April 9, 2009

Back from the Endo

Here's a report on my latest doctor visit.

The good news is that my High Sensitivity C-Reactive Protein, a measure of cardiac disease was .56 mg/L. This is extremely good. Under 1 is "low."

The not so good news is my A1c was 6.0%. I had stopped taking Levemir six weeks ago because I was not seeing consistent results and the fasting bgs I was getting without it didn't seem to be significantly elevated over those I'd been getting with it. My impression had been that the last vial of Levemir I got from the pharmacy was weak, but they wouldn't replace it and my copays are high. So my not using Levemir might explain the slight rise, though the difference in my fasting blood sugars was only about 10 mg/dl. My post-meal numbers have been testing in range and had even been a bit lower than usual as I was experimenting with Prandin which was giving me quite a few hypo readings in the 60s.

Everything else was fine. My total cholesterol was, as usual, very high, since I have that "large fluffy LDL" genetic variant. My dad also had this gene. He tested with a total cholesterol of 340 in the 1970s and lived to be 100 without any meds until his late 90s. As soon as he started a statin in his 90s, he became depressed and experienced a steep cognitive decline. My HDL was 72 and TGs were 110, which is a bit higher than usual for me but still fine.

My biggest problem has been that I have been gaining weight like crazy, even eating mostly low carb without insulin for 2 of the last 3 months and still eating a lot of low carb meals. I've only been using insulin or prandin for one meal a day. Even so, after dieting carefully for 8 weeks--eating only 1350 calories a day, weighted and logged with software--and losing 7 lbs, I managed gained back every pound I'd lost in four weeks of eating more normally, but more than 100 g a day and 1700 calories.

So I'm going to give Metformin ER another try. It doesn't so much of anything for my blood sugar, but through the years as I was taking it, I didn't gain weight. So I'll give it another try.

I had stopped taking Metformin as it was giving me burning pains in my upper gastric area. Testing found no sign of ulcer, but the burning pain was quite unpleasant. I hope whatever it was causing this has cleared up, as I had taken Metformin without problems for 3 years before that and it had made it very easy to maintain my weight even after I started insulin. In fact, I lost weight the first year I was using fast acting insulin with my meals, even though I was using twice as many units as I have been using during the past month.

One last interesting note. I discovered (on my own, not from the doctor visit) that the reason I was seeing those Prandin lows may be because I was eating fresh grapefruit to fight off a nasty cold. Turns out Prandin is one of those drugs metabolized with cytochrome P450 enzymes which get blocked by grapefruit. So when you take Prandin with grapefruit the body can't remove it from the blood stream.

This is probably why I saw the lowest blood sugar I've ever seen--in the 50s--last week. Usually my body just counterregulates lows right back up, but with the grapefruit Prandin affected me like a sulf which meant I was chugging carbs and still dropping low. Usually Prandin only works for an hour or so, but with the grapefruit it had my poor old betas pouring out insulin for about 3 hours.

That's enough about me. Now back to discussing topics of interest to everyone!

20 comments:

Anna said...

Jenny,

Did you get your 25 (OH)D level tested? That's Vitamin D for those who don't recognize the test name.

This is the time of year when people are usually at their lowest Vit D level (also cold and flu season), having used up whatever they stored in the summer months. In your Northeast location especially, deficiency is extremely common, as you haven't had any sun wavelengths capable of making Vit D in the skin since about October (assuming you even got some midday exposure on bare skin, which would be chilly).

Another good time to test is late summer/early fall, to see how much you'll have to get through winter. Most people need to supplement, at least during the late fall-winter-early spring months. And they need more than they think.

Jenny said...

Anna,

I had my vitamin D levels tested at my previous appointment after supplementing for many months. I was at the bottom of the range most Vitamin D enthusiasts suggest I'm supplementing at a higher level now and my doctor will test me again in six months.

ItsTheWooo said...

