BootCamp for Betics

A few months ago, my little brother (age 34) contacted me and said, “I need to talk to you about something. I think I have insulin resistance.”

“Why do you think that?” I responded.

“Well, our entire family has type 2 except for you,” he said. “So I’m pretty much doomed to get type 2.”

“Yep. you’re probably right,” I agreed.

“And I’ve been slowly gaining weight since I became an adult, which could be due to my lifestyle, but it could also be due to the fact that I’m becoming more insulin resistant as I get older.”

“That’s usually how it works,” I confirmed.

“And as a response to my insulin resistance that’s been getting worse over time, my pancreas has been producing more and more insulin. Which causes extra weight gain,” he said.

“All true. Where are you going with this?” I asked

“Well, my fasting glucose and glucose tolerance tests and my A1C are all normal. So according to the docs, there’s no sign of diabetes.”

“Right,” I said. “No one actually tests positive for diabetes or pre-diabetes until they’ve become so insulin resistant that their pancreas can no longer keep up. Basically, the only time you’ll get an interesting test result is when it’s already too late.”

“So,” said my brother, “I could be very insulin resistant, but I wouldn’t necessarily see anything interesting on a test, because my pancreas could be chugging along like the little engine that could, squirting out an ass ton of insulin into my body to keep my blood sugar normal, all the while secretly petering out and basically dying a slow pancreatic death.

“Well, it's more complicated than that, but as a summary, it's close enough,” I said.

“So at some point, my pancreas won’t be able to keep up with the demand for insulin, and then my blood sugar will finally start going high, and then I’ll be pre-diabetic, and eventually I’ll become diabetic.”

“Yes. All of this is true.”

Then he said, “Well, wouldn’t it be better for me to know that I’m insulin resistant NOW, when I’m 34, instead of in 20 or 30 years when it’ll be too late?”

And this stopped me in my tracks, and my heart sank.

I started to think.

He was so, totally, absolutely, 100% right. If my little brother is doomed to become diabetic, wouldn’t it be better to know NOW instead of in 20 or 30 years? Yes. Yes, it totally would.

I started to think even harder. Here’s what I thought:

Fact 1: Type 2 diabetes starts with insulin resistance, which is, at least partially, genetic. Quite simply, your body stops being efficient about its use of insulin, and so your pancreas has to start squirting more insulin (a fat storage hormone) into your body, which makes you hyperinsulinemic (too much insulin in your body), which, in many cases, causes you to get chubbier and chubbier.

Fact 2: Over time (years and years), your pancreas gets so exhausted from all the extra work that it just can’t keep up.

Fact 3: Your pancreas becomes even weaker as your cells continue to become more insulin resistant, and finally your pancreas just can’t squirt out enough insulin anymore, and your pancreas starts to peter out, and at some point during this process, your blood sugar starts to go up and you become pre-diabetic or diabetic.

The next logical question in my thought process was this: Why isn’t everyone in the entire world getting tested for hyperinsulinemia on a regular basis? Because wouldn’t the presence of hyperinsulinemia be a pretty damned clear indicator that you have insulin resistance?

Yes. Yes it would.

As it turns out, there are a couple of pretty cheap blood tests that can diagnose hyperinsulinemia in a person who otherwise appears healthy.

I immediately got on the phone and called my good friend Ed, who is a family medicine practitioner in Phoenix, and is also a type 1 diabetic.

I asked him, “Why wouldn’t doctors just test everyone for hyperinsulinemia, which, in many cases would indicate early-on insulin resistance and then we could better predict and ultimately prevent type 2 diabetes?”

Ed said, “That’s an interesting idea, but I’m not sure we can guarantee positive outcomes by telling people they’re insulin resistant. We already have tests for pre-diabetes and metabolic syndrome, which are known precursors to diabetes. And, there’s no real compelling evidence that a metabolic syndrome or pre-diabetes diagnosis is going to cause someone to implement the life changes they need to implement to avoid becoming diabetic.”

[interjection: Ed agreed that the diagnoses of these diabetes precursors typically occur when a diabetes onset is imminently likely, or, in other words, these diagnoses typically occur at the tail end of the insulin resistance duration. You know. Once you’re already old and set in your ways].

