There is a Word for Trying Something Over and Over and Expecting Different Results
I always said I didn’t want to do primary care because diabetes and hypertension don’t get better. Well, little did I know I had already been trained by the pharmaceutical industry and the medical establishment to believe that these were lifelong diseases and I hadn’t even made it in the door of med school. Nothing about my 4 years of medical school did anything to change this belief. (I also had the world’s most amazing OBGYN rotation and while I went to med school with that as my planned field, that rotation showed me that it was truly the most rewarding and interesting specialty.) I don’t think this is because I went to a bad medical school. On the contrary, I think Medical College of Georgia is an excellent school (and don’t ask me to call anything else - who comes up with the acronym GRUSOM when renaming a medical school) and the professors and doctors there genuinelly cared about their patients. They were practicing modern medicine, used the latest medications and still the patients got larger and the diseases got worse.
I then went to residency and did my first high risk OB rotation. When someone was diabetic, they were checking their blood sugar 4 times/day and focused on tight glycemic control with all blood sugars in the 100-120 range. Then I had to rotate through the family medicine department and the apathy towards diabetes management was profound. I remember a doctor telling me that asking people to check their blood sugar more than once a day just wasn’t something people would comply with. I do happen to think that a Freestyle Libre or other continuous glucose monitor would do more for diabetes management than many things we waste money on in healthcare, but I’m assuming that neither me nor you can fix that problem. When I was a 2nd year resident, I met the first doctor who truly seemed to believe that people had the capacity to change and that nutrion was as important as medicine in disease management. His name is Dr. Michael Fox. Good Calories, Bad Calories was required reading for him. He had a stack of copies of Why We Get Fat on the shelf to hand out to all new patients with metabolic disease. Both books are excellent and you will be throwing stuff by the time you finish them. If you want the truly nerdy deep dive, Good Calories, Bad Calories is about 40 hours on Audible and other than a complete inability to prounounce A1c correctly is excellent. The other was written for a more popular audience, but both are by Jeffrey Taubes and cover the same materials. Dr. Fox had a diet handout he gave all of these patients and when I finished residency, he was nice enough to send me a copy to continue passing on.
So, why the title of the artcle? Prediabetes. I cannot stand the word. Perhaps changing it to Early Stage Metabolic Derangement would be more appropriate, but the problem with prediabetes is that it convinces many people that they don’t yet have a problem. And these people aren’t all patients. Doctors became convinced that there was nothing they could or should be doing or recommending too. The result, people gain weight, get more unhealthy, develop comorbid conditions and then, then …. we win and diagnose them with Diabetes and Hypertension. It’s absolutely sickening. I knew this was a thing, but I had no real call to action because I was delivering babies and doing surgery. This was someone else’s problem.
And then, my mom got prediabetes. My mom is not now and never has been fat. She was thin until kids and then stayed between an 8-10 until menopause and then during stressful periods has been up and down, but in that same 6-10 range. I think she’s a little too skinny at the moment, but we’ll fight that battle another day. So, how did my not overweight mom get prediabetes? My brother says its because we never realized how much candy she ate and she stashes it everywhere, but I think a better answer would come when she got her CGM. So, you get that call that your mom has prediabetes and after a moment of self absorption and pity party realizing that if my not fat mother has prediabetes, there is no chance for her slightly larger child who has insulin resistance issues with a normal A1c, I pulled it together and said, “What’s your doctor doing about this?” I was dumbfounded with the response. “We are going to watch it?” Huh? Your A1c has been normal the last 70 years of your life and now its becoming abnormal, what do we think will happen if we do nothing? I insisted she call the doctor back, ask for a rx for metformin and that we were going to have to cut some carbs. After fighting with her doctor, she was finally started on metformin ER 500 mg. She asked me if I was really sure she needed that much, to which I replied, well mom, I take 1500 mg/day and I’m not even prediabetic, so I think you will be fine.
My mom mad some changes and reduced the sweets, but I also had her come down a little on her estrogen patch for totally unrelated reasons and … her A1c after staying steady in the pre range for a year or too climbed to 6.5. I asked my mom what her doctor wanted to do differently now that she officially had diabetes and was given an answer that my have inspired an expletive or two on my part. I’m sure my mom’s PCP must love me. She called back and had to ask for a higher metformin prescription and a freestyle libre. I explained to mom that even if she didn’t use it long term, using it in the short term would help identify what foods she did poorly with. Her doc had suggested that perhaps she should use a glucometer once or twice a day.
The power of the CGM. A freestyle Libre is a brand of continous glucose monitor that lasts for about 2 weeks at a time. You can look at any moment and see what your blood sugar is and you get a daily graph. It can average 3 months of data and gives a pretty reliable A1c estimate. I’m happy to report that my mom’s A1c is generally now even out of the prediabetic range typically running 5.5-5.7. It has taken serious carb cutting to do it and even for someone like me who has been steeped in metabolic data for years, the CGM has taught alot about what foods she can and can’t process. It leads to amazing questions like, “ Melissa, can you explain to me why I can eat a krispy kreme doughnut, but not a homemade pancake even without syrup?” Nope. “Melissa, why is it that piece of butter bread (mom’s long term favorite snack - using highly refined nature’s own white bread) makes my BS go crazy, but a reeses cup doesn’t? “ I definitely would have thought the opposite. So, the only conclusion I can draw is that maybe we all have our own unique metabolic profile and our ability to tell “good carbs” from “bad carbs” isn’t what we like to credit ourselves with? As I said, the CGM was a gamechanger. When her insurance refused to cover it fully when she switched to medicare, she chose to make that a worthwhile expense and I agree. My dad, on the other hand, hates the thing and says it makes her less fun and that she worries over it too much.
What lesson can we draw from this story?
Watching prediabetes will not make it better. You will just watch it turn into diabetes.
All new diabetics and I would argue prediabetics need a continuous glucose monitor and need to build a library of what foods do and don’t affect them. The company just made an over the counter version for the healthosphere marketplace.
Make good lifestyle choices as soon as you are able to because it will pay off in the end.
If you are going through menopause and are developing insulin resistance, kindly consider HRT as a way to help slow that.
The word that best fits doing the same thing over and over and expecting different results is INSANITY.
So, if you have prediabetes, prehypertension/hypertension, feel bloated and swollen all the time, have fatty liver, feel tired and sluggish and you don’t want to just “watch” while your health circles the drain … please find a doctor who is willing to care and insists that there are changes you can make.