T2 or NAFLD? ...or, a funny thing happened on the way to the surgery

[Chris24Main]

Total non-sequitur post, just a quick update in the realm of "is it food or is it hormones"

So - I do a little paddleboarding - I live near a river that's well controlled, and a couple of years I stumbled on the idea of doing the obvious thing - I have some years of experience of kayaking, so I just took to paddleboarding and I've been hooked ever since - "graduating" to a full race board that I try to get out on about once every other day - through the year.

now, safety has... just has... to be something you take seriously, around any watersport, but especially if you plan to be on the water during the winter in northern England. I spent the first year planning, and then this summer I was thinking again, could I be safe on a board designed with speed over stability in mind... I'd never fallen off, though I'd taken a spill on my beginner board a couple of times, but clung on each time.

Anyway - to cut to the chase; today I had my first serious test of all the preparations I'd made in the event of... There was a large rock under the water that I'd just never noticed before, and my fin caught it solidly - the board just stopped and I was catapulted off the front. I have a vague memory of grasping at the bow and realising that the rest of my body was still moving forward - this time there was no escaping; I was going in, and the temperature of the water was near freezing.

Some part of my mind is always "right - so now, you've kind of asked for this, what are you gonna do?"

It knows I'm too busy to answer, but it's kind of always right there, waiting for the opportunity. **** brain...

So, I tried the way everyone says is the easiest - pull yourself onto the back of the board - but no joy; my life jacket is just too bulky for that. I'm vaguely aware that my coffee flask is floating away, and I just register "floating, not sinking, that's good..." and then try on the side. One missed attempt, then I drag myself up and over the edge of my life jacket (PFD to be more precise, but it's quite a bulky, expedition affair with pockets and everything; life jacket is close enough). Onto the board. Out of the water. Step one. I get onto my knees and realise that my balance is not quite right; my hands are shaking - that'll be the adrenaline then. I have a mad second of wondering if I should continue, before I realise how stupid that would be - my entire safety protocol is based on getting warm and dry inside of 5 minutes; so I paddle to my paddle (I power down the heated gloves first - no point in trying to heat up the water in the gloves now, and they are too expensive to mess about with). Once I get to my paddle, sure enough I only really feel warm - that cold shock that you get that you only feel as warm; and my heart beat is coming back to normal - but - I'm going to feel **** cold once the adrenaline wears off, so I better stick to plan A.

All my clothes are massively heavy - wasn't quite expecting that for some reason, but I got back to the car, and fished the full-body changing robe I keep in the boot out, and got all the soaking layers off..

all good; no thermal shock, no real worry, back home and under a warm shower in about 10 mins. All my stuff in the washing machine, and I thought - I bet my blood glucose is high...

This is about 11am, and I haven't yet eaten. Morning blood was 4.4 and with very high ketones.
So - I measure again, and blood is 8 mmol/L - higher than I've measured in, well, nearly a whole year - Even wearing a CGM, I never got near 8 - this is really a load of glucose (for me, for right now.. where I am on my journey)

So - long story short, just another reminder that the liver, even with precious little glycogen around, is impressively capable of generating glucose when you need it.

I have to admit - I was buzzing ...

 

[Antje77]

That was quite the adventure @Chris24Main , glad your safety plan worked!

Have you considered you might actually be safer without your life jacket this time of year? Death by hypothermia happens pretty quick so it might be worth swapping the help with staying above water for being able to move better if you need to save yourself.

This is about 11am, and I haven't yet eaten. Morning blood was 4.4 and with very high ketones.
So - I measure again, and blood is 8 mmol/L - higher than I've measured in, well, nearly a whole year - Even wearing a CGM, I never got near 8 - this is really a load of glucose (for me, for right now.. where I am on my journey)

So - long story short, just another reminder that the liver, even with precious little glycogen around, is impressively capable of generating glucose when you need it.

I have to admit - I was buzzing ...