Hi Jenny,
Regarding the weight gain, have you considered raising calories BUT keeping carbs low? This might be more sustainable for you.
If I attempted to eat 100 carbs with 1700 calories I would gain weight in a flash, no problem... but if I keep my carbs around 50, I can maintain on that much. I've accepted I will not and can not eat over 60 carbs. The only way I can eat over 60 carbs is if I am also restricting calories a LOT, and this is unhealthy for the long term.

Also, it might help to raise protein a smidge. I know you are very against this idea and I am completely on board with your thoughts regarding protein (that it raises insulin, glucose, and generally is NOT a free food). However, I do notice *sometimes* if I eat more protein I can eat a lot more calories and actually lose weight. My belief is that high levels of protein can stimulate anabolism of lean tissues. But, this is only observed if I had been eating like 60 grams of pro WITH low cals (<1500) for a really long time. This is an insufficient amount of protein, protein need is increased on a low calorie diet.

Considering how you sometimes do low calories, and considering protein turnover is higher when calories are low (this is also true on low carb in general), I do think your weight loss would benefit from an addition of 10 or 20 grams of meat proteins.


Regarding the a1c... I'm wondering if a1c is all its cracked up to be. I'm not diabetic, mine is usually 5.4 which is considered rather high for someone like myself (thin, very low pressure, usually very low sugar). It is not uncommon for my sugar to be 60 when fasting, and I will have no symptoms other than hunger/fatigue. When I take random sugars after eating my normal very low carb foods, they are always under 100.
So I have no idea why my a1c is always relatively "high" and I have come to the conclusion a1c, like cholesterol, may not matter much for a significant amount of people... perhaps some people will always have a1c that is elevated even if sugar is good.

Jenny said...

ItsTheWoo,

I was eating more carbs and more calories with Metformin for several years and not gaining an ounce.

I can't stay at very low carb level (50-60 grams a day) for longer than 2 months because I start to feel dead. My fasting blood sugar goes up too, and because I'm so insulin sensitive, I can't use insulin when I'm eating at that level. I've tried, but it doesn't work for me. I have to use at least 1 unit of insulin to see results, and it's most effective with 2 units. But to use 2 units I need to eat 20-40 grams (depending on time of day.)

I have tried all kinds of approaches to this, but that's how it is. Since I had it working for several years while taking Met, I have to assume it's something flukey with liver glucose, since for me what metformin does seems to be blocking the formation and/or release of glycogen in the liver.

I ate 20-30 grams a day with 1300 cals tops, for an entire month without losing any weight in February, which was my experience last summer too.

Basically, my body has decided it wants to gain some weight. Since there's so much evidence connecting mild overweight with better health in people 65 and older, that makes sense. I'm heading for 61. I'm still in the "normal" BMI class but at the very top.

Anonymous said...

I wonder if you are physically able to weight train like Slow Burn maybe, might that help?

Jenny said...

I have such a bad back and such a tendency to tear tendons that weight training is not a good idea for me. I did what I could several years ago, along with an aggressive treadmill program, but I ended up damaging a foot. At that time a year of gym exercise 4 or 5 times a week didn't do much of anything for my weight loss (I started exercising after I'd already lost most of the weight.)

And I was able to maintain a significant weight loss for almost 5 years without exercise.

I did a walking program from spring through fall this past year but ended up with another foot problem. It's really frustrating but my tendons seem to shred very easily. I've taken out a shoulder, one knee and two different feet over the past 6 years.

When I was younger I was very physically active--probably TOO active. But my guess is that the disc and tendon problems are the result of an entire life spent with "pre-diabetic" blood sugars.

Anonymous said...

Hi Jenny,

I'm right with you on the gimpy tendons. I spent several years in construction work in the 80's and worked out with weights later. For a long time I believed that's what messed up my joints. Now I tend to think it's part of the genetic and diabetic gift from my family. My doc says it's part of the whole diabetic package: high blood pressure, inflammation, joints that go all to hell at the drop of a hat. Nothing shows up on xrays or mri's, so they throw me into the physical therapy routine. It doesn't stop the pain and it doesn't fix anything but it does make me stronger. As a side benefit, I can now flex my hooters. (woo-hoo.)
The only thing that's really helped is a cortisone shot to the knee, and now I'm scared to try it again because of the blood sugar, the belly fat, the pancreas...

