More questions

[cornylady]

A follow up to my earlier post. I have seen the diabetic nurse and tbh although she was very nice the whole appointment was less than helpful. The nurse never even discussed testing/levels/ etc or really made any helpful/useful suggestions. No advice on what to do just signposting me to other services for "education", eye checks etc. After a couple of weeks of trying to get my head around things myself and lots of reading, I decided that to understand what was happening I would invest in a Freestyle Libre2 as a short term measure with a view to then reverting to finger pricking when I was more confident about what I can eat. I have now had a CGM since Sunday eve so this is my 4th full day. I have reduced my carb intake (since learning my diagnosis) and currently varying between 70g and 130g per day as I'm figuring out what I can eat. So my questions currently are:

-If my levels spike after eating but are back within the 2/3 increase 2 hours after eating is this OK or a problem? (I wouldn't know about the higher reading if I didn't have a CGM?)

-Do you measure 2 hours after starting eating or finishing eating - sometimes I'm quite slow
I have noticed that some days (not every day)

-I have a spike in the morning as I wake up. I understand why this happens but then why not every day? Does it matter? What can I do to improve it (if anything).

-Is time in range a good indicator?

-Is the range correct? I didn't change the settings and used the default which was 3.9-10.0.

-What if you consume things slowly? Does that make a difference? Does it just avoid a spike but put you generally up?

-Nurse basically said that even if my numbers are looking good that could be because I am overproducing insulin to make it look like that so I will still wear out my pancreas early and therefore recommends that I start on medication as that increases your sensitivity to insulin. I didn't as I wanted to try the diet approach first but don't understand how if this is the case, that type 2's are not automatically put on meds straight away.

-Nurse also said she would see me in 6 months and would do a full check (feet etc) then. That is also when they will do the next Hb1Ac. I queried this but she said they don’t do it before because I haven’t had enough time to make changes. Is this normal?

Sorry, I know there are lots. Feel like I'm falling down a rabbit hole of numbers although I am a tech person so that’s how I work. However also all the counting/working out is a bit triggering for me but I don't see how I can work out what works for me without this as I am asymptomatic and don't feel any different. Also trying to lose weight which is also an issue for me.

Any help/guidance/answers/advice would be very appreciated.

 

[LivingLightly]

Evening @cornylady.

At this stage, you’ll learn most from blood glucose levels just before you start a meal and then two hours later. (That's two hours after your first bite, not two hours after finishing your meal).

The post-meal reading should be no more than 2 mmol/l higher than the first and not higher than 8 mmol/l. If that's the case, your body dealt with the arrival of glucose in your bloodstream and cleared it relatively quickly.

If you can achieve that consistently (by reducing your carbohydate intake where necessary), your blood glucose readings when you wake up in the morning should gradually improve, but those numbers are often the last to stabilise.

I'm afraid eating more slowly will not affect BG numbers. The carbohydrates you swallow will still end up as glucose in your bloodstream.

A review and HbA1c check after six months is normal. By then, you'll be able to assess the effects of the changes you've made.

Hope this answers some of your questions.

 

[Keith Saunders]

Well I came here to hopefully help and answer but it looks like @LivingLightly has answered pretty much everything in the same way I would of done. I'll go back to sleep now

 

[Outlier]

I try to eat slowly not because I have no option but because I therefore eat less and find what I do eat more satisfying. A bit like "eating mindfully". Though you have no choice but to eat slowly, you can harness it as a helper to get maximum enjoyment out of your new eating regime. That really helps in sticking to it rather than wishing you could eat other things which are not good for T2 diabetics.

