Medical Waste

Today's fact is inspired by my brother, who is apparently concerned about medical waste. Who woulda thunk it? Anyways,

Under Illinois law, household waste (including my needles and test strips and so forth) does not constitute potentially infectious medical waste.
Household medical waste must be put inside of a sturdy, nonpuncturable container, such as a sharps container or a laundry detergent bottle, marked DO NOT RECYCLE, and can be thrown out.

The United States does not have uniform regulations for disposing of hospital generated medical waste, but generally it is incinerated. I did not realize until I looked it up just now that that means reducing it to ash, energy, and gases. That's a pretty big pollutant sort of thing.

This concludes a month of diabetes facts. I decided to do this in honor of Diabetes Month, not nanoblomo, but I guess it works. But don't worry, I still have three brothers to interview, and lots more facts to share. Just not every day, probably.

Why, Yes, I Can Eat That

When I was diagnosed with diabetes, I was already fairly knowledgeable, for a member of the public, about diabetes. I had googled my symptoms and read a bit about diabetes, feeling sorry for those who had to take shots. And as a disability conscious person, I had met a few people with complications of diabetes. I had even read a few of books about children with diabetes, including in the month before my diagnosis, the book Sugar Was My Best Food by Gregory Adair and relatives, a nonfiction book about a boy who with type 1 diabetes who was not allowed much of any sugar.

Despite all of this, I believed at the time of my diagnosis that sugar was toxic to diabetics. Nobody disabused me of this notion until perhaps three days after my diagnosis when the pediatric endocrinologists finally asked me if I had any questions. I had one. One big, burning question. It wasn't about complications. It wasn't about research or a cure. It was, "What am I allowed to eat with diabetes?" She said I could eat anything. "You mean, anything? I can eat candy? As much of it as I want?" and she said, "Well, it will still make you fat of course!"
As a matter of fact, I now eat more candy than I want and I haven't gotten fat yet, but that's not diabetes' fault.

Many members of the public assume that sugar is toxic to people with diabetes, especially those of us whose diabetes they think of as severe, which is to say, type 1 diabetics. I will not say as a fact that sugar is not toxic to anybody. Maybe sugar is toxic to everybody.

I have taken advantage of this prejudice occasionally to stop somebody from giving me a food I didn't want by telling them I was diabetic. No thanks, I don't want your candy/cake/cookie, I have diabetes (and I don't want to take a shot right now).

What is a fact, however, is that there is no such thing as The Diabetic Diet that all medical professionals agree is good for everybody with diabetes. We are not all trying to lose weight, gain weight, maintain weight. Some of us avoid certain foods that affect our blood sugars in ways that we do not know how or perhaps can't prevent. These are NOT the same foods for every person with diabetes. Some people with diabetes eat a low carbohydrate diet; others eat a high carbohydrate diet; others eat whatever they happen to eat. None of these things are necessarily bad for their blood sugar control, although depending on the person, it might be.

One fact that is universally true however, is that sugar does not cause any greater requirement for insulin overall than other carbohydrates (excluding fiber) do. Sugar causes a more immediate and quick need for insulin; but not a greater need.

Currently, because of what they do to my blood sugars, I avoid the Sprite Zero soda absolutely, as well as flavored waters with artificial sweeteners. They supposedly have no carbohydrates but all of the times that I have had them, my blood sugar has gone very high. I don't know how to deal with that.
There are many times when I turn down a food because it would take too much effort to eat it without a bad effect on my blood sugar. Maybe I'm high at the time, or maybe it's a food that needs measuring exactly, or maybe it's a food that I tend to need to take two shots for. Sometimes it's just not worth it.
But my overall diet includes just about everything.

When you are offering food to people with diabetes, you should assume that they have the same dietary range as everybody else, but you should also keep in mind that there are lots of reasons why a person might not want to eat a food. Maybe they are picky eaters, trying to lose weight, have allergies, vegetarian, or just don't like to eat in public. You should also be aware of the nutritional content of the foods you offer or have nutritional information on hand, as this will make deciding on your food much easier not only for people with diabetes but for those with other food restrictions as well.

I got home today just as my parents were telling my 14 year old brother to go to bed. He has agreed to be interviewed tomorrow after school.

Neonatal Diabetes

Many people get confused about type 1, juvenile onset diabetes, and think that it is something you are born with. Autoimmune diabetes is not present at birth; it takes a little time to develop. It is almost never diagnosed in babies under six months, although about half of people who develop diabetes antibodies have them by the age of five years.

However, a few more than two babies per million are born diabetic, in that they are born with something affecting their ability to make insulin, and will be diagnosed with diabetes usually within the month and certainly within the year. There are many causes of neonatal diabetes. About half of cases of neonatal diabetes are transient- they go away on their own, and may or may not come back later- and about half are permanent.
Most forms of neonatal diabetes can only be treated with insulin, but those with a group of related forms of permanent neonatal diabetes may be treated with oral medications.


I see a bunch of parents writing about their non-diabetic children with diabetic siblings and I wrote a bit about my own experiences as a sibling to brothers with special needs and then about my brothers and then I thought, nah, that's bogus. Let's hear what they say. So, I promise, I will ask my youngest two brothers what they think about having a diabetic sibling. My guess is that they will say I talk about it too much, but we will see.

P.S. Sorry for the original title- I started writing a different post and realized I was running out of time to finish it.

Conditions That Cause Insulin Deficiency

In the most common form of type 1 diabetes, antibodies attack the islets of langerhans, destroying all or most of the body's ability to make insulin. Each antibody attacks only one thing (sort of- some will attack a couple substances that are similar to each other) and there are many antibodies associated with diabetes.Different antibodies are associated with slightly different disease onsets and courses; most people diagnosed with type 1 diabetes have multiple antibodies at the time. In general, more antibodies = faster onset.

At my diagnosis I was tested for three; insulin antibodies (which are least likely to cause diabetes, and which I did not have), GAD-65 antibodies, which attack the glutamic acid decarboxylase around the islet cells (this antibody is the most common antibody in LADA adult onset type 1 diabetes- my levels were about 5x the upper limit of normal) and Islet Cell Antibody 512, which attacks the islets cells themselves and is more common in younger children diagnosed with type 1 diabetes- my levels of this antibody were more than 50x the upper limit of normal.

People with autoimmune complexes, particularly polyendocrine autoimmune disease, are more likely to get type 1 diabetes.

About 5% of people with Down Syndrome develop autoimmune type 1 diabetes (oddly enough, one study I read comparing adults with Down's and diabetes to adults with type 1 only showed those with Down's to have lower A1cs).

Cystic fibrosis affects the pancreas directly by impairing the pancreatic ducts. Most people with cystic fibrosis develop deficiencies of pancreatic enzymes, but have only minor dysfunction of the endocrine pancreas. However, a significant minority of people with cystic fibrosis have enough damage to the islet cells of the pancreas, or the areas nearby that allow the insulin to get out and circulate, that they have diabetes related to not having enough insulin.

In rare cases, babies are born without fully developed pancreases. In these cases, they have permanent neonatal diabetes.

Rarely, people with pancreatic cancer have their pancreata (the plural of pancreas is pancreata) removed and thereby have diabetes.

High blood sugar over times stresses the islet cells; chronic high blood sugar can lead to an inability to make insulin.

Alcoholism can damage the pancreas, sometimes to the extent that the pancreas's ability to make insulin is irrevocably impaired.

What diseases are missing from my list?

Vampires and Diabetes

In the novel Sweetblood, Pete Hautman's protagonist, a teenage diabetic, formulates the theory that vampire myths arose out of the history of untreated type 1 diabetics. Personally, I think it's a bit far fetched, but I thought it made very interesting the

Fact: Anne Rice, one of, if not the most popular vampire novelists, has a diagnosis of type 1 diabetes. I was disappointed to learn that she was diagnosed well after most of her books were written, at the age of 57, and that diabetes was not the impetus for her interest in vampires.
From interviews with her, it sounds like she doesn't have a great grasp of type 1 diabetes (but frankly, what celebrity does?), but she was diagnosed in DKA after a lengthy illness and is on a regime of multiple daily injections.

