How are you doing Sue27? Have you found the source of your problems? Have you re-calculated your I:C ratios?
I was about pulling my hair out in January-April of this year when my ratios seemed to suddenly increase by 25-50% or even more. But they weren’t really consistent, occasionally they’d be back to the level they’d been for the previous four years. I finally discovered the reason. I had been taking high dose niacin since about the time my sudden increase started and had totally forgotten about that change, so hadn’t considered it as a cause. It wasn’t until my liver enzymes increased enough that I dropped the niacin and my I:C ratio went back to its previous level that it dawned on me that there was a connection. The reason the ratios hadn’t been consistent was that sometimes I’d decide I just couldn’t face such a huge pile of pills and not take some of my pills. Niacin was normally the first one I’d drop when that happened.
So I’m wondering if something similar might have happened to you, that you perhaps had made some change in other meds or OTCs that could be affecting your insulin needs.
I also have to wonder if you have considered the possibility of gastroparesis. Since you’ve had diabetes so long, I’d think that is something that should be considered as a possibility. I understand that can make for some erratic blood sugar control.
I agree with everything you say, Mohe. The fact that 4 to 6% of deaths among type 1 diabetics are the result of hypoglycemia is a sobering statistic, but because treating physicians generally know hypoglycemic episodes only from the outside, while they are an everyday part of life for many type 1 patients, means that their patients tend to be more blasé about hypoglycemia than physicians are. Dr. Zeuzler in Berlin isolated insulin long before Banting and Best, but when he tested it on a patient he thought that the foreign protein in the animal-source insulin he used had caused a massive anaphylactic shock, so he gave up the treatment as too dangerous. Yet in fact, what he saw was the world’s first instance of insulin hypoglycemia, since he had no way of knowing what was a safe dose to give. So hypoglycemia not only kills many patients today, but also delayed insulin treatment for a long time.
The quote from the famous early pioneer of diabetes treatment, Elliot P. Joslin, that while ketoacidosis may kill a diabetic, frequent hypoglycemia will ruin him, is still sadly true today, and all the pressure to achieve strict control is making it worse.
I think that my Doc and I have escalated our argument over this over the years. She now says that every low BG I have is killing brain cells and that even one instance of low BG is too many and she tries to drop my insulin down so that I’m running a steady 300 all the time in an effort to eliminate every low BG. Which, I think, might actually makes them more frequent because it starts the system rollercoastering.
But, perhaps I am too blase. Are daily lows fairly typical?
I believe first one must reach a common understand of what you mean by “low”.
Start basic. Work up.
ie - Some people would consider 79 "low. Others would consider 45 “low”. Others would only call it a low based on symptoms. Others have no symptoms when they truly are low.
P.S. My lawyer asked if she would take the stand. (I believe he saw a flash of terror in my eyes in this moment that I was unable to conceal.) The epilepsy people asked if she would write part of my medical directive. NOT a good idea. But, I know that she would communicate with the hospital if she ever knew I was there. She would go ape-sh**t, which is good. I trust her to be her. She’d show up with her pen and start circling. Its a bit like this. But I am good at this. She also wrote me a letter of recommendation for graduate school and inquired as to if I would ever want to take over her practice because her kids weren’t feeling it. She’s a nice lady.
Actually the figure of 4-6% of type 1’s dying from hypos is just not sound. I posted about this earlier, it is based on work by Philip Cryer and is deeply flawed generally confusing all cause mortality with deaths from hypos. And we need to be aware that doctors are often “risk averse” in a way that amplifies hypos over long term high blood sugars. Running high blood sugars certainly lead to complications, but you cannot trace it back a causal decision by a doctor. A hypo on the other hand could be immediately traced back by a doctors decision to start insulin treatment or increase doses. If that causes a hypo and a health consequence and liability that is bad for the doctor, hence they tend to be very hypo risk averse but often don’t seem to care when we run our blood sugars high.
I don’t think it’s they don’t care if a patient runs high but where most Docs are in the same boat as my Endo where 95% or greater of his patients have A1C greater than 10 to12 and the patient doesn’t do anything or care to do anything to improve so he is thankful for those that are 7. He is willing to work to get them lower. I have worked emergency medicine many years and it is rare to see a diabetic in the 6-7 A1C range, so the people on this site are a rare breed because you are not the norm in the diabetic world.
It seems to me that there are (at least) two ways to get A1c’s under 7.0. You eat a moderate to high carb diet and treat aggressively with large insulin doses. Or you eat a low carb diet and use small doses of insulin. Both can lead to low blood sugars. But I’m not convinced that the long-term effects of hypoglycemia are the same in both cases. I’d be very interested to know if any studies have teased out the differences in these two approaches.
