T2 - How low is too low?

[M Perks]

Hi - long story cut short, I've been dropping meds over past six months. Sounds good, but not quite sure if it's all good news?

Brief background: 50 years old. 16 years of type 2. Had been on insulin for past two years - basal, bolus. Weight was about 14st. Metformin, Canagliflozin.

Being doing fair amount of cycling this year. And changed diet a lot, cut out carbs, fats. Numbers now very good, but with exercise, often meant causing lots of hypos. Lowest weight for years around 12st 3lbs. Meant reassessing insulin. And for past three months? have now stopped it.

Prescribed linagliptin for past month to control highs. However, still getting hypos. Below/close to 4 at nighttime, or dips between meals. Then need to eat etc. to counter it.

Two weeks ago, stopped Linagliptin. Personal choice. Nurse off, back hopefully in a week.

This week, I've also stopped Canagliflozin too. As breakfast, mealtimes, for now at least, highs more controlled. But am still going low, hovering above 4 - 5.

Past couple of nights, I've crept below 4. One night below 3.5. Ate bread 2am to counter! Monitoring with Freelibre.

My QUESTION (at last!) is: while my pancreas appears to be kicking in, how low should I be at nighttime? I was 4 this morning. 5.5 waking, 8am. Is this expected? Or, as I suspect, my body doesn't appear to be metabolising carbs from fat stores etc. to up my sugars when needed?

My diabetic nurse is back in a week (as she's broken her foot!)

In the meantime, has anyone else experienced similar? Especially those who've lost loads of weight, even stopped their meds? As on the face of it, my numbers appear vastly better. I think due to my weight/fat loss. However, hovering above 4 in middle of night isn't normal? Plus, if I ride my bike (as in last week), I had a hypo.

Thoughts are most welcome!

Martyn

 

[rebrascora]

Hi Martyn
Congratulations on your fantastic progress. To come off medication and insulin particularly after so many years is an amazing achievement.
Are you relying solely on the Libre for your readings or are you checking with a finger prick when you are low, particularly in the night. I find that a Libre reading of 3.5 will often be more like 4.5 when I check with a finger prick, which is of course a perfectly acceptable reading. My gut feeling is that Libre is set up to read slightly lower at low levels in an attempt to try to keep people safer. Secondly, it is entirely possible that non diabetic people drop a bit below 4 whilst they are sleeping and at other times of the day.... the vast majority of people just don't wear a Libre, so would never know. The thing is, without medication which can drop it dangerously low, it should not be a problem.
Do you feel hypo when you get these low readings?
When you say, you had a hypo when you rode your bike last week. Was that the feeling of a hypo or the Libre telling you you had a hypo... or both.... and how low? Are you fueling your body with protein and fat before exercise, to sustain it. Protein typically doesn't start to break down until 2 hours after eating and then is quite slow release. I imagine fat is about the same timescale, so experiment with what and when you eat before exercise so that the fuel is there when you need it. Were you engaged in prolonged exercise when the hypo happened? Again, it is not unusual for a non diabetic person to drop below 4 during sustained exercise. It would be interesting to see the Libre results of these elite athletes/cyclists who are currently using them.
I have recently upped my exercise and find that I had to gradually reduce my evening basal insulin down to nothing and levels were still dropping too low so the answer for me was to go to bed with a higher BG level than normal and have a protein snack at bedtime, but I still have morning basal insulin in my system as I need it through the day, which will be playing some part through the night too, so my situation is a bit different being Type 1. If your pancreas is working efficiently now, you may be unable to elevate your BG levels before bed. The protein snack at bedtime may still be a good option though.
I have come to the conclusion that my muscles suck the glucose out of my blood during the night after regular daily muscle burn exercise much more than during the day and then as soon as I set a foot on the floor the next morning my liver pumps out glucose to get me going. It is fascinating to be able to see through the use of Libre how these bodily rhythms work.

 

[M Perks]

Barbara,

Thanks so much for such a considered reply!

You raise interesting points. I've completely relied upon Freelibre for past couple years. Wasn't offered a repeat for finger pricking [but neither a repeat for Freelibre - that's another story!]. So, I couldn't say what their difference in readings is.

But, when I used to get hypos on drugs a few year's back, I would get the classic 'angry' symptoms! Currently, I don't. That makes me wonder if it's a true reading. However, it cannot be far off? As I've had hypos before, where vision cuts out etc.

I think overall, my pancreas must be responding better. However, esp. when cycling, I rely on carb loading from the fear of hypos. Had a few scary moments. Hence, never tried the protein 'loading'. However, from your experience, maybe I could try it especially since my bloods 'appear' more controlled?

