I've been told to increase HbA1c to improve hypo awareness

ann34+

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Two years ago I was told I had osteoporosis of the left hip (no treatment besides vitamin D3). I'm due another DEXA scan this month. My consultant also specialises in osteoporosis but did not mention the risk of broken bones when he saw me last week. I've had Type 1 for 37 years with no complications (touch wood!)

I just don't like being told I must raise my blood sugars but not being told by how much or for how long.

interested that you have had diabetes a similar length of time to me , are insulin sensitive - i use about 18 or 19 iu TDD, and older and no complications, and also being told to raise your glucose levels. I have been told not to go below 7% HbA1c, and when i went higher than that all were pleased - now 7.3%, Problem i find is that doctors are so pushed for time it is not easy for them to discuss anything in detail - i am seriously thinking of having one private appointment just to find out more advice. it may be that so little is clear from the present research, that advice is not forthcoming. I am due my DEXA in a short while and also have been prescribed D3, though when i asked if this would build my bones i was told it was unlikely but might help prevent worse. Maybe you will be able to find out more about how long they want your blood sugars higher , and how high etc when you have a consultation to discuss your DEXA results?
P.S. Maybe you can post if your DEXA results when you get them have improved at all, as i have only recently started D3 and would be interested to know if it might slow bone problems? A very high dose was suggested for me, but i asked my GP for lower than that , Thanks, Ann

Just looked at your post again and wondered if you had the DEXA which found the hip problem. because your doctor routinely offers DEXA to Type one women who are older? ....i had never been offered one and was shocked when i broke my hip as i had been quite active and a hip break was not on the horizon at all.
 
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dancer

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Ann, I got the DEXA scan after breaking my wrist. I knew I'd osteopenia after breaking a bone in my foot but was shocked at it becoming osteoporosis. I thought taking up dancing would prevent that, along with the vitamin D3 I'd been advised to take.

I didn't even know that Type 1's were at risk of osteoporosis until I read it on the internet. I think we should all be prescribed vitamin D3 as a preventative measure.
 
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ann34+

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Ann, I got the DEXA scan after breaking my wrist. I knew I'd osteopenia after breaking a bone in my foot but was shocked at it becoming osteoporosis. I thought taking up dancing would prevent that, along with the vitamin D3 I'd been advised to take.

I didn't even know that Type 1's were at risk of osteoporosis until I read it on the internet. I think we should all be prescribed vitamin D3 as a preventative measure.

Thanks, Dancer. I am very torn at present, as only a little while ago i broke my toe and wish i could find out what is best to do, as i feel that, to build bone i must need to be normal blood glucose as much as possible, but this does not fit with the advice to raise. i do need a CGM i think, but cannot see how that will be possible
 

iHs

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I generally dance about an hour after lunch or 2 hours after dinner.
At lunch I reduce bolus by 30% and use a 70% basal for a couple of hours. In the evening I reduce bolus by 20% and again use 70% basal. Generally this works but I could go high or low during/after dancing for no apparent reason. I tend to eat the same type of thing every day so haven't been able to find a diet link to the success/failure of my routine.

Just a thought Dancer...have you tried just eating something protein based like large 2 egg omelette with some mushrooms, kale and some cheese and no carb and no bolus? Weirdly, my bg stay ok even with a 2 mile walk just eating protein. You could see how you go like that with a 70%% basal and may be a few jellybabies if needed.
 

LucySW

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I never knew about this association between Type 1 D and osteoporosis.

Just on a quick google, found this:

" Some studies have shown stabilized and improved BMD in patients with type 1 diabetes with improved glucose control over time.40,41 Hypercalciuria, a potential risk factor for osteoporosis, has long been noted in patients with poorly controlled type 1 diabetes42,43 or type 2 diabetes,44,45 and was shown to improve with lower A1C results.46 Thus, metabolic control appears to be a major factor in the increased incidence of osteoporosis in patients with diabetes. However, poor control cannot be the only factor unless there is a compensatory factor increasing BMD in type 2 diabetes.

