[Ronin]

Everyone:

In recent threads by Lori Lynn and Homeschoolmom the question of when medication is advised to manage BG levels was raised (again).

There was a recent story where it was reported that a medical trial was stopped because aggressive medical interventions to get BG levels into the "normal" range was causing more deaths than less aggressive treatments.

I have a stake in this question as a non-medicated Pre-D. If I accept the most cited study that says that "normal" BG levels must return to the 70-80 mg/dL range within two-hours of eating, then I'm not "normal." At best my BG levels drop to the mid-90's, and while that is good for a diabetic, it is not "normal" per the oft-cited study.

While I am a slim, exercising senior (>60) who manages his diet, and has a low C-Peptide reading would the addition of a small dose of insulin actually help or might it make things worse? I'm sure that some people who are Insulin Reisitant would be interested in the same question regarding medications that are designed to increase insulin sensitivity.

When do we say that diet and exercise is not sufficient and there needs to be supplamental medications?

While we will not agree, it may be useful to have a range of opinions expressed.

[wiseguy]

For myself, the answer to this question is equal to the answer of another, which is: at what blood glucose level does organ damage and other complications begin? Unfortunately, there is no clear cut answer to this question and maybe there cannot be one.

From everything I have read on this subject, the conclusion I have "settled" for, is that damage occurs at sustained BG levels of over 140 mg/dl. So this is the number I work at staying below at all times by whatever means that become necessary.

[Jan B]

George,

I think you are fine without any medication. Medications have side effects & carry risks, and as long as your post-prandial readings are in the nineties, that's good. If you see that number continue to rise toward 130, 140, then you should consider some help. I think you have a good thing going.

There is the belief (Dr. Bernstein for example) that we, as diabetics, want to mimic the levels of a non-diabetic. Within reason, this is great advice. But with the associated risks of drugs and insulin, AND the current knowledge that wiseguy talked about (sustained at above 140 may cause complications), I think you need to leave good enough alone! Keep exercising, riding, and doing the good job of taking care of the kitties!

[Ronin]

Jan, et al.,

I tend to agree. My A1c numbers would tend to indicate that I'm doing okay, but there is the nagging question of what damage, if any, is happening with A1c levels in the 5 - 6 range which is well above the mid 4's that "normal" people have.

Another, sub-issue is that of the relevance of age on the equation. As I noted in another post, "the study" that is most often cited used a sample of people who were in their 20's. It might be interesting to sample the same people today when they are older and see if they are always returning to the 70 - 80 mg/dL range at two-hours post-prandial. That could be revealing. My interest is more a product of finding more-and-more of my fellow Pre-D's who have low C-Peptide readings which indicate that their Pancreatic function is reduced. Is that genetic, environmental, or simply a factor of age?

The other lingering question is: if a Pre-D were to use insulin to bring their BG levels down into the 70's (assuming they have a low-normal C-Peptide), could this cause Insuin Resistance on top of the Pre-D condition?

Thanks to Jan for the positive comments. I did stray from my normal regimine today and got a post-prandial of 146 as a result. Forutunately, 25 miles of bicycling later I was back down to 119. Sometimes temptation is just too hard to resist and I have to realize the cost.

FWIW: for those not following the Chit-Chat forum -- the male Siamese we are guardians for, Mr. Muggels (who has Chronic Renal Failure), is doing much better although he is very high maintenance. (I have to be careful as it seems every time I report good news he gets a sour day.)

[BlueSky]

Originally Posted by Ronin

... While I am a slim, exercising senior (>60) who manages his diet, and has a low C-Peptide reading would the addition of a small dose of insulin actually help or might it make things worse? ....

Ronin, here is the case for taking insulin .

It seems like there is some uncertainty about your diagnosis. But in the end it doesn't really matter. In view of the fact that you c-peptide is low, you appear to be insulin sensitive, but blood glucose is above normal, we can reasonably conclude that a lot of beta cells must have been lost. There is no way of knowing how many of your beta cells have been lost, but there is a lot of built in redundancy. So by the time blood glucose starts going up large proportion of beta cells will have been lost - probably 30% - 40% of them.

This means that the remaining 60% - 70% of your beta cells are working overtime to keep your blood glucose down. And it is thought that all this hard work shortens their life. It causes "beta cell burnout". In which case injecting some insulin might just help them to last longer. This is how T1s and T1.5s extend their honeymoon period.

The next question I guess is when, what type and how much insulin to take. It would make sense to supplement your endogenous insulin where it is needed most. In your case that seems to be at mealtimes. If you could help your beta cells deal with the carbs by taking short acting insulin before you eat, they would be more easily able to maintain normal blood sugar during the rest of the day.

I don't think there is a compelling reason to do anything to reduce your your BG levels as they are near normal anyway. But it may be worth taking action to ensure that it stays that way in the future. Kinda like taking insulin as a prophalactic .

[Jan B]

BlueSky,

It's about time you chimed in . . . where have you been?! Your input is needed!

[David_S]

Originally Posted by BlueSky

Ronin, here is the case for taking insulin .

