If your blood sugar is normal, why are you still at increased risk of complications?

[Vectian]

I saw my consultant for the first time last week (6 months in). He said that if you have diabetes you are at higher risk of complications regardless of how well controlled it is. I am investigating to what extent that is true. All my metrics are well within the non-diabetic range, according to the QRisk calculator they use (you can check yourself with the same calculator here: https://www.qrisk.org/ ) if I was not diabetic my risk of heart attack/stroke is 3.5%. If I change that to Type 1, it becomes 11%.

I looked into this, yes diabetics have a considerably higher risk of heart disease, but when you look at why it's not so black and white. "High blood glucose from diabetes can damage your blood vessels and the nerves that control your heart and blood vessels. Over time, this damage can lead to heart disease". Same reason as neuropathy and retinopathy etc. But what if your blood sugar is not raised at all? My A1C is 36, he wants me to take statins because my cholesterol does not match the much lower diabetic targets, even though it's only a fraction (0.15) above the normal ranges. Those targets are based on mostly people in quite a different situation to me I would think, this seems like applying arbitrary targets to cover themselves and not taking individual cases into account.

I asked him if the greater risk of complications is because of the higher blood sugar causing problems, or it's greater purely because of having diabetes. He said just because of diabetes, but when I asked why he wasn't able to answer that. Does anyone know of any research or evidence one way or another?

 

[Antje77]

It's only since the common use of CGMs that diabetics can know what happens between fingerprick tests, and in the not so distant past diabetics had to rely on pee tests, which are nowhere near as accurate.

Diabetic complications develop over decades.
There is simply no data over decades because the means of measuring didn't exist.

To know the answer to your question, you'd need a large group of diabetics with an hba1c under 42 and a time in range in the high 90's with a tight range, and see how they've fared after 40 years.

Even with modern technology, those diabetics are hard to find, and you'll have to wait some 30 more years to be completely sure.

 

[ianf0ster]

@Vectian Considering that probably still over half of medical professionals still believe that even Type 2 Diabetes is progressive and irreversible, it's not surprising that they apply that increased risk to all diabetics.

It seems there is some doubt about your type of diabetes, since you appear to no longer be taking insulin (for some time). But even if you were just an ordinary Type 2 in remission there would still be no definitive evidence as to whether your risk of neuropathy, retinopathy, CVD, heart and stroke risk would still (in actuality) be higher than a non-diabetic or not.

There is still a great deal of debate and controversy about CVD, Cholesterol, insulin and whether statins are good and if so under which circumstances.

Have you read the Cholesterol and Statins thread started by user Bulkbiker ? (Yes, I realise that he was banned some while ago, but that doesn't reflect on the information in that thread and his many other posts which haven't been removed).

 

[Vectian]

It's only since the common use of CGMs that diabetics can know what happens between fingerprick tests, and in the not so distant past diabetics had to rely on pee tests, which are nowhere near as accurate.

Diabetic complications develop over decades.
There is simply no data over decades because the means of measuring didn't exist.

To know the answer to your question, you'd need a large group of diabetics with an hba1c under 42 and a time in range in the high 90's with a tight range, and see how they've fared after 40 years.

Even with modern technology, those diabetics are hard to find, and you'll have to wait some 30 more years to be completely sure.

Even without CGM data they could tell by what happens to diabetics with a consistently lower A1C? The other complicating factor is how can you separate out all the other factors that often go along with diabetes? For example someone with T2 may be more likely to be overweight, have a poor diet, high blood pressure, not get enough exercise etc. How much of the increased risk is due to all that? And for a T1, someone who has had it since childhood and consistently above normal ranges for many years is very different from someone with LADA for a short time.

By the way, I see you have LADA which is what they think I have. How long was your honeymoon period and were you taking insulin at that time?

 

[Vectian]

@Vectian Considering that probably still over half of medical professionals still believe that even Type 2 Diabetes is progressive and irreversible, it's not surprising that they apply that increased risk to all diabetics.

It seems there is some doubt about your type of diabetes, since you appear to no longer be taking insulin (for some time). But even if you were just an ordinary Type 2 in remission there would still be no definitive evidence as to whether your risk of neuropathy, retinopathy, CVD, heart and stroke risk would still (in actuality) be higher than a non-diabetic or not.

There is still a great deal of debate and controversy about CVD, Cholesterol, insulin and whether statins are good and if so under which circumstances.

Have you read the Cholesterol and Statins thread started by user Bulkbiker ? (Yes, I realise that he was banned some while ago, but that doesn't reflect on the information in that thread and his many other posts which haven't been removed).

I haven't read the thread, I will try to find it. They think I have LADA because I have GAD antibodies, although my C peptide was also completely normal which contradicts that and he was not able to explain that. Anyway it doesn't make much difference to how I am managing it. I had insulin for 1 month (bolus only) then stopped as it was making me ill. 5 months later with no medications, just low GI diet and exercise and 100% in range, so a bit odd (but not complaining!).

The cholesterol targets they use for diabetics are pretty much impossible to achieve without drugs even for a "normal" person - who has an HDL of 2? You can see what difference it makes on the QRisk calculator if you change things - if I change my cholesterol to in normal ranges (i.e. if I took statins) with everything else the same, it lowers my risk by 1% - hardly worth it.

 

[ianf0ster]

Just for information: At my last blood lipids test, my HDL was nearly 2.0, my triglycerides were nearly 1.0 but my LDL is high (not quite enough to qualify me as a hyper-responder).

Taking statins or not is a very personal decision. I tried them twice: first time muscle pains and very painful skin rash; second time memory problems and general 'brain fog'. I have never had a heart attack, but needed a 3x cardio bypass.

 

[Antje77]

Even without CGM data they could tell by what happens to diabetics with a consistently lower A1C?

Not if they're on insulin or some other medications.
If you run too low often and long enough you can skew the average enough to get a normal hba1c even when you're also having high spikes or lower but prolonged highs.

By the way, I see you have LADA which is what they think I have. How long was your honeymoon period and were you taking insulin at that time?

I was diagnosed with T2 eight years ago, and in hindsight had had symptoms for two years before diagnosis.
I started testing a lot right after diagnosis, and it very quickly became clear that tablets and lowering carbs didn't do the job so I started insulin (basal) after a month.
A month after that I begged for a bolus insulin, my numbers were steady now until I ate something, very frustrating.

Rediagnosis after referral only happened two years later but it didn't change my treatment, things already worked well for me.

As for my honeymoon period, I've never had one where I didn't need insulin, but my insulin needs steadily increased for the first 4 or 5 years until stabilising, which I suppose was the end of significant insulin production of my own, though I have no way of knowing.

Over the past year my needs have decreased a bit, but I've also lost some weight and exercised more, which is the likely cause of that.