Your Turn: Finding a way to fight off insulin dependence
In the middle of a weekday afternoon, my phone rang. I recognized the number as my endocrinologist’s office.
I recently had gone in for routine lab work, and my semi-annual office visit. Even though my glucose level was high (close to 200 mg/dL) and my weight was 210 pounds, I didn’t think much of it.
It was an office assistant. After a brief introduction, she spoke the words that would change my routine, my habits, and even my life.
“The doctor would like to start you on injected insulin as soon as possible.”
Stunned, I sat quietly for several seconds. Several thoughts tore through my mind fast and furious. I was taking metformin daily, but maybe it wasn’t enough; if I started with injections, perhaps every day or multiple times a day, it would be for the rest of my life.
The rest of my life!
Whatever was left of my body’s insulin-making capacity would be shut down, and I’d be dependent on drugs.
Because I had a long career as a scientist, I knew the longterm health consequences of injected insulin were serious and unsettling. And even with decent prescription insurance coverage, how much would that cost?
Not getting a response, the office assistant asked, “Mr. Zaccaro?”
I finally gathered my thoughts and said, “No. Not yet. I’m not ready for insulin dependence. I can do more than I have been doing on my own, with diet and exercise. Thank the doctor, but I’ll adjust my habits, and we’ll see how I am in a few months.”
That call was two years ago, when I was 62. It was a very clear healthcare fork in the road. I could take the path that too many Americans take: their diabetes progresses to the point where their blood sugar is out of control, and they must start taking insulin. Or, I could improve my diet and exercise. In other words — move more and eat less.
My developing plan in my mind did not involve a dramatic, extreme quick-change diet, but a manageable, sustainable shift in eating habits. My enhanced exercise routine would consist of whole-body, break a hard sweat, change your metabolism exercise. Twenty minutes of walking a day would not be enough.
The two most significant factors that led to this fork in the road were: weight gains since age 50 and genetic predisposition. On my father’s side, my aunts and uncles had become diabetic later in life.
Nothing can be done to change a genetic predisposition to diabetes. There is a lot that can be done to change personal habits.
The doctor’s call and lab tests were not long after the holiday season, with the traditional abundance of food; it was winter, and I had not been using the gym with regularity; and I had recently returned from a wonderful vacation — a rock and roll cruise in the Caribbean, which of course included an endless supply of rich food and alcohol. Let’s just say I got my money’s worth.
I have always been fairly active and in decent shape. My diet has been moderately healthy, with plenty of fruit, vegetables, grains and meats. But it has also included plenty of dessert, and casual social alcohol consumption.
Though not a finely honed athlete, I am coordinated enough to play several sports competitively, especially volleyball and softball later in life. I still play softball with and against guys half my age. I am comfortable with exercise, and my blood pressure and pulse are well within range of desired normal.
My optimal weight was around 180, but by my early 50s, I was tipping the scales at 215. Not coincidentally, my blood glucose began trending upward as well.
At the time my weight reached its highest, I joined a gym and began a routine that I have generally retained over the last 15 years: elliptical for an hour at a moderately high setting; several weight machines, and sessions of stretching.
This workout, plus moderate hiking, yard work and reasonable diet, kept my weight between 200 and 210, my glucose just over 100. Not ideal, but at least things weren’t getting much worse — until three years ago.
By March 2019. I was already taking 2000 mg of metformin a day, and tolerating it well. At this point, my doctor suggested prescribing glimepiride, a common drug that increases pancreatic insulin production. I tried it for a few months, but was concerned that the drug mechanism of action would eventually lead to an irreversible loss of the ability of my pancreas to produce insulin.
I switched to sitagliptin, which increases insulin production in the liver, and increases efficiency of insulin use in the body. At the same time, I increased metformin to 2500 mg per day.
These drugs are generally safe and effective at mitigating the effects of diabetic onset, and the associated complications that will likely occur over time. But only in conjunction with improved diet and exercise. This tweak in medication helped, but the most important changes I made were in my personal habits, basically move more and eat less.