P.S. Pete Hautman was himself diagnosed with type 1 diabetes as a young adult.

How Much Sugar is Really In Your Blood?

I thought I wasn't going to do anything for Thanksgiving. My family's not big on holidays and we almost never get invited anywhere or have anybody accept our invitations. I hate that everywhere is closed and there never seems like there's anything to do.

But last night, I got an email from a friend of mine. I met her a few years ago at a youth group and when I noticed her injecting, we got to talking. She moved a few states over some time ago and I haven't seen her in a long time. She emailed to say that she was in Chicago and had no plans for Thanksgiving, was my invitation to come over still open?

So I am thankful for having an extra reason to bug my father to count the carbs in what he cooks for us! Also thankful to have a father who cooks for me. He is making pizza today. Usually it ends up being about 20 carbs per slice.
I am also thankful for opportunities where somebody else is counting carbs at the same time as me and can give me feedback on how well I'm counting carbs. I love when I'm sitting with somebody else who's counting and one of says, "That's 5 carbs, right?" and the other says, "No, I count it as 15!" and we have to look it up. Usually I'm right, but I was totally wrong about popcorn a while back- I was counting it as 15 carbs per bowl and it was more like 5. Oops.
I'm additionally thankful that I have the math skills to count carbs, and I'm thankful that the hospital that did my diabetes education had switched to the carb counting model rather than the food choices model two years before my diagnosis. Not that I think the food choices model was such a terrible idea, just that I think it would be no where near accurate enough for a person of my size who makes no insulin, and also that it was more limiting.

My 18 year old brother likes to ask me what the highest possible blood sugar would be. I don't know. There are some limiting factors. For instance, the number of mg of sugar that would fit in an mL, and at what point a person would pass out and stop being able to eat. You can bypass the eating bit though, if somebody gives you an IV of glucose, which is how the man with type 1 diabetes below got a blood glucose level of 5600.

http://www.childrenwithdiabetes.com/dteam/1997-07/d_0d_1xf.htm

Although googling "highest blood sugar recorded" gets you a boy with a blood glucose of not even 2400, one of the doctors in my congregation told me about a patient (an adult) of his who has pancreatic damage and is cognitively impaired. His mother gives him his insulin most days, but a couple times per year this guy decides to go on a trip for a few days, usually to a concert, and doesn't take insulin for that time. Once he came back and came to the doctors, and was peeing in the waiting room, peeing, peeing, peeing. His blood glucose was 2600, or so I'm told. The doctor told me he wouldn't have believed it except that two hours later it was 2400, and two hours after that it was 2200 mg/dl.

Since mg is a mass (milligrams) and dl is a volume (a decaliter), there is no answer to how many mg are in an dL. However, I found a source that says that there are 620 mg/mL of sugar in a sugar syrup, which means that in pure sugar syrup, there are 62,000 mg/dl or sixty two thousand mg/dl.
Also, in older blood sugar records, blood sugar is given as a percentage. And a blood sugar of 200 translates to, in the way they recorded it, 0.2%, which suggests that the blood sugar is out of a total of 100,000 which is one hundred thousand.
So a sugar level of a million mg/dL is impossible even if it doesn't have to have blood in it.

Longevity and Diabetes

Most deaths in people with type 1 diabetes are attributable to diabetes; even among children, diabetics have about twice the risk of death.
Most people who die of diabetes die from heart disease.

However, among those who have certain risk factors- diagnosis in teens or twenties, African American, hypertensive- kidney failure is a real risk (and even with kidney failure, cause of death may be heart disease because kidney disease exacerbates heart disease). In the studies I have read, the median age for type 1 diabetics whose kidneys failed ranged from 37- 42. That is not old.
To reassure those of you reading this blog who are parents of kids with diabetes, I would like to point out that people diagnosed in the 15-20 age range have about 20x the risk of major kidney disease than those diagnosed in the 1-5 age range.
Out of more than 17,000 kidney-pancreas transplants done in the United States since 1988, more than 15,000 were done in people under 50. More than 5,000 were done on people under 35. Only 19 were done on people 65 or older. Admittedly, this is partly because of the bias in who gets transplants.
But among non-diabetics who received kidney transplants, 9% were over 65, compared to less than a tenth of a percent among diabetics who received kidney transplants. Source? http://optn.transplant.hrsa.gov/latestData/rptData.asp

So I can understand why a person might get fatalistic if they have diabetes. I listen to people worrying about passing on diabetes to their children... I'm more worried about abandoning children by getting sick and dying while they're young. I'd rather be diabetic than have a parent be sick and dying during my childhood, I think.

I find little comfort in the idea that better control means slower progression of complications. Frankly, control seems out of my control most of the time. But in addition to knowing that complications can happen despite my efforts, I also know that longevity happens to some people with diabetes despite their lack of control.

Joslin gives a medal to people who have made it 75 years with insulin dependent diabetes. They first awarded such a medal in 1996. That means the person had been diagnosed with diabetes before insulin was available and still made it for another 75 years. Whoa! Joslin has awarded 1-2 such medals per year since then.
If I made it 75 years with diagnosed diabetes, I would be 92 years old, and I don't think you have to factor in diabetes for me to not get that far- both of my grandfathers died at age 79.

While I tend to believe that people who make it 50 or more years with diabetes do probably have genes that most of us don't, I still keep in mind that most of us don't know what genes we do or don't have. I talked to a woman on tudiabetes chat back when it had a chatroom, who told me that she had a bunch of diabetic family members who died as young adults and she herself assumed that she was going to die young and when she got to thirty and was still perfectly healthy, other than the diabetes, she realized that she hadn't done anything to prepare to live the life she'd want to lead if she was going to live for a while yet.
In one of the books I read about diabetes, there's a story of a woman with diabetes who assumed she would die young, so she did a lot of dangerous things. She smoked on the theory that she would die before lung cancer could get her (bad idea- smoking triples risk of amputations with diabetes), she took drugs- and then she died young, not of diabetes but of a drug overdose. In numerous studies, youth with diabetes are at a higher risk of smoking, drinking, and using illegal substances compared to nondiabetic youth. I believe that this is partly because of the sense that we have got to do our living now.

While I was searching for information on Joslin medalists, I found the story of a guy who was on insulin for more than fifty years... and then found he didn't have type 1 diabetes after all! http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1547158/?page=1

I think he should get to keep the medal- he should get something for putting up with fifty plus years of shots!

My third leg sensor, like the first, ripped out. I hadn't cut the hair on my leg first, and all the hair seems to want to stick to the sensor- static electricity, I guess- and it didn't stick well. After a few days it ripped out. I'll try another leg sensor another time. I went about a day without a sensor. I was feeling kind of discouraged about the usefulness of the sensors.
I went to get a free A1c done at a Minute Clinic (special runs til tomorrow, for diabetic adults only) and since it was a Bayer A1c now, I don't know how accurate it was, but it said 6.1%, which is the lowest A1c result I've ever gotten. The nurse practitioner got kind of defensive when I questioned the veracity of the test, but in a good way. She read to me from the study of the test, and I'm not sure I understood it. Either their math was inconsistant or I misunderstood, and I think I misunderstood. But she said it showed the A1c was only accurate to plus minus a percent- like a 6.1 could be a 5.1-7.1 - and that the venous blood draws were almost as inaccurate. I doubt it was right but in case it was, I went home and had my father put in another sensor. I'm very proud of him for putting in these last two. He is kind of cute and nervous doing anything with my diabetes but he did just fine.
I'm getting my A1c done by venous draw in another couple weeks so we'll see how closely it matches. I hope it matches. 6.1 would be ace.

