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Clinical trials indicate Insulin producing cells destruction starts at just 5.6mmol/L

Ian DP

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Below are some clinical trials I have found on the web. If true I would have thought there should be a much stronger emphasis on keeping our sugar levels below 5.6 at 2hrs and below 7.8 after 1hr.

NHS guidance I have received are to keep sugar levels at much higher levels. After reading these clinical trials I am now testing every 1hr after meals (previously only testing before meals) and eating much less carbs in order to get under the above figures........ I am LADA, so still have some working beta cells..... And want to keep my good cells for as long as possible.

1). Beta Cell Destruction Begins at 2-hr OGTT Test Readings Over 100 mg/dl (5.6 mmol/L)....Italian research by A Gastardelli....The beta cells are the cells in the pancreas that produce the insulin your body uses to control your blood sugar.
Analyzing their data further, they found that with every small increase in the 2-hour glucose tolerance test result, there was a corresponding increase in how much beta cell failure was detectable. The higher a person's blood sugar rose within "normal" range, the more beta cells were failing.

2). Prolonged Exposure to Blood Sugars Over 140 mg/dl (7.8 mmol/L) Kills Human Beta Cells....R. Paul Robertson, one of authors of this study wrote, "I think the glucose toxic effects begin when blood glucose gets above 140 (7.8) and probably earlier."

3). One Hour OGTT Result over 155 mg/dl(8.6 mmol/L) Correlates with Markers for Cardiovascular Disease.....it is essential to keep one hour blood sugar reading after meals under 140 mg/dl (7.8mmol/L)


4). Beta Cells Die Off in People Whose Fasting Blood Sugar is Over 110 mg/dl (6.1 mmol/L)....An intriguing study shows the severe organ damage experienced by people whose blood sugar falls into a range most doctors consider to be near-normal. A team of researchers autopsied the pancreases of deceased patients who were known to have had fasting blood sugars that tested between 110 mg/dl and 125 mg/dl within two years of their deaths. The researchers found that these patients, whose blood sugar was not high enough for them to be diagnosed as diabetic, had already lost, on average, 40% of their insulin-producing beta cells.

5). Keeping Blood Sugars Below 140 mg/dl at All Times Improves Survival of Seriously ill Patients

6). Nerve Damage Occurs when Blood Sugars Rise Over 140 mg/dl (7.8 mmol/L) After Meals...neurology clinic at the University of Utah

From what I could establish, these clinical trials are not new (4 to 10 years old). But new to me and quite a shock...... Especially when I started 1hr testing, which I found were often over 10 at 1hr, but down to 5.5 before next meal.

I have now stopped eating potatoes and pasta, only eating small quantities of rice (basmati, brown where possible) and only low GI bread (whole grain) one slice max per meal, two slices max per day..... Seems to be working so far.... Time will tel how long!!!!

Ian







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Hi Ian!

I agree and always try to keep my HbA1c low although I get constantly nagged by my consultant and DSN to keep it higher. I don't think you're on insulin yet are you? I seem to recall you're on Glic? If so, the lower you keep your levels the better really but you might need to watch for hypos and reduce the glic if necessary.

If you look at the tight levels recommended to pregnant women, you'll see just how high the recommendations to the rest of us really are!

Smidge
 
I think that a lot of your references refer to correlations between complications and the results of OGTT. People whose levels are reaching this on a glucose challenge have already a degree of insulin resistance or insulin deficit. This is not being caused by the OGTT spike itself but the result of whatever has gone on in the preceding years where overall glucose levels will have been higher than normal.
The post mortem study you refer to is quite salutary and I've referred to this in the past and indeed there is other evidence of beta cell destruction. In his 2009 Banting lecture De Fronzo says
In summary, our findings (40–42) demonstrate that, at the stage of IGT, individuals have lost over 80% of their beta cell function while the results of Butler et al suggest that subjects with 'pre diabetes' have lost approximately half of their cell volume.
http://diabetes.diabetesjournals.org/content/58/4/773.full.pdf+html
I now think that this pessimistic view may not be giving a full picture for. T2. The results of bariatric surgery, the Newcastle Trials (see Prof Taylor's twin Cycle paper) and magnetic imaging is beginning to show a different more hopeful picture ie that beta cell function once thought of as 'dead' and unrecoverable maybe not so dead. (indeed even some T1 research has shown regeneration of islet cells)

I think the jury is still very out on whether high spikes cause the damage by themselves or simply because they necessarily contribute to overall glycation and if you have them frequently you will have a higher A1c