It seems like there is some uncertainty about your diagnosis. But in the end it doesn't really matter. In view of the fact that you c-peptide is low, you appear to be insulin sensitive, but blood glucose is above normal, we can reasonably conclude that a lot of beta cells must have been lost. There is no way of knowing how many of your beta cells have been lost, but there is a lot of built in redundancy. So by the time blood glucose starts going up large proportion of beta cells will have been lost - probably 30% - 40% of them.

This means that the remaining 60% - 70% of your beta cells are working overtime to keep your blood glucose down. And it is thought that all this hard work shortens their life. It causes "beta cell burnout". In which case injecting some insulin might just help them to last longer. This is how T1s and T1.5s extend their honeymoon period.

The next question I guess is when, what type and how much insulin to take. It would make sense to supplement your endogenous insulin where it is needed most. In your case that seems to be at mealtimes. If you could help your beta cells deal with the carbs by taking short acting insulin before you eat, they would be more easily able to maintain normal blood sugar during the rest of the day.

I don't think there is a compelling reason to do anything to reduce your your BG levels as they are near normal anyway. But it may be worth taking action to ensure that it stays that way in the future. Kinda like taking insulin as a prophalactic .

Just what I was thinking.. that c-pep reading suggests you will need it anyway.. the pancreas will need some help here.

[Ronin]

Everyone:

This is getting interesting. It seems that some of you advocate for the idea of using supplamental insulin. As one who has not done this, and presuming that you have, how do you calculate the dosage? Also, how do you time them, in particular Blue Sky said that I might benefit around meal times (I guess also where I know I'm likely to go "overboard a bit").

Finally, are there any anti-insulin arguments out there? I don't want this to be a one-sided discussion - I do want to hear the positive and negative sides.

[BlueSky]

Originally Posted by Ronin

.... are there any anti-insulin arguments out there? ....

Insulin is a natural hormone, so it doesn't do any harm if it is used properly. But a common reservation of injecting insulin for T2s is that it adds fuel to the insulin resistance fire. This is a valid concern. For whatever reason, the cells are shutting glucose out by down-regulating the number of insulin receptors. Injecting insulin aggravates this process. And increasing amounts of injected insulin may be required to keep blood glucose down as insulin resistance escalates. A more sensible strategy, is to improve insulin sensitivity.

In your case, there seems to be no evidence of insulin resistance. And, and bearing in mind your normal weight and active lifestyle, there is not much room for improving insulin sensitivity. Blood glucose is near-normal and c-peptide is low, at the same time. If there was insulin resistance, one would expect to see high blood glucose and/or high c-peptide. As you say, your problem appears to be reduced beta cell output. Injecting supplemental insulin would just be closing the gap between your body's needs and what your beta cells are producing. And it seems most unlikely that doing this would cause insulin resistance.

Having said all that, the causes of insulin resistance are still a bit of a mystery. So who knows might happen ...

[matingara]

i am similar to Ronin. active, working and reasonably slim.

i seem to have no problem with insulin sensitivity.

i have been considering using insulin to help my beta cells rest. my GP is supportive of this.

my main question has been - how much do i take? do i take it only at meals etc???

my normal fasting BGL is between 4-6 (72-108). so i imagine taking a basal dose of insulin might send me low. yes?

-- Joel.

[jacobsam622]

Originally Posted by Ronin

Jan, et al.,

I tend to agree. My A1c numbers would tend to indicate that I'm doing okay, but there is the nagging question of what damage, if any, is happening with A1c levels in the 5 - 6 range which is well above the mid 4's that "normal" people have.

Another, sub-issue is that of the relevance of age on the equation. As I noted in another post, "the study" that is most often cited used a sample of people who were in their 20's. It might be interesting to sample the same people today when they are older and see if they are always returning to the 70 - 80 mg/dL range at two-hours post-prandial. That could be revealing. My interest is more a product of finding more-and-more of my fellow Pre-D's who have low C-Peptide readings which indicate that their Pancreatic function is reduced. Is that genetic, environmental, or simply a factor of age?

The other lingering question is: if a Pre-D were to use insulin to bring their BG levels down into the 70's (assuming they have a low-normal C-Peptide), could this cause Insuin Resistance on top of the Pre-D condition?

Thanks to Jan for the positive comments. I did stray from my normal regimine today and got a post-prandial of 146 as a result. Forutunately, 25 miles of bicycling later I was back down to 119. Sometimes temptation is just too hard to resist and I have to realize the cost.

FWIW: for those not following the Chit-Chat forum -- the male Siamese we are guardians for, Mr. Muggels (who has Chronic Renal Failure), is doing much better although he is very high maintenance. (I have to be careful as it seems every time I report good news he gets a sour day.)

Are you saying that we are not normal. Well we may not be normal now but in another ten years diabetes will be the norm, that means adnormal people will be healthy. But thats for another day.

Numbers don't mean anything unless there is some Idea where they came from.
FPG, and OGTT measure blood glucose but 100 on one is not the same as 100 on the other. Throw in meter readings and
A1c and you have a real mess.

