Brittle/Labile Diabetes

[Clematis]

I'm 6 years out from DS. Started gaining a year ago and had evidence (solid poop) that fat malabsorption had slowed, but that isn't pertinent to this issue. Meanwhile, my fasting glucose and a1c have always been normal although I have had reactive hypoglycemia probably since I was born. When my mother developed diabetes in the 1990s I compulsively tracked my glucose for years and years and years, all normal (except when I was on statins). I stopped testing within months after DS.

A couple of weeks ago I had occasion during a gut biome test to wear a continuous glucose monitor and do a form of Glucose Tolerance Test with 85g carb. WELL... I spiked to 190, plummeted to 49 and then hung out in the high 60s/low 70s until I ate again. Subsequent morning fasting lower glucose tests (with only 58g carb) spiked to 156 and again down to 60s. None of this is quite the official definition (too lenient IMO) of diabetes but it sure as hell is not normal. When I'm asleep at night I am in the high 50s or low 60s but when I wake - even while laying in bed with eyes closed until I fall asleep again - my values will rise to low 70s (usually). By the time I wake, dress and make it to a lab for semi-annual fasting glucose my levels rise to near normal which is why that has flown under the radar. A1c is based on average of 3 months so if I am too high after eating AND too low otherwise, I average normal. Without this continuous glucose monitor I would never have known, and even with finger sticks could not have known, about nocturnal hypoglycemia.

I immediately restricted carbs to <5 net grams per 3 meals and 2 snacks for a total of 20 net grams. Glucose spikes vanished. Score 1 in my favor. But the monitor only lasted 14 days and until I get a script from my doctor in mid December for more continuous monitors I cannot see whether faithful carb restriction will eventually help raise my hypoglycemia numbers.

I have no idea how long this has been going on. I have seen some studies suggesting that WLS can cause this because of both malabsorption and delayed gastric emptying. (I thought I had researched everything about DS... guess not.) Regardless, Labile diabetes is not a common form of diabetes. Most treatment of hypoglycemia is in relation to Insulin dependent Type 1 or 2 diabetics, not this. And for nocturnal hypoglycemic episodes the impotent suggestion is to, gee, eat a little something before bed. (Not with my GERD.) Furthermore, that only buys an hour before I'd be right back to hypoglycemia. BTW, I have been having a terrible time with daytime sleepiness that is indistinguishable from narcolepsy - I literally cannot keep my eyes open. I wonder if this is because of the hypoglycemia? I'll get a better handle on that with the new continuous monitor.

Are any of you familiar with labile glucose response in relation to WLS? My doctor will be mystified. If there is some data I can provide for her it would be helpful. As always, thank you all for your input.

 

[MsVee]

I never knew there was a type 3 diabetes. I learn so much from this group. I am curious to learn more about this. I hope you are able to resolve the nocturnal hypoglycemia.

 

[Georgepds]

You have my sympathy, diabetes can drive you nuts. Many people on tudiabetes forum swear by the CGM monitors, so it looks like you should have good luck with that approach.


FWIIW, the people on the tudiabetes forum are helpful, compassionate, and informed. In many of the diabetes forums, to me, they often seem to go off the deep end with their cure du jour. Might be worth a look.


I wish I could help more, but one minor observation. Should you eat carbs again, one suggestion is to go high fiber.. it evens out the BG rise, and delays the release of sugar over the next ~4 hours. The rule of thumb is total carbs to fiber should be less than 5 to 1. Most do it to avoid the spikes, but, if you can eat anything at night, it may help with the hypo at night, though the gerd makes that tough


I also looked up two terms. Labile diabetes seems to fit with how you use the term, type 3 does not


"Brittle diabetes is also known as unstable diabetes or labile diabetes, meaning that blood sugar swings can be severe and frequent. This version is rare and happens mainly to people with Type 1 diabetes. "


"This “type 3 diabetes” is a term that has been proposed to describe the hypothesis that Alzheimer’s disease, which is a major cause of dementia, is triggered by a type of insulin resistance and insulin-like growth factor dysfunction that occurs specifically in the brain."

