Maintaining remission is going to be the challenge I hope it wouldn't be!

[PaulLa]

Just had my latest HBA1C result and it is a bit disappointing if I'm honest.

I've lost 6 1/2 - 7 stone since diagnosed last August with HBA1C of 51. Immediately went on diet and started an exercise regime (which I still maintain) and this paid off - I've never had meds by the way.

November HBA1c was down to 42, February 38, (told by DN that I was in remission). My latest result which I received today is 42.

From the beginning I feared that the good results while severely restricting carbs/calories would go the other way once I needed to stabilise my weight and eat more and this seems to be the case. Recently I've been eating around 2300 cals/200 carbs daily, up'd from 2000 cals/160 carbs a few weeks back. In the beginning I restricted carbs to around 100 and cals around 1200 for rapid weight loss which worked.

I'll try reducing carbs back to around 150-160 again in the hope of avoiding 'progressively' rising back into diabetic range.

Good news is that my cholesterol (5.7 at DX) and Triglycerides (2.5) are down yet further (3,9 and 0.5 respectively) - HDL ratio increased too.

Incidentally, when told I was in remission, the DN said she didn't want to see me for 12 months. Knowing I needed to stop losing weight and increase food intake, I said I would still like to get 3 monthly HBA1C tests to keep an eye on things - pleased I did!

 

[trophywench]

First of all - congratulations on your brilliant weight loss, Paul. Well done you!

'Remission' isn't a cure - only keeps it at bay - people who lower their carbs usually maintain their weight once they've got down to where they need to be, by using good fats rather than carbs to do so - things like eg oily fish, nuts and seeds. Maintain the exercise yes - but also remember that muscle weighs heavier than body fat.

Anyway - for all of us - this is a marathon, repeated over the years many many times - not a sprint or relay.

Good luck!

 

[rebrascora]

Hi PaulLa and MANY congratulations on your weight loss and improved cholesterol and HbA1c readings even if the last one has shown a slight increase.
Have you considered keeping the carbs low but increasing calories via fats and oils to stabilise your weight?
We have been fed information all our lives that fat is bad, so it is very difficult to go against that but the tide is starting to turn within the scientific community on this matter and it may well be that the low fat diet that we have been trying to follow for the past 70 years is what is now causing the diabetes epidemic which the world is currently experiencing. Those excess processed carbohydrates have made us overweight and diabetic because we ate more of them instead of the fat that we cut out of our diet. I am certainly finding that increasing fat intake makes food enjoyable again and therefore my diet is more sustainable long term and I am not putting on weight as a result of increasing fat intak,e but it has stabilised and from what I have read, there is no direct correlation between fat intake and blood cholesterol. Some people seem to be finding that their cholesterol is reducing despite eating more fats including dairy like butter, cream and cheese. Of course it has to be balanced with increased fibre from green veg and some exercise, but it sounds like you already have that covered.

 

[Martin Canty]

Well, you have come a long way in such a short time, but, as Jenny says, remission is not a cure; what your post is saying is that you are a well controlled T2 so we need to keep vigilant & monitor our BG daily.

 

[PaulLa]

Thanks Jenny, rebrascora & Martin - a lot of good advice and wisdom in your replies. It is easy to run away with the idea that you are cured, but despite hoping otherwise (reinforced by the fact Ive eaten occasional 120g carb meals and BG remained well within normal levels), in the back of my mind I knew that if I stopped being vigilant with diet and lifestyle things would deteriorate.

I've always had high cholesterol, but now that's normal and under better control than ever, I'm now more confident to further increase good fat intake (I've already been eating quite a lot of nuts, oily fish, etc but will further increase these).

Something I can definitely improve upon is sleep - the last couple of months I've had less than ever (< 5 hours per night) for a variety of reasons. It seems this can have an adverse effect on BG, so at least there are a few things I can do to try and stop things slipping further.

 

[Drummer]

I could never, safely, eat 200 gm of carbs a day - not even before diagnosis as I had been doing Atkins for decades and knew that my limit is 50 gm per day - I stopped weighing myself when I reached 264lb on a stupid high carb cholesterol diet - and now that I am no longer in the diabetic range of Hba1c I still stick to low carb foods - first of all I prefer them, and secondly - I really feel the need to emphasize that I can't eat stodgy foods after all the pressure to do high carb diets, and thirdly - I have decdied to regress to my hippy years, and I need a smaller waist to be able to wear the clothes still stashed in the back of the wardrobe.

