The Practical Diabetic

I thought I would go through the report I generate for my endo before every visit and the tools I use to create it.

Tool 1: Microsoft Word

All the graphs and tables I generate I put into Word and then save to PDF for emailing.

Tool 2: Nightscout (OOB Reports)

If you are unfamiliar with Nightscout it is, essentially, a web site which shows your CGM’s glucose readings. Very useful for allowing others to review your levels, and used in some looping setups.

For more details on Nightscout, go here. It all might sound technical but the automated scripts make things really easy and no coding knowledge is needed. Also, all the tools it uses are free.

It also comes with a report section which can generate a Glucose Distribution Graph. Generally I select three months for my graphs even if I have not been wearing a CGM for the whole time. This is what the graph looks like.

I am pretty happy with this. Using the conventional TIR range (3.8-10/70-180) I am 93% in range. Given I have not been particularly strict over the last three months, I am good with this. My predicted HbA1c is 6.0% which is creeping up but, given my pancreas is slowly being destroyed by my immune system, this is not overly surprising. Hopefully the blood tests will reflect a similar HbA1c when I get the results back.

Nightscout also has a Glucose Percentile report showing the spread of values over the day.

Looking at the highs, the areas of interest are night time (around 8pm – 1am) and lunchtime (2pm). In both cases it is likely poor food choices which are to blame. Maybe choosing less carby options at lunchtime will help and maybe I need to be more judicious in my late night snacking.

Tool 3: Nightscout Reporter (https://nightscout-reporter.zreptil.de/)

For this tool you will need Nightscout set up. Assuming you have Nightscout in place, you go to the Nightscout Reporter site, give it the web address of your Nightscout site and it does the rest. It also generates a table with similar information to the first graph.

To the casual observer, the “Lowest value in the period” at 1.7mmol/L (30mg/dL) may seem something of concern but this was simply a bad reading from my CGM; it is either a “compression low” (sensor giving a low reading by being squashed) or a worn out sensor giving nonsense readings. Being insulin independent it is impossible for me to go that low. The lowest I have ever been is around 3.5mmol/L (63mg/dL).

The Nightscout Reporter also has a Glucose Percentile Report but, as it is essentially a repeat of the same report from Nightscout reports, you only need one of them.

The next report I include in my report to my endo is the Comprehensive Glucose Pentagon. It is a spider graph of five parameters us people with diabetes need to keep an eye on and compares it to the typical values for a Muggle (non diabetic person).

For me, the outlier is the CV %, the variability in my glycaemic values. Again this suggests maybe less sweet treats and more lower GI options.

Finally, the Nightscout Reporter gives us a distribution graph of glucose values.

This also gives us a good indication of where our numbers sit.

Medications and Questions

Finally in my report to the endo I include a list of my medications and supplements, and any questions I have. Given my questions often involve new medications or protocols it seems fair to give my endo some notice before meeting them so they can do some research beforehand.

Longitudinal Analysis

The other benefit of generating these reports is I can review the results over time. For example, here are the results of my glucose distribution for 13/08/20-13/11/20, 17/06/21-14/09/21, and 12/12/21-12/03/22

13/08/20-13/11/20

17/06/21-14/09/21

12/12/21-12/03/22

If we look at the “Values above 10.0mmol/L” (180mg/dL) we see this is slowly increasing but still substantially less than the 25-30% guideline.

While the standard deviation is the same, the GVI is increasing suggesting less blood glucose control, but still in the “good” range.

Average glucose is also rising over time.

All of this is consistent with a LADA’s slowly deteriorating pancreas. The question will be when do I start looking at additional interventions, such as insulin? As per my analysis on when damage starts to accumulate, I am happy to let things progress until my HbA1c gets closer to 6.5% but this is also a good subject to discuss with my endocrinologist at my appointment.

This week was my fifth diaversary. It is a word you will not find in the dictionary and is used exclusively in the diabetes community. In short, it is five years since I was diagnosed with Type 1 diabetes.

It may seem a strange thing to celebrate, the acquisition of a chronic, damaging, sometimes fatal disease but it is important, at least to me.

