My sister preD

We have a long genetic history for a Type 2 diabetes. My sister is 10 months older than me and is 110 pounds. Walks a lot. Plus her husband had a 50 pound weight loss over a year ago, so they eat excellent. A1C5.9, I am so worried about her . I just never, ever saw this coming. She looks to me for advice. I told her do what she is doing, she sees her doctor next week. Any advice. Nancy50

Many T2s are diagnosed at normal weight, including my mom, 35 years ago. She is now almost 90, still normal/under weight. There are many new T2 meds, and she may be started on just metformin and reduction of sweets/high carbs.

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There are many different perceptions of what this really means. Diet plays a crucial role in the glucose metabolism. I would counsel that a systematic and frequent use of a fingerstick meter or, better yet, a CGM to educate herself on how her diet impacts her glucose values. Seeing numbers that react to her specific meals personally has greater value than reading some expert’s food advice.

I wouldn’t bat an eyelash at a 5.9, but it kinda depends on age.

She is almost 69. Has been 5.4 for years. She is going to up her exercise again. She was walking, 3 miles a day. But her husband had surgery, COVID19 hit,etc. thank you. Nancy50

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Nancy - Terry posted a podcast in another thread and I would recommend investing 2hrs to watch it.

One big take away from the podcast is A1c provides little value. The assumed dogma of T2 is it is caused by weight. It is not. It is caused by the pancreas no longer producing enough inulin for the needs of the body. The first indication is usually the loss of first phase insulin release after meals. In the podcast they refer to this as extended area under the curve - the time it takes to get back to baseline after eating extends and the initial PPG spike increases.

Without a CGM it is nearly impossible to see how she is reacting to her meals. Paying out of pocket for a Libre for a month or so may not break the bank but would provide invaluable information on her AGP. Maybe - if she can afford it she can talk the doctor into prescribing a Libre. IMO, this would be step one with her doctor so she can see what her AGP looks like.

The podcast is all about controlling PPG rises through foods but if she is already eating excellent and exercising and she wants to better control PPG she has a few choices. A ddp4 like a Januvia should help flatten the PPG curve but it does not address the underlying issue and just causes the pancreas to continue to work for a longer time to get back to baseline. I am also not a big fan of taking medications which effect one part of the body to try and solve another problem.

Assuming her PPG is spiking and the area under the curve is extended the best solution is afrezza which is human insulin and the exact same insulin the pancreas should be releasing. It also has a time action profile which nearly mimics first phase release.

The down side is afrezza probably won’t be covered under insurance as a “Pre-D”. A one month box off insurance will cost her $99-200 a month but it may take a month or so for her to dial in to how much to take at mealtime.

Any other medication like metformin, SGLT2s, etc will only mask the issue which can not hide on the CGM. As they said in the podcast 'data over dogma".

For next week I would try and get the Libre script. The doctor may very well say at your age of 69 an A1c5.9 is great just walk a little more. Until you see the data, who knows?

Nancy, has your sister recently started taking a statin or changed her statin? My husband’s A1c rose because of a statin.

On no medication. All other lab work is normal. Great thought. Thanks,Nancy