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steel

complications at normal A1Cs

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steel

Hi all

 

I came across a post elsewhere on complications developing in a t2 diabetic with normal A1Cs. They had a strong family history of diabetes and were thin. I was wondering what the mechanisms behind this might have been. I have read of some people being more genetically susceptible to complications even at lower AICs say about 7, but developing complications at a normal A1C in an active person on a low carb diet is pretty awful.  Cormobidities also worsened for them, so I was thinking it's possible for something like high cholesterol to worsen despite good diabetes control as there can be factors besides diabetes in play. But complications from diabetes occurring at normal A1Cs makes me want to understand the underlying mechanisms behind such an outcome.  Any thoughts would be welcome. 

 

 

 

 

Edited by steel

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adiantum

An A1c of 7 is not normal & would naturally attract complications.

 

 

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steel
3 minutes ago, adiantum said:

An A1c of 7 is not normal & would naturally attract complications.

 

 

For sure. This person's A1C wasn't 7. It's said to have been normal. 7 was just an example I gave of an A1C where complications develop, whereas some people have higher A1Cs than that and don't have complications (which doesn't mean they won't develop them).

 

The person in question had normal A1Cs and still developed complications. Retinopathy was one I think.

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Kit

A1C doesn't tell the whole story.

 

Looks at it this way.

An A1C of 6.0 is an estimated average glucose of 126 (7)

 

I can achieve that A1C by spending most of my time between 100 and 152.

I could also achieve that same A1C by bouncing evenly between 50 (2.8) and 202 (11.2)

 

The first one is relatively stable though higher than I would like.  The second swings wildly between too low and way too high.  Damage isn't done by averages, its done at the high end of those ranges.

 

Then we have human tendencies of deciding the meter which gives us lower numbers is in some way more accurate, potentially building an inaccurate picture of daily readings.  Which then tends to lead to people saying their A1C tests are too high.  I've seen it happen in the past.

 

But it also comes down to this for me.  Complications are pretty much guaranteed from high numbers.  Even if bringing our numbers down to non diabetic levels doesn't 100% prevent complications, the odds are still way better than not taking care of things at all.

 

And the fun part is there is a lot of disagreement on what normal actually is.  Dr Bernstein tries to get all of his patients under an A1C of 5.0.  (4.6 I think it was).  Listen to my last doctor, and there is absolutely no reason to have an A1C of under 7.0.  My lab reports give normal of 4.0 - 5.6.

Edited by Kit

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steel

@Kit that makes sense.  I was also wondering what normal meant exactly in their case.  This person was diet and exercise controlled, so it's likely they weren't going too low. But yeah..great points.

 

Dr. Bernstein's explanation for the 83 average, for which he aims, was that he tested a bunch of non Diabetic medical sales people and their numbers were at or close to 83. It's best to aim for A1Cs as close to 5 (or even below). But based on what I have read and understood, I don't think it's possible for most people to consistently get A1Cs under 5s without insulin. Jenny Ruhl talks about it in her Blood Sugar 101 book or her 1000 Diabetes questions book, can't remember which. I think an A1C in the low 5s  is a good goal, achievable and more sustainable than getting below 5 consistently. Most true non diabetics are likely in the low 5s rather than below 5, based on recent research Ruhl quoted. Below 5 is a great goal. Imo normal can be a bit higher and still healthy.

 

My lab uses the same range too. It seems to be the standard.

 

 

 

Edited by steel

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Fraser

I believe Dr. Bernstein, stated that he did not believe that T2 could achieve his goals for A1c with out using insulin. 

 

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steel
14 hours ago, Fraser said:

I believe Dr. Bernstein, stated that he did not believe that T2 could achieve his goals for A1c with out using insulin. 

 

Thanks I didn't know this.

