Mental Health Day at the Endo

Laddie_Head SquareI visit my endocrinologist twice a year. I used to go quarterly, but many years ago we decided that there just wasn’t much to talk about every 3 months. Sometimes even the semiannual appointments seem overly routine. My endo respects that I have had Type 1 diabetes for almost as long as she has been alive and that I am essentially a self-managed patient. At the same time she has the ability to pull me out of the tangles of diabetes minutiae and help me focus on the big picture of my overall health. And of course she is the portal to lab work, diabetes technology, supplies, and medications.

If you asked me how my diabetes has been for the last few months, I would answer frustrating. Too many lows, too many highs, too much of this, too little of that. I remember the bad stuff. The overnight lows in the 30’s when I must have acknowledged Dexcom alerts and gone back to sleep. The weekend of intractable highs from sampling a few gorging on Hershey’s chocolates. The party with too much wine and too little willpower. The days of “doing it right” and baffling wacky blood sugars. Insulin acting like water one day and nuclear fuel the next. Nothing unique to anyone with Type 1 diabetes. Probably no better or worse than other months in recent history.

I had my endo appointment on Monday. I arrived on time with Dexcom and Diasend reports in hand. We spent the first part of the appointment discussing a  recent physical with my internist. Some of my numbers have been creeping out of the normal range into that zone that is within target if you don’t have diabetes, but not okay if you do. This is a discussion for a later blogpost, but I agreed to start taking a statin. She could see my distress at these recent changes and emphasized that the differences from last year were not hugely significant. She also discussed that current standards indicate that all patients with diabetes should be on statins unless there is a reason not to be. But ultimately it was my choice.

As she pulled out the Dexcom tracings, I said that I knew they looked good, but they weren’t. This was bad. That was bad. I starting babbling about basals, highs, lows, chocolate.

STOP” she said.

Stop SignStop being so hard on yourself. Stop micromanaging. Stop obsessing over insignificant changes in health indices. Stop driving yourself crazy. Be confident that you are doing a good job. Relax. Take two aspirin with a glass of wine and call me in the morning. Oops, not the last one.

Very kindly she told me that she doesn’t know how people with perfectionist tendencies and diabetes do it. The frustrations, the illusiveness of perfection, the inconsistency, the unpredictability. She shared that her father is a “rocket science” engineer who does not have diabetes but would never being able to reconcile the “do it the same, get different results” illogic of Type 1 diabetes. I am not sure what she said next, but what I heard was “You are doing fine. Continue to respect your diabetes. Be kind to yourself. Keep up the good work.”

Then she walked me to the lab for my blood work. I went home. Definitely better off than when I came.


Laddie_Head SquareIn Thursday’s blogpost I discussed how I had considered postponing my endocrinologist appointment because I didn’t like what it might reveal.  I went to the appointment as scheduled and except for my interaction with one of the nurses, it was uneventful.  My doctor is part of a large endocrinology group and I have never received anything other than knowledgeable and professional care from her, the nurses, and the support staff.  Thursday was an exception, but in a more humorous than problematic way.

I had never met the nurse who called me back, but I assumed that she was a regular in the practice.  The first question she asked was “Are you taking your Lantus?”   No, because I don’t take Lantus. I use an insulin pump.  “Are you taking insulin with your meals?”  Of course I am because I have Type 1 and rarely eat without taking insulin.  “How is it going with your Novolin?”  Rather than explain that Novolin refers to NPH, Regular, and various mixed insulins produced by Novo Nordisk, I explained that I had never been asked these questions before and suggested that maybe they didn’t make sense.  “Did you bring your meter today?”  Yes, but I downloaded everything to Diasend and you can print out the reports for my doctor.  “That’s good and I’ll do that.  Did you bring your pump with you today?”  Silence.

Later in the appointment I learned that this nurse is one in a series of temps replacing the usual nurse who is on maternity leave.  Her ignorance wasn’t particularly annoying; it was just odd.  She couldn’t have been nicer and was doing her best to follow whatever instructions she had been given for updating my chart.  After taking my blood pressure, she said that she’d leave everything else for the doctor and quickly escaped to print Diasend reports.  For my visit her lack of knowledge was inconsequential, but it was a reminder of how little some medical professionals know about diabetes.

And now (drumroll please) my doctor appeared.  Her first question, as always, was “How are you?”   That can be an ultra-trite question, but I think she asks it to give me the opportunity to set the direction of the appointment which is never long enough to cover everything.  I believe that she would be open to discussing anything whether it be BG numbers, thyroid issues, or mental health.

My concern of the day was my multiple autoimmune/inflammatory issues and wondering if she had any opinions on whether a change in diet (particularly gluten-free) might be beneficial.  She indicated that there is no strong scientific evidence to indicate that a gluten-free diet would make a difference in my health, but anecdotally she has patients who feel that it has made a difference.  She suggested I give it a 3-week trial.