 

[PaulLa]

I could never, safely, eat 200 gm of carbs a day - not even before diagnosis as I had been doing Atkins for decades and knew that my limit is 50 gm per day - I stopped weighing myself when I reached 264lb on a stupid high carb cholesterol diet - and now that I am no longer in the diabetic range of Hba1c I still stick to low carb foods - first of all I prefer them, and secondly - I really feel the need to emphasize that I can't eat stodgy foods after all the pressure to do high carb diets, and thirdly - I have decdied to regress to my hippy years, and I need a smaller waist to be able to wear the clothes still stashed in the back of the wardrobe.

I'll be certainly reducing carbs again myself (the increase was more trial and error to see where my limitation are), along with getting to bed earlier and staying hydrated (I'm notoriously bad at going without fluids and I've let this slip again). I wish I'd left stuff in the back of the wardrobe, having last year had a clear out of stuff I could well do with now...it's costing me a fortune in clothes and motorcycle gear - even my helmet's slack now!

 

[Eddy Edson]

One thing to maybe bear in mind is that changes to red blood cell stuff can distort the interpretation of HbA1c results.

Remember that the only point of the HbA1c test is to get an estimate of what your average blood glucose has been over the last 2-4 months. So on the conventional translation, an HbA1c of 42 mmol/mol is read as indicating an average BG of 7.0 mmol/L, and so on. But that translation isn't exact - generally, for one in three patients, it will be off by more than about 0.9 mmol/L. So it's quite possible for somebody to get an HbA1c result of 42 with actual average BG of less than 6.1 mmol/L or more than 7.9 mmol/L.

Most of the difference is due to differences in average age of red blood cells at the time of the HbA1c test. RBC's die off and get replaced. The longer they hang around, the more they get sugar-ised and the more they will contribute to the HbA1c result. If your RBC's are older than the average person's, your HbA1c will read high versus the conventional translation; and vice versa.

Normally, your RBC's will be in rough equilibrium - rate of dying off is matched by the rate of new replacements. Your average RBC age may be different from the average person's, but it remains fairly constant. So your variation from the conventional translation will be roughly the same between different tests. If your HbA1c test result is high versus your actual avg BG on one test, it'll tend to be high on the next test too. So the lack of precision doesn't matter to some extent, clinically. No doctor worth his/her salt is going to look at an HbA1c number in isolation and treat it as an exact thing - what matters is the range and the variation over time.

The picture gets disturbed if your RBC dying versus new production isn't in equilibrium. For example, if they're dying off faster than they get produced, your average RBC age will be increasing and so, while this is happening, your HbA1c readings will tend high. If this turns around and RBC's are being produced quicker than they die, your HbA1c readings will tend low for a time.

One circumstance where the equilibrium can get disturbed is where your body weight is changing. I don't find enough info out there to give me a precise handle on how this works, but it appears that if you lose fat, your bod thinks it needs less haemoglobin and so rate of RBC production will decrease. Maybe it's different if fat is being replaced by muscle? No doubt exercise has some kind of impact and smoking cessation certainly does. I'm sure that there are plenty of other things which will disturb the RBC equilibrium one way or the other, if you are making major lifestyle changes.

Bottom line for me is that while you are changing your body and habits, I wouldn't stress too much about variations in HbA1c. An HbA1c of 42 could correspond to an avg BG of 6.1 to 7.9 mmol/L, or an even broader range. An HbA1c of 38 could be anywhere from 5.5 to 7.3, or broader. If you are making big changes to body/habits, I think the situation might be too fuzzy to tell the two apart. It might become clearer once things settle down.

Personally, I really don't trust my latest HbA1c result of 27. I haven't been testing so much recently, but I think it "should" have been more like somewhere in the low 30's. On the other hand, I think my previous 35/36 results were a bit high. For those previous results, I was losing RBC's as I lost weight and stopped smoking, which explained for me why HbA1c might have been high. More recently, as weight stabilised, maybe I was finding a new RBC equilibrium with temporary greater production than die-off, which could explain why HbA1c might have been a bit low. But who knows, really?