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Hammer

Yes, what Kit said, but to look at it even more closely, you can spike to, say, 200, and you stay at 200 for 15 minutes, then you slowly drop down to 60, but it takes hours to get there, but once you're there, you stay there for 5 hours.  If you average in all of the levels you went through to go from 200 to 60, and how long you were at each level, your A1c could show that your in a good range, but you can't know where you were at any given time, unless you have a Continuous Glucose Monitoring System (CGMS).  

 

There are also other factors that come into play....cholesterol levels, triglyceride levels, how strong your immune system is, genetics, and the list goes on.  One person could maintain an A1c of 5.0, but their triglycerides and cholesterol are too high, and they spike to 200, then drop to 60 frequently.  Combine all of this, and the person could have complications.  By the same token, a person with all of the things that I just mentioned, but has a strong immune system, might not develop complications.  Considering how complex the human body is, there is no way to know how it will react in situations like this.  The best we can do is to strive to get our BG levels down through diet, exercise and medications, and by doing that, we know that we did all we could do to guard against developing complications.  Yes, we might still develop complications, but we were able to hold them for a lot longer than if we did nothing.:)

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Dave_KC

I think if there's any clarity here, and what the goal should be, is to keep the blood sugar from spiking into non-diabetic ranges.  Sadly, there's a lot of thinking out there that it's OK for diabetics to have A1c's in much higher than I think is safe ranges.  

 

My goal is for my blood glucose and A1c to be in non-diabetic ranges.  While it's never a guarantee of the future, it should push off complications as long as possible, which is my goal.  

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Hammer

I think that the reason that doctors think that it's okay for a diabetic to have higher numbers than a non-diabetic, is because so many type 2 diabetics are non-compliant, and take no steps to control their glucose levels.  That results in non-compliant diabetics having really high glucose levels, so if the doctor sees a diabetic with lower numbers, even if those numbers are higher than a non-diabetics numbers, the doctor is satisfied that the patient is at least doing something to control their diabetes.  I think that if every diabetic did what we here try to achieve, that doctors would eventually change their attitudes regarding higher glucose numbers.

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steel
5 hours ago, Hammer said:

I think that the reason that doctors think that it's okay for a diabetic to have higher numbers than a non-diabetic, is because so many type 2 diabetics are non-compliant, and take no steps to control their glucose levels.  That results in non-compliant diabetics having really high glucose levels, so if the doctor sees a diabetic with lower numbers, even if those numbers are higher than a non-diabetics numbers, the doctor is satisfied that the patient is at least doing something to control their diabetes.  I think that if every diabetic did what we here try to achieve, that doctors would eventually change their attitudes regarding higher glucose numbers.

 

IMO the problem isn't that doctors think relatively higher numbers are okay because many t2s are non compliant. many t2s are labeled non compliant because doctors and the ADA set very high numbers as targets, and people are misled into believing A1Cs in the 8s or whatever are okay. i read that this goes back to the deadliness of lows, and doctors trying to save ass by preferring diabetics run higher so they themselves have less risk of malpractice lawsuits.  Dr. Bernstein touched on this in one of his Diabetes university videos. I know that t2s not on insulin or sulfonyureas etc.  rarely go low, but that seems to be one of the reasons behind high BG targets. other than that, diabetic complications are, as we all know, good for "business". keeping T2s, who are already blamed for their predicament (so called 'lifestyle' disease nonsense), sick doesn't just stroke doctors' smug egos but also makes them money. people are also given terrible dietary advice, and the common approach in the medical industrial complex is...t2d is a progressive illness and the end result is amputations, blindness etc. they don't give patients confidence (and truth) by telling them they can in fact control their blood glucose by significantly lowering their carb intake (doctors still talk about "sugar" rather than carbs which is very misleading).  people keep eating what damages them, then see their  numbers get worse despite eating "good carbs". i think a lot of people end up accepting that ..that's just how it's going to be and if eating the good diet prescribed by doctors isn't helping then...maybe they should just end up enjoying whatever time they have with their kidneys, eyes, feet etc still in place.