I can't state for a fact that all mammals have pancreases because I haven't got a source for that; but I believe it's true. Birds have pancreases too.
Dogs are even more likely than humans to get diabetes; in addition to an autoimmune diabetes that's like type 1, old dogs tend to get pancreatitis, which is an incredibly painful disease that can cause diabetes. Cats also tend to get insulin resistant as they get older, and also sometimes get pancreatitis.
Cats and dogs have about the same normal range for blood sugar that humans do.

Pigs, on the other hand, have a normal blood sugar range of 20-80. That's right, folks; a pig with a blood sugar of 25 is happy as a pig in a sty.
I learned this fact while reading about development of an artificial pancreas being tried in a pig where the authors were wondering about the issue of maintaining pig blood sugar in human range even though that's not where pig blood sugar is supposed to be.

Like Insulin For Diabetics!

Insulin and diabetics are a metaphor in the public mind.

Frequently when I read or hear about people explaining why taking a drug is important for people with a particular condition, they say that taking Drug for Condition is like taking Insulin for Diabetics.

It's rarely a fitting comparison, for reasons I suspect everybody reading my blog can think of. But the simple reasons are because of what insulin is to people who make no insulin:
1. What keeps us from certain death between now and next Monday.
2. Among the most likely things to kill us between now and next Monday.

Few medications other than insulin are really keeping people alive in a week by week sort of way.

But this is not as interesting to me as what it reveals about what people believe about insulin.

First, it suggests to me that despite the gnatterers who tell me that with exercise or herbs I could go off insulin, most people understand that diabetics really need insulin.
Since people frequently use the "like diabetics" to try to decrease the stigma around taking psychoactive meds, they must believe that taking insulin when you are diabetic doesn't carry much stigma. Taking insulin when you are diabetic does not represent weakness.
And lastly, one of the arguments used about why something is like insulin (correctly!) is that it fixes a deficit in the body. I need to use insulin because I make vanishingly little. A person might use insulin because they have less than they need.

Fact: Insulin levels themselves are rarely measured. People using insulin usually check their blood sugar levels on their meters, not their insulin levels.
Having an insulin level checked can be done through a blood draw from a vein (not on a meter).
This is more expensive and less useful than the more commonly done c-peptide test which figures out how much insulin a person is making, rather than how much they have in their bodies.

My mother was cleaning today and she came across my labs from when I was diagnosed. I had misunderstood some tests done in my hospitalization. I thought that I'd had my c-peptide drawn twice, and that once it was negative and once it was low but measurable. As it turns out, I actually had my insulin levels measured! They were measured at 8 PM on the day I was diagnosed with diabetes, while my blood sugar was 453. I think but am not sure that this was after I was already given insulin. At that time, my insulin levels were low but measurable. My c-peptide was measured the next day and was undetectable.

The Body's Response to Hypoglycemia

In a nondiabetic person, the body has more than a dozen responses to low blood sugar.
If you took my (presumably totally nondiabetic) brother, and shot him up with 15 units of insulin, here's some of how his body would respond:

First, his blood sugar would drop. Insulin is insulin.
Once his blood was low, his body would do the following, roughly in this order:

Turn down own insulin production, not quite off. This makes sense, right? If you're low, you don't want more insulin.
Turn up glucagon production. This causes release of glycogen from the liver, raising blood sugar.
Release cortisol- this creates insulin resistance and is also a hormone that helps the body deal with stress.
Release epinephrine aka adrenaline. In addition to possibly alerting him that something was wrong and making him eat, this would cause insulin resistance.
Release norepinephrine aka noradrenaline. Dunno what this does.
Release growth hormone. This is a hormone that is made partly in response to the presence of too much insulin and low blood sugar. It also causes insulin resistance.
Release pancreatic polypeptides. Don't know why, except perhaps because of decreased insulin secretion.

If he goes low enough, then his body will go into an emergency state- it will cut off circulation to his extremities and stomach, and after a while he will have a seizure.
Cutting off circulation to the extremities, in addition to being something you can feel that may alert you to a problem, will help keep the needed sugar by the muscles (heart and lungs) that really need it, as well as by the brain. The seizure will also help cause insulin resistance and raise blood sugar further.

Now, let's take a look at what would happen if I got 15 units of insulin.

First, my blood sugar would fall. I'm not insulin resistant either.
But here things fall apart.

I can't turn off my body's basal secretion of insulin; it doesn't secrete insulin. I can't take the insulin out of my body. Even if I were an insulin pumper, the insulin I'd be able to stop taking wouldn't raise my blood sugar for at least another 15 minutes and probably quite a bit longer.

Because the various hormones the body makes in response to hypoglycemia are a little dangerous (adrenaline can cause heart attacks), it is healthier for it to only respond strongly if it's really needed, so it has a threshhold for when it responds. Because I am frequently low, my body will not respond to a low until I am a lot lower than my brother.

Next, because my type 1 diabetes is not new at all, I will not make any glucagon in response to hypoglycemia.

My body CAN make adrenaline, noradrenaline, growth hormone, and so forth. And it will, a bit. Two things stop it. First, I've been low in the past. My body does not want to react to lows too aggressively, and it seems I've been low before. So it lets this go. Second, the body's ability to do these things are impacted by years of diabetes- autonomic neuropathy.

My body CAN go into emergency mode. As far as I know, this ability is not impaired at all in diabetics. Yay body!

Despite the assumptions of the general public, people with type 1 diabetes are less able to respond to low blood sugar than are nondiabetics. Despite the assumptions of most type 1 folks, we can and do survive many undetected episodes of hypoglycemia during the nights.

Early Detection Saves Lives

Fact: Undiagnosed diabetes is untreated diabetes.

It is estimated that by the time they are diagnosed, 50% of type 2 diabetics and 5% of type 1 diabetics already have complications- most commonly peripheral neuropathy and microalbuminuria.

Of small children diagnosed with type 1 diabetes, a third are diagnosed in DKA. Of adults diagnosed with type 1 diabetes, a fifth are diagnosed in DKA.

Even with the best medical care, patients who are in severe DKA at diagnosis often die within the week.

A higher HbA1c at diagnosis- meaning a diagnosis later in the disease course- predicts more complications.

A lower HbA1c at diagnosis -meaning an early diagnosis- predicts a longer honeymoon in which blood sugar is easier to control.

Individuals who do not have a close family member with type 1 diabetes are at thirty times the risk of being in DKA at diagnosis compared to those who have family members diagnosed before them. That suggests that being educated about the signs and symptoms of type 1 diabetes, as well as being diligent about reacting to them, can prevent at least twenty nine out of thirty cases of diabetes from being diagnosed while in DKA.

As a general rule, onset is faster in younger people, regardless of type of diabetes. But there is a huge variation in the amount of time that will pass from the time that a person has enough of a problem to benefit from treatment until the time that a person will die without it.

I was diagnosed in DKA after having been symptomatic for over a year and suspect that I had diabetes for multiple years before my diagnosis of type 1 diabetes. My HbA1c at diagnosis was off the charts (somewhere above 16%). My symptoms at the time I was diagnosed were no worse than they had been two weeks earlier.
Less than three years after my diabetes diagnosis, I had peripheral neurpathy. My feet tingle tingle tingle all the time. They don't hurt and I hope they never will. Tingle tingle tingle. Would they tingle if I had been diagnosed while my A1c was still below 10%? I don't think so.

You can detect diabetes painlessly with a simple ketodiastix test of the urine. These will test for the presence of sugar in the urine and ketones in the urine. Trace to small ketones may be present in a person under great stress who is healthy. Moderate to large ketones indicate dangerous dehydration and possibly diabetes. Sugar in the urine almost always means that a person has diabetes, although diabetes is possible without sugar in the urine.
For optimal detection of diabetes, the urine test should happen after a meal (say, dinner) because some people develop trace ketones overnight and in early diabetes the blood sugar falls to normal after hours of not eating.
You can buy 100 strips for 24 dollars.

