Sunday, December 16, 2012

Gentle Jet, G4, Glycemia, and Vitamin D- A Hodgepodge Post

I've been using the jet injector for two weeks now.

Pro: No needles to keep track of or accidentally poke myself with or pay for or pack.
Pro: Faster onset and action time.
Pro: No soreness after injection.
Pro: Can do shots totally in the dark without using my sight.

Con: More things to keep track of while injecting- especially the caps to both the insulin vial and the injector itself.
Con: Faster onset and action time (I keep going hypo while I'm still eating the meal I injected for- and I'm using Regular for pete's sake!)
Con: More frequent visible bruising, even when shots are not more painful.
Con: All the twisting to load the jet injector is hard on my hands, which have not entirely recovered from this summer's neuritis.

My G4 has arrived but because of how long it took I got more sensors to keep me going. I just put in the last of my 7+ sensors, so I guess I'll be starting on the G4 in the week of New Year's.

I'm having difficulty with my overnight blood sugars- have been for over a month (so not caused by jet injector). I'm having hard to predict and rapid onset extreme night time hyperglycemia. For a couple of weeks I had numbers above 300 roughly every other night, and was hesitant to raise doses much because some nights I'd go low. Then I raised the Lantus dose, and things got a lot better. But the night before last, I once again went to bed with a nice stable 120 (at 9 PM- I was really tired), and woke up at 3 AM with a blood sugar of 330, feeling pretty awful. During the daytime I'm tending to run low. I'm not sure if my issue is delayed absorption or not, because not all of the night time highs happened with a meal within hours of bedtime; OTOH it's a really large rise for just a basal drift. And I have been having issues in that I'm going low after some meals as if I haven't eaten.

I'm also noticing a very predictable pattern where my blood sugar shoots up after exercise. This is especially noticeable after swimming, juggling, or biking, where about ten to twenty minutes after I stop exercising, my blood sugar starts going up- on the Dexcom there's usually a straight up arrow, not even a mere angled one. My blood sugar has been dropping or stable during exercise, but afterwards... ugh.

Two interesting studies I came across:
One on risk of stroke, heart attack, and death from cardiovascular disease that looked especially at diabetes and weight. I thought it was interesting that the average diabetic (they don't differentiate between types but the average age is 58) was not underweight in this large study. It is also sobering that the increase in death was entirely in people whose weight was low or low normal.
Another is just a case series.  I am always paying attention to what's happening with the whole vitamin D thing, because my own experience was so contrary to what's reported. In this study, the authors merely report on the most recent fifteen patients they'd seen with vitamin D mediated hypercalcemia. In all cases, the people had severe cognitive symptoms, did not have a disorder affecting vitamin D metabolism (unlike me), and had been given injections of very high dose vitamin D by a licensed physician. These are interesting to me because these are people whose bad effects are due only to how much they took and not because of taking them without a doctor's approval or despite a disease that makes it a bad idea. These people did not have mild side effects; they were hospitalized for an average of over two weeks.
Their vitamin D levels overlap with how high mine have been, they all had higher calcium levels than I've had, their PTH levels overlap with mine (my PTH was measured at the bottom of normal), and they're all older than me and took more than ten times the dose that I took.

Friday, November 30, 2012


Cyclosporine given to early onset type 1 diabetics (who'd never been in DKA) was shown, before I was even born, to give almost even odds that a person would be not be needing insulin to get normal fasting blood sugars one year after diagnosis.

Thursday, November 29, 2012

Stuff Changes In The Diabetes World

I was diagnosed with diabetes 6 years and 3 months ago, which means I've been diagnosed 5 years fewer than the average American diabetic (including T2s). Even though that seems like a short time to me, a lot of things have changed.
This post, more than most of mine, is very much US centered. There are insulin pumps, CGMs, and insulins for sale in other parts of the world that I am not discussing and the products available here aren't available everywhere else.

-The only insulin pump that was for sale in the US when I was diagnosed, that is still for sale in the US now, is the Accu Chek Spirit. When I was diagnosed, the insulin pumps for sale were Cozmo, Minimed 522 and 722, Animas 1250, and Accu Chek Spirit.
Cozmo has gone out of the insulin pump business. Now for sale are Omnipod, Minimed Paradigm Revel, Animas One Touch Ping, Accu Chek Spirit and Spirit Combo, and the new TSlim. Omnipod is the only insulin pump without a cord (unless we count the V-Go, which I don't), the TSlim is the first with a touchscreen and also the first one that needs to be recharged, the Revel is the only American pump that can double as the receiver of a CGM, the Spirit is cheapest, the Ping inaugerated the whole remote to the pump thing (although the combo works as a remote and I believe the Revel has a remote too).

-The year I was diagnosed, animal insulins went off the market in the United States. Exubera, the first inhalable insulin to go on the market, came out a few months after I was diagnosed, and is no longer for sale. Apidra was introduced after my diagnosis. And the new newest insulin is degludec, which is being sold as Tresiba. Neither Apidra nor Tresiba has been shown to make a real difference in diabetes control compared to other insulins. Novolog, Humalog, NPH, Regular, Lantus and Levemir were on the market then and still are now.