Interesting re your BG. Obviously the adrenalin from your unexpected predicament made you BG go up in case you needed the energy. Had it taken longer to get out and warm, you might even have needed the extra glucose.
You might be interested in my findings in cold water here: https://www.diabetes.co.uk/forum/threads/cold-water-swimming-and-diabetes.200255/
Without the surprise element (I plan to go in, and it's much less dangerous so no fight or flight effect), swimming in cold water drops me quickly. Which makes sense, staying warm uses up a lot of energy.

 

[Melgar]

@Chris24Main well glad you got out of that water safely. At least you had the wherewithal to get out. Did you have a cold water wet suit on? If you didn’t maybe worth purchasing one. A lot of people here wear full wetsuits when out on the water, it’s perishing. Not that they are anticipating going in, unlike @Antje77 who clearly takes pleasure in that ’take your breath away’ plunge but **** happens. I’m a big kayaker myself. I can fully understand why you want to be out on the water all year. I also have an 11ft maybe it’s 12 not sure, paddle board. My knees are too messed up to go out on my paddle board. I have an electric outboard, not powerful but enough to get me out of trouble should that arise. It clips on to the back of my kayak.

 

[Outlier]

Very very interesting re: physical/mental responses during and after. Easy to forget for many involved in diabetes (professionally and personally) that BG does a survival job for us as well as being a devil to manage. How soon before yours came down again?

And a Winner for presence of mind and rising to the occasion.

 

[Chris24Main]

Oh - thanks all...
So I was back out again this morning - turns out it was an embedded tree branch that caught me - a million to one chance, and only in the precise direction I was going - but if you catch it just so, the board will stop dead. Makes me feel better, because I thought I knew where all the rocks are.

@Melgar - I totally love this river, and the wildlife (not for nothing that my avatar is a Kingfisher) - I get a huge boost just from being out, and it's an extraordinarily beautiful stretch, with some wild sections, some bridges and a viaduct - and the sun coming up is a bonus often, but not today.

My background is in wild water kayaking, but it's a long time ago now. Oddly though, I have some balance-saving strokes that are all pure reaction from years of kayaking that would be impossible to teach to someone who has only ever paddleboarded. Difficult to explain, but it's saved me on larger rivers where I go for longer expeditions (and would be much further away from any help).

I seem to have a brain that works differently in water - when I was 6 - I was swimming in an unsupervised outdoor pool in an expat compound in Nigeria - nobody in sight (hard to imagine, but this was Africa in the Seventies). I slipped on the ladder that I was using to jump off, and fell down between the ladder and the wall of the pool, and jammed stuck. The way my brain works - my thought was "this is interesting; I wonder how long I can hold my breath?". What I didn't know, was that a neigbour had seen this and was running to the pool from about 200 meters. I should really have died, but he got to me and together we calmly disentangled me from the ladder and everything was fine.

So - all of my watersport thinking is simply; people drown all the time, not because they cannot swim, but because they panic. @Antje77 - I do appreciate the thought, and totally respect the outdoor swimming angle; but as an activity - this is all about not swimming. I've seen people just mentally fall apart with the shock of very cold water. Surprise someone, hit them with cold which is more like physical pain, and stop them from breathing - not a good mix. So, any time I'm in the water, it's very much not planned, and I could be injured or concussed; so having something to make sure my head stays above the water is utterly - and I mean utterly - critical.

I was probably in the water for less than 10 seconds, but you also have to imagine trying to swim with trekking boots, skiing trousers, and 4 layers of clothes, and gloves. Interestingly - I also had a merino ruff around my neck - that stayed partially dry, which gives you an idea of how effective the pfd is. Not to mention the tether to the board itself and the current. Worn the traditional way on your ankle; in a river this can be a death sentence if anything traps the board, leaving you trailing behind your ankle; the power of moving water is difficult to appreciate. Even with a good pfd, people can drown, with nothing to keep you buoyant - forget it.

Wetsuit - Yeah, that sounds like a good idea, but you still get a huge shock hitting that water - back in the day, I ran a river in France that was fed by two glaciers. It was a sunny day, so I didn't put on my dry jacket - it was only about 20 minutes to run the full section, but one of the most thrilling 20minutes of my life- the water was exploding everywhere, and you could hear the rumble of boulders under the water - being "splashed" was more like running a gauntlet of baseball bat wielding goons. I'll never forget the experience.