There are no symptoms that are present in every person diagnosed with diabetes, except for high blood sugar. I misread a list of symptoms of diabetes in the month before I was diagnosed and thought that because I didn't have ketone breath (in fact, I did have ketone breath, I just couldn't smell it) I couldn't have type 1 diabetes.

Symptoms of high blood sugar include:
thirst, hunger, fatigue, needing to pee a lot(proportional to drinking a lot), blurry vision, lightheadedness, weight loss, dehydration despite clear pee

Symptoms of ketoacidosis include:
shallow breathing, fatigue, ketone breath (smells like rotten fruit, I'm told), confusion, disorientation, stroke, coma, death

Complications of having high blood sugar for months include:
urinary tract infections, weight loss, lingering illness, slow healing wounds, stronger glasses prescription, headaches upon waking, bloated stomach, peripheral neuropathy (especially painful feet), sensitivity to light, exhaustion

Leonard Thompson.

I restarted the second belly sensor for a third week. It is not giving any ???s but the accuracy leaves something to be desired; unfortunately I rely on my mother to help with sensor changes and she hasn't been available so I guess I'll keep wearing the sensor. It is doing okay. I placed it as high as I could that was still below the ribs (which is to say, about level with my belly button) on the advice of another diabetic who says she gets better results there.

Facts: Leonard Thompson was the first diabetic to benefit from insulin. He was diagnosed with diabetes at the age of 12; he first received insulin at the age of 14 (at which point he was in severe DKA in a hospital in Toronto), and he lived to the age of 27. Leonard Thompson had nasty skin reactions after shots. I have read that he died of pneumonia, diabetes complications, and impurities in insulin. I'm not sure which of these stories to believe.
I have found an article with the medical records of Leonard Thompson's death but I don't have a subscription. I will try later to see if I have an account somewhere (library, former school) that lets me access the article. Here it is: http://www.nejm.org/doi/full/10.1056/NEJM198202113060605
The first 100 words are an introduction to Leonard Thompson's hospital admission at age 27 in ketoacidosis.

Genes, genes, genes

Because type 1 diabetes tends to develop earlier in life than type 2 diabetes, and because the public is repeatedly told that type 2 diabetes is a result of poor lifestyle choices, most people, including most type 1 diabetics I have met, believe that type 1 diabetes is genetic or at least more genetic than type 2 diabetes.

Now, whether something is "more genetic" is something I realize is hard to define. Having a family member with type 2 diabetes puts you at a higher risk of diabetes than a family member with type 1... but then again, being a human being puts you at a higher risk of type 2 diabetes than type 1.
Having a family member with type 1 diabetes multiplies your risk of getting type 1 diabetes by many times more than having a family member with type 2 diabetes does... but that's in no small part because, with 1 in 3 members of my generation expected to develop type 2 diabetes in our lives, you can't possibly multiply that risk by more than 3.

A few forms of diabetes that are entirely genetic exist. They include some forms of neonatal diabetes, the various MODY diabetes, and diabetes associated with certain genetic disorders such as cystic fibrosis (in which the pancreatic ducts clog up).

But your run of the mill type 1 and type 2 diabetes are an interaction between environment and genetics. According to the ADA the genetic component of type 2 diabetes is larger. Having a family member with type 2 diabetes puts you at a higher diabetes risk than having a family member with type 1 diabetes does.
The ADA page contains stuff that is mathematically impossible though. It claims that the risk of a child developing type 1 is 1-6% if a parent has it; but that 1 in 7 type 1s have a particular gene and if they do have that gene, the kid has a 1 in 2 chance of type 1 diabetes. Well, 1/2 time 1/7 is 1/14 which is more than 6%. I don't buy it. For one thing, as far as I can tell, that gene does not exist. Polyglandular autoimmune syndrome 2 (which basically means having multiple auotimmune endocrine disorders, particularly thyroid disease and type 1 diabetes) has not been shown to be caused by any one gene.

I was going to write a lot about HLA types but I'm too tired. Let me say instead that the fact that fascinates me most about diabetes and genetics is that having a different high risk allele from each parent- being heterozygous- confers the highest diabetes risk.

Diabetes and Complications

Many diseases are more common in people with diabetes, for two reasons.

Reason 1: Something puts people at risk of developing both diabetes and other diseases.

Reason 2: Diabetes causes other diseases.

With sort of cross between them being

Reason 1.5: Something causing diabetes (tendency towards high blood sugar) also causes another dysfunction.

The diseases in the first category will usually be more common in relatives of people with diabetes as well as in diabetics themselves. Almost all autoimmune diseases fall into the first category for people with type 1 diabetes and their families.
Diabetes does not cause other autoimmune diseases, but both the genes and the unknown environmental factors leading to type 1 diabetes put people at higher risk of other autoimmune diseases.

The diseases from reason 2 and generally called "complications" of diabetes.

These include:

-glomerular nephropathy, or kidney disease. This develops in 60% of men with type 1 diabetes and 40% of women with type 1 diabetes. Risk is much higher for those diagnosed with diabetes during or after puberty, compared to those diagnosed prepubertally. Other factors affecting risk of nephropathy include diabetes control, genes (there is a gene that is strongly protective against diabetic kidney disease, and it is more common in people with diabetes), c-peptide levels, and blood pressure (low normal is best).
The good news about diabetic kidney disease is that the majority of cases never progress into symptomatic kidney disease. Especially in men, diabetic kidney disease tends to progress slowly. If it is in early stages, it sometimes even gets better.

-Atherosclerosis, or hardening of the arteries, is found in almost everybody with diabetes. Looking for studies to back up this assertion, I found this blurb studying children with type 1 diabetes and children without diabetes- there wasn't even any overlap between the two groups in terms of the flexibility of their arteries. Not a single of the thirty two children with diabetes had arteries as flexible as the least flexible of the fourty seven children without diabetes.
Arterial disease is part of why heart disease is assumed to be present in all people with diabetes and heart healthy activities and diet are important.

-neuropathy or nerve disease includes a whole bunch of diseases of the nerves. Some degree of neuropathy is present in 90% of type 1 diabetics after 20 years, but how much neuropathy, and whether it is enough that it makes any difference in the person's life, is affected by numerous factors, including unknown ones, but primarily blood sugar control.
Autonomic neuropathy can cause problems with hypoglycemia awareness, blood pressure, sexual function, continence, and digestion.

-gastroparesis is a disease of the stomach causing fewer contractions and impaired digestion with delaying of digestion. While some studies claim that more than half of type 1 diabetics have delayed gastric emptying, I believe that this is an error due to the fact that delayed gastric emptying is seen with high blood sugar in just about everybody (I think that's the body's way of stopping itself from going even higher). I think the actual portion of people getting gastroparesis after long term type 1 diabetes is probably more like 1 in 5. Blood sugar control affects risk of gastroparesis a lot.
Diabetics account for more than half of all people with gastroparesis.

-Numerous eye diseases are more common in people with diabetes but the most problematic and common is retinopathy. In retinopathy, the small veins in the retinas break and bleed, and the bleeding causes problems. In proliferative retinopathy, the eyes grow new veins to replace the broken ones, but the new baby veins are even more fragile and when they break there's even more bleeding.
Some degree of retinopathy develops in about 80% of type 1 diabetics. Getting severe retinopathy is more likely the longer you've had diabetes, the worse the blood sugar, and if you get pregnant (one in three women who has retinopathy at the beginning of her pregnancy will see a progression in the disease within that year).

-Although they are not generally thought of as complications, dementia, strokes, and hearing loss are more common in seniors with insulin dependent diabetes.