-The year I was diagnosed, the glucowatch biographer was still for sale. Dexcom and Medtronic were both earlier versions of their CGMs- Dexcom had just gotten approval for the Dexcom STS, which could only be calibrated by using the One Touch Ultra meter, which plugged into it (that was part of why I went with Medtronic for my first CGM), has sensors approved for only 72 hours of wear, and had transmitters that would last only six months (oh, that sounds familiar, you say?). Medtronic already had the Guardian RT out when I was diagnosed, although that is a slightly different version than the Guardian Real Time. The pump-acting-as-cgm-receiver didn't get released until the year I was diagnosed, 2006.  Abbott's Freestyle Navigator was not yet on the market when I was diagnosed; its brief foray on the US market started and ended during the period since my diagnosis. Two versions later, the Navigator is still selling in much of Europe and Asia, but not here in the US.
Insurance companies rarely covered CGMs then.
Here is a Dexcom STS user guide:

-The year I was diagnosed,  the ADA still had the reasonable position statement that diabetes could not be diagnosed by A1c alone, and that normal range for A1c went up to 5.9%. TnZ8 antibody tests weren't being done in a clinical setting. Bone marrow transplants for new onset diabetes weren't being done in the US (anywhere), and islet cell transplants were brand new. Nobody'd heard of Faustman, much less been disappointed in her data.

- The year I was diagnosed, the smallest insulin pen needles were still 5mm (now they're 4mm), and they still made reusable insulin pens for Lantus, and they sold Regular in cartridges (they still do that outside the US). There were four companies selling jet injectors to private individuals (there's one left).

When I was diagnosed, I figured that one of the perks of diabetes was going to be that I was going to try all sorts of products I never would have thought of. I've tried to change something every year, and mostly I have. I have tried a lot of things. I have used one NovoFlexPen (one was enough), Novopen Jr, Novopen 3, Novopenmate, an Inject-Ease, seven I-Ports, vials of Novolog and vials of Lantus, Solostar pens, Opticlik cartridges (since discontinued), a few versions of Bayer's syringes with 8mm needles, five sizes of pen needle, a bunch of meters (but only the Aviva as my primary- although its on its second type of test strip), the Guardian with Sof Sensors, Dexcom 7+, NPH, Novolog, Novolin R, and Lantus (in the morning, in the evening, and twice daily).
For me, changing stuff around makes everything more interesting.

In the immediate future, I expect to see some changes in the diabetes products available. In particular, I expect the Enlite sensors for Minimed to become available; hopefully the Veo too. I'm somewhat hopeful that the Animas Vibe will reach these shores in the near future. There are at least three insulins in clinical trials and I bet we'll have another one on the market sooner or later. I am interested to see if C8Medisensors turn out to work, and I'm hoping that bone marrow transplantation as a way of heading off type 1 diabetes will become safer and more effective with new methods.

Wednesday, November 28, 2012

The Glimmer of a Honeymoon Still Matters

Among type 1 diabetics, the ability to make even a tiny amount of insulin is strongly associated with the ability to get lower A1cs without more severe hypoglycemia.

A majority of Joslin medalists- people who have been on insulin for more than 50 years- are still making a detectable amount of insulin.

Among adolescents who still have measurable levels of c-peptide (and thus, insulin production) one month after diagnosis, more than 90% still have measurable levels of cpeptide two years later.

C-peptide levels at diagnosis of type 1 diabetes are usually younger in younger people.

Decline in c-peptide levels is those type 1 diabetics who are positive for c-peptide is usually most rapid in the first year after diagnosis.

Even among type 2 diabetics, lower c-peptide levels are associated with higher rates of some complications, such as kidney disease.

Some medications used to treat type 2 diabetes (especially the sulfanureas) lower cpeptide.

Tuesday, November 27, 2012

Vitamin T

1 in 4 men with type 2 diabetes has low testosterone levels, and insulin sensitivity usually increases in med with low testosterone levels. However, high testosterone levels in women (especially from PCOS) usually causes insulin resistance, and very high testosterone levels (about male normal range) also causes insulin resistance. 
Testosterone significantly affects insulin sensitivity, but not linearly.

Today marks five years since my first injection of testosterone. The five year mark is significant in an artificial sort of way because it's recommended that transmen get bottom surgery by then because of concerns about endometrial and ovarian cancers (more endometrial). In one of life's little ironies, transgender people are at increased risk of reproductive organ cancers (so, for that matter, are some types of intersexed people). 

Monday, November 26, 2012

A Senator With Diabetes

Norman Atkins (appropriate name), cofounder of Diabetes Canada, was also a member of the Canadian Senate. He was a type 2 diabetic, and that's what he died of; his son was (at least according to Canadian Senate speeches) the first Canadian type 1 diabetic fire fighter.

While looking for a fact for today, I found out that the US Senate has a candy desk - one senator keeps a desk full of candy to be eaten by all senators. Somebody claimed that this tradition was started by a diabetic, which is how my google search turned it up. But I don't think it was- it was started by George Murphy and I can find no link from George Murphy to diabetes, and I doubt Murphy was diabetic during his run as senator.

Sunday, November 25, 2012

NPH reduces A1c more compared to Lantus or Levemir in Type 2 Diabetics

When a person is started on only one type of insulin (not on a pump), making that insulin NPH or a mix of NPH and a short acting insulin, will reduce A1c more than taking Lantus or Levemir or a short acting insulin.
Probably this is for the very simple reason that if you are taking an insulin that acts as both basal and bolus, you can raise the dose to an extent that you can't do if you are taking an insulin that is only basal or bolus, and with more of your insulin needs covered.... ta da! Your A1c drops more.
Studies to this effect are included in the Lantus patient information, but a number of newer studies have shown the same thing, such as this one. I find this especially remarkable given that NPH or a 70/30 mix can be bought at Walmart for $25/1000 u vial, while Lantus can't possibly be bought anywhere for less than $90/1000 u vial (including amount paid by insurance).

And I'll throw in a bonus fact: the average A1c of a type 1 diabetic adults in different areas ranges from 7% to more than 10%. In the DCCT participants, the average A1c of the control group, and of the intensive group after they stopped getting intense attention from doctors, was 8.9%. If you are looking at data about average complication rates, you should probably assume that those are average for people whose A1cs are in the neighborhood of 9%- because that is about what average people seem to acheive if they are not personally doing a lot to change their diabetes outcomes.

