A life in the day

Or just an inchpebble?

Nice round number in the weight loss project. As you may know, I’m trying to lose a significant amount of weight. The doctor told me I should lose 75 pounds (2.2 pounds = 1 kg.) That was ten months ago. As of yesterday, I’ve lost 50 of them. My personal goal is another 15 pounds beyond what the doctor recommended, so I have between 25 and 40 pounds to go.

I also am off one of my medicines. I ran out of one prescription for a day or two, but once I’d refilled it I noticed that my blood sugar was remaining steady, so I never started it back up. I’m seeing the doctor next week and will double-check with her then. But for now, I’m down to one diabetes medicine. And I’m hoping to get off that one too next time. My dosage is already pretty small. If that works, I will be managing my diabetes with nothing but diet and exercise!

I haven’t checked my blood pressure lately, but my blood sugar is staying in reasonable ranges. I think I’m licking this thing!

In September, I posted my first progress report on my diabetes. It’s time for an update. I had various tests done at the end of January, and I finally got the results back. My daily blood sugar readings remain relatively good, although they are varying a little more than they did in September. The main long-term indicator for diabetes is the HbA_1c test. The target is a reading under 7.0. In September I’d gotten down to 6.2. This time I was at 5.9.

My blood pressure seems to run pretty consistently around 125/75. Although my weight has been sitting pretty still lately, I’m 40 - 45 pounds down. That means I still have between 30 - 35 (doctor’s recommendation) and 50 (my own hope) pounds still to go.

Cholesterol is good, too. The target for total cholesterol is under 200. I’m at 122. For the LDL (bad) cholesterol, I’m at 78, which is in the target range, of below 100, and my triglycerides, at 99, are well under the target of 150. Only my HDL (good) cholesterol is off. The target is to be in the range 40 - 50; I’m only at 28. Still not getting enough exercise, I guess.

The other news has to do with my hypothyroidism. I reported last month that there was concern that the Hashimoto’s Thyroiditis together with the diabetes was a sign that my immune system was attacking all my endocrine glands. There was a simple test for that, the GAD-antibody test. The result was … negative! Also, I had a thyroid scan, which reported no nodules. So the thyroid news is also good. When I was diagnosed my TSH test was 9.75 mIU/L. I’ve heard varying reports as to the target range, both 0.5 - 4 and the wider 0.35 - 5. While my current 6.96 is still too high, the progress looks good to me for one month.

And best of all, I feel good!

Go away. You probably don’t want to bother reading this.

Still here, huh? Well, I just had a doctor’s visit, and I want to record what he told me before I forget it. If you care about the link between diabetes and hypothyroidism, go ahead and read on.

Dr. Lampugnale’s office referred me to an edocrinologist, Dr. Abourizk, who directs St Francis Hospital’s Diabetes Care Center. I was referred because after I was diagnosed with diabetes in May, I was diagnosed as hypothyroid in December; we want to find out if there is some underlying issue causing my endocrine glands to malfunction.

We don’t yet have answers to that question (I have some tests scheduled), but I did learn a bit about the potential link between these diseases. First of all, the type of hypothyroidism I have is what’s known as Hashimoto’s Thyroiditis, which means that my immune system is creating antibodies to thyroid peroxidase (TPO). These antibodies are attacking my thyroid gland, gradual causing its destruction. So it sounds as though, barring some medical breakthrough, I will be on thyroid medicine for the rest of my life. I didn’t ask about possibilities of this being reversed. I imagine that with my immune system causing the problem, the most we can do is counteract the effects.

Since my immune system is attacking one endocrine gland, there is an elevated risk that it might be attacking another one, namely my pancreas. Something called GAD (glutamic acid decarboxylase, thanks Google) antibodies can attack the islet cells of the pancreas, decreasing production of insulin.

This would not match my diagnosis of Type 2 diabetes, which is a problem in the use of insulin, not in its production. But it’s possible that I’m going through a slow onset of Type 1 diabetes, in which case I will at some point become dependent upon insulin. We’ll know more after two tests I’ll have at the end of the month, one testing for GAD antibodies and another scanning the pancreas itself for unusual growth.

