Post-prandial control vs. fasting BG control

Community
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Been researching a lot, lately, and came across the site, What They Don't Tell You About Diabetes. A very interesting site, and what's particularly interesting to me is that the opinions are heavily referenced to peer research, so I can go read the actual studies.

Anyway, this fellow makes the case -- made on other sites I've come across recently -- that controlling with the goal of achieving normal BG values, and normal BG dynamics, is critical to reducing complications.

In fact, he makes a compelling, data and study-backed argument that what really predicts complications is post-prandial measures of BG, not average BG and A1c.

He argues for testing 2-hour post-prandial and keeping that under 140, always. He advises a low carbs, metformin, and if necessary insulin to achieve this.

Community: Thoughts? Who's seen this site, and done some real diving through it?

While I am anti-conspiracy theorist, especially when it comes to doctors (Dad's a retired doctor, have know many over my 51 year life, the conspiracy theorist stuff about drug companies and doctors, etc., is just so much hooey, I'm telling you). However, his arguments that doctors are reluctant to be agressive with their patients in BG control because of fears over serious hypo events is reasonable and sensical.

CGMs have changed all that. I'm agressively trying to keep my BG under 100, and post-prandial excursions under 140. I couldn't do it without a pump and a CGM.

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When there are so many diabetics out there whose bg is above 200 all the time (A1C > 9), and they rarely or never check their bg, maybe not taking their meds, arguing about postprandial vs fasting is a little bit like rearranging the deck chairs on the titanic.

For those already in excellent control working on postprandial numbers is a good thing. But these are already the goodytoshoes that are in good control.

Online discussion forums like this one, have many frequent and vocal posters who are already goodtoshoes in good control, resulting in a distorted "online view" which is really just a subset of the larger diabetic community. Even then there is some value looking at the wide range of folks who read and post here:

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I truly am sorry if I offended you guys. I had no idea!

I am very lucky to have been approved by insurance for both a CGM and a pump, as a Type 2. I know why I was approved, but I can't recommend it as a means to the end (i.e., ignoring your diabetes completely, going into chronic hyperglycemia for over a year and basically being sick all the time, vomiting several times a week, you all know the drill; after winding up in the ER with an A1c of 11, my endo had a pretty easy time of it getting approval).

Again, sincere apologies if I touched a nerve.

To be clear, my sole motivation is to treat this condition as well as possibly can be treated. Honestly, I'm scared about what damage I have already done. When I was in the ER from my out of control idiocy, I had >500 on the microalbumin test.

I'm 51, and scared to death I'm headed for dialysis. My endo has given me a great deal of reassurance that I'm probably OK, and that the albumin will come way down with good control. Then we'll see if anything pharmaceutical is needed.

That's where I'm coming from. I'm learning and doing everything I can to head off any more damage. I'm finding solid -- not nutjob -- stuff all over the net that basically says, yeah, keep your sugars like a "normal" person and the risks almost go away.

$$ is a big issue for PWDs. There is no way I could used the gear I am if I had to pay for it myself. The tragedy is, based on my brief use of a CGM so far, it is my strong opinion that it should be a standard part of therapy for all diabetics if they want and are willing to use one. As I've said elsewhere on the forum, it's like being given sight when you're blind.

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And it's disgusting we have to fight like that.

What other disease is treated by the health care industry as, "we'll keep you alive (most of you), but that's about it. Don't expect to be healthy, and if you want the tools to enable that, well, rob a bank, hank!"

Shawnmarie, did you appeal? I know we all have to pick our battles, and not knowing your life, I can't say that this is one you might have the motivation and energy to fight. I know that when the going got really tough in life for me a while ago, diabetes in its entirety was one of the battles I just couldn't fight. So I understand not wanting to go to the mat.

Still, Kerri Sparling who blogs Six until Me had quite a battle -- and eventual victory -- with insurance to get a CGM. If you haven't read through her experience, it might inspire you.

And if you have the mojo to take the fight to them, do it. It's absolutely worth it!
Her story starts with this blog post, and as I said has a happy ending!

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I had a stretch in the late 80s-early 90s when I had maybe 5-10 years of no doctor, b/c Walgreens were very adept at gettin rx's refilled w/o me actally seeing the doctor, getting tests, logging anything, etc. I still tested quite a bit but eventually, the doctor "fired" me and I found a new doc. The first time I went in, I got a 5.8 A1C (unk std deviation, ha ha...) so I wasn't doing too badly but had gained quite a bit of weight. When I started working out in 2004, I still had no clue what I was doing, mostly used insulin like something I'd buy in the parking lot of a Grateful Dead concert. I lost weight but, with the constant guessing, my A1C went up so I got a pump and the light bulb went on.

