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Occasional Contributor
confusingpredia
Total Posts: 5
Registered on: ‎02-05-2012

Extremely high insulin levels and c-peptide (OGTT)

Hi all. I'm new to this forum. I was diagnosed as insulin resistant 3 years ago. My weight then was 278 lbs. Today my weight is 211 lbs. I have been on metformin on and off the past few years, currently I am not taking it as per my doctor's recommendation. My fasting blood sugar is usually around 90 to 95. My a1c from early January is 5.1. I was officially considered insulin resistant but not pre diabetic. However I was finally able to convince my doctor to let me do a glucose tolerance test this week. The results are as follows.

C-peptide: 18 ng/mL (normal range per lab report: 1.1 - 4.4)
Insulin: 165.4 uIU/mL (normal range per lab report: 2.6 - 24.9)
Glucose, fasting: 87 mg/dL (normal range per lab report: 65 - 99)
Glucose, 1 hour: 233 mg/dL (normal range per lab report: 65 - 199)
Glucose, 2 hour: 140 mg/dL (normal range per lab report: 65 - 139)

There are no typos in the above. My c-peptide and insulin levels are correct. The test does not mention what time slot the results are from, but my guess is that it's fasting. My doctor mentioned to me to not worry about the insulin level. I am not convinced that is the right course of action. I cannot find any literature where someone has documented insulin or c-peptide levels any where near that high. I was never big into checking my blood sugar extremely frequently, but since this test, I've been keeping track to manage postprandial sugars, as well as check for hypoglycemia. For some reason, from the day I took the test, my blood sugar keeps dropping every few hours after meals to the 60 to 75 range. I have never waited it out to see if it upregulates after that as I always eat something. However, this behavior is very new and odd as in the past, most of the time my sugar would stabilize between 80 to 100.

My doctor told me to not worry about the insulin levels, but I cannot understand why I shouldn't worry. This is record high insulin and c-peptide levels and my sugar keeps dropping. I cannot sleep peacefully because I'm thinking that I will go into a coma. I wake up and eat something every few hours just to make sure I don't have a hypo during my sleep.

I'm just wondering if anyone else had any such experience or can share their insight into what is going on with these high insulin levels. Should I be worried about them? How do I handle the drops to the 60 to 75 range? My doctor says to wait it out and it will readjust but I feel too scared to let it drop below. Any insight would be helpful. Thank you.

Advisor
ronaka
Total Posts: 950
Registered on: ‎12-24-2011

Re: Extremely high insulin levels and c-peptide (OGTT)

Unlike many people diagnosed with diabetes or prediabetes you have a very extensive set of lab readings. I would suggest there is little doubt where you are. Your fasting suggests you are just under the prediabetes diagnosis limit of 100. Your OGTT two hour number is 140, which is exactly the lower diagnosis limit for prediabetes. Your A1C is in the range of prediabetes but alone should not be used to diagnose prediabetes. That has to be confirmed with a fasting or OGTT. It is an OR not both, and technically you are right on the bottom limit with the OGTT. So as I said in the beginning you know exactly where you stand.

 

On insulin that is very seldom tested, but it probably would be a good thing if it were done more often. I call diabetes a tip of the iceberg disease. BG is like the tip of the iceberg, while insulin is the big factor lurking under the surface. You like most type 2 diabetics appear to have high insulin resistance. That mean to get the job done in reducing BG it takes a lot more insulin than a non diabetic. So as the disease (insulin resistance) develops your pancreas produces more and more insulin. While it is able to do produce it fast enough and in sufficient quantities, essentially nothing happens to blood glucose. The day that it can't is when the tip of the iceberg reveals itself as elevated BG. However, the problem has been growing under the surface probably for years.

 

It used to be thought that being diabetic was like being pregnant. Either you are or you are not. Technically the numbers would suggest you are not even prediabetic. However, as you can see the problem under the surface is there big time. Diabetes is not a black and white disease. It is a shades of gray, and right now you numbers suggest a pretty dark shade of gray, but not over the technical limit.

 

The low BG after meals is most likely being caused by your high BG during the meal, lots of insulin being produced -- probably too much, and then the sudden drop. It is kind of a roller coaster effect. I would buy some glucose tablets and with them as backup just let it drop and see how low it really does go, and how fast it recovers. If you do get low symptoms then of course take the tablets to correct it. Most meters read a little low in the low BG range. They do not want you to think BG is OK when it is not -- so the meter probably predicts a low before one really is in effect.

