The Hypoglycemia Dilemma: Unraveling the Clinical Targets Mystery for Type 1 diabetes

🚨 This post follows up from an earlier post and answers the question of why the clinical glycemic targets set by diabetes organizations are substantially higher than the normal blood sugar levels the body naturally maintains for optimal health.

This is a lengthy, yet important post, so if you have the time, I recommend reading all the way through!

🙋‍♀️ The answer, is fear – specifically, the fear of hypoglycemia.

🏃‍♀️ TLDR: Clinical Targets are set due to a fear of hypoglycemia, and NOT for optimal health outcomes for those with Type 1 diabetes.

👉 In this post, I will also provide the solution which can mitigate hypoglycemia, and aim to safely achieve normal blood glucose levels.

A thorough examination of clinical target documents from organizations like the ADA consistently emphasizes the need to avoid significant hypoglycemia when setting glycemic goals.

The pervasive fear of hypoglycemia is deeply embedded in the recommendations, dictating the A1C goals to be less stringent, with a cautious approach to minimize the risk of hypoglycemia.

“Therefore, healthcare professionals should be vigilant in preventing hypoglycemia and should not aggressively attempt to achieve near-normal A1C levels in people whom such targets cannot be safely and reasonably achieved.” (ADA, 2023)

The clinical targets are not set with the goal to avoid unnecessary health complications as a result of blood sugar levels beyond the normal range, rather they are set with the primary goal to avoid hypoglycemia.

“The selection of a glycemic goal for a given patient at a given point in the evolution of that individual’s diabetes is a compromise.

While partial prevention or delay of microvascular complications is the upside, the morbidity and potential mortality of iatrogenic hypoglycemia are the downside of intensive glycemic therapy in diabetes. A reasonable individualized glycemic goal is the lowest A1C that does not cause severe hypoglycemia and preserves awareness of hypoglycemia, preferably with little or no symptomatic or even asymptomatic hypoglycemia. The selection of a glycemic goal should be linked to the risk of hypoglycemia…” (Diabetes, 2014)

The literature echoes this sentiment, underscoring hypoglycemia as the major hurdle in achieving optimal glycemia with insulin therapy.

"hypoglycemia is the limiting factor, both conceptually and in practice, in the management of diabetes mellitus." (Cryer, 1999)

➡️Insulin Medication: The Double-Edged Sword

"hypoglycemia is, by far, the most common adverse effect of insulin therapy," states Thota (2023).

One the one hand, exogenous insulin is a life saving medication used to manage Type 1 diabetes. One the other, it is potent and unpredictable with potentially serious life-threatening consequences.

The unpredictability of insulin's action, ranging up to 35% in some studies, poses a serious threat to safety and complicates the pursuit of normal blood glucose levels.

As insulin therapy remains far from perfect, the risk of hypoglycemia becomes the primary factor guiding clinical targets.

And the greater the dose of insulin, the greater the unpredictability of insulin's actions leading to an increased risk of adverse blood sugar fluctuations, and hypoglycemia.

I hope this clears up the confusion about clinical targets, and that the underlying reason as to why they are much higher than the goal of T1D management, is to provide a safety buffer to guard against hypoglycemia, rather then be primarily driven to avoid health complications as a result of elevated blood glucose levels.

But is setting Clinical Targets beyond the ranges of optimal health to avoid hypoglycemia the best strategy❓

Is this the only strategy available to those diagnosed with Type 1 diabetes❓

Is there a way out of this hypoglycemia dilemma❓

Indeed, there is a solution❗️

To reduce the unpredictability of insulin's action with the goal of reducing hypoglycemia, enabling smaller, safer doses of insulin, we must address the root cause – elevated blood sugar levels.

The factor that has the greatest impact on blood glucose levels is FOOD! 🍽

The key lies in nutrition, the missing, and overlooked element in the equation. 🥩🥑🥦

By adopting a Therapeutic Carbohydrate Reduction/Low-carb nutrition strategy tailored for Type 1 diabetes management, which emphasizes nutrient-dense foods low in carbohydrates with little effect on blood sugar levels, we can minimize blood glucose variability, resulting in smaller, safer doses of insulin, while creating a safer environment for achieving normal blood sugar levels.

