〈When Doctors are patients〉: My Struggle with Prediabetes for 15 years

〈When Doctors are patients〉:

My Struggle with Prediabetes for 15 years

Jen-Yih Chu MD, PhD

Department of Medicine, St. Louis University School of Medicine and Cardinal Glennon Children’s Medical Cental

Preface

When I went back to Taiwan 4 years ago, my twin cousins returned a few books I gave to them. Both are physicians and just a few years younger than me. When I left Taiwan for the United States soon after graduation from medical school, I gave these books to them. One of these books is a Chinese translation of When physicians are patients edited by Doctors Max Pinner and Benjamin Miller (Picture 1, reference 1).

Picture 1.  Book cover of “When physicians are patients” edited by Max Pinner and Benjamin Miller

I bought the book while I was a medical student and was very impressed. It is interesting to know that I wrote some notes at the end of the book more than 50 years ago. I wrote some comments that this was a great book and I should read again time to time. After I came back to US, I went to the library and borrowed the original book  which was published more than 60 years ago.

Both the original English and Chinese translation books had very moving stories about how and why the book were written or translated.  After searching I also found a  book review about the original book. (Picture 2).

Picture 2.  Book Review

After I read the Chinese translation again and also the original book, I wrote two articles in the Taipei Medical Association Magazine about these two books. I also made a plea to the physician colleagues in the articles. In order to continue this kind of spirit¸ let’s write similar but modern stories. If physicians write more about their stories, it will give the general public more accurate health information and it also will benefit physician authors as mentioned by many writers/translators in both books.

A physician friend saw my plea and asked me why not write an article about my experience as an example. He said at the age of 75, I must to have suffered from some medical problems.  Indeed, I have been hospitalized a few times and had a few surgeries. I agreed to write and hope my writing will encourage other physicians to write their experiences.

 I decided to write my own experience about my struggle with prediabetes for the last 15 years. The problem of diabetes has been increasing exponentially in the last few decades especially in the developing countries with new found wealth. Taiwan is one of these places.   

We all know that there are many problems once we have diabetes. The diagnosis of diabetes is frequently delayed because there are hardly any obvious signs and symptoms at the early stage. Most of those with early diabetes have no pain, no fever and other obvious discomfort. However, the major and capillary vascular damages occur at the time of prediabetes, well before the diagnosis of diabetes.  

Fortunately, the damage is rather mild as compared to those with full-brown diagnosis of diabetes. The morbidity and mortality increase tremendously after the blood glucose reached the threshold level of diabetes. Therefore, it is important to find out whether we have prediabetes or not.

The definition of prediabetes

             

            Quite different from preeclampsia, which is usually presented with edema, hypertension and/or proteinuria, prediabetes generally has no signs and symptoms. Therefore, we need to “find” the condition.  Even without any sign and symptom, people with prediabetes have slight higher mortality rate, higher cardiovascular diseases and other medical problems then those without.

The term of prediabetes was quite vague just couple decades ago.  The term of prediabetes has been implied by some for those developing diabetes during the pregnancy. The term of “borderline diabetes” has also being used for a while. The term of prediabetes was better defined when American Diabetes Association (ADA) set criteria for the diagnosis of prediabetes in 1997. The World of Health Organization (WHO) also followed the suit and set the similar criteria in 1999.

The originally criteria of fasting glucose of 110-125 mg/dl as prediabetes was later changed to 100-125 mg/dl. WHO and International Diabetes Federation (IDF), however, did not follow ADA. The criteria were somewhat confusing.  In 2011, the term of “categories of increased risk for diabetes” was introduced by ADA. Generally, these two terms are used exchangeable (Table 1). The 2015 criteria of prediabetes are set as the following table. (Table 1)

Table 1.  Laboratory definition of  Prediabetes/Categories of Increased Risk for Diabetes.

The main purpose to present these terms and criteria of the diagnosis of prediabetes / Categories of Increased Risk for Diabetes is to alarm people to be more careful.  Once anyone has prediabetes, it is very likely it will progress to diabetes if nothing is intervened.  Once the threshold of blood glucose levels of diabetes is reached, the vascular and other damage will increase tremendously.  Morbidity and mortality may increase few times higher.

The chance to become diabetes is much higher in prediabetes than people with normal blood sugar. Quite a few studies found people with prediabetes progressed to diabetes at the rate about 10% a year, if they did not change their life style or taking medicine.

My Own Experience how prediabetes was found

            About16 years ago, I had some leg and back pain. When I was first seen by my primary doctors, quite a lot of blood tests, imaging and other studies were performed. My physician missed my abnormal fasting blood sugar. My fasting blood glucose was just over the diagnosis of diabetes (127mg/dl) . My doctor did not tell me that my glucose level was higher than the criteria of diabetes.

