Your patient is very thought provoking…….
Unfortunately your patient has returned a Kraft pattern V in the presence of normo-hypoglycaemia. Dr Kraft recommended a retest in these situations after 14 days of 150g carbs /day.
In someone who has been LCHF, 3 days of carb loading is only sufficient for the glucose aspect of the OGTT, not the insulin where 14 days of carb loading is recommended. I’m not sure if you have Dr Kraft’s paper – as attached. I have some reprints of his papers, which don’t have the underlines etc.
This means that we don’t really know what is happening yet. Can you repeat the test after 14 days of loading? It’s a sod, because most patients don’t want to do 14 days once they have been LCHF.
Was the three hour hypoglycaemia symptomatic? (I’m assuming mmol/L for the glucose) Are they in nutritional ketosis (as indicated by a blood ketone level >0.5mmol/L)
A fasting glucose of 5.4 is suggestive of hepatic insulin resistance, but the 3 hour glucose of 2.5, would often suggest hyperinsulinaemia – which was not indicated in the results.
Some practical questions – was the results collected in plasma or serum? Were any of the samples haemolysed? Insulin is a very fickle and unstable protein and may degrade quickly. I prefer to collect in plasma so it can be spun/processed immediately, but this may be an issue for community labs. Did the patient perform any vigorous activity in the 24 hours preceding the test
May I have your permission to share to the wider community to see if other experienced practitioners have any insights?
Stavia wrote:Dunno Hubbs.
You did have an insulin spike (with resultant drop of glucose afterwards) to a glucose load you wouldn't eat normally. So it was an unusual situation. If you dont drop so low with your normal diet then its not an issue surely?
Yours is a puzzling case. If you do have a low beta cell function, Dr. Bernstein http://www.diabetes-book.com/read-online-diabetes-solution/ strongly suggests not taking the meds that will increase insulin output. He says they will just burn on your beta cells faster. If anything is needed to help, he says an appropriate (small) dose of insulin while continuing on a low carb diet is the best option.
I'm friends with a number of LADA diabetics, one with antibodies but who has maintained a "honeymoon" with some beta cell function for 9 years while using very low dose insulin (I think 9 units a day, in his case). I don't know you are LADA, I do think your beta cell function may be somewhat compromised. Again, like Lance, I'm not an endo or a doc at all.
Bernstein does suggest spreading the food intake out (3 meals/day) for diabetics with low/no beta cell function.
Like Lance, I'm certainly a low carb or ultra low carb person and think that the standard ADA advice for diabetics is poor. Hopefully you will not get an endo with this mindset.
LanceS wrote:Seems like you are making good progress. Be happy with that and continue experimenting with things that make sense.
I'm not sure you have enough information to make any sort of radical deviations on your current path. You'll have more information soon, and maybe that will help inform you as to better next steps. Speculation about what could be can induce alot of stress, but to be prepared for doctor discussions, you kind of have to engage in some background research. Try not to let it stress you out. Approach it in a way that is engaging and hopeful that you can find more things to continue helping you live your life to the fullest.
When I look at your response, a couple things occurred to me:
1) I am not substitute for an endocrinologist or any other doctor for that matter
2) Looks a little normal, just too high BG, maybe too low insulin (I couldn't tell the units and make them comparable to Kraft units, so I wasn't sure)... almost pointing toward insulin resistance initially, perhaps with some beta cell insufficiency, followed by insulin sensitivity as you went hypo. This could happen because of your diet (low carb diets often induce insulin resistance), genetics, or some combination of both.
3) Also looks like five as it seemed your insulin was too low and glucose too high.
With your hypo reading and dizzy spells, I would consider lightening up on supplements (like Berberine?) that reduce blood glucose. I'd put them on a list of questions to ask your doctor. If the dizzy spells don't go away, then perhaps you add the supplements back depending on doctor's advice.Hubbs wrote:Reading up on reactive hypoglycemic, saw most advices point toward eating small meals frequently to prevent the lows. Is it necessary to give up my current morning fasting? And which condition do I have - insulin sensitive or insulin resistance?
