How Good?

How good do we have to be?

Or maybe I should ask how good do I have to be? Because what is good enough to keep me healthy might not be good enough for you. Diabetes complications can be a capricious foe giving retinopathy or gastroparesis to people who have relatively good numbers and leaving others living with erratic sky-high numbers unscathed. But we mostly know that the better we do, the better off we’ll be. 

Me, I’ve made it through 44+ years of diabetes with no major complications. At age 69 my eyes, kidneys, nerves, and cardiovascular system are seemingly okay. Same for my sister at age 72 with 40 years of Type 1. Something crummy in our genetics made us susceptible to Type 1. At the same time something good in our genes is protecting us from diabetes complications. In 2005 the Joslin Diabetes Center launched the 50-year Medalist study to investigate why a select group of people had managed to thrive despite longterm Type 1 diabetes. I am not sure that they have found definitive answers but I think that I share in the good fortune of those longtime survivors. My endocrinologist insists that hard work and newer insulins/technology are what have protected me but I strongly believe that luck and “unknown protective factors” are also in the mix.

Diabetes social media is inundated with people who use CGMs, pumps, newer insulins, smart computer algorithms, strict diets, incredible motivation, and lots of diabetes know-how to push the boundaries of what blood glucose numbers are achievable for those of us with Type 1 diabetes. Some people argue that we are entitled to and should target “normal” blood glucose numbers. But what is normal? The lab normals for my A1c tests indicate that results between 4.0 and 6.0 are normal. The CDC indicates that an A1c of 5.7 and below is normal. But an A1c of 5.7 equates to an average blood sugar of 126 and a 6.0 A1c is a 136 average. Those aren’t “normal“ although they are good for people with existing diabetes. Dr. Bernstein insists that normal is a blood glucose of 83 and our bodies are being damaged by anything higher. That 83 translates to an A1c of 4.5. So depending on whom you listen to, normal can be anywhere from 4.5 to 6.0.

As a contrast to Bernstein’s beliefs there are studies and other diabetes doctors claiming that an A1c of 6.5 is good enough and that anything lower has diminishing returns. Stacy Simms of the Diabetes Connections Podcast has a 2019 interview with Dr. Bill Polanski of the Behavioral Diabetes Institute and Dr. Steve Edelman of TCOYD called “Evidence-Based Hope and Type 1 Diabetes: New Info, New Optimism.” These doctors cite research studies and argue that “decent care” might be good enough and that might include A1c’s as high as 7.0 or 7.5. 

Interlude: I am hesitant to mention Dr. Edelman since his recent three donuts video is causing conflict in the diabetes online community (DOC). But lots of things cause conflict in the DOC and I believe that it is medicinal to laugh at many of the absurd things we do to live with diabetes. I like donuts, especially the old fashioned ones with chocolate icing, and am not too proud to admit that I have eaten three at one sitting. And yes, the BG repercussions were horrible. I don’t look at Dr. E’s video as a how-to or permission to gorge on donuts. But I do like his attitude that I shouldn’t be mired in guilt at occasional dietary indiscretions.

So what blood glucose numbers and target ranges should those of us with Type 1 diabetes strive for?

Is there an optimal balance between diabetes mental health and diabetes physical health?

Is diabetes social media filled with numbers games that don’t necessarily translate to better overall health?

Are we playing the numbers game rather than focusing on a good life?

I should insert here that many people with diabetes are struggling to achieve any semblance of “good results” and please know that I respect your struggles. Diabetes is a tough adversary. Diabetes is especially tough when you struggle to afford insulin and technology. Diabetes is tough when you’re doing your best and it is never good enough.

This blogpost is targeting the superstars. The people on social media complaining about an A1c of 5.2 and wanting to be in the 4’s. The people who successfully achieve one target range and then immediately set a lower target range. The people who are critical of parents who allow their child a cupcake. The people who insist on low normal blood sugars when our doctors allow higher. The people whom I am jealous of. The people whom I think are crazy. The people like me who are never satisfied with how I am doing.

Is there ever a number that is good enough?

For sure I don’t know. I just know that I can’t live a “perfect” diabetes life. I make lots of good decisions but never reach the nirvana of a flat blood glucose tracing. I make lots of bad decisions and no amount of pumped insulin, injected insulin, and/or inhaled Afrezza can control the blood glucose spikes. And sometimes I make good decisions and still get a crazy high spike in the middle of the night. Hormones. Pump sites. Who knows? There is no end to the things that can go wrong.

