Do I have hypochondria?

Background

In the past months, maybe year I have been increasingly feeling sick 1-2 hrs after eating. I get shaky and clammy, sweaty and uncoordinated. I have to lie down and eat something to feel better, but I never really feel normal. This sounds kind of like hypoglycemia [1]. The result is I typically delay eating for as long as possible and then eat every 2 hrs thereafter.

I didn’t have a primary care doctor for unrelated reasons. So I found one off a list somehow and had an appointment. She said my symptoms were not possible, gave me a basic metabolic panel to shut me up, and sent me on my way.

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Doctor’s office empty, probably should have taken that as a warning sign.

I felt so depressed. Am I a hypochondriac? That little insecure girl in me wanted to hide and cry. The scientist in me said this is stupid, go read some papers and do experiments to make science & evidence based conclusions. MDs just follow flow charts to diagnose.

Hypotheses

After a couple days of depression, I did some reading [2,3] and formulated a couple hypotheses:

  1. too much insulin, extended insulin, or hypersensitivity to insulin causes lowered blood glucose
  2. hypersensitivity to epinephrine or too much epinephrine causes hypoglycemic symptoms in the absence of lowered blood glucose
  3. hypoglycemic symptoms can also be brought on by fast fall in blood glucose, regardless of actual glucose values

Experimental Plan

To test these hypotheses, I went and bought the cheapest blood glucose meter at Target and some strips. Happens I worked on the research and development on the product my first job put of college. Cool!

I chose two tests to emulate [4]:

  • fasting glucose
  • time course after meal

The fasting glucose will give me a baseline, to understand whether a sharp rate of change is responsible for symptoms (3).

The post-meal time course will show me whether or not blood glucose is actually lowered when I feel symptoms (1) or (2).

Taking the time course is important to me, in case there are some dynamic differences from normal that can be informative. Many patient oriented informational sites only list high end values and single time points. So I had to do some digging to find some normal values to compare my results to (fig 1).

Figure 1. Normal blood glucose after eating a meal. Average in blue, 2 standard deviations from the mean upper and lower bounds in brown.  From http://www.phlaunt.com/diabetes/16422495.php.
Figure 1. Normal blood glucose after eating a meal. Average in blue, 2 standard deviations from the mean upper and lower bounds in brown. From http://www.phlaunt.com/diabetes/16422495.php.

Methods

Meter accuracy – test blood glucose twice in a row to see variance inherent to assay.

Fasting – after 8 hrs no food first thing in the morning I measured my blood glucose.

Meal – after meal take measurements 15 min to 3 hrs, half hour intervals and then 15 min intervals after 2 hrs when I expect to feel sick.

Results

Two subsequent measurements yielded the same blood glucose value, suggesting accuracy of testing equipment.

Fasting blood glucose is 122mg/dL.

Meal blood glucose rose to 200mg/dL shortly after lunch and peaked at 223mg/dL approximately 60min post meal. Blood glucose fell about 100mg/dL between 60 and 120min. Hypoglycemic symptoms onset at 120min coincided with sharp fall, but a normal range reading of 125mg/dL. Readings in 15 min intervals thereafter showed some additional decrease but relative stabilization of blood glucose levels. The lowest reading was at 96mg/dL (fig 2).  The experiment was stopped prior to the planned 3 hr time course because I had to eat something.

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Figure 2. My post meal blood glucose time-course. Meal included hot & sour soup, eggroll, tofu, green beans, and white rice. Blood glucose peaked just before 1hr, and then fell sharply by almost 100mg/dL by 2 hrs.

Discussion

I was expecting to find hypoglycemic readings, but instead found that my blood glucose is high to the point of possible pathology accompanied by high variability.

My fasting level of 122mg/dL is near the top end of the prediabetic range at 125mg/dL [5]. Fasting blood glucose greater than 125mg/dL indicate diabetes has developed, rather than pre diabetes condition. I do not meet this criteria for full diabetes, although I am approaching this threshold.

My peak blood glucose level at 223mg/dL 1hr post meal is in the diabetic range and exceeds prediabetic levels [5].

However, I am able to reduce blood glucose levels from peak back into a normal range. This dynamic pattern is consistent with prediabetes rather than full diabetes [6].

It is possible that my blood glucose falls into the hypoglycemic range at times due to the sharp fall in blood glucose from peak [7], but hypoglycemic blood glucose values were not observed here. Likely hypoglycemic symptoms are often due to the high rate of change rather than actual hypoglycemic blood glucose.

A prediabetic condition is supported by the post meal dynamics and most blood glucose measurements. Only my peak post meal blood glucose at 1 hr is alarmingly hyperglycemic supporting full diabetes.

This dynamic pattern suggests a loss of first phase insulin release, which occurs within 2 minutes of first food intake in normal people and prevent rise over 140mg/dL [7]. The second, sustained insulin release appears to be intact which explains the fall in my blood glucose between 1 & 2 hrs. However, overcompensation in the second insulin release due to hyperglycemic conditions at 1hr could explain the subsequent sharp fall in blood glucose and hypoglycemic symptoms [7].

Loss of the first insulin response is a feature of prediabetes or Impaired Glucose Tolerance [7]. Asians are reported to have higher incidences than Caucasians of developing diabetes, 95% of whom develop type 2 diabetes [8]. Many, if not all, develop type 2 diabetes through loss of first phase insulin response which causes subsequent beta cell loss or dysfunction, impairment of the second insulin release, and insulin resistance in other tissues [7,8]. Loss of both phases of insulin release characterizes full diabetes [7].

I probably have prediabetes and need to see an endocrinologist for proper diagnosis and treatment. I will probably not return to the primary care doctor who thought I was a hypochondriac.  I will probably repeat these experiments for a total of 3 times to demonstrate reproducibility [UPDATE: this doesn’t seem possible because stabbing my finger 1-4x per time point to get enough blood hurts].

I have a lot of reading to do to better understand the normal physiology, pathological physiology, disease progression, underlying mechanisms, population incidences, existing treatments, and relevant drug development pipeline.

Understanding my particular disease development and its treatment may be a challenge because my BMI is 19 and I have hovered on this cusp of underweight for my entire adult life.  Most diabetes information and prediabetes treatments focus on slowing disease development by losing weight.  It is likely my disease onset is caused by a factor other than obesity-related lifestyle choices since I am not obese, so modifying my lifestyle may have no effect on my disease progression.  An additional impediment for me to this common  method of treatment is that I cannot really lose weight.

In conclusion, do I have hypochondria?  Sadly it doesn’t seem so.

References

  1. Hypoglycemia, Wikipedia
  2. Blood sugar regulation, Wikipedia
  3. Reactive hypoglycemia site
  4. American Diabetes Association diagnosis
  5. American Diabetes Association
  6. Blood sugar chart
  7. The beta cell and first phase insulin secretion, Medscape
  8. Joslin Asian American Diabetes Initiative

* I do not necessarily endorse or believe all information contained in the references above.