Yesterday I seem to have accidentally deleted the last six months' worth of comments on this blog. I hope none of you are as bugged by that as I am. Feel welcome to go back and make up for it by leaving lots of comments.
I am kind of annoyed at Dexcom because my case manager is not doing much. Not getting back to me, not getting a prescription. And everybody at Dexcom keeps  telling me she will. Ha!
My Gentle Jet is being built now. Yay!
My blood sugar's been a mess for a couple of weeks (random highs in the 300s) and I kept thinking the issue was delayed absorption of meals but yesterday I didn't eat after 5:30 PM, didn't go to bed until midnight and still went into the 300s overnight. So I'm thinking the issue is really mostly a too low Lantus dose even though it doesn't totally look like it (I keep going low too, for one thing). Tonight I'm raising the dose although I haven't decided by how much.

Saturday, November 24, 2012

Liver Diseases In Diabetics

Non-alcoholic fatty liver disease most commonly occurs in people with overweight people with insulin resistance- in type 2 diabetics, in fact. It's fairly treatable with a low fat diet.
Roughly 40% of type 2 diabetics have NAFLD.
I expected, when I looked for prevalence studies of NAFLD in type 1 diabetics, to find that we'd have lower rates- near normal rates. We don't. I found only two prevalence studies of NAFLD in type 1 diabetics (both on adults) and they gave prevalences of 44% and 53%

There are other liver diseases that are linked strongly with diabetes. One of the more unusual ones is called glycogenic hepatopathy, which is an acute liver disease caused by high blood sugars over a medium term- not a long term complication but you don't develop it in a week either (the cases I've read about have been in people with type 1 diabetes and A1cs between 10% and 14%). It goes away when you get better blood sugar control. It can be differentiated from NAFLD by liver biopsy. Glycogenic hepatopathy is one of those complications of diabetes that I figure I really do have the power to stop myself from getting- not maybe, but definitely.

Friday, November 23, 2012

Misdiagnoses Happen... and Sometimes They Matter

Recently I read a piece on a man who was diagnosed with type 1 diabetes at the age of 60, in France. He had gone to his doctor because he had lost 20 lb without trying, and he was thirsty. His random blood sugar was in the 300s, but his A1c was only 7.2%, indicating that he'd had a rapid onset of diabetes. So his doctor put him on insulin, and he felt better. His doctor did not test c-peptide or antibodies; he didn't see a reason.

Except that one month later this newly diagnosed diabetic went to the emergency room with extreme stomach pain, and was diagnosed autoimmune pancreatitis. Autoimmune pancreatitis is a rare condition mostly seem in middle aged men, and it usually gets a lot better when the person is put on steroids. So this guy was put on prednisolone for three months. After two months of prednisolone, he went off of insulin. Three years later, he is not on any medication at all, and his A1c is below 6%.

This particular misdiagnosis- autoimmune pancreatitis misdiagnosed as type 1 diabetes- is not common. For one thing, AIP is not common, and for another, the diabetes is usually not the first symptomatic part of it. And most doctos looking at a middle aged or elderly person with new diabetes are not going to leap to the assumption that it's type 1.
But misdiagnoses in general are common. Some of them are very serious- as when diabetes is the first thing seen in what turns out to be pancreatic cancer, and the doctor only diagnoses diabetes. Or as when somebody is diagnosed with type 2 diabetes, treated only with oral medications, and goes into ketoacidosis before getting insulin. Or when diabetes is misdiagnosed altogether as the flu. Or when a person with diabetes responsive to sulfonyureas is put on insulin only (if you were diagnosed with diabetes before the age of one year, for your own sake please get tested).

The following things make misdiagnosis more likely:
- Neither antibodies nor c-peptide were tested.
- A diagnosis was made that doesn't fit the c-peptide or antibody results.
- The person making the diagnosis was not an endocrinologist, and the patient has never seen an endocrinologist.
- The person is a young adult when symptoms start.
- The person is a baby when symptoms start.
-  The person first went to see a doctor early on.

If you were diagnosed with type 1 diabetes without ever having either a positive antibody test or a low cpeptide (and not low for blood sugar, but actually low), it might be a good idea to get your cpeptide levels tested. More than a few people have found that they've been on insulin for a long time without needing to be.

I find it comforting to know that my cpeptide is nil and my antibodies are positive. There are no doubts about my diagnosis.

Thursday, November 22, 2012

ABO Blood Groups and Diabetes

One of the interesting things to me about pubmed is that it sorts articles by newest to oldest automatically, and makes it easy for me to compare old articles and new articles.
Almost all articles on the topic of diabetes and ABO antigen blood types published before 1985 found no relationship. All of the articles I found published after 1990 found a relationship between ABO blood group and risk of type 2 diabetes. From reading these, my conclusion is:
Blood type B is protective against obesity related type 2 diabetes, particularly as compared to type O and type A blood types.
Some people with type A blood have a particular form of the allele that, when homozygous, raises risk of type 1 diabetes.
Having a blood type that is different from your mother's blood type is a risk factor for multiple autoimmune diseases, including type 1 diabetes.

Wednesday, November 21, 2012

The Israeli Army Accepts Type 1 Diabetics

Most of the world's armed forces- including those of the US, Canada, Mexico, Great Britain, and Australia- do not accept diabetics on insulin, although those diagnosed while they are already in the army may or may not be allowed to stay- if they do stay they are usually moved to noncombat positions.
In Israel, where army service is compulsary for most people, type 1 diabetics are given the option of joining the army or not. The evidence from those who have chosen to join the army is that they are capable of serving in the army well, and that they generally have good diabetes control while in the army. They are generally not assigned to combat, but still undergo things like basic training. The Israeli army has two pilots with type 1 diabetes.
Right now the only other country I'm finding that accepts diabetics is Finland, but I believe that there is an African country that also accepts diabetics into its armed forces.

