Got diabetes? Need advice? Of course you do!  And you came to the right place: Ask D'Mine, a weekly Q&A hosted by veteran type 1, diabetes author and community educator Wil Dubois.

{Need help navigating life with diabetes? Email us at AskDMine@diabetesmine.com}

Wil goes deep this week on blood sugar control issues. Enjoy!

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Liz from Oklahoma, type 2, writes: I get lightheaded and shaky even after eating a good meal. My blood sugar is around 118 before the meal—my primary doctor insists on this and feels I don't yet need to go to the Joslin Center. I have been told these episodes may be "false lows." I'd like your input. Thanks!

Wil@Ask D'Mine answers: Your blood sugar is OK before the meal, but what's your blood sugar after the meal, when you start feeling shaky? Common wisdom holds that after-meal numbers are generally higher, but that's not always true. You need to test after a meal to find out what's really going on.

Here's why: early in the course of type 2 diabetes, your body is totally freaking out. Nothing is quite working to design specifications. In some cases the pancreas over-reacts to food. It produces a huge wave of insulin and can actually cause a low. This is particularly common with high-carb meals. Picture the pancreas getting a telegram that a Grand Slam Breakfast is on the way. Lights flash. Alarm bells ring. In commmmming!

In fact, episodes of hypoglycemia are one of the warning signs that can lead to a diagnosis of diabetes. So you need to check your blood sugar when the lightheaded shakies hit to see if you are actually going low after meals. If so, use the speed-dial to call your doc.

As to the issue of you having "false lows," I doubt it. The term false low, in med-speak called "relative hypoglycemia," is something that happens to people who have been high for a long time, once their blood sugars start to normalize.

The human body is a real champ at adapting to its environment, both external and internal. If your blood sugar has been at 350 night and day for months your body starts to think that's normal. If you take a med that quickly lowers you to, say 200, your body flips out. It only knows you just dropped 150 points and that can't be a good thing; it's forgotten it was too high to start with. All of the hypo warning signs and symptoms are triggered, even though you are still critically high.

So you can feel like you're hypo even if you are nowhere close to it.

But I doubt you are experiencing this because you told me you are running 118 before meals. Relative hypos really only happen when your blood sugar has been elevated all the time for an extended period of time. Ups and downs between normal readings and higher readings won't trigger the effect.

Still, something is causing your symptoms. Check your blood sugar after eating. If nothing unusual crops up, look next to your blood pressure... then your vitamin B or D... then your thyroid... and then...

I hope when they dx'd you they remembered to tell you that having diabetes is like playing a supersized version of Clue... only with higher stakes.

  

Natalie from Nevada, type 1, writes: My BGs are usually in a reasonably good place — running around 120 fasting and overnight, and 140-180 postprandially. I average about 35u of insulin a day, with 18u of that as basal. I've had diabetes for 20 years, and have no complications. My A1Cs are usually in the 6s. My BMI is 24.0. I do have some insulin resistance, though apparently mild. My question is, is it worth the extra insulin to try get my fastings lower, say in the 80-100 range, and PP's below 140 (per the AACE)? Is there any solid evidence that hyperinsulinemia contributes to cardiovascular disease? Is it better to run somewhat higher than normal BGs or to use more insulin to get them lower?

Wil@Ask D'Mine answers: Now wait a cotton pickin' minute.

You have a perfect A1C... for two decades.

Your insulin usage is nearly perfectly split at 50% basal and 50% fast-acting.

You have a trim and sexy Body Mass Index.

Your postprandial numbers are nothing short of totally astounding.

Are you really sure you have diabetes?

I'm not convinced.

At the very least, you're making the rest of us look bad. If you keep this up, we may have to kick you out of the family.

So, yeah, OK, your fasting numbers could, in theory, be a little lower. But if the sign says "Danger: thin ice" would you go skating? Frankly, for type 1s, a fasting of 80 makes me queasy. Don't forget that AACE guidelines are for all people with diabetes: both type 1s and type 2s. They are blanket guidelines to cover all the bases. You need to individualize these targets for both you and your diabetes. For T1s like us, 110 or 115 fasting is considered golden. You're pretty darn close.

In terms of complication risk, average blood sugar and blood sugar variability are

both major players. And both are arguably equally damaging. On top of that, recent research, like the ACCORD study, is beginning to point fingers at hypos possibly causing more longer term damage than previously believed.

Why am I blathering on about this? Well, shooting for a fasting of 80 ups the ante on your hypo risk. Given your low average and tight range in the first place, I don't see any significant benefit to you in trying to get it even better.

But of course, that didn't really answer your question, which is about whether hyperinsulinemia, a.k.a. high levels of insulin, might be damaging to your heart. You asked if there's any solid evidence.

(Insert sound of person laughing hysterically to the point of passing out)..... Let me refer you back a few weeks to this column where we discuss that fact that "solid" evidence doesn't exist for anything in medical research. I can't even find any solid evidence that medical research even exists in the first place.

Anyway, forgetting the whole concept of solid evidence for the moment, the role of high insulin levels as a risk factor in cardiovascular disease is one of those things that scientists politely call "controversial." Some studies have shown no link at all. Some studies have shown there's a link. Some studies show maybe there's a link sometimes, in some cases, but a small one.

But a link is only an association. Association doesn't necessarily imply a cause.

Here's the problem with trying to figure out if insulin screws up your heart or not: High levels of insulin are most commonly found in only one place in nature: early-to-mid stage type 2 diabetes where the pancreas is working triple time and nights and weekends to try to overcome the disease's signature insulin resistance with wave after wave of insulin. The problem is, and please don't take offense all you type 2s, there's also a whole lot of other metabolic dysfunctions taking place at the same time. It starts to get very chicken and egg trying to sort out the complex interrelationships between the various markers, much less assign cause and effect to any of them.

And even if it eventually turns out to be true that hyperinsulinemia is a cardiovascular risk factor, it would be a moot point for you. You're literally sipping insulin—35u really isn't that much. A frickin' vial is lasting you a whole month, for crying out loud. Even if you were inclined to fine tune your fasting numbers (a modest increase in your basal would do the trick), I doubt you'd be taking more 45u per day.

Consider that many type 2s use 100u to 150u per day.

You, my dear, don't even qualify to enter the hyperinsulinemia marathon.

And making it double moot is the following: even if hyperinsulinemia is a cardiovascular risk factor, and even if you injected at ton of insulin, you're still talking cats and dogs, apples and oranges. Taking a lot of insulin isn't really the same thing as being hyperinsulinemiaic. If anyone has actually studied the role of injected insulin as a possible cardiovascular risk factor, I'm unaware of it, nor have I been able to find any trace of it on the internet.

The bottom line for everyone is: even if in the future solid evidence for hyperinsulinemia causing heart trouble is discovered, I think it would still be a hell of a stretch to apply that discovery to injected insulin as well.

Bottom line for Natalie is: I don't think more a little more insulin would put your heart at any more risk; but at the same time I think your blood sugar control is already beautiful. I don't think it matters much which way you choose to go.

This is not a medical advice column. We are PWDs freely and openly sharing the wisdom of our collected experiences — our been-there-done-that knowledge from the trenches. But we are not MDs, RNs, NPs, PAs, CDEs, or partridges in pear trees. Bottom line: we are only a small part of your total prescription. You still need the professional advice, treatment, and care of a licensed medical professional.

Disclaimer: Content created by the Diabetes Mine team. For more details click here.

This content is created for Diabetes Mine, a consumer health blog focused on the diabetes community. The content is not medically reviewed and doesn't adhere to Healthline's editorial guidelines. For more information about Healthline's partnership with Diabetes Mine, please click here.