 

If I were in your situation I would ask the doctor about going back on metformin. It is thought to improve the communication with the liver that regulates BG. So while it may seem counterintuitive, it may help your BG regulation as well as reduce average BG. And weight loss if that is a factor always helps. A BMI or around 22 may be close to ideal.

 

Hope that helps some. Thanks for posting your detailed numbers. They are very informative, and not often seen.

Ron

Not a doctor, only another T2 diabetic with, unfortunately 11 year experience. Be cautious about accepting advice, including mine, on medical conditions from the internet. It can be a good place to get ideas, but validate them with your doctor and other medical professionals first.
lizzylou
Total Posts: 13,840
Topics: 561
High Fives: 1,931
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Registered on: ‎10-31-2009

Re: Extremely high insulin levels and c-peptide (OGTT)


confusingpredia wrote:

Hi all. I'm new to this forum. I was diagnosed as insulin resistant 3 years ago. My weight then was 278 lbs. Today my weight is 211 lbs. I have been on metformin on and off the past few years, currently I am not taking it as per my doctor's recommendation. My fasting blood sugar is usually around 90 to 95. My a1c from early January is 5.1. I was officially considered insulin resistant but not pre diabetic. However I was finally able to convince my doctor to let me do a glucose tolerance test this week. The results are as follows.

C-peptide: 18 ng/mL (normal range per lab report: 1.1 - 4.4)
Insulin: 165.4 uIU/mL (normal range per lab report: 2.6 - 24.9)
Glucose, fasting: 87 mg/dL (normal range per lab report: 65 - 99)
Glucose, 1 hour: 233 mg/dL (normal range per lab report: 65 - 199)
Glucose, 2 hour: 140 mg/dL (normal range per lab report: 65 - 139)

There are no typos in the above. My c-peptide and insulin levels are correct. The test does not mention what time slot the results are from, but my guess is that it's fasting. My doctor mentioned to me to not worry about the insulin level. I am not convinced that is the right course of action. I cannot find any literature where someone has documented insulin or c-peptide levels any where near that high. I was never big into checking my blood sugar extremely frequently, but since this test, I've been keeping track to manage postprandial sugars, as well as check for hypoglycemia. For some reason, from the day I took the test, my blood sugar keeps dropping every few hours after meals to the 60 to 75 range. I have never waited it out to see if it upregulates after that as I always eat something. However, this behavior is very new and odd as in the past, most of the time my sugar would stabilize between 80 to 100.

My doctor told me to not worry about the insulin levels, but I cannot understand why I shouldn't worry. This is record high insulin and c-peptide levels and my sugar keeps dropping. I cannot sleep peacefully because I'm thinking that I will go into a coma. I wake up and eat something every few hours just to make sure I don't have a hypo during my sleep.

I'm just wondering if anyone else had any such experience or can share their insight into what is going on with these high insulin levels. Should I be worried about them? How do I handle the drops to the 60 to 75 range? My doctor says to wait it out and it will readjust but I feel too scared to let it drop below. Any insight would be helpful. Thank you.



Hi Con,

 

First, stop worrying about going into a coma while sleeping.  The low range is 65-70, and that's just slightly low.  If you go low your liver will dump glucose into your system, that's what livers do.  Since you're not taking insulin or an oral that stimulates insulin you have no worries.  There's a lot of drama around this coma situation, most of it in the movies. 

 

Your test results indicate that you are insulin resistant.  What that means is the your body makes plenty of insulin but doesn't use it properly.  It makes more and more to achieve results in controlling your BG numbers,  This is a condition, also called metabolic syndrome, and it most cases it does lead to diabetes if the proper steps are not taken.  Perhaps your doctor is old-school and thinks that you're either diabetic or not, but modern thinking knows that there are steps before full-blown diabetes is evident. 

 

The reason that you are experiencing lower numbers is because they're rebounding from high ones.  You can see on the OGTT the one hour number is 233.  That's higher than any normal person would ever go.  Then you see an hour later that it's 140, one point over normal.  That's a pretty big drop.  My guess is that the three hour number would probably have been in your 60-70 range.  By that time your insulin levels finally caught up with the carbs, but they overcompensated with too much insulin.

