The goal in the treatment program laid out in this book is to give you the tools and the knowledge to take control of your disease by normalizing blood sugars. My interest is not just in treating the symptoms of diabetes, but in preventing or reversing its consequences and preserving pancreatic beta cell function. Essential to treatment is learning to monitor your own blood sugars.
Before you begin to monitor and then normalize your blood sugars, you should ideally have a baseline analysis of your disease. How much have your beta cells “burned out” in part from high blood sugars? Have you already developed some easily measured long-term complications of diabetes? What are your risks for other diabetic complications?
Answering these questions will aid you and your doctor in learning the extent and the consequences of the disease. Your test results will also serve as valuable baseline data to which you will be able to compare the effects of blood sugar normalization. Once your blood sugars have been normalized, such tests can be repeated from time to time, to show what you’re achieving. Your improvements will give both you and your physician ongoing incentive for sticking to the program.
The remainder of this chapter describes a number of tests your doctor’s laboratory can perform in order to give both of you a picture of your diabetic condition. I have laid these out not because it’s necessary for you to memorize them, research them, and know all the ins and outs of them, but so that you may be more likely to get the treatment you deserve. By outlining these tests, I’m giving you a “shopping list” of tests I perform on myself and on my patients.
Generally, I recommend as many as you can afford or your insurance or health maintenance organization (HMO) will pay for. Completing more of the tests will add more dimensions to the picture you gain of your disease. As some of these tests are costly, any or all may be skipped if you cannot afford them or if your insurance or HMO won’t pay for them.
It is your physician’s obligation to provide you with copies of all your test results, whether from laboratory tests or from physical examinations. This is your right; however, you must request them. The laws governing medical records vary state by state, and legislatures are listening to health care consumers and making changes regularly. At this writing, however, it is most often the case that medical records are the property of the provider, so do not neglect to request copies of any results. Such results can be potentially of great value when you visit another physician or specialist for treatment of any problems.
Glucose binds to hemoglobin (the pigment of red blood cells) when new red cells are manufactured. Since the average red cell survives about four months, the percentage of hemoglobin molecules that contain glucose (HgbA1C) provides an estimate of average blood sugar over this time frame. One of the benefits of this test is that it gives your physician an index by which to test the accuracy of your own blood glucose self-monitoring results. If your measurements are strictly normal but your HgbA1C is elevated, then your doctor has a clue that something is awry.
There are, however, a couple of significant drawbacks to this test. First is that the test is only a measure of average blood sugars. Second, elevated blood sugars may take 24 hours to have any long-term effect on HgbA1C, and if blood sugar is elevated for only part of each day and is normalized or too low the rest of the time, your HgbA1C results may appear deceptively low. Thus, if your blood sugars are only elevated for a few hours after meals, your HgbA1C may not be affected, but many tissues and organs throughout your body will be injured.
The other drawback is that the upper and lower ranges of “normal” values reported by most labs are usually erroneously high and low, respectively. In other words, the ranges are usually much too wide. Thus, it’s up to your physician to decide, based upon his experience, what the proper normal range for his lab should be. Some doctors have their own formulas for estimating average four-month blood sugar levels from HgbA1C. A normal value should correspond to blood sugars of about 75–86 mg/dl. The experience I’ve had with the lab I use (the largest in the United States) for my patients is that a truly normal HgbA1C ranges from 4.2 percent to 4.6 percent, which corresponds to blood sugars of about 72–86 mg/dl. A recent study of “nondiabetics” showed a 28 percent increase in mortality for every 1 percent increase in HgbA1C above 4.9 percent.
Because the blood contains more recently made red cells than older ones, recent blood sugars have more of an effect on HgbA1C than do earlier blood sugars. The test value therefore levels off after about three months. Any ailment that hastens red blood cell loss will cause a deceptive shortening of the time frame reflected by the HgbA1C. Such ailments include liver and kidney disease, blood loss, hemoglobinopathies, et cetera. High doses of vitamins C and E can cause a deceptive lowering, and low serum levels of thyroid hormones can cause an increase without increasing blood sugars.
C-peptide is a protein produced by the beta cells of the pancreas whenever insulin is made. The level of C-peptide in the blood is a crude index of the amount of insulin you’re producing. The level is usually zero in type 1 diabetics, and within or above the “normal range” in mild type 2 obese (insulin-resistant) diabetics. If your serum C-peptide is elevated, this would suggest to your physician that your blood sugar may be controllable merely by diet, weight loss, and exercise. If, at the other extreme, your C-peptide is below the limits of measurability, you probably require injected insulin for blood sugar normalization. C-peptide measurements, to be most significant, should be checked after an 8-hour fast when blood sugars are normal. The test can be best interpreted if blood sugar is measured at the same time, because in nondiabetics high blood sugars cause more insulin (and C-peptide) production than do low blood sugars.