I agree with being aggressive with control. If you are aiming at 140 and hit it, your A1C can still run pretty high. I like to keep it to 120 after meals, still a 40 point rise from the 80s where I like to hang out but it seems to do the trick at keeping A1Cs closer to normal. I also think a FBG target of 85 is useful because there's no "wiggle room" and the doses have got to be pretty accurate or the lows will be a very clear sign to make an adjustment. I agree that the pump and CGM make this much easier both from the smooth delivery of insulin and also the relentless record keeping. It makes a huge difference for me to be able to look at the CareLink reports and see "oh, I'm running high [or low or whatever...] after breakfast every day and need a bit more juice..." Hypos where you keel over are very unpleasant but I think that hypophobia is a big problem.

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OMG, is that a TuAnalyze map? Is that still around somewhere? That was one of my favorite things ever! I was so bummed when they shut it down!!

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Don't get me wrong, if your control is so good that you have no problem with fasting numbers ever being high, the next place to work on certainly is the postprandial numbers. There's simply no place left to improve in your fasting numbers at that point and most of the average bg/A1C excess you have will be postprandial.

That puts you in the top one percent of best controlled diabetics, and is a worthy goal. If you keep your postprandials below 140 all the time then you are doing better than some young non-diabetics, e.g. bg profiles below are for non-diabetic youth, chart below taken from this presentation: What is Normal Glucose? – Continuous Glucose Monitoring Data from H...

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Found that just googling for pictures with the search string "tuanalyze".

I think the TuAnalyze results were strongly biased by heavy participation from the best-controlled and especially recently-diagnosed young diabetics, but maybe not quite so biased as the frequent posters in online forums.

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I've actually taken a fair bit of time reading through the research posted on that site.

Regarding the 140 mg/dl as a line for where damage begins, the conclusions are either misunderstood at best by the webmaster, or deliberately rewritten by the webmaster to be misleading at worst. The truth is, the vast majority of studies linked on that site are not designed to determine at what BG organ damage actually begins, or employed any type of methodology to search for the point at which organ damage begins.

Simply put, the 140 mg/dl line for organ damage has been somehow construred or wrongly derived from the Oral Glucose Tolerance Test which simply specifies that a 2 hour post prandial BG above 140 mg/dl is indicative of a problem in metabolizing BG.

http://diabetes.about.com/od/symptomsdiagnosis/a/ogtt.htm

Basically, the collection of studies on the site, employ a methodology that seperates subjects, or data on subjects, into two groups, those showing a decreased ability to metabolize BG according to an OGTT, and those who do not. Not surprisingly, if you show a decreased ability to metabolize glucose, you show a higher probability having a virtual smorgasbord of problems associated with organ damage all the way down to the cellular level.

Here are the actual conclusions from the first study linked under the very misleading heading Nerve Damage Occurs when Blood Sugars Rise Over 140 mg/dl (7.8 mmol/L) After Meals.

My emphasis to show the distinction between the actual conclusions and the extrapolation made by the webmaster.

CONCLUSIONS—Our results suggest that IGT may cause or contribute to small-fiber neuropathy, which is similar in phenotype to the painful sensory neuropathy commonly encountered in diabetes. Two-hour OGTT is more sensitive than other measures of glucose handling in screening these patients.

Here, IGT means Impaired Glucose Tolerance.

Reading through the studies, you'll find that actual 2 hour post-meal BG levels of the study subjects are all over the map and, in many cases, are much higher than the 140 mg/dl cut-off for IGT.

To be fair, the discussion on the site does make it very clear that the studies are based on OGTT data but, since the studies do not employ any type of methodology to determine the point at where damage begins, it is very misleading to conclude that damage actuually begins at 140 mg/dl.

Now, I'm not saying that you shouldn't try to keep your 2 hour-postprandial below 140 mg/dl. I certainly do and I get very frustrated and OC Diabetic when I cannot do that. I start to think the worst of myself and imagine my organs dissolving into a pool of slimy goo because I'm having BGs above 140 mg/dl.

That doesn;t mean it's actually happening, though, and that's the very important distinction to make. There are probabably a gazillion variables associted with the number of times that happens in a given time period, how long post 2 hours you're spending above a certain threshold, etc etc, that contribute to diabetic complications. All of them need to be studied, and should be studied, before panic inducing headlines can be published and scientifically supported.

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I went to a presentation at the Friends for Life Canada conference in 2010 and the researcher there said they had done studies that showed cellular damage begins at about 10 mmol/L (180 mg/dl). Something to do with AGEs and such. Unfortunately I didn't take notes. But for me, this means I try to keep out of the "double digits" as my primary goal, although even that isn't something I achieve every day (most days I go above 10 at least once).