FPG is your fasting blood glucose between 100 and less than126 would indicate pre-diabetes 126 and above would mean you have diabetes

OGTT measures whether you have impaired glucose tolerance
if you your s are between >=140 and <200 you have pre-diabetes
over >=200 you have diabetes

A1C measures your blood glucose over a three month period with weighted numbers toward the last month before the test. anything over 7.0 is bad.

meter readings vary from meter to meter time of day health issues. anything between 80 and 120 is normal.

Studies are just that studies you can make them show anything you want. there are studies that say type 2 diabetics are not do not suffer from the dawn effect. I know from my experience and others that it not only real but a major cause of stress.

Eat right and get lots of exercise and hopefully you will never need to take any diabetes medicine, for that path leads to the dark-side and once you start down that path forever will it dominate your life. IMO

Now which tests are you getting your numbers from

[Ronin]

Hi Joel!

You are listed as a Type-2 and taking medications to increase insuin sensitivity. On what basis was the Type-2 diagnosis made? I am particularly interested in the C-Peptide levels (1 being low-normal and 5 being high-normal). If you haven't had this checked, you might want to do so as you may be mis-diagnosed.

I note a rather dramatic drop in you A1c numbers -- how did you accomplish that?

You did repeat my question about timing and dosage for supplamental insulin injections -- perhaps somebody will step forward on that question.

I'll throw one more into the mix -- what is the shelf life of insulin?

[matingara]

Originally Posted by Ronin

Hi Joel!

You are listed as a Type-2 and taking medications to increase insuin sensitivity. On what basis was the Type-2 diagnosis made? I am particularly interested in the C-Peptide levels (1 being low-normal and 5 being high-normal). If you haven't had this checked, you might want to do so as you may be mis-diagnosed.

I note a rather dramatic drop in you A1c numbers -- how did you accomplish that?

You did repeat my question about timing and dosage for supplamental insulin injections -- perhaps somebody will step forward on that question.

I'll throw one more into the mix -- what is the shelf life of insulin?

hi Ronin,

yeah - look i think i may have been mis-diagnosed. but the GP is just happy with my BGLs and A1C. that is enough for him (and me) at this stage.

i am scheduled to have a c-peptide test in June. i am not rushing at this stage.

i got my A1C down dramatically by watching my BGL and reducing my carb intake.

the medication i take stimulates my pancreas. it does snot increase my sensitivity.

i am going to see how my body pans out over the next two months. if i get to the point where i can barely eat any carbs then i will ask for some sort of insulin regime. at the moment i am consuming almost no carbs - and my BGL stays between 4 and 7 (72 - 126) - but i think i need a bit more freedom and i think insulin will let my beta cells rest.



-- Joel.

[Ronin]

Hi Joel!

Apologies for misunderstanding the type of medications you are on. So many of the Type-2 meds are focused on increasing insulin sensitivity that I made an assumption.

The C-Peptide part of this is really important. Pushing your Beta-Cells will increase your available insulin, but the down-side risk is that you may be hastening Beta-Cell-Burnout. As a Pre-D I have found more-and-more of my fellow Pre-D's who are slim, active, and do not fit the profile of the "typical" Type-2. Almost to a person, when they get their C-Peptide checked, they find that they have low readings which indicate a pancreas that is not producing sufficient insulin to work with the glucose in the blood stream.

Like you, I have done a lot with diet and exercise, but I have also found that there are some limits while trying to live in the world today. My tandemning/bicycling, particularly in high season (which is just starting) burns carbs at a very high rate and I can, to some extent, get away with more carbs than I can in winter. However, I do wonder what is happening with my pancreas. Therefore, I'm trying to get at least an annual C-Peptide reading to monitor my pancreatic output. All I know for certain is that if/when my BG cannot be managed by diet and exercise Insulin will be the treatment of choice (this freaks my wife out, despite my telling her that insulin is a natural hormone whereas the other drugs are not). For the time being I'm in "Watchful Waiting" mode. We will like hearing about the results of your C-Peptide test later in the year.

[lottadata]

Well, I was told I was a "classic Type 2" and the doctor refused to give me insulin because she said it would just pack weight on me. (I was and am a normal weight)

Eventually I was going over 140 mg/dl eating under 12 grams of carb a meal with a full dose of metformin and Avandia and I got my family doctor to give me some basal insulin.

And I promptly hypoed on a dose LESS than the usual starting dose for a Type 2 my size. Turns out I wasn't the least bit insulin resistant.

Now I am using 2-3 units per meal and it makes a huge difference in what I can eat and what blood sugars I get.

I do not think my situation is as rare as doctors would suggest. I think they tend NOT to give people insulin until they are on the brink of blindness or amputation and a lot of smaller people who follow the usual high carb diet recommendations get blood sugar related heart attacks first so they never find out about their insulin sensitivity.

That said I still can't get my fasting bgs down lower than the 90s, but 90s beat the 120s which is where I am without insulin relying only on diet.

I would not personally start insulin unless diet could not control the post-prandial numbers to safe levels, because hypos can be an issue.