-The acute complication of type 1 diabetes is diabetic ketoacidosis, which is mostly preventable. It most commonly happens in three circumstances: undiagnosed diabetes, insulin discontinuation (which can happen on purpose, through poverty, or when an insulin pump or pump site or insulin pen breaks), or illness. In situations of illness, ketoacidosis is still usually preventable but when the insulin needs go drastically up, many people do not know how to raise their doses appropriately and will go into ketoacidosis.

-Diabetic mammopathy or breast disease is about the most benign diabetes complication I can think of. It happens in about 1 in 7 women who develop diabetes before menopause and the disease consists of getting dense masses in the breasts that are impossible to tell apart from cancer without a biopsy. Diabetic mammopathy therefore results in lots of breast biopsies.

-Other: Fatty liver disease is found primarily in people with type 2 diabetes and is rarely symptomatic in type 1 diabetics. Blood formation may be accelerated in people with higher blood sugar due to higher rates of blood cell death. Urinary tract and bladder infections are more common in people who pee sugar, including the majority of diabetics and occasionally nondiabetics. Gum disease can be caused by diabetes. Ermm... I believe that's all, folks.

Next up: genetics of diabetes.

Administering Exogenous Insulin

One of the misconceptions people most frequently tell me that they have had about diabetes, along with "At least it's manageable" and "You must have some sweet tooth!", is that you can take insulin by mouth.
And why shouldn't they think that? From the very beginning of oral hypoglycemic agents, the press has confused medication to improve the body's natural ability to make and use insulin with insulin itself.
Not only that, but when insulin was being developed by Banting et al, they did try giving it orally before it occurred to them that it might need to be injected.

But insulin is digested if you try taking it orally. It will not lower blood sugar. It might, maybe, alter the way that the body's immune system deals with insulin- it has been tried for prevention of diabetes- but it does not work as insulin.

But there are lots of ways to bypass the digestive system.

You can inject insulin into a vein- only regular insulin is approved for this use, and since intravenous injections are kinda dangerous and tend to damage veins over time, and you kinda need your veins, and plus you don't usually want to get your insulin that fast - people don't usually take insulin this way. Insulin is given through IV mostly in hospital settings either in treatment of DKA or during surgery, although it may be given IV at other times.
Dr. Bernstein of the low carb diet recommends IV insulin as a method of getting blood sugar down as quickly as possible but frankly I think the risks outweigh the benefits by a long shot (get it? a long shot!)

You can inject insulin into your skin. It will form a painful bubble before being absorbed into the fat layer underneath and from there to the blood stream. That hurts, is hard to do on purpose, and leads to slow and inconsistent absorption. As far as I know, people mostly do this by accident, and not very often even then.

The most common and recommended way of getting insulin into people is by injecting into fat. The trickiest part of this is that some people (like me) don't have a whole lot of fat to inject. Injections into fat have all the problems of other injections: they can hurt, cause bleeding, cause scarring, and damage tissue. But at the moment it seems to be the best bet. Injecting into fat generally causes a gradual and consistent release of insulin into the blood stream.

Another place you can inject insulin into is muscle. Personally I do this an awful lot, mostly by accident. I can tell because I feel resistance from the needle as it breaks through. Injecting into muscle has both the advantage and disadvantage that it causes quicker absorption of insulin. It may also be less regular, because using the muscle will change how the insulin absorbs. Injecting muscles tens to cause more bleeding, scarring, etc.

A great study I recently read about skin, fat, and muscle thickness is here. The most important take away is that skin thickness is 1mm- 4mm, and that especially in skinny and male adults, it is not unsual for the fat layer in the arm and thigh to be thin enough that shots intended to be subcutaneous will be intramuscular even with very short needles, if they are used at a 90 degree angle. The other take away that is important is that in almost 400 people, more than half of them overweight, they did not find a single person who would be injecting into skin if xe injected at a 90 degree angle even with the shortest needles on the market- 4mm.

Another misconception I hear a lot is that insulin injections involve needles like you get your immunizations from. Generally they don't; you can, like I just said, use a teeny tiny needle- 4mm is about a sixth of an inch. You can also inject without a needle at all if you're really needle phobic.
You can inject with various lengths and widths of needles; you can use syringes, insulin pens, jet pens without any needles or cannulas (IV or SC) introduced by a needle which is then removed.

Of course, many people think that there ought to be a better way to get insulin.

Exubera was the first insulin on the market that was not intended to be injected; it was inhalable. Unfortunately, it was poorly marketed, expensive, gave boluses only in increments of three units, and short acting. It was removed from the market on the grounds that it wasn't making enough money; follow up studies of exubera suggest it may have increased risk of lung cancer.
Despite this, research on inhalable insulin continues (Technosphere Inhalation Insulin is in phase three studies) and it is clear that, whatever, the downsides may be, it is possible to lower type 1 diabetics' blood sugars via inhalers.
You cannot currently legally buy insulin to inhale; the only ways to get some currently is either to have a stash from when Exubera was on the market (not so long ago) or to participate in a study for Technosphere Inhalation Insulin, which is being studied currently only in type 2 diabetics who are taking Lantus but no meal time insulin and who need a meal time insulin.

Insulin has also been shown to work when given in suppository format, although I haven't heard much enthusiasm about that from the diabetes community generally, for the obvious reasons that sticking insulin up your butt is a heck of a lot less discrete than taking a shot, and many of us suspect it might be even less pleasant. There are currently no trials happening with this concept and I'm doubtful that there ever will be.

Animal studies have also shown that insulin can be given, with other chemicals, in eyedrops and will lower blood sugar. Insulin alone doesn't work. I'm not sure if this will ever be useful to humans. May be.

And of course, I may have dismissed the oral route too quickly. I could not find any studies on oral insulin in humans taking place currently. This article claims that there are currently oral insulins in development that should work as bolus insulins. We'll see.

In conclusion, insulin cannot currently be bought to be taken any way other than through infusion or injection. Insulins that may work as bolus-only insulins might in the next ten years be available in non-injectable formats, but the basal needs of type 1 diabetics will probably continue to be met only by insulin injected or infused.

And thanks for the kind sentiments on the previous post!

Pulsing Pancreases!

Fact: The normal pancreas makes insulin in a pulsatile rather than continuous way. Insulin production goes dramatically up and down in three to six minute intervals. Insulin infusion from a pump is more steady than from a pancreas.
I first read this fact on wikipedia but got a much more thorough explanation from this article which notes that the oscillations are in reaction to uptake of calcium (big whoop), that all of the stuff the islet cells release are released in pulsatile form, that insulin and glucagon releases happen opposite to each other, and that when humans make insulin in a more steady instead of pulsatile form, it is an early sign of type 2 diabetes.

Today was a doozy of a day. I had two scheduled activities: to help run the weaving studio in the morning, and to supervise my chess guys in the afternoon.
Well, I went hypo just before swiping in in the morning. I then had a record number of people to assist in the morning, and in between them I ate my mints and squeezed that honey bear. My blood sugar was just coming up when lunch began two hours later.
I ate a pear (I thought it was 15 carbs but on second thought I guess 25 carbs) and a corn cake (9 carbs) for lunch and did not inject at the time.
In the hour that I stayed after lunch, I was again busy busy.
I left at about 1:40 to go to chess. My blood sugar at that point was just over 200 so I changed my mind about the free lunch, and injected.

It was the last day of the Monday chess club for the fall, and we were having awards and a party. I didn't get as much done as I was hoping and I finished the class feeling drained. A review of the Dexcom showed that I had gone up to about 270 before dropping and I was hovering around 190.