And how will I ever know if I am living a D-life that is “good enough”?

One answer is that according to my standards, my numbers recently haven’t been “good.” Control IQ with my Tandem pump keeps me somewhat higher than my previous targets. At the same time I feel good. I hike 5 miles. I walk for 18 holes of golf. Although I’ve gained weight in recent years, my clothes still fit. So I am probably doing “good enough.”

Another answer is that although my numbers with Control IQ have been higher recently, my endo loves them. I really appreciate virtually having no lows and when I do have lows, I feel them more than I have in the ten or twenty years. The fact of the matter is that I feel the same with an average of 125 as I feel with an average of 100. And if my average were 150, my guess is that I would still feel good. Is my body being damaged with higher numbers? My endo would say no and she would emphasize that at my age that it is hugely important not to have severe lows, falls from lows, and disorientation from lows. She very frankly says that I probably won’t live long enough to get complications from my current blood glucose numbers.

But I struggle to accept my current numbers. They “fail” compared to the stellar goals and numbers of some of my online diabetes friends. But they are probably great compared to most people with Type 1 diabetes. I often think my mental health is more at risk than my physical health when I look at my day-to-day life with diabetes. 

I play golf and am pretty good at the game. To me diabetes and golf are about the same on the frustration scale. No matter how good a golfer you are, you wish you were better. I think that a 6-handicapper is just as frustrated or more frustrated than a 30-handicapper. Same with diabetes. You start to get BG numbers that you never thought were possible. But you know you could do better. You remember those 3 chocolate chip cookies last week. You remember the unexplained highs last Tuesday and the crazy lows after changing your pump cartridge yesterday. All of a sudden your time in range is not good enough because there are people on Facebook getting 100% with a much-tighter range. 

Sometimes I wonder: Are we living diabetes instead of living life?

And BTW I can quit golf but I can’t quit diabetes.

Lots of questions. Not a lot of answers.

Diabetes, Arthritis, and the Dog

I left Arizona in mid-April and have spent the last month in Minnesota watching snow melt followed by grass turning green and trees getting leaves. For better or worse, medical stuff has taken a good chunk of my time in recent weeks. 

The Dog:  Abby the Black Lab is 12 years old which is old for a big dog. For the last 6 months her breathing has been loud with occasional gagging and coughing. It turns out that she has chronic bronchitis which is kind of like COPD for dogs. Her treatment? A steroid inhaler. The vet told me that I could check out prices locally but recommended that I buy the inhalers from Canada. Sounds familiar for those of us on insulin…. One inhaler at Costco. $369. One inhaler from Canada. $69. My understanding is that while it is illegal to import prescription drugs from Canada, the ban is not being enforced. I am not losing sleep over the threat that I could go to jail for importing medication for my dog. Dr. Google mentions that canine patients can be “uncooperative” when dealing with inhalers and the Aerodawg chamber. Well, duh.

Pump Supplies:  More than once I have written about my need to change infusion sets every two days. I had always received sufficient supplies with no problems until 2018. I recently criticized CCS Medical for being less than helpful in resolving the problem and switched to another supplier. Meanwhile reflecting the power of Social Media I received a call from a customer service supervisor at CCS and I suspect that she would have helped me to navigate the process. But I was several weeks into working with Solara Medica and it didn’t make sense to go back to CCS. I did eventually get my 45 infusion sets from Solara but it wouldn’t have happened without my bulldog sales rep Stephanie. My endo’s assistant had to submit, resubmit, and re-resubmit medical necessity forms and office notes. The normal 30-day BG log wasn’t enough and I had to provide a 60-day log. Ironically none of the ever-morphing requirements for 2-day site changes had anything to do with adhesive allergies and site infections. I am now good for 3 months and dread starting over again in July.

Fiasp:  At my April endo appointment, I was given a Fiasp sample. There were no vials available and I took home a yellow and blue 300ml pen with several pen needles. I didn’t do systematic testing to see if Fiasp injections brought down highs better than Novolog, but I assume it did. I filled a pump cartridge and started using it in my Tandem X2 pump. Immediately I seemed to have an easier time with my morning BG’s.  Unfortunately as others have reported Fiasp seemed to run out of steam on Day 3. By Day 4 my numbers were terrible and I switched back to Novolog.