@Brian_BSC, so what’s your best guess regarding death from hypo? If you had to guess. I find cause of death stats very unreliable and confusing because there can be so many compounding factors. Are you guessing less than 4%? I, personally, have no idea. But, it’s something I feel that I should know. Takes a bit more intuition to read between the lines than I feel I have.
It’s taken me a while to accept this reality. I feel clinicians who adopt the unthinking rule of thumb that any A1c under 6.0% automatically means excessive hypoglycemia. This is not always true.
One simple metric that doctors (and patients) can use to analyze hypo vulnerability in patients who use a CGM is to examine blood glucose variability as measured by standard deviation. The higher the standard deviation (SD), the higher glucose variability.
Here’s an example. Let’s say a patient receives the news of a 5.9% A1c from her/his doctor and and their CGM data reveals a standard deviation of 70 mg/dL (3.9). That A1c equates to an average blood glucose of 123 mg/dL (6.8). A standard deviation of 70 (3.9) means that roughly two thirds of all their data points fall within one standard deviation on either side of their average. In this case that means 123 +/- 70 or a range of 53 to 193 (2.9 to 10.7).
Contrast that with another patient who also has an A1c of 5.9% but whose CGM standard deviation is 30 mg/dL (1.7). That means that approximately 2/3 of their blood glucose falls with a range of 123 +/- 30 or 93 to 153 (5.2 to 8.5). As you can see the risk of hypos is dramatically reduced with this lower SD. In fact, this patient could target lowering their BG average without increasing hypo risk!
What I’m trying to say here is that a reasonable BG average as indicated by an A1c measurement is not the full story. It’s when a reasonably in-range BG is combined with large variability that is the real culprit.
Variability as measured by standard deviation should be the focus of the doctor/patient treatment discussion. Concentrating on the A1c number alone is not helpful and misses an opportunity to really help the patient. In some cases I see this short-sighted analysis as lazy. And it insults the clinician’s best performing patients!
If you want a lower A1c yet also don’t want to increase your risk of hypos then concentrate on BG variability first and average BG second.
That is a good question. I don’t have an answer, information on hypos as a cause of death is not collected and someone having repeated severe hypos is more likely to have poorly controlled blood sugars which can itself increase your mortality risk. All I know is that the stated rates overestimate the likely real rate.
I have written about this before. Unfortunately the interpretationns of the ACCORD study are deeply flawed. According to the further interpretation of results it was not intensive control that caused excess mortality. It was attempts to impose intense control and excessive medication on patients who were poorly controlled. The upshot is that patients who really struggled to achieve tight goals but were basically poorly controlled were at high mortality risks. Patients who readily achieve tight control goals actually had lower mortality risks.
It is also important to remember that patients in the ACCORD study were told to eat a high carb diet (OMG!) and most were medicated with Avandia, a drug now essentially off the market because of it’s increased mortality risk.
But what is to be done if the patient has a high intrinsic level of glucose variability but wants a good A1c value? Since 50% of serious episodes of hypoglycemia occur during sleep, as the A1c approaches 5% the nocturnal consequences could be catastrophic. So should the patient deliberately cultivate poor control? It is not yet clear which ranges of hyperglycemia are most damaging, so if the range between 5 and 7% causes a disproportionate degree of diabetic complications, then anything less than perfect control may be extremely harmful.
I don’t remember all the particular points of the discussion but I remember some people did not think that standard deviation was a good proxy for glucose variability. They made the point that blood glucose data does not constitute “normal” distribution and because of that standard deviation was not a valid indicator of variability. Normal distribution is also known as Gaussian distribution.
I am not formally educated in statistics and most of what I know has been learned due to my interest in blood glucose data. I still don’t understand the significance of their point and I don’t think it matters with my practical data use. I only know that when my SD goes down, my blood glucose traces overall are smoother and flatter.
So my old assertion was more defensible than others passionate refutations. I was not able to fully understand their arguments so I just held onto the incomplete knowledge that made sense to me.
Thanks for the link!
If a patient has a high level of glucose variability then it makes it tough to reduce the overall average. If the SD is 100 mg/dL (5.6), then that even makes a 7.0% A1c number hypo risky. A 7.0% A1c is equivalent to an estimated average of 154 mg/dL (8.6). So that means that 2/3 of the glucose data runs from 54 (3.0) to 254 (14.1). 54 mg/dL is the upper border of “serious, clinically important hypoglycemia.”
If you want to hold the SD high then you cannot lower the average BG without taking serious hypo risk. I agree that someone with a high SD cannot approach a 5.0% A1c safely.
I personally think that most people with diabetes can reduce their BG variability if they wanted to. Everyone is different and some people have an easier time of it than others, yet I believe most people can do better, not perfect, but better.
Absolutely. Somebody with poor control should have a higher target. As their control improves, their target can be lowered in relation to their control improvement.
Trying to drop somebody’s target significantly without improving their control is foolish.
