Looking For Root Cause: Suspect Poor Glucose Regulation

[JudiBlueHen]

Tired of taking a scatter-shot approach to improving my energy and health, I'm beginning to suspect poor glucose regulation/metabolism might be one of the Root Causes of my issues. Briefly, I have a history of: PCOS (as a teen), hypoglycemia (GTT "flat curve" ending at 52), insomnia, "nerves"/fatigue, frequent energy slumps, allergies/sensitivities (grass, trees, mold/fungus, fumes), SVT, chronic cough (chest XR clear).

Here are my relevant metabolic test results (newest first):

• HbA1c: 5.5, 5.6
• Fasting glucose: 96, 91 mg/dL
• Adiponectin: 20.6 ug/mL
• Insulin: 16, 18 uU/mL
• HOMA-IR (a calculation): 3.8

Other tests that might be related:

• hs-CRP: 0.5, 0.7
• total cholesterol: 271
• TSH: 5.35 (on 25 mcg T4), 10.96 (while not taking T4) uIU/mL
• Free T4: 1.18, 1.14 ng/dL
• Total T3: 1.0, 1.4 ng/mL
• Serum calcium, potassium, chloride - normal; Mg slightly high at 1.7 mmol/L

FYI I'm a 73 yo female retired engineer - one of the OLD fans of this forum . A recent comment by @yerrag on @haidut post "Simply diluting old blood..." got me thinking along these lines. Appreciate any insights!

 

[Jessie]

TSH and cholesterol is elevated, sign of hypothyroidism and decreased steroid synthesis. The HOMA is high, obviously, and A1c is borderline. This suggests you aren't really utilizing glucose well, which is so to be expected in subjects with hypothyroidism. Your CRP is good, which is an important inflammatory marker for heart disease. It would've been great to know what the HDL was, because HDL tends to be high in people with excess endotoxin.

If you're doing low carb, then my first suggestion would be to bring the carbs back. Because low carb can kill thyroid activity and raise cholesterol too. When you're lost, and you don't know where to start, bacterial overgrowth tends to be a centric issue with people having problems with low thyroid, and/or high cholesterol. It will also keep the stress cycle turned on by a feedback mechanism, which will keep lypolisis perennially elevated which hampers your ability to utilize glucose efficiently.

So, some basic things to address up front would be:

- avoiding low carb diet (150+ grams daily is best)
- bacterial overgrowth (there's several methods to address this, like charcoal for example)
- selenium deficiency? (needed to convert T4 into active T3)
- vitamin A deficiency? (needed along with thyroid to convert cholesterol into steroidal hormones)
- try thyroid (even after everything else is addressed, some people still may need a grain or two of thyroid)

 

[Energizer]

Ray mentioned he didn't know a single person who said they felt well with a TSH over 1 and people reported feeling optimal with a TSH under 1.

 

[JudiBlueHen]

TSH and cholesterol is elevated, sign of hypothyroidism and decreased steroid synthesis. The HOMA is high, obviously, and A1c is borderline. This suggests you aren't really utilizing glucose well, which is so to be expected in subjects with hypothyroidism. Your CRP is good, which is an important inflammatory marker for heart disease. It would've been great to know what the HDL was, because HDL tends to be high in people with excess endotoxin.

@Jessie - thanks! I do avoid low carb - tried it once and couldn't tolerate it. I currently take 25 mcg levothyroxine and still have high TSH - haven't tried T3 yet.

Here are the lipid details

• HDL-C: 74 mg/dL
• non-HDL-C: 197 mg/dL
• Trigs: 134 mg/dL
• Direct LDL-C: 191 mg/dL
• ApoB: 132 mg/dL
• LDL-P: 2008
• VLDL-C: 6 mg/dL
• Lp(a): 43 mg/dL
• ApoA-1: 194.2 mg/dL

 

[james2388]

Daily few ounces of liver. Donating Blood - stimulating EPO. B1, & B2.
IMHO it is so often overlooked that b vitamins are responsible for glucose regulation.
Also pregnenolone, Dhea and prog cant hurt.
Vitamin A is essential for cholesterol conversion.

The thing that now defies modern civilization, is we no longer have to expand calories to obtain them. Thus if you are not 'searching for food' being active in some manor just walking as an example, your metabolism and caloric needs will decrease. Insulin sensitivity will decrease, and you will store fat.

