Diagnosis and Possible Reversal of Pre-Diabetes #4

Addressing Accurate Diagnosis And The Significance of Patient Compliance

We are surrounded by pre-diabetes (PD), insulin resistance (IR) or syndrome X—all names for the same thing. While we all may know what to look for, it can still sometimes be difficult to see.

Below are some of the hallmark symptoms of PD.

· Central obesity.
People with elevated insulin will store every extra calorie they eat as central fat. On days they are trying to be “good” by skipping meals or starving themselves (a bad idea) they will burn muscle and not fat. The result is an overweight trunk with thin legs and arms.

· Constant hunger.
When a person with PD eats a high glycemic index (GI) food, the blood glucose (BG) rises, followed by an exaggerated insulin release, resulting in reactive hypoglycemia, which in turn results in hunger. If he “fixes” hunger with another high GI food, the cycle will start all over again.

· Blurred vision
BG is a major component of the osmotic pressure in the blood. With swings in BG come swings in osmotic pres­sure, causing a distortion of the lens and cornea of the eye, which results in blurred vision.

· Fatigue.
In PD, insulin receptors are insensitive to insulin. This results in low muscle concentrations of available carbohydrate and inefficient energy metabolism.

· Depression.
The metabolic derangement resulting from PD has many psychological effects. Depression may arise from the same type of energy metabolism inefficiencies seen in fatigue.

· Brain fog.
The brain is the most prolific consumer of glucose of any organ. With problems in glucose metabolism and transport, brain fog seems to arise.

Many clinical tests exist to diagnose PD, but some are more accu­rate than others.

· Fasting blood glucose (FBG). FBG is a late indicator of pre-diabetes. The metabolic disorders known as PD may exist for 3 to 5 years prior to diagnosis if done by FBG. A fasting blood sugar level between 100 and 125 mg/dL is considered pre-diabetes. Optimal blood sugars are significantly lower—some say as low as 70.
· Postprandial blood glucose (PBG) and glucose/insulin tolerance testing (GITT). PBG is a better indicator of pre-diabetes because it is more like a stress test of the glucose metabolism system. I generally do a GITT with a fasting insulin and FBG, then a 75 gram glucola followed by a 2-hour postprandial insulin level and BG. I look for fasting insulin less than 10 and FBG less than 95 (some say 85). The postprandial limits are insulin less than 3 times the fasting level and not greater than 30, the BG not greater than 140 (although I think that is too high).
· Lipids. Lipid levels are another early indicator of PD. We know that those with PD have elevated triglyceride and low HDL levels. An ideal triglyceride to HDL ratio (THR) is less than 2. A THR greater than 4 is worrisome and probably represents PD. A THR of 6 or more is a significant risk factor for heart disease.

Maintaining a high index of suspicion for pre-diabetes is key to the diagnosis. Following proper diagnosis, one of the key challenges with treatment is patient compliance.

The treatment of PD is primarily a lifestyle issue. While there are pharmacological treatments available, studies have shown them inferior to lifestyle management. The primary problem with lifestyle management is compliance. In my early practice I had a “my way or the highway” type of approach to lifestyle. With age comes some humility, accompanied by greater empathy for my patents.

Whether the treatment plan features a low glycemic index diet, increased activity, or various nutrients such as fish oil or lipoic acid, theadvice is sound. What fascinates me is how we often do not do what we know is good for us. I am trained in functional medicine. This means I assess the biochemical individuality of the patient, consider his current lifestyle, and then determine whether the two are ideally compatible. Once this is accomplished I set up a program with follow-up visits. It is not uncommon for the subsequent visits to reveal a lack of follow-through with the program. In days gone by I would have been quite irritated by this. I now see it as the therapeutic moment.

The therapeutic moment is when you have an opportunity to understand and intervene in noncompliance. Understanding why a patient was not able to comply with a plan is far more important than the noncompliance itself. Sometimes it is time, sometimes money, and sometimes preference. Often it is a deeper issue, like food as comfort and companion. Creating a therapeutic alliance with the patient and exploring these issues is often magical, not just for the patient but for the provider as well.

Tom Sult, MD, is a residency trained and board certified family doctor. He is boarded in Holistic medicine and on the faculty of the Institute for Func­tional Medicine (IFM). Dr Sult’s practice is in Central Minnesota were he has a consultative, tertiary care clinic for Functional Medicine. He primarily sees autism, Lyme disease, autoimmune disorders, envi­ronmental illness and other chronic complex disease. Dr Sult teaches GI and Toxicology for IFM. His primary interest is addressing the underlying causes of illness and addressing the interplay of genetic predisposition with lifestyle and environmental change.

http://www.naturalmedicinejournal.com/pdf/NMJ_OCT09_CR.pdf

http://www.depsyl.com/

http://back2basicnutrition.com/

http://bionutritionalresearch.olhblogspace.com/