Diabetes Mellitus Type II is the physiologic state in which the body’s fuel tanks become unable to hold additional fuel. Each time a person with diabetes consumes more fuel in the form of carbohydrates and fats, the excess fuel spills into the blood stream in the form of glucose (sugar) and triglycerides (fatty acids). The glucose sticks to places it doesn’t belong, including red blood cell (RBC) membranes. This process is called “glycation”. Every year, your doctor measures the degree of RBC membrane glycation using a blood test called Hemoglobin A1c; HbA1c for short.
If your HbA1c is less than 5.7%, you’re “normal.” If it’s between 5.7% and 6.5%, you have “pre-diabetes.” If you’re over 6.5%, you have diabetes.
But, what if I told you that these thresholds are not based on prevention or early diagnosis, but on the prevalence of diabetic complications like retinopathy; that HbA1c is not a reliable metric; that HbA1c reflects average glucose, but not glucose peaks; that physiology doesn’t care about man-made lab thresholds, and that in many cases, metabolic health deteriorates long before HbA1c passes 5.7%? The detection of poor metabolic health is essential to preventing its downstream effects: the development of chronic diseases, disability, and ultimately death.
For this reason, I am a proponent of monitoring glucose using a continuous glucose monitor (CGM) even in people who do not meet the conventional diagnosis of diabetes. In fact, I encourage all of my clients to use a CGM at least once so they can see real-time glucose measurements for themselves.
It won’t come as a surprise to anyone who knows me that my thinking on this has been influenced by Dr. Peter Attia. His most recent “Ask Me Anything” podcast is on the topic of continuous glucose monitors and glucose control. Here are some highlights from the podcast, which I highly recommend you listen to:
Listen to Dr. Attia’s episode here for a more complete and rigorous discussion with examples and citations from medical literature and from his unique longevity medicine practice.
Amazon Unbound by Brad Stone. This book is about Amazon and its CEO Jeff Bezos. It takes you behind the scenes of Amazon’s corporate culture, business decisions and innovations, and into the mind of its genius CEO. I am finding the stories fascinating and inspiring. For example, Stone reveals in impressive detail the decade’s long effort to create the Amazon Echo (aka Alexa), a journey which started with Bezos sketching the device on a whiteboard in his office. A copy of the sketch is included in the book. If you’re looking for creative and productive inspiration, I highly recommend this book.
Every Patient Tells a Story by Lisa Sanders, MD Lisa Sanders is a physician, author of several books, and the NYT column titled “Diagnosis.” She was also the primary medical consultant for the show House. Her book contains thoughtful reflection on the diagnostic process. She shares cases that many people will find thrilling, medical professional or not.
One such case that appears early in the book is about a college age girl who becomes critically ill. Nobody in the hospital can make the diagnosis, so the team calls the head of the department of medicine, Dr. Walerstein.
It was early evening by the time Walerstein had a chance to see the patient. He didn’t read her chart. He never did in tough cases like this. He didn’t want to be influenced by the thinking of those who had already seen her. Far too often in these difficult cases something has been missed, or misinterpreted. And even if they had collected all the pieces, they had clearly put the story of this illness together incorrectly. Instead he went directly to the patient’s bedside.
Walerstein interviews the patient and scours her chart before concluding (in a flash), that she must have a rare disease of copper metabolism called “Wilson’s Disease.” He wants to confirm the diagnosis, but doesn’t have access to the relevant lab test.
But there was another way to diagnose this disease. Patients with Wilson’s will often accumulate copper in their eyes—a golden brown ring at the very outermost edge of the iris. Walerstein hurried back to the ICU. He carefully examined the girl’s eyes. Nothing. He couldn’t see the rings, but maybe an ophthalmologist with his specialized equipment could. “It’s not often that you call the ophthalmologist at nine p.m. on a Friday” to do an emergency examination, Walerstein told me. But he related the girl’s story one more time—this time with a likely diagnosis, if only he could confirm it.
His diagnosis was right, and the girl’s life was saved by the geniuses of transplant medicine who gave her a new liver.
I read stories like this to keep unusual diagnoses fresh in my mind, but also to understand the diagnostic process of expert physicians.
I was glad to learn of Walerstein’s predilection for proceeding straight to the bedside before reviewing the chart. This is something that I do as well, and it’s nice to see this practice validated by someone more experienced and expert than I.
I also made special note of Walerstein’s practice of thinking in first-principles. I left out the relevant excerpt, but it was clear in the book that instead of becoming distracted with the details of specific tests or symptoms, Walerstein backed up to ask, “what is the fundamental problem?” The first step in his mind was to realize: it’s the liver. The liver is the problem. Once he picked this as the primary issue, he was able to think systematically about liver problems. This is a powerful way of thinking, one that I’m glad to be reminded of by this master, and one that ultimately led him to the diagnosis.