I took another shot on the bus. I decided not to take the bus home and instead went to the library to work (I have been a library volunteer since 1999), which was fortuitous as somebody came in looking for a recommendation for a tutor for their child and the library staff pointed to me and I now have another small job.
My Dexcom had one flashing bar for the battery, and I started shelving. In a 60 minute period, my blood sugar went from 180 to 250 heading up, so I figured the correction was not enough, went and took another shot (I forget now how much) and decided that I was sick of looking at high numbers.
So I plugged the charger in in the backroom, connected the Dexcom, and left it there while I ran around the library, shelving, and running router (running router is my second favorite thing to do at the library, after assisting patrons- it means finding books that people have put on hold).
When I came back and retrieved the Dexcom a little over an hour later, the Dexcom showed an out of range symbol (no surprise) and when I next looked down it showed 195 heading down.
Although I sometimes think I should stay in range of the Dexcom as much as possible, it seems at other times that being able to put it away while I'm out of range especially, takes some stress off of me.

Diabetes in the World; or a Ramble on Economics

On World Diabetes Day, I'd like to bring your attention to the

Fact: Many people do not have access to insulin due to price and geography.

Sometimes I feel pretty guilty about being able to pay out of pocket for a Dexcom when many people I know cannot afford to test their blood sugar at all. Sometimes I feel guilty when I think about how entitled we in North American and Europe act about getting pumps and test strips and CMGSes when world wide, the majority of people who get diabetes cannot get a regular supply of insulin.
The exact figures as to how many people cannot get insulin, or even approximate figures, are not known.

In this study from 2005 on insulin and syringe availability in Mozambique and Zambia, it was noted that supply of syringes alone reveals that very few people can continue to use insulin every day; assuming a syringe could be used for two weeks, less than 500 people could use the syringes in a year, and more than a hundred thousand people in Zambia have diabetes. The amount of insulin used, and where, also shows that few people are getting insulin. And blood sugar testing is rare.
http://care.diabetesjournals.org/content/28/9/2136.abstract

And while I like to pretend sometimes that it is only in Africa or South America or somewhere far away that people do not get insulin, it happens here too. It happened to somebody while I was reading his blog, in fact. In my years on the online diabetes community, I have heard it a few times.

A sizable portion of the people in the United States have neither health insurance nor the money to pay for doctor visits and insulin and syringes. Companies that manufacture and sell insulin do have programs to help, but awareness is low, and red tape is high, and it is difficult to get the insulin.

The Lilly Cares program, for instance, from the first company to distribute insulin, will give free insulin (Humalog, regular, or NPH) to people at less than three times the poverty line, who are US residents and have no health insurance, and who see a doctor. Lilly sends the insulin to the doctor who is supposed to give it to the patient for free.
The NovoNordisk Patient Asisstance Program requires jumping through more hoops but will cover Levemir, Novolog, NPH, and needles, which they will once again send to a doctor for the patient.
These companies also send insulin to third world countries so that the insulin there costs no more than 1/5th of what it does here, which is still often more than they can afford.
However, I do not see these things by the insulin companies as particularly heroic; it is their faults that insulin prices since 1940 have gone up up up. They charge more for the newer insulins.
Regular or NPH insulin (which is to say, unaltered insulin made to be like human insulin, with no modern innovations) can be gotten as cheap at 60 dollars for 1000 units or 6 cents per unit.
40 years ago, a 10 mL vial of insulin probably contained 400 units and cost no more than 2 dollars (see here). That's 1/2 a cent per unit, for insulin that was more pure than the insulin sold now.
Controlling for inflation, the price of insulin has still doubled since 1970, and that's if you don't use modern insulins. If you want to use a newer insulin (not NPH or Regular) you can expect that you or your insurance will pay twice that.
And that's without looking at the fact that changing to U-100 means that those of us (I use less than 10 units of Lantus per day) who have lower insulin needs will lose money by having to buy insulin in larger containers when it still goes bad.

Fact: Type 1 diabetes prevalence has a huge variation worldwide. Finland has the highest rate of people (and especially young children) diagnosed with type 1 diabetes.
The average age at diagnosis of type 1 diabetes, the way in which diabetes is treated (are pumps common? is insulin easily available? what's the average A1c), and the male:female ratio of type 1 diabetics is also pretty variable from country to country, and even within countries by geographic area, racial and socioeconomic groupings.

I'm a little bit proud to have one of the few autoimmune diseases that is more common in men, at least in most parts of the world. I always think it must be embarrassing, or at least lonely, to have a disease that is way more common in people of the other sex. Like those poor guys with breast cancer. Or even women with Asperger's. I was actually a teeny bit self conscious about having thyroid disease when I think about the fact that autoimmune thyroid disease is about 10x as common in women. But fortunately (???) my thyroid disease doesn't seem to be autoimmune.

Insulin Manufacture

Fun Fact: Insulin was the first product ever sold that was genetically engineered in the sense that we use the term. E coli's genetics were carefully changed so that the bacteria would produce insulin identical to human insulin.
This was done to address the issues of cost, supply, and purity of animal insulins; unfortunately it was really an improvement only in that there is an unlimited supply of insulin you can get from bacteria, and in that fewer people have allergic reactions to human insulins. But I personally am happier to know that my insulin doesn't depend on killing any animals.

I actually learned that one in a class on genetically modified crops, a few months before I was diagnosed with diabetes. :-)

Insulin Sensitivity, or The Therapeutic Index

Last spring I was (I think erroneously) told that I had a very low vitamin D level and that I needed to supplement. My doctor suggested 50,000 IU per week. When I started reading about how safe it was to take vitamin D supplements, I learned about a concept called the therapeutic index. Basically what the therapeutic index of something is, is how much you have to take for it to be dangerous, divided by the amount that's the most healthy to take.
The example that was given that made it clear was water. If xe drinks and drinks and drinks water, the average person can get dangerously sick from about 40 cups of water in a day. The healthiest amount of water for the average person to drink (or eat in food) is 8 cups per day. So the therapeutic index of water is 40 divided by 8 or 5.
The therapeutic index for vitamin D is about 10- you have to take a lot more vitamin D than you need in order to get sick. Despite that, I ended up taking an amount of vitamin D that was dangerous for me... so much for doctor internet.

But something about this that got me thinking was imagining the therapeutic index for insulin. Insulin is pretty tricky to dose. Two times your correct dose of insulin will almost definitely make you sick, so the therapeutic index of insulin is definitely less than two. I can't find anyplace online where an actual value for the therapeutic index of insulin is stated, and actually it would be pretty meaningless, because the therapeutic index of a drug is computed for an average person and frankly, average people don't take insulin.

But let's look at the insulin needs of a type 1 diabetic with little to no counter regulatory ability to deal with hypoglycemia.
Let's say the person's blood sugar is 200. Xe would like to get down to 140 or less. Getting down to 60 or less is what we'll consider toxic. Now, if the person uses an insulin sensitivity factor of 60, they assume that 1 unit will lower them to 140, two units would lower them to 80, and two and a third units would lower them to 60, making the therapeutic index two and a third- not too low, actually.
Now, let's assume this same person wants to eat 100 carbs, has a blood glucose of 200, and has a carb ratio of 1:12. They should take 9 1/2 units of insulin. It would still take only one and third extra units to make xem hypoglycemic. Now the difference between the best dose- 9 1/2 units -and the dangerous dose 10 5/6 units - is pretty small, and the therapeutic index is now 1.14; pretty low.

There are two other problems with calculating the therapeutic index of insulin.

One is how much insulin sensitivity varies from person to person. As you may have noticed, most medications don't come in a very wide variety of doses. One dose may not quite fit all... but close enough. And you can probably guess the right dose with a simple weight chart.
Insulin's not that easy. Two people who both weigh 150 lb can have wildly different insulin needs. One person weighing 150 lb can have wildly different insulin needs simply depending on how active xe is, or especially if she's a woman, on the time of the month.
Type 1 and type 2 diabetes are sometimes distinguished by a tendency for the type 1 diabetic to have fairly normal insulin needs- normal still being a wide range- and type 2 diabetics to have fairly high insulin needs. But simply classifying people as insulin resistant and insulin sensitive, which is often what happens when doctors are doing the classifying, ignores the reality that everybody gets a little more insulin sensitive and a little more insulin resistant sometimes.