Anyway - the point being that wetsuits are great if you are wet. If you are dry, then you are overeating, and you still get the thermal shock. So, if you can stay dry, then it's all about the layers - and having a plan for what to do if it goes wrong.

What I should have done, of course, was practice all of this during the summer.

 

[Chris24Main]

On the topic of the effect on blood glucose, that's interesting.
So - I was in deep ketosis, with low blood glucose at the time. This is definitely a fight or flight response, so much adrenaline; and I mentioned that I was shaking a little. Not panicking - but aware that my muscle control was a little off - this is the heart-racing effect of adrenaline; you need to be able to react in the moment, and I effectively had to haul myself, and a bucket of water's worth of wet clothes, over a pfd that added maybe two inches to my chest. Not a time for half measures. But - it's amazing how much extra energy is made available - that, I think all happens metabolically - leaving the need for more glucose to cover the "energy dept" - then cortisol kicks in to trigger gluconeogenesis to pay off that dept. Adrenaline wears off fairly quickly, and that's when there is a risk of hypothermia. Which is why I was rushing to the car and the changing robe.

twenty minutes later, blood glucose was still high, but this whole episode has allowed me to answer one question - if your blood glucose is high due to non-food reasons (ie, not because of high glucose hitting the pancreas from the portal vein from the stomach) do you still get a corresponding raise in insulin?

So - I'm not currently wearing a CGM, and cant show a graph, but even if I could, you could argue that just enough glucose was generated, and that maybe it was all simply used up.

But - this morning, I've had one of the biggest drops in ketosis that I've seen, ever - from very high (about half way to the level of DKA, though I use that only for reference, I could not find myself in DKA) to about the lowest I've been in months. The episode bumped me out of ketosis - meaning that the elevated glucose must have triggered an insulin response, even though there were never any carbs involved.

 

[Peanut234]

Your winter water experience brings back memories
In my younger years I did an outdoor course in winter and yes the sudden cold water immersion takes ones breath away. Doubly so when you are practicing righting an overturned kayak by jumping off a rock into the water, and manage to wind yourself when landing on the overturned kayak. Especially difficult when the instructor is upside down in the overturned kayak.
Thankfully managed to stay calm, turn it over and somehow explain to the instructor that I now needed some assistance myself.
I'm still not sure how I managed, but I agree, somehow staying calm is the first step!
Oh the things we do when we are young But valuable lesson learned for later life.

 

[Peanut234]

On the topic of the effect on blood glucose, that's interesting.
So - I was in deep ketosis, with low blood glucose at the time. This is definitely a fight or flight response, so much adrenaline; and I mentioned that I was shaking a little. Not panicking - but aware that my muscle control was a little off - this is the heart-racing effect of adrenaline; you need to be able to react in the moment, and I effectively had to haul myself, and a bucket of water's worth of wet clothes, over a pfd that added maybe two inches to my chest. Not a time for half measures. But - it's amazing how much extra energy is made available - that, I think all happens metabolically - leaving the need for more glucose to cover the "energy dept" - then cortisol kicks in to trigger gluconeogenesis to pay off that dept. Adrenaline wears off fairly quickly, and that's when there is a risk of hypothermia. Which is why I was rushing to the car and the changing robe.

twenty minutes later, blood glucose was still high, but this whole episode has allowed me to answer one question - if your blood glucose is high due to non-food reasons (ie, not because of high glucose hitting the pancreas from the portal vein from the stomach) do you still get a corresponding raise in insulin?

So - I'm not currently wearing a CGM, and cant show a graph, but even if I could, you could argue that just enough glucose was generated, and that maybe it was all simply used up.

But - this morning, I've had one of the biggest drops in ketosis that I've seen, ever - from very high (about half way to the level of DKA, though I use that only for reference, I could not find myself in DKA) to about the lowest I've been in months. The episode bumped me out of ketosis - meaning that the elevated glucose must have triggered an insulin response, even though there were never any carbs involved.