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Congrats for sticking with your aggressive fingerstick program. It enables mid-course corrections and saved me punishing consequences more than once. I love my CGM and your story reminds me how lucky I am to have very good access to health care. Everyone should have a right to this. Science has shown that diabetes complication rates go down when BG control gets better. Insurers are being very short-sighted for denying CGM coverage for any diabetic, including T2s.

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I'm so glad to have someone respond that's looked at the site. I've only come across it recently.

As I said above, I think the guy's a bit extreme. However, at least there is peer-reviewed research referenced so that one can (like you did) independently look at the source and draw conclusions.

My concern is my kidneys, in light of the horrific microalbumin results I had 3 months ago after being wildly out of control for a fair period of time. Hence my strong interest (and research) in this particular angle to our shared "challenge".

Also, the other thing that concentrates my thinking is how BG metabolism and profile looks in a "normal" person. Seems to me that getting as close to that as practical is a good thing.

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I was very lucky to find Jenny's site soon after diagnosis, I read everything on the site many times through. I followed her "eat to your meter" plan and set my goal of under 140 based on the research she presents.

Plus, she is diabetic herself and walks the walk in addition to talking the talk.

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It still good info for us newer T2 diabetics who are trying to take contol of it, and not end up on insulin especially when we’re limited to testing bg because of high cost of strips :slight_smile:

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Yeah, there's nothing like complications to focus your mind on a set of goals. I also had a couple of bad microalbumin results that sent me on a internet reading spree. Those results brought me to this site which, in turn, took me to many other sites including Blood Sugar 101.

Really, all I did was click through each link from Blood Sugar 101 to read through the abstracts, data presented, and conclusions presented. Where ever I could, I found the source publications from which the abstracts were taken. Like I said, I don't think any bad advice is presented there, and it's probably good advice if you can manage it.

I try very hard to keep my BGs stable, keep my A1c below 6, and limit BG excursions outside of the 70 to 140 range. Not because I've found any data that say I should or any data that say those are normal BGs, or that anything outside of those ranges, even post-prandial numbers, are what "normal" people achieve. Truth be told, I haven't found anything in the primary scientific literature that says anything like that.

I maintain the BGs I do because that's what I can manage without making my life a miserable and tedious experience, on the one hand, or putting my health at unecessary risk on the other. Fortunately, perhaps due to my BG control, probably a combination of both luck and my BG control, I don't spill microalbumin anymore and other signs of diabetic complications are minimal. That's just going to have to be good enough for now.

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Thank you for taking the time to do that analysis. I was similarly very disappointed by Ruhl's supposedly "scientific" approach, and after reading a few of her articles concluded she was full of crap. Some of her advice may be worthwhile - she certainly isn't the first one to advise to keep BG in normal range and "eat to your meter" - Joslin has been preaching that since meters were invented. What bothered me about her site was its hysterical tone, conspiracy-theory wackiness, and failure to understand the papers she was citing.

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Another source for the <140 pp goal is the American College of Endocrinology Consensus Statement on Guidelines...

Quoting from the paper:
"Independent of complications per se, diabetes control
targeting postprandial hyperglycemia proved more effec-
tive than use of fasting hyperglycemia in reducing HbA1c
levels in pregnant and nonpregnant patients with type 2
diabetes (27,28). Indeed, investigators have suggested that
postprandial glycemia may better correlate with HbA1c
levels than fasting glycemia (28). In subjects without dia-
betes, blood glucose levels typically peak approximately 1
hour after the start of a meal and return to preprandial lev-
els within 2 to 3 hours; 2-hour postprandial blood glucose
levels rarely exceed 140 mg/dL (39,40). Therefore, the
consensus panel recommends a treatment-targeted 2-hour
postprandial blood glucose level of <140 mg/dL."

In effect they are figuring backwards. Normal people seldom go over 140 and normal people don't get diabetic complications so if diabetics keep their post prandial below 140 they won't get complications. Although such reasoning does not constitute scientific proof, in the absence of studies that would give us a better number I still think 140 is a useful goal.

Incidentally the bloodsugar101 website references this paper here

In my own experience, at my T2 diagnosis, my first blood sugar test was 392 and my A1c was 13.2. Counter intuitively, when my numbers started coming down I started experiencing severe burning in my legs and sharp pains in my toes. I adopted 140 as my goal, based on the BloodSugar101 website, and changed my diet, based on "eat to your meter". Very quickly, I found I could meet my goal most to the time. Slowly over the next 6 months the burning and pain subsided.