To celebrate I went all out with Italian:

• Half of a 14″ meat-lovers pizza
• 4-inch square of lasagne
• half a garlic bread roll
• single serve of tiramisu

A nightmare to manage for most Type 1s. Being a honeymooning LADA, albeit an insulin-independent one, helped although I still spiked, peaking at around 12.2mmol/L (220mg/dl) and then headed down.

So why subject my body to such a stress? Because sometimes it is the healthiest thing you can you do for yourself.

My Usual Eating Routine

I characterise my diet at “lowish carbohydrate”. Where there is an obvious, practical low/no carbohydrate alternative to a food, I will eat it. I do not drink sugary drinks, opting for the ‘diet’ alternatives. I am very comfortable with sugar substitutes such as phenylalanine and sucralose. As a general rule I try to make sure anything solid I eat has 10% net carb or less and, for liquids, zero carbs. That is it.

The result, when I stick to this, are blood glucose traces like this.

The thing is, even with these relatively light rules, it still requires commitment and effort to maintain. If I am eating out, I need to scan the menu for the friendliest options. I need to make sure, if I order a soft drink, that the diet version has been served and not its sugar-filled cousin and so on.

Other Common Eating Regimens

Other common eating regimens for people with diabetes are even stricter. If we consider Bernstein’s approach we are eating:

• 30g of net carb or less per day
• Roughly the same amount of carb every day for breakfast, lunch, and dinner e.g. 6g, 12g, 12g
• Eating at roughly the same time every day

That is a lot to keep on top of and while I am sure the ‘Gritters’ will say it is not a big deal and worth it because “we deserve normal blood sugar levels” there is no doubt it does require effort and will impact social interactions with those not complying with this routine.

The strictest of all is probably the zero-carb carnivore diet. This pretty much speaks for itself; if it was not once part of an animal (or is a drink with practically no calories) it is off the list.

At the other end of the spectrum we have the Forks Over Knives advocates, where eating involves a “plant-based diet”. In short a “small v” vegan diet where no foods are off-limits but some (those from animals) are to be avoided.

This one is relatively friendly and, for those looking to reduce insulin resistance the benefits of avoiding animal fats may outweigh the additional carb intake.

Whatever system that is followed, assuming a person with diabetes is adopting some kind of food management, rules mean conscious effort.

The Risk To Mental Health

Orthorexia nervosa is defined as “an unspecified feeding or eating disorder characterized by an exaggerated, unhealthy obsession with healthy eating”. “The affected individual might be driven by dietary asceticism, cherry-picked evidence, or even by evidence-based recommendations, leading to a restrictive dietary pattern in pursuit of improved health”. Overly strict diets which individuals religiously follow, and myths about the food we eat feed, reinforce this kind of unhealthy thinking.

Another aspect is willpower (also known as volition) is a finite resource. A person can only perform conscious actions for so long before they need to take a break. A person with diabetes is ‘on’ 24-7 (except possibly the closed loopers but they are still the exception rather than the rule). They know that maintaining their blood sugar is necessary to stay alive and stay healthy. So what happens when they run out of willpower to manage their disease? Diabetes Burnout. They simply stop managing the disease because they need to take a break.

Obviously there is a lot more to managing diabetes than food intake but it certainly contributes and can be overly burdensome when it becomes all-consuming.

Food Myths Which Contribute To Orthorexia And Diabetes Burnout

There are a few myths when it comes to blood sugars and food which focus on 140mg/dl (7.8mmol/L)

“Damage Starts Happening When Your Blood Sugar Goes Over 140mg/dl”

I tackled this in a previous blog. In short, there is no evidence that damage begins over 140mg/dl. There is literally no study which has examined people with blood sugars at 141mg/dl and observed cellular damage occurring. It is a myth used to sell books but has no basis in scientific fact. It is true that having a sustained high blood sugar will do damage in the long term but this is better measured through metrics such as the HbA1c or Time in Range (TIR).