This week, i have left my food out to see where my blood levels out to. And it now hovers around 4... until I eat. I am equally paranoid of hypos without loading beforehand. As I could burn everything just from a fairly brisk walk.

I don't really have a response to this, apart from something metabolically is changing in how my pancreas, the liver is reacting. This morning, from 5, ate usual 80g toast/peanut butter. Two hours later, I seem to have topped out at 7.6 with x 2 500mg metformin. I could never have been anywhere near that a month ago. Would have been peaking between 10 and 12 two hours later.

Thanks for your reply. As makes me wonder about proteins, and how accurate the Freelibre is? I'll wait to see what my nurse says too.

Martyn

 

[Eddy Edson]

I typically have low 4's in the middle of the night, usually 4.4-4.9 on waking. These are perfectly normal, "non-diabetic" numbers. It's also within the range of "normal" to go below 3.9 a bit overnight - the data I benchmark against says non-diabetics on average spend 2%-3% of their time below 3.9. It doesn't have to mean you're having a hypo.

I was a bit worried when I was wearing a Libre and it was showing me spiking down into the 2's overnight while asleep. I still don't know if that was accurate or a Libre glitch but I decided to ignore it 🙂

 

[M Perks]

Eddy,

Thanks for that notes. I'm coming to the conclusion that being in the 4s is normal like you say. Earlier this year I did have a nasty hypo lasting a few hours are a strenuous cycle. Although, while really worried, I didn't have classic hypo symptoms. It went below the sensor would read it! Lower than 2.5... and spent hours munching bread, glucose etc. to counter it.

I suspect the Libra can be too accurate, and cause more anxiety. I have a habit of waking mid night and checking numbers. Anxiety is back, with these numbers. But, maybe I should just chill out again! But that's been a while... on normal numbers 😉

Martyn

 

[Drummer]

If you are taking Metformin your liver is inhibited from releasing glucose. Although it doesn't normally cause hypos it might be preventing you recovering from exercise as quickly as you might like.

 

[M Perks]

Not sure about metformin, as it appears to be keeping me from being too high. But never considered the reverse after exercise. This is where everything gets very confusing... for now, won't stop metformin until have clinical advice...

Martyn

 

[Eddy Edson]

Eddy,

Thanks for that notes. I'm coming to the conclusion that being in the 4s is normal like you say. Earlier this year I did have a nasty hypo lasting a few hours are a strenuous cycle. Although, while really worried, I didn't have classic hypo symptoms. It went below the sensor would read it! Lower than 2.5... and spent hours munching bread, glucose etc. to counter it.

I suspect the Libra can be too accurate, and cause more anxiety. I have a habit of waking mid night and checking numbers. Anxiety is back, with these numbers. But, maybe I should just chill out again! But that's been a while... on normal numbers 😉

Martyn

My (limited) experience with Libre was that it often tended to err on the low side, increasingly as time went on.

This piece is convenient for links to most of the studies I've seen which address what "normal" BG levels are: https://www.levelshealth.com/blog/what-should-my-glucose-levels-be-ultimate-guide

Can I also say that weight loss will very often normalise glucose regulation for T2's. Clearing fat from the liver increases its insulin sensitivity which means it stops over-producing glucose (via gluconeogensis, from protein and lipids), especially overnight, so leading to normal waking BG levels. And clearing fat from the pancreas can lead to beta cells rebooting, increasing insulin production. Prof Roy Taylor's work is really interesting for this: https://www.ncl.ac.uk/magres/research/diabetes/reversal/

When I saw 2's overnight I wondered a bit whether my liver was having trouble doing the gluconeogenesis thing, but who knows?

 

[M Perks]

Eddy, really useful links. Yes, clearing out the fat makes a lot of sense. I've always been sceptical about remission. But coming around to the idea, esp. the effect on enabling the pancreas to reboot/grow better islet cells etc.

Am also intrigued, after thinking about Drummer above, re metformin and exercise. As I've always found sugars shot through me without being able to keep it. Wonder how much metformin is responsible for that.

As ever, so many factors to consider.