This article has a pretty decent summary of the current situation:

Tuesday, November 20, 2012

When Good Control Is Bad Control

The extent of the need to get diabetics' blood sugar as normal as possible has been debated since before insulin was available for injection, and that debate has never died down.
After the DCCT, a large study on type 1 diabetics with good hypoglycemia awareness, with a very large portion with kidney disease, showed that frequent review and revision of insulin doses with an aim at normalizing glucose levels decreased risk of death as well as risk of kidney failure and progressing eye disease, public opinion swung strongly towards the idea that normalization of blood sugars was a good thing.

But in the following years, a number of large studies on type 2 diabetics showed pretty strongly that aiming for and even achieving lower A1cs wasn't associated with better outcomes. Those with lower A1cs had heart attacks and died at roughly the same rate as those with higher A1cs. One study (ACCORD) even stopped early because the people in the part of the study aiming for "better"- more normal- blood sugar control were dying faster. 
Aiming for lower A1cs, in both type 1 and type 2 diabetes, has been shown to lower the risk of development of certain complications, most especially kidney disease. But the majority of diabetics- especially those who are not diagnosed at ages where kidney disease is at the highest risk of developing (dx roughly 10-45 years old) die of heart disease. And no study yet has shown a decrease in heart disease with intensification of blood glucose control.

Monday, November 19, 2012

Dolphins' Blood Sugar

One of the theories about what positive affect high blood sugar might have on humans- what survival advantage it could give- is that higher blood sugars help people's bodies deal with colder weather. I think the evidence for this theory is weak but I still find it interesting.
Some animals increase the concentration of sugar in their blood as part of their adjustment to colder weather.

About two years ago, somebody did a study on dolphins' insulin levels, and found that dolphins have higher insulin levels when they haven't eaten. Apparently they are insulin resistant overnight (I'll count that as a fact) which has led to some interesting speculation on the theory that people need diabetes (or rather, insulin resistance) in order to cope with low carb diets. Found that an interesting twist.

Sunday, November 18, 2012

Diabetes and Height

- Children diagnosed with diabetes before the age of 1 year tend to be small- short and skinny.
- Children diagnosed with type 1 diabetes are, on average, tall. 
- It takes really bad blood sugar to do it, but diabetes can stunt growth.
- Among diabetic adults, both among type 1 adults and separately among type 2 adults, shorter ones are more likely to develop microvascular complications such as kidney disease and neuropathy.

Saturday, November 17, 2012

How Much Of Our Costs is Their Profit?

For 2011, Dexcom reported a revenue of over 76 million dollars, and under 36 million dollars in cost of revenue, which means the cost of manufacturing the receivers, transmitters, and sensors. That looks like 40 million dollars of profit. But no- Dexcom says that it also paid out 49 million dollars for sales, administrative people, etc, and another 30 million dollars for research. It ended the year in debt and therefore the company paid no money to investors or the IRS.
 $76 million in revenue, if it all came from sales, would mean a minimum of 19,000 Dexcoms in use in 2011, not counting those in clinical trials that weren't paid for (because people aren't averaging a cost of greater than $1000 per year per receiver + transmitter, and $3000 per year for sensors), which I think is kind of alot. I think if the numbers all come from sales, 30,000 Dexcoms in use in 2011 is more likely, which kind of blows me away. I thought we were a smaller minority. But anyways. Of our money, less than half was used to actually produce our products. Less than half was used for the costs of research. 
I find it extremely implausible that more than a small portion of that other $49 million was spent on the people I get when I call their phone number, because I usually have a long wait time on the phone and those people don't strike me as all that trained (or for that matter all that moral but that's another story). That means it was probably spent on ads (and that website!). And executive bonuses. And lands the company in $40 million of debt. 
And that is where your money, both the money you're paying directly, and the money you are paying vis a vis your insurance company, goes when you buy a Dexcom.

In contrast, most other diabetes companies sell many products and report large earnings every year. Medronic reported that sales generated over $16 billion in 2011 (whoa!). They spent under $4 billion in producing their products, another 1.49 billion in research, and $5.6 billion on sales and executives and all that, and overall spent enough money on other things (like lawyers) to report earnings of just 200 million dollars to the IRS.

Friday, November 16, 2012

State by State Adult Rates of Diabetes

The US State with the highest rate of diabetes diagnoses in adults is Alabama, where 13.2% (between 1 in 7 and 1 in 8) of adults had been diagnosed with diabetes as of 2010. The lowest rate of diabetes diagnoses is in Alaska, where 5.3% (about 1 in 19) of adults had been diagnosed with diabetes as of 2010.
In the United States as a whole, 8.7% (about 1 in 12) of adults had been diagnosed with diabetes as of 2010.


Thursday, November 15, 2012

Diabetes Affects Hearing

Diabetics of all ages are at increased likelihood of having hearing loss or deafness.  Compared to people of the same age, younger diabetics are at higher risk of hearing loss; in terms of absolute risk, older diabetics are at higher risk (because nondiabetics are more likely to have hearing loss as they get older).
Some of this increase in risk is due to diabetes (hearing loss as a complication) and some of it is because of syndromes that include both hearing loss and diabetes (such as mitochondrial diabetes).
While some studies have not shown major hearing loss in diabetics, I find the evidence overwhelming. In some studies, a quarter of children with diabetes have at least mild hearing loss, meaning that they need a sound to be at least 25 decibels in some of the more commonly used frequencies, before they can hear it. - about children in Iran - about adults in Brazil - about Sudanese children (with poor metabolic control) - about US adult diabetics (mostly type 2, and two thirds hearing impaired)

I kind of wonder if this means we should have more hearing screenings. Is hearing loss a problem if you don't notice a problem? I wonder if I have high frequency hearing loss.