“Muggles (Non-Diabetic Folk) Never Go Above 140mg/dl”

This is simply not true. A recent article gave a great summary of some of the research that has been done in this area. Here are quotes from the studies examined:

• Muggle Study #1: “On average, their daily glucose levels stayed between 70–140 mg/dl for 93% of the day, with very small portions of the day spent above 140 mg/dl or below 70 mg/dl”
• Muggle Study #2: “Levels were lower than 70 mg/dl for 1.7% of the time and greater than 140 mg/dl, only 0.4% of the time.”
• Muggle Study #3: “Participants spent 93% of time between glucose values of 70-140 mg/dl, with 3% of the time below 70 mg/dL on average and 4% of the time above 140 mg/dl on average”
• Muggle Study #4: “2.1% of glucose sensor values were >140 mg/dl”
• Muggle Study #5: “Glucose was above 140 mg/dL for only 0.8% of the day”
• Muggle Study #6: “Participants spent 1.6% of the time above 140 mg/dl”

Literally every study showed that while going above 140mg/dl was the exception, even Muggles do it for short periods of time every day.

In other words, not only are these myths untrue, anyone believing them is putting themselves under unnecessary mental stress for effectively no discernible gain.

Diaversary As A Mental Steam-Release Valve

This is why I celebrate my diaversary. My diaversary is a day when I give myself permission to not to be as concerned with my blood sugars, secure in the knowledge that one day of spiking is going to do little but give me a mental break and help me recharge for the other 364 days. I genuinely believe the one day of poor bloods is a small price for sustained mental wellbeing. While maintaining healthy blood glucose levels is important, so is managing my mental health. My diaversary is a key element in my approach.

For Part 1, looking at reconciling the reports for diagnosis, go here.

Thanks to the generosity of #dedoc°, I recently had the privilege of virtually attending the world’s largest Diabetes conference: EASD 2021. Arguably the biggest news at the conference was an international consensus on the diagnosis, treatment, and management of Type 1 Diabetes. Interestingly, last year an international consensus was released for the diagnosis, treatment, and management of LADA. In Part 1 I reviewed how the two differed in terms of the diagnosis of Type 1 and LADA. In this second and final part I will look at the two reports’ recommendations for treatment and consider questions such as:

• Should someone diagnosed with LADA go onto insulin immediately?
• Are there treatments for Type 1 other than insulin?
• If I do use insulin what are the pros and cons of the various methods of delivery?

As usual, for those who want the short version, you can go to the tl;dr section at the end.

Where We Landed In Part 1

In Part 1, I concluded the diagnosis flow chart from the Type 1 report was the more detailed and effectively covered LADAs flow chart.

So, assuming someone has LADA or Type 1 diabetes means either:

• We have some reason to suspect diabetes (unintentional weight loss, ketoacidosis, glucose > 20 mmol/L (>360 mg/DL) etc.)

AND

• Auto-antibody presence OR
• Low C-peptide (less than 200 pmol/L (0.2 nmol/L) ) OR
• No features of Type 2 diabetes (BMI >= 25 kg/m^2, no weight loss, no ketoacidosis, less severe hyperglycaemia etc.)

Treatment According to the LADA Report

The LADA report has a flow chart for treatment which looks like this:

The Type 1 C-peptide limit is different (0.2 nmol/L vs 0.3 nmol/L) but, given there are two other options available which do not consider the C-peptide level in the Type 1 report (auto-antibody presence and no Type 2 features), there is still the possibility that someone with Type 1 could have a C-peptide in any of the above three ranges.

I go through the LADA and Type 2 guidelines in detail in my “Gold Standard” LADA article. In short, if your C-peptide is over 0.7nmol/L (700 pmol/L) options include:

• Metformin
• GLP-1 RA
• SGLT-2i
• DPP-4i
• Basal insulin
• TZD

While part of the Type 2 algorithm, there is a notable exception of Sulfonylureas not being used with LADAs because “The panel concluded that sulfonylureas are not recommended for the treatment of LADA, as deterioration of b-cell function as a consequence of this treatment cannot be ruled out”.

For patients with a C-peptide below 0.7 nmol/L, there are two flow charts. The first is if heart (ASCVD/HF) or kidney (CKD) disease is present with the same medications as before except TZDs which may have been excluded because of the limited evidence of benefit and increased risk of bone fracture.