Was this is a fair trial of Fiasp? Absolutely not and it doesn’t matter. Fiasp is not covered by Basic Medicare and I have no interest in paying out of pocket for it. I had to laugh because several times on my blog, I have mentioned that my sister is very adverse to changes in her diabetes care. After a few days of Fiasp I determined that I am entirely too lazy to figure out pump settings to be successful with a new insulin. Meanwhile my sister has switched her mealtime insulin from Regular to Humalog and will be starting Tresiba soon. She is actually considering ordering the Freestyle Libre! So who is adverse to change???

Arthritis:  A year ago I wrote that arthritis is the “health problem that most threatens my Pollyanna “Life is great!” philosophy.” My systemic arthritis is well-controlled with NSAIDs, but degenerative osteoarthritis in my hands and feet is relentless. Last week my foot doctor indicated that surgery is the only option for my left foot. I am not totally on board with cutting into my foot. It fixes one joint but I still have tendon and heel problems. And then I have my right foot. Psychologically I struggle with having this surgery because it opens the door to dealing with my other bad joints. There is something comforting with staying with the pain I know and avoiding the pain and unknown results of surgery. 

I will schedule surgery for mid-August with the option to cancel it. Two weeks on the couch with drugs will be followed by two months in a boot with a knee scooter. In the short run I have abandoned the close-by health club where I enjoy the fitness classes but know that they are not good for me. I have joined the YMCA which has an extensive schedule of fitness and water aerobics classes directed at various levels of senior fitness. Argh! I can’t even stand to write this but I know that I will feel better. 

Frozen Shoulder:  I think that I am in the early stages of frozen shoulder on the right side. I am unfortunately an expert on this condition and on the 4-year plan. I had my first FS in 2001 on the left side. Four years later my right shoulder was affected and four years later the left again. Now it’s back to the right. Only the first one was horrible. The rest have been annoying and long-lasting but not hugely debilitating. Don’t tell me to stretch the shoulder in the shower. As I wrote in 2013, “if you can get rid of your “frozen shoulder” by doing a week’s worth of exercises in the shower, you don’t have adhesive capsulitis.” My experience with frozen shoulder indicates that it is an inflammatory disease-driven condition that is more related to duration of diabetes than A1c levels. Whatever. If you want to learn more about frozen shoulder, check out my “Argh! Frozen Shoulder” blogpost.

Summary:  That’s it for today. The dog is old. I’m getting older and my feet hurt. So do my hands. I’m a chicken when it comes to surgery but hate the idea of quitting the activities that I love. I had diabetes yesterday and still will tomorrow. But the sky is blue and the grass is green. Life is good.

Happy spring to everyone! 🌷🌷🌷

Considering the Heart | Part 3 | My Story

I delayed finishing this blogpost because despite my research on cardiovascular disease, I felt quite ignorant about my specific risks. After recent lab work, a specialized CT scan, and a visit with my internist, I am comfortable that I am competent to share my story.

Laddie_Head SquareIn Part 1 and Part 2 of this series about cardiovascular disease (CVD), I mentioned my tendency to play the “Not Me” card and dismiss the possibility of heart disease. My rational self knows better and I am aware that statistics indicate that my risk is significant. To date I have never experienced cardiac symptoms nor been diagnosed with CVD.

The American Heart Association website indicates that cardiovascular risk is determined by a combination of uncontrollable and modifiable factors. I do not get a good grade on uncontrollable risks. I am a post-menopausal woman who has had Type 1 diabetes for almost 40 years. I have a family history of heart disease including a father who had a heart attack before age 55. I have the negative factor of long-term use of prescription-strength NSAIDs for my inflammatory arthritis.

At the same time all is not gloom and doom because I have many checkmarks in the “heart-smart” column of things that reduce CVD risk. I am not overweight and IConsidering the Heart exercise regularly. I have never smoked, I eat a reasonably good diet, and my A1c is well within target range. I sleep okay for the most part and am not burdened with depression or an overly stressful life.

My blood pressure is in target range for “normal people,” but I have flirted with being out of the recommended range for people with diabetes. I am currently on a  low dose of blood pressure medicine and have no problems with it. Because BP meds have been shown to provide kidney protection for people with diabetes, I figure that I am getting a double benefit from it.