If you want to geek out on this stuff, check https://www.ncbi.nlm.nih.gov/pubmed/27708063 By the same group at MassGen responsible for the original work establishing the conventional HbA1c to average BG translation, so presumably they know what they're talking about.

 

[PaulLa]

One thing to maybe bear in mind is that changes to red blood cell stuff can distort the interpretation of HbA1c results.

Remember that the only point of the HbA1c test is to get an estimate of what your average blood glucose has been over the last 2-4 months. So on the conventional translation, an HbA1c of 42 mmol/mol is read as indicating an average BG of 7.0 mmol/L, and so on. But that translation isn't exact - generally, for one in three patients, it will be off by more than about 0.9 mmol/L. So it's quite possible for somebody to get an HbA1c result of 42 with actual average BG of less than 6.1 mmol/L or more than 7.9 mmol/L.

Most of the difference is due to differences in average age of red blood cells at the time of the HbA1c test. RBC's die off and get replaced. The longer they hang around, the more they get sugar-ised and the more they will contribute to the HbA1c result. If your RBC's are older than the average person's, your HbA1c will read high versus the conventional translation; and vice versa.

Normally, your RBC's will be in rough equilibrium - rate of dying off is matched by the rate of new replacements. Your average RBC age may be different from the average person's, but it remains fairly constant. So your variation from the conventional translation will be roughly the same between different tests. If your HbA1c test result is high versus your actual avg BG on one test, it'll tend to be high on the next test too. So the lack of precision doesn't matter to some extent, clinically. No doctor worth his/her salt is going to look at an HbA1c number in isolation and treat it as an exact thing - what matters is the range and the variation over time.

The picture gets disturbed if your RBC dying versus new production isn't in equilibrium. For example, if they're dying off faster than they get produced, your average RBC age will be increasing and so, while this is happening, your HbA1c readings will tend high. If this turns around and RBC's are being produced quicker than they die, your HbA1c readings will tend low for a time.

One circumstance where the equilibrium can get disturbed is where your body weight is changing. I don't find enough info out there to give me a precise handle on how this works, but it appears that if you lose fat, your bod thinks it needs less haemoglobin and so rate of RBC production will decrease. Maybe it's different if fat is being replaced by muscle? No doubt exercise has some kind of impact and smoking cessation certainly does. I'm sure that there are plenty of other things which will disturb the RBC equilibrium one way or the other, if you are making major lifestyle changes.

Bottom line for me is that while you are changing your body and habits, I wouldn't stress too much about variations in HbA1c. An HbA1c of 42 could correspond to an avg BG of 6.1 to 7.9 mmol/L, or an even broader range. An HbA1c of 38 could be anywhere from 5.5 to 7.3, or broader. If you are making big changes to body/habits, I think the situation might be too fuzzy to tell the two apart. It might become clearer once things settle down.

Personally, I really don't trust my latest HbA1c result of 27. I haven't been testing so much recently, but I think it "should" have been more like somewhere in the low 30's. On the other hand, I think my previous 35/36 results were a bit high. For those previous results, I was losing RBC's as I lost weight and stopped smoking, which explained for me why HbA1c might have been high. More recently, as weight stabilised, maybe I was finding a new RBC equilibrium with temporary greater production than die-off, which could explain why HbA1c might have been a bit low. But who knows, really?

If you want to geek out on this stuff, check https://www.ncbi.nlm.nih.gov/pubmed/27708063 By the same group at MassGen responsible for the original work establishing the conventional HbA1c to average BG translation, so presumably they know what they're talking about.

Thanks very much Eddy for taking the time to right such a detailed response to my concerns. It is very useful - I wont be quite as worried realising the potential for fluctuations (the link you added was very useful). It all makes a lot of sense - I don't do a lot of bg testing but the 3 I did today are pretty similar to the nominal results I've was getting as my HBA1C fell to the low of 38, e.g 4.9 pre breakfast, 5.8 post 48g carb breakfast, 5.1 late night random. Hopefully, some of inherent inaccuracy tolerances of the HBA1c test/RBC cycles and the lifestyle changes you described may have been at play. Thanks again, Paul

 

[PaulLa]

A quick update...latest hba1c result (last week) is 37. Seems Eddy was right about inaccuracies as I could not explain my previous result of 42 having had a one of 38 beforehand. 37 is pretty consistent with the bg tests I was doing.