In type 1 (unfortunately there is no really long term data for T2). It seems that it is the overall control that matters, higher HbA1cs and variability of control, meaning cycles of tight control followed by periods of more lax control definitely increase the risk of all sorts of complications. However , in the DCCt people whose HbA1c was made up of a spiky profile (based on capillary 2 hour readings) didn't have any worse outcomes than the people whose HbA1c was made up of a smoother one.
Unfortunately many people with T1 who have much lower HbA1c levels also have a loss of hypo glycaemic awareness and are at risk of serious and sometimes life threatening hypos.
Yet, we also know that many people who didn't have the ability to fine tune their levels ( preblood glucose meters, using perhaps one or two insulin doses a day) have been able to live to an old age with no complications; so perhaps there is something else going on. The average HbA1c over the years in the Joslin 50year medallist is in the mid 7s, and interestingly there is no difference in HbA1c between those who have or don't have complications.

There are papers that report CVD at quite low HbA1c levels but on the other side there are also those that show a U or J shaped curve with those with lower levels being more likely to die than those with slightly higher levels.
Many of these people may have beenquite sick and taking large amounts of medications (for diabetes and other conditions) , in these cases striving for very low post prandial (or any other time of day) levels may be counterproductive.

I think at the moment the best advice on glucose target is that contained in most recent sets of guidelines ie that targets should be individualised. It depends on age, other illnesses, type of medications, type of diabetes etc etc.
 
Why would the NHS want to recommend having levels higher than the average for someone who doesn't have diabetes; seems pretty illogical to me.

Indeed it does and it's all down to the belief by HCP's that if your HbA1c is normal and you use insulin then you MUST be having constant hypo's(well that's the attitude I've come up against with some HCP's) despite that being far from the truth in the well controlled-It's far easier for them to advise higher numbers as complications are easier to explain away as simply being inevitable as opposed to someone possibly dying of a serious hypo whilst under their care.
 
Hi smidge
You are right, I am not on insulin yet, indeed I am not on any medication at all.
I was on Gliclazide and Metformin, but my diabetes doc advised me to stop taking the glic when I was diagnosed T1 / LADA, and also said that whilst Metformin would do no harm, in his opinion it would do little good either.
Ian


Sent from the Diabetes Forum App
 
Why would the NHS want to recommend having levels higher than the average for someone who doesn't have diabetes; seems pretty illogical to me.

Sadly this is just a symptom of the ridiculous one size fits all approach to health guidelines in this country.

I should think that for many people with diabetes that would not be realistically achievable without very strict dietary control of the the that only a few of us have the willpower to manage. By setting a target which some people can't hit they risk those people just giving up all attempts at control, so rather than give a range of options based on the patients situation and ability they just go for the easily hittable targets.

Personally I try to keep my BGs under 5.5mmol before eating and 6.mmol 2 hours later and manage that most of the time. The target I was given was below 7.0 before and 10.0 2 hours after, far too high for me.


Sent from the Diabetes Forum App
 
Unfortunately many people with T1 who have much lower HbA1c levels also have a loss of hypo glycaemic awareness and are at risk of serious and sometimes life threatening hypos.

The fear of hypos is one of the key influences that pushes up HbA1c's in Type 1 and insulin using diabetics - I think many of us have had direct experience of that from our healthcare providers. I wonder though on what this is based; I'm not aware of any diabetic dying from a hypo; Phoenix do you have any information on that?

The DCCT clearly demonstrated the risk of complications dropped with every point reduction in HbA1c and yet the 'take away message' from it seems to be make sure you don't go too low. My view is that the problems occur because of the method of going low (i.e. lots of insulin) and not the HbA1c in and of itself.

Regards

Dillinger
 
Dillinger
For a long time many of the Dead in Bed cases (mostly young people) have been thought to be because of hypos but there hasn't been proof. Glucose levels obtained in a post mortem may not be reliable.
There have certainly been proven cases where people have had prolonged hypos and ended up in a coma from which they sometimes recover and occasionally don't. This often seems associated with alcohol and hypos (like the case on this forum)
Recently though there have been some cases where the person has been wearing a continuous monitor which gives information on glucose levels at the time of death.
This is the first reported case: It is documented on the CGM and in fact the levels of glucose in the vitreous humor (eye) were also low. Of course it doesn't prove this to be the cause of death but there were no other causes discovered.
http://www.ncbi.nlm.nih.gov/pubmed/19833577

Hypos can also trigger major CV events (strokes and heart attacks) in those susceptible. Sorry, I haven't time to look up references.
 