This test, while of interest, is not absolutely necessary.
Part of most medical workups, this is a routine diagnostic test that can disclose the presence of ailments other than diabetes. A CBC measures the number of various types of cells found in your blood—white cells, red cells, and platelets. A high level of white blood cells, for example, can disclose the presence of infection, while too few red blood cells can indicate anemia. Many diabetics have inherited thyroid dysfunction, which can cause low-normal to low white cell counts. A white cell count less than 5.6 suggests that a full thyroid profile should be performed. This must include free and total T3 and T4.*
A CBC can also detect certain hematologic malignancies, which are usually more effectively treated the earlier they are discovered.
This battery of twelve to twenty tests is part of most routine medical examinations. It includes gauges for such important chemical indicators of health as liver enzymes, blood urea nitrogen (BUN), creatinine, alkaline phosphatase, calcium, and others. If you have a history of hypertension, your doctor may want to add red blood cell magnesium to this profile.
This is a measure of total body iron stores. Although usually used for diagnosing iron deficiency anemia, high ferritin levels can cause insulin resistance and type 2 diabetes. Sometimes this form of diabetes can be treated by diet, exercise, and regular blood donation.
Although serum albumin is usually included in the blood chemistry profile, it is not widely appreciated that low levels are associated with double the all-cause mortality of normal levels. It is thus very important that patients with low serum albumin receive further tests to determine the cause.
Globulins are antibodies produced by the immune system. They help the body to fight off infections and malignancy. If you experience frequent colds, sinusitis, diarrhea, cancer, or slow-healing infections of any type, you may have an immunoglobulin deficiency. If your total serum globulins are low or even low normal, you should be tested for specific immunoglobulins, such as IgA, IgG, and IgM. We recently published evidence that at least 19 percent of diabetics have an inherited immune disorder (common variable immunodeficiency, or CVID) that may be treatable.
This is a battery of tests that measure substances in the blood that may predispose you to arterial and heart disease.
IMPORTANT NOTE: Sometimes, long before or even months to years after a patient has experienced normal or near-normal blood sugars and resultant improvements in the cardiac risk profile, we might see deterioration in the results of tests such as those for LDL, HDL, homocysteine, fibrinogen, and lipoprotein(a). All too often, the patient or his physician will blame our diet. Inevitably, however, we find upon further testing that his thyroid activity has declined. Hypothyroidism is an autoimmune disorder, like diabetes, and is frequently inherited by diabetics and their close relatives. It can appear years before or after the development of diabetes and is not caused by high blood sugars. In fact, hypothyroidism can cause a greater likelihood of abnormalities in the cardiac risk profile than can blood sugar elevation. The treatment of a low-thyroid condition is oral replacement of the deficient hormone(s)—usually 1–3 pills daily. The best screening test is free T3 as measured by tracer dialysis. If this is low, then a full thyroid test profile should be performed. Correction of the thyroid deficiency inevitably corrects the abnormalities of cardiac risk factors that it caused. TSH, the inexpensive thyroid test performed by most physicians, does not correlate as well with symptoms of hypothyroidism as free T3. My goal with these patients is to use supplemental T3 and T4 to get free T3 and free T4 to the middle of the normal range.
Lipid profile. This profile measures fatty substances (lipids) in your blood and includes total cholesterol, HDL (high-density lipoprotein), triglycerides, and “real” LDL (low-density lipoprotein). Other cardiac risk factors (discussed below) include C-reactive protein, fibrinogen, lipoprotein(a), and homocysteine, and may be more predictive. Abnormalities indicated by these tests are frequently treatable and tend to improve with normalization of blood sugars.
These tests should be performed after you have fasted for at least 8 hours. The easiest thing is to have them scheduled in the morning. If you haven’t fasted before the test, the results will be difficult to interpret.
Maybe you’ve heard of “good” cholesterol and “bad” cholesterol?