Your drop in Ketosis is really interesting. Obviously your cause was that single event, but it would be interesting to compare to general life stressors that also raise cortisol, (and sometimes adrenaline) eg busy traffic, noise, presentations at work, worry about medical issues etc, and see how much that effects blood glucose and insulin. I know that life stress (unavoidable factors) are an issue for my blood glucose, and it would be great to understand it, and ways to minimise it (- yes I know about yoga and exercise and meditation, but any others) or manage it better.
I'm wondering if I can 'carb count' and pre treat for some of them for instance...Hmmm

It may explain why I haven't been able to get into ketosis for the last 12 months. Another Hmmm

 

[Melgar]

Ha, well years back now I volunteered in a youth program for severely disadvantaged kids. Mom’s were drug addicted, that kind of thing. We took these kids sailing. So these kids boarded the large schooner we had chartered. I wasn’t going to go, but I was talked into it. As I was last minute I took my bag with me, purse, phone the lot. We were out in the bay. It was great. One of the young staff took the helm and started to do manoeuvres. We would turn this way and that. It was very exciting, the wind in my hair and all that nonsense . I noted that as the boat turned the water came up high along side. I could actually touch the water with my hands. We did this a few times, then as we performed this manoeuvre again, the boat was turning in a dramatic way, the water came up and then over the side of the boat. I mean it gushed over the side like a massive wave, forcing this rather beautiful and majestic boat onto its side. That‘s the last thing I remembered before I found myself forcibly pulled under the water. My legs were tangled in ropes or something. I’m not sure what. The drama of it all, the noise, the turbulence, the bubbles, the fear. I don’t know how I got free, the life vest propelled me to the surface. The coast guard arrived and we were all pulled safely from the water. I have this recollection of my bag and being overly concerned about it, of all things and that I had lost it and the contents all on the sea bed. This was about 40 years ago now, but I have never forgot it. I have had a healthy respect for bodies of water ever since. I love the water, and the ocean in particular, but that incident is always with me when I’m on the water. I have no idea what my blood sugars were doing. I’m sure they were high, but I was still relatively young when all that happened.
Ed grammar.

 

[Chris24Main]

Funny how we all see it through the lens of what was going on with blood glucose...
Great story.
I used to do a bit of sail racing, nothing serious, couple of days, that kind of thing, as a teenager.
Totally magical, racing through the night with a trail of phosphorescence stretching out behind the boat and the sky ablaze with stars, and no land in sight.

 

[Chris24Main]

@Peanut234 ... insulin down-regulates ketone production. Insulin needs to be low for a while before any significant ketone production gets going, and my n=1 study would indicate that the threshold for that is also determined by insulin resistance level. (I've been using ketone production as an indicator of reducing insulin resistance). If you are taking insulin, my guess is it will stop all ketone production dead (because of the way it hits the liver compared with the gradual increase from the pancreas).

 

[Antje77]

I'm wondering if I can 'carb count' and pre treat for some of them for instance...Hmmm

I do 'carb count' and prebolus for some of the stressors I know will cause extra glucose to hit my bloodstream.
The obvious one is Foot on the Floor, getting out of bed doesn't cause me stress, but it does prompt my body to add some extra glucose to help get me started for the day. I inject for it before getting out of bed.
Other things I can count on to raise me if I don't inject for it are dentist visits and my yearly diabetes appointments. I take some insulin for both in the parking lot before going in.

If you are taking insulin, my guess is it will stop all ketone production dead (because of the way it hits the liver compared with the gradual increase from the pancreas).

I have no idea on the mechanics, but many T1's following a keto diet are in ketosis, even if they use insulin.
I'm puzzled and interested. Why would injected insulin take you out of ketosis but endogenous insulin not?

 

[Chris24Main]

So - that isn't quite what I'm saying.
When we look at any of the blood glucose measuremnts, none of them measures what the pancreas actually sees - blood from the portal vein carrying digested glucose from the stomach.

