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Spiking and neuropathy/complications

My D consultant always puts a lot more emphasis on the spikes and the best way of reducing them rather than the HbA1c -as long as that is 7% or under.
 
Thanks for this post because Upton now I've being telling myself small spikes over the recommend rise were fine (only diagnosed the end of November 2014) that looks like that thought is out of the window.
There is so much more to being a diabetic than the idea of "just avoiding sugar" that most undiabetic people think.
My brain aches
Thanks again for bringing this subject to the light
Jan
 
Well my Ophthalmologist said when I developed diabetic retinopathy that diabetics should try to avoid high fluctuations in bg levels and keep them as stable as possible to avoid complications and to stop them getting worse, they said that an Hba1 of 7% or below is an ideal target to aim for.

Undoubtedly uncontrolled diabetes will inevitably lead to complications in long-term diabetics, but genetics also play a role as to who goes on to develop complications. There was a study a few years ago by the Joslin Institute where they looked at all the type 1 diabetics who had received their 50 year medals and were free from complications or had very few, it was found that some were still producing small amounts of insulin and it was thought that genetics played a huge part , what was surprising from the study was the fact that the average Hba1c of the group was 7.2%, I'll tag @phoenix as she very knowledgeable about the study and this subject in general.
 
There is very little evidence that intra day variation does matter in type 1. (except in the case of hypoglycaemia as a complication).Type 2 may be different .(more evidence)
Using the data available from EDIC and DCCT there were three things that made a difference.
Average glucose levels ( risk for CVD)
HbA1c (as a risk for microvascular complications)
variation between HbA1c (ie periods of overall higher and lower glucose levels)
(see Kilpatrick, various papers).
This variation between HbA1cs has also been demonstrated as having an association with retinopathy in a large German trial http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0091137#pone-0091137-g001

However, since there were no CGMs at the time of these studies, the daily blood glucose profiles came from 7 fingersticks carried out at 3 monthly intervals .
It has become a matter of debate between those who say it must have an effect (and can point to mechanisms such as increased oxidative stress which could be causative) and those who point to the lack of any evidence.

These two review papers (2013) describe the evidence base
Glucose variability; does it matter?
http://press.endocrine.org/doi/full/10.1210/er.2009-0021
Glycemic Variability ,both sides of the story
http://care.diabetesjournals.org/content/36/Supplement_2/S272.full

There was also another review in Sept 2014 (so fairly up to date) http://www.diabetesresearchclinicalpractice.com/article/S0168-8227(14)00275-7/abstract
Eighteen studies reported the association between glucose variability and diabetes-related complications exclusively in type 2 diabetes. A positive association between increased variability and microvascular complications and coronary artery disease was consistently reported. Associations between glucose variability and other macrovascular complications were inconsistent in type 2 diabetes.

Seven studies examined the association between glucose variability and complications exclusively in type 1 diabetes. Increased glucose variability appears to play a minimal role in the development of micro- and macrovascular complications in type 1 diabetes.

Consistent findings suggest that in type 2 diabetes glucose variability is associated with development of microvascular complications. The role of increased glucose variability in terms of microvascular and macrovascular complications in type 1 diabetes is less clear; more data in are needed.
Click to expand...


I found two recent papers using CGM. This will give better data on day to day glucose excursions but expense means short trials and small numbers of subjects (doubt if there will ever be another long term trial like the DCCT/EDIC with CGM).
1) looked at a very small sample of T1s with and without microvascular complications. They used a CGM for 2 weeks. This did find that those with complications had a higher degree of variability in terms of SD and MAGE though HbA1cs were comparable. They concluded 'This supports the hypothesis that increased GV might be associated with MVC in type 1 diabetes and that HbA1c may not describe diabetes control completely.'
( standard deviations (4.1±0.6 vs. 3.4±0.8 mmol/L; ) .)
http://online.liebertpub.com/doi/abs/10.1089/dia.2013.0205

2) A similar shorter trial with T2s some with, some without, micro albuninuria also found a significant association with SD and Mage but this was lost when further statistical analysis took place and so they concluded 'At least in terms of relative measures of glycaemic variability, we failed to demonstrate an independent association between glycaemic variability and albuminuria extent in patients with inadequately controlled Type 2 diabetes' http://onlinelibrary.wiley.com/doi/...ionid=4F735EF9D41894B64CF9E6397EE80AE0.f01t03

These types of trials don't show the degree of variation before the development of complications so won't , in any case really settle the debate.


I do think that people who consistently have a relatively low HbA1c are really unlikely to be having very large glucose variations because they tend to be proactive. They are probably far less likely to be on the glucose roller coaster : very high levels, overcorrections followed by very low levels and then over correcting and high levels again. What some people call a spike, is no different to the rise that occurs in non diabetics.
 
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LucySW said:
I don't think we should get paranoid over what we can't control tho. Or we'll just be depressed. We decide what we're aiming for, right?
Click to expand...
wow this is the thread of threads, real eye opener but its made me feel sick to my stomach, i thought my control was getting better and i was on track, this has just raised the bar even more. it looks like a test every hour and bolus accordingly to keep bg within range the only option is a cgm with an alarm or really sore fingers. I'm seeing my diabetes team next week im hoping for something from them perhaps a cgm or a pump. Panicking right now. will be better in a bit after the 'valium' (Joke).
 
@Spencer67, to put this entire thread in context, I and many others on here have been diabetic for 25+ years with minimal complications. I have background retinopathy. That's it. Others have less than me. Up until last year, all I had was MDI and finger pricks. Others are in similar positions starting in the early 70s with no blood testing.

