Aldosterone and insulin resistance.

Via the Yahoo PA group, this really great article just came my way, addressing the relationship of aldosterone to insulin resistance. I’ve been saying this all along, but this is the first time I’ve found Actual! Scientific! Evidence!! to back it up.

The adverse effect of excess aldosterone on insulin metabolic signaling (Figure 1) has generated increasing interest in the role of hyperaldosteronism in the pathogenesis of insulin resistance and resistant hypertension. This association was initially described more than 4 decades ago in individuals with primary hyperaldosteronism and impaired glucose tolerance (34). Increased plasma aldosterone levels are associated with insulin resistance independent of other components of the metabolic syndrome (35-37). In patients with primary hyperaldosteronism, resection of aldosterone-producing tumors and pharmacologic treatment both decrease blood insulin and glucose levels, which indicates an improvement in insulin sensitivity (37,38).

I’m happy to be able to report that now, nearly a year and a half after my adrenalectomy, I continue to no longer show ANY signs of insulin resistance. When my illness first became apparent in my early 30s, I thought the sudden weight gain concentrated in my midsection was due to approaching middle-age. When this was followed by abnormal labs showing IR and borderline high fasting glucose, I thought I was not only doomed to a typical apple-shaped middle-aged body, but to the diabetes that runs in my maternal family. This all seemed terribly incongruous to the lifestyle I was living – unlike my maternal relatives, who smoked like chimneys, drank like sailors, and lived in the suburbs planted on their butts in front of the TV or in their cars, I lived in the city and walked everywhere, was (then) a vegetarian with a textbook-perfect diet, practiced yoga, went hiking, rarely drank, and had smoked a cigarette exactly once in my life. It didn’t seem fair. Hell, it wasn’t fair.
But. The tumor is gone, and so is the weight gain, the abdominal obesity, the worry that I will have to face diabetic foot in my lifetime (warning, extremely graphic Google image search). And I say this all the time, but I have to say it again – I am so, so incredibly grateful to everyone – the doctors, the hospital staff, the friends who saw me through this journey – that I have this second chance.
~ ~ ~
I get stupid thankful about this, just about every day of my life. After seeing a most amazing gig last night with a dear friend, I was already bordering on the stupid-emotional side. He asked me, as he does from time to time, how I was doing health-wise. I’m not a crier, but I came thisclose to bursting out in tears. That I am doing okay – that I am doing damn fine, even – that I have friends who remember what I’ve gone through and who care enough to check in about that, is just something that overwhelms me almost every single day. Sometimes that fact that I am here, and well, is the thing that doesn’t seem fair nowadays, since every day that I check into the Yahoo group it seems that there is yet another person who is NOT doing well at all. I realize life can be, in general, a matter of luck – I’m lucky to live five minutes from a research hospital, I’m lucky to be a trained researcher myself who can read articles like the one linked above, I’m lucky that my disease was caught before it did any real damage. And the fact that not everyone afflicted with this condition has equal access to the resources I do absolutely pains me.

Six months (!) post-adrenalectomy.

Yesterday – Friday the 13th! – marked the six-month mark since my surgery. Six months! I’m not sure how that happened. My memory of being in the hospital remains crazy-clear and so much more recent. I’m still pondering conversations I had with visiting friends. And wondering if I really *did* flash my scars to everyone who visited.

But. How am I doing? Just fine, thanks. I’m not really due for much in the way of bloodwork until the 1-year mark, but here are the numbers that seem to matter right now:

  • Blood pressure: averaging 122/79. I’m not checking it obsessively as I once did, but am happy to report that when I do, the numbers are nearly always in the 120s/70s. Except immediately after drinking coffee, which is something I’m trying to determine if I should be doing at all any more.
  • Weight: steady at 111, despite the fact that I’m eating rice pretty much daily. Or potatoes. Or hey, when I’m feeling really daring, sometimes both! Before the surgery, rice – the only grain I can eat, due to a miles-long list of food intolerances – made me pile on the pounds pretty easily, and gave me a bit more reactive hypoglycemia than I was comfortable with. Potatoes gave me really, really bad reactive hypoglycemia – full-on food coma, even in tiny amounts. Now neither one bothers me, which is my unscientific way of proving that (a) the tumor caused insulin resistance, and (b) now that the tumor is gone, so is the insulin resistance.