Blood flow from the pancreas tail where insulin is made goes straight into the liver.

In other words, the liver experiences a rise in insulin as quickly as is possible in the sense of Bernstein's "small numbers" control theory.

When I was pontificating on whether I had been bumped out of ketosis myself - that answered a question I had had myself - if glucose is generated in the liver - it really has to flow around the body first before hitting the pancreas, to have an insulin response. Would that be enough - the answer is Yes - at least for me.

When you inject insulin, the idea is to inject close to the liver, but of course nobody can inject directly into the liver - but - as I understand it, ketone production is very sensitive to insulin - so the rapid rush of insulin from an injection (somewhat regardless of dose) was what I was thinking about - injecting is deliberately as like a surge of insulin from the pancreas as possible, so should switch off ketone production.

T1 people following a ketogenic diet - by definition are following a diet and dosing regime to keep insulin levels low. Absolutely no reason why that would not be possible (though clearly more difficult without risk) but there was no indication that this was the case in the example, so I was suggesting that a normal insulin dose was likely to switch off ketosis.

If I was still T1 myself, by the way - this is absolutely what I would be trying to do - but I do not know nearly enough about attempting keto on T1 myself to comment.

Short version - endogenous insulin from non-food event DID bump me out of ketosis, and for most T1 - my assumption is that the influx of insulin from injection is greater than the insulin generated in my liver and going around my body before hitting the liver.

 

[Melgar]

Just picking up a point you made, and probably a blatantly obvious one, but surely that fight for flight mode you were in, whereby your body (liver) produces excessive amounts of energy, namely glucose for the purpose of survival. Your body would use the glucose first, it’s naturally programmed to always use glucose as a first line energy source, and fat metabolism second due to necessity. If you liken it to electricity always taking the least line of resistance, but there is always residue electricity in less conductive material, but if the less conductive material is the only path available for the electricity to ground then it will take that route. Glucose metabolism being the least line of resistance and fat metabolism second as it’s harder to metabolize. Hence you came out of ketosis. Insulin production would occurs as soon as your beta cells, which are the most sensitive cells in the body, detected that rise in glucose so your pancreas would release insulin as part of that fight or flight response. There is an inverse relationship between insulin production and ketone production I’m sure I’ve grossly over simplified it.

 

[Peanut234]

I do 'carb count' and prebolus for some of the stressors I know will cause extra glucose to hit my bloodstream.
The obvious one is Foot on the Floor, getting out of bed doesn't cause me stress, but it does prompt my body to add some extra glucose to help get me started for the day. I inject for it before getting out of bed.
Other things I can count on to raise me if I don't inject for it are dentist visits and my yearly diabetes appointments. I take some insulin for both in the parking lot before going in.

Interesting. I don't know if I would trust myself yet to inject first thing before I am fully awake I'm not a morning person. Maybe in time.
Dentist and diabetes appointments are great examples.

Unfortunately I get worried about things others don't so can't prebolus for all scenarios, but I can try and choose the worst. I would raise my long acting insulin, but some days are quiet days without the stressors (or at least lots less) so that won't work either.

My blood glucose raises with exercise too, and I am hesitant to prebolus with it as I don't want to go low afterwards.

How do others handle exercise?

Sometimes I do wonder if getting a pump would be easier for this point in my life.

It's interesting as my Diabetes nurse has not mentioned this at all. Only prebolus' for food.

 

[Peanut234]

So - that isn't quite what I'm saying.
When we look at any of the blood glucose measuremnts, none of them measures what the pancreas actually sees - blood from the portal vein carrying digested glucose from the stomach.

Blood flow from the pancreas tail where insulin is made goes straight into the liver.

In other words, the liver experiences a rise in insulin as quickly as is possible in the sense of Bernstein's "small numbers" control theory.

When I was pontificating on whether I had been bumped out of ketosis myself - that answered a question I had had myself - if glucose is generated in the liver - it really has to flow around the body first before hitting the pancreas, to have an insulin response. Would that be enough - the answer is Yes - at least for me.