Eight months ago I had an out-of-range cholesterol test for the first time ever. Because my lipid numbers have always been ideal and my HDL (“good” cholesterol) is insanely high, my internist was okay with the “wait and watch” philosophy before prescribing statins. I saw my endocrinologist a few months later and she strongly suggested I start a statin drug. The 2016 Standards of Care in Diabetes includes this recommendation:  “In all patients with diabetes aged ≥40 years, moderate-intensity statin treatment should be considered in addition to lifestyle therapy.”

In December I accepted a prescription for a low dose of a statin. I filled it, took the pills for a month, and quit. I BECAME A NONCOMPLIANT PATIENT. I quit because I wasn’t mentally ready to take a drug that I swore I would never take. I also wanted one more cholesterol test without medication to confirm the previous results. This spring after great results from a repeat cholesterol test and a coronary artery calcium scan ($100 out-of-pocket), my internist and I agreed that it was appropriate for me to refuse a statin drug at this time. (This blogpost is not about the statin controversy and I suggest that you do your homework on statins and work with your medical team to make the best decision for you.)

I sometimes worry that I have characteristics that will lead to suboptimal diagnosis and care in case of a cardiovascular event. This article by Carolyn Thomas of Heart Sisters describes why women often delay seeking medical care mid-heart attack and I realize that I could be such a woman. I know that I might be apt to dismiss symptoms as “nothing” or sit at home wondering if my symptoms are significant. I am definitely the personality who might drive herself to the ER with chest pains. Even worse as someone with T1 diabetes, I know that I am at risk for an asymptomatic heart attack. Symptoms of a stroke are probably more clear than those of a heart attack and I know that it is important to not delay treatment for those symptoms.

I’m now at a point that I am somewhat educated about cardiovascular disease and knowledgeable about my risk factors. I work hard to be an empowered patient and although I don’t always agree with my doctors, I listen to them. I do my best to eat well and live well. After that, there is not much that I can do except try not to get run over by a bus tomorrow….

Summary: I hope that my series on cardiovascular disease as related to Type 1 diabetes and being a woman has taught you something and inspired you to educate yourself. Some of my diabetes friends have already been diagnosed with CVD issues and the rest of us are “at risk”. None of us should live our lives in total fear of where statistics might lead us. At the same time we shouldn’t stick our heads in the sand and be stupid.

A lot of the data contained in my first two posts is gloomy. I think that it is important to remember the statistic from the EDIC study that intensive diabetes therapy can reduce cardiovascular events by 42%. As much as you may hate the monster that is diabetes, do your best to manage it. We’ll never be perfect, but maybe we can make a difference.

Please remember that I am not a medical professional. Although this post presents information about cardiovascular disease and Type 1 diabetes, it is by no means complete. Do your homework and talk to your medical professionals about your risk.

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Related Posts

Considering the Heart | Part 1 | Type 1 Diabetes

Considering the Heart | Part 2 | Women with Type 1 Diabetes

Considering the Heart | Part 2 | Women with Type 1 Diabetes

Laddie_Head SquareIn Considering the Heart | Part 1 | Type 1 Diabetes, I addressed my pretense of belonging to the “Not Me” club. As a woman, it is easy to think that I have a similar “Not Me” pass when it comes to heart problems because isn’t heart disease a man’s disease? Based on the attention given to breast cancer in this country, shouldn’t cancer be my biggest concern? Wouldn’t I have symptoms if I had cardiovascular disease (CVD)? Won’t I know if I am having a heart attack or a stroke? Although I know that my risk for heart disease has risen because I am in my 60’s, aren’t younger women protected from cardiac problems?

Let’s burst these bubbles right away—

FACT:  Heart disease is the leading cause of death for women in the United States. About 1 of every 3 female deaths is the result of heart disease.

FACT:  Every year since 1984, more women than men have died of heart disease in the United States. Alarmingly, women are twice as likely as men to die following a heart attack.

FACT:  Heart disease is more deadly than all types of cancer combined. Six times as many women will die of heart disease in the coming year compared to deaths from breast cancer.

FACT:  Heart disease may be silent and not diagnosed until a woman has a heart attack or stroke. Almost two-thirds of women who die suddenly from CVD had no previous symptoms.

