T2 or NAFLD? ...or, a funny thing happened on the way to the surgery

[HSSS]

@RachelG. you might be interested in this https://www.hughcalc.org/chol-si.php tool that assesses your results. The reason your total cholesterol is a little high is because your HDL is higher than many have and that’s a good thing. Your trigs are good too. I’d be happy with those results personally

 

[Chris24Main]

What I was dropping in to ruminate on, much of my focus has been on insulin, and what insulin resistance may be. (no, really...) Honestly, I thought I had it nailed in the first couple of weeks, but I look back now as if I was a schoolkid who had figured out maths, because all you need to do is count your fingers.

One aspect of insulin, is that any elevation of insulin levels should down-regulate Ketone production. This is fundamentally why Ketoacidosis is so dangerous; if there isn't any insulin (in the case of T1) then there is nothing to regulate Ketone body production, and you get too much circulating in the blood, along with too much glucose.

Turning that on it's head, any strategy to reverse insulin resistance should show a slow increase in the average ketone levels, as well as a gradual reduction in the amount of fasting blood glucose. Minute-to-minute control of blood glucose we all know about, but if your body is becoming more sensitive to insulin, then it should be requiring less to do the same job. Also, the fasting glucose level should be gradually dropping because your body is gradually getting used to not needing to produce as much glucose to get you going in the morning. (this, I should stress is my interpretation, not medical fact).

A quick aside here - why do we use the term "glucose dump" when we talk about the liver breaking down stored glycogen? - It implies something negative and ... like the liver is doing something it knows is a bit naughty - it's only reacting to the balance of hormones, so if you want to change the outcome, change the balance...

Anyway - so my thing was to measure ketones and blood glucose first thing in the morning and see if there was a trend. Forget the absolute measurements - (different ways of measuring and totally different units) but is there a trend?

to cut to the chase - over three months or so, that's exactly what I'm seeing:
Blue line (average ketone trend) is rising slowly over time.
Red line (average fasting glucose trend) is dropping slowly over time.

This overall should mean that my dawn phenomenon is slowly reducing (this is always before I eat anything) and at the same time, is kind of a measure of becoming more and more "fat adapted".

 

[Chris24Main]

Wanted to take a bit of a detour.

Well before I could even tell the difference between Type 1 & 2, in fact before the dark days of COVID, I read what in retrospect was the first book to tip me into the pain in the proverbial know it all I am today... "Why we sleep" by Dr Matthew Walker. Unbelievably, this was simply a case of having an Audible token I needed to use up in a hurry, and I'd always been interested in dreaming.

To cut a long story short - my sleep patterns have been totally different ever since - I never valued sleep, but now I'm tucked in before 11 pretty much without fail, and I stopped having coffee past early afternoon, and in some ways that was my first step to giving up my lifelong pursuit of happiness in a bottle.

I won't even try to get into the details - though I would utterly, utterly recommend it; suffice to say I was shocked at the data on inflammation, infection rates, likelihood of cancer and aggressiveness of growth, and certain mental capabilities, relating to short term memory and mood fluctuation.

Now - the science really is fascinating - much of the work is all new, based on people trained in lucid dreaming (being aware of dreaming, while you are dreaming) while undergoing MRI scans during different phases of sleep - you can actually map the path of packets of information around the brain - amazing stuff. Anyway - I say that only to stress that this is a book focused on the function of the brain.

- and as an aside - this week (this will sound like science fiction, but it really is true) was the first recorded passing of information between one dreaming person and another in a different place - truly astounding, but a little tangential.

anyway - as I dig into more and more metabolic literature, I'm struck by how many of the effects of lack of sleep overlap with the effects of chronic high blood glucose and insulin resistance. Just so many parallels that - I thought - there has to be a connection, and sure enough, there is.. or at least a review of a few studies suggest a strong association and a few causal links.

On the one hand, lack of sleep is one of the things that can drive IR at a cellular level, but the reasons why are fairly complex.

On the other - it's another balance thing - The main reason for sleeping is to allow the body to heal and repair. In fact, you can argue that we evolved asleep long before we further evolved to wake up.. and now we live lives in two states - the time when we are awake (and under control of our frontal cortex - the "here and now" part of our brain) which we value and tend to want to make the most of, and feel like we're wasting our time if we don't get more... and the time when we are asleep, and under control of much older parts of the brain, during which we encode long term memory, and allow the rest of the body to undergo healing. If you don't get enough, and good quality of the latter, eventually you affect the former.