You don't need more than that to maintain control. The bar hasn't changed. It's as much about what you eat as about what you inject and monitor.
 
We know there are some people who run higher HbA1cs and never get complications. We know there are others that run excellent HbA1cs and get horrible complications. Therefore, there are definitely other factors at play. I strongly suspect variation is a big factor and the fact there is little evidence is simply because there has been little interest in looking for any. As Phoenix says, there hasn't been a long study of Type 1s using CGM - and there is unlikely to be. If you really want evidence, that's what you need to so. Using a series of BG tests in a study of this type is pointless and misleading. I record my SD as I feel it is an important measure of control (along with average and percent of time in target) - with the continuous Libre data over a 2 week period, my SD was 2.0 - the same period on 7 BG tests a day it was 2.6 - the volume of data from the Libra is really important to the validity of SD.

The subject of variation and complications has always worried me because although I get great HbA1cs, the variation within that is much worse than I would like.

Smidge
 
tim2000s said:
Whilst I have nothing to refute the analysis, the hypothesis this raises for me is that non-diabetics seeing post prandial spikes of >8 should also see nerve damage. Yet there seems little evidence of this, which suggests it is more complex than just spikes.
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Some of those studies Jenny quoted are reporting damage in people who don't meet the diagnostic criteria for diabetes. (I think - I skim-read the page)
 
phoenix said:
Glucose variability; does it matter?
http://press.endocrine.org/doi/full/10.1210/er.2009-0021
Click to expand...
This is worth quoting:

B. Available options to target glucose variability
As for outpatients with type 1 or type 2 diabetes, long-acting insulin analogs seem to improve glucose stability; treatment with long-acting analogs has been shown to diminish hypoglycemia and glucose variability (74, 75, 76). Prandial insulins, and even more short-acting analogs, diminish postprandial hyperglycemia and consequently glucose variability specifically in type 2 diabetes patients (77, 78). In comparison to the long-acting analog insulin glargine, the glucagon-like peptide-1 receptor agonist exenatide reduced glucose variability with a similar reduction in HbA1c (79). Furthermore, compared with multiple daily insulin injections, the use of continuous sc insulin infusion [pumps] is in type 1 diabetes associated with a decrease in glucose variability (60, 80, 81). Whether diminishing glycemic variability in these patient groups translates into improved outcome is unknown, although it has been shown that patients with the largest glucose variability benefit the most from switching from multiple daily insulin to continuous sc insulin infusion [pumps], achieving significant lower HbA1c values (72).
 
tim2000s said:
Or in short @Spiker, getting a pump is good.
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Well it kind of says everything is good. Long acting basal analogs are good, short acting analogs are good, shorter acting analogs are better, pumps are good. It's all good.
 
Spiker said:
Some of those studies Jenny quoted are reporting damage in people who don't meet the diagnostic criteria for diabetes. (I think - I skim-read the page)
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She questions the cut-off for diabetes diagnoses. Rightly so IMO as the cut-off is very high and BG-related damage is done at much lower levels. I think she is a star.
 
tim2000s said:
@Spencer67, to put this entire thread in context, I and many others on here have been diabetic for 25+ years with minimal complications. I have background retinopathy. That's it. Others have less than me. Up until last year, all I had was MDI and finger pricks. Others are in similar positions starting in the early 70s with no blood testing.

You don't need more than that to maintain control. The bar hasn't changed. It's as much about what you eat as about what you inject and monitor.
Click to expand...
Yes, Spencer, Tim is right. With Libres, CGMs etc, we know more now so much tighter monitoring is possible now. But try it, it's diff to keep up very tight monitoring all the time - you get tired and bored. If you do keep it up all the time, it'll rule out certain kinds of life for you. You may not want that - or not all the time. I think the point is a) that now we can know much, much more than doctors used to tell us (or than many know); and b) that this knowledge gives us the chance to choose what and how we're going to do. That choice is ours. That's truly liberating, isn't it?

People like Tim and Spiker and Yingtong have been doing what they could, well, for all these years without the fancy schmancy stuff, and they're okay.

So we can get into all this stuff, try it out, learn the standard deviation techniques, know what we're doing, then decide where we're going to aim.

No?
 
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But - just to go and spoil everything - I do think it's impossible to avoid spikes if you don't cut carbs. Just can't be done.
 
Hello All,
this year i will have been a type 1 for 54 years, but in my experience it is more important to test before meals and not to get to overcome with testing after meals, as in my case i have nearly always spiked to some degree for some time post meals, the only time i test after a meal is when i get a sudden feeling of dropping and that could be 15 minutes to 2 hours after a meal, some times stress or work just keeps coming and eventually shows up in one manner or another. Over the years i have seen many changes and in years past the format for me was to have the same amount of insulin each time and meal, but what happens is that you are sometimes over and sometimes under the required levels, old insulin's did work much slower, but what i have found now is that by counting carbs the insulin now reacts differently with me, now i am on less insulin than i have ever been, but the down side is that every action is now much faster, either up or down big influences for me has been stress and pain, they both really upset BG levels, and some times not as you would expect. I know that everyone is different and you need to find out what works best for you, but i ry not to get upset and worry about HBA1c as this is all past tense and you need to focus on the now, remember you can not change your past but try and control your now. Hope this may help some one to think about where you should focus your efforts. The other issue here is that type 2 have different requirements than type 1 we may have the same goals, but how we get there is very different.
Best Regards+
Toby
 
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