Another problem is that insulin itself changes insulin sensitivity. When your blood sugar goes high, your body doesn't use insulin as efficiently and when your blood sugar is lower, the insulin works more. That is, once insulin starts working... it really works. And once it isn't... it's not.
The idea that a person has a fixed insulin sensitivity is just that: an idea. A useful one. But the reality is more likely that the person has an insulin sensitivity of, say, 55 when xyr blood sugar is 300. An insulin sensitivity of 61 when xyr blood sugar is 200; an insulin sensitivity of 66 when xyr blood sugar is 100. An insulin sensitivity of 70 when xyr blood sugar is 60.

So it takes more insulin to get down from 200 to 150 than it does to get down from 100 to 50.

In 2004-2005 insulin was the second most common drug sending seniors in the United States to the hospital, responsible for 1 in 7 visits to the hospital caused by taking a medication (1 in 4 of these was from hypoglycemia that caused loss of consciousness).

EDIT: When I first posted this, I had the ISFs in the wrong order, which just goes to show that diabetes math is tricky.

Autoimmunity

I'm still having trouble with food digesting slowly. If I inject before eating, I go low (and my lows are taking at least forty minutes to come up), sometimes followed by a high. If I wait until the CGMS shows a rise, it's too late to stop the spike, but it's not showing any rise until more than an hour after I eat. So I think I need to inject about half an hour after I start eating in order to both prevent the spike and the low.

Yesterday on the bus I couldn't help noticing a young African American woman with large irregular white patches of skin, and patches of white strands in among her mostly black braids. It took a little effort to keep from blurting the diagnosis: VITILIGO! (so I signed it to myself instead)

Vitiligo is a group of diseases, like diabetes is, only vitiligo is about a dysfunction of the pigmentation. It turns patch(es) of skin and hair white. Some people with vitiligo just have a small patch that can be covered up; others have patches covering most of the body. It's more obvious in people with darker skin.
Vitiligo usually can't be treated, although sometimes people bleach the neighboring skin or hair to make the patches less obvious. It confers a slightly higher risk of skin cancer.

One form of vitiligo is autoimmune, and estimates of the prevalence of vitiligo among type 1 diabetics range from about 2% to 10%.

People with type 1 diabetes and their immediate families are at increased risk of various autoimmune disease, even the ones they don't have high risk genes for (such as multiple sclerosis).
But the additional autoimmune diseases that are most common in type 1 diabetics are Hashimoto's Thyroiditis, celiac sprue, and vitiligo.
Women and girls with type 1 diabetes are especially at risk for celiac and thyroiditis.

Red flags for for thyroiditis include: lethargy, loss of appetite, weight gain despite stable or decreased food intake, goiter (swelling at the location of the thyroid at the base of the neck). Asymptomatic thyroiditis does not really have bad side effects. Treatment is thyroid hormone pills.
Untreated celiac can have negative impacts long term even without symptoms, so it is important to get screened and not depend on being able to tell if there are symptoms. Treatment is a gluten free diet.

I came across this interesting case report recently. The title is Vitiligo Associated With Subcutaneous Insulin Lispro Infusion In Type 1 Diabetes but don't be fooled- it is only one patient, and she gets vitiligo in response to both insulin lispro and insulin aspart, plus she had it before she started pumping.

6 Attitudes I Wish People Had About Diabetes

Apparently today is diabetes blog day but I am blogging every day this month about diabetes anyways.
The question people seem to be answering is, what are the top six things you wish people knew about diabetes, but I think that there are not things I wish people knew so much as attitudes I wish people held.

1. All life and all experiences have value.

2. You can never assume somebody else's quality of life and especially not lack thereof.

3. Blame is of very little value.

4. No diabetes algorithms are perfect.

5. What you know about diabetes management in one person has only a little bit of bearing on diabetes management in another person.

6. And the last attitude I wish people had is, carbohydrate counting and labeling is the least I can do for my friends.

Fact: Fibers are carbohydrates that cannot be digested, nor the calories used. Soluble fiber delays digestion of other carbohydrates; eating fiber lowers post-mealtime blood sugar, which is a good thing if you are prone to post-prandial blood sugar spikes and a bad thing if you tend towards delayed gastric emptying.
Whether your diet should be higher or lower in fiber is a classic example of YDMV.

Diabetes Numeracy

Numeracy is to math as literacy is to reading; numeracy refers to a people's ability to use and understand math.
Numeracy is strongly associated with better diabetes outcomes; unfortunately a large portion of people struggle with the math associated with following doctor's orders regarding diabetes, and an even larger portion of people struggle with figuring out on their own how to use math to fit together the pieces that make up diabetes management.


A knowledge of diabetes is not required to take the following test (I got them all right):
http://www.mc.vanderbilt.edu/diabetes/drtc/preventionandcontrol/files/diabetes-numeracy-test.pdf

Basic diabetes numeracy that people measure and that is on the test above is knowledge of how to follow instruction so that you can:
-Understand how many units of insulin you are supposed to take.
-Measure out that number of units on multiple types of syringe.
-Read and understand nutrition labels on packages.
-Compute nutrition information with actual servings you took to figure out number of carbohydrates in what you're eating.
-Use a correction factor.
-Understand how soon you will need a refill or how long your supplies will last.
-Understand what is relevant and what is not when looking at a problem.
-Add times to know when 15 or 20 minutes have passed.

Slightly fuller numeracy might include:
-Being able to use nutritional guides instead of merely nutrition labels to accurately figure out the nutritional content in everything.
-Understand duration of insulin to know when to correct.
-Be able to spot patterns and put them in mathematical terms to change and articulate changes in insulin needs such as carb ratios and insulin sensivity factors as well as blood carb ratios.

My blood sugar today has been mostly hypo, but I just went high in the past hour, and am sitting at 232 at the moment.

Fact: Type 1A diabetes, usually just called Type 1 diabetes, is an autoimmune disorder in which the beta cells are damaged or destroyed. At least six autoantibodies have been identified that play a role in causing type 1 diabetes.

Q:What is a diabetic's least favorite toy?

A: The yo-yo.
(Just a joke- I love yo-yos, actually).

This has been so far the worst 24 hours of blood sugar I've had while wearing the Dexcom and shows no signs of letting up. I suspect it may qualify as my worst blood sugar day in the past year, although maybe that's because other days are not so fresh in my memory.
Last night after supper I had a stomach ache and went hypo. My blood sugar according to the Dexcom spent three hours in the hypo range despite me eating a huge amount of sugary stuff. When I checked on my meter, the Dexcom said 50, meter said 55. I went to bed as the numbers were rising (I was around 100), suspecting I'd go high.
My numbers went up most of the night, and I corrected around 5 AM (270). When I got up a few hours later, I was going hypo (apparently I overshot with the correction). The Dexcom said 73 and the meter said 70. The hypo did not respond quickly and I went to LOW and stayed there for a while. I ate candy an then a muffin, trying to rise a little more quickly because my brother was waiting for me so we could walk to the synagogue together, and figured I'd inject when I came up a little bit. I injected as my blood sugar got up to 100.
A half hour later in the synagogue, the Dex read 199 with two arrows up and I injected a little more.
An hour later, the Dex said HIGH, the first time I've seen it do so. I decided to simply wait.
Soon it began to plummet. By the end of the service, I was dropping rapidly, and on the walk home I was back to LOW. I finished going home, ate, injected a small amount, came up a little, dropped back down. Throughout the afternoon, my blood sugar would come up to about 110 before plummeting. When I checked on my meter while the Dexcom said 58, the meter said 41.
As the Sabbath ended, the numbers suddenly started soaring upwards. I went from 70 to 350 in about an hour. Right now the number is 324 dropping slowly.