Immediately following the call from my endocrinologist, I adhered to this routine. I went to the gym faithfully, typically every other day, kicked the crap out of the elliptical for an hour, followed by the 25 minutes of weight machines and stretching.
Glucose receptors are everywhere in your body, so exercising leg, arm and other muscles uses glucose in essentially all tissues. Between trips to the gym, I did moderate hiking, cycling and yard work, as possible.
I shifted my diet over time to less carbohydrates, but more important, less volume. Fewer desserts across the board, though I did not eliminate them. And even though I was helping out my son at his recently opened craft brewery, I decreased my alcohol consumption by 90%.
My typical breakfast became, and remains, one hard boiled egg, half a banana, a portion of some other fruit, such as cut melon or berries, and half a bran muffin or bagel.
For typical lunches, it turns out half a sandwich is enough. I supplement with a small bowl of soup, or a side such as coleslaw, and usually some chips, pickles or yogurt.
For dinners, I did not change much, other than portion size. I typically have a meat, a carb side dish and a veggie. I just eat less. One plate’s worth, no seconds or refills. Whatever desserts I have, I eat less of them, and only shortly after dinner. I then have nothing to eat for the remainder of the evening.
During this period of habit shifting and adherence, I need to emphasize a key factor you may not have heard discussed before, but it is critical for glucose lowering and weight loss: Get used to feeling hungry.
It’s okay to feel hungry! It doesn’t matter!
If you can get used to that, the remainder of these habit shifts are just a matter of organization and commitment. That feeling will become an indication that you are doing the right things!
For the few months after the doctor’s call, I was diligent with these dietary habits, with more regular and significant exercise, and my own patience with the feeling of hunger. My next lab tests and doctor’s visit were in early July, less than four months later.
I knew I had lost weight, and I had been keeping track of my daily glucose. When these endpoints were all professionally measured, my weight was 185 and my glucose was 108. I lost 25 pounds, went from size 36 to 34 waist, and from an XL to an L shirt size.
After that first four-month period of reclaiming desired levels, I have not done anything extreme, but instead have maintained those shifted daily personal habits. The changes I’ve made are sustainable, with no additional monetary cost. It is a commitment of time, and the personal acknowledgement that it is the responsibility of no one but me to improve my future health and quality of life.
For the past year, my fasting glucose has stayed between 90 and 125 daily, and my weight is always between 180 and 183. I have had to buy new shirts and jeans. But as Dooneese would ask on SNL, “Is that bad?”
During the COVID-19 pandemic, use of the gym has been limited, so opportunities to obtain regular exercise require more creativity. Physically demanding yard work, hiking and cycling have had to suffice.
Though I still love pie, and any dessert, and usually indulge once a day with something I shouldn’t, it is almost always as a mid-afternoon snack, not after dinner. I could be doing better with my activities, but I’m doing okay.
And remember, I am not giving myself injections of insulin. My body still makes its own insulin. With mild, safe medicines, and sustainable, non-extreme habits of exercise and diet, I plan on keeping diabetic complications, and more extreme treatment requirements, out of my life.
Lawrence M. Zaccaro of Waterford performed pharmaceutical research and negotiated legal contracts during his career. He has written a science fiction novel, adult comedy novel, and a children’s book.
Your Turn is a chance for readers to submit stories and commentary. To contribute, email firstname.lastname@example.org.
Ways to avoid insulin dependence
1. With your physician, work out a realistic and sustainable plan, combining available medicines, that supplement diet and exercise that work for you.
2. During exercise, use your whole body in an assortment of techniques. Don't be afraid to work up a hard sweat!
3. Gradually shift to moderate and improved dietary habits that you can sustain indefinitely. No extreme, quick-fix diets.
4. Medicines mitigate symptoms but are not a substitute for proper diet and exercise.
5. Get comfortable with feeling hungry. You will come to realize it indicates you are doing the right things! Hunger equals success.
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