The One With TMI

It's time for my somewhat-yearly post, I guess.

Apparently, I've had type II diabetes for about 6 years. Not "pre-diabetes", not "borderline diabetes", not "a minor blood sugar issue", and my "sugar" wasn't "a little high." It was a few weeks ago that I came to this realization and I've been facing facts since then. I got myself enrolled in a "How to manage your diabetes" class, and I've been learning (and re-learning) some things. It turns out, if you don't actually have diabetes, probably everything you "know" about it is wrong, including the basic "well, your blood sugar is high all the time, right?".

This post is just me organizing my thoughts around what I thought I knew, what I've learned, what life is going to be like from now on, and some numbers from the last couple of weeks, and whatever else I feel like.

Here's what I thought I knew:

• I have blood sugar issues because I'm fat.
• If I lose weight, it'll go away.
• If I exercise a lot, I'll lose weight.
• I don't actually have diabetes, but I could get it if I don't straighten up and fly right.
• I got myself into this, I'm going to have to get myself out of it.

It seems that none of that was actually true.

It's not at all clear that the causation arrow goes that direction on the first one. Really, I have blood sugar issues because I have type II diabetes and I have type II diabetes because I chose my ancestors poorly. Seriously, it's genetic. It's possible that had I taken better care of myself in my 30s, that I might not have become symptomatic until later, but this was set in motion before I was born. So, I guess it isn't really my fault, and maybe I should put that aside and worry about what I'm going to do going forward, right?

I was actually told that if I lose weight, it'll go away. By an M.D. (or D.O., I don't remember for sure). Sadly, that's not the case. I will have this for the rest of my life. If I lose weight, it will become easier to manage, but I have a pretty well-mapped-out progression to look forward to which will eventually lead to me having to administer insulin in some manner. I can put that off, though, by managing my BG (blood glucose) levels correctly now.

I've been exercising for the last year. A lot. For the entire year, the scale did not move. There's a reason for this: my BG has been out of whack and nothing's working right. It's pretty discouraging to work as hard as I've been working and not see any results on the scale. It's good to know there's a reason.

I really wish the doctor had just told me "You have diabetes, dude. If you don't control it, you're going to go blind and I'm going to have to cut your leg off." Seriously, that is scary and I might have actually read about the disease and taken it more seriously. But, instead, it was "Well, your blood sugar is a little high". I definitely could have been more curious, but she never used the D-word.

The last point is the hard one. I don't like to ask for help. I never have. "I DO IT!" has been my motto since I was a little kid. However, I am not an endocrinologist, and a lot of this stuff is really counter-intuitive (e.g. "My BG is high in the morning" is frequently solved by "eat more right before bed". Wha?). In a nutshell, I needed help. Fortunately, they have people for that. Actual scientists who can impart the actual science behind what's going on. I dig actual science as practiced by actual scientists, so there's a bit of synergy.

Anyway, back to the story. My doctor retired. I had to get a new doctor, which I didn't do until I absolutely had to, which means I got injured while sparring and ended up at the emergency room with an infection on my left shin, and orders to follow up with my family doctor. So, I made an appointment with a doctor recommended by my old doctor, and when I went in, she gave the leg a cursory look, said to follow the directions from the ER doctor, and then proceeded to do a full history and work-up, and demanded that I get myself to a diabetes education class immediately. (The leg ended up being a problem, but for unrelated reasons; I broke a largish blood vessel without knowing it and it was still bleeding. She fixed that and it's healed and I'm back at taekwondo as of today).

So, I've been attending this class, and learning all kinds of things:

• I definitely have type II diabetes.
• I'm probably fat because of that and the complications that uncontrolled BG cause.
• Diabetes isn't just about high BG. Lows are also a major problem, and can be more acute.
• When I eat and what I eat are just as important as how much I eat and maybe even more important.
• Getting my BG checked once every 3 months is almost useless.
• Losing weight is not a good primary goal for a diabetic.

I've never seen my glucose under 100 mg/dL. I've rarely seen it under 110. Now that I'm monitoring, I regularly see it in the 170s. That's diabetic.

In type II diabetes, several things are at play. Not everybody has all of these things, but most have some combination. 1) my pancreas is bad at creating insulin. 2) my liver really likes generating glucose. 3) My muscles only grudgingly allow insulin to do its thing. 4) Fat cells are happy to let insulin do its thing. Insulin is the "key" that unlocks the cell and allows glucose to enter the cell. If I don't have enough insulin, and what insulin I do have is rejected by my muscles, any glucose I have that's not used by my brain is going to one of two places. It can get flushed out in the urine, or it can go into fat cells. I have both. This is not conducive to losing weight. The result is that even though the exercise is good and all, I'm not going to see any appreciable weight loss.