 

[AndBreathe]

A follow up to my earlier post. I have seen the diabetic nurse and tbh although she was very nice the whole appointment was less than helpful. The nurse never even discussed testing/levels/ etc or really made any helpful/useful suggestions. No advice on what to do just signposting me to other services for "education", eye checks etc. After a couple of weeks of trying to get my head around things myself and lots of reading, I decided that to understand what was happening I would invest in a Freestyle Libre2 as a short term measure with a view to then reverting to finger pricking when I was more confident about what I can eat. I have now had a CGM since Sunday eve so this is my 4th full day. I have reduced my carb intake (since learning my diagnosis) and currently varying between 70g and 130g per day as I'm figuring out what I can eat. So my questions currently are:

-If my levels spike after eating but are back within the 2/3 increase 2 hours after eating is this OK or a problem? (I wouldn't know about the higher reading if I didn't have a CGM?)

-Do you measure 2 hours after starting eating or finishing eating - sometimes I'm quite slow
I have noticed that some days (not every day)

-I have a spike in the morning as I wake up. I understand why this happens but then why not every day? Does it matter? What can I do to improve it (if anything).

-Is time in range a good indicator?

-Is the range correct? I didn't change the settings and used the default which was 3.9-10.0.

-What if you consume things slowly? Does that make a difference? Does it just avoid a spike but put you generally up?

-Nurse basically said that even if my numbers are looking good that could be because I am overproducing insulin to make it look like that so I will still wear out my pancreas early and therefore recommends that I start on medication as that increases your sensitivity to insulin. I didn't as I wanted to try the diet approach first but don't understand how if this is the case, that type 2's are not automatically put on meds straight away.

-Nurse also said she would see me in 6 months and would do a full check (feet etc) then. That is also when they will do the next Hb1Ac. I queried this but she said they don’t do it before because I haven’t had enough time to make changes. Is this normal?

Sorry, I know there are lots. Feel like I'm falling down a rabbit hole of numbers although I am a tech person so that’s how I work. However also all the counting/working out is a bit triggering for me but I don't see how I can work out what works for me without this as I am asymptomatic and don't feel any different. Also trying to lose weight which is also an issue for me.

Any help/guidance/answers/advice would be very appreciated.

I’ll just cover a couple of things.

Time in range is a decent indicator of how things are going, without focusing on any blips. I would suggest an ideal range would be a bit lower at the top end; say 8. It can always be adjusted later.

in terms of wearing your pancreas out, I remain skeptical on that, if you can achieve decent control. No guarantees of course, but uncontrolled numbers do give the old pancreas a bit of a kicking, so bringing them down to a decent range eases that anyway. How much insulin resistance you continue to have remains to be seen, but I can’t imagine your nurses offer of meds is a one time offer.

In terms of monitoring, NICE Guidelines state 3-6 months until numbers stabilise. It used to be a flat 3 months, but has changed.

Recommendations | Type 2 diabetes in adults: management | Guidance | NICE

www.nice.org.uk

Personally, I’d ask for a test nearer the (3 months) time. If you have bloods done for other conditions, like thyroid, or whatever, it can be easy to just add an HbA1c. I have never been declined a test, provided I have a fair reason.

 

[KennyA]

-If my levels spike after eating but are back within the 2/3 increase 2 hours after eating is this OK or a problem? (I wouldn't know about the higher reading if I didn't have a CGM?)

-Is time in range a good indicator?

-Is the range correct? I didn't change the settings and used the default which was 3.9-10.0.

-Nurse basically said that even if my numbers are looking good that could be because I am overproducing insulin to make it look like that so I will still wear out my pancreas early and therefore recommends that I start on medication as that increases your sensitivity to insulin. I didn't as I wanted to try the diet approach first but don't understand how if this is the case, that type 2's are not automatically put on meds straight away.

I have a particular bee in my bonnet about calling a perfectly normal BG rise after eating carbs a "spike". If you eat carbs, diabetic or non-diabetic, you will see a BG rise. The T2's rise might be a bit higher and last a bit longer. As you'll have noticed already, you hit the highest BG post-meal level somewhere in the first hour. For me it depends what I ate and what with. The lactose from hot milk will be in my blood in under 30 minutes, for example.