My first thought would be that ONLY for meals that you think will provide challenging postprandial glucose levels, maybe you eat about 25% of your meal an hour (or a bit more) earlier (that 25% number is just a guess). That way the glucose from the 75% portion may find its way into cells more quickly (because insulin from the 25% is already in your system) and hopefully the 25% doesn't drive your blood glucose too high (if it does, then you would eat less than 25%, if it doesn't drive it high enough, than more than 25%). But I think you have to be careful, because IF your Beta Cells are in dysfunction, this seems like it might stress them out even more. The recommendation to eat small meals certainly seems to me to put Beta Cells under more stress. So if a 25% plan works for glucose causing meals shouldn't be taken for a license to eat alot of those types of meals. Some of this debate is currently ongoing in the Type I community and can ironically be found:
https://www.facebook.com/AmericanDiabet ... catino=ufi
The ADA is accepting of dietary advice that accepts carbs. These folks on the ADA's own forums are rebelling and sharing their anecdotes and stories about how they are living life more fully (low / ultra low carb zealots). I JUST WANT TO EMPHASIZE, I DON'T THINK YOU HAVE THE DATA TO ASSUME YOU ARE A TYPE 1 DIABETIC. Also I am a bit of a practicing low carb zealot, just fyi full disclosure. But I think you have to remember there are many many more people out there with the ADA approach to carbs than the ultra low carb approach. These two approaches are somewhat diametrically opposed. I can't tell you which one is right or wrong for you. But IF you end up finding that you have Beta Cell dysfunction, you probably have to ensure that whatever meal strategy you end up with that it doesn't continue to stress out the Beta Cells. It seems that having some fruits helps make your diet manageable... I think there would hopefully be a middle ground between carb up whenever and ultra low carb approaches that will allow for this. I think there are some stories of folks who went ultra low carb and gave their beta cells a rest and then later went back to a lowish carb diet and found their beta cells were functioning better.
Lastly, some folks think that GLUT4 transporters can come out and soak up glucose during and after resistance training. Because females are smaller and lift less weight some folks think this effect is not all that realizable in women. I don't know enough about it, but I know some have found success. Perhaps weightlifting or some form of high intensity interval training would allow for "glucose excursion meals" afterwards? Might help in your management, also might be something to ask your doc about.
Silverlining wrote:Hubbs, I've mentioned before I have very similar BG pattern. My GTT peaked over 200 at one hour, ended at 60 two hour mark, don't know what it was at three hour. I do know that I have severe near blackouts whenever I have huge BG swings like these. These blackouts caused me to seek medical care in 2010 where an endocrinologist worked me up for every type of diabetes, all negative. I ended up going extreme low carb to avoid the blackouts, but I got too thin since I started out on the thin side. I currently use small amounts of rapid acting insulin for medium carb meals. We have at least one other member, LAC1965 with similar pattern.
Edited to add I was sent for a workup on the near blackouts (termed pre syncope). They put me on a tilt table with adrenaline infusion (standard test protocol) and I had a very strong response (plummeting heart rate and blood pressure in less than one minute)...the cardiologist gave me a diagnosis of neurocardiogenic syncope. I can control this condition very well if I control BG swings. If your dizzy spells coincide with high, then low BG, you might find they are eliminated when your BG stays relatively flat.
2nd Edit...went googling neurocardiogenic syncope, also known as vasovagal syncope and found a pubmed study stating that some young women who have a positive tilt table test were also found to have insulin sensitivity. "Another study showed that young women who had vasovagal syncope with a positive tilt test result had a greater sensitivity to insulin. Insulin, in addition to its known metabolic effects, has sympatho-excitatory and vasodilatory actions on muscular blood vessels. The authors of this study conclude that insulin hypersensitivity could be one of the predisposing factors for vasovagal episodes". http://www.ncbi.nlm.nih.gov/pubmed/1276 ... t=Abstract
I'm not a young woman, but I definitely have this reaction.
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