Wednesday, November 14, 2012

World Diabetes Day

Today is World Diabetes Diabetes. Somebody would probably like it if you wore blue (I am wearing blue myself, but it's a coincidence- I wore blue yesterday and the day before too). World Diabetes Day was established in 1991 by the International Diabetes Federation. To "raise awareness and advocacy." This year's theme is prevention and education.
As you all know, I believe that type 1 diabetes probably can be avoided in some way or another (because it isn't wholly genetic), and that that way has not yet been discovered.
Right now, if you are newly diagnosed with type 1 diabetes, 12 or older, never been in DKA, antibody positive, your best shot at being nondiabetic is probably an autologous bone marrow transplant. This will have many possible side effects, including death (more probably including infertility), and it is not at all guaranteed to work. I think this is a reasonable option.

But haha, let's go back to things the IDF says. Here is what they say in their position paper on bariatric surgery and type 2 diabetes.
-15% of type 2 diabetics of European descent are not overweight (in the United States, for comparison purposes, 40% of all adults are not overweight).
- Type 2 diabetes risk goes up with increasing BMI such that it is a larger risk at greater degrees of obesity, and in the most obese groups of women, the risk is increased 93 fold (this seems hard to believe because I thought the risk was already more than 1%)
-people rarely sustain large weight losses through lifestyle alone (my grandfather did)
- Type 2 diabetics whose blood sugar control does not improve despite taking more and more medications are at higher risk of death both compared to those whose blood sugar does improve on medications and compared to those on fewer medications with the same blood sugars.
- After bariatric surgery in obese type 2 diabetics, 62-72% are in remission two years later. Remission from diabetes means using no medications but having an A1c below 6%, having normal fasting blood sugar, and keeping that up for a year. Notably, without surgery, the remission rate two years after a diagnosis of type 2 diabetes can be over 25%.
-36% were still in remission ten years after bariatric surgery. To break that down, 1/3 don't have a remission lasting even two years, 1/3 have a remission lasting 2 to 10 years, and 1/3 have a remission lasting more than 10 years.
-Most diabetes groups recommend bariatric surgery for diabetics with a BMI of 40 or greater, as well as for those whose BMI is 35-40 with some other disease where weight loss matters (such as arthritis).The different organizations had different opions about whether or not bariatric surgery was appropriate for people with BMIs below 35.
- This is recommended for type 2 diabetics as young as 15 years old.
-Although the IDF says risk for bariatric surgery are as low as those for elective cholecystectomy, I can tell you complication rates for cholecystectomy (and I had complications after elective chole) are lower than what they report for four different bariatric surgeries- they report one year complication rates of f 4.6%, 10.8%, 14.9% and 25.7%.
-A number of these surgeries can create a high risk of vitamin deficiency (a book I once read by a neurologist described a patient he saw in the hospital who was dying of unrecognized vitamin deficiencies following bariatric surgery).
-The IDF recommends bariatric surgery as a treatment for type 2 diabetes when BMI is greater than 35 and A1c greater than 7% despite metformin and weight loss efforts, and when BMI is greater than 40 no matter the A1c.
-The IDF's position is that only 2% of the number of bariatric surgeries that should be performed, are.

Personally, I'd like to raise a little awareness of the fact that being obese does not by any means prevent a person from having autoimmune diabetes only responsive to insulin. I wouldn't go so far as to say that being overweight can cause autoimmune diabetes as a fact, because studies on the topic have had mixed results. But at least a few studies have shown higher antibody rates (among nondiabetics) in obese kids, and a higher rate of obesity among type 1 diabetics (despite the fact that our median weight is very slightly below average). You are not going to get medication free diabetes control if your diabetes is autoimmune.

Tuesday, November 13, 2012

Molecules of sugar to a milligram

If you've been on the online diabetes community long enough, you've probably noticed that some of us use mg/dl as a measurement of blood sugar, while others of us use mmol/l. To convert blood sugar in mmol/l to mg/dl, you multiply by 18. OK, boring you so far.

Did you know that the conversion factor of 18 is specific to glucose? The conversion by 18 essentially says this: 10mmol/dl = 18 mg/dl. 10 mmol of sugar = 18 mg of sugar. A mmol, a milimole, is 602,000,000,000,000,000,000 molecules. 
6,020,000,000,000,000,000,000 molecules of glucose weighs 18 mg.

That is why, when you look at converting something else from mg/dl to mmol/l or back (say, cholesterol) you'll have to multiply or divide by a number that's not 18 (in the case of cholesterol, 38).

Monday, November 12, 2012

Seabiscuit's Jockey Was a Type 1 Diabetic

I don't know how many of you read the book Seabiscuit, about a famous racing horse, or watched the movie, when they came out in 2002/2003. I read the book a couple years after it came out, which was a couple of years before I was diagnosed with diabetes, and diabetes wasn't much on my radar. I was particularly interested in the part of the book that talked about horse jockeys, and how they'd starve and purge themselves to be lower weights for their horses. I was especially interested because, due to my size and middle name, my nickname is Jockey (it was on all of my schoolwork from my middle school/high school years and the first couple years of college).

What I don't remember being in the book is that one of the jockeys who rode Seabiscuit didn't swing his weight with diets and purges. It was too dangerous- he was an insulin dependent diabetic.