.. and to some extent that mirrors the way we (I, certainly used to) think about lifestyle and food - we just don't value the time we spend "not eating" enough, we value the time we spend doing and eating, and give little thought to "not eating" as a positive thing - but we are designed to be using that time healing and repairing in just the same way. Carbs play a part in this, because we end up (at a cellular level) running around like a headless chicken trying to deal with all the excess glucose.. filling up all the time with snacking, and of course that can affect sleep directly, but I don't mean to be that clumsy; it's more about realising the value of the downtime itself - we need to give the body more time to be in healing and repair mode because over time we get run down in exactly the same way; at the most basic level, and the science is catching up and presenting us with more and more evidence of exactly how things go wrong when we do the equivalent of thinking we can get away with partying all night for ever...

 

[Melgar]

I take sleep seriously. It’s all quantified on my Fitbit. I’ve however, stopped obsessing over my sleep as that too can have a detrimental action. I try and get to sleep between 9-10pm. I have cut out all caffeine, I don’t drink, well I did have wine when at my brothers, but now I’m back, no alcohol. I eat before 6pm. I pee a lot at night. So 3-4 times I’m in the bathroom. It doesn’t seem to affect my sleep score, which hovers between 75 - 83.

My body has had to deal with jet lag, going through 8 time zones and back again, the effects on my body is striking. So it’s my circadian rhythms that have been messed up. I was of course dealing with COVID while in the UK, although I was asymptomatic. I was mildly tachycardic for the entire time I was in the UK. My blood sugars were raised, like they were over 10mmol/ls during the night. It is difficult to quantify the effects of disrupted sleep because of the COVID, however, I’m now COVID negative, but I see that my RHR is about 10 beats per minute faster. I find it more challenging going West to East than East to West.

So sleep disruption, in my view, does affect your body clocks. As you know @Chris24Main circadian clocks are present throughout your body and in particular , your pancreas and your liver have cellular circadian clocks as well as the master circadian clock in your brain (hypothalamus). So there are so many processes that are affected due to disrupted sleep patterns, all influencing metabolism. The liver is under circadian control, a point of importance. I will attach an article called ’Reviews in Basic and Clinical Gastroenterology and Hepatology’ , ‘Circadian Clock Control of Liver Metabolic Functions’ by Hans Reinke and Glad Asher, an interesting read . I’m thinking this article will be right up your alley. I certainly enjoy reading about the circadian clocks and the body. The liver’s interrelationship with food intake and the liver’s circadian clock and how these clocks are intrinsically intertwined with a person’s feeding cycles are very apparent. So glucose control by the liver, and of course the pancreas brain, and skeletal muscles provide a baseline for homeostasis. Circadian clocks provide a broad basis by which we set our daily feeding patterns , we eat during the day and starve during the night. Therefore, insulin production / secretion and glycogen secretion are impacted by our circadian clocks.
Have a read.

https://www.gastrojournal.org/article/S0016-5085(15)01725-4/fulltext

 

[Chris24Main]

Ah - great to see you back to top form @Melgar - You're spot on, and yes, I look forward to reading that article.
For what it's worth - I had the very first Fitbit, or at least their very first batch of the first product that was designed for wearing on a wrist - I had to wait for them to get CE marked - it was a whole thing, but they used Nickel in the band, and I had a reaction to that, so I'm all in on Withings now - so my sleep is monitored both by watch and a sleep mat that sits under the mattress...
Which I'm sure is no surprise at all...

 

[Melgar]

Funny, I changed my fitbit rubber strap because it annoyed me, so I have an array of coloured cloth straps now, the colour I chose will depend on my mood. Mine was a gift. It’s never off my wrist. I like having a window into my bodily stats mind the mat under your mattress sounds impressive.

 

[Chris24Main]

So - quick one from last night - this is the kind of detail you get - dark blue is deep sleep, and light is REM, the grey being awake. This often matches with direct observation, so last night I had a reasonably disturbing dream very early morning which I awoke from, and didn't really get great sleep afterwards - that's exactly what the graph shows.

Where it gets interesting from a metabolism perspective, is that you can see the corresponding heart rate (being woken up by my wife's alarm for example) but also during dreaming cycles. When I was wearing a CGM, this would also track with glucose drops. Not a great deal of deep sleep last night, and my fasting glucose was higher than it's been, and much lower ketosis.

Interestingly, the mat also monitors sleep apnea and snoring (can distinguish your breathing from your heart beating - very cool tech) - and I've more or less stopped snoring since giving up carbs - who knew?

Back to your article - still digesting, but to add to it, from a sleep management perspective, the circadian cycle is only one mechanism (like our inner ear isn't the only way we balance) - you have a another based on light (which is why using blue-light filters in the evening is so important, and alarm lights are so much better than alarm bells) and melatonin; which works like a Japanese water fountain .. you gradually fill up through the day, building up sleep pressure, then it drains away when you sleep, but is blocked amazingly well by caffeine, even 8-10 hours after a coffee - which is why no afternoon coffee. All being well, the three cycles peak at the same time, and you fall straight asleep -

but - yeah - this is really why almost everything related to sleep hygiene starts with - regularity is king.