If the relationship between osteoporosis and diabetes were only related to hyperglycemia, one would expect a similar incidence of osteoporosis in patients with type 1 and those with type 2 diabetes, but most studies show more osteoporosis in patients with type 1 diabetes.31,47 There may be differences between types of diabetes other than glucose control that affect BMD. Several factors have been investigated, including treatment with insulin, endogenous insulin levels, age of onset, and A1C, but the actual mechanism for lower BMD in type 1diabetes is not known.


Krakauer et al.40 and Tuominen et al.31 have separately compared patients with type 1 and type 2 diabetes treated with insulin, showing that exogenous insulin is not the cause of the bone loss. Krakauer et al. also found decreased BMD in men and women with type 1 diabetes as compared with those with type 2 diabetes or with control subjects.


Epidemiological studies at Rancho Bernardo, Calif.,48 and in Rotterdam, The Netherlands,49 suggested correlations between fasting and post-challenge insulin levels and BMD in women without diabetes, but in the Rotterdam group only, these lost significance after adjusting for BMI. In patients with type 2 diabetes, no consistent association of BMD with endogenous insulin levels, using fasting or post-challenge levels, has been found.34,50,51 However, insulin levels are quite variable within type 2 diabetes because of the decline of β-cell function over the course of the disease.
An autoimmune- or inflammation-mediated process has also been considered because a decrease in BMD has been noted during the first several months to years after diagnosis, with an attenuation thereafter.27,37,52 This suggests an initial insult not specifically related to control, but perhaps to the autoimmune process, similar to that seen in rheumatoid arthritis, in which bone loss is seen in the involved joints.


Increasing evidence suggests that type 1 diabetes in particular may impede new bone formation possibly because of defective function of osteoblasts, the primary cells responsible for bone formation.53,54 Preliminary data suggest that poorly controlled diabetes with hyperglycemia and consequently increased osmolarity contribute to decreased osteoblast function.53 In addition, patients with type 1 diabetes are known to have lower levels of insulin-like growth factor I, an anabolic hormone that maintains healthy bone formation.55"


From this : http://m.clinical.diabetesjournals.org/content/22/1/10.full
 
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dancer

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Thanks for that LucySW. It looks like I'm between a rock and a hard place!
 

LucySW

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But that article says 1) bad BG control seems to make it worse, but 2) other factors are clearly at work as well, as yet unknown.

So how on earth does *raising* BG help? The opposite, I would think.

That article mentions avoiding hypos in the context of lessening risk of falls, not for metabolism reasons.

?? Don't follow the logic.
 
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ann34+

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But that article says 1) bad BG control seems to make it worse, but 2) other factors are clearly at work as well, as yet unknown.

So how on earth does *raising* BG help? The opposite, I would think.

That article mentions avoiding hypos in the context of lessening risk of falls, not for metabolism reasons.

?? Don't follow the logic.

Hi, Lucy, i think that the advice to raise levels short term to try to regain hypo symptoms, seems reasonable to me , especially given someone has had breaks before and has osteoporosis. I only know i was given the advice, for various reasons, including falls prevention - maybe the reasons are different in Dancer's case. There is a lot in the research showing that falls and slips increase in older people generally, and even more so in diabetics, for a whole lot of reasons, one of which may be not quite 100% attention when mildly hypo , and falls/slips can lead to breaks.
i myself only had a minor slip on some papers on the floor when i broke my hip, and DEXA did not even show osteoporosis, only osteopenia (Type ones - young and old, men and women - have been found to have altered bone turnover, and some of the bone changes do not, apparently , even show up on DEXA scans.)
The advice i have been given to raise HbA1c to still only just over DCCT intensive control levels , as i have no complications and am older, seems good to me, especially as so little is clear cut at present. I would like a CGM but this is not possible, it is not an ideal world.