I learned several other things in this visit: Hashimoto’s disease is significantly more common among women than men, and has a strong genetic component. If the immune system is attacking these endocrine glands, the adrenal glands are often in for some rough treatment as well. (The first symptom would be loss of appetite; no problem there.) Finally, I learned some about the relationship between the pituitary gland and the thyroid gland. The pituitary releases thyrotropin, a thyroid-stimulating hormone, also known as TSH. TSH induces the thyroid to create the hormone thyroxine (T4) as well as others. This T4 then inhibits the pituitary’s release of TSH, in a negative feedback loop. The most sensitive check for thyroid functioning is the check for TSH, since a drop of 50% in T4 corresponds to an 800% increase in TSH. The normal TSH range is 0.5 - 4 mIU/L. My reading was 9.75 mIU/L. I don’t have a sense of how bad that is, except that I’m now on the lowest dose of synthetic thyroid hormone generally prescribed. (And that mathematically, if the top of the normal range is eight times the bottom, having a level 2.5 times that of the top of the range might not be that bad.)

It sounds as though hypothyroidism won’t complicate the treatment of my diabetes, but it is likely to make certain of its symptoms worse. It’s going to be harder to lower my blood pressure, although today’s 105/88 reading is encouraging. It may also make it more difficult to lose weight. After losing 45 pounds in six months, I put eight back on in short order. Now I’ve taken three of those back off, but it’s very slow going. And hypothyroidsm may create cholesterol problems, although my cholesterol has been very good. Dr. Abourizk discussed putting me on statins. He’s very gung-ho on statins, and an article about the uses of statins, originaly published in the Hartford Courant with quotes from and a picture of Dr. Abourizk, is prominently displayed in his office. I will have to do more research first.

Still, I really am feeling old! I’m going to need one of those weekly pillboxes.

Long time no blog…

It’s not that there hasn’t been much happening. Just the reverse, in fact. Still suffering some post-election depression, but what can you do?

The big thing was an illness last month. I was in bed for ten days, sleeping 12 - 16 hours per day. I was constantly cold. I also had minor gastro-intestinal distress and some joint aches. The doctor had me tested for what she thought was most likely, hypothyroidism, but also tested to try to rule out Lyme disease.

It turns out I had both! I’m on thyroid medicine and antibiotics, and have been feeling much better.

I guess hypothyroidism is not particularly unusual in diabetics. But I’m going to see an endocrinologist to figure out why my glands are starting to give me problems. When I was diagnosed as diabetic last summer, I immediately started detailed research into it. This time, I’ve read almost nothing. I don’t know why the change, except perhaps that hypothyroidism doesn’t seem nearly as threatening. The Wikipedia entry on hypothyroidism isn’t even a tenth the size of the one on diabetes, and I think that’s evidence that hypothyroidsim is not considered nearly as serious.

The illness and the holidays conspired to slow my excercise program to a halt for almost a month, and I’ve gained back six or eight of the forty-five pounds I’d lost. My blood sugars haven’t been nearly as good as they were, although I’m still doing okay. And the blood pressure is way up. I’m a mess!

Man, I’m feeling old.

And I’m not even 39 yet. (Still seven hours until the birthday!)

I’m half-way there!

When I was diagnosed with diabetes (nearly six months ago, wow!) the doctor told me that I would really need to lose some weight. She set a target weight that was 75 pounds below where I started. (For my vast horde of international readers, 1 kg = 2.2 pounds.)

I lost quickly at first, losing 35 pounds in eighteen weeks. And sat there. And sat there. And sat there for five weeks, bouncing around between 31 and 35 pounds down. But this week, I seem to be heading in the right direction again. And today I’m down 37 ½ pounds!

Of course that is just the doctor’s target. I’m aiming lower. I want to shoot for my high school weight, which is 90 pounds below my starting weight. But it feels really good to reach this point.

