Just got some interesting quarterly lab results

Not to be rude - but I flatly do not believe this.

You don’t believe what? That I read it somewhere? Or that it’s correct?

I’m no diabetes researcher, so I can’t speak to the latter. But I did read it:

“The number of deaths of this kind per 10,000 patient years has been estimated to 2-6.4 For a population of 100,000 persons with diabetes, this represents 20-60 deaths per year or approximately 6% of all deaths in persons with diabetes aged less than 40 years.4”

http://www.childrenwithdiabetes.com/d_0n_g00.htm

I do apologize for clearly offending you.

However I stand 100% by my post.

I will neither argue the math, the trivia nor continue anything which could be construed as a personal attack of which this is not.

You didn’t offend me—I just wanted to clarify that I did read this inforamtion and didn’t just make it up. It is hard to tell intentions and tone in writing online. I truly can’t tell what you are disagreeing with and am not sure what point your posts are raising. I’m sorry.

A1C per se is of course always kinda problematic because it’s an average, as I know you know. But I think an additional factor here is treatment regimen. When I was on basal-bolus MDI and fingersticks my endo did not like to see me get below 6.5 because the assumption was that you had to be hitting a lot of hypos to produce that number, essentially because the system was just not that refined. But with a pump you can ride things a lot more closely, so that a 6.0 isn’t necessarily the result of a lot of low excursions. MDI with a CGM, maybe similar though you really can’t fine tune your basal as well. I’m currently at 6.0 using a pump+CGM and my endo is fine with it because she can look at my data and see that I’m staying in range 90+ % of the time.

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David Mendosa looked at this and had a few comments. Population studies are inherently studies of association. It is really hard to know whether people with impaired cognitive function or macrovascular problems have a lower A1cs or vice versa. And if those with low A1cs are truly experience severe hypos then it is entirely believable that having a lows could result in these problems. But that doesn’t mean that an A1c of 5% without severe hypos leads to either cognitive impairment or macrovascular problems. And I’ve never seen credible studies that suggest A1cs of 5-5.5% represent issues. And I don’t consider things like ACCORD to be credible.

I would note that if you look at the source of this number it is from a 1999 report on diabetic patients younger than 40 years old and represents “all cause mortality.” This is not mortality from hypos. And these patients were from the “pre DCCT” era when people didn’t believe that blood sugar control affected complications and the standard of care was conventional insulin therapy and there weren’t any blood sugar meters.

Philip Cryer is considered an expert in this area and has a book “Hypoglycemia in Diabetes: Pathophysiology, Prevalence, and Prevention.” But I consider Cryer and bit of a wolf cryer. For instance, in his chapter on hypoglycemia in the 2016 book “Textbook of Diabetes” he writes:

Three early reports indicated that 2–4% of people with diabetes die from hypoglycemia [87–89]. More recent reports indicated that 6% [83], 7% [90], and 10% [91] of deaths of people with T1DMwere the result of hypoglycemia. In T2DM, mortality rates of up to 10% during episodes of severe sulfonylurea-induced hypoglycemia have been reported [92]. In one trial of T2DM, between 1 and 9% of evaluable deaths were attributed to hypoglycemia [93].

But if you look up the references:

83, 87-89 and 90 were all in the time era I talked about above and confounded all cause mortality with hypos.

90 was a study entitled “Acute Complications and Drug Misuse Are Important Causes of Death for Children and Young Adults With Type 1 Diabetes

91 was a study of children born between 1972 and 1982 and were under 15 years when diagnosed. They looked at causes of mortality, none of which included hypos.

92 A 2003 paper entitled “Risk of Hypoglycaemia with Oral Antidiabetic Agents in Patients with Type 2 Diabetes” which didn’t have a mortality finding as a major result.

93 was a study of severe hypoglycemia in the ACCORD study which while it found that severe hypos increased risk of death, tight control did NOT increase severe hypos or death

What is uniformly dissappointing about Cryers work is that as a scientist he is critically flawed. He takes these studies, misinterprets the results, fails to understand the difference between association, doesn’t understand confounding factors and then spins number that are likely wildly inflated. And these numbers are repeated and repeated. Even the JDRF repeats them.