As I keep yammering on about over at the Yahoo board, I really, strongly believe that there is so much more to this disease than hypertension and low potassium. So. Much. More!!! I realize that those two things are the things that can kill, but so can insulin resistance/diabetes, which I am fully convinced goes hand in hand with this illness. And considering how common IR and T2 diabetes are in the U.S., I have to wonder if it’s really a “rare” disease. My mother, for example, is one of seven siblings – the only one not to develop T2 diabetes and die at a younger age than her mother (who lived to be close to 100; her mother’s mother made it to 103!). My mother’s father, on the other hand, died of a heart attack in his early 50s. My hypothesis: adrenal adenomas, all of them, passed down along the paternal line to all except for my mom, who seems to have won the genetic lottery in many ways. Perhaps it’s no coincidence that from a phenotypical point of view, she resembles her mother; I, on the other hand, am a carbon copy of her dad.

I’m also pretty certain that as long as this country’s health care system remains unchanged, this will remain a “rare” disease and people will continue to die young, of heart attacks and strokes and diabetic complications, or suffer compromised quality of life. There is so obscenely much profit in drugs for hypertension (none of which work in PA, but most doctors don’t know that), and even more profit in drugs for diabetes. If a relatively simple surgery like mine can fix the problem and eliminate the need for drugs entirely – imagine the losses the drug companies would suffer. As long as healthcare remains profit-oriented, this cycle is not going to end.

I’ve said all of this before, I know. And I’ve also stated my belief that I’m one of the lucky ones. Not a single day has passed in the last six months when I haven’t thought about this, how thankful I am for the circumstances that made me able to say this: the accident of where I live (5 minutes from a top medical school), the support of my friends (without whom I never would have had the balls to go through with a surgery that may or may not have worked), and my own darned stubbornness (if I don’t like the answer I am given, I keep asking until I do like it).

Moderation: just another word for “denial.”

In my last post, I briefly touched on the relationship between PA and insulin resistance – in short, that it can be caused by the potassium depletion from the PA. I’ve been thinking about this quite a bit lately – what it meant for me during the 10 years that I had untreated PA, what familial link there may be, and on a larger scale, where it might fit in to the nation’s diabetes epidemic.

In January 2003, when I was at my sickest (and my highest weight, a whopping 173 pounds), I was diagnosed with two of the three: insulin resistance and metabolic syndrome. With a strong maternal family history of diabetes and heart disease, this would have been enough to scare me into action, but I was lucky: I was also diagnosed with fructose intolerance at the same time. The end result of following a diet for fructose restriction was essentially a low-carbohydrate diet – no sugars, no grains, no fruits – which enabled me to lose 50 pounds in less than three months. I’m pretty certain that this saved my life – at the very least, it reversed many of the symptoms of metabolic syndrome – and thus, I am a big believer in carbohydrate restriction as a preferable treatment (over drugs) for insulin resistance.

My mother, age 86, is the middle child of seven siblings, and is the only surviving one except for the youngest. Of the five who have died, four of them have died from diabetic complications or heart disease (or a combination of both, as all were diabetic). All were obese. The youngest living sibling is also obese and diabetic. The only two of the seven not to become both obese and T2 diabetic are my mother and the one sister who died young (a suicide).

When one begins the diagnostic process for PA, there are a lot of questions about family history. I don’t have a lot of information, but based on what I was able to put together – mainly, the above paragraph – I came to two conclusions: first, while I have no proof of this and never will, I suspect that every one of the siblings above who died of diabetic complications had an adrenal tumor. And, second, if one becomes diabetic as an adult, the best things one can do are remove all sugar and grains, processed foods, and “eating for entertainment” from one’s diet; and get up off one’s butt and move. I am convinced that I reversed my insulin resistance early on because I refused to remain sick and fat (even if this could not reverse the tumor!), and I am convinced that my mother’s apparent immunity to these diseases is due to her lifelong habit of walking everywhere (she never learned to drive).

