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leosmith

What's reversible?

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ronmesnard

Clint that is good news!  I was DXed when they wouldn't 'worry you' until your A1c was over 7.  By going after the preDs, they are doing everyone a favor.  At least  the preDs in this forum seem to be winning or at least not losing the fight.  I heartily approve of the loosening of the preD definition by using an impaired glucose tolerance as the criteria.  These persons with a 'normal' A1c should have the easiest time beating the 'beast'.  

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leosmith

I heartily approve of the loosening of the preD definition by using an impaired glucose tolerance as the criteria.

Are you talking about a different test - a glucose test instead of A1c?

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inglucerant

Are you talking about a different test - a glucose test instead of A1c?

Yes, this is absolutely what's needed. I had A1c's in the 5.7 range for a decade, and never was diagnosed as pre or T2, until I developed neuropathy. But a simple fasting BG isn't good enough either. You need to see what's happening to your BG after meals - 1 hour and 2 hours later. Unless you have a good glucose tolerance test, the only way to find out if you're headed toward trouble is to test yourself.

 

On another note, I saw that Kaiser is going to start testing overweight people for prediabetes (http://khn.org/news/new-guidelines-boost-diabetes-screening-for-overweight-adults/). This might reverse the leveling off of diabetes mentioned above, since I bet there are millions of people who are preD and don't know it.

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leosmith

Yes, this is absolutely what's needed. I had A1c's in the 5.7 range for a decade, and never was diagnosed as pre or T2, until I developed neuropathy. But a simple fasting BG isn't good enough either. You need to see what's happening to your BG after meals - 1 hour and 2 hours later. Unless you have a good glucose tolerance test, the only way to find out if you're headed toward trouble is to test yourself.

 

On another note, I saw that Kaiser is going to start testing overweight people for prediabetes (http://khn.org/news/new-guidelines-boost-diabetes-screening-for-overweight-adults/). This might reverse the leveling off of diabetes mentioned above, since I bet there are millions of people who are preD and don't know it.

What do you think of an OGTT with insulin assay (http://www.tuitnutrition.com/2015/09/its-the-insulin-1.html)? Needed or not?

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OldTech

I think that there is a simpler test than an OGTT and that is to just check your 1 and 2 hour readings after a meal. If you are spiking into the pre-diabetic range, you're headed for trouble. The ADA defines this range as 100 to 125 mg/dL (5.6 mM/L to 6.9 mM/L) for fasting, but I would use this for postprandial as well. 

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leosmith

I think that there is a simpler test than an OGTT and that is to just check your 1 and 2 hour readings after a meal. If you are spiking into the pre-diabetic range, you're headed for trouble. The ADA defines this range as 100 to 125 mg/dL (5.6 mM/L to 6.9 mM/L) for fasting, but I would use this for postprandial as well. 

Yeah, I've done all that and I am (or was) definitely pre-diabetic. But I'm interested in what people think about the article I linked to. It says that even if you're in the clear with the other tests, you still might have insulin issues which technically make you diabetic (by someone's definition).

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OldTech

I agree and now think that it is higher levels of insulin that cause vascular damage which turn can lead to insulin resistance and type 2 diabetes. 

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inglucerant

Yeah, I've done all that and I am (or was) definitely pre-diabetic. But I'm interested in what people think about the article I linked to. It says that even if you're in the clear with the other tests, you still might have insulin issues which technically make you diabetic (by someone's definition).

 

In my case, once I tested 1 hr. and 2 hrs. after every meal, and found myself spiking over 140 routinely, I didn't need any more tests. At that point it was simply a matter of changing my life to keep my neuropathy from getting worse and/or getting other complications. I did that with regular exercise and limiting my carb intake to < 50 grams a day.

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ronmesnard

Actually I think the mechanism is

Eat too many carbs -> high blood fats -> activates RAAS producing hypertension and if you have the wrong genes insulin resistance (RAAS hormones produce insulin resistance)-> insulin resistance cuts down the insulin in blood vessel walls -> which causes CVD.  

 

I will quote my notes on an article that you posted a link.  " NO is involved in the insulin-elicited capillary vasodilatation" is a direct quote from that article

 

 

In insulin-resistant subjects, endothelium-dependent vasodilation is reduced.  This is because insulin resistance cuts down the amount of insulin getting into the endothelial cells that make NO.  Conversely, the loss of endothelium-derived NO permits increased activity of the proinflammatory transcription factor nuclear factor kappa B (NF-κΒ), resulting in expression of leukocyte adhesion molecules and production of chemokines and cytokines.8 These actions promote monocyte and vascular smooth muscle cell migration into the intima and formation of macrophage foam cells, characterizing the initial morphological changes of atherosclerosis.