And I personally think he is just crying wolf. Not that severe hypos can’t kill you. But that the number suggesting that upwards of 10% of us will die from a hypo is just not even in the ballpark of real. It is an alternative fact.

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Maybe this is too far into the weeds and OT, but the term “drug misuse” in that article title sent up some red flags for me in the context of insulin dependency, so I hunted down the article. Sigh. Yes, they’re lumping insulin OD deaths in with those from “recreational” drugs like meth, opioids etc. (for some reason they exempt alcohol, god knows why), even though they don’t know whether those deaths were instances of “misuse” at all:

Our findings also revealed that six of these fatalities were due to insulin overdoses, although we were unable to establish whether these were accidental or not.

Well, if they were accidental then they weren’t “misuse” were they? Unlike, say, OD’ing on meth which you are “misusing” by taking it at all. Stupid, question-begging category error grumble grumble arrgggh.

Sorry to go OT, just another irritating example of why that whole thing of dragging insulin dependency into discussions of substance abuse is confusing (and offensive) rather than helpful, but I couldn’t pass it by…

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Ancel Keys revisited, except that he was doing it on purpose, deliberately and with premeditation.

As far as the low A1c being dangerous, I can’t prove it but I am convinced (especially given the other things she said), that this endo is coming from the old traditional wisdom that if your A1c is anywhere near that of a non-diabetic person’s, you must be experiencing lots of bad lows, irrespective of and without really bothering to learn what your individual practices and circumstances are.

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So, let me jump back into the fray. After reading the thoughts on hypos and low A1c, you’re sort of confirming my (pre-existing) bias: I am not worried about having an A1c below 6.0. Personally, I think being in the 4.5-5.0 range seems pretty good, and my other markers (kidney, heart, liver, lipids, etc.) are excellent.

As @David_dns suggests, I also kind of get the idea that the endo I saw yesterday is of the “ADA orthodoxy,” old-school variety. She was pretty dismissive, didn’t even consider it a possibility I could be anything other than Type 2, and clearly thought I was wasting her time. Given that she’s the only endo up here in the hinterlands, I suspect I’ll have to make do with my family doctor (who is great) “until something changes” or I move to somewhere with reasonable medical care.

And, it’s also quite possible, that I really am one of the super-weird types of diabetic where my symptoms and test-results just don’t match the population studies. That could mean pre-symptomatic Type 1, idiopathic Type 1 (or “DKA prone Type 2” as I learned it’s also called), or who the hell knows.

I do know that my three closest relatives with a similar presentation all became insulin dependent, but I clearly don’t need insulin at this point. I can’t see how I would take basal without going low, since I already have that issue. I can’t see how bolus would be useful (unless I intentionally ate half a dozen doughnuts to spike my BG over 250, which would indicate more serious problems than diabetes).

I talked with my wife last night, and her take on the endo appointment was this: “great! it means you’re doing fine, and you don’t have to worry about this stuff so much anymore.” There is probably some truth there, in the sense that I’m working with the best tools available (diet, exercise, Metformin) for my case, regardless of antibodies, family history, and weirdness. She did think that I should probably just keep doing what I’ve been doing, continue to see the metabolic specialist (who seems to be the sharpest tool in these parts), and monitor the situation.

Seems pretty reasonable to me, and it’s clear that doctors around here aren’t willing (or capable) of digging deeper to find answers to what the hell is going on with me. And, I’m not sure I really need to know what the hell is going on with me. I’m healthy, and that’s the bottom line, right?

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That’s always a possibility to take seriously. As you know, T2 isn’t a true diagnosis; it’s a diagnosis of exclusion. When test results don’t clearly pinpoint something that a doctor can identify with confidence, you get thrown into the T2 bucket. As a consequence, T2 isn’t one thing; it’s many things, with presentations and indications that disagree and conflict when you try to view them as a single group. For instance: the traditional gospel is that T2 is all about insulin resistance. Well, I have next to none of that, so what pigeonhole do I fit in? Etc.

And that’s what matters at the end of the day, whether you’re Type 1, Type 2, Type 79, or whatever, and regardless of anyone else’s opinion (doctor included). If you have good numbers and what you’re doing is working, that’s the bottom line. Everything else is angels dancing on the head of a pin.