 

[JudiBlueHen]

Ray mentioned he didn't know a single person who said they felt well with a TSH over 1 and people reported feeling optimal with a TSH under 1.

Wow I don't know what I'd have to do to get it that low. My sister had a thyroidectomy and her endocrinologist always wanted her TSH below 1, and it was done with about 100 mcg synthroid.

 

[Energizer]

[TSH (Thyroid Stimulating Hormone)] I think it's best to keep the TSH around 0.4

I think it's good to have TSH below 0.4, and that probably contributes to loss of hair.

I think it's good to have lower TSH. It contributes to some of the circulatory and inflammatory problems seen in hypothyroidism. People with TSH below 0.4 were the freest from thyroid cancer.

Since T3 is used up very quickly, allowing the proinflammatory TSH to rise during the night, it would help if you used Cynoplus at bedtime, instead of Cynomel. If you were taking 10 mcg of cynomel, then a third of a tablet of cynoplus would provide that, as well as the T4 that holds the TSH down longer.

[Less neuropathy and body pains when alternating Armour and Synthroid, low cholesterol] T4 suppresses the pro-inflammatory TSH, without activating the metabolism, so probably spares the cholesterol and other antiinflammatory things. Does she eat enough sugar? Starches and irritating, bacteria-supporting foods increase inflammation and probably interfere with cholesterol synthesis. Custards, sweet fruits, and Haagen Dazs ice cream are safe ways to increase cholesterol.

With your TSH so high, you should probably add a thyroid supplement, until you get it down to about 1.0, or less. (The normal range, according to the American Association of Clinical Endocrinologists, is from 0.3 to 3.0.)

Thyroid is the easiest way to lower TSH, other than thyroid surrogates such as aspirin, coffee, and standard the dietary interventions (which I assume you already do to lower inflammation since you are one of the long time members of the forum). Since you are an older woman I would not presume to know your complex health issues, maybe emailing Raymond could help as he might have more ideas.

Ray Peat Email Exchanges - Ray Peat Forum Wiki

 

[Jessie]

@Jessie - thanks! I do avoid low carb - tried it once and couldn't tolerate it. I currently take 25 mcg levothyroxine and still have high TSH - haven't tried T3 yet.

Here are the lipid details

• HDL-C: 74 mg/dL
• non-HDL-C: 197 mg/dL
• Trigs: 134 mg/dL
• Direct LDL-C: 191 mg/dL
• ApoB: 132 mg/dL
• LDL-P: 2008
• VLDL-C: 6 mg/dL
• Lp(a): 43 mg/dL
• ApoA-1: 194.2 mg/dL

Great, I would suggest having a discussion with your doc about maybe getting Armour or something that at least has both T4 and T3 in it.

In regards to the lipids, the HDL is mildly elevated, typically you see it around the 40-50 range in most people. But this is likely not going to draw any red flags, most docs actually consider a high HDL good.

It also dosen't definitively mean you have endotoxin problems, as certain other things (like infection) can also cause a high HDL, but it's something to take note of. Particularly when you factor it in with the high LDL and TSH.

 

[yerrag]

Hi Judy, continuing on from the thread we came from,

Can you provide temperature, heart rate, oxygen saturation, and urine pH information for a day at wake up, 1 pm, and 5 pm? While your endocrine panel seems to point to hyporthyroid, I'd like to see how these other metrics measure up. I'm trying to minimize on blood testing at this point. I hope you have an oximeter, and urine pH test strips. If not, do you mind buying as these would be very helpful to have. The urine pH test strip you can buy from Amazon - Hydrion pH range 5.5-8.

You have signs of poor blood sugar regulation and poor glucose metabolism - energy swings, allergies, chronic cough.

How long ago was your GTT? Was that a 3hr OGTT or a 5hr one? Do you have the data points and do you have a chart showing the blood sugar curve over time?

As we discussed earlier, I'd like to focus on your blood sugar regulation as improving it, it also means you're improving on your glucose metabolism. If one improves, it's because the other is also improving - we want to turn from a vicious cycle into a virtuous cycle. In optimizing BS regulation, you benefit in more ways than one. You essentially minimize production of 3 stress hormones - insulin, cortisol, and PTH. In so doing, you enable more endogenous vitamin D production as insulin inhibits conversion of cholesterol to vitamin D. In lowering cortisol production from having a steady supply of BS, you protect your thymus from getting smaller, and improve immunity - as the thymus gland is where immune T-cells mature. And in having an ample supply of vitamin D, you're able to get your calcium balance - and this keeps PTH from being produced (with enough calcium intake).