Well, this is why a reading for total cholesterol by itself won’t necessarily reflect cardiac risk. Most of the cholesterol in our bodies, both good and bad, is made in the liver; it does not come from eating so-called heart attack foods. If you’ve eaten a meal that’s high in cholesterol, your liver will adjust to make less of the “bad” cholesterol, LDL. Serum triglyceride levels can vary dramatically after meals, with high-carbohydrate meals causing high triglyceride levels. Some people—because they’re obese or have high blood sugars or are genetically predisposed—make more or dispose of less LDL than they should, which can put them at a higher risk for cardiac problems. High levels of LDL are thought to increase the risk of heart disease, which makes LDL the “bad” cholesterol. HDL, on the other hand, is a lipid that reduces the risk of heart disease and is the “good” cholesterol. So it is the ratio of total cholesterol to HDL (total cholesterol ÷ HDL) that is significant. You could have a high total cholesterol and yet, because of low LDL and high HDL, have a low cardiac risk. Conversely, a low total cholesterol with a low HDL would signify increased risk. Recently, as more has become known about cholesterol, research has shown that LDL occurs in at least two forms—small, dense LDL particles (or type B, the hazardous form) and large, buoyant LDL particles. LDL particle size is now being measured by commercial laboratories. Larger particles, classified as size A, are considered benign, while smaller particles carry cardiac risk. Associated with the test for particle size is apolipoprotein B. When the Apo B test result is lower than 120 mg/dl, or when LDL particle size is type A, even high LDL levels are considered benign and should not be treated with statin drugs.
The only truly accurate measure of LDL is the “real” LDL test. The customary, calculated measure of LDL is estimated mathematically, which can result in values that are sometimes grossly in error. The “real” test, however, may cost more than the rest of your lipid profile.
Recently a commercial lipid panel called “VAP cholesterol” has become available. It contains all of the lipid tests described above. It is costly but can be ordered from most commercial laboratories.
The role of serum lipids in heart disease has come into question by some studies showing that at least 50 percent of people who suffer heart attacks have normal lipid profiles. There is evidence that the new (difficult to obtain) tests for oxidized and glycated LDL may be even better predictors of cardiac risk.
Also important to remember is that—as we will discuss in Chapter 9, “The Basic Food Groups”—fats and cholesterol in the diet do not cause high-risk lipid profiles in most people. On the other hand, diabetics tend to have lipid profiles that suggest increased cardiac risk, if their blood sugars have been elevated for several weeks or months.
Thrombotic risk profile. This profile includes levels of fibrinogen, C-reactive protein, and lipoprotein(a). These are also “acute phase reactants,” or substances that reflect ongoing infection or other inflammation. These three substances are associated with increased tendency of blood to clot or form infarcts (blockages of arteries) in people who have had sustained high blood sugars.
In the cases of elevated fibrinogen or lipoprotein(a), there is, additionally, often an increased risk of kidney impairment or retinal disease. Obesity, even without diabetes, can cause elevation of C-reactive protein. In my experience, all these tests are more potent indicators of impending heart attack than the lipid profile. Treatments are available for elevations of each of these. Blood sugar normalization will tend to reverse most of these elevations over the long term. Fibrinogen can be elevated by kidney disease, even in the absence of elevated blood sugars. It will tend to normalize if kidney disease reverses. Lipoprotein(a) will also tend to normalize somewhat with blood sugar normalization, although your genetic makeup (and low estrogen levels in women) can play a greater role than blood sugar. Abnormally low thyroid function is a common cause of low HDL and elevated LDL, homocysteine, and lipoprotein(a). Although serum homocysteine is also a cardiac risk factor, it was recently discovered that the usual treatment for elevated values (vitamin B-12 and folic acid supplements) actually increased mortality.
Serum transferrin saturation, ferritin, and total iron binding capacity (TIBC). These are all measures of total body iron stores. Iron is vital, but it is also potentially dangerous. Levels that are too high can indicate a cardiac risk, can cause insulin resistance, and are a risk factor for liver cancer. I will discuss insulin resistance at length in Chapter 6, “Strange Biology.” Higher iron levels are more likely in men than in premenopausal women because of blood (iron) loss during menstruation. (This is why I recommend iron-enhanced vitamin supplements only for those with an established need.) Iron levels that are too low (iron deficiency anemia, which is more common in premenopausal women) can cause an uncontrollable urge to snack, which in turn can lead to uncontrollable blood sugars. Both high and low iron stores can be easily determined and readily treated.
Chronic blood sugar elevation for many years can cause slow deterioration of the kidneys. If caught early, it may be reversible by blood sugar normalization, as it was in my own case. Unless you think frequent hospital visits for dialysis might be a nice way to meet people, it’s wise to have periodic tests that reflect early kidney changes. It is also wise to have all these periodically performed together, as the results of each can clarify the interpretation of all.