This was something I misunderstood for a long time. While the most prevalent symptom of diabetes is high blood glucose, and indeed that's how a diagnosis is made, it's not that the glucose is always high, it's that the swings in levels are quite wide. A normal person will stay around 85-90 most of the time, and be at most 139 two hours after a meal. A diabetic is shooting for between 70 and 120 before meals and lower than 180 after meals. That's the target range. 70 is pretty low, and 180 is pretty high. Most people don't feel any different at 180, but lots of people feel not great at 70, and with a low, one can get quite confused, get the shakes, get irritable on top of a whole litany of other symptoms. People don't die from their BG being at 180, but a severe low can cause death because of increasing confusion and inability do treat the low. Like I said, I didn't know this.

Managing one's blood glucose levels means managing how fast glucose enters the blood stream. Lots of things contribute to this, and how much one eats is a, but not the, primary contributor. The most important thing is to carefully craft meals to have the right ratio of carbohydrates, proteins and fats. The second most important thing is to break up and schedule food intake throughout the day such that BG spikes and falls within a narrow range. After all that, how much you eat just determines how long the food is going to cause glucose to enter the system. There are also medications to help regulate this, but without getting the food right, nothing else really matters.

In order to manage my blood glucose, I need to know what it is at fairly frequent intervals. Once a day is really not enough, because that doesn't give me my curve throughout the day. Once every 3 months is certainly of no use. I mean, the HgA1C test can give an estimate of what my average BG was over the last three months, but even that doesn't tell me what the curve looks like. If I have a low of 120 and a high of 180 on a particular day, and a low of 50 and a high of 250 on another day, those both have the same average, but the first day is a pretty good day, and the second day is an unmitigated disaster (at least for me). I specifically asked "Should I be checking my blood sugar regularly at home?" and was told that I didn't need to do that. So wrong.

Goal one is to get the blood glucose under control. I need to concentrate on that. If I do that right, the weight will start regulating itself, especially if I'm getting regular exercise, which I do. If I focus on the weight loss, I'm going to be disappointed, because the uncontrolled blood glucose is going to sabotage anything I do. I have anecdata to support this, too: I've lost 10 pounds since I started the class, and this is without even really trying. I've been laid up, so I haven't been to taekwondo for quite some time, yet I'm losing weight just by managing my blood glucose level. This is an awesome thing.

So, where am I now?

Well, on the one hand, I'm pretty excited because I've gone from "what? I actually have diabetes?" to "okay, I can do this" in a pretty short time. So, the class was definitely worth it. Now that I'm testing all the time, I know what my current glucose curve looks like, and mostly, it's good now. Mostly. I've got this new thing, called the "dawn phenomenon" where my levels are consistently high in the morning before I eat. The last three days, it's been 156, 161 and 168 right before breakfast. This is not what I want to see (remember between 70 and 120 back there?). So, I need to tinker with my food, and I also need to tinker with the timing of my medication. On the advice of the diabetes educator, I started taking my metformin with breakfast and dinner instead of at bed and when I wake up. I have a sneaking suspicion that the bedtime dose of metformin was keeping my liver from dumping all the glucose in the middle of the night, and now it's not, so my levels are high in the morning. So, I'm going to have to tinker.

All in all, though, things are looking up. I get to go do taekwondo tonight, and my lunch was perfect (111 before lunch, 152 two hours later). I'll be interested to see how the TKD class affects all of this.

For my records these, are the last 3 days of readings:

4/16	8:00am	156	fasting
4/16	10:00am	150	2-hr post
4/16	noon	108	pre-lunch
4/16	2:00pm	169	2-hr post
4/16	8:30pm	122	pre-dinner
4/17	7:00am	161	fasting
4/17	9:00am	172	2-hr post
4/17	11:45am	116	pre-lunch
4/17	1:45pm	148	2-hr post
4/17	6:00pm	153	pre-dinner
4/17	8:20pm	168	2-hr post
4/17	10:30pm	114	before bed
4/18	6:00am	141	fasting
4/18	7:30am	168	still fasting (!)
4/18	9:30am	168	2-hr post
4/18	noon	111	pre-lunch
4/18	2:15pm	152	2-hr post