 

[rebrascora]

@Drummer makes a very valid point. There are two ways in which Metformin works.... it helps to reduce insulin resistance at cellular level and it discourages the liver from dumping glucose. If you are now fit and have lost weight then you are unlikely to be very insulin resistant and if you are like me your muscles will be sucking glucose out of your blood to recover their stores during the night but the liver may be being hampered by the Metformin from drip feeding more glucose into your blood stream to keep you at an appropriate level, in the absence of food. I think it is worth discussing stopping/reducing the Metformin with your Health care professionals or suggest having a trial period without and see how you get on. No harm in starting on it again if you need to. I do wonder if you have an unrealistic idea of normal BG levels. Even non diabetic people spike after eating food. It is the size and timing of the spike which is relevant.
Can I also mention that bread is not an appropriate treatment for a hypo. You mentioned it a couple of times so I thought it should be challenged. You need to get fast acting sugary carbs into you like Dextrose tablets or jelly babies or full sugar fizzy drinks etc. The recommendation is take 15g of these carbs so 3 dextrose tablets or jelly babies and retest in 15 mins with a finger prick or probably nearer 30 with Libre due to the delay in the glucose getting from the blood to the interstitial fluid that Libre measures and treat again with another 15g after that time if still too low. It may be helpful to have a digestive biscuit or some peanut butter to provide slow release carbs after the initial 15g to stabilise levels.

It is also worth mentioning that Libre sensors can exhibit compression lows if you lie on them or have something pressing against them, so always bear that in mind and perhaps double check with a finger prick if you get a "Lo" reading indicating that it has dropped lower than it can measure, unless you are clearly experiencing hypo symptoms, in which case get those sugary carbs into yourself pronto. It is also worth noting that the cells in the mouth can absorb glucose from these sources into the blood stream, so chewing hypo treatment well before swallowing is helpful to release the glucose quicker.

 

[M Perks]

Barbara, yes I agree that perhaps a trial dropping metformin might make sense, with my nurse support etc. It's never occurred to me that it could stop glucose absorption, hence perhaps be responsible for my rapid drop in levels after walking, cycling etc. Likewise, at night. To your broader point: having been diabetic since 2004, I've certainly lost sight of what 'normal' is.

What is odd/good about all this is that everything has (in my impression) changed quite suddenly, over the past couple months. My weight has dropped fairly rapidly since the summer, losing about half a stone. I'm slim apart from a belly. Looks like a few things have come together?

On hypos, yes I know bread is too slow. I eat it since my Libre showed a slow decline. If it was a rapid drop as experienced many times, I'd be munching glucose etc. I think, overall though, I'm much more relaxed about reverting hypos compared to the past. Primarily, because they are not as rapid?

And never realised that about the sensor re lying on it etc. Very interesting. And points to that I've been taking its readings as gospel. Might get a temp finger prick to compare.

Again, everyone - you've taught me masses in just a few hours! Thanking you!

 

[trophywench]

Is why I now use Rowntrees fruit pastilles to treat my hypos - you absolutely HAVE to chew them, and the absorption of the sugar (= glucose) through the insides of your cheeks, is enabled by your saliva. This is where the absorption of all food and drink starts - grief - wasn't that long when I was diagnosed, since I'd done my GCE (they hadn't added an S) JMB O Levels, of which the Biology curriculum included the enzymes in the human digestive tract. Can't recall now whether Ptyalin is the only one in the mouth or whether the Pepsin is in the gob too! LOL

(Funny what you remember from school - though I do know Chapter 1 of the O level Biology textbook was 'The Earthworm' and the very first sentence told us that the earthworm is a cosmopolitan and having to look cosmopolitan up in the big fat dictionary at home to get the actual proper definition of the word! Now there's a useless fact for 99.9% of people ...... much the same as simultaneous equations really .....)

 

[rebrascora]

It's never occurred to me that it could stop glucose absorption, hence perhaps be responsible for my rapid drop in levels after walking, cycling etc.

Actually, Metformin doesn't stop glucose absorption, it encourages it.... but it discourages the liver from outputting glucose so if your levels are reasonably normal when you start exercising, your muscles will happily suck the glucose out of your blood to power them, but the Metformin may well be hampering your liver from replacing it.
Carbs as a food, give you a pretty instant boost of glucose but once they are gone, they are gone, particularly IF your pancreas is now working as normal, so you may be left with a deficit of glucose in your blood because the Metformin is discouraging the liver from producing any more and there is no food in your digestive tract providing any and your muscles are using it at a rapid rate. Eating more protein an hour or so before exercise, along with some carbs and good fat (something like eggs would be good.... maybe an omelette) should provide you with slow release glucose to sustain you through the exercise, but I definitely think the Metformin may be part of the problem.

Wouldn't it be great if you came all the way back from insulin and all that other medication to not needing any anymore!

I know what you mean about no longer being aware of what normal is anymore and I understand how worrying hypos are so it is easy to lose perspective. Being more chilled and doing some finger prick checks is definitely a good plan.

Let us know how you get on and what the nurse says about dropping the Metformin.