Until my break my HbA1c averaged 6% to 6.4% for the over 20 years that the test was offered, (the HbA1 and the fructosomine tests were the earlier tests and they were in the normal range also ) and for some years my HbA1c was lower, in the 5's, , when i had more hypos on human insulin.
My own view is that maybe another reason for advice to try to stop hypos could be connected to one of the recent suggestions i.e. - that too much circulating insulin itself could be one problem, especially as Type 2s also have bone problems but of a different type. But if i have understood some of the research ideas, lack of ones own insulin may mean some complex beta cell signalling is faulty - i dont know, not qualified enough to understand, see 2008, 2014 research, and 2015 discussion, be interested to know what you think
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2518333/
http://link.springer.com/article/10.1007/s00125-014-3338-1/fulltext.html
2015 full text discussion if you google Diabetes and Hip Fractures: an Important Underrepresented Topic in the Related Literature Marks R* Department of Health and Behavior Studies, Teachers College, Columbia University, USA * Published: May 06, 2015
 
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Spiker

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They maybe trading off the avoidance of acute short term problems (hypo related falls) at the expense of long term problems (worsening osteoporosis). :-(
 

dancer

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They maybe trading off the avoidance of acute short term problems (hypo related falls) at the expense of long term problems (worsening osteoporosis). :-(
Osteoporosis wasn't even mentioned. They're only concerned about the hypos. I think I'm the only one concerned about anything else. I'm even worried now that I could be developing thrush!
 

Flowerpot

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I am also up to my neck in a similar position with fractures that won't heal, osteoporosis at a young age ,no hypo awareness for years, desperate to maintain the small amount of sight I have and being told to keep an HbA1c of at least 7%+ whilst my brain is telling me to aim for 6.5%. My bone chemistry and fracture healing is absolutely up the creek after 37 years of Type I and calcium levels, Vit D levels and Parathyroid levels are all involved. It is a minefield to find a balance where I'm doing the optimum thing to best serve all the factors involved and minimise future risks and complications.The diabetes tightrope continues to narrow even further.

I'm a bit shocked at the suggested levels to aim for to try and regain hypo awareness! I was told to aim for 8-10 for 8 weeks but alas 10 years later my hypo awareness has never returned and trying to control blood sugar without any inbuilt early warning system is one heck of a scary ride even with the help of cgm.

I hope you can find that elusive happy balance Dancer where you feel safer to exercise without jeopardising anything else.
 

ann34+

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They maybe trading off the avoidance of acute short term problems (hypo related falls) at the expense of long term problems (worsening osteoporosis). :-(

A fall is definitely not a short term problem, it is anything but if it results in a hip fracture. Apart from the experience itself (of waiting for 2 ambulances which never arrived - diverted due to drunken fracas - and laying waiting for hours in a weekend A and E while everyone is rushing round dealing with bigger emergencies - there was a cocaine overdose and a man running with blood from stab wounds, and hordes of police milling around - by the time i had been processed my allotted surgeon had gone off shift) there is the immense shock to the body which takes months to get over, it is difficult to explain, but it is actually a physical shock, and the healing is longer and the disablement is a shock also. And the longer term consequences.

Also i think the more recent research quoted showed there seem to be many possible factors involved and that things re bone problems are rather complex.
 

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donnellysdogs

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NICE guidelines state that levels should not be artificially set outside their normal targets.....

10-15 for 8 months...?? I would be asking them to prove where they got their figures from and quoting NICE back....
 

AmandaD

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I lost all hypo awareness during my second pregnancy its taken me 5 years to get it back and even now its not fully back to where it was. Higher blood sugars helped. I am quite sensitive to insulin so minute changes are all I need to see an effect. I've a CGM and thats the only thing that helped really cos I can see what my blood sugar is doing all the time. I use more extended boluses now than I did before to avoid going low. My blood sugar tends to drop very rapidly and during exercise I have to use temporary basal rates sometimes as low as 10% to avoid a drop. I try and not have a blood sugar over 10 as to me thats high enough, maybe if I'd runt hem higher I would've got my awareness back sooner ??
 

AmandaD

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Your total daily amount is quite similiar to mine and my team have never seen it as a problem