And although I had to resume the medicine that I tried to stop at the fourteen week mark, I have now cut the dosage in half, while still keeping the sugars under tight control. So I’m feeling pretty good about that. The exercise is going well again now that Daily Savings Time is over and I have some daylight to walk in before I have to get ready for work. (The alternative is the gym, which I hate, although I’m sure it’s good for me.) The only number which doesn’t make me happy now is blood pressure. I’ve been doing pretty well, I thought, but today it was 135/82, slightly above the 130/80 recommendation and my usual 125/75 numbers. I assume it was just a fluke. I’m feeling too good to think it’s anything more.

In a July entry I discussed my confusion about the units of the Body Mass Index (BMI). Yesterday the doctor told me that they are going to stop using the BMI within a year or so because it doesn’t properly measure muscle mass or bone structure. I didn’t ask who “they” were.

While it clearly wasn’t the most exact measure of body fat, it was an extremely simple one to make. The research I read said that there was a strong correlation with body fat percentage, which can measured, but not as easily. I wonder what they (them again!) will use to replace it as a simple test of whether someone is overweight .

I’m quite disappointed to return to taking the medicine I gave up several weeks ago. I gave myself a fair chance without it, but my sugars shot up much higher than they were on it. So, I’m back on it, and the sugars are back down, almost to the enviable levels I had during vacation. I’ll keep working on losing the necessary weight, and hopefully try again in a few months.

I really wanted to get off of this.

Well, it’s been fourteen weeks since diagnosis. I wanted to report progress after three months, but I didn’t have the results of the bloodwork at that point. So fourteen weeks will have to do.

My diagnosis of diabetes has meant changes to my diet and my exercise habits. The exercise has not been as regular as I would like, but hasn’t been bad. The changes in my diet seem to have been quite successful. Just last week, I stopped one of the medications I’ve been on. I think I’ll be on the other for some time still. But I retain hope that I can eventually get off it altogether.

The most important number I need to track is my blood sugar. There are two types of readings:

• My twice-daily readings measure glucose in the blood in units of milligrams per deciliter. My targets are for values below 120 for a morning fasting level, and absolutely below 180 at bedtime, preferrably below 140. But, at least within reason, the lower the better, so a morning reading of 110 or lower is still a better goal, and maybe 130 at bedtime. I’ve been pretty close. Until I got an infection recently, my morning levels were 95 - 105, and bedtime, 90 - 120. Right after I licked the infection, I stopped one of the medicines, and my numbers have been higher than they were. But the morning levels are still 100 - 120, and evening levels have been 100 - 140, except for two readings around 160. These are slowly going back down, too. I hope that in a few weeks I’ll be back to the levels before the infection, and I’ll be managing it without taking the glipizide. For comparison, the readings that led to my diagnosis were 340 and 270 mg/dl.
• A hemoglobin A_1c reading measures blood glucose as well, but on a longer scale. It records the average level of sugars in the blood over the course of two or three months. The mechanism is simple. Red blood cells’ lifespans are around 120 days. At any time in their life, a hemoglobin molecule in a red blood cell can get glycated, which means that it has a glucose molecule attached to it. It will stay attached as long as that cell lives. So the percentage of hemoglobin molecules that are glycated is a good indication of the amount of sugar in the blood over the last two months. When I was diagnosed as diabetic, my HbA_1c reading was 10.8%. The target is to keep it under 7%. My recent bloodwork has a reading of 6.2%.

There are other factors to consider besides blood sugar. At diagnosis, I was at least 75 pounds overweight, and probably more like 90 pounds. In the fourteen weeks since, I’ve lost 28 pounds. My blood pressure was slightly high at diagnosis. For diabetics, they prefer blood pressure below 130/80. Mine was more like 140/85 or 140/90. At my last doctor’s visit it was down to 120/78. And finally, my cholesterol numbers are very good. Total cholesterol was 137 mg/dl, which is well inside the desirable range (below 200); the LDL (bad) cholestorol number was 82, which is in the optimal range (below 100) ; and the triglycerides were 103, which is well in the normal range too (below 150). The only slight issue is that my HDL (good) cholesterol was a bit low. For men, the normal range is 40 - 50. Mine was only 34. That points to a need for more exercise and to the fact that I still have a great deal of weight to lose.