 

[southernlady]

Dr. Bernstein controls brittle diabetes by controlling blood sugars. http://www.diabetes-book.com/
Esp since type 1’s are more prone to brittle diabetes which is actually a misnomer, it just means uncontrolled diabetes.

One thing I would do is get an immediate referral to an endocrinologist in a teaching hospital (if possible). I understand the frustration you are dealing with. Diabetes is a beast we know but not all the nuances of it. So you need help.

 

[Clematis]

Hahaha well if I wasn't happy about labile diabetes I sure as hell wouldn't be happy to learn I'm on the road to Alzheimers. Oh wait, maybe then I wouldn't care (or know) that I am slipping into labile diabetes. Thanks Georgepds for the clarification about Type 3. Someone had used the term to incorrectly signify Labile and I duplicated the mistake. I've deleted that term from the title. And thanks for the link to tudiabetes.

 

[Clematis]

LOVE Dr. Bernstein!! I got his book in the 90s when my mother was DXed but she could not manage his strict protocol (she was already showing signs of dementia) and the assisted living I moved her to would only follow (sort of) ADA more-carbs-the-merrier let's-kill-you-slower food recommendations. Atkins Diabetes Revolution is along a similar vein to Bernstein. I've reread them both in the past few weeks.

Yes, I feel I can resolve this by essentially remaining on an Atkins-like diet for the rest of my life. Within a day my glucose was normalized pre- and post-prandial but on the low side (graph was relatively flat along the border of normal and hypoglycemia) I can't complain: I have a friend with stage 4 ovarian cancer. If someone told her she could live if only she eliminated simple carbs from her diet she'd be thrilled.

I'll start with my PCP in 2 weeks then move on to endo. But most MDs kowtow to the questionable teachings of the ADA and consider Bernstein a fanatic with an unsustainable diet. In the end I'm probably on my own.

 

[Georgepds]

Found a link that might be helpful... it uses an animal model of T2DM recurrence after DS. They conclude a high fat diet, HFD, induces insulin resistance that influences/causes recurrence

Diabetes recurrence after metabolic surgeries correlates with re-impaired insulin sensitivity rather than beta-cell function

To investigate factors causing diabetes recurrence after sleeve gastrectomy (SG) and duodenal-jejunal bypass (DJB).SG and DJB were performed on rats with diabetes induced by high-fat diet (HFD) and streptozotocin (STZ). HFD was used to induce diabetes ...

www.ncbi.nlm.nih.gov

You might want to consider an alternative to a HFD. Now this study was in animals, but in animals with and without a DS.

"SG and DJB were both performed on rats with HFD/STZ-induced diabetes,...which confirms that HFD can induce diabetes recurrence after gastrointestinal metabolic surgery. This remission-recurrence model helps us to understand the mechanisms of diabetes recurrence... In conclusion, this study demonstrated that HFD induced diabetes recurrence after initial remission with SG and DJB surgery. The re-impairment of hepatic and muscular insulin sensitivity was likely responsible for the recurrence, and alterations of beta-cell function, body weight, and gastrointestinal hormones (GLP-1, PYY and ghrelin) seemed not to correlate with recurrence."

The time frame is off... they made their observations ~12 weeks post op.


Edit... looked a little closer.. you can always induce diabetes in rats with a HFD, it's SOP in rat diabetes research.. the observation here is you can induce diabetes in rats after they've had a DS or VSG. News to me about the DS, one would expect the fat malabsorption to limit the effect of a HFD

 

[southernlady]

It’s hard to argue with Dr. Bernstein and his results. After all, his methods has kept him alive and pretty much complication free for 7.5 decades. A man who made home glucometers possible for everyone. He has a teleseminar/webcast (in fact one is this evening) to answer questions. He’s still a practicing endocrinologist, not usual for a man of 87. And to still be alive and extremely healthy at 87 as a type 1 is unheard of.

One thing I would insist on is a C-Peptide test to be sure it’s not Type 1 or LADA. Its not impossible for us to become autoimmune.