 

I think we live in (and always have) in societies that foster acquiescence to people in positions of authority. we are conditioned to assume doctors know best because they're the experts. we are taught to follow doctor's orders, even when things aren't adding up aka worsening BG despite eating whole grains etc. doctors themselves scoff at patients who ask questions, who are critical consumers of information. doctors derisively call them 'medical googlers'. like sure some people are hypochondriacs etc. but most people (like most of us here on this forum who learnt from the experience of other diabetics) are being proactive. and being proactive about your health isn't encouraged, when it means going against the bad advice of doctors. It is getting easier I think in a more socially connected world online ..to learn from each other and share info. and lessons we've learnt. A lot of diabetics who don't have access to these communities, for a whole host of valid reasons, are being labeled non compliant despite their compliance, albeit to harmful diet advice and BG target setting.

 

of course there are  Diabetics that are truly non compliant for complex reasons that I don't think I am in any place to judge (not saying anyone else is being judgmental here). but the very vast majority of diabetics are wrongly labeled as non compliant and just not given the information needed to manage diabetes. IMO as information becomes widely available (thanks to online communities) and as LCHF goes mainstream (with doctors joining voices as well), the complication rates for Diabetics will go down, and that whole Diabetics live 20 years less than Non Diabetics nonsense will be proven wrong too.

 

 

 

 

Edited by steel

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Dave_KC

I love that I've made some heads really spin at the clinic I go to, because of what I've done with my diabetes diagnosis.  They were rather shocked that someone could go from 12.6 A1c to 5.0 and then stay there without meds.  They've said I'm one of, if not the only one, who's made this level of improvement with my diabetes at their clinic.  

 

They also acknowledge that I haven't followed their dietary advice. 

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meyery2k

What can be frustrating is when I am asked how I lost all the weight, I have to explain that being diagnosed with diabetes was the thing that made me want to change. 

 

When I explain how diet and exercise were the primary reasons for getting both under control, that is accepted.

 

When I am asked about diet, I share what I do.  Then our paths diverge.  I am astounded when someone will reply that their doctor says my diet is unhealthy and will make me worse.  I reply that I can only really work off of what I can observe and I would respectfully disagree with your doctor.

 

I think @steel is onto something about the malpractice angle.  I seem to be very fortunate.  My doctor actually encourages me now to keep doing what I do.  At first, he was skeptical about the diet.  He thought I should eat more carbs but after seeing the results with his own eyes, he was impressed.

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Kit

I'll guarantee @steel is correct.  Its primarily about malpractice.  Someone can die or end up in the ER from a hypo immediately.  Diabetes complications can take decades to rear their heads.  And, of course, complications are inevitable so there's no reason to think the cause might be treatment related.

 

Now I don't mind them mentioning various levels of control.  Yes, someone floating in the mid and upper 100s might be better than they were 200-300s.  Kind of like good, better, best control idea.  But, they should be willing to work with patients who want that better or best control.  Or, not do what my last doctor did, and treat my control like an insult she needed to fight against.

 

I mentioned my goals to her and before I was even able to finish what I said, kept going "who told you that" and would not listen to a single word I said from that moment on.  She was also adamant that there was absolutely no reason to have an A1C of under 7 since she said that is where heart attacks are reduced and apparently the only complication she cared about.   Part of me hopes one day she realizes that she worked very hard to assure her diabetic patients die a really horrible death.

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steel

My doctor also smirked when I mentioned my BG targets. That kind of condescending response is very common.  :| I wish diabetes, high a1c numbers and complications on these doctors. 

Edited by steel

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Dave_KC

I'm probably blessed that I didn't mention my targets to those I saw at the clinic, but just went out and did it...  and shocked the socks off of them.  I really think there's wisdom to just work hard and do your best, and let the chips fall where they may.  They've struggled to argue with what I'm doing when my numbers are so good.  

 

And wouldn't you know it my cholesterol numbers are all great too.  

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