George Woolf (1910-1946) rode and won the first horse race in which the stakes were $100,000. He won 721 races, in fact. He died after falling off a horse during a race- the only time he ever fell off of a horse during a race. It is speculated that he may have fallen off because of hypoglycemia, but whether that's true or not, who knows. He was known to have hypoglycemia unawareness. Horse racing is not the safest of sports, and blood sugar meters didn't exist in 1946. Woolf rode multiple horses and Seabiscuit had multiple jockeys, but Seabiscuit was Woolf's favorite, and Woolf is the jockey on Seabiscuit in the statue at the Remington Carriage Musuem.

P.S. I went and checked Seabiscuit out of the library again, and looked up Woolf in the index. The book does talk about him and his diabetes, although I think it has some facts wrong. It says he was diagnosed in 1931 (age 21?) which I would guess is correct. But it also says that he used canine insulin, which I doubt is correct.

Sunday, November 11, 2012

In Which Diabetics Do It Better

While very out of control diabetes can and does raise lipid levels, most type 1 diabetics have better cholesterol levels than nondiabetics. This sometimes surprises people who do studies on the topic.
For example, in this study, 44 overweight kids with type 1 diabetes were matched to similarly overweight kids without diabetes, who were the same age, etc.  The diabetics had lower total cholesterol, higher HDL (the one you want) and lower LDL and VLDL.
The authors speculate that this is because, if diabetes is what's making you fat, it doesn't raise your cholesterol, vs. if a sedentary lifestyle is making you fat, it'll also raise your cholesterol. I don't know. Personally, I don't think that explains it. In any case, it's also interesting to note that overweight kids with type 1 diabetes have blood markers that suggest better health than nondiabetic overweight kids.
This study similarly surprised its authors, and is about the same thing.

While a number of studies have convincingly shown that diabetes can have bad affects on your ability to think, in a number of studies diabetic children acheive better grades and higher standardized test scores than their non-diabetic peers. This is especially apparent in math- it's good practice, I guess.

And, of course, diabetes is a risk factor for climbing Mt. Everest!
(since I wrote that piece, a young woman with type 1 diabetes has climbed on Everest as far as the base camp, and another group of four young people with type 1 diabetes are planning an Everest climb as part of an advertising campaign for a diabetes company).

Saturday, November 10, 2012

FDA Votes For Degludec

The FDA recently approved the new insulin degludec, and the vote was 8 to 4. I thought the 4 who voted against made an excellent case for why it should not be approved, or at least not yet, and I strongly advise you to avoid using degludec, at least until larger studies show that what looks like an increase in heart attacks isn't. Because I think that at the least, there's evidence that there's not enough evidence to say it's safe.

The FDA votes against medications are usually on one of three grounds.
3. Possible human error would lead to problems. For instance, if U500 insulin was accidentally given instead of U100 insulin.
2. Not enough safety evidence, or trials were done poorly.
1. Medication's side effects are a really big deal compared to possible benefits.

In my opinion, a no vote because of #3 is something a consumer should be aware of but is not a reason to avoid a medication- after all, you know what user error you want to avoid. #2 is sometimes nitpicky, but if a medication doesn't hold big promise, then this is a reason to avoid it. #1 should really make you pay attention.
For degludec, members of the committee raised issues #1 and #2, because the studies were not well done and because the risk of heart attack was higher in the group using degludec vs glargine.

I started wondering what committe votes looked like for other insulins. Unfortunately, I didn't find them. So here's an FDA fact for you: in was founded in 1938, and prior to that, there was no review process required before the release of a drug in the United States or much of anywhere else.

Friday, November 09, 2012

Methods of Glycosolated HbA1c Detection

There are six different methods for measuring glycosolated HbA1c percentages.  Two methods rely on electrical conduction- they use the fact that glycated HbA1c has less charge than non-glycated HbA1c.
There is an immunoassay method that uses antibodies to a part of the glycated HbA1c- when measuring this way, the test looks at antibody attacks, and it looks at total HbA1c levels, and does a calculation that way. Boronic acid reacts differently to glycosolated HbA1c and so that can be used too. Spectrometers can actually really and truly look and measure the glycosolation.

I am relying on one source more than I usually do for today's fact. That source is Unexpected Hemoglobin A1c Results, by Alina-Gabriela Sofronescu, Laurie M Williams, Dorinda M Andrews, and Yusheng Zhu.


If you are a diabetic who would like to be interviewed and profiled, let me know. 

Thursday, November 08, 2012

Temperature Affects Insulin Absorption

The first thing I read on a diabetes forum that surprised me was somebody stressing out about when to give her kid a bath. Because that bath was drop her kid's blood sugar.
Really? I went and asked my CDE. She said, if it's a hot bath. Above about 110 degrees Fahrenheit (43 Celcius). It will make the insulin get absorbed more quickly and fully. So I took a thermometer in the bath with and me and low and behold my favorite bath temperature is 109 degrees Fahrenheit.
I suspect the threshhold is an artificial thing- in real life, any amount of warming will both speed up and increase insulin absorption. But my CDE was trying to put a number on how hot it has to get before she expected it to make a noticeable and significant difference.

If you were to use this effect consciously, you'd probably want to take your baths right after meals or at whatever time you are most likely to go high. 

Some researchers are hoping to make a site warmer to go with an insulin pump to speed up the insulin absorption.  With their warmer, they found that Novolog action peaked 35 minutes earlier than without it.

This effect is not specific to insulin. All drugs injected subcutaneously will be absorbed faster in heat, because of the changes in how blood circulates- it circulates more and closer to the skin when you're warmer.
Also, if you are storing insulin under warm enough conditions, it will be less effective- heat makes the insulin get absorbed more by your body but if you decide to bring your insulin vial into the sauna with you, your insulin in the vial is going to be less effective, even as the insulin already injected (or about to be injected) is more effective.

Wednesday, November 07, 2012

How Hypodermic Needles are Made

This is a five minute video on hypodermic needles from the Discovery Channel. I sure hope these aren't insulin needles, 'cause they're big.