~ ~ ~

Even if my adrenalectomy has, at least for the time being, rescued me from the danger zone of developing diabetes, I remain extremely interested in the subject, and I have RSS feeds set up for news items about the disease. So even though I don’t watch television and could care less about celebrity chefs, the recent hubbub about Paula Deen’s diabetes diagnosis came across my radar. And I’m siding with Anthony Bourdain here – she really is the most dangerous woman in America.

Why? Not because she advocates eating bacon cheeseburgers sandwiched between two glazed donuts, but because she advocates moderation (WARNING: link with sound!). Loudly and emphatically. Sorry, Ms. Deen, but I’ve got news for you:

Moderation doesn’t work. And you are living proof of it.

First, moderation goes against human nature. We’re hardwired to survive, and survival, historically speaking, means beating famine. So, when presented with food, we eat. Simple enough.

And, second, as I noted above – when one has metabolic derangement, carbohydrate restriction can work wonders. And that means complete and total restriction of all processed foods, sugars, and grains. That doesn’t mean “once in a while,” that doesn’t mean “have a cheat day,” that doesn’t mean “a little bite won’t kill you.” Because it will. Maybe not today, but slowly and painfully, it will kill you. If you don’t believe me, do a Google image search for diabetic foot (WARNING: disgusting images!).

Moderation, in my opinion, is just another word for denial. The minute one is diagnosed with any form of metabolic derangement, be it insulin resistance, T2 diabetes, or metabolic syndrome, one’s life changes. Or perhaps more accurately, one has to change their life – that is, if one wants to take control of the situation and get healthy again. The choices are simple:

  • Stop “eating for fun” – that means no cupcakes, no ice cream, no fast food, no corporate chain restaurants serving plates of ConAgra with a side of Monsanto – and get up off your butt and move.

OR:

  • Practice “moderation” and expect to be feeling crappy, popping pills, and getting fatter and sicker for the rest of one’s life.

There are only two choices. It’s up to you.

~ ~ ~

If you have been diagnosed with insulin resistance, pre-diabetes, or metabolic syndrome, read this first. It’s a pretty decent overview of what each of the terms mean.

Once you have done that, head over to Blood Sugar 101 and read every word that Jenny has written. Chances are it will contradict everything your endocrinologist tells you. And, unlike what your endocrinologist tells you – moderation, lots of whole grains, and many expensive drugs – it will work and you will feel better. It’s worth a try, isn’t it?

Food.

I have not been able to eat much since the surgery – in addition to the hiatal hernia I was born with, it feels as if the residual CO2 has filled every possible space in my abdominal area, and I have felt uncomfortably full all the time since Thursday. But I also know that I have to eat something, just a little even, so on Monday my dear friend C accompanied me on a little shopping trip to Whole Foods.

Making the right dietary choices has been critical to managing this disease from the very start. Because of the insulin resistance (IR) it causes, I am extremely sensitive to carbohydrates; as I often jokingly say, I look at a potato and I gain five pounds. Because sodium exacerbates water retention and increases blood pressure, I avoid restaurants, prepared foods, and any situation in which I can’t know with full certainty that my food has been prepared without any added salt.

Except – now I don’t have to watch sodium. Before I left the hospital, my surgeon told me not to worry about that any more. In fact, some doctors actually encourage patients to eat high sodium at all meals for a short time post-adrenalectomy, in order to get the remaining adrenal to “wake up.”

As for insulin resistance, some studies, such as this one, posit that IR in PA patients will reverse within 6 months of treatment, whether surgical or medical. This is a little less cut-and-dried than the sodium bit; no one can really advise me as to when/if I can be more lenient about carbohydrates.

So, it’s back to a routine I’m already all to familiar with: my body, my science experiment.

I’ve already lost seven pounds since the surgery, so I’m not all that worried about weight gain (and its undesired dangerous side effects of increased fasting blood sugar and elevated BP) in the short term. In addition, when I’m not feeling 100%, my favorite food to eat is rice. So, I’m allowing that. In addition, since my digestive system seems to have gone to sleep, I’m giving myself a rest from all animal proteins for the time being – no chicken, no fish, no eggs until I feel a little more normal. Nothing against these foods; they just feel a little heavy for me at the moment.