 

[M Perks]

Yes, so could be my liver is kicking in and needs to do its job of releasing glucose when I need it. Lots of factors, but sounds right. I'll see what my nurse reckons, as its looking potentially like a big re-think!

When I have news, I'll post a message... !

 

[Drummer]

Is why I now use Rowntrees fruit pastilles to treat my hypos - you absolutely HAVE to chew them, and the absorption of the sugar (= glucose) through the insides of your cheeks, is enabled by your saliva. This is where the absorption of all food and drink starts - grief - wasn't that long when I was diagnosed, since I'd done my GCE (they hadn't added an S) JMB O Levels, of which the Biology curriculum included the enzymes in the human digestive tract. Can't recall now whether Ptyalin is the only one in the mouth or whether the Pepsin is in the gob too! LOL

(Funny what you remember from school - though I do know Chapter 1 of the O level Biology textbook was 'The Earthworm' and the very first sentence told us that the earthworm is a cosmopolitan and having to look cosmopolitan up in the big fat dictionary at home to get the actual proper definition of the word! Now there's a useless fact for 99.9% of people ...... much the same as simultaneous equations really .....)

Good heavens - Joint Matriculation Board GCE Biology O level - me too.
Pepsin is released in the stomach to digest proteins. ( I went on to do a B.Sc.)

 

[trophywench]

Well there you go! I wonder if Percy Potter Runs Across The Lawn Every Monday Evening, still? (he used to do it Every Monday Morning, but then they discovered Enterokinase, so he had to change his habit!)

 

[Eddy Edson]

This piece is convenient for links to most of the studies I've seen which address what "normal" BG levels are: https://www.levelshealth.com/blog/what-should-my-glucose-levels-be-ultimate-guide

Just a quick note on that link: the studies it links to are well worth a look but the conclusions the article itself draws about optimal levels are crap & should be ignored. If you drill down into the references they cite you'll see that they often don't support the conclusions drawn & are somtimes directly contradictory. In short, the recommendations are ridiculously over-strict.

The site itself seems to be part of some BS for-profit diabetes management something-or-other & probably best ignored.

 

[M Perks]

Just a quick note on that link: the studies it links to are well worth a look but the conclusions the article itself draws about optimal levels are crap & should be ignored. If you drill down into the references they cite you'll see that they often don't support the conclusions drawn & are somtimes directly contradictory. In short, the recommendations are ridiculously over-strict.

The site itself seems to be part of some BS for-profit diabetes management something-or-other & probably best ignored.

Agreed. For 'normal' people, fairly sensible diet, bit of exercise is fair and all that is needed. Your body should take care of the rest. Am sick of moralising about food, lifestyle habits, finger-pointing.

 

[Eddy Edson]

Just a quick note on that link: the studies it links to are well worth a look but the conclusions the article itself draws about optimal levels are crap & should be ignored. If you drill down into the references they cite you'll see that they often don't support the conclusions drawn & are somtimes directly contradictory. In short, the recommendations are ridiculously over-strict.

The site itself seems to be part of some BS for-profit diabetes management something-or-other & probably best ignored.

Just nerding on a bit ... I hadn't seen the Park et al study referenced in that article before and it has some interesting bits.

- "Normal" HbA1c is 5.3% +/- 0.3%, or 33 - 40 mmol/mol, which is ~the same as all the other studies I've seen (+/- one standard deviation range). But note that only people with US-style "normal" HbA1c <= 5.7% were included, so a bit circular, maybe.

- 60% of people spent some time above 7.8, 28% above 8.9 and 13% above 10.0. Again this is broadly consistent with other studies & just goes to reinforce the point that messages like "normal people never go above 7.8" etc etc are wrong.

 

[M Perks]

Hi - a quick update, and another question...!

Past week, numbers have been brilliant, as above. Until 2 days ago. Ate chocolate bar, rice/dinner. Before, that was kept low by my body. However, Wednesday, numbers shot up to about 15.

What was different is that since then, according to my sensor, they have at best plateaued to 9, inc. overnight. Yesterday/morning today, best was 10. This was with metformin and nothing else.

Until my nurse comes back, has anyone experienced a similar 'plateau' effect? As I'd thought my pancreas, liver etc. would have brought everything down again, to my earlier great levels of 4-5?

Pure speculation, but is it that maybe my body can only get rid of so much glucose and then... give up? Not quiet sure what's caused this plateau? Not sleeping great, but nothing new there.

Thoughts, experiences appreciated...!

btw - back on Canagliflozin & Lipagliptin to bring things back down to where they were.