....

Consequently, there is decreased availability of NO, increased production of endothelin (ET-1), activation of transcription factors such as NF-κB and AP-1, and increased production of prothrombotic factors such as tissue factor (TF) and plasminogen activator inhibitor-1

Subsequently, we examine the link between endothelial dysfunction and IR. NO is involved in the insulin-elicited capillary vasodilatation. The insulin-signaling pathways causing NO release are different to the classical.

...

IR is associated with an imbalance between both pathways in favor of the vasoconstrictor one.

 

 

This concludes 

 

 

It is suggested that enhanced activity of renin-angiotensin-aldosterone system may underlie development of insulin-resistance and hyperinsulinemia. The latter plays a significant pathogenetic role in forming clinical picture of essential hypertension in insulin levels > 12.7 mcU/ml.

This states hyperinsulinemia plays a  pathogenetic role but no details as to how.  

http://www.ncbi.nlm.nih.gov/pubmed/10097296

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leosmith

In my case, once I tested 1 hr. and 2 hrs. after every meal, and found myself spiking over 140 routinely, I didn't need any more tests. At that point it was simply a matter of changing my life to keep my neuropathy from getting worse and/or getting other complications. I did that with regular exercise and limiting my carb intake to < 50 grams a day.

Same here. I think the main point of the article was to say that there's way to test for pre-diabetes that can catch it earlier on.

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ronmesnard

Yes leo and that was the right article for the question.  

 

The rise in Ac1 occurs years after OGTT with an insulin assay can detect insulin resistance. OGTT used to be the litmus test for determining if you had a sugar problem.  There is a move to bring this back.  Patients with D complications who have normal BGs fail this test.  

 

My reading shows insulin resistance IR does most if not all the body damage for pre diabetics.  The only thing the sugars do at this stage is make the b-cells sick so they produce less insulin.  I don't even consider this real damage since this is fully reversible. This is the only reversible problem in the D cycle.  For most of us IR hormones kills b-cells.  This is not reversible.  IR causes CVD which is not reversible as detailed in my last post.  It is most likely the cause of all the other complications.  If the CVD occurs in your eyes you get eye complications.  If it occurs in your kidneys you get kidney problems.  If it occurs to capillaries that feed your nerves, they go bad.  Because ALL these diseases can happen to patients with perfectly normal A1cs (low 5s), we need to understand IR is our worst enemy not even the sugar.  

 

Type 2 specific meds reduce IR and  protect our body.  Only the diabetics that don't kill b-cells can safely get off the meds.  These have the ability to completely recover from runaway A1cs. The ones that struggle with BG control while pre-Ds are likely in that other group.   It is also VERY smart to go the med route instead of relying on life style changes.  Don't get me wrong, the life style changes are important because your sugars DO matter.  But you are better off trying to fix what is broken as you improve your life style.  This can only be done with drugs.  Thanks to old tech I have read new material and reread old stuff that I hadn't fully grasped the big picture.  My advice to you leo, is medicate until you are in the low 5s but avoid sulfa ureas.  To my knowledge they do not reduce IR. Drugs like Invokana also don't reduce IR.  Metformin, Januvia and the inject-able GLP1 drugs are your friends; Metformin irritates the gut to produce more GLP1.  Januvia slows the destruction of GLP1s.  GLP1 is the yin and RAAS hypertension in the yang of this process. These are part of our survival mechanism just like the sympathetic and para sympathetic nervous systems.  RAAS is part of our fight or flight system.  It constricts a blood vessel that helps us with fight and flight as well as making us less likely to succumb to massive bleeding. The Yin and Yang should stay in balance.  RAAS can be ramped up by excess blood fats.  This is why your typical pre-D is overweight.  The ones that are not have worse genes.  There is a major genetic factor.  Normal persons just get fat when they have excess blood fats.  It is probably there are shades of how badly your RAAS reacts to too much blood fat due to your personal genetics.  You want to get your GLP1s high enough to have good sugar control with a healthy diet.  Think of your A1c as an indication of how well your IR is controlled and less that is an indication of your health.  I bet the RASS reduces the release of GLP1s into your blood. GLP1s counter what the RAAS system does.

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leosmith

Type 2 specific meds reduce IR and  protect our body.  Only the diabetics that don't kill b-cells can safely get off the meds.  These have the ability to completely recover from runaway A1cs. The ones that struggle with BG control while pre-Ds are likely in that other group.   It is also VERY smart to go the med route instead of relying on life style changes.  Don't get me wrong, the life style changes are important because your sugars DO matter.  But you are better off trying to fix what is broken as you improve your life style.  This can only be done with drugs.  Thanks to old tech I have read new material and reread old stuff that I hadn't fully grasped the big picture.  My advice to you leo, is medicate until you are in the low 5s ...

