I was fortunate that, in spite of being 50, my primary doc diagnosed me as T1. Based on little more than my crazy high A1C, he referred me to an endocrinologist. I underwent the usual tests and was started on MDI immediately. With the help of the wonderful folk on this site, I’ve worked hard to test often, manage my carb ratios and lower my A1C. I eat a moderate carb diet (about 120/day) and am on fairly low doses of insulin (about 15 TDD) split pretty evenly between Lantus and Humalog. (My C-pep test showed that I was still making a bit on my own). My last result was a 5.4 with only a few hypos and even fewer very high numbers. I strive to be between 70 and 120 and am usually pretty close. I don’t beat myself up for higher numbers but, do correct for anything over 160 or so.
The problem: My endo makes is very clear that he thinks I’m obsessing too much. At each appointment he wonders aloud if I’m suffering from anxiety or if I’m letting diabetes “control” me. He claims that most of his other patients worry about highs OR lows, not both. At my last appointment he downloaded my meter and declared that my numbers were “too good” and that my A1C is “too normal”. I assured him that I was living a full life. I work a full-time job, have two young kids and a rock-solid marriage, stay active, eat a wide variety of food and enjoy a glass or two of wine when I want to. At my last appointment my endo told me to relax my ratios. When I pointed out that I’m not having many hypos he said, “I’m not sure you need to manage so closely. Wouldn’t it be nice not to have to someday?” I indulged him and faxed in my log with the predictably higher numbers. No response.
My question to the wise people reading this is, should I simply find an endo who doesn’t make me feel like I’m crazy? Or might he have a point? Am I experiencing tight control because I’m lucky enough to still eke out some insulin? Might I not need as much insulin? Is it possible to inject too much without going low by overworking some other mechanism in my body (alpha cells)?
Thanks in advance for any guidance.
So there's nothing to be concerned about in terms of my alpha cells? If insulin protects the beta cells, does too much harm the alpha cells? Or just cause hypos which I'm very, very rarely having? I'm not worried about me burning out, just my cells. I'm well motivated to take care of myself for the long haul.
Thanks for the sanity check. Now for the hard work of finding a new endo.
The alpha cells produce glucagon to raise the blood glucose by glucogenesis. I think you fear that by having too many lows your alpha cells might be harmed. Thus you would loose the capability to fight lows. It is true that many T1 diabetics only show limited glucagon response. But the causation is a bit different. Our lows are always induced by excessive insulin. This insulin is also regulating the response of the alpha-cells down. In healthy people excessive insulin does indicate that carbohydrates are coming from the digestion. Thus there is no need to waste valuable deposits of the liver. This role of the insulin to down-regulate the alpha-cells is the reason why the glucagon counter reaction is broken by design for insulin dependend diabetics. The theoretical model behind this is called the "switch-off" theory first formulated here: the insulin production has to switch off first before the alpha-cells can start to increase their glucoagon release. In other words you are concerned about alpha-cells that can not help you sufficiently against insulin induced lows.
I'll need to read this a few times but, really, really appreciate your response. I was actually hoping you'd weigh in . . . you're so wise.
My understanding is that the alpha cells which produce glucagon are unaffected by T1. Also, our bodies react to challenges by adapting. If you "demand" more glucagon, your alpha cells grow and adapt to the increased demand. As Holger points out, with those of us who use insulin, the normal counterregulation response to a low is disrupted. As Holger points out, the "switch-off" suppression of glucagon plays one role in the, insulin also inhibits gluconeogenesis (production of glucose by the liver), all which leave us vulernable to hypos.
Personally, I would hardly worry about alpha cell burnout. If anything, an occaisonal hypo might actually keep your alpha cells working in tip top shape.
Thank you Brian. I'm always impressed with how helpful you are on this site.
This reminds me of one doctor who came into the room and said, "You don't have diabetes. Go home and eat a candy bar." Turned out he mixed up my basal rates with my boluses and thought I was giving a just unit for each of my meals. We never saw that doctor again.
Anyway, it's possible that your endo is afraid of burnout for you. But it's strange that he's worried that much about it. My endo and my doc say that they're excited to see me on the patient list, mainly because I have good control (relatively).
Probably it's time for a new endo. Does he encourage you at all? Seems like he's focusing a lot on the negatives and not enough on the positives of your control.
Now that you mention it, zero encouragement at all. I keep going to my appointments expecting a gold star and instead leave there feeling confused. If I think about it honestly, my hardest D days are the ones immediately following seeing him.
Then I change my vote to finding a new one.
He's doesn't fight my request for lots of test strips but, probably not worth being made to feel bad. Thanks for caring.
Yes, he should be asking you to give seminars for his other patients! When I told my endo that I dosed 20 - 30 minutes before eating, when reasonable, he acted like he had never heard of such a thing! They don't like radicals!
I think a lot of doctors have a sort of formulaic response to lower A1C type of numbers, as was mentioned, because they get used to seeing higher ones. If you are low, their "manual" says "they must be zonked out of their gourds all of the time." I don't have a huge level of engagement with my doctor but she has revealed that she's smart and I trust her to be helpful, from the few times issues have arisen. If the current doc is shoveling on the test strips, that may be something in his favor. If you shop around and find other docs, there may be pros and their may be cons but a doc you know may be better than one you don't?
Thanks! I think that I've been too afraid to switch because he does rubber stamp all of my requests. It would be refreshing though to have a conversation with a more like-minded doc. Perhaps you folk are fulfilling that need. I appreciate your input . . . . I've been reading your helpful responses for 18 months and admire how well you take care of yourself. Hope to be able to manage, run and party in your club some day.