Issue and Related Journals

I keep up with a few journals, culling them for useful or interesting articles, so thought to share, maybe useful for some if unfamiliar with the publications…

Hypoglycemic Effect

Severe Hypoglycemia and Risk of Atherosclerotic Cardiovascular Disease in Patients With Diabetes | Diabetes Care (diabetesjournals.org)

How the lock down has been good for some of us

Stay-at-Home Orders During the COVID-19 Pandemic, an Opportunity to Improve Glucose Control Through Behavioral Changes in Type 1 Diabetes | Diabetes Care (diabetesjournals.org)

Closed Loop Systems

Fully Closed Loop Glucose Control With a Bihormonal Artificial Pancreas in Adults With Type 1 Diabetes: An Outpatient, Randomized, Crossover Trial | Diabetes Care (diabetesjournals.org)

Diabeloop DBLG1 Closed-Loop System Enables Patients With Type 1 Diabetes to Significantly Improve Their Glycemic Control in Real-Life Situations Without Serious Adverse Events: 6-Month Follow-up | Diabetes Care (diabetesjournals.org)

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American Diabetes Association (diabetesjournals.org)

Interesting I have heart stents, but I have never passed out from hypoglycemia. I have never been hospitalized at all for my diabetes since 1959 when diagnosed. My husband has injected me twice with glucagon over the years, which I may or may not have needed. I have had maybe 5 lows when I have needed help eating something. I still think my atherosclerosis was caused by 22 yrs of urine testing and high LDL when very low carbing. I have had a couple of lows in the very low 20’s over the years so who knows for sure.

My calcium scores are quite high, but have excellent treadmill performance with no issues shown with nuclear scans. Because of my fitness, I’ve often had ultrasounds, since my fitness leads to some false positives, and these latter tests are always fine.

As for the calcium scores, I am a little dismissive, as initial studies were not strongly supportive of the technology, but the manufactures have persisted in publishing more and more studies to bolster their case, but personally of questionable value, considering what I believe the reason behind them. As for why my calcium might be high, I smoked heavily from the age of 12 to 29, 18 months abstinent, and my diet before 25 consisted heavily of meat, cheese, milk, and simple carbs. Also, I have seen studies showing high coronary calcium levels in committed runners, so I wonder about the causes behind it, maybe related to hormones that kick in when losing weight. Also, I was consistent runner back in my 20’s and 30’s, along with biking, and didn’t transition to rowing until my early 30’s.

In the study, severe hypoglycemia (SH) was recorded in the emergency room or hospital, and I’ve never needed help to eat or recover from LBS, and neve required glucagon. There was a time it was so low, by feeling only, that I was scared I would die, with my vision incomparably blurry that I compensated by figuratively ‘eating the freezer’. I have had lows measured at 28, and although conscious, with sweat literally streaming of my arm, quite conscious and capable of feeding myself.

I just don’t know about coronary calcium scores. I asked my cardiologist about doing one on me, but he said that he didn’t know why I would want to since I am doing everything I can to stay alive including riding my exercise bike daily 7-8 miles, and eating a low fat pescatarian diet. He would like me to use cholesterol meds but realizes that my body reacts badly to them. My latest nuclear stress test showed no change from the one I had in 2019. Also my latest cholesterol tests were pretty good, and very good if I wasn’t a diabetic.

My husband’s two heart tests were inconclusive so next week, I will ask his cardiologist why he can’t recommend the the coronary calcium score test before going to the more invasive tests. I think he will say that the test just isn’t as good. Maybe it could buy us some time though.

Interesting what you said about runners. Is that why runners are known to drop dead while running? That happened to a doctor we knew at our beach house. He appeared to be in good shape, but dropped dead while doing his daily run. He was 72.

So the study looks at the following;

“The outcomes of interest were ASCVD events, defined as a composite of nonfatal myocardial infarc- tion, fatal or nonfatal ischemic stroke, or death due to coronary heart disease. The exposure of interest was an SH event defined by a primary diagnosis of hypo- glycemia in the emergency department or principal diagnosis in the hospital.”

“Baseline was determined by the date of the first SH event during 1 January– 31 December 2013. For each individual in the reference group (no SH event), base- line was a randomly assigned date in
2013. We followed subjects from base- line until censoring due to ASCVD event, death, loss to follow-up, or the end of the study, 31 December 2017. Adjusted mul- tivariate Cox proportional hazards mod- els were specified to estimate time to ASCVD events by SH.“

They’re looking specifically at events. I don’t think atherosclerosis on its own would have even registered in this study- one would have needed to have had a heart attack or one of the other events named above.

It looks like the study included people with both type 1 and type 2 diabetes. Approximately 14% of those in the SH group had type 1. Only 4% in the non-SH group had type 1.

They don’t identify separate hazard ratios by type of diabetes.

I guess the reason I posted anything is because the study actually feels like scaremongering.

Their basic conclusion is that one severe hypoglycemic event in 2013 resulted in a cardiovascular event that happened potentially years afterward, with no regard to anything else about the patient (A1c, medication, average bg levels). They say in the research paper that they adjust for some of those things, but I’m not sure how you could possibly adjust for the composition of type 1 vs type 2 patients…? Or for duration of diabetes- especially if you’re not distinguishing by type of diabetes.

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Regarding runners, I didn’t want to overgeneralize, but exercise is strenuous, and although it’s beneficial, it can’t overcome other effects, like lifestyle and genetics. Even then, runners often focus on weight loss, and that itself might lead to higher calcium (just a thought, not to be taken seriously).

