Sunday, October 30, 2016

Type 2 Diabetes, a Dietary Disease #352: If you’re a Type 2, DON’T READ THIS.

Metformin* is designed for cheaters, like me! By that I mean Metformin is designed to work, or works best, with a “load” or “carbohydrate challenge.” That is my hypothesis, which recently came to mind after a “test” or “experiment,” as a friend jokingly refers to it, in which I consumed a large quantity of carbs in a short time.
I have to admit my judgment was impaired. We’d been indulging all afternoon with friends, and I’d had more than a little red wine. Then, after a light supper that my wife prepared, she “raided” the freezer, and while her back was turned, I snuck a taste of her ice cream. And then – she is so noble – to be sure that I ate no more, she finished the container. Later, when I snuck back to the kitchen, opened the freezer and discovered this, I found a new pint of Talenti Gelato (Hazel Nut Chocolate Chip) and ate half of it, about 50g of carbs.
And if that wasn’t bad enough, the next day was Sunday, my weekly comeuppance day. It’s the day my Excel program averages the previous week’s seven Fasting Blood Glucoses and records my week’s weight loss. But, lo and behold my FBG was only 98, up from 91mg/dl the day before. And the weekly average was 96, up from 94 the week before. Thus, my hypothesis: Metformin works best with a carbohydrate challenge.
So, if Metformin is so effective at improving glucose uptake when presented with a big carb load, like a 50g slug, what incentive is there to not indulge now and then? I mean, we all do it from time to time, right?
Well, I didn’t test my blood sugar post gelato, but considering it’s been more than 30 years since I first developed Insulin Resistance (IR), I can only imagine the rise that my blood sugar and blood insulin levels took in the immediate aftermath of that slug of sugar. It had to be precipitous, taking me well into the over 140mg/dl zone where damage is done to my organs. And it certainly took me out of a mild state of ketosis.
My weight the next morning was only a pound more than the day before, but how long, I wondered, would it be before the new glycogen stores were used up and my water weight dropped again. And how long would it be before my blood insulin level dropped, the bloat was gone, and I had that lean, high-energy feeling again.
Was it worth it? Probably not. But was it avoidable? For some, the answer apparently is “yes,”, or so I’m told by readers who profess not to be tempted. But then they may be people to whom temptation is not often presented – people who either live alone or with someone who is also attempting to eat Very Low Carb. In these households there IS no ice cream in the freezer. I am also definitely tempted by visual stimuli, or a lack of will to resist a visual stimulus. Or maybe it’s just a case of “arrested development” from a dysfunctional adolescence. Who knows? We are all, as we non-compliant folks rationalize, different. Indeed.

*  My current Metformin regimen (recently up from 500mg/d), is 1500mg/d, divided between AM and PM. That’s the only anti-diabetic medication that I have taken since I started to eat Very Low Carb (…most of the time, lol) in 2002. I am experimenting (there I go again) with the larger dose since recently reading that Metformin is really effective only at higher doses. I wish I could find that reference to link to.
I had also observed at a Metabolic Therapeutics conference that I attended earlier this year that a large cohort of normoglycemic men, specifically fitness experts and body builders, were taking maximum doses of metformin (2000mg/day) to enhance glucose uptake and suppress gluconeogenesis. They want to facilitate ketogenesis to break down body fat, enabling them to reduce stored body fat and, by rigorous exercise, to build muscle. Metformin has several known mechanisms of action and, in general, is very well tolerated. 

Sunday, October 23, 2016

Type 2 Diabetes, a Dietary Disease #351: Am I a Type 2 Diabetic?

Note: If you are asking this question for yourself, look at “How Diabetic Do You Want to Be?” Part 1 (#344) and Part 2 (#345) But read on if you are interested in a short essay on the subject “Am I a Type 2 Diabetic?” The answer depends on whom you ask.
First, you need some “history.” I was diagnosed a Type 2 in 1986, before the A1c test was developed and the glucose test standard was fasting blood glucoses on two consecutive office visits of ≥140mg/dl. That changed to ≥126mg/dl in 1997, and the ADA adopted the hemoglobin A1c test to replace the FBG in 2002.
In 1986 my doctor started me out on the only anti-diabetic oral medication available in the U.S. at the time, a sulfonylurea (SU) called Micronase (generic name: Glyburide). No doubt he advised me to lose weight (I was obese), but instead I gained. I do not recall if he gave me any dietary advice, but if he did, it no doubt would have followed the ADA’s Standard of Practice and the Dietary Guidelines for Americans, first issued in 1980.
When Metformin (in use in Europe since the mid ‘50s) was permitted in the U.S. in 1995, my doctor started me on that too. When in a few years I was maxed out on both, he then started me on a 3rd class of oral drugs, the TZDs. I was then at my heaviest weight, and in yet another effort to get me to lose, my doctor suggested I try a Very Low Carb diet he had read about in The New York Times. It was Atkins Induction (20g of carbs a day) as described by award-winning science writer Gary Taubes in the Magazine cover story, “What If It’s All Been a Big Fat Lie?” It created quite a stir. I tried it and, over time, lost altogether 170 pounds.
On strict Atkins Induction, from the first day, to prevent hypoglycemia (low blood sugars) I had to give up first the Avandia (the TZD), then cut the other two meds in half, and then cut them in half again. A while later, I gave up the SU (glyburide) altogether and continued the 500mg Metformin once a day for the next 14 years.
In addition, in no time at all my lipids (cholesterol) improved dramatically. My HDL average more than doubled (39 to 81), my triglyceride average plummeted by 2/3rds (from 137 to 49), and even my LDL came down! And with all the weight lost my blood pressure improved substantially (on the same meds). All these changes were from diet alone, no exercise.
So, am I a Type 2 Diabetic? A clinician who looked at my fasting blood glucose today (90mg/dl) would say, “Consistent with the absence of diabetes.” Yet, 30 years ago I was diagnosed a Type 2. Was it a mistake? Am I still a Type 2 Diabetic? Or, has my Type 2 Diabetes been “cured” because my “symptom” has gone away.
A clinician who looked at my hemoglobin A1c would see 5.7% and say, “Consistent with an increased risk for diabetes (prediabetes).” They would have no basis to conclude otherwise. They’d say, “We’ll continue to monitor that” (until it gets worse), and then maybe they’d write a script for a minimum dose of Metformin.
An endocrinologist would order a 2-hr Oral Glucose Tolerance Test (OGTT) in a hospital outpatient setting. It would reveal the underlying Impaired Glucose Tolerance (IGT). Result: Definitely, a Type 2 Diabetic.
The truth: Starting probably 40 years ago, I gradually developed Insulin Resistance. I became Carbohydrate Intolerant. Insulin receptors on the surface of muscle, that are supposed to “open the door” to allow glucose to be taken up, started to gradually fail. My pancreas made more insulin. With overuse, its capacity to make beta cells began to wear out. That loss of function is not going to change. It’s not reversible, but my Type 2 Diabetes is treatable, by making my insulin receptors work better. The only treatment that works for that underlying metabolic dysfunction (Insulin Resistance) is a low carbohydrate diet. This treatment works!
It’s not as hard as you might think. After a few days, you lose your sense of hunger because your body has started to break down fat for energy. It’s good energy. You feel alert. Pumped, actually. You don’t get sleepy after lunch. Your energy level is constant and your blood sugar pretty flat – no peaks and crashes – and you feel lean. You’re ready to hunt.