FACT:  Symptoms of heart attacks can be different for women compared to men. Although many women experience the most common symptom of chest pain, about 40% Considering the Heartof women experiencing a heart attack have no chest symptoms at all. Instead of or in addition to pain, they may have severe fatigue, shortness of breath, indigestion, and anxiety.

FACT:  Although heart disease is more common in older women, it is a threat to all women. The incidence of sudden cardiac death for women in their 30’s and 40’s has risen 30% in the last decade.

The above statistics are relevant to all women. Now for a few disturbing facts that pertain to women with Type 1 diabetes.

♥︎♥︎♥︎  Although rates of CVD in the general population are lower for premenopausal women than for men, this female sex protection is not seen for women with Type 1 diabetes. At all ages women with T1DM are more likely to have a CVD event than healthy women.

♥︎♥︎♥︎  According to one large meta-analysis of sex-specific mortality from 1966-2014, women with Type 1 diabetes were found to have nearly twice the risk of dying from heart disease compared to men with T1 and a 37% increased risk of stroke.

♥︎♥︎♥︎  CVD risk factors are more common in children with T1DM than for the general population and even at a young age, girls with Type 1 have a higher risk burden than boys with T1DM.

In the past and even currently, the incidence of heart disease in women has been under-estimated. I follow an excellent blog about women and CVD disease titled Heart Sisters. Patient Advocate Carolyn Thomas launched the blog in 2009 to provide current and relevant CVD information to all women. She had previously suffered a heart attack with a 99% blocked coronary artery two weeks after being sent home from the ER with a diagnosis of acid reflux. A startling statistic in her About Me page says it all:

“According to research published in the New England Journal of Medicine, women my age and younger are seven times more likely to be misdiagnosed in mid-heart attack and sent home from Emergency compared to our male counterparts presenting with identical symptoms.”

There is hope that the diagnosis/care gap for women with heart disease is being addressed as evidenced by a January 2016 AHA Scientific Statement titled “Acute Myocardial Infarction in Women.” This paper received broad coverage by mainstream media, including this report on CBS News. The most powerful statement in the CBS video is by NYC cardiologist Dr. Holly Andersen: “Heart disease in women is under-researched, under-diagnosed and under-treated.

Most of us with Type 1 diabetes have learned the value of education and how to advocate for ourselves.  As women, particularly women with Type 1 diabetes, we need to do the same in regards to our cardiovascular health. A lot of the information in this post seems to be gloom and doom. In general I prefer to be an optimist and view it as a wake-up call to intensify my efforts to address my controllable risks for cardiovascular disease. Because CVD is highlighted in the ADA Standards of Medical Care in Diabetes—2016, those of us with diabetes may have a head start on other women in having these conversations with our doctors. Below you will find some links to launch your education on women and cardiovascular disease.

In the concluding section of this 3-part series on CVD, I will share my experiences and thoughts on my cardiovascular risks as a woman with diabetes. There is no doubt that although I follow most of my doctors’ recommendations, I have often dismissed these risks in the past. It is a difficult post to write because like all of you, I am dealing with statistics and probabilities along with no black-and-white answers or guaranteed outcomes. For the most part, I just don’t know.

Please remember that I am not a medical professional. Although this blogpost presents a lot of information about women and cardiovascular disease, it is by no means complete. Do your homework and talk to your medical professionals about your risks.

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***   Relevant Links for Women & CVD Disease   ***

AHA statement on women and heart disease January 2016

American Heart Association Go Red for Women

Am I Having a Heart Attack? | Heart Sisters

Heart Disease Statistics | The Heart Foundation

Myths & Facts | Heart Sisters

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***   Relevant Links for Women with Type 1 Diabetes & CVD Disease   ***

ADA Women, Coronary Heart Disease and Diabetes

AHA/ADA Scientific Statement: Type 1 Diabetes Mellitus and Cardiovascular Disease: A Scientific Statement From the American Heart Association and American Diabetes Association