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I appreciate the reply, and the re-confirmation of my existing bias :smile: One of the things I love about the community here is the no-nonsense “do what works for you” attitude and the concomitant acceptance of everyone.

I have to admit, I was really hoping for a measure of certainty: “You are ____, and I know this because I’ve seen it before.” That, in my mind, would have allowed for a bit of futurecasting based on other people’s experience. As it is, I can still do that to an extent, but I am fond of reducing error and probabilities…

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My only comment on the question of the “damage” done by maintaining a “low A1c” is that Dr. Richard K Bernstein maintains his own A1c at or around 4.7 and has done so for decades. He’s about to (or just has?) celebrated his 83rd birthday and is still practicing. Brain damaged? Don’t think so.

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First let me say I am a health teacher living with type 1 diabetes. Misuse means that a medical drug or a product that has been made for s specific purpose, is not used according to the prescribed directions. Medicine and products that have labeled instructions about how it is supposed to be used and also lists possible side affects are either used or misused and sometimes leads to intentional abuse. For example, when people are diagnosed narcotics for pain but misuse it by taking more than directed, then they develop tolerance leading to needing more. This need for more because they began to enjoy the psychological and physical euphoria (high) is what makes their actions abuse, that may have started from misuse. But an alcoholic cocaine addict or binge drinker was never prescribed these things to cure or manage a diagnosed condition. They chose to use and then abuse for the sole recreational purpose to get high. We are not using nor do we abuse insulin because we are seeking a high. Just remember all drugs are not medicine but only medicines can be misused.

That’s a bit too broad and sweeping for me to be comfortable with. Alcohol is not a medication in the conventional accepted sense. Alcohol taken in moderation in a social setting is not being misused. Alcohol consumed in substantial quantities before driving a car, is. (Just to select one from the legion of exceptions.)

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There is no disagreement . Yes, alcohol is not misused. People consume it in moderation or binge for recreational reasons while less than 10% of the population are physically dependent. But in the end, they are all either self controlled users or abusers of a drug that has no medicinal purpose. So there is no mistake being made when you choose to take a drink and drive. That’s called alcohol abuse in which you suffer the consequences of a DUI or worse.

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So . . . “abuse” vs. “misuse”. I don’t care to explore the semantic parsing. To borrow a phrase from Oscar Wilde, that’s a distinction without a difference.

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Congrats on having such a low a1c! It sounds like metformin is helping you keep your numbers low, but that your beta cells are slowly getting depleted, even though you’re on low carb. You should make the switch to insulin and off metformin to give your beta cells protection from having to make so much insulin on their own.
Your lipid panel is great, because your sugar has normalized, so keep expecting to see such great numbers!
WBC - have you had a viral/bacterial infection lately? That would potentially cause your WBCs to be wacky, especially the leuks and neutrophils. I would recommend repeating your WBC in a few weeks, when you’re feeling 100% and if it’s still low, I would recommend further workup. Otherwise if it’s normalized, I’d just take it as possibly a mistake in lab or an outlier result.

Insulin is a good idea, but insulin and metformin are not mutually exclusive. Using one is not a reason to dump the other; metformin is beneficial whether one is on insulin or not. iI does not cause the beta cells to do extra work—if anything, it gives them some relief. In addition, it has a positive effect on insulin sensitivity, which is helpful regardless of any other factors.

As a completely unrelated but rather nice side effect, it significantly lowers the risk of certain cancers, especially for women.

Just wanted to point out - the first statement

  • “kills up to 6% of childre and young adults with Type 1…”

and the second statement,

  • “…this represents 20-60 deaths per year or approximately 6% of all deaths in persons with diabetes…”

Are not the same thing.


So like Tim said, the first one does not sound believable, but the second one does.

Anyway, hope you guys can kiss and make up. :slight_smile:

It’s hard to read anything into a single lab bg reading of 101. Yes that may be marginally out of the lab reference range but it’s still remarkably close to the reference range. If your meter says you are averaging 99 and a random lab sample says 101 that’s entirely to be expected. Everything including that 101 number, looks outstandingly good!

As to really slow-onset LADA, the typical “honeymoon period” in full-blown diagnosed-younger T1 was at a few months to a year. For me it was at 1 year post-diagnosis, that I didn’t need any insulin shots for a few weeks. Do I read your timeline right, 1 year or so?