Four Years Later

The Diabetes II diagnosis was in late March 2015.

I still take 500 mg of metformin a day because I think it is a good idea.

My PCP has officially classified me as non-diabetic for the purposes of calculating the prospective need to take other drugs that are typically prescribed when a condition interacts positively with diabetes (e.g., heart disease) because I am asymptomatic.

The A1c is still flat, and he’s only interested in collecting the data annually now.

Back in September 2016, I did that little (informal) glucose tolerance experiment, chewing up a set of my blood glucose test strips by measuring every hour to see how things were going after eating. The results were quite positive, in that all of the spikes were under any of the troublesome thresholds. The data are consistent with the way you see a pre-diabetic person respond to eating (high spikes that come down). Admittedly, a total of 64g of carbs and 14g of added sugars (64C/14S) is not the normal US diet, but it is mine.

For the 4th anniversary I decided to run that experiment again.

September 2016: eat at 9 (16C/10S), 12 (24/0), 4 (14/3), and 7 (10/1) [total 64/14]

March 2019: eat at 9 (16/10), 12 (14/2), 3 (20/2), and 7 (14/0) [total 64/14]

September 2016

March 2019

If real, the 2019 results are more consistent with the way a non-diabetic person reacts to eating. And while I am not going to try this at the normal US dietary levels, the comparison is as reasonably well-controlled as a pair of one-off days might be, and could be interpreted as an improvement (i.e., recovery of beta cell function) from 2016 to 2019.

My contention about the way diabetes is diagnosed remains the same as when I figured most of this out in 2015. People with a family history or other risks for developing diabetes, if they are interested in their health, should not wait until their A1c is elevated on an annual level. They ought to spend $30 on one of these testing kits and look at the hourly response to food intake, because the diabetic condition is going to show up a lot sooner than in the A1c value.

Again: if this 2-data point response change is real, it is a significant difference, and it is not picked up by my A1c, which has been constant. And that means that a person could go from detectably non-diabetic to pre-diabetic in their response to eating (my 2019 versus 2016, I just happen to be headed in the other direction) LONG before seeing the change in their annual A1c test result (if they even get it).

Within 5-10 years, blood glucose nano-bots will exist and feed this information in real time.

And some behaviors will change; and some will not.

Three Years Later…

I take 500 mg/day of Metformin voluntarily.

A1c remains flat at 5.0% (now measured only every 6 months).

AM blood glucose (by the strips) averages 70 (clinical blood analysis is more like 80). All other measures are dead-on normal (too).

I average 1050 calories a day – 60 g fats, 70g carbs (15g fiber, 18g added sugars), 55g protein and 900 mg sodium

Two Years Later…

Two years ago, this month, I got the diagnosis. Here are two years worth of A1c tests. The standard non-diabetic range is 4.2-5.6%

The conclusion here is that testing this regularly is no longer warranted, and to start pushing it off to 6-9 months, and potentially just keep up with it at the annual exam.

From April 2015 to April 2017, a number of other indicators have all swung from OK levels into the “really healthy” category, too.

Cholesterol has gone from 164 to 146 mg/dL (< 200 is good)
HDL has gone from 37 to 63 mg/dL (>40 is good; >60 is beneficial)
LDL has gone from 96 to 69 mg/dL (<130 is good)
The Cholesterol/HDL ratio has gone from 4.4 to 2.3 (<4.5 is good)
And total triglycerides has gone from 157 to 70 mg/dL (<150 is good)

My blood pressure is probably better than it has ever been, and currently running about 106/60 quite regularly, and only jumping up to 120 in response to white coats!


Diabetes: Glucose Tolerance

I was curious to see what was happening to my blood glucose level over the course of a normal day for a while. I’m approaching one full year at the target weight, with dietary practices intact, and on the (now-elective) 500 mg/day of metformin.

Metformin is an interesting compound. There are positive metabolic effects on how fats are broken down, apparently, and so, in addition to the inhibition of carbohydrate hydrolysis (its main function it is reduce the free sugars derived from carbs) there are other positive side effects. It is likely that being in metformin helps relieve the development of hunger pangs, for example, because of the way fats are handled. Bottom line: although I had the option of going off of it completely, I have elected to stay on the 500 mg/day, which is the typical prophylactic level for pre-diabetics.

