Stop the diabetes madness!

Totto · Feb 19, 2014

I have done some extensive reading during the past week and so far as I understand diabetes diagnostic tools and care are abysmal.

Diagnosis: two fasting bg readings at or above 7 OR a OGTT 2h reading above 11.1/12.2 depending on test method.

But why are the limits set so extremely high?

The result is that when the medical staff finally take notice we already have organ damage as this start when bg goes above 6 for any length of time.

we are told to check bg two h after a meal when the levels are going down again, but not to check at 45-60, where bg peaks. Why?

Most of us are told not to check bg at all so we are completely in the dark. And we are told to eat enormous amounts of carbs that will make our bg shoot up and cause more organ damage.

And we are recommended bg targets that are sure to damage us more and lead to stroke, heart failure, blindness, renal failure, amputations, cancer and dementia.

I really don't get this.

I will however be given a bg monitor on prescription tomorrow, after threatening not to eat a single carb ever more in my life until I was given one.

kesun · Feb 19, 2014

Because (1) T2 is entirely the patient's own fault; and (2) we're going to die anyway, so it's purely about managing our deterioration - and who would deny a dying person a cream bun?

Kate

Mud Island Dweller · Feb 19, 2014

Dont forget on the readings the higher the fat content the slower food is absorbed that is probably why the 2hr was set.
Having said that eating as per nhs you would possibly need a 1hr but l dont know.
I am guessing cost was also factored in to things.

phoenix · Feb 19, 2014

Lots of questions there.
Heres some places for you to research further.

Why use those figures (and actually HbA1c nowadays). The straight answer is it is the levels at which it has been shown that complications, in particular retinopathy rise sharply. but they only had data on a few populations.
http://www.who.int/diabetes/publications/Definition and diagnosis of diabetes_new.pdf

we already have organ damage as this start when bg goes above 6 for any length of time.

Controversial this one.
There is also evidence that people can live for long periods of time at mildly elevated levels without causing damage. Lots of long term T1s have shown this More recently a sort of natural experiment; a study of people who have had a form of MODY that results in lifetime mildly raised glucose levels demonstrated no difference in complications between them and people with normal glucose levels.
(the people with MODY had an average HbA1c of 6.9% compared with 5.8% in the non diabetic controls)
This compared starkly with those that had T2 who had an average HbA1c of 7.8% and who a much higher level of complications but also had higher levels of obesity, cholesterol levels, blood pressure and continued smoking...so it may not have been glucose alone that was the culprit.
Easy press release
http://www.eurekalert.org/pub_releases/2014-01/uoe-dbg011514.php
more detail from original paper and editorial' Insights From Monogenic Diabetes and Glycemic Treatment Goals for Common Types of Diabetes' but will need access to read in full.
http://jama.jamanetwork.com/article.aspx?articleid=1814212&resultClick=1
http://jama.jamanetwork.com/article.aspx?articleid=1814194
Certainly there is evidence for sustained high glucose levels as reflected in HbA1c being the biggest risk factor. There are some researchers that also feel glucose variability ie spikes themselves are damaging but others who deny it ,
It would take too long to go through it! Have a look at this paper; it reviews the evidence as of 2010 http://press.endocrine.org/doi/full/10.1210/er.2009-0021

Normal people do have some glucose peaks. It is only in very recent years that we have been able to monitor them by using continuous glucose monitors.
Have at look at table 1 in this paper :
100% of people spent some time above 6.1mmol/l , in fact they were above that for a median time of 395 min in 24 hrs , 99% breached 7mmol/ for a median 109min , 93% breached 7.8mmol/l with a median time of 31 min. (a few went above 11.1 but these were people with the highest HbA1cs so perhaps at risk or even diabetic in spite of having normal HbA1c and fasting levels)
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2892065/?report=reader#!po=31.8182

Lastly, there has not really been any good evidence about the average fasting and post meal levels needed to achieve A1c levels.
(again using continuous glucose monitoring combined with intensive capilliary testing)
They found that in some cases fasting glucose targets may be higher than needed but that some post prandial ones are too high, Unfortunately the results they give are in quite broad terms . (they probably have to be as there seem to be a wide variation in the amount people glycate
ie some people can have relatively higher levels than others to achieve the same HbA1c.