Several factors cause false positive results in some of these tests, so you should keep them in mind when your doctor schedules the tests. You should avoid strenuous or prolonged lower body exercise (which would include motorcycle or horseback riding) in the 48 hours preceding the tests. Additionally, if on the day the tests are to be performed you are menstruating or have a fever, a urinary tract infection, or active kidney stones, you should postpone the tests until these conditions have cleared.
A basic renal risk profile should include the following tests.
Urinary kappa light chains. If early diabetic kidney disease is present, this test reports “polyclonal kappa light chains present.” This means that small amounts of tiny protein molecules may be entering the urine, due to leaky blood vessels in the kidneys. Because these molecules are so small, they are the first proteins to leak through tiny pores in the blood vessels of the kidneys that may have been affected by disease.
This test requires a small amount of fresh urine. If the test report states “monoclonal light chains present,” there is a possibility of treatable malignancies of certain white blood cells.
Microalbuminuria. This less costly test can now be performed qualitatively (by dipstick) in your doctor’s office, or quantitatively at an outside laboratory. It, like the urinary kappa light chain test, can also reflect leaky vessels in the kidneys, but at a later stage, since albumin is a slightly larger molecule.
A quantitative measurement requires a 24-hour urine specimen, which means you’ll need to collect all the urine you produce in a 24-hour period in a big jug and deliver it to your physician or laboratory. Given the potential embarrassment of carrying a jug full of urine around at work, you might want to schedule your test on a Monday and collect the urine while at home on Sunday. Many of my women patients report that it’s easier to collect urine initially in a clean paper cup, and then pour it into the jug. An easier screening test is the measurement of the albumin-to-creatinine ratio in a first morning urine sample.
24-hour urinary protein. This test detects kidney damage at a later stage than the preceding two tests; it also requires a 24-hour urine collection. As with the other tests, false positive results can occur following strenuous lower body exercise, as previously noted.
Creatinine clearance. Creatinine is a chemical by-product of muscle metabolism, and is present in your bloodstream all the time. Measuring the clearance of creatinine from the body is a way of estimating the filtering capacity of the kidneys. Test values are usually higher than normal when a person is spilling a lot of sugar in the urine, and eventually lower than normal when the kidneys have been damaged by years of elevated blood sugars. It is not surprising to see an appropriate drop in creatinine clearance when blood sugars are normalized and urine glucose vanishes.
The creatinine clearance test requires a 24-hour urine collection, and your lab will simultaneously draw a small amount of blood to measure serum creatinine. The most common cause of abnormally low values for this test is failure of the patient to collect all the urine produced in a 24-hour period. Therefore, if other kidney tests are normal, tests with low values for creatinine clearance should be repeated for verification.
A low creatinine clearance without excess urinary protein suggests a nondiabetic cause of kidney impairment.
When it is impractical to make a 24-hour urine collection, as for small children, a new test requiring a small amount of blood, crystatin-C, can be performed. Crystatin-C is believed to be a more accurate measure of kidney function than creatinine clearance, but unfortunately many insurers still consider this test to be “experimental” and won’t pay for it.
25-OH vitamin D-3. This is the standard test for vitamin D. Normal values range from 50 to 80 mg/ml. People who are not regularly exposed to sunlight are usually deficient in this essential vitamin, which can be replaced by supplements. A deficiency can cause insulin resistance.
Serum beta2 microglobulin. This is a very sensitive test for injury to the tubules of the kidneys, which pass urine filtered from the blood (see Figure A-1, here). As with fibrinogen levels, elevated values can also result from inflammation or infection anywhere in the body. Thus an isolated elevation of serum beta2 microglobulin without the presence of urinary kappa light chains or microalbumin is probably due to some sort of infection or inflammation, not to diabetic kidney disease. Such elevation is commonplace in people with AIDS, lymphoma, and immunodeficiency disorders.
24-hour urinary glucose. This test too requires a 24-hour collection of urine, and is of value for proper interpretation of creatinine clearance.
NOTE: If, as you’ve been reading about these tests, you’ve imagined yourself lugging around multiple jugs of urine, most of us only need one 3-liter jug. This should give you an adequate specimen for your laboratory to perform creatinine clearance, microalbumin, 24-hour protein, and 24-hour glucose. Nevertheless, it’s wise to bring home two empty jugs, just in case your urine output is very high.