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I now think that this pessimistic view may not be giving a full picture for. T2. The results of bariatric surgery, the Newcastle Trials (see Prof Taylor's twin Cycle paper) and magnetic imaging is beginning to show a different more hopeful picture ie that beta cell function once thought of as 'dead' and unrecoverable maybe not so dead. (indeed even some T1 research has shown regeneration of islet cells)

I agree although I think the recovery will always be incomplete and very slow especially the older you are. I also think you need to "rest" your pancreas i.e. limit the requirement for insulin production while any repair process is progressing. Certainly T2's who at first diagnosis are TEMPORARILY (6 weeks) placed on an insulin regime seem to recover some function. I would guess they would pretty soon lose it again unless they take care to change the underlying reasons.

There are papers that report CVD at quite low HbA1c levels but on the other side there are also those that show a U or J shaped curve with those with lower levels being more likely to die than those with slightly higher levels.
Many of these people may have beenquite sick and taking large amounts of medications (for diabetes and other conditions) , in these cases striving for very low post prandial (or any other time of day) levels may be counterproductive.

Isn't that the discredited UKPDS study?. It was rejected by the Swedes in 2011 and latterly by the Americans in the latest ADA position statement. Didn't they find the real reason was that now banned diabetes medication Avandia was the real cause of the CVD and that once you accounted for that it showed that aiming for lower hBA1c was always the best thing to do. The latest NHS advice is anyone without a major health reason should aim for an HbA1c of less than 6.5%.

On the OPS post those 5.5 mmol after 2 hours and 7.8 mmol after 1 hour targets are my de-facto targets for precisely the reasons the post states. I don't think occasionally exceeding those targets will do a lot of harm but they are good targets for a newly diagnosed T2 who has gained control of BG's to aim for imo.
 
I think you mean the ACCORD study not the UKPDS.
There are other studies that also demonstrate some risk at lower levels for those who are older or sicker, including a recent British one http://www.plosone.org/article/info:doi/10.1371/journal.pone.0068008
The ADA 2014 Standards of Care take this variability into account.(and discuss all the various bits of evidence)
They suggest that a reasonable A1c goal for non pregnant adults is <7%
With a tighter level of <6.6% that could be the target for those with short duration of diabetes, long life expectancy, and no significant CVD
On the other hand, those who have other illnesses, very long standing diabetes, advanced age, history of CVD or severe hypoglycaemia they set the bar at < 8%
They use similar wording to describe those who should perhaps have lower or higher post prandial targets. Though the general level is still set at a peak of 180 mg/dL* (,10.0 mmol/L) which I believe is still higher than the 140mg/dl used (or used to be used, I haven't checked) by the American Endo society.
http://care.diabetesjournals.org/content/37/Supplement_1/S14.full.pdf html
 
Yes you are right ACCORD. It is interesting that the PLOS ONE article seems to restate the discredited ACCORD position. I really find it counter intuitive that aiming to have a low hBA1c i.e.. a non diabetic persons hBA1c increases risks. Surely if higher hBA1c's were better then people would have evolved to mostly have that higher range as that would be more successful in evolutionary terms.

The Hunt 2 study found a similar relationship with cholesterol in men i.e below about a total count of 5.5 and your risks begin to increase.

I suppose everyone should make their own judgement. In my case I'll continue to believe having an hBA1c at roughly the evolutionary average is best.
 
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As far as I know, you aren't sick with other things It might be a different matter if you are already suffering from serious co-morbidities. I don't think that natural selection has any relevance when we're talking about a population that has probably procreated and may only be alive because of modern medicine ( I mean the people that seem to be at risk with lower glucose levels)
Actually there was an hypothesis that higher glucose levels kept blood from freezing during the last ice age and hence people from Northern climes are more likely to have the gene for T1 (interesting but very speculative ;) ) http://www.nytimes.com/2005/05/17/health/17diab.html?pagewanted=all&_r=0
 
As far as I know, you aren't sick with other things It might be a different matter if you are already suffering from serious co-morbidities.

I think that's exactly right (already suffering from diabetic complications). It would be interesting to see the results split out by hBA1c versus various health markers. There is a table of results referenced somewhere in the forum posts (can you remember) that shows life expectancy in years based on your hBA1c, blood pressure, cholesterol and smoker status. It reckoned I added 22 years to my life expectancy by controlling my T2 early on if I remember!