I was told that when I got my diabetes under control, I would notice many positive benefits, including greater energy and possibly clearer eyesight. I’ve not noticed any changes. But I hadn’t had any particular problems with energy. And I hadn’t had any incidents of fuzzy vision, beyond the normal expectations of my astigmatism. I’m sorry not to see greater positive benefits. But I understand well the risks of diabetes, and I’m quite sure I have the discipline to keep with the program.

And there is one clear and obvious result: my profile is shrinking noticeably. I need to buy new belts!

I noticed that the American Diabetes Association has an Ask the Pharmacist link, which is perhaps not what I really wanted for researching the infections/blood sugar link, but might help. It’s an excellent service, provided in fact by RiteAid, and available online. I asked about the mechanism by which infections raise blood sugar, and within an hour or so got this response:

Thank you for using Rite Aid Clinical Services. In reviewing our drug information resources we have found that an infection is a stress on the human body. To deal with stress, your body releases hormones to help fight the infection. These hormones can raise blood sugar levels directly, and interfere with insulin, which will also affect your blood sugar levels.

It’s a great service. I have to look for an online “Ask a physician” service.

Of course now I have to go looking to find out how stress and the related hormones affect blood sugar. But this is clear-cut progress.

A big thank you to RiteAid and the American Diabetes Association!

Back from vacation. A great time was had by all…

Actually, although the weather was better than last year, it was the second worse trip I remember weather-wise. We still had a lot of fun, and rainy days at Sebago are better than rainy days at home. I ended up with an ear infection, though. I got one last summer too, so I think I’m going to have to try something to prevent them.

Until I got that infection, my blood sugar was fantastic. The infection drove it up 35 points or so, to around 130. I’d like to learn more about the mechanism by which infections raise the blood glucose. But I still haven’t done the research into body mass index, so I don’t know when I’ll find time for a new topic. I’ve been home from vacation three days, and I still haven’t even found time to get through all my e-mail or snail-mail. Uggh!

I’ve got to write a little application for posting my blood sugars on my website, with some analysis and graphing tools, and stop typing all those silly

Blood sugar: Some pm: ###, Next am: ###.

lines. Soon. Real soon…

Right! As though I don’t have enough to do…

Well, the trends are definitely for the better. Even with my unfortunately high reading last night of 159, you can see in these graphs that I’m doing okay.

Clicking on either graph gives a larger version of it.

Blood sugar: Tuesday pm: 159, Wedneday am: 109

I don’t understand the justification for the Body Mass Index (BMI). I guess they’ve found a strong correlation between BMI and body fat percentage, and the correlation is the most important thing. But I don’t understand the units. It’s measured in kg/m². Wouldn’t kg/m³ be more logical? Are we supposed to be two dimensional?

This scale would give the same score to a five-footer and a six-footer who weighs just 44% more (6²/5²). I would expect that the logical equilibrium point would be 72.8% more (6³/5³.) I know that children are treated somewhat differently, but in the existing scale, a 25-pound three-foot tall child would scale up to a six-foot tall adult weighing only 100 pounds.

(For those with more logical measurement scales, 2.2 pounds = 1 kilogram, and 1 foot = 12 inches = 30.48 centimeters.)

I can find many BMI calculators online, and some medical references to the relationship between BMI and body fat percent. But nothing explains why the units are in mass/height².

I’m puzzled.

Update: A more recent entry notes that the use of the BMI by medical professionals is being eliminated.

And I thought I was doing so well with my weight. I lost about eighteen pounds in the first month. Since then I’ve gained back some of it, and am bouncing around between ten and fifteen pounds down. The trouble is that it’s still far too heavy. I need to lose sixty-five pounds more. (That’s thirty kilograms for my horde of international readers. ) My caloric intake is down substantially; my exercise has increased a lot. The blood sugar numbers are reasonable, although I’d like them a little lower. Blood pressure is around 125/75. Now if I can only get the weight down.

Blood sugar: Monday pm: 120 Tuesday am: 114.

Blood sugar: Sunday pm: 110, Monday am: 97.

Blood sugar: Saturday pm: 115, Sunday am: 116.

Blood sugar: Friday pm: 92, Saturday am: 122.