How Diabetes Differs for Men and Women, Diabetes Forecast, Oct., 2011

Women with Type 1 Diabetes “Twice as Likely” as Men to Die from Heart Disease

***  Related Posts  ***

Considering the Heart | Part 1 | Type 1 Diabetes

Considering the Heart | Part 3 | My Story

Considering the Heart | Part 1 | Type 1 Diabetes

Laddie_Head SquareThose of us with any type of diabetes are constantly told that we are at high risk for cardiovascular disease (CVD). As someone who is in relatively good health despite 39 years of Type 1 diabetes, I have been quick to play the “Not Me” card. Although I follow through with all of the tests that my doctors recommend, I do them with the conviction that I don’t have heart disease. My internal dialog has been along the lines of:

♥︎  Heart disease affects people with Type 2 who have metabolic syndrome. Metabolic syndrome is defined on Wikipedia as “a clustering of at least three of five of the following medical conditions: abdominal (central) obesity, elevated blood pressure, elevated fasting plasma glucose, high serum triglycerides, and low high-density lipoprotein (HDL) levels. Metabolic syndrome is associated with the risk of developing cardiovascular disease.”

♥︎  I have diabetes because of an autoimmune attack on my pancreas. That doesn’t have anything to do with metabolic syndrome or heart disease. I am not overweight nor do I have other characteristics of metabolic syndrome.

♥︎  I understand that heart disease can result from “poorly controlled” Type 1 diabetes. My A1c’s are well within the ADA guidelines and have been for a long time. My diabetes is “well controlled.”

♥︎  All of the recommendations for addressing cardiac risk factors for people with diabetes are based on research of people with Type 2 diabetes. There are few studies of specific cardiac risks for people with Type 1 diabetes, especially for those with A1c’s in target range.

♥︎  I am extremely active and exercise daily. I have no pain or fatigue that might suggest CVD.

♥︎  I am a woman and heart disease affects more men than women.

Considering the HeartI could go on and on listing excuses for discounting my risk for heart disease. Instead I decided to do some research by starting with the Google search term “Type 1 diabetes and heart disease.”

I was surprised to find quite a few links. Some were relevant. Others were just the inclusion of Type 1 diabetes into “general” diabetes, really meaning Type 2. By far the most helpful document I found was a 2014 article titled “Type 1 Diabetes Mellitus and Cardiovascular Disease: A Scientific Statement from the American Heart Association and American Diabetes Association.” This statement was prepared by a committee of physicians chaired by Sarah D. de Ferranti, MD, MPH and is a thorough investigation into current knowledge and studies on the relationship of Type 1 diabetes and cardiovascular disease. The introduction to the statement begins:

Despite the known higher risk of cardiovascular disease (CVD) in individuals with type 1 diabetes mellitus (T1DM), the pathophysiology underlying the relationship between cardiovascular events, CVD risk factors, and T1DM is not well understood. Management approaches to CVD reduction have been extrapolated in large part from experience in type 2 diabetes mellitus (T2DM), despite the longer duration of disease in T1DM than in T2DM and the important differences in the underlying pathophysiology.”

This statement is long, but very readable. If you have Type 1 diabetes, you should definitely read it or at least bookmark it for future use. The full text of the article is available for free. There is no way that I can summarize the statement completely, but below I will share some things that I learned:

♥︎  Although I tend to think of the link of ‘heart disease” to Type 1 diabetes, I need to consider the whole CVD package of coronary heart disease (CHD), cerebrovascular disease including strokes, and peripheral artery disease (PAD).

♥︎  While admitting that more research is needed to understand the incremental risk and clinical presentation of CVD in people with T1DM, the authors state that “Overall, CVD events are more common and occur earlier in patients with T1DM than in nondiabetic populations.” Statistics mentioned are that the age-adjusted risk in Type 1 is about 10 times that of the general population and that CVD events occur on average 10-15 years earlier than for matched non-diabetic subjects. One analysis of 5 studies indicates that for each 1% increase in A1c, the risk for peripheral artery disease goes up by 18%.

♥︎  Although rates of CVD in the general population are lower for premenopausal women than for men, this female sex protection is not seen for women with Type 1 diabetes. At all ages women with T1DM are more likely to have a CVD event than healthy women.

♥︎  Atherosclerotic abnormalities can be seen in children and adolescents with T1DM.

♥︎  Autonomic neuropathy in T1DM can result in silent (asymptomatic) cardiac events with delayed diagnosis due to absence of pain and other vascular symptoms.