The Libre comes with a range set. The "time in range " is of more use to people who are adjusting their insulin to match carb intake, and it gives (so I understand) an estimate of how successful the adjustment has been. Us diet-controlled T2s don't do that, and the range is whatever you set it to be - so you would need to know what your "normal" daily pattern was intended to be, and then use the range to work out how successful you were.

As above, a rise after eating carb is normal. I don't want it to be too high or go on too long - which is a sign that it's too much for my system to cope with. Personally, I'd rather have a higher rise that was over in minutes rather than a lower rise that lasted hours, but that's me.

I have to say that I'm not sure what your nurse is on about. Your body produces insulin in response to glucose triggers. In non-diabetic people, the insulin produced matches the body's requirement and deals with the glucose. For T2s, generally, we have insulin resistance/ impaired glucose tolerance (essentially the same thing) and our systems often over-produce insulin to deal with the equivalent glucose load. Prolonged high levels of insulin are generally thought not a good thing and seem to contribute considerably to IR/IGT progressing.

So - the key here is to reduce the glucose load, to consequently reduce the need for insulin production. You can do this eg by not eating glucose/carbohydrate, or by taking metformin, which lowers blood glucose by inhibiting your liver from topping up your BG with its own self-made glucose. But unless they're going to run an C-peptide test on you to establish how much insulin you actually are producing - your current level of insulin is just speculation.

 

[coby]

I have a particular bee in my bonnet about calling a perfectly normal BG rise after eating carbs a "spike". If you eat carbs, diabetic or non-diabetic, you will see a BG rise. The T2's rise might be a bit higher and last a bit longer. As you'll have noticed already, you hit the highest BG post-meal level somewhere in the first hour. For me it depends what I ate and what with. The lactose from hot milk will be in my blood in under 30 minutes, for example.

The Libre comes with a range set. The "time in range " is of more use to people who are adjusting their insulin to match carb intake, and it gives (so I understand) an estimate of how successful the adjustment has been. Us diet-controlled T2s don't do that, and the range is whatever you set it to be - so you would need to know what your "normal" daily pattern was intended to be, and then use the range to work out how successful you were.

As above, a rise after eating carb is normal. I don't want it to be too high or go on too long - which is a sign that it's too much for my system to cope with. Personally, I'd rather have a higher rise that was over in minutes rather than a lower rise that lasted hours, but that's me.

I have to say that I'm not sure what your nurse is on about. Your body produces insulin in response to glucose triggers. In non-diabetic people, the insulin produced matches the body's requirement and deals with the glucose. For T2s, generally, we have insulin resistance/ impaired glucose tolerance (essentially the same thing) and our systems often over-produce insulin to deal with the equivalent glucose load. Prolonged high levels of insulin are generally thought not a good thing and seem to contribute considerably to IR/IGT progressing.

So - the key here is to reduce the glucose load, to consequently reduce the need for insulin production. You can do this eg by not eating glucose/carbohydrate, or by taking metformin, which lowers blood glucose by inhibiting your liver from topping up your BG with its own self-made glucose. But unless they're going to run an C-peptide test on you to establish how much insulin you actually are producing - your current level of insulin is just speculation.

 

[coby]

That's a great, and very informative answer @KennyA x

 

[Bogart99]

I had exactly same thoughts as you cornlady. Nurse at surgery nice but not very detailed in what figures of BG one should be aiming for .I too am trialling the Libre2 and my only concern is the In range setting. Mine is in mmol/L
and I have no problem with the low setting 3.9 but think, my opinion only, the seemingly approved top figure of 10
seems to me rather high. The figure of 10mmol/L equates to an HbA1c of around 62. Well if that states I am in range
at 10 not good if that as constant at all times. So I am going to do some maths to come up with a lower in range setup so it averages out at under say HbA1c of less than 40. Needs a few more days figures to do the maths.

 

[TheSecretCarbAddict]

Some of the standard ranges have been set around points at which you are more likely to develop different types of complications. 10 mmol/l is around when excess blood glucose starts to spill into urine. Below 4 mmol/l is where you are heading towards hypo, but you can still self-correct. I'm sure @KennyA once posted different hypo thresholds, and you become incapacitated around 2.5 or 2 mmol/l.