Despite the advancements of newer and faster acting insulins, as well as the development of exciting diabetes technology such as smaller, and more accurate CGMs, and insulin pump technology, few diagnosed with Type 1 diabetes actually meet the ADA’s A1C elevated Glycemic Targets.

In fact, “One reason the goal of <7% cannot be reached in practice, and in fact is seldom reached in clinical trials as well, is the limitation imposed on aggressive therapy by the fear of hypoglycemia.” (Oyer, 2013)

🧐“Insanity is doing the same thing over and over again and expecting different results.” Albert Einstein

🎯 Type 1 diabetes is a metabolic condition, and a specifically tailored nutrition strategy which aims to safely achieve normal blood glucose levels, and provide essential nutrients for optimal health must be at the heart of all clinical guidelines and targets.

If you are interested in successfully implementing a Therapeutic Carbohydrate Reduction/Low-carb nutrition strategy, so you can safely achieve normal blood sugar levels, and nourish your child's growing body, please don't hesitate to:

🖱 https://www.t1dnutrition.com/
📨 [email protected]
📬 m.me/107379384792655

Follow T1D Nutrition on:

Website: https://www.t1dnutrition.com/
Facebook: https://www.facebook.com/t1dnutrition/
YouTube: https://www.youtube.com/@t1dnutrition

P.S. Here is a protein breakfast bowl! Low-carb Greek Yoghurt, with added protein power, NuTrail Keto Blueberry Cinnamon Nut Granola (purchased from Walmart in the US), Blueberries. Optional: can add a low-carb syrup such as Lakanto Maple, Wholesome Yum Zero Sugar

📚 REFERENCES:

Cryer P. E. (1999). Hypoglycemia is the limiting factor in the management of diabetes. Diabetes/metabolism research and reviews, 15(1), 42–46. https://doi.org/10.1002/(sici)1520-7560(199901/02)15:1<42::aid-dmrr1>3.0.co;2-b

Cryer P. E. (2014). Glycemic goals in diabetes: trade-off between glycemic control and iatrogenic hypoglycemia. Diabetes, 63(7), 2188–2195. https://doi.org/10.2337/db14-0059 Heinemann, L. (2008). Variability of Insulin Action: Does It Matter?, Insulin, 3 (1), 37-45. , https://doi.org/10.1016/S1557-0843(08)80010-3. page 37

Nuha A. ElSayed, Grazia Aleppo, Vanita R. Aroda, Raveendhara R. Bannuru, Florence M. Brown, Dennis Bruemmer, Billy S. Collins, Marisa E. Hilliard, Diana Isaacs, Eric L. Johnson, Scott Kahan, Kamlesh Khunti, Jose Leon, Sarah K. Lyons, Mary Lou Perry, Priya Prahalad, Richard E. Pratley, Jane Jeffrie Seley, Robert C. Stanton, Robert A. Gabbay; on behalf of the American Diabetes Association, 6. Glycemic Targets: Standards of Care in Diabetes—2023. Diabetes Care 1 January 2023; 46 (Supplement_1): S97–S110. https://doi.org/10.2337/dc23-S006

Nuha A. ElSayed, Grazia Aleppo, Vanita R. Aroda, Raveendhara R. Bannuru, Florence M. Brown, Dennis Bruemmer, Billy S. Collins, Marisa E. Hilliard, Diana Isaacs, Eric L. Johnson, Scott Kahan, Kamlesh Khunti, Jose Leon, Sarah K. Lyons, Mary Lou Perry, Priya Prahalad, Richard E. Pratley, Jane Jeffrie Seley, Robert C. Stanton, Robert A. Gabbay; on behalf of the American Diabetes Association, 14. Children and Adolescents: Standards of Care in Diabetes—2023. Diabetes Care 1 January 2023; 46 (Supplement_1): S230–S253. https://doi.org/10.2337/dc23-S014

Oyer D. S. (2013). The science of hypoglycemia in patients with diabetes. Current diabetes reviews, 9(3), 195–208. https://doi.org/10.2174/15733998113099990059

Thota S, Akbar A. Insulin. [Updated 2023 Jul 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560688/

#t1dnutrition
#type1diabetes
#TherapeuticCarbohydrateReduction
#lowcarb
#NormalBloodGlucose
#normalbloodsugar
#letmebe83