Av Fasting level corresponding to HbA1c of 5.5–6.49% (37–47 mmol/mol) = 122 mg/dL ( 6.7mmol/l)
Av 90 min postprandial level corresponding to HbA1c of 6.5–6.99% (48–52 mmol/mol) = 139 mg/dL (7.7 mmol/l )
There are other HbA1cs and bedtime levels in the paper
Good summary here:
http://www.medscape.com/viewarticle/820587
complete results in abstract:
http://care.diabetesjournals.org/content/early/2014/02/04/dc13-2173.abstract

Unbeliever · Feb 19, 2014

phoenix said:
Lots of questions there.
Heres some places for you to research further.

Thanks for that Phoeix. I think it will be some time before the evidence is good enough to make any appreciable difference to treament , especially of T2. I am not surprised that it has been shown that some people with Mody are able to survive slightly elevated bloood sugar levels for long periods without damage. much in the same way as people can run high cholesterol levels without damage.

I have had maculopahy for some time now and am apparenly a difficult and unusual case. None of the factors mentioned above , relate to me.
Mine was caused by medication. No one denieds that this is the case. What I am hearing constantly from the hospital is that they are gradually learning how T" complications are much more diffficult to treat than T1. They have llearnt to stop assuming that the patient is to blame - it is very often slim , non smokers with a good HBa1C who sufffer most.
Whenever I encounter {quite frequently as it happens] a new trainee opthalmologist I am exposed to questions about all the areas you mention above. Smoking , lipids , HBA1C etc and i see the amazement on their faces when I do not fit the profile.
]This confirms my view that we are a long way off really understanding T2.
Now with more awareness and perhaps earlier dignosis future generations may be better informed and treated.
In the meatime I do not understand how so many in the medical profession can be so dogmatic about matters they don't really understand and why they cannot be more supporive of those who have found their own way of controlling the condiion.Things are changing I believe but many newly diagnosed are still being denied information which could help them.

Harpar · Feb 19, 2014

So how come people can have fasting levels in the 3's or 4's, an Hba1c in the mid 6's but still produce spikes up into double figures? So their very selective tests only reinforce GPs opinion that if they look at a persons fasting level and its fine then there is no need to worry.

desidiabulum · Feb 19, 2014

phoenix said:
Lots of questions there.
Heres some places for you to research further.

There is also evidence that people can live for long periods of time at mildly elevated levels without causing damage. Lots of long term T1s have shown this More recently a sort of natural experiment; a study of people who have had a form of MODY that results in lifetime mildly raised glucose levels demonstrated no difference in complications between them and people with normal glucose levels.
(the people with MODY had an average HbA1c of 6.9% compared with 5.8% in the non diabetic controls)
This compared starkly with those that had T2 who had an average HbA1c of 7.8% and who a much higher level of complications but also had higher levels of obesity, cholesterol levels, blood pressure and continued smoking...so it may not have been glucose alone that was the culprit.
Easy press release
http://www.eurekalert.org/pub_releases/2014-01/uoe-dbg011514.php
more detail from original paper and editorial' Insights From Monogenic Diabetes and Glycemic Treatment Goals for Common Types of Diabetes' but will need access to read in full.
http://jama.jamanetwork.com/article.aspx?articleid=1814212&resultClick=1
http://jama.jamanetwork.com/article.aspx?articleid=1814194
ct

Many thank for this, Phoenix. First time I've felt happy about having MODY!

Totto · Feb 19, 2014

phoenix said:
Lots of questions there.
Heres some places for you to research further.

Why use those figures (and actually HbA1c nowadays). The straight answer is it is the levels at which it has been shown that complications, in particular retinopathy rise sharply. but they only had data on a few populations.
http://www.who.int/diabetes/publications/Definition and diagnosis of diabetes_new.pdf

Controversial this one.
There is also evidence that people can live for long periods of time at mildly elevated levels without causing damage. Lots of long term T1s have shown this More recently a sort of natural experiment; a study of people who have had a form of MODY that results in lifetime mildly raised glucose levels demonstrated no difference in complications between them and people with normal glucose levels.
(the people with MODY had an average HbA1c of 6.9% compared with 5.8% in the non diabetic controls)
This compared starkly with those that had T2 who had an average HbA1c of 7.8% and who a much higher level of complications but also had higher levels of obesity, cholesterol levels, blood pressure and continued smoking...so it may not have been glucose alone that was the culprit.
Easy press release
http://www.eurekalert.org/pub_releases/2014-01/uoe-dbg011514.php
more detail from original paper and editorial' Insights From Monogenic Diabetes and Glycemic Treatment Goals for Common Types of Diabetes' but will need access to read in full.
http://jama.jamanetwork.com/article.aspx?articleid=1814212&resultClick=1
http://jama.jamanetwork.com/article.aspx?articleid=1814194
Certainly there is evidence for sustained high glucose levels as reflected in HbA1c being the biggest risk factor. There are some researchers that also feel glucose variability ie spikes themselves are damaging but others who deny it ,
It would take too long to go through it! Have a look at this paper; it reviews the evidence as of 2010 http://press.endocrine.org/doi/full/10.1210/er.2009-0021