It's frustrating as hell to hear "walking is an exercise almost everyone can do." Not!
As for the metformin weight loss, it seems to be helping in that department, although I'm sure that the--how to say this politely--accelerated digestion may have something to do with it. Gas doesn't weigh much. Maybe I'm full of helium.

Ages ago, when the doc prescribed iron pills for my borderline anemia, the gnawing and burning feeling in my gut was intolerable. DH has to take his meds in a vertical position lest he suffer from esophageal erosions. At first we thought it was just his prednisone doing it, but it turns out any pill will do it. So remain upright! ;o)

Jenny said...

A course of prednisone seems to be what pushed me from life-long "pre-diabetes" to full fledged diabetes. I avoid cortisone. It does terrible things to my blood pressure and pulse as well as blood sugar. And it doesn't do much for the tendons either.

I recently read that they found a gene that correlates with disc rupture. It runs in my family along with the abnormal blood sugar. Whatever it is, I've learned the very hard way to be extremely careful with what I do physically. It's ironic, because I enjoy activity and did a lot of it when I was young not for health reasons but because I was a high energy, very physical kind of person.

Oh well. At least I'm alive. I'm at the age where there are quite a few people I've known who can't say the same thing!

Colleen said...

I enjoyed reading your update - I always, always learn something here. Thanks!

Harold said...

Do you stretch? I found more problems with patients who thought stretching was good than any other group. I would not stretch at all but I would start any exercise program very slowly and gradually work up.

Jenny said...

Harold,

I don't stretch anymore since I'd read bad things about it. One of the first bad things I did to my back years ago was with a bad stretch.

Trinkwasser said...

More proof that you are weird! Mostly good weird but not entirely.

Michael Eades did some recent posts on weight loss and plateauing, here's one from Mark Sissons

http://www.marksdailyapple.com/weight-loss-plateau/

maybe tinkering with the balance between protein and sat fats would find a sweet spot

Have you ever tried Alpha Lipoic Acid? It only drops my BG by about 5 - 10 points, a fraction of what I can achieve through diet, but it's main function seems to be to stop my liver doing its party tricks of shooting me high or dropping me low. It might be an alternative to the met.

I don't know if it's simply BG control or some other aspect of diet but my tendons and joints seem to have stopped annoying me in recent years. If I knew how I'd done it I'd post you some. Mostly I walk at varying speeds carrying varying amounts of weight and keep cardio-level stuff down to short bursts, that keeps the muscles gulping down the glucose and the IR in check without overstressing anything.

It's been a bad winter here for minor infections though. Just watch out that you didn't catch anything as the doctor's!

Jenny said...

Trink,

I tried ALA years ago but saw no impact at all. Interesting that it limits glucose dumping for you. I'll keep that in mind and have another look as that previous trial was before I was injecting insulin.

Because I don't seem to have IR--given my response to 1 unit of insulin--exercise doesn't have the effect of reducing IR for me. If I get to very high cardio levels I will burn off my glucose and go low but only if I'm eating low carb and have no stored glycogen, which makes sense.

Carol Will said...

Hi Jenny, I don't really have any advice however to many of us that 6.0 A1C is GOOD news! My last one was 6.3 and I believe that's the lowest it's ever been. Are we bound for problems...I'd love to be a member of the 5 club...will it take a pump for me? I know that you are pretty expert at the topic of diabetes but try to remember that 6.0 is pretty darn good. :-)

Carol

Jenny said...

The problem for me is that, as my doctor pointed out, it has been 4 years since I had a 6% A1c. And beyond that it's been climbing every appointment for the last year--ever since I quite the metformin.

So it's more the relative change than the absolute number.

But it is also baffling because my control hasn't changed, and if anything seemed better. So I wonder if I might have been running a bit high because of coming down with the cold.

In the past I have seen a single day of high blood sugars raise A1c a whole 1% when it occured the day before the lab test. (This happened when I took a hormone, once that pushed blood sugar way up for a single day.)

Trinkwasser said...