♥︎  The follow-up study to the Diabetes Control and Complications Trial (DCCT: 1983-1993) was the Epidemiology of Diabetes Interventions and Complications study (EDIC: 2005). EDIC reported that intensive therapy reduced the risk of cardiac events by 42%.

♥︎  The downside of improved glycemic control is that it can lead to weight gain and insulin resistance in people with Type 1. It is assumed that as A1c levels improve, the importance of general cardiac risk factors such as central obesity, high blood pressure, high LDL cholesterol, and high triglycerides gain increasing importance.

♥︎  Most research on the incremental risk and clinical presentation of CVD in people with diabetes is based on studies of people with Type 2 or no distinction is made as to type. However, the studies which are specific to Type 1 find increased risks for people with Type 1 when compared to healthy control subjects.

One other article of particular interest is from the August 2013 issue of Diabetes Forecast and is titled What’s Behind Heart Attacks in Type 1 Diabetes? This article highlights the research of Joslin Diabetes Center Investigator Myra Lipes, MD and outlines the idea that autoimmunity may be behind the increased rates of CVD for people with Type 1. Initial studies have suggested that an out-of-control autoimmune response post-heart attack is responsible for the fact that people with Type 1 diabetes are at high risk for poor outcomes after a heart attack.

Summary:  I have learned a lot about cardiovascular disease and Type 1 diabetes. Although more studies are needed to understand the specific CVD risks for people with Type 1 diabetes, there is definite proof that I should not continue to play the “Not Me” card. In my next post of this 3-part series on cardiovascular disease, I will share information on the particular risks that women have for heart disease.

Please remember that I am not a medical professional. Although this post presents a lot of information about cardiovascular disease and Type 1 diabetes, it is by no means complete. Do your homework and talk to your medical professionals about your risk. 

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***   Relevant Articles   ***

AHA/ADA Scientific Statement: Type 1 Diabetes Mellitus and Cardiovascular Disease: A Scientific Statement From the American Heart Association and American Diabetes Association

Type 1 Diabetes and Coronary Artery Disease, Diabetes Care, November, 2006

Type 1 diabetes and cardiovascular disease, Cardiovascular Diabetology 2013

What’s Behind Heart Attacks in Type 1 Diabetes?, Diabetes Forecast, August, 2013

Wayback Wednesday: All About Diabetes and Heart Health, Diabetes Mine

 

***  Related Posts  ***

Considering the Heart | Part 2 | Women with Type 1 Diabetes

Considering the Heart | Part 3 | My Story

It’s Always Something

Laddie_Head SquareI’ve got a secret list.  A list that I won’t share even if I knock on wood with Woody Woodpecker-like fervor.  A list that the mere mention of the Top Ten (or is it the Bottom Ten?) would jinx me for sure.  If you’ve got diabetes, you probably have a list like this.  It’s the list of diabetes complications that you don’t want to get.  It’s a list with negotiated rankings.  I could deal with this as long as that doesn’t happen to me.  I know that this might be inevitable, but I’ll be okay as long as I don’t have to live with that.  I know I’m brave, but please, please, please never test my courage with <fill in the blank>.

Some of the complications on this list are life-threatening.  Other things are merely cosmetic or at worst a minor irritation.  Some line items are thought to be the result of too many high blood sugars (let’s add a boatload of guilt here!) while others are related to autoimmunity, duration of diabetes, and age.  Some of these complications share the clubhouse with diabetes and doctors aren’t sure why.  My list is always changing because things that I have never heard of keep jumping into my medical chart.

My most frustrating health issue right now is a skin problem called disseminated granuloma annulare (GA). It doesn’t hurt; it doesn’t itch; it is ugly, ugly, ugly.  The most common form of GA is localized with a small number of clustered nodules usually on the hands, feet, knees or elbows.  These clusters often disappear in a year or two with no treatment.  Disseminated (or generalized) annulare granuloma is an out-of-control inflammatory condition that can tattoo your whole body with a variety of nodules, red patches, and unsightly blemishes.  It can last for ten or more years.

Two and a half years ago I had a bunch of bumps on my elbows.  Thinking that they might be the beginning of psoriasis, my rheumatologist recommended a dermatology consult.  My dermatologist indicated that the bumps were not psoriasis (yeah!).  She believed that they were granuloma annulare and took a biopsy to confirm.  I had never heard of this condition and quickly consulted my online physician, Dr. Google.