Normal people do have some glucose peaks. It is only in very recent years that we have been able to monitor them by using continuous glucose monitors.
Have at look at table 1 in this paper :
100% of people spent some time above 6.1mmol/l , in fact they were above that for a median time of 395 min in 24 hrs , 99% breached 7mmol/ for a median 109min , 93% breached 7.8mmol/l with a median time of 31 min. (a few went above 11.1 but these were people with the highest HbA1cs so perhaps at risk or even diabetic in spite of having normal HbA1c and fasting levels)
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2892065/?report=reader#!po=31.8182

Lastly, there has not really been any good evidence about the average fasting and post meal levels needed to achieve A1c levels.
(again using continuous glucose monitoring combined with intensive capilliary testing)
They found that in some cases fasting glucose targets may be higher than needed but that some post prandial ones are too high, Unfortunately the results they give are in quite broad terms . (they probably have to be as there seem to be a wide variation in the amount people glycate
ie some people can have relatively higher levels than others to achieve the same HbA1c.

Av Fasting level corresponding to HbA1c of 5.5–6.49% (37–47 mmol/mol) = 122 mg/dL ( 6.7mmol/l)
Av 90 min postprandial level corresponding to HbA1c of 6.5–6.99% (48–52 mmol/mol) = 139 mg/dL (7.7 mmol/l )
There are other HbA1cs and bedtime levels in the paper
Good summary here:
http://www.medscape.com/viewarticle/820587
complete results in abstract:
http://care.diabetesjournals.org/content/early/2014/02/04/dc13-2173.abstract

Some more reading to be done for me! I have had a quick glance on some of the links but not on the MODY ones, will save them for later. What I can see from the brief time I spent looking at them, it is basically we don't know OR I don't trust the outcome as in one study of non-diabetic bg values they had omitted to do a OGTT and relied on fasting readings.

Thanks a lot for all those links, I will probably have time to read them in more detail tonight.

Totto · Feb 19, 2014

Harpar said:
So how come people can have fasting levels in the 3's or 4's, an Hba1c in the mid 6's but still produce spikes up into double figures? So their very selective tests only reinforce GPs opinion that if they look at a persons fasting level and its fine then there is no need to worry.

Do you know of people/studies with FBG below 4 who get pp readings in double figures? Looks like me! lol

I have to admit that the night before I was going for a fasting bg test I had a box of chocolate and achieved a reading of 6, highest ever for me and enough for my GP to take me seriously and order the OGTT that diagnosed me. We don't all get high fasting levels but I have in the last year had two random tests, both pp that were suspicious and no one was interested.

Totto · Feb 19, 2014

What I would like to know is:

1. What is the safe upper limit?

2. Is diabetes a progressive disease?

3. What is the value of testing bg two hours after meals instead of one hour?

Harpar · Feb 19, 2014

Do you know of people/studies with FBG below 4 who get pp readings in double figures? Looks like me! lol

And me. GP wont take it seriously either.

paul-1976 · Feb 19, 2014

Fasted readings can appear good and are the last thing to deteriorate whilst the 2nd phase insulin response is reasonable,with the 1st phase impaired though and with the large spikes that can go hand-in-hand with this,the damage is being done despite slipping the diagnostic net with a standard fasted venous sample.

Totto · Feb 19, 2014

Yes Paul, that is why I think a on hour OGTT reading or any pp one hour reading should be of interest. The box of chocolate I had was hard work and I mourn it as it probably was the last one I had, but it made my fg reading go up enough to make my GP sit up and take notice, along with a series of visits over the past years and a HbA1c of 46.

My 1 h reading at the OGTT last week was 20.6. I was horrified.

paul-1976 · Feb 19, 2014

Totto said:
Yes Paul, that is why I think a on hour OGTT reading or any pp one hour reading should be of interest. The box of chocolate I had was hard work and I mourn it as it probably was the last one I had, but it made my fg reading go up enough to make my GP sit up and take notice, along with a series of visits over the past years and a HbA1c of 46.