Then Ed asked, “If an actual diagnosis of metabolic syndrome or pre-diabetes doesn’t result in a lower eventual diabetes diagnosis rate, then what good will come of an even earlier insulin resistance diagnosis?”

My friend Dr. Ed has a good point. In fact, a recent study confirms how good his point is.

But I still wanted to believe that a early absolute predictor of type 2 diabetes would cause a younger person to take steps to prevent the eventual diabetes diagnosis. Wouldn’t it?

Ed said, “We don’t actually know the answer to that, because there’s not enough data. That would have to be a really long and expensive study, spanning many decades.”

And then, I started doing more random thinking. And here’s what I randomly thought.

Fact 4: People get diagnosed with metabolic syndrome or prediabetes only after their pancreas has had years to slowly peter out from exhaustion.

Fact 5: Most medical professionals will tell you that your goals in preventing diabetes are to eat right and exercise while ensuring that your blood sugar stays in target range.

I’d like to pick apart these facts. First, I think, “eat right and exercise” is a fine thing to say, but I have two problems with this advice.

The first problem I have with this advice is the TIME at which we’re giving it. Once you have a prediabetes or metabolic syndrome diagnosis, it’s almost too late. You’ve probably already gained a bunch of weight over the years as a result of your insulin resistance, you probably feel like crap, you’ve probably spent years developing habits to compensate for how your body feels as a result of the insulin resistance and, essentially, the barriers to “eat right and exercise” are unbelievably high. If you say “eat right and exercise, because you are going to get diabetes” to a 65 year old with insulin resistance, this advice is likely going to be far less catalytic than if you were to tell a 35 year old the same thing.

The second problem I have with the common “diabetes prevention” advice is that it isn’t focusing on outcomes more specific than “not getting diabetes.” The outcomes that a hyperinsulinemic normoglycemic at-risk person should instead focus on are, in my opinion, these:

1. Reducing insulin resistance
2. Preserving pancreatic endocrine function

[Note: If you are type 1 and at risk of insulin resistance, don’t bother getting these tests and don't bother preserving pancreatic function. Just work on reducing insulin resistance.]

And certainly, “eating right and exercising” can contribute to both of these goals. But the “eat right and exercise” advice is nowhere near specific enough to actually help someone who wants to reduce insulin resistance and preserve pancreatic function! There’s also a whole bunch of other stuff (besides “eating right and exercising”) that you can do to reduce insulin resistance and preserve pancreatic function. And, there’s a bunch of stuff you can do to ruin your progress toward these goals. As a diabetic community, we aren’t giving at-risk people the tools they need to reduce insulin resistance and preserve pancreatic function (But I will! I promise! That’ll be another blog post!).

So, if you have a family member who is at risk of diabetes, telling them to “eat right and exercise” just isn’t likely to work. Here’s what to do instead:

1. Encourage your family member to get tested (every year or two) forfasting insulin levels to see if the pancreas is overproducing insulin (hyperinsulinemia) or under producing insulin (hypoinsulinemia). This should start at age 35 or anytime they become overweight. [Note: hyperinsulinemia, in rare cases, is an indicator of a handful of other health conditions. So check with your doctor about these.]
2. Encourage your family member to also get their fasting glucoselevel or their A1C tested every year or two.
3. Have your family member track the results of their fasting insulin levels from year to year. Does the fasting insulin level increase from year to year? If so, insulin resistance could be getting worse.
4. Does your family member notice lower fasting insulin levels from year to year and higher fasting or average glucose readings? This could indicate depressed pancreatic function and could turn into pre-diabetes or metabolic syndrome.
5. If your family member has/had gestational diabetes or PCOS, they are automatically at risk.
6. If your family member is at risk of diabetes, help them take steps to reduce insulin resistance and preserve pancreatic function. I’ll write another article about how to do this soon. I’ll send it to my email list as soon as I publish it.

What’s my point, here? I have several.

1. I don’t think the medical community is diagnosing pre-diabetes early enough. We’re diagnosing pre-diabetes when, for most people, it’s too late. We have the capability to pre-diagnose pre-diabetes YEARS earlier, and we’re not doing it.
2. People at risk of type 2 diabetes need to get the right information at the right time about how to delay or prevent type 2 diabetes.
3. There’s a ton of stuff you can do to delay or prevent diabetes, and the earlier you start, the better.
4. Diabetes is extremely expensive for an individual. Preventing diabetes is, by comparison, dirt cheap, as long as you do it in a way that is actually effective.

