The goal in the treatment program laid out in this book is to give you the tools and the knowledge to take control of your disease by normalizing blood sugars. My interest is not just in treating the symptoms of diabetes, but in preventing or reversing its consequences and preserving pancreatic beta cell function. Essential to treatment is learning to monitor your own blood sugars.
Before you begin to monitor and then normalize your blood sugars, you should ideally have a baseline analysis of your disease. How much have your beta cells "burned out" in part from high blood sugars? Have you already developed some easily measured long-term complications of diabetes? What are your risks for other diabetic complications?
Answering these questions will aid you and your doctor in learning the extent and the consequences of the disease. Your test results will also serve as valuable baseline data to which you will be able to compare the effects of blood sugar normalization. Once your blood sugars have been normalized, such tests can be repeated from time to time, to show what you're achieving. Your improvements will give both you and your physician ongoing incentive for sticking to the program.
The remainder of this chapter describes a number of tests your doctor's laboratory can perform in order to give both of you a picture of your diabetic condition. I have laid these out not because it's necessary for you to memorize them, research them, and know all the ins and outs of them, but so that you may be more likely to get the treatment you deserve. By outlining these tests, I'm giving you a "shopping list" of tests I perform on myself and on my patients.
Generally, I recommend as many as you can afford or your insurance or health maintenance organization (HMO) will pay for. Completing more of the tests will add more dimensions to the picture you gain of your disease. As some of these tests are costly, any or all may be skipped if you cannot afford them or if your insurance or HMO won't pay for them.
Standard Blood Chemistry Profile
This battery of twelve to twenty tests is part of most routine medical examinations. It includes gauges for such important chemical indicators of health as liver enzymes, blood urea nitrogen (BUN), creatinine, alkaline phosphatase, calcium, and others. If you have a history of hypertension, your doctor may want to add red blood cell magnesium to this profile.
This is a measure of total body iron stores. Although usually used for diagnosing iron deficiency anemia, high ferritin levels can cause insulin resistance and type 2 diabetes. Sometimes this form of diabetes can be treated by diet, exercise, and regular blood donation.
Although serum albumin is usually included in the blood chemistry profile, it is not widely appreciated that low levels are associated with double the all-cause mortality of normal levels. It is thus very important that patients with low serum albumin receive further tests to determine the cause.
Globulins are antibodies produced by the immune system. They help the body to fight off infections and malignancy. If you experience frequent colds, sinusitis, diarrhea, cancer, or slow-healing infections of any type, you may have an immunoglobulin deficiency. If your total scrum globulins arc low or even low normal, you should be tested for specific immunoglobulins, such as IgA, IgG, and IgM. We recently published evidence that at least 19 percent of diabetics have an inherited immune disorder (common variable immunodeficiency, or CVID) that may be treatable.
Cardiac Risk Factors
This is a battery of tests that measure substances in the blood that may predispose you to arterial and heart disease.
IMPORTANT NOTE: Sometimes, long before or even months to years after a patient has experienced normal or near-normal blood sugars and resultant improvements in the cardiac risk profile, we might see deterioration in the results of tests such as those for LDL, HDL, homocysteine, fibrinogen, and lipoprotein(a). All too often, the patient or his physician will blame our diet. Inevitably, however, we find upon further testing that his thyroid activity has declined. Hypothyroidism is an autoimmune disorder, like diabetes, and is frequently inherited by diabetics and their close relatives. It can appear years before or after the development of diabetes and is not caused by high blood sugars. In fact, hypothyroidism can cause a greater likelihood of abnormalities in the cardiac risk profile than can blood sugar elevation. The treatment of a low-thyroid condition is oral replacement of the deficient hormone(s)-usually 1-3 pills daily. The best screening test is free T3 as measured by tracer dialysis. If this is low, then a full thyroid test profile should be performed. Correction of the thyroid deficiency inevitably corrects the abnormalities of cardiac risk factors that it caused. TSH, the inexpensive thyroid test performed by most physicians, does not correlate as well with symptoms of hypothyroidism as free T3. My goal with these patients is to use supplemental T3 and T4 to get free T3 and free T4 to the middle of the normal range.
Lipid profile. This profile measures fatty substances (lipids) in your blood and includes total cholesterol. HDL (high-density lipoprotein), triglycerides, and "real" LDL (low-density lipoprotein). Other cardiac risk factors (discussed below) include C-reactive protein, fibrinogen, lipoprotein(a), and homocysteine, and may be more predictive. Abnormalities indicated by these tests are frequently treatable and tend to improve with normalization of blood sugars.
These tests should be performed after you have fasted for at least 8 hours. The easiest thing is to have them scheduled in the morning. If you haven't fasted before the test, the results will be difficult to interpret.
Maybe you've heard of "good" cholesterol and "bad" cholesterol?
Well, this is why a reading for total cholesterol by itself won't necessarily reflect cardiac risk. Most of the cholesterol in our bodies, both good and bad, is made in the liver; it does not come from eating so-called heart attack foods. If you've eaten a meal that's high in cholesterol, your liver will adjust to make less of the "bad" cholesterol, LDL. Serum triglyceride levels can vary dramatically after meals, with high-carbohydrate meals causing high triglyceride levels. Some people-because they're obese or have high blood sugars or are genetically predisposed-make more or dispose of less LDL than they should, which can put them at a higher risk for cardiac problems. High levels of LDL are thought to increase the risk of heart disease, which makes LDL the "bad" cholesterol.
HDL, on the other hand, is a lipid that reduces the risk of heart disease and is the "good" cholesterol. So it is the ratio of total cholesterol to HDL (total cholesterol HDL) that is significant. You could have a high total cholesterol and yet, because of low LDL and high HDL, have a low cardiac risk Conversely, a low total cholesterol with a low HDL would signify increased risk. Recently, as more has become known about cholesterol, research has shown that LDL occurs in at least two forms-small, dense LDL particles (or type B. the hazardous form) and large, buoyant LDL particles. LDL particle size is now being measured by commercial laboratories. Larger particles, classified as size A, are considered benign, while smaller particles earn.' cardiac risk. Associated with the test for particle size is apolipoprotein B. When the Apo B test result is lower than 120 mg/dl, or when LDL particle size is type A, even high LDL levels are considered benign and should not be treated with statin drugs.