 

These are all real problems.  If your doctor won't level with you about that fact my suggestion is to seek another doctor.  You have a good chance at this stage to take steps to perhaps not develop diabetes, or not for a very long time.  This would have to be done with lifestyle changes and some doctors also prescribe Metformin now. 

 

Are you a female?  There's a good reason I ask this, I"m not just being nosey :smileywink:

 

To look at lifestyle modification methods, click on the links below:  Testing 101 and All About Carbs.  They will give you some information regarding what steps are involved.  Super Jock Nancy Powerwalker will probably be along to talk about exercise.

 

Lizzy

Knowledge is Power!





Here's some useful links, click on the titles


Testing 101
 
 All About Carbs

Resources For The Un-insured and Discount Medicine and Equipment

LizzyLou Videos



Lizzy's Blog
for lots more  


Occasional Contributor
confusingpredia
Total Posts: 5
Registered on: ‎02-05-2012

Re: Extremely high insulin levels and c-peptide (OGTT)

[ Edited ]

Thank you so much for the quick responses. I really appreciate it. It's very reassuring to know that I won't go into a diabetic coma. As per the dietary guidelines, thank you so much for that. I am assuming you are referring to ketogenic diets. That is another interesting matter regarding my physiology (or maybe pathology is the more appropriate word).

For me, in the past few months, it takes almost no effort to go into ketosis. Even after eating close to or even higher than 100 grams of carbs, if I don't eat for too long, I jump into ketosis very quickly. As an example, I had my OGTT four days ago. Later that day I have a sandwich and a burrito at night. The next day, I ran my home OGTT by eating a plain bagel (60 to 70 grams of carbs, 90 mg/dL fasting, 140 1-hour, 172 90-minutes, 121 2-hours, 109 3-hours, 90 4-hours, 78 5-hours) after fasting, and then ate (white) rice and some meat at night. Then the next day, I had a meal with glass noodles and shrimp and then I didn't get to eating dinner till about 8 hours later. At the five hour mark of those 8 hours, I detected ketones in my urine. Please note that this is albeit having had more than 100 grams of carbs the two prior days and even having carbs during lunch of the same day. This pattern is constant and worries me as I feel I go into ketosis too quickly. My basic blood work suggests no real problems with my liver or kidneys, but in the past I could not go into ketosis as quickly as I can now. Though from a weight loss standpoint this is a good thing, it seems that long-term ketosis can cause harm to your liver and can even predispose you to liver cancer. This certainly concerns me. In addition to this though, there are a plethora of other matters.

Though the hypo worries have affected my sleeping, there have been noticeable changes to my body in the last year albeit me losing weight. I have started experiencing knee pains, orthostatic hypotension, GERD (extreme levels, reaching the larynx), lower levels of libido, substantially increased urination frequency and volume (12 to 15 times a day with substantial volume, used to be 3 to 4 times before), flank pains as well weakness in arms and legs. I get the “pins and needles” feeling quite often on my feet. In addition, after eating a moderate amount (20 g) of high GI carbs, I feel tingling and itching in my arms and legs. My postprandial can be as high as 200, but usually around 160 to 180 1 to 3 hours after the meal, until the drop begins. Though my fasting has typically been in the 80 - 100 range, I recently became aware of the damage that postprandial spikes can do to the vessels, arteries and nerves. Given all the conditions, I feel that peripheral, proximal and autonomic neuropathy has already started to take some effect (I hope it’s not advanced enough to be irreversible).

My LDL cholesterol is 126, my HDL 35, triglycerides are 125 and my C-reactive protein is 17 (should be less than 8). I have also had a sustained higher WBC count for the past 3 years (12,000 to 13,000). Though these are not alarmingly bad, they need to be monitored. When I had an NMR done, my LDL particle size was extremely small so the chances of arterial blockage are higher.

My theory is that the postprandial blood sugars have caused damage which has lead to all these symptoms and conditions. I am working on weight loss and do prefer ketogenic diets but fears of liver and kidney damage stray me away from that approach (I have done it in the past but getting and keeping ketones in urine was much harder then). Though DKA is unlikely for someone like me, I have noticed at times moderate to high levels of ketones in my urine albeit me having eaten substantial amounts of carbohydrates and having normal blood sugars.