Based on my ave BG over the past month, my A1c should be about 4.9 now (down from 5.8 when I was diagnosed). You're the only one who has told me I should be on meds. Do you mind telling me where the material you read that lead you to this conclusion is?

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OldTech

Dr Berstien recommends an A1c target between 4.2 and 4.6 and average BG around 83 (I usually think below 100 all the time). But don't forget about IR because it can continue to do damage even with normoglycemia. At a minimum, I recommend metformin (as does Dr. Bernstien) and then if you have BP above 120/80 an ACE Inhibitor may be a good choice since it reduces IR in the arteries. And if you have ED then ED meds have been reported to reduce IR as well. A likely reason that you are pre-diabetic is that you have been consuming excess carbs along with being IR for many years. IR is deadly and leads to many complications including CVD and diabetes.

 

If you have not done so read "It's the Insulin, Stupid" at http://www.tuitnutrition.com/2015/09/its-the-insulin-1.html.

 

PS: Don't forget intense muscle exercise because it too will reduce IR.

 

Also see:

 

http://press.endocrine.org/doi/10.1210/jc.2015-3415?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed

 

http://www.hindawi.com/journals/ijhy/2013/230868/

 

http://diabesity.ejournals.ca/index.php/diabesity/article/view/19

 

http://www.ketotic.org/2013/08/the-ketogenic-diet-for-metabolic.html

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leosmith

If you have not done so read "It's the Insulin, Stupid" at http://www.tuitnutrition.com/2015/09/its-the-insulin-1.html.

 

PS: Don't forget intense muscle exercise because it too will reduce IR.

Done those, and will read the other articles. My doc definitely wouldn't agree to put me on meds; I'd have to really be convinced to switch docs.

 

Dr Berstien recommends an A1c target between 4.2 and 4.6 and average BG around 83

I've never read Bernstein. I see his book was originally written in 1997 - is it still worth reading today? 

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Fraser

Definitely worth reading. Also definitely important to evaluate his recommendations as to how it fits with your diabetes.

I prefer moderation, as long as my meter agrees with me.

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OldTech

Done those, and will read the other articles. My doc definitely wouldn't agree to put me on meds; I'd have to really be convinced to switch docs.

 

I've never read Bernstein. I see his book was originally written in 1997 - is it still worth reading today? 

 

If you're happy with your doc then don't switch. The suggestions that I made are just that based on what I am reading.

 

The latest revision is 2011. See http://www.diabetes-book.com/diabetes-solution/. 

 

The main focus of his book is 1) diabetics deserve normal blood glucose, 2) dealing with severe complications, 3) the idea that many complications can be reversed with normoglycemia and time, and 4) small steps mean small mistakes (mostly in regard to insulin). He is also a proponent of a very low carb diet (less than 30g per day).

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ronmesnard

Based on my ave BG over the past month, my A1c should be about 4.9 now (down from 5.8 when I was diagnosed). You're the only one who has told me I should be on meds. Do you mind telling me where the material you read that lead you to this conclusion is?

Leo you might have an up hill battle in any case.  It may be best to present this case to your Dr.  Print out the articles and leave them with your Dr.

 

Sure!  The articles are not obvious.  You will need to piece together information from many articles. 

 

I will add a little of my own theroy.  GLP1 is the antithesis of insulin resistance. IR is part of out fight/flight mechanism.  GLP1 and IR are supposed to be in balance but for some reason (higher free fatty acids)  IR becomes the dominant force.   

 

GLP1 reduces a destructive hypersension hormone angiotensin II.  Which is an IR hormone that does most of the damage to blood vessels and b-cells.  

The finding of GLP-1's ability to reduce angiotensin II concentration - See more at: http://press.endocrine.org/doi/abs/10.1210/jc.2012-3855

 

 

 

RAAS linked with insulin resistance and b-cell death (apoptosis)  (RAAS = hypertension IR)

Renin-angiotensin-aldosterone system and glucose homeostasis

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3223326/

At a cellular level, angiotensin II and aldosterone induce insulin resistance by increasing oxidative stress and altering insulin signaling, leading to decreased glucose transport. Angiotensin II also contributes to oxidative stress, inflammation, and apoptosis in pancreatic β-cells. 

 

 

 

GLP1s do many good things that are opposite IR.