 

[southernlady]

BTW, the ADA has finally gotten the message that “the more carbs the merrier“ is horrid for diabetics.

 

[southernlady]

Clematis im gonna move this to the non DS Medical.

 

[Clematis]

OK whatever you think is best, but my point in posting is that the DS may have CAUSED the diabetes. https://pubmed.ncbi.nlm.nih.gov/17072232/

"A 2006 report identified the main causes of "brittleness" as malabsorption, certain drugs, including alcohol and antipsychotics, defective insulin absorption or degradation, defective hyperglycemic hormones, especially, and delayed gastric emptying."

 

[southernlady]

OK whatever you think is best, but my point in posting is that the DS may have CAUSED the diabetes. https://pubmed.ncbi.nlm.nih.gov/17072232/

"A 2006 report identified the main causes of "brittleness" as malabsorption, certain drugs, including alcohol and antipsychotics, defective insulin absorption or degradation, defective hyperglycemic hormones, especially, and delayed gastric emptying."

It may have but then again, you may have developed it as an autoimmune response

 

[southernlady]

If it’s proven to not be autoimmune, I’ll move it back.

 

[Georgepds]

OK whatever you think is best, but my point in posting is that the DS may have CAUSED the diabetes. https://pubmed.ncbi.nlm.nih.gov/17072232/

"A 2006 report identified the main causes of "brittleness" as malabsorption, certain drugs, including alcohol and antipsychotics, defective insulin absorption or degradation, defective hyperglycemic hormones, especially, and delayed gastric emptying."

Hi ..

I looked at your ref... just curious.. were you able to do any of these measurements with your cgm?

"To quantify instability, measures which have been developed, include Mean Amplitude of the largest Glycemic Excursions (MAGE), Mean Of Daily Differences (MODD), Lability Index (LI), Low Blood Glucose Index (LBGI), Clarke's score, Hyposcore, and continuous blood glucose monitoring."



Also.. what makes you think you have "delayed gastric emptying." I thought the VSG part of the DS enhanced gastric emptying.

 

[Georgepds]

It’s hard to argue with Dr. Bernstein and his results. After all, his methods has kept him alive and pretty much complication free for 7.5 decades. A man who made home glucometers possible for everyone. He has a teleseminar/webcast (in fact one is this evening) to answer questions. He’s still a practicing endocrinologist, not usual for a man of 87. And to still be alive and extremely healthy at 87 as a type 1 is unheard of.

One thing I would insist on is a C-Peptide test to be sure it’s not Type 1 or LADA. Its not impossible for us to become autoimmune.

Umm.. It’s not that hard to reconsider Bernstein's methods for the T2 diabetic.

Re Bernstein two things moment to mind


1)first Gotta ask.. seems like many times I bring up a nutrition result it's pointed out that result may not apply to the DS population because of altered anatomy. Yet, when the good Dr Bernstein recommends a strictly controlled low carb diet, there is no suggestion that the altered anatomy of the DS population may respond differently. Perhaps this is just a case of Emerson's observation, foolish consistency is the Yada Yada Yada " SFAIK, the good Doctor never treated a DS patient


But I don't think so. I think both general nutrition results and Bernstein's anecdotal ( by that I mean case study) apply equally well, with some consideration given to the possible effects of DS


2) Next, there two tools in Bernstein's box: low carb diet and early use of insulin. Both will control blood sugar, one can kill you

Let's consider a moment why most Doctors consider insulin a last resort for the T2 diabetic... it can easily kill you. Now if you're T1, you've no choice, you need insulin and you must master the tools to carefully monitor your response to both diet and dose both to control BG, but more importantly, to avoid death by hypoglycemia


It short you must become the same type of guy the good Dr Bernstein is: a major nudjnick, in fact a nudjnick cubed. Count every carb, monitor every dose to achieve the desired result, and avoid iatrogenic ( look it up) death


Iatrogenic death by hypoglycemic coma.. that's why most doctors don't follow Bernstein's insulin path with T2 diabetics, except as a last resort


Or, you might consider an alternative...