All of this is very confusing to me and I can’t help but feel concerned with what is going on. I am turning 28 in a few months; considering the insulin production by my pancreas, I may have complete beta-cell failure before I’m 30 and have to switch to insulin. I do not have any fears or qualms about starting insulin, but I just worry how this relates to my prognosis for type 2 diabetes.

I will continue to lose weight and plan to reach an ideal body weight for my height (5’8”), but my condition is worsening even though I have lost weight. As a male with pre diabetes this early, and with signs of advanced complications already starting, I just feel like I’m trapped. If I try to lose weight and control sugars with a ketogenic diet, I risk harming my liver and kidneys. If I try to control by eating a moderate amount of carbs to avoid ketones, then I risk beta-cell failure and overwork my pancreas (beta-cell failure can be a precursor to pancreatic cancer). Even trying to incorporate exercise is difficult due to the joint and tendon pains in my knees and limbs. I should start the metformin again but I worry about long term kidney damage and vitamin B-12 deficiency. I just wish there was a way out of this that could balance all the concerns. Or perhaps my concerns are not all valid. However, any insight would be helpful. I am having an extremely difficult time dealing with this condition. Thank you.

Trusted Contributor
morrisolder
Total Posts: 10,430
Registered on: ‎11-28-2009

Re: Extremely high insulin levels and c-peptide (OGTT)

Obviously you have thought a lot about this and read a lot, and know more about it than most newly diagnosed people arriving here.

 

A couple of things occurred to me reading your posts.

 

One is that you mention going 8 hours between meals on one day, and it seemed like a long time on the other. And you maybe eating only 2 meals--I'm not sure. Given that your OGTT at the lab, and also the bagel one at home shows that you react strongly to lots of carbs, more meals, with snacks in between, with less carbs each time, may work a lot better for you.  100 grams of carbs in a day is not much at all-the average American eats 450 grams per day, and the USDA food labels are based on 312 grams per day. But if you are putting those 100 in 2 meals, 50 grams at a time may be too much for you, causing your glucose levels to shoot way up and then come crashing down when your insulin finally takes over.  So more of a grazing approach, with 3 small meals and snacks in between, even with the same number of carbs, or even a bit more, may work a lot better.

 

And yes your liver will protect you against lows. Your liver and your pancreas act as a blood guar thermostat in your body.   Blood sugar too high--insulin is added.  Blood sugar too low--the liver releases glucose into the blood.  I have read that typically happens somewhere around 55-60.  So without drugs that stimulate insulin production, and without taking insulin, your liver will not let you go below that, unless perhaps you drink a lot of alcohol, which can distract the liver from its sugar job.  So you are not going to go in a coma if your blood sugar declines at night.  You may or may not want to test enough to figure our how low you go before your liver responds, but it should be somewhere near the typical range.

 

Your biggest problem would appear to be insulin resistance, and metformin does help with that, even if it is not its primary action. Unfortunately the 2 drugs that most effectively address insulin resistance, Avandia and Actos, have come under a side-effects cloud, though you could ask about Actos. Metformin will not be as effective, but does not have any serious side effects. While it is not recommended for weak kidneys, when you are taking it, that will  be part of your lab tests, so that it can be discontinued if your kidneys go South. But that seems pretty unlikely for along time in your case...

Morris

Diagnosed Type 2, with an A1c of 11.4 in 2003; averaging a 5.0 A1c since then with diet, exercise and Glipizide XL + meds for blood pressure and cholesterol. 
A bit dated, but scroll down on this page if you want to know more ...


Advisor
ronaka
Total Posts: 950
Registered on: ‎12-24-2011

Re: Extremely high insulin levels and c-peptide (OGTT)

[ Edited ]

A few thoughts on your detailed comments:

 

- I would suggest you do not have to worry about DKA. It is caused when you have high BG (which you have at times), but at the same time low insulin levels (which you do not have). DKA really only affects those that are deficient or very low in insulin.

 

- statins will typically reduce c-reactive protein as well as cholesterol. Some like Crestor can increase HDL.

 

- not everyone agrees that beta cells fail by wearing out. It may be that they fail as part of the insulin resistance and fat cell growth cycle. Weight loss and exercise is probably the best thing you can do to avoid beta cell loss. I have not seen any evidence that overworked beta cells causes pancreatic cancer. If it did, pancreatic cancer would move from the rare to epidemic category. Type 2 is not rare.