Tuesday, November 06, 2012

Size of Pancreata

When you were born, your entire pancreas, if it had been taken out and smushed, would probably have fit inside a vial of the size that insulin comes in (most insulin vials hold 10mL of insulin and another 2 or so mL of air, and a baby's pancreas is about 9 mL- can be bigger or smaller). Almost half of your pancreas was made up of fat, with the other half being busy with the business of making digestive enzymes and hormones like insulin and glucagon.
Assuming you didn't develop type 1 diabetes or pancreatitis, your pancreas kept growing. The business part of your pancreas reached its maximum size sometime in your teens, twenties, or thirties. Then it began to slowly, slowly, slowly, atrophy.
The fat part of your pancreas grew too. Depending on how heavy you were, your pancreas may have put on a lot of weight. Unlike you, it didn't lose it. Your pancreas got more fatty as you got older, as the rest of it atrophied, and the fat part didn't.
If you were a normal or type 2 diabetic adult, your pancreas probably reached a maximum volume between 40 mL and 120 mL. After that... well, the average pancreas shrinks by about 20 mL between the ages of 30 years and 80 years old. Type 2 diabetes does not affect the size of the pancreas, although being overweight will make both the business part and the fat part of the pancreas larger, and being obese will make the fat part of the pancreas a lot larger.

If you are a type 1 diabetic... those antibodies likely attacked more than just your beta cells. About half of type 1 diabetics show mild signs of having exocrine pancreatic disease in terms of blood work (few show more than mild signs). An even higher portion have shrunken pancreata on imaging studies. The average pancreas size of type 1 diabetics is consistently small in the studies published, but the average size in different studies varies from 8 mL ( the size of a newborn baby's pancreas) to about 50 mL (the lower end of the normal range).

Source: (I have also read through the studies linked to in this article, but the article I am linking to is my main source).

Monday, November 05, 2012

According to data from the US National Health Survey, in 2009 there were roughly 3,234,000 diabetic Americans aged eighteen to forty four (about 3%); 9,886,000 diabetic Americans aged forty five to sixty four (about 15%), 4,107,000 diabetic Americans sixty five to seventy four (about 23%), and 3,263,000 diabetic Americans  age seventy five or older (about 18%), for a total of 20,490,000 (twenty million, four hundred ninety thousand) diabetic American adults. Prediabetics and the undiagnosed were not included.

Sunday, November 04, 2012


Endocrinology is, at least etymologically, the study of hormones.
Diabetes doctors are endocrinologists because diabetes was historically thought to be all about insulin (I say historically because I think if we knew then what we know now about type 2 diabetes we might not classify it that way).
But not all endocrinologists are about diabetes. The endocrine system in the body has a number of parts: the gonads (ovaries, testes, or things that seem like they would have become ovaries or testes), the islet cell portion of the pancreas, the adrenal glands, the thyroid, the four parathyroid glands, and the pituitary gland.

Most endocrinologists fall into one of three categories: reproductive endocrinologists, who deal primarily with issues of infertility; metabolic endocrinologists, who deal primarily with diabetes but also with thyroid disorders and occasional pituitary, adrenal, and parathyroid disorders; pediatric endocrinologists, who deal with endocrine issues in kids, mainly diabetes, growth hormone deficiencies, adrenal hyperplasias, and thyroid diseases. A rare few endocrinologists actually specialize in thyroid disorders or adrenal disorders, or even endocrine cancers.
Endocrinology, diabetes, and metabolism is a specialty that a doctor gets after being an internist.
Reproductive endocrinology/infertility is a specialty that a doctor gets after being an OB/GYN.
Pediatric endocrinology is a specialty a doctor gets after being a pediatrician.

Many diabetics get their diabetes treated primarily by an internist, geriatrician, or pediatrician, or by somebody who's not a doctors such as a diabetes educator, nutritionist, or nurse. Or, of course, by themselves.

Saturday, November 03, 2012

There are More than 100 Different Meters on the Market

Blood sugar meters were first developed so that emergency responders and ER personnel could figure who was passed from low blood sugar, and who was passed out for other reasons. Today, their use at home is recommended for most people with diabetes. There are hundreds of meters out there (about fifty available in the United States).
I have listed more than a hundred meters and this is not a complete list.

Accu Chek (Roche) makes more than fifteen meters, although it has really different selections in different countries.
Accu Chek Active (made in at least three models, and I think this is the same as the Sensor)
Accu Chek Advantage
Accu Chek Aviva/ Plus (same meter, different strips)
Accu Chek Aviva Compact
Accu Chek Combo
Accu Chek Compact Plus
Accu Chek Aviva Expert (this one will calculate insulin doses for you!)
Accu Chek Aviva Nano
Accu Chek Advantage
Accu Chek Go
Accu Chek Mobile
Accu Chek Performa
Accu Chek Performa Nano
Accu Chek Nano
Accu Chek Voicemate (for blind people)

Advocate meters sells four:
Redi-Code DASH
Redi-Code Duo
Redi-Code Plus

Arkray makes seven fairly obscure meters:
Assure Platinum
Assure Pro
Assure 4
Glucocard 01(which talks)
Glucocard 01 Mini
Glucocard X
Glucocard Vital

The Bayer line has three basic meters with some variations:
Breeze 2
Bayer Contour
Bayer Contour Link
Bayer Contour Next EZ
Bayer Contour USB
Bayer Contour USB Next
it has also sold
Contour TS
and Bayer Didget, which connects with Nintendo systems

Agamatrix has four meters that it makes solo:
Keynote Pro
As well as two that it makes in partnership with Sanofi:

Bionime advertises five meters, sold with and without the word "Rightest" in front:
But makes a handful more, such as

Biosense makes the Solo V2 (which not only speaks English and Spanish, but also Mandarin Chinese).