  
As it turns out, my brother is indeed hyperinsulinemic. But he’s also 34, so there are steps he can take NOW to reduce insulin resistance and preserve pancreatic function and potentially delay or even prevent a diabetes diagnosis. My next article will be for him and for everyone else who needs to do the same.

I’m sure he’s really excited to have his big sister boss him around and tell him what to do. It’ll be just like old times.

Our people are dying, senators. We must do something quickly.

Below are 60 of the 3,445 Google searches from the last month that resulted in traffic to my article about how to take matters into your own hands when you can't afford insulin.

​It's reckless. It's dangerous. And unfortunately, it's necessary to prevent death due to lack of insulin.

Here's what more than one hundred people per day are searching for:

Please forward this to anyone who might be able to help.

If your family is anything like mine, you’ll have ample opportunity to completely skyrocket your blood sugar levels tomorrow.


When I was younger, here’s what my Thanksgiving Day experience looked like:


My family starts Thanksgiving day drinking mimosas and eating something luxurious like quiche with fruit while wearing our pajamas.


Then, after breakfast, we munch on the pre-thanksgiving appetizers.


There’s usually a cheese & cracker tray, a relish tray, cookies, at least three different kinds of chips, dip, salsa, pigs in a blanket, and, well, you know the drill.


By the time Thanksgiving dinner is ready, I’m usually too full to eat anything, but that doesn’t stop me from eating a full plate of food or two, after which I’m so exhausted and stuffed that I have to lay down and go to sleep.


An hour or two later, I wake up and eat some pie. And ice cream.


By this time, one of two things happens. Either my blood sugar goes extremely LOW because I took way too much insulin for all the food I ate, or, my blood sugar goes extremely HIGH because, even though I took the correct amount of insulin, the insulin just can’t catch up with all the food I’m eating.

​
Now, over the last few years, I’ve figured out how to protect my blood sugar from imminent annihilation by employing blood sugar stabilization techniques that I’ve compiled into my new Thanksgiving Survival Guide. These techniques will work whether you take insulin or not. 

Photo credit: http://nerdywithchildren.com/wp-content/uploads/2012/11/banner1.jpg

ALERT (November 12, 2016): THIS POST HAS BEEN UPDATED TO:

1. REFLECT A RECENT ANNOUNCEMENT BY TRUMP
2. MORE THOROUGHLY DESCRIBE THE HISTORY AND POTENTIAL IMPACT OF USING HIGH RISK POOLS TO COVER PEOPLE WITH PRE-EXISTING CONDITIONS

Today is Friday, November 11 and the sticky, sweaty shit storm of election dust has not yet settled, but, I’m going to chill the heck out for a few minutes here so that I can share what the reversal and replacement of Obamacare might mean for people with diabetes.

Despite the fact that Donald Trump has said that he wants to continue to cover people with pre-existing conditions, his policy makers, according to his website, have decided to make it extremely difficult for people with pre-existing conditions to get insurance coverage if they've had a gap in coverage. Here's what's on Trump's website as of November 11, 2016:

The Administration also will work with both Congress and the States to re-establish high-risk pools – a proven approach to ensuring access to health insurance coverage for individuals who have significant medical expenses and who have not maintained continuous coverage.

Now, the way this is written, to the untrained eye, it sounds kind of good, right? Sounds like Trumpcare is going to cover people with pre-existing conditions.

But, to the well-trained eye, this statement is a half-assed squirt of Febreze on a rug saturated with cat piss.

To be clear, as a policy, BootCamp for Betics doesn’t argue ideology or have political opinions except as it directly relates to people and communities affected by diabetes.

And boy, does this ever.

The imminent repeal and replacement of the ACA could affect your diabetes care and coverage in a very undesirable way. So listen up, folks.

