Recovering from Holiday Diet Mayhem

A quick scan of various diabetes support boards shows that people have either stopped posting completely, or they're posting messages along the lines of, "I can't believe I ate the whole thing!"

Yup. It's holiday time again.

Personally, I believe it is dangerous to be too perfect with any diet, because when people are utterly perfect, and never eat a single uncounted gram of carbohydrate, when they eventually DO crash off their diet plan, they tend to go off massively and end up harming their health and their weight. One day off plan won't do terrible things to your health, nor, for that matter, three days But if you're still eating your head off three weeks after Christmas, yes. You are in a world of hurt.

It's long been my belief that if you go off plan every so often you will learn how to get back on track, so you'll be more likely to handle times of excess like the holidays when temptations and the weight of family traditions make it extremely difficult to avoid diabetes-related food craziness.

There isn't any way around it. Unless you are one of those lucky people who have no emotional issues around food and could live happily on Purina People Chow, at times like Christmas, you either don't eat the special foods that have decades worth of warm associations and end up feeling like the Little Match Girl, standing in the cold, peering through the window at the more fortunate people enjoying the glorious family feast. Or you pig out and end up feeling like crap, because your body can't handle the carb-load and then spend the next week hiding from your diabetic friends out of embarrassment--hence the quietness on the diabetes discussion boards.

Fortunately, the official Diet Season starts January 2, and we can all stop thinking about party food until the Diet Season's Official End, which is of course, Super Bowl Sunday. Don't you love the irony of the way the supermarkets fill the "seasonal" shelves with diet food January 2, and then, 3 weeks later, replace them with Cheese filled Cheese Doodles and nacho sauce?

Meanwhile, for those of you who are relatively new to cutting back on carbohydrates, who did over do it on Christmas, here's a page I put together some years ago which helps you understand some of the physiological effects that can make you very hungry and feeling crazy when you try to get back to good dietary control. If you find yourself in a non-stop binge, reading this page may help you get back on track.

Crashing Off Your Low Carb Diet

Me, I'm going on a diet next week, until, of course, Super Bowl Sunday.

The Formulas equating HbA1c to Average Glucose Level Don't Work with Near Normal Blood sugars?

NOTE: Important New Information Added to this post in OCT 2007. Please scroll to bottom to read!

I got my new A1c result yesterday, the first in six months.

It was 5.5%.

During this period, my blood sugars have been significantly better than they had been for years. My fasting blood sugars have dropped about 20 mg/dl and my post-meal values have dropped by about 30 mg/dl. These changes have been measured many times using reference meals with known blood sugar outcomes.

In the past, my A1cs were almost always 5.7%.

The drop in A1c doesn't seem to capture the significant lowering of my blood sugars over this period.

The usual formula to estimate the relationship between A1c and mean plasma glucose was derived from the DCCT study.

That formula is:

Mean Blood Glucose = (A1c * 35.6) - 77.3

Applying this formula, an A1c of 5.5% is supposed to correspond to a mean plasma glucose of 118.5 mg/dl and an A1c of 5.7% is supposed to correspond to a mean plasma glucose of 125.6 mg/dl.

Neither of these values correspond to anything I have ever seen in my testing, and I test a lot and at many different times of day. My 30 day meter average, based on 150 measurements, has ranged between 98 and 103 during this period.

There is another, less cited formula that works better, at least for me. It is called "The Nathan Formula" it is:

Mean Plasma Glucose = (A1c * 33.3) -86

This formula yields a mean plasma glucose value of 97 mg/dl, which comes much closer to what my meter's 30 day average has looked like throughout this period.

Here's a calculator that will give you the Nathan Formula A1c/Mean Plasma Glucose equivalents:
A1c Calculator

However, I think the most important point is this: despite doctors' reliance on A1c it is not a particularly accurate measurement of what your blood sugars have been over the past three months. And not only that, the DCCT formula seem to work a lot better in people with very high blood sugars which is the group from which it was derived than they do those of us with near normal ones.

Here's a study published in the Journal of Family Practice that looked at the evidence connecting observed glucose measurements and A1c.

Does daily monitoring of blood glucose predict hemoglobin A1c levels?

The conclusions of this review include the following statements:

The relationship between HbA1c and blood glucose levels is such that blood glucose levels from the preceding 30 days determine about 50% of the total HbA1c. (10) This relationship may be altered by uremia, intake of vitamins C or E, and conditions that affect erythrocyte turnover. (11)

It remains unclear whether management strategies that focus on minimizing HbA1c levels are optimal for prevention of diabetic complications.

Although HbA1c levels correlate with the risk of some complications, aspects of glycemia not reflected in the HbA1c level, such as the heights of glycemic "excursions" from the mean, may independently affect the risk of complications of diabetes. (12) If so, quantitative analysis of day-to-day blood glucose levels might yield a better estimation of the risk of diabetic complications than HbA1c levels.