When you inject insulin, the idea is to inject close to the liver, but of course nobody can inject directly into the liver - but - as I understand it, ketone production is very sensitive to insulin - so the rapid rush of insulin from an injection (somewhat regardless of dose) was what I was thinking about - injecting is deliberately as like a surge of insulin from the pancreas as possible, so should switch off ketone production.

T1 people following a ketogenic diet - by definition are following a diet and dosing regime to keep insulin levels low. Absolutely no reason why that would not be possible (though clearly more difficult without risk) but there was no indication that this was the case in the example, so I was suggesting that a normal insulin dose was likely to switch off ketosis.

If I was still T1 myself, by the way - this is absolutely what I would be trying to do - but I do not know nearly enough about attempting keto on T1 myself to comment.

Short version - endogenous insulin from non-food event DID bump me out of ketosis, and for most T1 - my assumption is that the influx of insulin from injection is greater than the insulin generated in my liver and going around my body before hitting the liver.

Thats really interesting. In particular that the insulin is made in the tail.

My Pancreas is 'made' differently, with significant plumbing differences to the norm. (not recommended!) I'm wondering if the cell mapping and blood flow are a bit different too...

 

[Chris24Main]

Just picking up a point you made, and probably a blatantly obvious one, but surely that fight for flight mode you were in, whereby your body (liver) produces excessive amounts of energy, namely glucose for the purpose of survival. Your body would use the glucose first, it’s naturally programmed to always use glucose as a first line energy source, and fat metabolism second due to necessity. If you liken it to electricity always taking the least line of resistance, but there is always residue electricity in less conductive material, but if the less conductive material is the only path available for the electricity to ground then it will take that route. Glucose metabolism being the least line of resistance and fat metabolism second as it’s harder to metabolize. Hence you came out of ketosis. Insulin production would occurs as soon as your beta cells, which are the most sensitive cells in the body, detected that rise in glucose so your pancreas would release insulin as part of that fight or flight response. There is an inverse relationship between insulin production and ketone production I’m sure I’ve grossly over simplified it.

OK - let's break it down, what you're saying sounds like it makes sense, but it gets to the heart of what I was interested in my own response. Homeostasis doesn't work under the concept of path of least resistance, it's all about concentrations of hormones. Pretty much everything you talk about is all controlled by insulin level. If Glucose is high, you are producing insulin. If insulin is high, you are storing fat, not releasing it to be available for metabolism. Thus - you only have glucose to metabolise, and ketone production is stopped.

I don't buy that beta cells are more sensitive (I suppose you mean sensitive to glucose) than any other cell in the body. You would have to explain how. They are in the path of the highest concentration of glucose, being that the blood from the stomach and gut goes first to the tail of the pancreas then the liver. Ie glucose from food produces the highest concentration of glucose in the pancreas. (that's how I see it, and the plumbing backs that up) not that the cells themselves are more sensitive - the cells can only interact with what is around them.

So - what you are laying out is pretty much what I was thinking - in the event of cortisol-generated glucose in the liver; that now goes into general circulation (for use in fight or flight, but mechanistically because the liver is downstream of the pancreas) It makes sense, because the glucose has been made to be used - but will it all be used, or will it still find its way into the pancreas, and generate enough insulin to disrupt ketosis. (again, that inverse relationship is purely a question of insulin level; ketone production only starts when insulin is low for a while, and will stop if insulin rises)

I think your observations are correct, but the inferences are not (in my humble opinion - of course you are entitled to your opinion, and I may well be wrong). Your body is not programmed, because it is not a computer, it is a homeostatic system under control of hormones. Your body does not choose the metabolism of least resistance, because it is not a lightning strike seeking ground, it is a homeostatic system under control of hormones.

Fat isn't harder to metabolise. Fat metabolism is more efficient, and produces more ATP and less ROS; so, you can make a case for it being much easier at that level - more energy out, and less energy used to mop up. However, if insulin is high, that fat is simply not available to burn, because the adipose tissue is under orders to lock it away. Thus, only glucose is available, and insulin will also usher that into the cells for burning.