For some people A1c doesn't correlate too well with spot readings whereas for others it does, maybe some other factor's in play. You could try a fructosamine test if you can find one. My A1c went UP with better control, probably the reactive hypos I used to do cancelled out the spikes and now I seldom do either my A1c is about 0.3 - 0.5% higher than it calculates. Usually that's fairly consistent between individuals though, I hope you can get to the bottom of why yours is changing.

Part of my belief structure is that IR can differ significantly between muscle and liver receptors, and may change on a temporary basis, cf. some Type 1s whose ratios change markedly at high BG levels. My glucose transporters start to crap out around 120 and the effect is quite noticeable around 150 which is ridiculous considering the numbers some people hit.

The ALA seems to work on the alpha cell/glucagon/liver circuitry for me, maybe the people it doesn't work for don't have a defect in that system.

Maybe you still don't have IR but something has set off leptin resistance, hence the weight gain? The more I read the less I know, these systems and their interractions are stunningly complex. I waited until *after* the holidays to put on weight, but it's gone away again now, what set that off is unknown but I did have a chronic sinus infection, and a tooth exploded.

Dr. Art Ayers said...

Jenny,
I just wanted to comment on tendon, joint and back health. One of my students suffers from celiac and she pointed out to me that back problems are a common symptom of that disease. Gut flora and gut health may be an issue and this may indicate probiotics, glucosamine, etc.

I have another student who has some kind of an oxidative stress problem that gives him connective tissue problems as an athlete. He compensates by increasing his vitamin C, but he uses 2-4 g/d, depending on sun exposure.

Vitamin C is of course used in collagen production and a shortage because of oxidative stress, could lead to lots of connective tissue problems.

Just some thoughts from my inflammation obsession. Glad to hear that your CRP is down.
Art

LynP said...

Jennie, I find that I am sensitive to different formulations of metformin...must be something in the fillers. The discounted version at Kroger's makes me feel horrid but the one from another mfg (my insurance's mail order provider) does not have that effect. I've tried met from several mfgs and 2 evoke that I feel horrid reaction...all have been the extended release formulation. Could be your gastric effect is a reaction to one of the fillers and not to the met itself...just a thought.

Anna said...

LynP,

That's a really good point and is more common than people think. Whenever possible my endocrinologist prefers to prescribe the 50 mcg dose of T4 in whatever multiple necessary (1, 2, 3 x 50 mcg tablets instead of 100, 150, 200 mcg) because it has no dyes, because many react to the additives.

Gluten and casein are often contained in pills and supplements (binders?), too, and can cause reactions in sensitive people, though someone might think they are following a strict GFCF diet.

Anonymous said...

Don't want to belabor the weight training topic, but do you understand the difference between conventiol weight training and slow strength training?

In slow methods of weight training, very lightweight weights are used. Jerking or abrupt actions are not used, just gentle, slow lifts and then lowering in both directions for only a few reps, until 90 seconds or it isn't possible to complete a rep with good form. This technique doesn't rely on momentum to lift heavy weights. It's surprising how hard it is to v-e-r-y s-l-o-w-l-y lift and lower weights(or even just body weight) compared to lifting them with a fast motion. I have never seen anyone do this at a public gym unless it was a gym that specialized in this technique.

In fact, my understanding is that these techniques are actually protective of tendons and joints specifically because of the slow, controlled rate of lift and lowering, only about 1 inch per second. I started with a dumbbell set that topped out at 10 pounds and the ankle weights were much lighter (though I need a somewhat heavier set now that I've increased strength). One can even start out without any weights, just using body weight and the slow motions.

I'm finding a home version of this weight routine very gentle on my couple of "tricky" joints (I do the routine no more than 2 x week for about 30 minutes to allow for muscle tissue recuperation). When I did conventional weight training at a gym with higher weights, faster lifting technique, and many more reps, I had a few joint problems and actually didn't gain as much strength as I do with slow strength.

My husband has painful flare-ups of sciatica sometimes and the slow weight routine hasn't bothered the sciatica at all since he started a few months ago; in fact, it could be helping.