I'm also just again struck at how complex the liver is. Just incredible.

 

[RachelG.]

This is all very interesting. I did a genetic test earlier this year- probably not very sophisticated as testing goes but it picked up I am a strong night owl, napper and not sensitive to coffee which describes me very well! I am generally a good sleeper if I can more or less dictate when I have to wake up and there's no noise at night. Luckily I'm self employed so most of the time I set my own hours.

I haven't noticed much difference in blood sugar levels after less sleep than normal, for me the unexpected thing was being on my period, the levels were up significantly for the whole time and I had spikes to about 15 mmol/L after eating a small bowl of egg pasta with pesto, have never had that big a spike before. Sorry you can't compare @Chris24Main!

 

[Chris24Main]

Yep - you have me there - that's the one area of hormone balance I'll never have any experience of...

 

[Chris24Main]

I haven't noticed much difference in blood sugar levels after less sleep than normal.

Yeah - so I did make that comparison, but I don't think I can make the data stick over the longer term; as far as sleep quality versus fasting glucose goes, it's just too complicated and there are so many variables - underlying stress being the most obvious.

[though - as I write that, I realise that for an n=1 study, I already have the data over a few months, maybe I should plot it and see...]

It's safer to say (I think, and as usual, this is an opinion, not fact) that sleep quality has a relationship directly with insulin resistance, so that over time, your (my) blood sugar in fasted state will be lower because there is a lighter touch on the tiller -

What the hell do I mean by that? - well, more simply put; better quality sleep means a more rested repaired and healed body and mind, so more effect can be achieved with less. Less meaning less hormone (including insulin).

The more subtle thing of course is that it's all inter-related on a much more obvious basis. If you have a good night sleep, you will be more likely to actually go for that walk, or follow through on that decision, or finish that report that's been hanging over you, and cook the meal you planned to; and so on..

Lack of sleep also leads directly to a craving for specifically sugary foods, interestingly enough. That directly from Matthew Walkers book, though again, I think we could now translate that into driving insulin resistance, which drives hormonal craving for sugar.

 

[MrsA2]

and I've more or less stopped snoring since giving up carbs - who knew?

More likely connected with weight loss. My husband's snoring stopped after a low calorie diet (and keeping the weight off), and only resumes if he drinks too much beer...!

 

[Chris24Main]

Yeah, I lost 3 stone on a calorie restricted diet, and that made not the slightest bit of difference.
I haven't technically lost any weight since being first diagnosed.. I put a bunch on taking insulin, then lost it all again when I switched to low carb. Other than that I'm currently exactly the same weight I was a week before being diagnosed.

The scientific reason is actually pretty simple. Your tongue becomes insulin resistant much like everything else, therefore has too much glucose.. too much glucose means too much water (this is the same mechanism behind blood pressure). Too much water means your tongue is bigger than it should be, and thus it flaps around blocking the back of your throat when you're asleep.

Cut the carbs, and you loose a lot of water weight, including in your tongue. I'm not going to argue on the drinking, except that the drinking is more (as relates to this) about the sugar than the alcohol. In my opinion, of course..

I can only really speak for myself.. but cutting carbs was like switching off the snoring button (according to my sleep mat... just asked my wife, and she does put it down more to stopping drinking, so maybe I am putting too much on Ben Bikman on this one... )

 

[Wilbach]

Amazing story, helps so much with my difficulties. Still confused about Metformin. Using a CGM, Metformin my glucose levels were high 10-12 nearly all the time. Now my doctor has put me on Metformin and linagliptin and has gone down to 8-9 but still not low enough. Never will I persuade him to stop Metformin! If I ask him to separate the drugs will the effect be greater if I take linagliptin by itself? I am on strict keto but certainly not feeling any better, feel lousy to be honest. He tried to put me on jardiance- does the heart good! I have had five stents a year ago, never obese but have lost weight, BMI 24, 76 years, neuropathy clicking in, eyesight blurred etc. any advice suggestions most appreciated.

 

[Wilbach]

Should I stop those two drugs and see what happens? Maybe worth trying with your explanation of Metformin.

 

[Wilbach]

Originally taking Metformin with consistently high levels of glucose, explains a lot and probably explains my deteriorating condition but perhaps it is just old age!

 

[Wilbach]

Interestingly my glucose levels dip around am, god knows why?
Will stop these drugs and berberine which may act like Metformin. I will be cross (delighted)if my glucose levels drop to “normal” levels. We shall see in the next few days what the CGM says.