The first thing I'm going to do is translate Trump's website's policy statement for you to make sure you understand what it really says:

The Administration also will work with both Congress and the States to re-establish high-risk pools. A high risk pool is a group of sick people who need more medical care than other, regular, healthy people, and these sick people cost insurance companies a lot of money. So, with the new Trumpcare plan, people with pre-existing conditions will be taken OUT of the regular group and put into a high risk group. This means that regular people who aren't sick can pay less for their insurance premiums, while people with pre-existing conditions will either have to pay for a private plan at a much higher rate than regular, healthy people OR that people with pre-existing conditions can apply for insurance through their state risk pool.  - a proven approach to ensuring access to health insurance coverage for individuals who have significant medical expenses  Sounds great, right? If you can't afford the jacked up private insurance rate for your pre-existing condition, just sign up through the high risk pool! Wait. Wait. Let's talk more about that. Risk pools, back in the day (before Obamacare), were largely run by the states and they operated at a loss. Funding came from various sources, some state, some federal. Often, there wasn't enough money in the high risk fund to subsidize everyone, so people with pre-existing conditions had to go on a waiting list. So, your ability under Trumpcare to procure an insurance plan from a state high risk pool may be limited depending on what state you live in, what type of care you need, and whether or not the state pool even has the money to subsidize you. This creates risk and uncertainty. The truth is, we have no idea exactly how Trumpcare plans to cover people with pre-existing conditions. and who have not maintained continuous coverage There just isn't a way to actually pay for pre-existing conditions for people who've had a gap in insurance. That's what's missing from Trump's plan.

Ok, let's move on.

The next thing I'd like to do is provide encouragement to our president-elect, and to congressional leaders, to continue to find a way to provide affordable, and not prohibitively expensive, healthcare coverage for people with diabetes (and for other sick people) as they work through the imminent reversal and replacement of Obamacare (or whatever Trump & congressional republicans decide to do).

​Do you want to write your senator or representative? Scroll down to download and print my letter templates.

Finally, I'd like to help those of us with Diabetes hedge against insurance loss so that you don't get totally fucked. Read on, my friends.

Here's what you need to do to hedge against potential insurance loss:

1. If you don't have it, get insurance NOW. If you and your spouse both have jobs, and if you can afford it, consider getting double-insured. This may seem excessive, but the truth is, we just don't know what's going to happen and I am very risk-averse when it comes to healthcare. I've been screwed too many times. If you have insurance through your employer, you are in the best possible position right now. Don't quit your job. If you don't have insurance through your employer, go to healthcare.gov and enroll. If you don't currently have health insurance, your opportunity will be lost when open enrollment closes unless you experience a qualifying event. Let me put this another way.  If you don't have 2017 insurance coverage by January 31, 2017 you could be in trouble whenever Trumpcare takes effect (probably 2018). Listen. If you already have insurance coverage when the new healthcare law takes effect, it will be more difficult (though not impossible) for your insurance company to jack up your rates and/or deny your diabetes coverage. If you can't afford insurance, sell your clothes, ask your family members for money, or stop grocery shopping and start eating peanut butter sandwiches.

2. Call, email or write your senators and your representative (you can download a template below) to see if they'll reconsider their position on pre-existing conditions. Do it now, because they are already working on the ACA's replacement.

3. Start saving money.

4. Do what you can to get your blood sugars into target range as often as possible. The sooner you do this, the better. A lower A1C means fewer health problems, and if you're on your own next year without insurance, you'll need to do everything you possibly can to keep yourself healthy so that you can continue to stay alive.

To be clear, NONE of this is certain. No one knows what is going to happen. It's the level of risk and uncertainty regarding pre-existing conditions that I'm uncomfortable with.

Obamacare has its problems, but it also has some features that support the lives of people with diabetes.

I’d like to encourage congress, in its effort to repeal and replace Obamacare, to consider continuing to support healthcare coverage for people with diabetes.

Love,
Kara Stiles

Update 3/6/17
This is an update based on a Facebook discussion about how successful Metformin is, overall, at reducing weight in the general diabetic population. 