Blood sugar: Thurdsay pm: 139, Friday am: 104.

Blood sugar: Wednesday pm: 92, Thursday am: 103.

Blood sugar: Tuesday pm: 102, Wednesday am: 95.

Just when I think I’m doing great with fasting blood sugar levels of 100 - 120, and bedtime levels 100 - 140, I hear from Hosea Kelly, from my diabetes training class, whose levels are 85 - 95 and 100 - 135. Show off! Actually, congratulations to Hosea for doing so well! I am actually quite pleased with my progress. I’m hoping my HbA_1C levels end up pretty good at the three month mark.

Still eating too much ice cream. Not a lot in any one day, but I keep finding my levels are low enough that I can justify a little. Not a good idea except as a special treat, but this one’s turning out to be harder than I thought. Even harder than orange juice, which I thought would be the killer.

Blood sugar: Monday pm: 81, Tuesday am: 109.

Blood sugar: Sunday pm: 132, Monday am: 119.

I can’t figure out how long to stick with my new dosage. I was warned about diarrhea, and I had it for the first three days. Then a day without. Then back again for another day. Gone for two days. And back for two days. It’s never been severe. But twice it woke me up at my witching hour, and I couldn’t get back to sleep for hours. I guess if it wakes me up again tonight, I’ll call the doctor tomorrow. But I’m afraid that I’m just wimping out becasue I simply don’t want to increase the dosage. I want to be getting off of it altogether. Mild diarrhea is nothing new for me. I get it often enough and don’t think twice about it. Hmm….

Blood sugar: Saturday pm: 140, Sunday am: 105.

Blood sugar: Friday pm: 119, Saturday am: 102.

Blood sugar: Thurdsay pm: 114, Friday am: 102.

Blood sugar: Wednesday pm: 99, Thursday am: 97.

Blood sugar: Tuesday pm: 154, Wednesday am: 110.

Blood sugar: Monday pm: 142, Tuesday am: 105.

Blood sugar: Sunday pm: 98, Monday am: 117.

Blood sugar: Saturday pm: 131, Sunday am: 102.

Blood sugar: Friday pm: 144, Saturday am: 143.

Although the doctor (and the medical student on rotation in her office) seemed very happy with my overall progress, my dosage of medicine is still increasing. I’ve lost fourteen pounds in the last six weeks, got my blood pressure down to around 125/80. My fasting blood glucose is generally 100 - 120 mg/dl, and two hours after a meal it’s 100 - 150 mg/dl.

The doctor would clearly like to see my sugars still lower. She’s upped my metformin dosage from 750 mg per day to 1000. Last time I tried upping my dosage I ended up with gastrointestinal problems. She says to live with them for a few days if they are not severe to see if I can adjust. I’m sure I will adjust, but I really don’t want to. I’m hoping to get off all medicine as soon as possible. I know that most people can’t do that, but I’m shooting to be part of the five percent who can. I’m still on 5 mg per day of glipizide ER, too, and I thought she was going to have me off that one by now. Interesting. I was sure I would always be one to ignore doctor’s instructions I don’t like; but I’m sticking with it for now. And I’m going to try for still lower numbers for my next visit. (not until October!)

Blood sugar: Thurdsay pm: 133, Friday am: 117.

Blood sugar: Wednesday pm: 138, Thursday am: 117.

Blood sugar: Tuesday pm: 136, Wednesday am: out of test strips.

Blood sugar: Monday pm: 103, Tuesday am: 103.

Blood sugar: Sunday pm: 115, Monday am: 102.

Blood sugar: Saturday pm: 152, Sunday am: 131.

Blood sugar: Friday pm: 122, Saturday am: 119.

It’s very strange not to be able to interpret certain signals from my body. I can’t easily distinguish between “too full” and “starving”. I guess it’s the change in my eating habits, but when my stomach isn’t quite right, I have to stop and think about how much I’ve eaten recently to figure out what I should be doing. It’s an odd dissociation. I just expect to stay in tune with what my body is doing. Very odd…

Blood sugar: Thursday pm: 112, Friday am: 117.

Blood sugar: Wednesday pm: 129, Thursday am: 117.