As indicated under “Cardiac Risk Factors,” significant kidney damage may also be accompanied by elevations of serum homocysteine and fibrinogen.
Rapid correction of very high blood sugars can, on occasion, cause exacerbation of a common complication of diabetes called proliferative retinopathy. This condition can cause hemorrhaging inside the eye and blindness. Such exacerbations are usually preceded by an increase in serum levels of insulin-like growth factor 1. A baseline level of IGF-1 in the blood should be measured in people with proliferative retinopathy. Repeat determinations should be made every two to three months. If levels increase, blood sugars should then be reduced more slowly.
The purpose of this study is to test the functioning of the vagus nerve, and it should be part of your initial diabetic physical examination. It is performed like an ordinary electrocardiogram, but it requires fewer electrical leads (i.e., only on the limbs, not the chest).
The vagus nerve is the largest nerve in the body, running from the brain to the lower body. It’s the main neural component of the parasympathetic nervous system, or that part of the nervous system that takes care of vegetative, autonomic functions, the functions that run more or less on “automatic pilot” and that you don’t actively have to think about to make happen. These include heart rate and digestion.
Like any other nerve in the body, the vagus nerve can be injured by long-term exposure to high blood sugars, but since it plays such a central role in bodily function, damage to it can cause many more disorders than damage to most other individual nerves.
The vagus plays a major role in a number of diabetic complications involving the autonomic nervous system, including rapid heart rate, erectile dysfunction in men, and digestive problems, particularly gastroparesis, or delayed stomach-emptying (which we will discuss in detail in Chapter 22). The good news is that when you’ve had your blood sugars normalized over an extended period, it can slowly recover proper function. (Many of my male patients who have been unable to achieve or maintain an erection report that after blood sugars have been normalized, that ability has returned.)
This nerve is unique in that its function can be investigated simply and cheaply. If the vagus nerve is working properly, there should be a considerable difference in heart rate between inhaling and exhaling. By measuring the variation of your heart rate with deep breathing, we can get a picture of just how much the function has been impaired. In nondiabetics, the heart rate increases when they inhale deeply and slows when they exhale fully. So a twenty-one-year-old nondiabetic’s heart rate might typically slow as much as 85 percent from inhaling to exhaling. This may drop to about 30 percent for a seventy-year-old nondiabetic. A young type 1 diabetic with ten years of very high blood sugars may not have any heart rate variation at all. (The variation is measured by looking at the interval between “R-points,” or peaks on the tracing of the electrocardiogram. As you’re probably aware, each time your heart beats, the electrocardiograph traces a shape resembling a mountain. The tip of the mountain is the R-point, so the physician measures the intervals between R-points.)
I consider this test an important, reproducible, quantitative measure of an important diabetic complication and perform it on all of my new patients before blood sugars have been stabilized. I repeat it about every eighteen months, for several reasons. It’s a very good index of how, with aggressive blood sugar control, neurologic complications can and do reverse, and it gives both patient and doctor good, concrete evidence of the success of treatment, and encouragement to keep it up. Additionally, the digestive disorder of gastroparesis, which I mentioned above, can be and frequently is one of the most difficult barriers to blood sugar normalization, and can even make blood sugar control virtually impossible in some people who require insulin. A low heart rate variability on the initial test can be a good indicator that the patient is likely to have a problem with delayed stomach-emptying. It can also give the doctor clues as to causes of other problems that a patient may be experiencing—sexual dysfunction, fainting upon standing when arising from bed, and so on.
If your physician would like to learn how to perform this study in his or her office, he or she should read my article “R-R Interval Studies: A Simple Office Protocol” (Diabetes Care 1984; 7:510–513). If he or she is unwilling to do an R-R study, there are several companies that offer it; just search the Internet for “tests for cardiac autonomic neuropathy.”
In addition to a standard physical examination, it is desirable (but not essential) that a routine neurologic exam be performed before blood sugars are corrected, and again every few years thereafter. These tests are not painful. They should include checking for sensation in the feet, reflexes of limbs and eyes, double vision, short-term memory, and muscle strength. In my experience, performance on a number of the neurologic tests improves after many months of essentially normal blood sugars. Performance tends to deteriorate if blood sugars remain high.
One of the most valuable retinal studies, the Amsler grid test, can be performed by any physician or nurse in less than a minute without dilating your pupils. Since chronically high blood sugars frequently cause a number of disorders that can impair vision, your eyes, if normal, should be examined carefully by an ophthalmologist or retinologist every one to two years.
