Talking to your doctor

(Annette ) #1

I started Keto three months ago at the urging of my doctor. He and his family are all on it. I had tried it before but had quit when the Keto flu got bad. I thought I had an ally.
Yesterday, I asked for a fasting insulin lab order through the patient portal. The doctor is refusing, telling me it “isn’t necessary” and ordering an A1C.
I tried to challenge him nicely with the data, but he’s holding firm. I’m incredulous.
I guess I need to schedule an appointment to discuss this. Does anyone else have any effective strategies for when this type of thing happens?

#2

Just because a Dr realizes that keto helps people, doesn’t mean they REALLY understand this stuff. The sad reality is, that many of us normal people here know FAR more than our Doctors when it comes to getting/keeping ourselves healthy. On the fasting insulin, unless you’re a diabetic in recovery or are having issues that could be related to possible high fasting insulin, it’s true you probably don’t need one. With that said, just go to a lab like Quest or LabCorp and have them do one. They’re not expensive tests.

EDIT: Just noticed you’re in MA, you can’t order your own tests there. Gotta hit NH or RI to pull that off.

#3

If you can, maybe use an independent lab where you don’t have to involve your doctor…I had a specialist once argue with himself (literally), in front of 2 med students, a nurse, and myself about whether he was ordering a cancer screening test for me - he finally landed in a solid NO…and I knew in that moment or at least hoped to never see his indifferent face again lol.

(Bob M) #4

Fasting insulin isn’t a great indicator. Mine is all over the map, while my A1C went down, now back up slightly to 5.1.

My strategies for when my original doctor would not order an A1C: get a different doctor. Then, pay for the test myself.

If you wanted to discuss this, you could say you wanted to calculate a HOMA-IR to determine possible insulin resistance. Or he could give you a script for an OGTT that’s at least two hours long with insulin, and at least both insulin and glucose at the zero, 1 and 2 hour marks. (Though you should probably eat higher carb for at least a few days before the OGTT.)

(Annette ) #5

I have had gastric sleeve surgery 2 1/2 years ago and had high fasting insulin levels then. I want to see if my weight loss stall on Keto has anything to do with a high insulin level or if I’m doing better. I’m not diabetic but I suspect I was prediabetic before the surgery because my fasting glucose levels were in the 120’s.

(Cancer Fighting Ketovore :)) #6

Do you think that you could get him to order the fasting insulin along with the A1C? I mean, its not like the doctor himself is paying for the tests. It is true that fasting insulin can be all over the map, and maybe that is why he thinks its not necessary. You could always ask him for the reasons he feels its not needed.

I’m assuming that the doctor himself sent the reply saying its not necessary, rather than his nurse or MA (on his behalf).

(Jason ) #7

I ran into the same with my primary care physician, although with mine it was a much more sociable exchange. I had asked to get a fasting insulin, and his response was that he couldn’t do that. When I politely pressed him a bit, what he was trying to say what that I didn’t have a diagnosis that would justify a fasting insulin test, and therefore my insurance wouldn’t pay for it. As Bob says, they can be all over the shop, and not a good indicator of anything concrete. Once I realized this, I told him that I would happily pay for it myself out of pocket as I just wanted to understand my baseline, and I did end up getting the order. Not sure if your experience would be similar with an in-person discussion, but it might be worth a try.

(Bob M) #8

Just to illustrate, these are my values:

Insulin2
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My HbA1c is now 5.1, which I think is as low as it’ll go. I’m down about 60 pounds over this time, muscle mass increased, while my insulin has varied from less than 3 to 33. Without an insulin tester I can do at home, I don’t know why these are like this. (I did not show the OGTT with insulin I got; I only show the first value on 1/20/18.)

In general, is it better to have lower fasting insulin? I would say, yes. If you get a high value on one test for insulin, should you freak out? I don’t think so.

But if you have to fight to get a test done, insulin might not be worth the fight. Maybe GGT or ferritin or HbA1c, or others (CAC scan) would be worth fighting for, but I’m not sure insulin is.

(Jason ) #9

Thanks for Sharing, Bob. Interesting stuff, and I agree other tests may be more impactful.

(Annette ) #10

Yes, he sent it. I was clear with the reason I wanted it. In my mind at least, it seems like a reasonable ask.

(Cancer Fighting Ketovore :)) #11

Hopefully you can get it ordered. But as others have said, it’s a"noisy" number, changing alit.

(Annette ) #12

Ok. I guess I’ll just calm down then. I can probably get it done in December when I go for a follow up in the weight loss clinic.

(Bob M) #13

Don’t get me wrong, as there are a lot of people recommending fasting insulin as a test. But my experience with it hasn’t been great. Here’s my entire table:

image
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(By “entire”, I mean relative to the insulin part; there are a lot of columns of data I’m not showing.)

On 5/9/18, I went to the doctor’s office and was doing a 36 hour fast. I went in the afternoon, and she took blood tests, including insulin. The value then was 5.7. That’s one of the lowest ones I got.

Here’s my theory. I was able to achieve lower insulin in the morning in 2015, as I was only low carb for not that long, and might have been eating slightly higher carb than I do now (I was trying paleo/resistant starch, and it might have been about that time). Now, I have more physiologic insulin resistance in the morning, which I think yields both higher blood sugar and higher insulin in the morning. This is why my lowest insulin reading in a long time was taken in the afternoon.

The highlighted yellow are after 4.5 days of fasting. I wish now that I would’ve gotten insulin done then, for all of these, to see what happens (a trend of insulin being higher over time would fit with my theory). Alas, since I pay for most of these myself, these tests get very expensive. So, that’s why I did not get them done.

As for the two really high readings on 10/31/16 and 11/14,/15, I have no idea what caused them. Looking at my records, I was doing a bunch of 3 day fasts right before the 10/31/16, so I would have thought my fasting insulin would be lower. My insulin then shocked me so much that I got another test done on 11/14/15, even though I went on vacation in the interim. (Check out the difference in cholesterol readings in two weeks, or even when fasting and in a week or less.) I’m still flummoxed as to what happened to those two readings.

It would be really nice to have an insulin meter. That would help to answer some of these questions. For instance, does my insulin – like my blood sugar – go up in the morning, then down all day long? How does eating affect these? Does my higher protein diet affect these levels? None of these questions are answered by a morning, fasting insulin test. It really only tells you when something is really wrong.

#14

I had an first appointment with a new doctor last spring and she nearly refused to order an A1C. I really had to press for it. When she agreed to do it “this time” I knew it would also be the last with her. There were other reasons I didn’t really like her, but I live in a major city and should be able to find a doctor who not only doesn’t argue with me over basic tests, but orders them without me asking.

(Annette ) #15

Agreed. That’s a basic test.

(You've tried everything else; why not try bacon?) #16

Fasting insulin is not the best indicator of your metabolic status. A far more accurate indicator would be an oral glucose tolerance test, which is expensive and time-consuming. Also, HbA1C, which you say your doctor did order, is a pretty reliable indicator of metabolic health.

Your reasons for wanting a fasting insulin may not have registered fully with the doctor. I suspect he was primarily thinking of which markers would most effectively enable him to diagnose your metabolic health, so it might be worthwhile to spend a bit more effort trying to get through to him with what your concerns actually are.

In my area, fasting insulin is an automatic part of a routine blood workup, and it is HbA1C that one has to fight to get tested.

(Annette ) #17

Here’s an update: my doctor got back to me and agreed to do the fasting insulin. My level is 3.8! I am absolutely thrilled with that number. I was as high as 19 in the past.

(Bob M) #18

3.8 is great! Mine have varied between “<3.0” to 33, so that’s a wonderful result.