            My leg and back pain gradually got better and I did not go back for follow-up.  I visited another physician for an unrelated problem a few months later. I was seen by a medical student first. She looked at my chart and told me I had diabetes and she showed the blood glucose result to me. I was “shocked” to know that.  In order to confirm the diagnosis, I went back to my primary doctor to repeat the blood tests as indicated at the end of in the next Table2.

Table 2. The 2015 criteria for the diagnosis  of diabetes.

            The repeated blood tests including A1C, fasting glucose and 2 hour after glucose loading were all in the range of prediabetes and did not reach the criteria of diabetes in the past 15years.

Literature Review

            After the diagnosis of prediabetes, I had a discussion with an endocrinologist colleague,  and he recommended a new medicine to me. I just asked him in the hallway or in the lounge.  He did not examine me in his office. Fortunately, I did not follow his advice. The medicine he suggested was later reported to have quite a few significant side effects.

            I did considerable literature search and had discusssion with my physician. He agreed with me that taking medication should not be the first step. Life style change is more important.  After reviewing the literature, I believe there are 3 independent factors of my life style I should follow carefully.  The three factors are: 1) weight control 2) increase physical activities through labor and exercise 3) modifying my diet.

There are a lot studies confirming the life style change is the most effective means to prevent or delay the advancement of prediabetes to diabetes. Many studies showed those with prediabetes decrease their risk of developing diabetes at least 50% if they undergo an  intensive education program to modify their life style.

After reviewing literature, I remind myself time to time that I have a high risk of diabetes.  Once the criteria of diabetes are reached, I have much higher mortality rate and much more health complications.  I tell myself I must work hard to modify my life style in order to prevent or delay the progression of prediabetes to diabetes.

How I try to modify my life style

I know I should work on these three important and independent programs mentioned above.  Good weight control is effective even without increasing physical activity or changing diets. Similarly, labor/exercise will also benefit diabetes prevention without any effort on weight control and diet change. There are many different dietary programs recommended by the experts, there are still some common rules.  I can follow.

1)      Weight Control         

Body Mass Index (BMI; ie dividing weight in kg)by height in meter square) is a good guide for weight control.  In general, BMI of 25 kg/m² is set as the normal upper limit.  Above 25 is overweight and more than 30 is obesity. In Asians, many organizations use 24 (some even use 23) as the cut point for upper normal limit, 28 and more as obese.

In a nurse study in USA, if BMI of 18-22.9 is base index of 1, the risk to have diabetes for those with BMI of 23-24.9 was 2.67, for overweight of 25-29.9 was 7.59, for those of obesity at BMI at 30-34.9 was 20.1, severe obesity at BMI of over 35 was 38.8.

 Various bariatric surgical procedures to lose weight is enough to improve the condition of diabetes or prevent diabetes. To control weight by labor/exercise and diet will have much better results.

I tried very hard to control my weight. When I knew I had prediabetes, I was close to 60 years old. My weight was about 145 pound.  I lost about 10 pounds and I did try to lose weight to maintain a BMI around 22-23. There are considerable data that the BMI at the borderline of overweight (i.e. 25-27 ) has the lowest mortality for seniors.  I did not find the data for East Asian in US. However, I found a report from Hongkong. It is best not to increase or decrease the weight for seniors (>65 years old). Now, I try hard to maintain my weight around 140-142 pound my BMI at 23 or slightly higher.

2)      Labor/ Exercise

Insulin resistance is the main feature in Type 2 diabetes.  Because of insulin resistance, the functions of insulin decrease. With the blood glucose increases and glucose and lipid metabolism are in dysfunction. Increase in physical activities is effective to decrease insulin resistance. Labor and /or exercise not only decrease the blood glucose it will also increase high density (good) lipoprotein and decrease the low (bad) density lipoprotein and triglycerides.

Most articles discuss mainly the benefit of different exercise, I believe labor should be emphasized. In a few developed countries, the people that live the longest and are the most healthy are those in the areas the people need to do more labor such as Okinawa of Japan.  We should learn from our ancestors. Just a few generations ago, our grand and great grand-parents needed long hours of labor to make a living, hardly anyone of them got diabetes.

I like vegetables gardening(Picture 3). There are many folds of benefits to grow vegetables in your own garden. Labor for gardening is quite significant. Not only are the home growing vegetables without insecticides more healthy, I eat more vegetables just because I grow them myself and I don’t want to waste them.