It’s amazing to note how difficult it is to intentionally start a routine. Falling into routines is quite easy, but doing it on purpose, well… At first, you’re religious about it. I didn’t miss a morning or evening reading once. I rememberd my pills every morning. I had a small snack two hours after each meal.

I managed to be good for about a month. This weekend things started to fall apart a bit. Saturday night I came back from the fireworks show and forgot to take a reading. I know I forgot to, but I think I didn’t want to admit it to the Doctor. If it’s not that, I can’t figure out why the next morning I filled the entry in with a reading I’d taken midday on Saturday. (So, Dr. Lampugnale, if you read this, one of my evening entries was not accurate. Mea cupla.) Sunday I worked around the barn, straight from breakfast to lunch with no snack. I don’t think I overdid lunch, but it’s hard to tell for sure sometimes. I was sure I wouldn’t do that again for a while; but I did it again on Monday! Then Tuesday morning I’m pretty sure I forgot to take my pills. What kind of routine is this?! And on Tuesday night I overate, sending my blood sugar up to 180!

Gotta get my groove back.

Blood sugar: Tuesday pm: 181, Wednesday am: 125.

Blood sugar: Monday pm: 112, Tuesday am: 121.

Blood sugar: Sunday pm: 160, Monday am: 118.

Blood sugar: Saturday pm: ???, Sunday am: 110.

Blood sugar: Friday pm: 117, Saturday am: 126.

I need to read more about the effects of exercise on blood sugar. I remember being told in class that it can in fact increase blood sugar. It sounded, though, as if that was less likely than a reduction. Yet I’ve picked up some long walks before breakfast, fairly aerobic, and each time my blood sugar has increased 5 - 15 mg/dl over the course of the walk. Those aren’t huge increases, but I don’t really understand the mechanism. Is it simply increased metabolic rate stimulating the liver to release more glucose? I may have to see what happens if I try eating breakfast first.

Not much posting lately. I hit my lowest reading yet last night: 86. I really have to get some sugar pills or raisins or something handy in case I hit low sugar reactions. I imagine that if I can reduce from 136 one evening to 86 the next, I have to be prepared to go significantly lower still.

Blood sugar: Thurdsay pm: 86, Friday am: 104.

Blood sugar: Wednesday pm: 136, Thursday am: 103.

Blood sugar: Tuesday pm: 171, Wednesday am: 119.

Blood sugar: Monday pm: 170, Tuesday am: 113.

Blood sugar: Sunday pm: 122, Monday am: 111.

Blood sugar: Saturday pm: 102, Sunday am: 107.

Blood sugar: Friday pm: 121, Saturday am: 120.

Blood sugar: Thursday pm: 140, Friday am: 114.

I’ve been testing my blood sugar many times each day to see what effect eating at various times and in various quantities has on it. The most interesting result for me is that it seems I can get away with a much larger lunch than dinner. Last week, when I ate more at lunch than at dinner, my fasting levels came down to 100 - 120. This week, I’ve reduced lunch in favor of dinner and my fasting levels are 120- 140. But in each case, the readings just before and two hours after a meal have bounced around between 110 and 150, with no particular consistency.

I’m hoping not to increase my medication. I’m on Glucophage XR, 750mg/day, and I’d rather not increase the dosage. In fact, I hope I can get off of medication relatively soon. But I understand that there has been little sign of any noteable effect at doses below 1500mg/day. I think it’s because of gastro-intestinal side-effects that the dosage usually starts low and is gradually increased. If I can’t get the morning readings down below 120, I know Dr. Lampugnale is going to suggest I increase the dosage. I think I’ll really have to concentrate on having small dinners.

The other news of course, is that there has been no news. This is the first time since I started this journal that I skipped a day posting, and in fact I skipped several. But never fear, I’ll still keep my loyal listener informed of his blood sugar levels. (Oops, did I just let it slip that I’m the only one reading this, dear diary?)

Blood sugar: Wednesday pm: 104, Thursday am: 136.

Blood sugar: Tuesday pm: 153, Wednesday am: 122.

Blood sugar: Monday pm: 214, Tuesday am: 126.