For patients without heart or kidney disease, we have this chart where the SUs are still not present but which does include TZDs.

What is good is this set of flow charts covers the entire Type 1 C-peptide spectrum which means, even when someone with LADA becomes a “classic” Type 1 because of declining C-peptide levels, we have a prescribed course of action. What is missing is a complete answer to the question “When should someone with LADA start using insulin?” The answer from the above flow charts is “If the HbA1c is above target” but no target is firmly established. Let us move to the Type 1 report.

Treatment According to the Type 1 Report

In fact, the Type 1 report immediately addresses the issue of targets for Type 1 in their first table.

Here the target HbA1c is 7.0% with the caveat that “all glycemic targets should be individualized and agreed with the person with diabetes.” So, unless we have discussed and agreed on a different target with our health care team, achieving an HbA1c equal to or below 7.0% is a good benchmark for considering moving to the use of insulin. This is in agreement in my post where I considered how high someone’s HbA1c could be before a significant risk of long term damage.

For the specific question of when someone with LADA should consider bolus insulin, we also have guidelines for post-prandial (after meal) insulin levels with the suggestion that 1-2 hours after a meal a person’s glucose level should be less than 10 mmol/L (180 mg/dL) and the option of pushing this to less than 7.8 mmol/L (140 mg/dL) if safe to do so.

In contrast to the LADA report, the Type 1 report takes an “insulin-first” approach saying “The cornerstone of type 1 diabetes
therapy is insulin replacement” and providing the following summary of the multi-pronged approach suggested for the newly diagnosed.

Given how difficult it can be to manage insulin therapy in the newly diagnosed, it acknowledges the need to prepare for hyperglycemia (“highs”) and hypoglycemia (“lows”).

The Type 1 report also talks about the relative merits for the different ways of delivering insulin.

Where money is no object, clearly, closed-loop technology is the winner.

Eventually (page 27 out of 37 pages), the Type 1 report talks about “Adjunctive therapies”. In other words, treatments which can be used alongside insulin.

There is common ground between the two reports with both reports mentioning Metformin, GLP-1 RA, and SGLT-2i. It also mentions pramlintide which is an amylin analogue (another hormone produced by the beta cells and, therefore, compromised in Type 1 diabetes). It fails to mention DPP4i and TZD. TZD may be because of the limited evidence but I am not sure why DDP4i’s were left off the list. They affect the same hormone cycle as GLP-1 RAs and therefore have similar effects/benefits.

Reconciling the Two Reports

In contrast to Part 1 where I sided with the Type 1 flow chart for diagnosis, here I am siding with the LADA report for treatment. There are a few reasons for this:

• It explicitly considers treatment in the presence of heart and kidney disease
• It offers a more comprehensive range of non-insulin treatment options e.g. DPP4i and TZD (but should likely include Pramlintide as well)
• It takes the approach that insulin may not be necessary in patients with high C-peptide levels and, given the inherent hypo/hyper risk that comes with using insulin, if target ranges can be maintained, this seems like a sensible approach to me

This being said, the Type 1 report is much more comprehensive in considering the various ways of delivering insulin to the body (injection, pumps etc.) and also has a lot to say about looking beyond medication for individualised treatment e.g. considering lifestyle factors and diabetes education.

One big takeaway for all people with Type 1 or LADA should be that treatment no longer begins and ends with insulin. There are a range of other medications which can help with managing long term blood glucose levels and have other benefits such as helping a patient lose weight or reduce blood pressure.

tl;dr

Arguably, the LADA report’s flow charts for the treatment of Type 1 diabetes are more detailed for treatment than what is presented in the Type 1 report. Not only, does the LADA report consider insulin independence for patients with high C-peptide levels, it considers which medications are appropriate in the presence of heart or kidney disease. However, the Type 1 report fills in a significant gap of providing target values to chase and which help inform decisions such as when to move to insulin therapy.

The Type 1 report also goes into more detail in the areas of:

• The relative merits and costs of different insulin delivery methods
• Treatment of Type 1 diabetes beyond medication e.g. lifestyle factors and education