Any kind of labor such as cleaning house, yard or other household work all can achieve the same or better effects as exercise. I don’t need to find a gym. Labor has another superiority, the brain coordinates the different parts of body to complete the task. Labor may be better than certain monotonous exercises.

Picture 3.  Healthy vegetables growing from a small area need a lot of labor.

            No exercise is too small to do. When I get older, I can’t do more strenuous exercise. I walk quite a lot regularly as my routine exercise. I use stairs instead of elevator except when it is more than 5 floors. Sometimes, I purposely choose to walk to a place to talk to people instead of using phones. I park my car in the far away areas in the parking lot.  I like to go to shopping with my wife because I can walk in the mall while she is shopping.

            In order to “force” myself walk more, I turn off the water in the bathroom in the first floor at home. I forces me to walk upstairs regularly. I use the printer in the larger office far away so I can walk more. I don’t  get my coffee in the next room, I go to the main lounge 2 floors above.

3)      Dietary management

There is a lot of evidence that dietary habits in rich societies contribute significantly to the current world epidemics of diabetes.  The tremendous increase in diabetes in the world in developing countries is due to the abundant and easily available Western foods.

What is the best diet program that will help to prevent or delay diabetes is quite controversial.  I try very hard not to eat too much in order to keep my weight stable.  There are many different diets recommended for those with diabetes and prediabetes.  Even though there are many quite different diet programs recommend, there are some common grounds I can follow.

I eat less meat, especially beef and pork, of course less animal fat. I eat chicken, turkey and fish instead. I avoid bacon and butter in any kind of food in any meals. I eat a lot of vegetables and fruits. I use different kinds of vegetable oils especially olive oil. Try hard to eat food made from whole grains.

I try very hard to avoid junk foods such as french fries and donuts (Picture 4).  I only occasionally eat one quarter of a donut or an order of fries. In restaurants, I eat only part of dessert. Small portion of desserts I enjoy are mainly homemade, the types prepared with much lower portion of sugar and fat.

Picture 4.   Food I try hard to avoid.

 

The dietary program I described above probably will be most consistent with a Mediterranean diet. I use more olive oil and eat more vegetarian meals than I used to in the last few years.

I eat mainly home cooked simple meals. During the season, we used a lot of vegetables from my own garden and other commonly available ingredians. I try hard to avoid delicious food in the restaurant because those are generally prepared with a lot of salts, animal fats and sugars.

To stick to “healthy diets” is not an easy task. Many studies show different kinds of diet programs have very similar effect of losing weight gradually. The maximal effect is usually achieved around 6 months. People then start to gain weight gradually.  Many people participating in the studies eventually regain their weight after the programs are terminated. Of all diets, Mediterranean diet has the best reputation that people will continue after the study program is finished. In addition, some studies showed the Mediterranean diet probably the “best” diet program for people with diabetes and prediabetes.. 

How to self-discipline : 

Once I knew I had prediabetes I started above program immediately. I did not postpone to a later day. In order to maintain these programs of labor and exercise, healthy diets and good weight control, self-discipline is the most important issue. Good blood sugar control achieved for a short period isn’t enough. We need a plan to make the good control to last “forever”.

During any study program, people are monitored closely by the program management team. Nurses or other personnel in the team will teach or remind them frequently how to modify their life style. They are reminded of their exercise program and diets. Once the program finished, many “relapsed” to the old life style and lost the good control.  I borrow the idea how to monitor myself closely like the study programs.

In the beginning, I use quite different ways to remind myself to stick to the good life style. I bought a pedometer to make sure I walk enough steps every day. I recorded the steps on a calendars for a few years. I also recorded my main course of meals every day. At the end of month, I review my dietary history of the month and make adjustments later according to my record.

In addition, I bought a home use glucose monitoring devise. I check my fasting blood glucose every few days or during my trials of special diets and/or exercise programs.  When I go to see my physicians, I ask them to order A1C for me. I monitor my status of prediabetes very carefully.

 I believe all these different kinds of monitoring system remind me of what study coordinators would do. As a high risk person of developing diabetes, I need those systems to remind me to continue  a good life style and do my best to get good control.

Conclusion:

Because of reading an old book When Doctors are patients which was published more than than 60 years ago, I tried to write my own experience about my struggle with prediabetes in the last 15 years. Try hard not to let prediabetes becoming diabetes with weight control, labor/exercise and diets. Most importantly, how to self-discipline myself  to stick with a good life style is the most difficult one.

Reference:

1)      Pinner M, Miller BF：When doctors are patients. 

         New York, WW Norton and Co., 1952.