Wednesday, July 26, 2006

On the diabetes wagon

Diagnosis: Five years ago this coming October I was diagnosed with Type II diabetes, and put on amaryl. I spent two hours being annoyed at my doctor for the fact that I had to be the one to diagnose it, despite that I was a clear high-risk case and by the time of diagnosis my sugars were incredibly high (an A1c of 12.1, where normal range is 4.0-6.0). Then I was over that and started working on figuring out what I needed to do.

Education: The first thing was learning all I could about diabetes. Within a mpnth I'm sure I knew more about it than my doctor does. I didn't just read the medical descriptions, but also accounts of people who had been living with it, and found these to be sometimes at odds; generally speaking, there was value and truth in both. The best sources I found were the Usenet newsgroup and the book The First Year Type 2 Diabetes: An Essential Guide for the Newly Diagnosed. The worst source: the American Diabetes Association, which seems to have missed a few sea-changes in diabetes management, and still recommends practices which are deleterious to good control.

Treatment: My efforts went into full swing within a couple of days. The key elements were diet and exercise. The key fact about diabetes management today is that it's patient-driven: easy access to frequent blood glucose tests lets the patient develop his own regimen by seeing how his body responds to different kinds of food, activities, and meds. With diligence and determination you can get remarkable levels of control using diet and exercise by taking advantage of that.

Diet: The key is carbs. Almost immediately I learned how the profiles of carbs, protein, and fat affected blood glucose, both in the theoretical and in the practical. Taking blood tests before and two hours after meals let me see precisely what different kinds and combinations of foods did to me. This can be predicted by counting digestible carbs and considering glycemic index, but I was learning this in the days before the Atkins diet craze, so this was esoteric stuff back then. However, even those only give you a rough idea; your own body's reactions may differ, and mine did in a few ways. After a while, I could predict the impact of a meal on my glucose.

It's important to note that the American Diabetes Association still recommends a diet which is almost all carbs. If you follow their diet, your numbers are likely to go up, not down, unless controlled with meds. Their reasoning for this is backwards. Uncontrolled or poorly controlled diabetes causes higher risk of heart disease; consumption of fats and proteins exacerbates such risks. Ergo, avoid proteins and fats if you're diabetic. The flaw: controlled diabetes does not generally cause higher risk in those areas, and a key part of the best way to control diabetes requires fats and proteins.

The ADA also focuses on weight loss. No surprise there; the whole medical community obsesses about weight loss. Whenever they're shown any of the volumes of evidence that show that it's the underlying metabolism that causes weight gain which causes almost all of the higher risks associated with weight, that losing weight rarely works at all and when it does rarely reduces the associated risks appreciably (any more than bleaching dark skin reduces the risk of sickle-cell anemia), and that health factors such as blood glucose control and blood pressure are far, far better predictors of longevity, they stick their fingers in their ears and hum loudly. Most GPs would, if presented with a fat patient who'd just been hit by a bus, suggest that it was their weight which caused their injuries and suggest a diet. Weight loss often happens as a side effect of the things one does for good glucose control, but pursuing the decrease of that one arbitrary and mostly-meaningless number is a good way to lose sight of what you're really trying to do, and screw it up. Usually weight control is a way to distract people from doing what they really should be doing for their health, since weight is a nice simple easy number, and like most nice simple easy answers, it's a dangerously wrong answer.

It wasn't hard to find lower-carb ways of doing most things; but it wasn't easy, either. The Atkins craze helped a lot, and I'm sad to see it go, but even in its height, there were a few things it was hard to find a substitute for. It's not that it's impossible to make desserts that satisfy a sweet tooth without hitting blood glucose hard. It's that it takes a lot of work. You don't realize how much of a difference it makes to be able to just pick up some muffins, a pint of ice cream, a candy bar, a cake, or even canned fruit, until you are forced to make equivalents yourself or do without. That, more than anything, is the greatest source of temptations to break the diet; do you want to stop what you're doing and bake a batch of low-carb cupcakes from scratch, or just nosh on something in the pantry?

Ultimately, what you end up with is nothing more or less than a budget. You can afford a certain number of carbs (or more accurately a certain amount of blood-glucose-impact) in any stretch of time. If you cherish fruit juice but could take or leave ice cream, you spend your budget accordingly. You look for places where you can free up carbs to use elsewhere: leaving off the buns on a burger means you can afford to have some pasta with it, for instance.