Note: Studies don't show consistent weight loss with metformin use, that's for sure. My hypothesis is that in order to experience successful weight loss on Metformin, you have to meet some very specific conditions. First, you have to be euglycemic virtually all of the time before starting the metformin. This is hard to do, especially when you're on insulin. You also have to remain euglycemic as you continue to take the metformin. And insulin dependents have to do this by adjusting (read: reducing) basal and bolus dose calculations. This is not easy. But starting metformin while euglycemic and remaining euglycemic throughout the treatment will, I hypothesize, result in weight loss, because it results in less sugar in the blood, which means less required insulin, which means less fat storage. I am a sample size of one, of course. And my experiment is driven by personal curiosity, not scientific inquiry. I would like find some research on whether metformin has caused weight loss in people withOUT diabetes. I'm sure it's out there, and that I just haven't found it yet.

Now, continue on to the article below.

I’m using a diabetes drug experimentally, and I’m having loads of fun doing it.

Every once in awhile, when I get bored or curious, I experiment with drugs (legally prescribed ones, that is). And, since so many new diabetes drugs have hit the market in the last few years, and since my blood sugars have been mostly stable since the birth of baby George in December, I’m ready to resume my drug experiments.

The next drug I’m going to try is Metformin. Now, I know a LOT of people take Metformin, but not everyone knows how it works.

Most doctors will tell you that Metformin (of the drug class biguanide) is a medication that “makes your body less insulin resistant” or “improves how your body handles insulin.” Which is true, but, have you ever wondered HOW Metformin does this?

Well, in order to understand how Metformin works, we have to understand something very important about our liver. Your liver (and everyone else’s liver) stores a bunch of glucose.

In addition to storing glucose, your liver releases a fairly steady stream of glucose into your body throughout the day to give you energy.

Your liver also releases *extra* glucose into your body as a reaction to other stimuli (at last count, I had a list of 24 non-food events that can cause your liver to release glucose into your blood).

So basically everyone (diabetic or not) gets a steady drip of glucose squirted into their blood thanks to the liver.

Well, Metformin’s job is to suppress the release of glucose by the liver, which, of course, lowers the amount of sugar “hanging around” in your blood, thereby lowering your “baseline” blood sugar levels.

Metformin is good stuff for type 2 diabetics. But, it can also be good for type 1s and for non-diabetics, too!

Here’s what Metformin would do for you, based on your circumstance:

1. Metformin can help people with type 2 diabetes who have high blood sugar by lowering overall baseline blood sugar levels. If you get diagnosed with Type 2 diabetes and you’re prescribed Metformin, the drug will suppress hepatic glucose release (doesn’t that sound fancy? Hepatic means “of or relating to the liver), causing *less* sugar to get squirted into your bloodstream, ultimately resulting in lower blood sugar levels. For you, Metformin is a blood sugar lowering drug.
2. If you’re type 1 (like me), you take insulin. Well, Metformin does for you the same thing that it does for people with Type 2 diabetes - it suppresses hepatic glucose release (causes less sugar to get squirted into your bloodstream), and, if your blood sugars were already under control before you started taking metformin, the metformin will cause your body to need *less* insulin. This will cause your cells to soak up less glucose, which means less fat storage. So for you, the end result isn’t lower blood sugar. It’s weight loss. You slowly start to shed pounds. For you, Metformin is a weight loss drug. Also, if you pay cash for insulin or if you don’t have insurance, you can save a lot of money because you won’t need so much insulin if you take Metformin. Metformin is about $5 per month and insulin is at least $520/month. For you, Metformin is also a money saving drug.
3. If you are type 2 diabetic and your baseline blood sugar levels are within target range and you’re not already taking Metformin, you can start taking Metformin and you will probably shed pounds. For you, Metformin is a weight loss drug. If you are on insulin, Metformin can also save you money because you won’t need so much insuilin.
4. If you are NOT diabetic, you can start taking Metformin and you will probably shed pounds (remember, Metformin causes your liver to release less glucose into your blood, thereby causing your body to require less insulin, which is a fat storage hormone). For you, Metformin is a weight loss drug.
5. (Important) If you are AT RISK of getting type 2 diabetes due to a family history of type 2 diabetes, you can start taking Metformin at any age (the earlier, the better) and significantly reduce (and, in some cases, potentially eliminate) your chances of getting type 2 diabetes in the future (more on this, later). For you, Metformin could be a preventive drug.

Why am *I* trying Metformin?