Now is not the best time for a gluten-free trial.  I am dealing with a frustrating skin condition called granuloma annulare (a topic that warrants its own blogpost).  Because I have the disseminated form of GA, I have abandoned topical products and am in the early stages of trying to find a drug that will slow down or eliminate the autoimmune/inflammatory condition.  I see my dermatologist this week and expect that I will be moving to a new class of drugs.  It doesn’t make sense to change my diet at the same time that I change medications because I won’t know if any improvement is from the new drug or the elimination of gluten.  So a gluten-free experiment will have to be put off for a while.  My opinions about going gluten-free are also worthy of a dedicated blogpost and I’ll save those thoughts for another day.

Back to my endo appointment.  I have been frustrated by overnight highs that occur between midnight and 2:00AM.  My endo ignored those and was more concerned FollowUp_Clipboardwith the lows that precede those highs.  I guess that I was aware of the lows but didn’t see the cluster of them the way that she did with her usual expertise at seeing patterns in CGM tracings.  Sometimes I think that I’m too deep in the trees to see the forest.  In my opinion, both the lows and highs are caused by the same thing:  too much after-dinner eating that is not matching up well with my insulin.  She’d like to see me reduce my basal and bolus rates through the evening.  I’d like to see a reduction in post-dinner snacking which is really the cause of both the highs and lows. I am working on the problem and already seeing some improvement.

I didn’t get any comments on my weight gain (!) so it’s back to me to deal with it or not deal with it.  At the very least I don’t want to gain more weight.  My guess is that if I take care of the blood sugar problems from evening snacks, the weight will take care of itself. Imagine that.  Everything is related to everything else.

In summary I survived the appointment.  My thyroid tests were in range and my A1c was much better than expected.  I only see my endocrinologist twice a year so the countdown to December has started.  20 minutes with her.  262,780 minutes with me running the show.

Endo Appointment

Laddie_Head SquareI have an appointment with my endocrinologist this afternoon.

Last week I wrote myself a note to call and postpone this appointment.

I’ve gained about 5 pounds in the last year. I’m thin and that is not the end of the world, but for me this is a big gain. I am now over a threshold number that I haven’t seen in ten or twelve years. My endo is pretty observant and I suspect she is going to notice the pounds. I keep reading research reports that indicate that people who are thin and people who are obese have the worst life expectancy numbers. So I can argue that it is good for me to have gained weight and maybe it is. Or maybe not. Or maybe it doesn’t matter at all. None of that changes the fact that I have gained weight that I am having a hard time losing.

My Dexcom graphs are ugly. I have a 10-year run of A1c’s that I privately take great pride in. But it is rare that I have a blood draw that I don’t think that this is the A1c that will end my streak. We read about hypoglycemia unawareness and hyperglycemia unawareness. Even with Dexcom Studio and Diasend (and previously Carelink), I definitely have A1c unawareness. I don’t have a clue what my report card will reveal. I do know that if I postpone this endo appointment, I can definitely have better results in a week month year.

I have had great success in the last couple of years by reducing the number of carbs that I eat. I strongly believe that diabetes, whether Type 1 or Type 2 is a disease of carb intolerance. I’ve read books like Why We Get Fat by Gary Taubes, Wheat Belly by William Davis, and The Diabetes Solution by Richard Bernstein. These books make sense to me. You need to read these books.

My weight gain is the result of following a low carb diet with plenty of high calorie foods such as cheese and nuts and then eating carbs In addition to that diet. My Dexcom tracings are good during the day. A glass of wine, dinner, and then cravings for nuts and SF Jello with mounds of whipped cream lead to lows at midnight followed by Himalayan spikes at 2:00AM.

But I didn’t cancel the appointment. Avoiding this appointment would be little different than hiding candy bar wrappers in the garbage. Avoiding this appointment would be little different than not testing my blood sugar because I don’t want to see the result.  Endo OfficeAvoiding this appointment would be little different than refusing to step on the bathroom scale. Avoiding this appointment would be hiding and in some ways “lying by omission”.

Not getting an A1c today doesn’t change the patterns of my blood sugar for the past few months. Whatever the status of my health is today isn’t going to change by not printing out my Dexcom tracings or Diasend reports. I am an adult and for better or worse, I need to be accountable for my lifestyle and decisions.

Avoiding my doctor is a slap in the face to her education, experience, and value in my life. She has never belittled me or made me feel guilty. She has always supported me and made sure that I have access to the latest medical technologies and the most appropriate medications. She is my doctor in order to help me live as healthy a life as I can with Type 1 diabetes. How can she help me if I don’t go see her and tell her the truth?  Maybe she will have some suggestions to level out my BG at night so that I can have an occasional CGM alarm-free night. Maybe she will say something to help me get back on the right self-care track. I am starting to have more autoimmune/inflammatory issues and maybe she will have some advice about whether I should give a gluten-free diet a try.

So I am going to see my endocrinologist this afternoon and I think I’ll survive it.