 

- drug companies are forced to reveal all possible side effects of drugs no matter how rare they are. If they don't then ambulance chasing lawyers will sue them to collect "free money". On the other hand it is very easy to overlook the side effects of doing nothing. Unfortunately when heath develops complications there is no zero risk option. You always have to balance the risk of doing nothing, which can be severe, vs the risks of a treatment drug which most often is rare.

 

- I forget the proper term but there is a common condition that medical students suffer from. They tend to "contract" the disease they are studying. It happens, well really it doesn't. I say it because you seem to have had virtually ever test known. I can't remember if I posted it, but there is an extension of the tests you have had, called a HOMA test. It is a measure of insulin resistance. I asked one of the specialists at Joslin about the use of it in diagnosing diabetes early. He said that it is not used as the test is not that accurate on an individual basis. It is primarily used on large groups in studies where it is more meaningful. You may be able to calculate it as you can work through the units, as you have the raw numbers. In any case I'm suggesting you may be over reacting a bit in your concern.

 

- In addition to statins there is also some research from the HOPE study that indicates ACE inhibitors reduce risk of CVD especially in diabetics. This reduction is significant and cannot be explained by BP reduction. It is thought they have a role in reducing endothelial dysfunction.

 

- Last there is some evidence from the DECODE study that BG peaks from the OGTT is more predictive of future mortality and in particular CVD. My thoughts are that you cannot do anything about the genes you have, but there is evidence from the DPP that diet (weight loss), and exercise, and metformin can slow or even reverse the progress of the disease if you start early enough. I think that is where I would focus. I would also ask the doctor about the need for a statin and ACE inhibitor on a preventative basis. And don't worry that everything that could happen will happen!

 

 

 

 

Ron

Not a doctor, only another T2 diabetic with, unfortunately 11 year experience. Be cautious about accepting advice, including mine, on medical conditions from the internet. It can be a good place to get ideas, but validate them with your doctor and other medical professionals first.
Visitor
stacey3569
Total Posts: 2
Registered on: ‎11-27-2012

Re: Extremely high insulin levels and c-peptide (OGTT)

Hello - I just came across this posting from a google search on high insulin levels.  I have PCOS (poly cystic ovary syndrome) and have been taking metformin for about 10 years now.  My levels have always been well maintained, insulin around 6 and glucose between 90-100.  My weight is 140lbs and I'm 5'8".  I had routine blood work done the other week and the doctor called me in yesterday to discuss the results.  Seems my insulin level has spiked to 157 and my glucose is at 123.  The strange thing is that over the past year I have decreased my sugar intake dramatically, and cut back on starchy foods.  The doctor is a bit concerned about the test results and has more scheduled in 2 weeks time.  She said that if the insulin level is still above 50 she will send me back to an endocronologist (I was diagnosed by an endo originally, but my GP has been monitoring my medications and blood tests since).  She asked if I'd been feeling "ok" the last few months and actually I haven't - very fatigued feeling, kind of "confused" in the head / can't think clearly, my bp has gone up and down (I had some heart problems a couple of years ago, so monitor my bp at home), and generally just don't feel "right".   She doesn't want to jump the gun until she has the new tests done, but what could this all mean?  When looking stuff up online I don't see much of anything about such high insulin levels.  Thanks. 

lizzylou
Total Posts: 13,840
Topics: 561
High Fives: 1,931
Solutions: 139
Registered on: ‎10-31-2009

Re: Extremely high insulin levels and c-peptide (OGTT)


stacey3569 wrote:

Hello - I just came across this posting from a google search on high insulin levels.  I have PCOS (poly cystic ovary syndrome) and have been taking metformin for about 10 years now.  My levels have always been well maintained, insulin around 6 and glucose between 90-100.  My weight is 140lbs and I'm 5'8".  I had routine blood work done the other week and the doctor called me in yesterday to discuss the results.  Seems my insulin level has spiked to 157 and my glucose is at 123.  The strange thing is that over the past year I have decreased my sugar intake dramatically, and cut back on starchy foods.  The doctor is a bit concerned about the test results and has more scheduled in 2 weeks time.  She said that if the insulin level is still above 50 she will send me back to an endocronologist (I was diagnosed by an endo originally, but my GP has been monitoring my medications and blood tests since).  She asked if I'd been feeling "ok" the last few months and actually I haven't - very fatigued feeling, kind of "confused" in the head / can't think clearly, my bp has gone up and down (I had some heart problems a couple of years ago, so monitor my bp at home), and generally just don't feel "right".   She doesn't want to jump the gun until she has the new tests done, but what could this all mean?  When looking stuff up online I don't see much of anything about such high insulin levels.  Thanks. 