 

[Chris24Main]

I have something a little different;
A couple of posts ago - I was chewing over the idea of all diabetes being on a spectrum. Part of that was a question I've been mulling over - what is it really that's at the heart of the auto-immune attack on the pancreas that characterises T1DM. The more I get into the role that insulin plays in inflammation, and the role that inflammation plays in the immune system, it just seems unfathomable, that for no explicable reason, the body mobilises an attack on a small part of a small part of a small organ, and knocks out - just - the cells responsible for generating insulin, unless insulin itself plays a part.

To this end, I reached out to Dr Ben Bickman through his website (not really expecting an answer) - and put it to him, in the form of an analogy - it was like a mob forming in a major city and going on a rampage of destruction, but only burning down one convenience store. Difficult to explain unless it was personal somehow... anyway; to my surprise, I did get a reply, not from Ben Bikman, but one of his researchers (who of course I cannot name) responded with a very interesting answer that opens up another rabbit hole. @Melgar - I think you may be particularly interested in this.

I include verbatim while removing names - Alessio Fasano is a researched at Harvard - I consider that name to be in the public domain:

Thanks so much for reaching out to Insulin IQ with your intriguing question about why beta cells are targeted in the autoimmune attack resulting in Type 1. Although Dr. Bikman would love to respond to every thoughtful inquiry sent to Insulin IQ, his commitments as a researcher, professor, and speaker limit his ability to respond. But as one of the certified coaches with Insulin IQ, and a T1D as well, I wanted to follow up with you! I also submitted your question to Dr. Bikman to touch on in a monthly rapid-fire Q&A that happens in our coaching circle, so if he has any insights, I'll forward them on to you.

In my own thought process, I've wondered the same thing as you. I've read the theories of molecular mimicry with the proteins on beta cells when the immune system is fighting a virus. I've read about theories that gluten or dairy might be environmental triggers that trigger gut inflammation and create an opportunity for foreign particles to leak out. I've also read about the gene association link to T1D.

Alessio Fasano has a working hypothesis for autoimmunity in general. A genetic predisposition, plus intestinal permeability, plus an environmental trigger are all necessary for the immune system to go awry and begin to identify "self" as foreign. And it's an interesting question about whether insulin itself could be a trigger. It seems, however, that it's the genetic predisposition that dictates where a person's immune system might go wrong. For instance, T1D, celiac, and thyroid disease are three autoimmune diseases that occur in tandem. All of them are diseases strongly associated with the Human Leukocyte Antigen (HLA). Certain HLA alleles can significantly increase a person's susceptibility to developing these disorders.

To use your analogy, it's like the immune system mob sees a sign on the convenience store that says, "Start here." But there may be other stores around the corner with the same sign. I have all three of the HLA-associated disorders. I first developed T1D, then 10 years later developed Graves' disease, then 15 years later discovered I have celiac disease.

Be assured that many people are asking the "why" questions. It's just that no clear answers have been discovered. Most reports about T1D development are that the mechanism pathway is "uncertain" or "not clearly understood." But that's how discoveries are made! People with curious minds ask questions.

Again, thanks so much for your question. I'm sorry I don't have any hard evidence to steer you towards, but hopefully this gives you some direction to continue researching. And again, if Dr. Bikman has more insight or some recommended research, I'll certainly pass it along!

 

[Antje77]

How do others handle exercise?

I think you'll like this very long thread on exercise and T1, which likely will apply to your T3C as well: https://www.diabetes.co.uk/forum/threads/managing-exercise-and-insulin.127691/

 

[Chris24Main]

I'm right now waiting for a researchgate account to read the article that the researcher pointed me at from Dr Fasano. As you apply for such an account, of course most people are existing published researchers of various types- so one of the things you have to do is declare - are you this author.. and I'm skipping through one paper after another, thinking I have a more common name than I suspect - hang on, back up...

And sure enough, on one paper I really am one of the listed co-authors ...

Entirely unrelated to this in any way, and to do with my day time job, but it's definitely me... how unexpected..