My first day out of surgery, my total food intake was a half-cup of basmati rice. The next day, a half avocado. The day after, another half avocado. Which brings me to Monday, my day of shopping.

I began my day with 1/4 cup of plain, whole-milk Greek yogurt. Around noon I actually started craving “real” food for the first time since the surgery – specifically, Indian food. I pondered this a bit and while it was definitely curry that was on my mind, it was also salt that I was craving. So, when we got to Whole Foods, I decided to do something I rarely do – check out the prepared food offerings. And when I saw Curry Garbanzo Tofu soup, I got brave and took home a small container. More a stew than a soup, it went over a bit of jasmine rice and was absolutely the most delicious thing I had tasted in many months.

I half expected my usual symptoms from sodium intake to come on overnight – headache, irregular heartbeat, weight gain. I also expected to feel like I was going to crash from the carb intake within 40 minutes of eating, even though I only had a small portion. But – nothing. In fact, I was down another pound in the morning.

Tuesday I had my first post-op follow-up with my nephrologist. I told him what the surgeon had said, to not worry about sodium, and that I felt that it was still unwise. I also told him what I had done, to no ill effect. His advice was that this was entirely appropriate – don’t go out and eat a bag of potato chips, but don’t stress out about every bite. I can do that.

I’m not entirely certain where all of this will take me – as mentioned before, I have hopes of being able to cut back on the animal protein as much as possible since I hate cooking it and don’t enjoy eating it. If the insulin resistance truly does go away, and Every Single Carbohydrate doesn’t go straight to my belly, perhaps this can be done. I know that my dietary intolerances to lactose, fructose, and gluten are an entirely separate issue and will not likely be influenced by my lack of a bad adrenal; this I don’t mind, as I very strongly believe that sugar and gluten are not “good” for anybody, and would never go back to eating them. So, as I continue to decline your offers of cookies or bread, please don’t take offense.

Right now, I’m just excited at the possibilities that have opened up just knowing that I can eat something that somebody else made. And thrilled at the prospect of Indian and Thai and Japanese food being a part of my life again.

Weight just a minute.

While waiting for my appointment in the very busy office of the endocrine surgeon, I noticed one thing right away: I was the only person present in the waiting room who was not overweight. Overweight, actually, would be an understatement in describing the other patients: I’m pretty sure every one of them would have qualified as obese. Even the young girl, who could not have been more than 11 years old: she probably outweighed me by a good fifty pounds.

None of this should come as a surprise to anybody who knows a thing or two about the endocrine system. In addition to adrenal diseases, this field encompasses such things as thyroid, parathyroid, pancreas, and liver. And as anybody with an endocrine disorder knows, when this system is defective, weight loss becomes nearly impossible.

The very first sign that I had that I was sick was weight gain. I’m short – 5’3″ if I stand really tall – and very small-boned. In 2000-2001, when I first became ill, I had never weighed more than 103 pounds. Usually I weighed less – somewhere around 95.

But by early 2001, I mysteriously gained 50 pounds over the span of a couple of months. Nothing had changed in my diet or lifestyle – I walked a lot, rode my bike at the beach, went to yoga, and was a vegetarian (albeit an unhealthy one – more on that later). The sudden weight gain freaked me out, but at the time the doctor I was going to felt that, as a then-36-year-old woman, I was better off at 140 pounds than 95. I tried to believe him, but I wasn’t convinced. And I wasn’t going to buy that bit about the middle-aged middle: I didn’t, and I still do not, believe that with middle age comes weight gain. Not unless something else is wrong.

I obsessively tracked every low-fat, vegetarian – vegan, actually, at one point – bite. I did not exceed 1000 calories a day, ever. I ate the food pyramid’s recommended 6 servings of grains and 5 fruits a day – and really, little else. Minimal protein, as little fat as possible. The nutritionist my doctor sent me to reviewed my food log and proclaimed it “exemplary.”

I developed severe gastrointestinal symptoms – use your imagination, you name it, I had it. I had chronic migraines. My left side went all numb and tingling, to the point where I could barely carry anything. I qualified for a disabled placard, which I rarely used because on outward appearance, I looked young and healthy. When I would pull into a disabled space at Trader Joe’s, people would give me dirty looks, or worse, call me a liar.