The ophthalmologist will evaluate the retina, lens, and anterior chamber in each eye, and you can expect to have your pupils dilated with special drops. A proper retinal exam requires the use of both direct and indirect ophthalmoscopes and a slit lamp. If an abnormality is found, certain examinations may have to be performed by a retinologist every few months.
Because ulcers of the diabetic foot are avoidable, even when blood sugar is not well controlled, you should ask your physician to examine your feet at every routine office visit. Foot problems that aren’t prevented or treated properly can lead to serious complications, even amputation. Your physician should train you in foot self-examination and preventive care. In Appendix D, I have reproduced the same instructions I give my own patients on how to care for their feet.
This inexpensive test utilizes a simple blood pressure cuff connected to a small instrument that should be in every doctor’s office. It gives an index of the adequacy of pulsatile circulation to the legs and feet. Since long-standing, poorly controlled diabetes can seriously impair peripheral circulation, this test is fairly important. All diabetics should take special care of their feet, but if you have an abnormal oscillometric study, you have to be extra careful. People who have diminished circulation in the legs usually also have significant deposits in the arteries that nourish the heart, brain, kidneys, and arteries necessary for penile erection. Therefore, if this study shows impaired circulation, your doctor may want you to undergo tests that would help diagnose coronary artery disease and, if you have certain symptoms, diagnose impaired circulation to the brain. Oscillometry can be performed by any trained physician in a few minutes. It is taught at many medical schools throughout the world but rarely in the United States, where hands-on care is diminishing. Your physician can search the Internet on “oscillometer” if he or she wishes to purchase one. Most insurers will compensate doctors for doing this test.
Prolonged high blood sugars can cause glycation of tendons. Glycation is the permanent fusing of glucose to proteins, and the simplest analogy is bread crust. Think of the soft inside of the bread as your tendons as they should be, and the crust as what happens when they’re exposed to elevated blood sugars over a long period of time. Glycation of tendons occurs in such common diabetic complications as Dupuytren’s contractures of the fingers, frozen shoulders, trigger fingers, carpal tunnel syndrome, and iliotibial band/tensor fascialata syndrome of the hips and upper legs. All of these conditions are easily treated if caught early and blood sugars are controlled. A musculoskeletal examination can identify these in their early, treatable stages.*
As valuable as they can be to you and your physician, none of these tests is crucial to our central goal of achieving blood sugar normalization. If you are without medical insurance, or if your insurance won’t pay for these tests, and financial considerations are a top priority, all can be deferred. If, however, you are experiencing problems, such as impairment of vision, you should be tested immediately. Also, examination of your feet, and learning how to care for them properly, is vital and can prevent or forestall serious problems.
The most valuable of these tests for our purposes is the HgbA1C, because it alerts your physician to the possibility that your self-monitored blood sugar data may not reflect the average blood sugar for the prior three months. This can occur if your blood sugar–measuring technique or supplies are defective. More commonly, some patients, with a scheduled visit to the doctor approaching, will improve their eating habits so that their blood sugar records improve. I have seen several teenagers whose falsified blood sugar data were discovered by this test. I therefore suggest that HgbA1C be measured at regular visits every two to three months. This test costs about $65 in the United States.
Ideally, the other blood and urine tests should be performed before attempting to normalize blood sugar and annually thereafter. If an abnormal value is found, your physician may wish to repeat that test and related tests more often. The exception is the fasting C-peptide test, as there is little value in repeating it except to see if pancreatic function is deteriorating or improving. I certainly like to repeat the thrombotic risk and lipid profiles about four months and then eight months after blood sugars or thyroid tests have been normalized. The improvement that I frequently see tends to encourage patients to continue their efforts at blood sugar normalization. The R-R interval test should be performed every eighteen months. I consider it the second most important test I perform on my patients after the HgbA1C.
A FINAL NOTE: Dietary vitamin C is important to good health. In doses above 500 mg/day, however, vitamin C supplements can destroy the enzymes on blood sugar test strips and can also raise blood sugars. Finally, in levels higher than about 400 mg/day, vitamin C becomes an oxidant rather than an antioxidant and can cause neuropathies. If you are already taking supplemental vitamin C, I urge you to taper it off or lower your dose to no more than 250 mg daily. Use only the timed-release form.
I will personally answer questions from readers for one hour every month. This free service is available by visiting www.askdrbernstein.net.