Well, as it turns out, my liver squirts an obscene amount of sugar into my blood throughout the morning (this has always been the case), requiring lots of insulin (which equals lots of fat storage), and, my liver squirts even MORE sugar into my blood when I exercise.

I started a new fitness program three months ago and as a result of the hepatic glucose release during my high intensity exercise, I’m having to take extra insulin after my workouts.

I’ve been working out pretty intensely for the last three months (minimum 3.5 hours per week) and have put on 6 pounds, despite keeping the same diet. Now. I have very detailed data on working out and why it’s good and why I’m going to keep doing it, but that deserves its own article topic, as does the “Why the hell aren’t we diagnosing insulin resistance at its onset, instead of 15-30 years later, once it’s full-blown diabetes” article.

But for now, I’m going to see if I can continue to exercise withOUT gaining any more weight. Stay tuned, you guys. And stay well. And for goodness sake, can someone start a change.org petition to add Metformin to the water supply?

This is all I have to say to you today.

Love,
​Me

​If you're anything like me (diabetic), you've probably had this experience.

Sometimes, I eat a completely normal healthy meal, take insulin or meds as usual, only to discover that 1 hour after eating, my blood sugar has shot up to 250 or 300. Gah!

Blood-boiling rage doesn't even begin to describe my emotional state when this happens.

Why does this happen, anyway?

Well, one theory is that I took the wrong amount of insulin/medication.

Another theory is that I screwed up my carbohydrate counting.

A third (and more satisfying) theory is that my blood sugar is an asshole.

But, what if I didn't mess anything up? Is it possible for my blood sugar to spike after meals, even though I've gotten everything else right?

Yes. Yes, it is totally possible.

Why?

Sometimes, carbohydrates metabolize and turn into glucose quite quickly after you eat them. This can cause a blood sugar spike in people with diabetes. The insulin (whether you take injectable insulin or whether it comes from your pancreas) just can't keep up with the glucose absorption, so your blood sugar spikes high, and then eventually comes back down to normal once the insulin has had a chance to work. When carbohydrates metabolize more slowly, this blood sugar spike is much less severe.

Now, there is a bunch of information on the web about glycemic properties of foods, and if you have a bunch of time and want to learn more about these properties, you can go online and spend days reading articles about the glycemic index. There's also a bunch of stuff you can do with insulin, if you take it, that can help with blood sugar spikes. We cover that topic pretty thoroughly in BootCamp for Betics.

But. If you don't have a bunch of time to go prowling the internet, let me give you a quick solution that will help mitigate post-meal blood sugar spikes.

How? Well, wouldn't it be nice if we could FORCE our bodies to absorb carbohydrates more slowly? Is this even possible?

Yes. It very much is.

There are two nutrients that, once consumed, have the effect of slowing digestion. If you consume these two nutrients just a few minutes before you eat your regular meal, your food will take longer to digest, glucose will take longer to absorb, your insulin will have a chance to do its job, and you won't have such a big blood sugar spike.

It's not magic. It's science.

1. Soluble fiber increases the thickness of stomach contents after a meal, which slows digestion and glucose absorption.

2. Fat takes a quite awhile to move through your GI tract, so when you eat fat, this gums up your body's absorption of carbohydrates, slowing down glucose absorption.

Now that we know this, how can we practically apply it to our daily lives?

Well, we need to be careful with fat. There's saturated fat and unsaturated fat. Saturated fat can raise our triglycerides and cholesterol, and put us at higher risk of heart disease. Ew. But unsaturated fats don't do these bad things.

What does this mean?

Well, it means that if we eat soluble fiber and/or unsaturated fat shortly before a meal (like 5 minutes before you take your first bite), we can reduce postprandial spikes.

Next time you eat a meal, try doing one of these things 5 minutes before your first bite:

• Eat 10 walnuts (NOT the candied kind)
• Eat 10 pecans (again, not the kind that's dipped in sugar)
• Eat 10 almonds
• Eat 1/2 of an avocado
• Eat 1-2 tablespoons of peanut butter
• Eat 1-2 tablespoons of almond butter
• Eat flaxseed (I've got a mug muffin recipe that I'll send in a few days)

...Or find another food that contains soluble fiber, unsaturated fat, or both, and consume it 5 minutes prior to your meal.

(a diabetes test)