Things like the Danish Steno study follow a similar vein. In that they took 160 uncontrolled aged 50 something T2 diabetics and put half on an intensive hBA1c reduction regime. The results were not that pretty for either half. The shocking statistic that stood out was in the 80 who were left uncontrolled half were dead by the end of the study some 13 years later i.e. half had died by their mid to late 60's. A significant portion of the survivors were blind or amputees or both. Those in the hBA1c intensive reduction group did better but not that great. It shows that you need to get control really early on as otherwise it can turn into a real battle if you let yourself run uncontrolled for years.
 
Yes you are right ACCORD. It is interesting that the PLOS ONE article seems to restate the discredited ACCORD position. I really find it counter intuitive that aiming to have a low hBA1c i.e.. a non diabetic persons hBA1c increases risks. Surely if higher hBA1c's were better then people would have evolved to mostly have that higher range as that would be more successful in evolutionary terms.

The Hunt 2 study found a similar relationship with cholesterol in men i.e below about a total count of 5.5 and your risks begin to increase.

I suppose everyone should make their own judgement. In my case I'll continue to believe having an hBA1c at roughly the evolutionary average is best.

The drugs are a big factor in mortality rates, I changed to low carb and got off gliclazide which was only treating the effects of the healthy balanced diet:***: I was given on diagnosis. I can't see the point in chasing ever increasing BG levels with more medications when a simple reduction in carbs can do the same job.

However, most patients on diabetes medication will also be offered dietary advice, making difficult any definite distinction about differential reduction in HbA1c levels between diet and medication in observational studies.

It is likely that mortality risks may differ for different drugs and drug combinations and several studies [34], [35] have linked sulphonylurea drugs with increased mortality and glitazone therapy with increased risk of cardiovascular events [36], [37]. These are important hypotheses that deserve to be evaluated as primary hypotheses of interest in purposely designed studies, rather than as secondary analyses in studies implemented for other purposes such as the present study.
http://www.plosone.org/article/info:doi/10.1371/journal.pone.0068008
 
The Gastardelli Study is an old paper, from 2004 and it needs to be placed in context.
Beta-cell dysfunction and glucose intolerance:results from the San Antonio metabolism (SAM) study

Most of this is to do with the understanding the onset of the intermediate stages of Impaired Glucose Tolerance and Impaired Fasting Glucose before overt Type 2 diabetes. This was in the days before HBA1c. One also should refer to the tables of ethnicity, sex, age, BMI waist measurement, fat mass, fat free mass, waist to hip ratio and family history of diabetes.

Also of interest is a study from 2006, Contributions of Beta-Cell Dysfunction and Insulin Resistance to the Pathogenesis of Impaired Glucose Tolerance and Impaired Fasting Glucose which suggests:

"Epidemiological studies demonstrate that the two categories describe distinct populations with only partial overlap, suggesting that different metabolic abnormalities characterize IGT and IFG. Insulin resistance and impaired beta-cell function, the primary defects observed in type 2 diabetes, both can be detected in subjects with IGT and IFG. However, clinical studies suggest that the site of insulin resistance varies between the two disorders."

The latter study highlights a shortfall which is often mentioned on this forum, ie, that diabetes is diagnosed on the basis of blood plasma glucose levels alone and little or no attempt is made to discover why. The above states that although the results of a fasting plasma test or an oral glucose tolerance test are both used to diagnose type 2 diabetes, the causes are different, something hardly ever investigated.

However, at that time, 2006, the HBA1c test was not recommended as a diagnostic test and this test was not sanctioned as a diagnostic marker until about 2011.

The Belfast Study, Dietary management of maturity-onset diabetes., in 1980 already showed, as Roy Taylor points out, "A clear distinction must be made between weight loss that improves glucose control but leaves blood glucose levels abnormal and weight loss of sufficient degree to normalize pancreatic function. The Belfast diet study provides an example of moderate weight loss leading to reasonably controlled, yet persistent diabetes. This study showed that a mean weight loss of 11 kg decreased fasting blood glucose levels from 10.4 to 7.0 mmol/L but that this abnormal level presaged the all-too-familiar deterioration of control."

This has been known for over 30 years. In fact, anythng above 6.0 in a test is considered pre diabetes. It is a complete puzzle to me that the NHS pat type 2 diabetics on the back for achieving this level, a level that they know will presage a loss of control and a deterioraition of condition. It is a self fullfilling prophecy, 'we told you it was inevitable'.
 
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