Exercise: If carbs are something you buy on a budget, exercise is the currency with which you purchase them. Want more carbs today? Just do more exercise to pay for them. I started out right away walking three times a day, after each meal: at first only a few minutes of very light walking, but gradually building up to thirty minutes of moderately brisk walking. I maintained this regimen steadily, rain or shine, every day, for years. I soon learned that timing was very important: the same walk done before eating, or more than two hours after, tended to be of relatively little use. The closer to the sweet-spot of about an hour after eating, the better it did at keeping my glucose down, since it was burning up glucose just about the time it most needed burning.

I also learned that walking was the ideal exercise. Something more aerobic like fast swimming would tend to raise my blood glucose, not lower it. Your body gets into "fight-or-flight" mode when you work hard, and your liver dumps glucose into the bloodstream thinking you're about to need it for a rush of activity, which would be fine if your insulin was up to managing that glucose, which it isn't. Generally speaking you want to have the most brisk exercise you can make yourself do regularly which does not make you out of breath; usually, that's walking, and you vary it by picking up the pace. I find walking on a treadmill at 2.4mph gets me the best balance; walking on a path ends up too relaxed and slow, so has no heart benefits. (But there are other advantages to it, so I still do that sometimes too, depending on weather.)

Results: I am sure my doctor didn't expect much of me. But within two months, I brought my A1c (a measure of long-term glucose control) down from 12.1 (somewhere in the stratosphere of "emergency!") to 7.1 (which was not too long ago the target level for diabetics, and generally considered something it takes years to reach). By five months I was within target ranges, and had gone off meds entirely on the way, controlling my glucose entirely with diet and exercise. Three months later I was within the range of normal people, something even the doctors don't suggest aiming for. My doctor was floored.

Falling Off: I kept up this regiment for about three years unfailingly. I never missed a day getting my three walks in. But gradually I tested my blood less and less because I already knew what it was going to be, and I hadn't had a significant spike in months, years. After a while, I decided to ease off on myself a little; I felt I had my control good and solid enough that if I eased off, my control was still strong enough to be able to take it, since my numbers were so incredibly rock-steady. I kept testing for a while as I eased off to make sure the numbers didn't slip, and they didn't, and then I cut back on testing again. And gradually, I got out of the habits.

First, I let the exercise ease. I decided I didn't have to rigidly do exactly three walks every day at prescribed times. Adding a little flexibility to my daily schedule was a boon I appreciated greatly. Then diet slipped. The convenience of pre-prepared foods and the time it took up to avoid them with homemade, plus the few things there was no proper substitute for (like a simple chocolate bar -- virtually all the substitutes are based on sugar alcohols, which cause me way too much gastrointestinal distress to be worth it) and cravings for those made it harder and harder. Gradually our pantry filled up with sweet and salty carby snacks; none of them was inherently bad, they were all fine as part of a carb budget, but they were being used instead of the low-carb equivalents and blowing the budget more and more as time went by, and those homemade low-carb solutions that are better and tastier, gradually stopped getting made, ever. All those high-carb snacks in the pantry nag at me; I'm too frugal to be willing to throw them away, so they become a burden I have a hard time resisting. And my fasting (morning) glucose numbers crept back up.

Fortunately, my A1c has mostly held within tolerable ranges. Even having fallen off the wagon this badly I still have some of the habits. But it's been creeping up. If I have one more slip, I'll probably go back on metformin for a while. (Which isn't bad, really; metformin doesn't give me any bad side effects, and it's actually good for heart health on its own.)

Getting Back On: A few times over the last few months I've made attempts to get back into those habits, but it seems to be harder to re-establish them than it was to establish them in the first place. One thing I did wrong was trying to jump right back in where I left off; thirty-minute walks were killing me and that was discouraging. So I'm trying to ease up with shorter walks instead, to recreate the gradual steps by which I worked my way into the habits the first time. Even so, it's been a lot of false starts; and the more false starts you have, the easier it is for each new one to get set aside because you can always try another new start next week.

Yesterday was the first day of another start but I'm determined it'll be the one. I am going to test before and after meals again, and make sure my walks happen at the right time. I'm going to carefully budget my carbs: I won't give up all the snacks, but I'll put them in the budget, and won't let the pantry feel like a to-do list. I will record all my meals so I won't be unaware of what I'm doing with my carb budget. And I'm not going to let it slip again.

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