Currently, we need to establish your current blood sugar condition. Are you amenable to getting a 5hr. OGTT? If this is going to be difficult to get done outside, it can be done by yourself, as I've done a few by myself. A blood glucose meter is needed, and a supply of glucose, and a companion, to just be on standby in case you feel like fainting from lowering blood sugar, in which you need to eat bread or sandwich. But if that sounds risky, you can dispense with the glucose, and just use your breakfast or lunch to do a makeshift OGTT. This would still get a blood sugar curve. No matter how imperfect, it would still be better than nothing. HbA1c to me is not helpful. It is literally one-dimensional and has no diagnostic value.

Just for the record of what we discussed earlier, I discussed possible magnesium supplementation, and vegetable juicing to increase potassium stores. I also broached changing the carbs from OJ to brown rice or sweet potato in your meals - to slow down the rate in which glucose is assimilated into your bloodstream after a meal, in order to minimize getting into a blood sugar high after the meal, so as to avoid an insulin spike that will cause your blood sugar to plummet. This change to a fibrous complex carb may be more suitable to your current state of blood regulation, and will keep blood sugar from going through a yo-yo. Having as steady a blood sugar with minimal fluctuation will help ensure an interrupted supply of fuel to your tissues.

Speaking like an engineer, I'd like to get your blood sugar eventually to reach good process control capabilities achieving its setpoint with minimal variation.

 

[JudiBlueHen]

Great - a project!
I have a pulse ox meter (generally runs about 96-97%), will get urine test strips and blood sugar meter. I don't have access to my old 5-hr GTT from about 30 years ago at this time, I just remember that it had only a slight rise after glucose but fell to 52 before the end of the test; Doc called it a form of hypoglycemia.
Recent urine pH 7/17/20 was 6.5, when I was at urgent care for probable kidney stone.

 

[Ledo]

Speaking like an engineer, I'd like to get your blood sugar eventually to reach good process control capabilities achieving its setpoint with minimal variation.

Hi yerrag,

How do you know what good process control is as it relates to glucose getting into the cells. Maybe some cells needed higher glucose spike with short time duration and others need lower magnitude and longer time duration? And maybe the same cells need changing magnitude and duration depending on variables such as activity, time of day - first meal second meal etc, time of day - stress level, and so on.

Sp besides the curve being in control how do we know its optimal shape?

Thanks a lot for championing this subject. I think ultimately continuous glucose monitoring with a dexcom type technology is going be the most helpful thing for people as all their real life activity, as well as things like OGGT can be baselined and optimised.

Maybe this is that secret sauce that "skinny people that eat anything" do automatically.

Edit: Might as well add to weight management any chronic or acute disease management and treatment. Dial in on'es curve for diabetus, CVD, cancer, ...

 

[yerrag]

Great - a project!
I have a pulse ox meter (generally runs about 96-97%), will get urine test strips and blood sugar meter. I don't have access to my old 5-hr GTT from about 30 years ago at this time, I just remember that it had only a slight rise after glucose but fell to 52 before the end of the test; Doc called it a form of hypoglycemia.
Recent urine pH 7/17/20 was 6.5, when I was at urgent care for probable kidney stone.

The oxygenation saturation looks very good. At least we know you have good tissue oxygenation. That checks out with your urine pH reading, although more tests during the day will be needed to confirm that.

Glad your doctor knows how to diagnose for hypoglycemia. I had my primary care doctor write me up for a 5hr OGTT. Results came back and he said my blood sugar was fine. I had to check for myself. Graphed the data points into an x-y chart and drew a curve. Compared to a book, and I diagnosed myself as hypoglycemic. The doctor, as usual, was comparing me to the general US population, and I was "normal" being that I'm inside the bell curve. That was my initiation into the reality of the medical world.

You still need some maltose for your glucose. If you plan on doing a real 5 hr OGTT:

https://smile.amazon.com/Maltose-14...hild=1&keywords=maltose&qid=1597630920&sr=8-2

 

[yerrag]

How do you know what good process control is as it relates to glucose getting into the cells. Maybe some cells needed higher glucose spike with short time duration and others need lower magnitude and longer time duration? And maybe the same cells need changing magnitude and duration depending on variables such as activity, time of day - first meal second meal etc, time of day - stress level, and so on.