The Multiple Actions of GLP-1 on the Process of Glucose-Stimulated Insulin Secretion

http://diabetes.diabetesjournals.org/content/51/suppl_3/S434.full

 

Metformin increases GLP1s as do a few other T2 drugs.  

 

I will try to find an article where d-neuropahty was diagnosed in persons with an A1c as low as 5.0.  This says to me IR starts to damage your body even in the 4s.  Metformin is few bad side effects.  Ask your Dr "What would be the harm of taking the lowest dose before bed? "  It doesn't make low blood sugar the Drs main fear.  What it does is helps restore a normalcy to your metabolism.  It fixes what is broken. You may actually have less GLP1s than a normal patient.  

 

While you sleep is the most sensitive time for diabetic progression or healing.

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leosmith

My advice to you leo, is medicate until you are in the low 5s 

I finally got around to reading all the articles you and OldTech posted links too, and my conclusion is that I should continue doing what I've been doing, which means no meds. I will go to a specialist after I fix my current insurance problem though.

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ronmesnard

You are making an informed decision. I am fine with that.  Your Dr might not even prescribe meds for you even if you insist.  I am not fine with persons too lazy to make an informed decision.  I am not completely convinced my side of the argument is 100% correct for everyone.  I am certain that side has a great deal of validity and I am the only member taking that side.  There have been rare cases where someone with D-neuropathy are found with an A1c of 5.0.  Now that they test D-neuropathy patients with a glucose tolerance test with an insulin assay if their A1c is normal, they have proved ALL D-neuropathy is caused my insulin resistance.  In the case of the 5.0s IR can damage your body even if your A1c is in the 4s.  I would guess it probably takes a decade or more for mild IR to produce enough damage to create a complication.  By taking a counter IR drug such as metformin you reduce that risk.  I put emphasis  on risk because there is no way to tell if IR is destroying your body. It is likely but not proven.  Our genes may dictate how aggressive the IR will destroy our body. There is no evidence to suggest that A1cs in the 5s are any safer than A1cs in the low 6s.   Yet most members will want to reduce their A1cs to the 5s to reduce a not measurable risk.  I am guilty of this.  I just find it illogical for persons to strive in areas that show little to no promise and ignore real risks that can simply be avoided by taking medicine.  We have a sizable population of members with various complications.  Who knows if they could could have avoided their complication by fighting this disease smarter.  The worst part is there is little to no warning for any complication which makes us all a bit crazy. 

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Barry6547

OldTech, I find Dr. Bernstein's book to be most helpful.  He is very aggressive about what we should consider normal.  He also has an internet meeting monthly where one can pose a question to him.  He mentions that numerous times throughout his book.  And, he lists his phone number per chance you want to know which BG meter he currently recommends for accuracy and repeatability.  When I called after purchasing the book I mentioned to his nurse that I had gotten my A1C down to 5.2. Her response was "good, now see if you get down to 4.8."  I believe it was  4.8 but not certain.  Dr. Bernstein still takes patients as well.  I need to get back to the book as I have been less aggressive this past year and my numbers have slipped.

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OldTech

I think that the number is from 4.2 to 4.6. Yes, he is very aggressive or should I say conservative, however, that is only with respect the advice given out by our officials. In reality, his targets are what you would find in healthy individuals that are not eating SAD. Also, note that he does talk about insulin resistance which Ron has been talking about. IR is not really new news although it is new to many of us. I still think that Dr. Bernstien is right.

 

I know in my case that I not only do not have any new complications, but I am reversing many of the ones that I had at diagnosis. That includes ED, PAD, and chronic constipation. My skin is also much better and I am not seeing the many pre-cancerous skin anomalies. I also now have a healthy mouth for the first time in my life (no plaque or gum disease).

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ronmesnard

Old tech I didn't know you had PAD which is now on the retreat. That would make sense with your research.  

 

Mouth bacteria are extremely sensitive to BGs.

 

I can also say I have benefited by moving to a healthier life style. Back in the science section there was a post concerning which genetics effected what types of complications you will be the most vulnerable to.  I am awaiting my test results.  I am itching to go through that report. 

 

Do you have diabetic feet?  If so are they healing?   

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OldTech

Old tech I didn't know you had PAD which is now on the retreat. That would make sense with your research.  

 

Mouth bacteria are extremely sensitive to BGs.

 

I can also say I have benefited by moving to a healthier life style. Back in the science section there was a post concerning which genetics effected what types of complications you will be the most vulnerable to.  I am awaiting my test results.  I am itching to go through that report. 

 

Do you have diabetic feet?  If so are they healing?   

 

Mouth bacteria also love carbs.

 

No, I don't. At least, that's one complication that I don't have.

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