So what this means is this. The improvement I've made in my blood sugar by keeping my "excursions" (i.e. post meal values) around 110 instead of 140, is probably a lot more significant, healthwise, than the measily .2% improvement in A1c.

Keep this in mind if your A1c results don't match your observed daily testing results, and trust what you see on your meter not a cheering (or baffling) A1c.

UPDATE OCT 31, 2007

The American Association of Diabetes Glucose Trials has come up with a new and improved equation to relate A1c to mean glucose developed using "hundreds of thousands of readings" and CGMS data.

It is the A1C-Derived Average Glucose (ADAG) formula:

Measured in MMOL/L: Average Glucose = 1.583 * A1c - 2.52

Measured in mg/dl: Average Glucose = (1.583 * A1c - 2.52)*18.05

Using this formula:
4% = 69 mg/dl
5% = 97 mg/dl
6% = 126 mg/dl
7% = 155 mg/dl
8% = 182 mg/dl
9% = 211 mg/dl
10% = 239 mg/dl

In short, 1% of A1c equates to a difference in mean glucose of 29 mg/dl.

UPDATE: 4/23/2008.

I've put together a calculator that will convert A1c and average blood glucose using the new ADAG formula.

You'll find it at http://bloodsugar101.com/A1Ccalc.php

ADOPT - Avandia "Wins" If You Ignore the Doubled Bone Fractures

Following the publication of the results of the ADOPT study, GlaxoKlineSmith, the makers of Avandia have been touting the finding that Avandia delayed the progression from "Monotherapy" i.e. taking one drug to taking additional drugs better than Metformin.

In the diabetes oral drug sweepstakes, they'd have you believe that Avandia is the "winner." What was missed in this interpretation was that this same study also found that women taking Avandia had twice as many bone fractures as those taking Metformin and three times as many as those taking glyburide.

Here's an excerpt from the story as it ran on several news sites. This one is from Yahoo News.

"After the five-year period of study, commonly reported adverse events across the treatment groups were oedema (rosiglitazone 14.1 percent; glyburide 8.5 percent; metformin 7.2 percent); weight gain (rosiglitazone 6.9 percent; glyburide 3.3 percent; metformin 1.2 percent); gastrointestinal side effects (metformin 38.3 percent; rosiglitazone 23.0 percent; glyburide 21.9 percent); and hypoglycaemia (glyburide 38.7 percent; metformin 11.6 percent; rosiglitazone 9.8 percent).1

[emphasis mine] Recent further analysis showed a lower rate of fractures reported as adverse events in women taking glyburide or metformin versus rosiglitazone (glyburide 3.5 percent; metformin 5.1 percent; rosiglitazone 9.3 percent), most commonly involving fractures of the foot and upper limb bones.1 There was no observed difference among treatment groups in the number of fractures reported in men.1"

This says that women on Avandia (rosiglitazone) had twice as many fractures as those on Metformin and almost 3 times as many as those on Amaryl (glyburide.)

The total number of fractures was not huge, but this finding takes on more importance when linked to a previous study, published in November that also found that Avandia and Actos increased the incidence bone fractures in older women in nursing homes who had been taking it.

Here is a report of that study, as reported in the Diabetes in Control newsletter: TZD’s Can Increase Bone Loss in Type 2 Women

The reason why this might be happening as reported in the nursing home study was that Avandia apparently disrupts the parathyroid hormone that regulates calcium.

This is very disturbing because it may mean that in people who are taking Avandia, it is very slowly and without anyone observing it causing bone to be remodeled in a way that will not become obvious for years to come but will eventually ruin lives.

By the time the bone changes do become obvious, the old ladies who have taken Avandia for a decade will begin to break their hips and die, but it will be too late. Their bones will have already been weakened.

That the drug manufacturer completely fails to mention this new, and dangerous side effects in its hail of advertising to physicians and its press releases to the public is very troubling.

If nothing else, if you have been taking Avandia for any length of time, insist on having your doctor order a bone scan and have it repeated every couple years to be sure that that you aren't developing early signs of osteoporosis that won't otherwise be detectable for many more years. Osteoporosis causes fractures in older people that lead to death in 25% of all cases in people over age 50 and more in the more elderly.

Some Inspiring Stories

I answered a newbie on another board who had just been diagnosed, mentioning that I knew many people who had been diagnosed with blood sugars far worse than hers who had been able to get completely normal blood sugars.

The lady wrote back that reading that message had made her burst into tears which had not happened even when she'd gotten her diagnosis.

Only when she could believe it wasn't a sentence of death, or blindness, or amputation, could she begin to think about this huge change in her life!

With that in mind, I spent the day combing through 5 years of newsgroup messages, looking for inspirational tales. I've extracted excerpts from postings where people have reported that they have managed to get back to normal blood sugars often from very high initial numbers. (Normal in this case is defined as having an A1c of under 6%, or what people in the alt.support.diabetes newsgroup used to call "The 5% Club.")