When my dawn phenomenon is not acting up I can easily meet the <140 goal, at other times, I will experience 150s routinely, in the morning, despite the fact that my usual breakfast has about 2g of carbs, the rest to the day is a piece of cake, low carb of course:-). Perhaps this is the reason I still have some residual numbness in my feet. Much of the value in participating in the DOC is reading of others experiences. In the absence of scientific proof, I see nothing wrong with trying things that have worked for others, to see what effect it has on our own situations. I believe such "crowd sourcing" was the genesis of Jenny's site and is the reason many of us have found her advice so useful, conspiracy theories aside.

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Very interesting post!

I found the same paradoxical response to getting my BG in line, after my wild, out of control year+. I started having minor classic neuropathy symptoms in my feet (prickly pinprick pain, but not severe). Also started having more "fall asleep" numbness issues with my fingers/hands when resting my arm with pressure on certain areas.

It's been 3 months since I got it all back under control. My endo said this didn't always happen when people regained control, but it wasn't uncommon, and in her opinion was a good sign -- she thinks it's damaged nerves on the way out recovering and coming back on line.

Not scientific, of course, but my own experience is consistent with that theory. I seem to have more sensitivity in my feet to touch than I had when I was a walking barrel of high fructose corn syrup.

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Others here have reported the same phenomenon after they regain control of their blood sugars. I tend to agree with your endo that it is a good sign. Here's a blog post from Jenny that explains why neuropathy takes so long to heal especially in the feet.

Quoting the post (edited):
"neuropathy may come from damage to the mitochondria that burn energy to supply the nerves, not just, as hitherto believed, the tiny capillaries that supply the nerve tissue."

"What's new and interesting about this new study is the discovery that mitochondria are born at one end of the nerve nearest the spine and migrate toward other end, and that, because the feet nerves have the longest journey, their mitochondria take the longest time to make the trip and hence the oldest and the most prone to manifest damage."

"The study suggests it takes two to three years for the mitochondria in the feet to migrate to their destination."

"As the nerves heal you may experience some pain, tingling, or itching in your extremities as the nerves start working again. This is normal and happens when any damaged nerve starts to heal, especially ones that previously were numb. The pain is a short term effect and should be replaced in a few months by normal function."

I to "was a walking barrel of high fructose corn syrup" in the years my diabetes was developing as well as after it was full blown, but undiagnosed. I was a carpenter and drank 2 regular cokes a day, every day. I depended on the sugar and caffeine to get me through days that included lots of heavy lifting. When I switched to working in IT I usually had 12 oz. of orange juice with lunch thinking I had switched to a healthier alternative. No HFCS, but probably just as bad for me.

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Yeah, I absolutely agree that you should have a post-prandial target to shoot for, and <140 mg/dl is a completely reasonable target that should be obtainable for diabetics intent on limiting the probability of having complications somewhere down the line.

Again, my argument is simply that the idea that some plus or minus line where organ damage begins has been divined using scientific methodology or any other reliable systematic methodology is completely unjustified if not irresponsible. From what I can tell, the source of this misrepresentation of scientific literature appears to originate with the Blood Sugar 101 site. While it's easy to dismiss this level of misrepresentation, given that the goals are completely reasonable, misrepresenting data, results, and conclusions doesn't help generate a better understanding of science.

I think the ACE Guidelines you linked are excellent. Those guidelines are reason enough to set a goal of 140 mg/dl 2 hours post-meal without having to sensationalize speculative and subjective opinions from a tertiary source like Blood Sugar 101. In fact, here's the leading paragraph of that paper that contains the quote you have:

Postprandial Glucose Target
The published literature includes a relatively smaller
body of evidence from which to draw conclusions about
guidelines for postprandial glucose control. No interven-
tional trials with outcome data have focused on postpran-
dial glucose control per se. Many of the studies are epi-
demiologic, and data have been obtained with use of
postchallenge glucose levels rather than postprandial
loads. Some of the test meals have been liquid, which may
yield outcomes that differ from those with solid food.
These caveats notwithstanding, a large number of highly
robust cross-sectional and prospective epidemiologic
studies have clearly implicated a close association
between postchallenge or postprandial hyperglycemia and
cardiovascular risk

That about as clear a statement as we can get on how much is understood, scientifically, about the importance of post-prandial numbers. It's extremely important to keep that number at a safe and reasonable level. No need to read into the data more than what is actually there to invent false conclusions that are not supported.

Like you said, if the data show that people without diabetes, on average, show 2 hour post prandials below 140 and, largely, escape the type of complications that PWDs who routinely go out of range experience, it's probably a good idea to get those numbers down.