I got tested for all the wrong things. First the doctors thought it was MS, then fibromyalgia. Eventually I found myself a step or two ahead of them and diagnosed myself with B12 an zinc deficiency – and I was right. Adding some chicken and seafood back into my diet – reluctantly, because I’ve never much enjoyed knowing my food once had a heartbeat – solved the headaches, numbness and tingling. But I was still fat, and still sick to my stomach almost all the time.

Then I lost my job, and with it, my health insurance. And in late 2001, the incident that led to my first ever diagnosis of hypertension happened, and I found myself in the emergency room at County-USC, along with the gunshot victims and gangbangers, getting an education but not much in the way of answers.

The answers began when I was seen by a free-clinic doctor from Iran, who had been educated in Moscow. Rather than push pills, like the American medical establishment is oh so happy to do, she asked me extensively about my diet. Her first question – “Do you eat a lot of carbohydrates?” – left me feeling stupid, because I had absolutely no idea what a carbohydrate even was. Without running a single test, she told me that my “exemplary” diet was severely deficient in protein and that I was likely intolerant to gluten and fructose, in addition to lactose (the latter I had been diagnosed with in infancy). She diagnosed me as insulin-resistant. I was really, really clueless about what any of this meant. She told me to read Atkins.

I was horrified. Didn’t that mean, like, eating bacon dipped in mayo? But I read it anyway and thought the basic premise – eat more vegetables, sufficient protein, and ditch the grains and sweets – seemed pretty sound. So I tossed out all the “healthy” granola bars and vegetarian frozen dinners in my kitchen, and stocked the fridge with fish – the only protein I was comfortable cooking at the time – and veggies.

And within 3 months I had lost fifty (!) pounds.

Oh, and the gastrointestinal distress was gone completely.

That was in early 2003. I’ve maintained the weight loss ever since, except for when I have occasionally tested myself by eating rice or legumes or potatoes, each time putting on somewhere between 10 and 15 pounds within a couple of weeks. None of this is difficult for me, except the eating animal protein part – I’ve never been comfortable with it and probably never will be. But avoiding all the foods that make me fat and sick? Not a problem.

The thing is, though, it seems to be a problem for just about everybody else. On the two support boards I frequent where hyperaldo patients hang out, it seems that EVERYONE is overweight. And why shouldn’t they be? First, our disease predisposes us to insulin resistance due to our potassium problems. Secondly, most of us are being given the advice to follow the DASH diet, a government-backed approach that is heavy on this country’s government-sponsored grains (and sugar-fortified grain products).  And as I have proven, through my science experiment of one, insulin resistance + grains and sugars = FAT. There’s a reason animals destined for slaughter are corn-fed.

In this country, we are constantly bombarded with government-mandated nutritional advice that is slowly killing us while at the same time making us dependent on Big Pharma, doing nothing for our health and wellbeing but working wonders at growing profits for both the pharmaceutical and agricultural industries. To cite but one example: the American Heart Association puts their seal of approval on Bisquick and Cheerios – both calorically-dense and nutritionally devoid of anything beneficial, but hey, both made by Big Agribusiness companies that liberally dole out cash to the AHA. By following the AHA’s advice, not only is it guaranteed that demand for these government-subsidized products will continue to grow, but demand for drugs to treat the conditions that they contribute to – heart disease, obesity, diabetes – will also grow. Capitalism at its finest, folks.

Time and again I see people in the hyperaldo groups post about how they gained 40 pounds in 3 months. Yeah, so did I. But I was able to lose it, and I have been able to keep it off – but only by ignoring conventional wisdom and figuring out what actually works. Or they post about how the government-backed DASH diet is making their postprandial glucose rise or causing hypoglycemic symptoms or other undesirable metabolic problems. Yeah, I know; if I ate that diet I would very quickly go from “borderline insulin resistant” to T2 diabetic, I’m sure of it. It just wouldn’t work for me; I would trade one health problem for another. I don’t consider that an option.

