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How Successful Are Type 1 Diabetics In Regulating Diabetes?
November 12, 2020 /

How Successful Are Type 1 Diabetics In Regulating Diabetes?

27 min read

From the very beginning, in the first few days after the diagnose, we are confronted with unquestionable facts:

 

  1. Type 1 diabetes is a chronic, autoimmune disease that increases the risk of cardiovascular complications, chronic kidney failure, blindness and shortens life expectancy from 11 to 18 years 
  2.  Keeping your  blood sugar level normal (or close to normal) is necessary for prevention or prorogation of chronic diabetes repercussions,  
  3. Normal blood sugar level is < 5,6 mmol/L before eating, <7,8 mmol/L after eating with HbA1c < 5,7%,
  4. To achieve better  blood sugar level regulation, there are international guidelines for diet regulation and medicine usage

 

The last count worried me a lot for a long time. There are regulations that are clear, and in theory, I understand what I have to do. However, in everyday life and all the challenges it throws at you, I was so far away from good regulation. My motivation levels varied in different phases in life; sometimes I tried hard, sometimes not enough, but one thing remained the same, I couldn’t follow the standard guidelines and achieve good regulation. My reasonable conclusion was that the problem lies within me. Was it because of the wrong dosage, lack of discipline or wrong calculation? Something just wasn’t right…

 

If you look up HbA1c for “Diabetes type 1”, you will find a series of pages where you can check the normal levels for it. However, you will need to dig deeper into the story to find information of real HbA1c levels among the diabetic population.

 

A while ago, an article that answers that exact question (in the American population) was published. In cross-sectional studies, there was 22,697 type 1 diabetes examinees included. The data was collected from 2016 to 2018 and then compared to an examination done 5 years prior (from 2010 to 2012). The results were, unfortunately, withering. The average HbA1c from 2016 to 2018 in kids from 0 to 5 years old was 8,1 % and it then grew to 9,3 % in the group of teenagers from 15 to 18 years old, after which it reduced to 8% in the group to 28 years old, and after 30 y/o it stabilized somewhere in between 7,5 and 7,9 %. In the ADA guidelines, a recommended HbA1c in kids is < 7,5 %, in grown-ups < 7,0 %, which only 17 % of young ones and 21 % of grown-ups with diabetes managed to achieve. Furthermore, there are notes of average HbA1c worsening in comparison with the 2010 to 2012 period (8,4 % vs. 7,8 %).

What is the condition in Croatia like? Briefly, we can’t tell. New and relevant data about blood sugar levels of Diabetes type 1 persons in Croatia doesn’t exist. Currently, the only available resource is CroDiab Register where we can see the latest data from 2015 (https://www.hzjz.hr/wp-content/uploads/2017/04/Izvje%C5%A1%C4%87e-za-2015.-godinu.pdf). In the register, all diabetic persons are put in the same basket, which complicates the inside of Type 1. 

 

Anyway, let’s see the data:

 

26,78 % patients had good blood sugar levels  (HbA1c < 6,5 %), 33,26 % of patients had partly satisfying blood sugar levels (6,5 % < HbA1c < 7,5 %) and 39,96  % of patients  had bad blood sugar regulation (HbA1c > 7,5 %) with an average HbA1c of 7,46 ± 1,41 BSL* without eating, 8,61 ± 3,02 and postprandial BSL 9,37 ± 3,35.

 

In my evaluation, these numbers are too optimistic. Since Type 2 diabetics have lower BSL than Type 1 diabetics, I guess the real results of type 1 BLS regulation are worse than stated in the register.

 

Of course, HbA1c is not an absolute and all-powerful goal, neither measure without defiance. Its standard shortcoming lies in the lack of standard everyday BSL deviation insight. For example, how high then how low our BLS’s are in one day. There is an awesome article on this topic written by Maja Vučković, which I absolutely agree with. For now, HbA1c is the only thing we got and we can use it wisely. Especially if we pay attention to low HbA1c with rare hypo’s.   

 

I am going to draw the line here and try to make a conclusion.

 

First, we have some sort of guidelines and directions for what good regulation looks like. 

 

Second, only a small number of diabetics achieve results they’re proud of and satisfied with, results that give them comfort and a chance for delay or prevention of complications.

I believe there are three possible explanations of why not every achieves these results: 

 

  •   Goal levels are too strict and unreal.   
  •   BSL regulations are inaccurate and inefficient. 
  •   People with diabetes don’t apply instructions from BSL regulation, either because of lack of knowledge or lack of discipline.  

 

For most of my life, I considered the ADA’s goal BSL hardly accessible. I was diagnosed with diabetes when I was 9. For the next 19 years, I lived with 7 to 8,5 % HbA1c and I reached 6,7 % only once and it didn’t last until I corrected my approach to the problem, information and efficient tools that would help me overcome unpredictable and disobedient BSL’s. The HbA1c < 7 % levels seemed so far away and unattainable. There were a lot of times when I tried to fix my BSL’s and many times I didn’t succeed, so I’d back off with a conclusion that I will have to reconcile with my lack of discipline, disease stubbornness and its distressing consequences. Right now, 7% seems so far away too, but from the opposite side.