As for your doctor, people can do all the right things, but there is always the variance in that we all don’t benefit or suffer to the same degree from our life choices. Also, people are more likely to die while exercising, but the benefits of the activity over the long-term in reducing illness and death outweigh the short-term increase in risk.

As for the calcium scoring, one cardiologist I had used that to justify the stress testing. In and of itself, it is not better than other types of tests, but can be additive, in that a calcium score addd to a stress treadmill is better at predicting outcomes than the treadmill alone.

Katers87, 11 yrs ago, I would have had a heart attack,if I had continued on my hike, but instead we went to the ER and I ended up with two stents.

Thanks for pointing out the fear mongering. It sure is hard to trust studies.

I’m so glad that you went to the ER instead!

I wasn’t trying to diminish the seriousness of your condition. I’m sorry if it came across that way.

Understandably, studies like these can be hard to interpret, but I don’t think they went for scaremongering. It was written for medical professionals, and the last paragraph, preceding the last sentence, goes to great lengths to circumscribe and limit overgeneralization. They leave it up to others to investigate further.

There are several limitations to note. These data are derived from a regionally based integrated health care delivery system and may not be representative of the U.S. Most SH events (for which the patient requires assistance) are treated outside of the health care system and are not captured in the medical record; we estimate that ∼5% of SH results in emergency department or hospital utilization (5). Although we adjusted for a wide range of potentially confounding factors, the observational nature of these data precludes causal inferences. Moreover, we cannot rule out that ASCVD also increases the risk of SH.

No, I didn’t take it that way!

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Every article or study has a similar statement. The article was still published in a mainstream journal and then linked here by you.
If the results aren’t worth trusting because of the many limitations… then it’s certainly not the article I would’ve chosen to post here.

Honestly, I have a fairly high tolerance for medical and academic science and the related ambiguities of most types of studies. I wasn’t sharing what I thought was guidance on how to maintain one’s health, but appealing to individuals that like thinking in more medical terms.

Granted, some people don’t, and although I will continue to use and share this kind of information, since I know of several that also appreciate it, I can certainly consider adding a disclaimer for those that don’t, but seriously, the study is trustworthy within the bounds of its conclusion.

SH is a potential marker for heightened risk of ASCVD. Increased vigilance in care for patients with history of SH is warranted.

It appears that you’re implying that I’m not capable of reading, understanding, or appreciating medical studies.

I think that’s really offensive.

Just the opposite, but I thought you were expressing concern for others, those that might take it too literally, or that don’t have my tolerance, even enjoyment, of ambiguity.

I don’t think you have to put up a disclaimer when linking a study published in a mainstream journal.

I will push back when I don’t think a study is adding value. I think the limitations of this study really impact its usefulness.

Given how few people are actually hitting the 7% A1c goal, I have knee jerk reactions to studies that focus on hypoglycemia. Some doctors seem obsessed with hypos while their patients are suffering from complications resulting from targeting high bg levels in order to avoid mild hypos.

I think studies like this can feed those perceptions. Hence my referring to it as scaremongering.


Hypos can kill you very quickly. High sugars takes years.
That’s why doctors focus on not being low.
I was a runner for most of my life. I’ve done a few marathons, one when I was type 1. The other 2 were before dx
I have dupuytrens in my feet which keeps me from running now, but my doctor warns me about heart issues from all the running i did in the past.

Just like blood sugar control, you avoid one issue only to gain a new one.

In my life I can tell you that moderation in all things seems to work out for me.

I still hike and walk I eat moderate carbs, about 100 per day.
And my sugars are 95% in range. A1c right at 6%
I don’t tolerate statins, so I accept cholesterol in the 180s

At some point I accepted that I’ll have more issues as I get older, however I’ve accepted that I am doing the best I can.
I just celebrated my 55th birthday. That is also 34 years w T1

I see those 34 years as a gift, and also I want more.

I signed up to join a study for a truly closed loop pump system w insulin and glucagon. I think for when I’m old it might be really good. There is no blousing, I really want to try it.

Is this the BetaBionics iLet dual-hormone trial?

I share your enthusiasm with this concept as I age; I’m 13 years ahead of you. I have experienced some mysterious blood glucose traces that would be best explained by a lack of glucagon. I’ve read that people with T1D can suffer from too little glucagon.

As a side issue, I wish that the creators of shelf stable liquid emergency glucagon would release a product that would enable “mini-glucagon” doses. It appears the Gvoke and Baqsimi are only interested in selling their high-priced emergency kit.

I should just buy a sterile empty vial, get an Rx for Gvoke and dump the entire amount into the vial and experiment with “mini-glucs” shots to correct minor hypo trends.

I’ve been terrified that the dual hormone system would over-deliver insulin up front to mitigate post-prandials and just cancel it out on the backend with the glucagon. At only 5 foot tall, I’m terrified of the potential for extra insulin weight gain.

But the little feedback I’ve seen on the insulin-only trials is actually showing a lower TDD and statistics that don’t vary much from their Control-IQ values. I’m much more excited about this system now!

Unfortunately, it’s expected to retail too late for my next pump decision. I’m have to wait another 3 years to see what comes of it.

Sometimes I wish I wasn’t so rural. I would love to participate in these kinds of trials!

I’ve been using Loop for over four years now and I’ve often observed my best management statistics (TIR, SD, time low, average BG) coincide with days I use use the fewest units of insulin.