There is also a concept of tight range - 3.9 mmol/l to 7.8 mmol/l, which is thought to reduce diabetes related risk factors further.

I'd say diabetes management is effectively tradeoff between how tightly you can manage your blood glucose with or without medication and risks related to elevated blood glucose levels (underlying insulin resistance in T2 or balancing supply of extraneous insulin in T1)

 

[KennyA]

Some of the standard ranges have been set around points at which you are more likely to develop different types of complications. 10 mmol/l is around when excess blood glucose starts to spill into urine. Below 4 mmol/l is where you are heading towards hypo, but you can still self-correct. I'm sure @KennyA once posted different hypo thresholds, and you become incapacitated around 2.5 or 2 mmol/l.

There is also a concept of tight range - 3.9 mmol/l to 7.8 mmol/l, which is thought to reduce diabetes related risk factors further.

I'd say diabetes management is effectively tradeoff between how tightly you can manage your blood glucose with or without medication and risks related to elevated blood glucose levels (underlying insulin resistance in T2 or balancing supply of extraneous insulin in T1)

I'm not sure I remember posting anything about that - I'll have a check and see.

 

[Art Of Flowers]

I had exactly same thoughts as you cornlady. Nurse at surgery nice but not very detailed in what figures of BG one should be aiming for .I too am trialling the Libre2 and my only concern is the In range setting. Mine is in mmol/L
and I have no problem with the low setting 3.9 but think, my opinion only, the seemingly approved top figure of 10
seems to me rather high. The figure of 10mmol/L equates to an HbA1c of around 62. Well if that states I am in range
at 10 not good if that as constant at all times. So I am going to do some maths to come up with a lower in range setup so it averages out at under say HbA1c of less than 40. Needs a few more days figures to do the maths.

I have a Dexcom One+, which is their latest CGM. It too has a fixed target range of 3.9 to 10. This seems to be an industry standard. You can set high and low alarms at different levels. The GMI figure on reports is an estimate of the HBA1C. The other stats are average glucose, Time In Range (3.9-10) and Glucose Level Variability. I did a post earlier today on understanding CGM reports … https://www.diabetes.co.uk/forum/threads/understanding-cgm-reports.204728/

 

[cornylady]

I had exactly same thoughts as you cornlady. Nurse at surgery nice but not very detailed in what figures of BG one should be aiming for .I too am trialling the Libre2 and my only concern is the In range setting. Mine is in mmol/L
and I have no problem with the low setting 3.9 but think, my opinion only, the seemingly approved top figure of 10
seems to me rather high. The figure of 10mmol/L equates to an HbA1c of around 62. Well if that states I am in range
at 10 not good if that as constant at all times. So I am going to do some maths to come up with a lower in range setup so it averages out at under say HbA1c of less than 40. Needs a few more days figures to do the maths.

I set mine manually to 3.9 to 8.5. I had read somewhere about keeping below 8.5 but I can't remember where now and that seemed more reasonable as I also thought 10 seemed too high. I initially found I checked my levels religiously but now I find I feel more relaxed but appreciate the overview so I can see what is happening. I had to take a short course of steroids recently and it was eye opening to see how it messed with my BG but having the monitor allowed me to feel still in control. I definitely find it useful. It has enabled me to bring HbA1c from 55 to 41 in the first 3 months of diagnosis and I am continuing as aiming for mid 30's. Good luck!

 

[TheSecretCarbAddict]

Here is an older thread with some interesting discussion points and references around target ranges:

Time in Range references

Looking up the NICE / NHS and FDA guidance on TIR we find 3.9-10 mmol/L is recommended for diabetics, with a comment that

www.diabetes.co.uk

@KennyA - This is the one that features a graphic you posted on different stages of hypos.