Today, ADA’s guidelines concern me for a different reason. I consider them too loose. Why aim at 7% when healthy people have up to  5,7 % HbA1c (before they’re diagnosed as pre-diabetics). Standard and considerable answer is that there is too much of a risk for a serious hypo, if the goals are set under 7 %. This fact is true, but conditionally. The condition is to try to lower average BSL while you eat foods that are suitable for diabetics (the likes of Mayo Clinic or Zivim.hr)

Can we, at least for a second, be naive, brave and curiously ask: is it possible to achieve a normal BSL’s without or at least diminished risk for hypoglycemia?

 

Last year, an article that was published showed something rare and special; people with diabetes type 1 and an average 5,7% HbA1c (11). Examinees in this study were using various methods for BSL regulation, but the most efficient method with which they achieved awesome results is through a very low carb diet. The comments in this article were mixed. It’s correct that the results are very good. It’s correct this is just a study. It’s correct that more studies need to be done. It’s correct that the low carb diet consequences are not examined enough. Consequences of common high BSL’s are examined enough and they are pretty bad. It’s correct that we have to pay attention to other factors (besides glycemia) that complicate the lives of type 1 diabetics and also present a potential risk of chronic complications. It’s correct that random clinical experiments, a golden standard of medicine based on proof are needed. Regardless of my medical and scientific background( my vocation is a doctor of medicine, currently working at Faculty of Medicine and getting my doctorate), I’d very much consider and probably decline to be an examinee because the fear of getting in a group of people with diabetes that needs to eat standard diabetic foods suggested in the healthy eating pyramid, where bread is at the bottom.

Science strives to be objective in the biggest possible way, and it would be catastrophic if there is any other way. On the other hand, human life is subjective. I’ve had enough of 19 years of high BSL’s, unsatisfying controls and a bad quality life. I write this knowing which foods I must avoid, without that ugly, sticky feeling of Hyperglycemia, with 4,9 – 5,1 % HbA1c, with Hypo’s are so rare and so mild that they pass through with half of dry date, with healthy kidneys with erased perennial microproteinuria and with quality of life I was seeking for a long time and nearly gave up on.

When your goal is clear and attainable,with successful,long-term, sustainable methods and your tasty foods, the problem of discipline fades away so easily that you catch yourself asking if you were ever undisciplined or the problem laid somewhere else, maybe in ineffective guidelines…

 

Reference:

  1. Rawshani A, Sattar N, Franzen S, Hattersley AT, Svensson AM, Eliasson B, et al. Excess mortality and cardiovascular disease in young adults with type 1 diabetes in relation to age at onset: a nationwide, register-based cohort study. Lancet. 2018;392(10146):477-86. Epub 2018/08/22.
  2. Huo L, Harding JL, Peeters A, Shaw JE, Magliano DJ. Life expectancy of type 1 diabetic patients during 1997-2010: a national Australian registry-based cohort study. Diabetologia. 2016;59(6):1177-85. Epub 2016/01/23.
  3. The relationship of glycemic exposure (HbA1c) to the risk of development and progression of retinopathy in the diabetes control and complications trial. Diabetes. 1995;44(8):968-83. Epub 1995/08/01.
  4. Nathan DM, Cleary PA, Backlund JY, Genuth SM, Lachin JM, Orchard TJ, et al. Intensive diabetes treatment and cardiovascular disease in patients with type 1 diabetes. The New England journal of medicine. 2005;353(25):2643-53. Epub 2005/12/24.
  5. Selvin E, Steffes MW, Zhu H, Matsushita K, Wagenknecht L, Pankow J, et al. Glycated hemoglobin, diabetes, and cardiovascular risk in nondiabetic adults. The New England journal of medicine. 2010;362(9):800-11. Epub 2010/03/05.
  6. 2. Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes-2018. Diabetes care. 2018;41(Suppl 1):S13-S27. Epub 2017/12/10.
  7. 4. Lifestyle Management: Standards of Medical Care in Diabetes-2018. Diabetes care. 2018;41(Suppl 1):S38-S50. Epub 2017/12/10.
  8. 8. Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes-2018. Diabetes care. 2018;41(Suppl 1):S73-S85. Epub 2017/12/10.
  9. Foster NC, Beck RW, Miller KM, Clements MA, Rickels MR, DiMeglio LA, et al. State of Type 1 Diabetes Management and Outcomes from the T1D Exchange in 2016-2018. Diabetes technology & therapeutics. 2019;21(2):66-72. Epub 2019/01/19.
  10. Introduction: Standards of Medical Care in Diabetes-2018. Diabetes care. 2018;41(Suppl 1):S1-S2. Epub 2017/12/10.
  11. Lennerz BS, Barton A, Bernstein RK, Dikeman RD, Diulus C, Hallberg S, et al. Management of Type 1 Diabetes With a Very Low-Carbohydrate Diet. Pediatrics. 2018;141(6). Epub 2018/05/08.
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