What works for me isn’t necessarily going to work for the next guy. Quite simply, here’s what works for me: I’m stubborn as hell and I hated being fat, so I will do just about anything to ensure that that never happens to me again. I don’t know what will work for you; I can only report back on my science experiment of one. But I do know this – that middle-aged guy who came to the endocrine surgeon’s office with a soda in each hand? That’s not gonna work. The 11 year old girl whose mom gave her a pastry and a soda while she waited? That’s not gonna work, either. And the guy on the support board who refuses to say goodbye to his Subway  sandwiches washed down with a gallon of Gatorade? Sorry.

Drugs, week three.

The cruel irony behind all of this? I never much enjoyed the idea of taking drugs recreationally. No wonder the fact that I have to take something daily for the rest of my life is getting me down! Anyway.

It hasn’t been all bad. It’s the psychological stuff that sucks, but aside from that I am seeing some improvements. These are good things:

  • I’ve only had one attack of palpitations in the past two weeks.
  • No more Giant Potassium Pills.
  • The blood pressure and tachycardia have started dropping a little bit. It’s still crazy out of control all over the place, but I keep an average and the average for both has dropped steadily over the last two weeks.
  • My trapezius muscle spasm has gone away for the past three days. This is the longest it’s been gone in about 7 years.
  • The only time I woke up with a headache was the day after I had a glass of wine. Er, make that two glasses of wine. Prior to the spiro, I could count on waking up with a headache just about every other day.
  • I don’t seem to be getting episodes of low blood sugar anymore. Maybe there is something to the notion that this will have a positive impact on my insulin resistance.

But other things aren’t so great. Such as:

  • That wine I mentioned? About an hour after I drank it I got hit with the most intense dizziness I’ve ever felt. Won’t be doing that again soon. I’ve had numerous bouts of dizziness without wine this past week, though, so perhaps the wine was only a coincidence. Still… proceeding with caution.
  • Postural hypotension. When I get up too quickly from sitting, of when I come out of forward bends in yoga class, my pulse starts racing and I feel like I’m going to black out. It’s supposed to be temporary, according to the doctors, and is not unexpected that this is happening because they believe my baroreceptor reflex is not working properly because of the aldosterone excess. I sure hope it passes quickly, since I’m not much enjoying it. I do not want to be forever known as The Girl Who Passed Out in Yoga Class.
  • And the big one – the psychological stuff. I’ve gone from the mindset of “a relatively simple surgery and the problem is solved” to “I’m stuck with this for the rest of my life,” and that’s not an easy transition to make. This may sound melodramatic, but the only time in recent memory I’ve felt this emotionally out of control was a couple years back after a friend’s suicide. I would be fine, and then out of nowhere it would hit me – I will never see this person again. This feels really similar – I’m fine one moment, and then I’m not, because – I will never have my old life back. Or maybe because The possibility that this will be cured has been taken away from me. I really, really need to figure out how to accept this and move on, but for now? I’m maybe only 50% there.

 

Insulin resistance and aldosterone.

Two doctors familiar with my case are convinced that my insulin resistance will go away as soon as the aldosterone overproduction is stopped, whether it is by surgery or eplerenone. I don’t want to get my hopes up, but – what can I say, my hopes are up 🙂

Here are a few relevant articles on the relationship between aldosterone and insulin resistance and/or Type 2 diabetes:

Role of aldosterone and angiotensin II in insulin resistance: an update (link opens PDF)

There is abundant evidence linking aldosterone, through non-genomic actions, to defective intracellular insulin signalling, impaired glucose homeostasis and systemic insulin resistance not only in skeletal muscle and liver but also in cardiovascular tissue.

Insulin Sensitivity in Patients with Primary Aldosteronism: A Follow-Up Study

Conclusions: Insulin resistance is present in patients with tumoral and idiopathic aldosteronism, but the defect appears less severe than in patients with essential hypertension. Treatment with surgery or aldosterone antagonists restores rapidly and persistently normal sensitivity to insulin.

Salt, aldosterone, and insulin resistance: impact on the cardiovascular system (link opens PDF)

Current clinical knowledge points towards an impact of salt restriction, RAAS blockade, and MR antagonism on cardiovascular and renal protection, but also on improved insulin sensitivity and glucose homeostasis.