 

[ianf0ster]

Type 2's using CGMs should realise that they are historically and primarily optimised for Type 1's.
Thus they warn of hypos at low levels and allow a cushion for insulin does to work from higher levels. An additional complication is that almost any meal contains some carbs and thus (in the very short term will raise blood glucose) even in a non-diabetic!
So we Type2's tend to ignore the first 2hrs after 1st bite of a meal.

 

[KennyA]

Here is an older thread with some interesting discussion points and references around target ranges:

Time in Range references

Looking up the NICE / NHS and FDA guidance on TIR we find 3.9-10 mmol/L is recommended for diabetics, with a comment that

www.diabetes.co.uk

@KennyA - This is the one that features a graphic you posted on different stages of hypos.

I remember now - I think it was the "thresholds" bit that threw me.

 

[Melgar]

I use a Libre 2. I’m a big fan of cgms, particularly the Time in Range (TIR) feature. I find it more revealing and helpful than the clunky Ac1 test. My blood sugars will not budge no matter what I do and they are unstable which makes managing my diabetes very difficult. My fasting blood sugars are all over the place, they can be 8 mmol/s one morning and 4 the next. I had my CGM set at 4.5 - 10.3 up until recently. I have now tightened my upper limit and brought it down to 7.5. The lower limit is set at 4.5 to give myself time to correct falling blood sugars. I would rather my blood sugars run a little high than low. The low events have significantly decreased since upping my carbs. It now means I am 30% out of range, mostly above my set range. My brother had to up his as he was running 80% out of range. I find it the best tool to shave off high spots.

 

[Bogart99]

Would agree that it needs setting to individual requirements. I am only on day 6 so still getting used to it. I also find the average glucose helpful
that is more like a HbA1c ib a way but a bit more select. I am running at 6 currently. The average varies between 5.5 mornings until a jump to around 6.8 between 12.00 and 15.00 and similar between 21.00 and midnight hence the overall average of 6.
What I do find strange is that I can eat at say 19.00 and get maybe a reading of 7 after 2 hours but at mignight it might be 8 even then drops but at 2am is back at over 8 albeit for a very short time, why these seemingly random numbers. And one morning in bed for hours at around 03.00
was about 3.3 lowest I have registeredIt bounced around between 3.3 and 4.5 until say 08.30.

 

[_Steve_]

I've been using a Libre2 for 3 months since I was diagnosed, I find it very helpful every single day. Things like exercise, hot showers, heat etc. brings my glucose down and see the effects of what food I eat and what it does to me.

My experience is you'll want to set your own goals, first month I was never in range (> 14mmol) and had constant alarms so had to turn the alarms off. Now I know what I'm doing, my current range is 3.5 - 9 and I'm 96% in range according to the CGM.

If you're into stats and want more in-depth look at your numbers, check out https://www.libreview.com/ if you haven't already. The glucose report is invaluable.

With the late eating at night, I found eating as early as possible and still feeling full is the best. If you're able to not snack after say 7pm I've found my FBG and overnight levels keep low, and usually wake up in the 4-5 range. Estimated A1C, GMI (from LibreView) and Time in Range I look at the most.

 

[Bogart99]

Still getting used to this Libre2 gizmo. Find some of the readings interesting for want of a better word. It is helpful insomuch as it gives a 24 hr reading minute by minute. I am not sure why on a daily graph it shows for instance going from 5 at midnight to over 11 at 4am when I had not eaten anything
later than 9pm the previous evening. Then by 5.30am down to 6 but back up to 9 at 6.30am. There seems to be lots of ups and downs with no attributable reasons. I have been trying out various foodstuffs to see if any give a noticeable rise. I know that both pasta and chocolate are frowned upon but in my case both seem to have a very limited effect in raising bg value. A pint , or two, of beer does have an effect but soon subsides. It is giving me an estimated A1c of 34mmol/mol which is way lower than my surgery gave me. Though in their defence the Libre2 figure is only over some 10 days and not 3 months.