There is not a lot of information on what causes granuloma annulare.  In a 2013 case report by Mariele De Paola et al., it is stated:

The pathogenesis of GA remains still obscure. Possible pathogenetic factors suggested include humoral and delayed type hypersensitivity, vascular damage, metabolic disorder, or primary collagen and/or elastin alteration mediated through an immunologic mechanism.

One study indicates that diabetes is in the picture about 10-15% of the time while another study indicates that there is no statistical correlation between GA and Type 2 diabetes.  A 2007 retrospective analysis at the Mayo Clinic found insulin-dependent diabetes in about 10% of the GA cases studied and thyroid disorders in 16%.  These statistics at best show a weak link to diabetes, but most researchers still keep it in the equation.  A 2006 article about granuloma annulare by Peggy R. Cyr, M.D. reports that there is a stronger link to diabetes in those patients who have the disseminated variant that I have.

The American Diabetes Association positions granuloma annulare at the bottom of its list of skin complications of diabetes.  I wish that my experience was as simple as the ADA advises: “See your doctor if you get rashes like this. There are drugs that can help clear up this condition.”

My somewhat localized granuloma annulare exploded last fall.  By December it was spreading noticeably from day-to-day and was officially disseminated granuloma annulare. The prescription-strength cortisone cream that helped two years ago was useless.  Because this variation of GA is unusual (about 15% of all cases), there are no large clinical trials to guide my dermatologist in choosing an effective treatment.  Instead she keeps showing me the “big brown book” with the list of medications that have been helpful for patients in small anecdotal studies of 1 to 10 patients.  Many of these drugs overlap with medications for rheumatoid arthritis, psoriasis, and acne and the list includes Dapsone, Accutane, Plaquenil, and Remicade.  As Dr. Cyr writes: “The possible benefit of treatment, which is unclear given the lack of clinical trials, must be balanced against the significant toxicities of most of these treatments.

No Photos AllowedI am currently taking nicotinamide which is a water-soluble member of the B vitamin group.  Nicotinamide rarely causes side effects even at high doses and my dermatologist has prescribed this treatment because of its lack of toxicity.  The basis for the use of this product is a 1983 paper by Alice Ma, M.D. discussing the complete clearing of generalized granuloma annulare in one (!) patient after 24 weeks of high doses of nicotinamide.  It has also been used successfully for inflammatory acne and that is probably the more likely justification for using it for GA.

Is nicotinamide helping me?  Some days I think so.  Other days I think not at all.  Is GA affected by blood sugar levels?  Not in my experience and not according to any articles that I have read.  Is GA related to other health issues besides diabetes?  Granuloma annulare has been linked to autoimmune thyroid disease, some types of cancer, and HIV infection in addition to diabetes.  Is GA autoimmune?  No, it’s inflammatory, but inflammation and autoimmunity go hand-in-hand when you have clusters of autoimmune/inflammatory conditions as I do.

One thing that I find interesting is that when I write about my medical issues, I usually link them to Type 1 diabetes.  Granuloma annulare actually seems to have a stronger correlation with thyroid disease but typically I have glossed over that.  I suppose I do that because I have never been symptomatic for hypothyroidism and the little pill I take every morning is an inconsequential part of my life.  On the other hand, diabetes always demands attention and is woven into almost every minute of every day.

An important issue is what granuloma annulare is doing to my psyche.  One good thing is that GA rarely shows up on the face.  Therefore I can live the rest of my life in turtlenecks and long pants.  A great solution for cool weather but not so great for summertime….  The hardest part is that I can follow my doctor’s orders and still have no control over the unsightly lesions.  When you have Type 1 diabetes, you get used to the idea that WHAT I DO MAKES A DIFFERENCE in my health.  GA abuses that notion daily.  I have to admit that I am getting used to dealing with it and I try to remind myself that it’s not itchy, painful, or life-threatening.

Growing older with a cascading series of autoimmune/inflammatory issues requires an acceptance of today without worrying about tomorrow.  My secret list of diabetes complications will always be in my back pocket, but being afraid of it accomplishes nothing.  Granuloma annulare is a frustrating skin condition and I hope that it eventually goes away.  But there is no reason to let it ruin today or tomorrow.  It is what it is and nothing more.