My 1 h reading at the OGTT last week was 20.6. I was horrified.

Yes,20.6 is certainly high indeed and going by Jenny Ruhl's 'Bloodsugar 101' site,any random reading over 11 mmol is a truly diabetic reading.
After testing non diabetics I know,at various points after eating a carb fest and not once them getting close to 11 mmol-I'd agree with that.

AnnieC · Feb 19, 2014

Totto said:
I have done some extensive reading during the past week and so far as I understand diabetes diagnostic tools and care are abysmal.

Diagnosis: two fasting bg readings at or above 7 OR a OGTT 2h reading above 11.1/12.2 depending on test method.

But why are the limits set so extremely high?

The result is that when the medical staff finally take notice we already have organ damage as this start when bg goes above 6 for any length of time.

we are told to check bg two h after a meal when the levels are going down again, but not to check at 45-60, where bg peaks. Why?

Most of us are told not to check bg at all so we are completely in the dark. And we are told to eat enormous amounts of carbs that will make our bg shoot up and cause more organ damage.

And we are recommended bg targets that are sure to damage us more and lead to stroke, heart failure, blindness, renal failure, amputations, cancer and dementia.

I really don't get this.

I will however be given a bg monitor on prescription tomorrow, after threatening not to eat a single carb ever more in my life until I was given one.

Yes my doctor said there has to be two consecutive tests with levels 7 and above to be diabetic my fasting levels were 6.9 amd 6.8 and have been like this for the last three years so still prediabetic.

Totto · Feb 19, 2014

AnnieC, why haven't you had an OGTT test? As your fg tests are almost conclusive, but not quite?

Harpar · Feb 19, 2014

It seems that doctors need to pay more attention to the early warning signs.

Scandichic · Feb 19, 2014

Totto said:
I have done some extensive reading during the past week and so far as I understand diabetes diagnostic tools and care are abysmal.

Diagnosis: two fasting bg readings at or above 7 OR a OGTT 2h reading above 11.1/12.2 depending on test method.

But why are the limits set so extremely high?

The result is that when the medical staff finally take notice we already have organ damage as this start when bg goes above 6 for any length of time.

we are told to check bg two h after a meal when the levels are going down again, but not to check at 45-60, where bg peaks. Why?

Most of us are told not to check bg at all so we are completely in the dark. And we are told to eat enormous amounts of carbs that will make our bg shoot up and cause more organ damage.

And we are recommended bg targets that are sure to damage us more and lead to stroke, heart failure, blindness, renal failure, amputations, cancer and dementia.

I really don't get this.

I will however be given a bg monitor on prescription tomorrow, after threatening not to eat a single carb ever more in my life until I was given one.

I agree 100%! As you live in Sweden, can you not quote Andreas Eenfeldt? I would feel lost without my bs monitor and now have one of the sd codefree ones where the strips cost a third of the price of the others! Lycka till!

phoenix · Feb 19, 2014

desidiabulum said:
Many thank for this, Phoenix. First time I've felt happy about having MODY!

Desi. don't want to deflate you or anyone else (I suspect you will read the paper) but it was one type of MODY. The one that probably goes unnoticed in many people because the only thing that seems to be abnormal is the level at which the bodies glucose levels are kept hence the 'moderate' rise in levels. As such it is a good model fro the effect of slightly higher glucose levels, without any other confounding problems.
There are several other MODY mutations and they all have different effects.

Totto · Feb 19, 2014

Scandichic said:
I agree 100%! As you live in Sweden, can you not quote Andreas Eenfeldt? I would feel lost without my bs monitor and now have one of the sd codefree ones where the strips cost a third of the price of the others! Lycka till!

Tack ska du ha, Scandichic! Har du förresten gått med i Kostdoktorns forum än?

My aim with the thread about diabetic madness is about the fact the diagnosis seem to step in far to late and care seems slack. I really don't understand why diabetics are encouraged to eat a lot of carbs and discouraged to keep their bg at safe levels. And I really want to know what a safe bg level is. I have seen HbA1c goals of 52! Why not aim for 36? Or lower? Why not aim for a safe level? I know you are with me here Scandichic, but I am a bit upset about what I perceive as a lack of proper scientific basics that leads to diabetes being accepted as a progressive disease etc.

There is a fantastic site for thyroid sufferers called Stop the thyroid madness. I feel the diabetic madness is close in terms of madness, even though thyroid problems are more common, in women at least.

Stop the diabetes madness!

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