To recap: I went from under 40 to over 400 in two hours, and in less than another hour was back down to under 40. The insulin I've been taking has shown itself to be promptly effective, but the food seems to be kicking in with much delay. My stomach has been hurting, my neck is so tender that it hurts to swallow (and it hurts in my neck, not my throat) and I've been told I'm looking flushed.
Differential diagnosis: stomach bug, gallstones, thyroid flare up? Maybe just plain diabetes weirdness.

Anyways, the plan for the next 24 hours is to lower the Lantus dose (from 8 1/2 to 7), be conservative with corrections (I'm going to use a 100 ISF instead of a 60), drink lots of fluids, check ketones (have not done that yet), and eat small meals if I can.
My rationale is that hypos are going to be very hard to treat, so I don't want to go there. Eating large meals that don't digest will set me up for more problems than small meals that don't digest, and maybe I could digest smaller meals better anyways).
If this keeps up, and I check a high number on the Dex and find that I really truly am over 400. I'll call the endo on Monday. I don't remember seeing a number over 400 in the past year. I feel crummy!

I wanted to do a fact on math skills in children with type 1 diabetes but couldn't find my source. Then I got distracted reading about numeracy. Then I read a study with a lower amputation rate than I had expected, looked for more studies, and decided they disagreed with each other too much for me to feel like I have a solid fact about them.


P.S. Whoa, Nelly. My Dexcom was still reading over 300, and it was time to calibrate. The meter said 197. :-/ Not great but way better. Maybe trusting the meter on the higher numbers was the problem.

So here's a fact that is probably already known to most of my readers:
Symptoms of high and low blood sugars are different for different people at different times. The same person may have different symptoms for the same blood sugar on two different days. Symptoms for most people change over the years and threshholds vary.
You may not have symptoms with a high or low blood sugar. Conversely,you cannot be sure of a high or low blood sugar merely because of symptoms.
I get kind of annoyed with people who think they have low blood sugar but have never tested, and I was really put off in a book I read on organ transplants in which the author (who had a liver transplant but no diabetes) claims that diabetics learn to feel their blood sugar levels to the nearest 10%.
No, sorry, it doesn't work that way.

There's been a lot of people writing, in light of recent news of children dying of diabetes, that diabetes is a terrible horrible thing that should never ever be funny. Or laughed at. Or made art out of.

I don't say anything to them, because they are speaking from the depths of their emotions.

But this is my truth: I have diabetes. Although there are treatments that may make living with diabetes a very different kettle of fish sometime in the next ten years, there is nothing on the horizon that is likely to make it go away.
I did not choose to have diabetes but it is here for the long haul.

I can focus on the worst parts of it. I can decide that every shot is an injustice that I should not have to endure, I can get mad at my brother for being scared of catching diabetes, I can get mad at the world. I could obsess on how horrible it would be to go blind, or die young or any number of complications. I could live angry.
I could also pretend that everything is normal. I could just take my shots 4 times a day, check my blood sugar 4 times a day, make dosage adjustments only at endo visits, and assume that everything is going well.
I could even go into total denial. I could decide that everything is too horrible to be faced, never check my blood sugar, and go in and out of DKA.
I could probably do what most people do and treat it as a frustrating chore.

But this is not what I do. I went into diabetes with the belief that almost all experiences have something of value in them. I struggled mightily with the realization that sometimes I am really bummed and scared of what is to come. But mostly I tried to find the value.
I look for diabetes humor. I look for diabetes art (and occasionally make some). I look for diabetes pride. I look for studies that show that diabetes does something, anything, good (it does- I gotta use some of those studies for facts later this month).
And I face my fears head on. I look at complications and I say, well, okay, if that happens, let's see what that would be like. Because I must be able to find something good in that too. I read about diabetes. A lot. I read about complications, causes, mechanisms. I read stories.
I look for the community. I look for where I fit.
Sometimes I am sad and
sometimes I am mad and
sometimes I am fascinated and
sometimes I am amused and
sometimes I just am and
sometimes I am happy.
I try to dwell on the happy.

Because I will probably be living with diabetes for a long time yet, and I intend to make it the best life I can.

Fact: Insulin does more than act as a channel for glucose to leave the blood stream and go into cells- it serves as signal to alpha cells that they should not be releasing glucagon.

In cystic fibrosis related diabetes as well as in full blown (as opposed to early stage, honeymooning) autoimmune type 1 diabetes, but not in type 2 diabetes, the alpha cells release a larger amount of glucagon most of the time, release a bolus of glucagon at meal times, and do not release glucagon at times of hypoglycemia.

I pulled out the sensor with about 20 minutes to go in the third week. Took a long bath, spent about an hour and a half with no sensor, and then inserted sensor the sixth into my abdomen. It's still in the warm up period.

FACT: Sonia Sotomayor, the newest Supreme Court Justice, was diagnosed with juvenile diabetes at the age of 8. She takes multiple daily injections via syringes.



When I was reading the CDC health statistics for 2009, I was shocked to learn that 1 in 5 American pregnancies that is not miscarried ends in abortion. :(

Trying to get myself to wake up from alarms on the CGMS at night drives me nuts. Last night I went to bed with a blood sugar of 75. I ate a small snack at bedtime, and I raised the low alarm threshhold to 80, with a snooze of one hour, thinking I could wake up in an hour if I was still below 80, and treat again, but not wanting to overtreat.
I woke up around 7 AM. It was beeping. It said I was 67, and my meter said 61. The Dexcom showed my blood sugar as having been in the 50-75 range THE ENTIRE NIGHT. Did it wake me up? Nooooo. The Guardian wasn't very good at it either. I know I should get some sort of amplifier. Blech.

Fact:
1 international unit of insulin is equivalent of 1/22 mg of pure cyrstaline insulin. In the United States, you can buy insulin at a strength of 100 units in one mL (U-100 insulin) or at a strength of 500 units in one mL (U-500) insulin. You can also buy a dilutant to be used with some insulins and make insulin at any lower concentration.
Historically, U-30, U-40 and U-80 insulin were prevalent on the US market.
Using a higher concentration helps with absorption of larger doses (U-500 is recommended for those with a sustained need for more than 200 units per day), and a lower concentration helps with measuring lower doses (particularly for those who frequently need doses under 1/2 unit), but having different concentrations has sometimes caused dangerous mix-ups.
Historically the lower concentrations were due to the difficulty of concentrating the insulin.

My sensor is still in, and it's now in its twentieth day. It's been reasonably reliable; no ??? in the past day and only an hour or so of ??? at a time, twice on Monday and twice on Sunday.


Fact: More than thirty thousand pancreas transplants have been performed in the United States. Most were performed at the same time as a kidney transplant, some were performed after a kidney transplant, and a few hundred were done in diabetics whose kidneys had not failed.
Most pancreas transplants come from dead people; a few partial pancreas transplants have been done from relatives.

Band-Aids

I put a band-aid on my butt today because the Lantus shot lead to bleeding (hope that doesn't mess up my numbers for the next 24 hours). The band-aid was partially pulled off when I went to the bathroom a little later and I had a panicky, did-I-pull-my-sensor-off moment. Fortunately not.

In honor of November being diabetes month, I'm gonna give you a post with a fun fact every day. I promise none of them will be anything other than facts.

Fact 1: Jackie Robinson, the first African American to play in Major League Baseball, was diagnosed with type 1 diabetes at the age of 38, which was his final year in the majors (I have not been able to find out whether he was diagnosed shortly before or shortly after retiring).
He died of diabetes (heart attack) fifteen years later at the age of 53. By that time he had also lost a lot of his vision, also from diabetes.
His brothers Mack and Edgar were diagnosed with diabetes before he was; Mack died of diabetes related causes at age 88, and I can't find data on Edgar.