Good process control is about having the main variable staying with the limits. If the process is optimal, it will have good tolerance, meaning it does not fluctuate much. If the tolerance is good, the variability will be even tighter than what the limits allow.

In the case of our body, the blood sugar we use for the test reflects a systemic state as exhibited by blood, which is the same blood the whole system uses. If we get from the fingers the blood, we always get from the fingers, though not necessarily the same finger as that's not necessary. If there are some cells needing higher glucose and some cells needing less, the systemic nature of the blood test doesn't require drilling down to such detail. The cells and tissues and organs don't change their behavior, unless we intentionally seek to change them - within the same environment and within the same time space in time. We are also talking about taking blood sugar in a state of rest. As for the variables you mention such as time of day, it is not as significant and it is assumed we do this during the day. With engineers, this is called value engineering. We don't build features buyers don't need that increases the cost, which would increase the price, and make us uncompetitive.

For the same reason, I eschew the use of HbA1c to measure blood sugar health. I take the trouble to take more than one data point - in a 5 hour OGTT I need a minimum of 6, and I use 5 hours for the test, whereas an HbA1c requires a split second of time. It is worth taking the extra time and effort because the data I get is much more useful. Instead of a one-dimensional value, I get a two-dimensional curve that helps me in determining the state of my blood sugar regulation, and not only that, it helps me troubleshoot the cause of sub-optmality in blood sugar regulation.

Sp besides the curve being in control how do we know its optimal shape?

This is an explanation of how I used an OGTT:
Anti-Peat - Saturated Fat TERRIBLE For Liver Health & Diabetes. Compared To PUFA

I think ultimately continuous glucose monitoring with a dexcom type technology is going be the most helpful thing for people as all their real life activity, as well as things like OGGT can be baselined and optimised.

That is helpful to have, as long as one has the means and is willing to spend for it, or if insurance pays for it, is willing to have something stuck under the skin for that purpose.

I personally think there are simpler ways to get that done. That approach maximizes on the data-centricity of it, but what's more important is how well you use that data. I prefer to maximize on the quality of the analysis of data. Data is good, but data is like ice cream. At a certain point, you reach a point of diminishing returns.

Maybe this is that secret sauce that "skinny people that eat anything" do automatically.

I think so. The stability of sugar supply to the body is like having a good supply of gas to your vehicle. Imagine having an engine that sputters. It still runs, but don't you just hate it?

Edit: Might as well add to weight management any chronic or acute disease management and treatment. Dial in on'es curve for diabetus, CVD, cancer, ...

A good part of a good physician's toolkit, I should say.

We won't go back to a mechanic who doesn't know how to make your car engine running smoothly. If he doesn't know how to fix the reliability and consitency of gasoline being fed to the engine, he is toast. Funny though, that we don't apply the same level of scrutiny and discrimination to our doctors.

 

[JudiBlueHen]

I bought a blood glucose monitor and began some random testing. Here are the measurements so far, over the course of about 4 days:

• fasting >4 hrs: 91, 95
• <= 1 hour after eating a meal: 144, 147, 160
• >1 hr and <4hr after a meal: 96, 100, 103, 104, 114, 121, 122, 127, 130, 133

So nothing is actually low - perhaps I have outgrown hypoglycemia, and am now tending toward insulin resistance? These numbers look generally a bit high.

 

[yerrag]

I bought a blood glucose monitor and began some random testing. Here are the measurements so far, over the course of about 4 days:

• fasting >4 hrs: 91, 95
• <= 1 hour after eating a meal: 144, 147, 160
• >1 hr and <4hr after a meal: 96, 100, 103, 104, 114, 121, 122, 127, 130, 133

So nothing is actually low - perhaps I have outgrown hypoglycemia, and am now tending toward insulin resistance? These numbers look generally a bit high.

Good that you started with it.

Since you're eating a meal instead of using the maltose, it's actually safer to do. But we can get more useful data if you took six readings instead. 1st reading before meal, then the 2nd reading 1 hour after meal (don't take too long with the meal though), then the 3rd to 6th every hour thereafter.

Then we can chart it in an z-y chart with the time in the x-axis, and the glucose reading in the y-axis.

Please take note what your meal consists of as well.

 

[JudiBlueHen]

Will do. Any recommendations on the substance of the meal? mostly carbs or mixed P/C/F?

 

[yerrag]

Will do. Any recommendations on the substance of the meal? mostly carbs or mixed P/C/F?

I think what you usually eat will be a good start.