Based on my average A1c values since November 2015 (5.1% +/-0), the calculated average blood glucose level for 5.1% is 100 +/-4 mg/dL

So I got up, took my usual BG reading, and ate on the hour at 9, 12, 4, and 7, recording BG at the hour (and prior to eating). The total carbs and added sugars (from the food labels) is noted.

Not taking into account the hours without readings while I slept, the 7AM-11PM average of 92 +/- 11 is certainly consistent with the A1c average (not bad for an N=1 case… haha… but it is also true that I am pretty consistent on what I eat in terms of what I target for macronutrient numbers).

This was clearly not a glucose tolerance test with a 75g blast of glucose. On the other hand, all the levels for this are also quite normal. It is interesting to see for one’s self that thinking about the timing between small meals is pretty much calibrated to a 3-4 hour interval. The difference in the restoration time after eating is most likely due to the fat/protein content of the food and how that influences the way the carbs are used. My insulin reaction to this level of carbs/sugars is low-mid normal for non-diabetics. Not bad.


Diabetes: A new BMR

I do not care what the calorie total is, alone, because it does not tell the whole story. From April 1 – Nov 1, 2015, at 750 calories a day, I was losing weight at a regular rate. I aimed at a weight goal in the lower portion of my BMI range, and it seems my Basal Metabolic Rate (BMR) is about 1000-1100 cals/day, because, at least for now, this is maintaining my weight +/-2 pounds since Nov 1, 2015.

With a calorie target in mind, I also have to figure out how many grams of each nutrient I need. The FDA gives guidelines for this:

30-35% of calories from fats (and there are about 9 cals/g)
40% of calories from total carbs (4 cals/g), including 10% from added sugars
20-30% of calories from proteins (4 cals/g)

For the 2000 cal/day diet (or any number of calories you want), using the cal/g values, you end up with an easily calculated set of daily targets, including sodium < 1500 mg/day

The World Health Organization recommends 25g added sugar/day as their guideline, and I have been between 20-23g/day, but not zero. I have also been sticking with a lower carb total (but not zero). So for my actual current daily average of 1010 cal/day, I have been hitting 63 g fats (56%, higher to compensate for the lower carbs), 66 g total carbs (27%), 22 g sugars (9%), 13 g fiber, 55 g proteins (22%), and 875 mg sodium. And so I just measure everything, and write down the nutrients on everything, and decide what to eat based on coming in on average, over a few days, with these values.

I adopt and adapt recipes to stay within these targets.

In the know – If you know about numbers, here is what my A1c has looked like since my diagnosis. The mystery here: 10-12 months prior to this, I was in the non-diabetic ranges. Something spiked, which is probably why I could bring it under control so quickly.


Diabetes: On the Road

I have not touched on the challenges of travel and living in hotels, which I do quite a bit. As long as I have a small refrigerator and access to at least a convenience store, it has not been a problem. I also carry a small store in my backpack, now (various nuts, protein bars, and low-salt chicken jerky). Those portable packets of tuna, along with the jerky, are perfect travelling protein, when you are not cooking; do not forget the plastic utensils.

My opinion is that what I am recommending involves putting the control on you rather than turning it over to some external thing: your endless computer and phone apps, your fitbit recorder, your Atkins Diet, your Weight-Watcher program, your standing desk. All of these things are great, but why ignore the fundamentally simple idea of looking at the input of food into your body, which is a thing you have total control over. And even if it is not actually controlled, monitoring it to know, if only to you in complete privacy, is worth knowing.

Maintaining and manipulating a detailed spreadsheet is also probably not for everyone, either, but I am figuring that if you are still reading this, you can handle it. Someone other than me can try to develop the way to automate it, but I have a sneaky suspicion that automation leads to externalization of control. In a critical way, I think that having to pound the numbers and think about every detail are actually critical to the psychology of this approach. I also love to cook, and invent and adapt meals. If a person did not like to cook, or had to deal with feeding a family, this would all be much more challenging (not the recording, mind you, but the changes).

I knew calories. I knew labels. I knew portions. I had a good idea of what to avoid. But I did not figure it out until I really had to, and when I put all of the pieces into one place. And (frankly) I was shocked at just how easily a normal trip to the grocery store adds up in an unbalanced way. I think there are entire aisles from the grocery store that I will not eat from any more, even when I move my calorie count up to a weight maintenance level.