Hi Stacey,

 

Having PCOS does put you at risk for developing type-2 diabetes and a mark of T2 is high insulin levels caused by insulin resistance.  If the 123 was a fasting number it is with the range for what they call "pre-diabetes" and what I call diabetes:  click here.  Here's a chart that also defines it:

 

Blood Glucose Tests

 

The symptoms you've been having also indicate diabetes.   My suggestion would be to go ahead and jump the gun and start taking measures to control diabetes, here's how:  click here.  The earlier you start the easier you can gain control.  BTW, sugar is just a carb and carbs are what need to be controlled to lower the numbers.

 

Lizzy 

Knowledge is Power!





Here's some useful links, click on the titles


Testing 101
 
 All About Carbs

Resources For The Un-insured and Discount Medicine and Equipment

LizzyLou Videos



Lizzy's Blog
for lots more  


Visitor
stacey3569
Total Posts: 2
Registered on: ‎11-27-2012

Re: Extremely high insulin levels and c-peptide (OGTT)

Thank you for the info :smileyhappy:

Established Advisor
Lowcarbwalking
Total Posts: 322
Registered on: ‎05-31-2012

Re: Extremely high insulin levels and c-peptide (OGTT)

Hello Con,

This is in regard to your concern about low carb eating and ketones. 

 

I have had T2 diabetes for just over 2 years now and also considered how a low carb diet, ketogenic or not, might effect my kidneys as I have a bit of diminished kidney function which I have had for the last 35 years as a result of begin tumors of the parathyroid gland.  (The tumors were removed long ago.)

 

 

The first year and a half or so of being a T2 I stuck to an eating plan of 20-30 grams of carb a day in order to lose weight and control bg.  It worked wonders for me for both weight loss and lowering blood glucose.   And my kidney function tests actually improved a smidgen.  I now eat 50-70 grams of carb a day and take 500mg of metformin once a day.  Still no ill effect on my kidneys based on the kidney function tests my endocrinologist does.  

 

 

I have never tested for ketones.  My concerns in this area were put to rest by what Dr. Richard Bernstein, a type 1 diabetic and endocrinologist wrote in his book titled, “Dr. Bernstein’s Diabetes Solution”, about s ketones.  He says no need to test for ketones unless you have elevated blood glucose over 200.  Dr. Bernstein even states in his book that many nonobese people will show positive tests for urinary ketones after going without food all night and no big deal.  

 

 

Another credible source I found that put my mind at ease about ketones and low carb eating came from the book titled, “The Art and Science of Low Carbohydrate Living”.  The authors are  Jeff S. Volek, Phd, RD and Stephen D. Phinney, MD, Phd.  They use a term, nutritional ketosis, that they define as a benign metabolic state that gives human metabolism the flexibility to deal with famine or major shifts in available dietary fuels.  Low carb eating gives you nutritional ketosis not diabetic ketoacidosis.    

 

 

A third source on the difference between nutritional ketosis and diabetic ketoacidosis can be found on a blog called The Eating Academy which is written by Peter Attia, MD.  He is a Stanford trained doctor who no longer is in clinical practice but works as a healthcare consultant.  He follows a ketogenic eating plan and gives very detailed biologic explanations about a lot of medical topics around eating.  I think you might feel better about nutritional ketosis if you read Peter’s blog post on the topic. Here is the link:   http://eatingacademy.com/nutrition/is-ketosis-dangerous

 

 

If my bg is ever over 200 I will test for ketones otherwise I don’t see the point since I know, because I choose to eat low carb, I probably do have ketones in my urine.  

 

 

If you decide to eat low carb perhaps you can ask your doctor to do kidney function tests occasionally to verify that you are not having a problem.

Ruth
T2 Diagnosed Aug 2010 with A1c of 7.7
A1c has been under 6 since Dec 2010.
Last A1c 5.1 in March 2013; fasting bg 72
Low Carb eating & daily walks
Metformin 500mg twice aday