 

[RachelG.]

What the hell do I mean by that? - well, more simply put; better quality sleep means a more rested repaired and healed body and mind, so more effect can be achieved with less. Less meaning less hormone (including insulin).

The more subtle thing of course is that it's all inter-related on a much more obvious basis. If you have a good night sleep, you will be more likely to actually go for that walk, or follow through on that decision, or finish that report that's been hanging over you, and cook the meal you planned to; and so on..

Lack of sleep also leads directly to a craving for specifically sugary foods, interestingly enough. That directly from Matthew Walkers book, though again, I think we could now translate that into driving insulin resistance, which drives hormonal craving for sugar.

So this all totally makes sense but as usual, I feel it's describing more the population as a whole than me! I get above average levels of sleep and absolutely do get the exercise, cook the meal from scratch etc (ADHD means I can't really deal with desk based jobs as I'm driven to move around a lot which is bad for earning money but good for health!). I do wonder if I actually have insulin resistance though or just a deficit of insulin. God knows why I'd have become resistant to it, none of the explanations really make sense for me.

I decided to buy a body composition scale, both to see what would happen if I lost weight within the normal range and also to see what insight it might have about being TOFI/'skinny fat'. So far my visceral fat is 5 (0-9 is okay, 10+ is high) but I am in the high range for muscles (I already knew that!). So not amazing visceral fat level but not bad. And I think the TOFI theory is meant to be where you lack muscle mass. I'd like to try to reduce the visceral fat and see if that has an effect on my hba1c though.

 

[Melgar]

So this all totally makes sense but as usual, I feel it's describing more the population as a whole than me! I get above average levels of sleep and absolutely do get the exercise, cook the meal from scratch etc (ADHD means I can't really deal with desk based jobs as I'm driven to move around a lot which is bad for earning money but good for health!). I do wonder if I actually have insulin resistance though or just a deficit of insulin. God knows why I'd have become resistant to it, none of the explanations really make sense for me.

I decided to buy a body composition scale, both to see what would happen if I lost weight within the normal range and also to see what insight it might have about being TOFI/'skinny fat'. So far my visceral fat is 5 (0-9 is okay, 10+ is high) but I am in the high range for muscles (I already knew that!). So not amazing visceral fat level but not bad. And I think the TOFI theory is meant to be where you lack muscle mass. I'd like to try to reduce the visceral fat and see if that has an effect on my hba1c though.

So, @RachelG. I do not produce enough insulin and my C-peptides are low normal so I‘m thinking that I do not have an insulin resistance problem, else I would be producing a lot more insulin, and correspondingly, my C- peptides would be higher. I keep my blood sugars in check with work outs. I do around 25,000 - 30,000 steps a day, plus resistance training. I’ve had some high night time blood sugar readings recently, not sure why. Yes TOFI is a thing. It depends on where your body decides to store excess fat. In TOFI the fat tends to congregate around your organs and belly region, adding IR into the mix. For sure poor muscle mass can affect your blood sugars , not surprising really as your skeletal muscles use up to 70% of your blood glucose.

I’m going to get my C-peptides checked again as it was a while back I had them tested. If your insulin production is significantly compromised, for what ever reason, then any slight rise in insulin resistance will affect your blood sugars. There are some interesting research papers on ’lean’ diabetes on line.

 

[Melgar]

My other half suffers from sleep apnea. They are seeing a specialist , apparently it means surgery to correct a deviated septum. Luckily, I don’t have sleep apnea.

 

[Chris24Main]

@Wilbach - sorry for the lack of reply - you understand that nobody on the forum should ever try to diagnose anyone else or suggest changes in medication. This thread in particular has become kind of a safe space for those interested in digging deeper into some of the science, to try to find out if we can learn together - But I have to keep stressing that this is all learning on the go - I certainly do not have any medical credibility, and you should take nothing here as medical advice.

That said - Metformin is an interesting medication. It originated as a natural compound, so the simple truth is that it's effective at lowering blood glucose, and I think most would agree that it does so with the least amount of side effects, but nobody really knows all the ways it affects the body. One of the biggest ways that it does seem to work is by interfering with the process that has the liver break down stored sugars - so that there are less in the blood. That is good from a blood perspective, but my starting point was that I wanted to reduce the fat in my liver, so anything that was going to block it from working as it wanted to may go against my plan...

But - I had been using a CGM for many months at that point, and I was very finely attuned to my blood sugar in different scenarios, and I felt confident that fasting was going to be more effective than Metformin, and I set out to prove it to my GP. In the end my GP was happy, but my situation is not the same as yours.