The people quoted in these messages have used a variety of techniques to get to normal numbers, cutting carbs, testing blood sugar after meals, medications, exercise, and insulin. What they have in common is that they got there.

Here's the link to some of these stories. If you've been needed some inspiration I hope you'll find it here. And if you have an inspiring story of your own, please let me hear it!
http://www.phlaunt.com/diabetes/16535158.php - The Five Percent Club

Metformin vs Metformin ER

I'm seeing quite a few posts on BBSes from people who are having problems with metformin because of side effects that could be eliminated if they were taking the extended release form of this drug.

For some reason, many family doctors don't seem to be aware that there is a ER version of this drug that has such benefits. This is probably because metformin is a cheap generic and isn't promoted by herds of beautiful ex-cheerleaders turned drug company salespushers who "educate" doctors about far more expensive--and less effective--newer drugs.

Here are the facts: Metformin (also sold under the brand name Glucophage) comes in a regular version which is taken at meal time, three times a day, and an extended release form (marketed as ER or XR) which is taken once a day.

Almost always, when people report diarrhea or intense heartburn with metformin, they are taking regular version. I experienced the heartburn on the regular drug. It was very disturbing because the pain was localized over my heart and felt just like the description of a heart attack you read in articles. My doctor assured me it was coming from the metformin, but that didn't make it any easier to live with because I kept wondering how, if I were having a real heart attack, I'd know it wasn't a pain from the drug?

The ER version releases the drug more slowly and this usually eliminates the gastrointestinal problems.

The trade off with taking the ER form is that the amount of blood sugar lowering you see might be a bit less than with the regular form as the drug acts in a slower smoother fashion rather than hitting all at once. But if you can't take the regular at all drug because of the side effects, the slight weakening in effect is a reasonable trade off. Plus, you only have to remember to take one dose rather than three. For me, this is not a trivial benefit. Even remembering to take one dose a day is sometimes a challenge!

One important point that my doctor missed when prescribing the ER version of metformin is this: The maximum dose of Metformin ER is LOWER than the maximum dose of regular Metformin.

According to the prescribing information, the maximum dose of the ER is 2000 mg a day. That of the regular is 2550 mg/day. Don't count on a pharmacist to catch the error if your doctor prescribes too much. Mine didn't, but I felt distinctly unwell on the high dose, and a quick look at the prescribing information online showed me the error.

Fortunately, a metformin overdose appears to be surprisingly benign. People have survived suicide attempts where they swallowed as much as 85 grams of the stuff at once. (They did develop lactic acidosis, which can be fatal, but survived.)

The dose at which metformin is supposed to be effective for most people is 1500 mg per day, though I know some smaller people who find a dose of 1000 mg effective. Your body weight will make a difference here, so if you are very large, you may need the maximum dose. In any event, don't conclude that metformin doesn't work until you have tested the dose up to the maximum.

It also takes up to two weeks for the full effect of metformin to become evident. While I will see an increase in my blood sugars if I forget a single day's dose, if I stop the drug for two weeks I see a slow rise in blood sugars through this period. My guess is that this two stage effect is because metformin works both on the liver (where it reduces the release of glucose) and the muscle (where it tricks the tissue into thinking it has just exercised and thus ramps up its burning of glucose). Whatever the explanation, give the drug a few weeks to see what it really does.

Also, many people who experience gas after taking metformin find that cutting way back on their intake of starchy carbohydrates helps eliminate the problem.

Because you only take metformin ER once a day you might wonder what happens if you take it a few hours earlier than usual. Will this cause a dangerous overlap? My experience has been that this isn't a problem. I suspect that the drug does not release evenly over the 24 hours it is supposed to act, and by 20 hours it is pretty much done, so there is no need to be obsessive about taking it at exactly the same time each day.

If I completely space out and don't remember to take the drug for 5 or 6 hours, though, I usually only take half my dose because that way when I take the normal dose at the usual time I don't have too much overlap to worry about.

I have found that there can be significant differences in how the different manufacturers' versions of generic metformin affect my blood sugar. The version I'm taking now, the 750 mg ER pill manufactured by Teva, does not seem to be quite as slow in releasing the drug as other brands are, so I get a much stronger effect during the day, but it wears off by the next morning. Other brands last better through the night, but I don't get anywhere near as good post-prandial numbers at lunch and dinner.

Not so coincidentally, the Teva version of metformin ER comes in a compact, flecked pink pill, while the other versions are pillowy white pills that appear to involve an indigestible matrix in which the drug is embedded. I suspect that the pillowy stuff works a bit better at slowing the digestion of the drug which makes the Teva version sort of a semi ER/semi regular version. That works for me.

I've tried splitting the dose to even out the response, however, I find that if I take Metformin in the evening I end up having to get up to pee at night more than usual. Since this is already a problem for me, I prefer to take it in the morning.

Finally, both Metformin and Metformin ER are currently available for a $4 copay at Wal-mart pharmacies offering the $4 copays on selected generics.