Beurer has a number of meters, which in makes in mg/dl and mmol/l versions. The ones with B measure blood pressure as well as blood sugar:
BGL 40
BGL 60
GL 32
GL 40
GL 44

Broadmaster Biotech makes three versions of the Glucose Shephard. I think one of them tests ketones. They applied for FDA approval (and from one I can tell from the FDA website, they got it) but they don't sell meters here.

Fifty50, the diabetes supply company, also makes its own meter, the Fifty50.

ForaCare sells fourteen blood sugar meters, four of which also test blood pressure:
Premium V10

GlucoCom sells the GlucoCom.

Infopia sells three monitors:

Life Scan is selling five meters:
One Touch Verio IQ
One Touch UltraSmart
One Touch Ultra Mini (in lots of colors)
One Touch Ultra 2
One Touch Ultra Link
but has also made
One Touch Select
One Touch Verio
One Touch Verio Pro
One Touch  VITA

Abbott sells five meters:
Freestyle Freedom Lite
Freestye Lite
Freestyle InsuLinx
Precision Xtra
and for hospitals Precision Xtra Pro

Refreshingly enough, Microdot makes nothing but the microdot.

And MyGlucoHealth makes nothing but MyGlucoHealth (and accessories).

Nova Cares just sells two versions of practically the same thing:
Nova Max Plus
Nova Max Link

Nipro sells six that all sound like shoes to me:

Oak Tree International sells thirteen meters, but only one is FDA approved (they mostly, from what I can tell, sell in Asia):
EasyMax L
EasyPlus R2N
Android APP

Omnis makes two

OKBiotech makes four:
OKmeter Optima
OKmeter Match -this one gives a smiley face for a good reading :- )
OKmeter Link
OKmeter Direct

The Prodigy line has three:
Prodigy Autocode
Prodigy Pocket
Prodigy Voice

Simple Diagnostics sells:
CleverChoice Mini
CleverChoice Pro
CleverChoice Voice
CleverChoice Voice+
CleverChoice AutoCode

Telcare makes the :
Telcare (surprise!)

Walmart's Relion Line includes four meters:
Relion Confirm
Relion Micro
Relion Prime
Relion Ultima

I don't know who makes
Glucoleader Enhance
Glusensor i-Care
SmartCare Mini

Friday, November 02, 2012

The wrong 1 in a 1,000,000

According to the CDC, 1 per million people under age 20 died of diabetes in 2008-2009 (at least according to their death certificates). This is less than half the rate from forty years ago in the US, but it still represents roughly forty deaths from diabetes in children and teenagers nationwide, per year.

Thursday, November 01, 2012

Age at Diagnosis Affects Risks

It's November again! For those new to this blog, that means it's time for me to post one diabetes fact per day, generally something I think is interesting or often ignored by the diabetes community.

Today's fact is that people diagnosed with autoimmune type 1 diabetes at different ages (and it can be diagnosed at almost any age- although autoimmune diabetes diagnoses in people under about six months should be looked at squinty) have really different overall profiles for complication rates as well as for associated conditions that aren't complications.

A person diagnosed at the age of two, compared to one diagnosed at the age of twenty, will on average have a much shorter honeymoon (if he has one at all), has about four times the risk of developing celiac, a much higher risk of leukemia, and if female, ovarian cancer. She has a dramatically lower risk of developing end stage renal failure, and a much lower risk of losing his eyesight from diabetes.

This is extremely important to know because when people talk about trends in diabetes complications, they often compare cohorts with really different ages at onset of diabetes. It's also somewhat important to know because people should always look at the ages at diagnosis in the people in any particular study before they start thinking that the study is relevant to their own risks.

While some of the difference in risk probably has to do with genetics, other parts of it clearly don't, because the difference in complication rate based on age at diagnosis is apparent within families.

Some studies that make me certain that this is factual:

The Risk of Proliferative Retinopathy in Siblings With Type 1 Diabetes, a study of sibling pairs. The younger diagnosed sibling (average age at dx: 8 years) had, after 30 years, a 37% risk of proliferative retinopathy. The older diagnosed siblings (average age at dx: 16 years) had, after 30 years, a 53% risk of proliferative retinopathy..

This study on Mortality in Finnish Type 1 Diabetics compares risks 20 years from diagnosis for people diagnosed above and below the age of 15 (all dx below age 30).  I am not entirely certain that it proves my point because it doesn't follow the younger diagnosed people longer, but it does certainly show that, in the 20 years after diagnosis, the causes of death in those diagnosed at different ages are pretty different. For one thing, at least in Finland, alcohol is a major cause of death for those diagnosed in late adolescence/ early adulthood.

Studies that compare the rate of celiac in people diagnosed with diabetes at different ages can be found by clicking the linked words in this sentence. I will admit to cherry picking: I did also find two studies that didn't find a linkage but I consider them small in comparison to the studies that do find a linkage, especially given how strong of a linkage many of these studies found.

A number of studies on kidney disease and type 1 diabetes have shown that being diagnosed young- the younger the better- with some studies not having any diabetic kidney failure in people diagnosed under age 5- is protective against kidney disease, or at least against advanced kidney disease. However, the risks don't keeping going up for older and older ages at diagnosis- those diagnosed as adults are at lower risk than those diagnosed in their teens.
When age at diagnosis is the same, type 2 diabetics are at much higher risk of kidney disease and failure than type 1 diabetics.

Friday, October 19, 2012

Must Read Study on Meter Accuracy

This is a comparison of 43 meters, and I think they did a great job. Please check out your meter. I think the biggest surprise on this list was that the Bayer Contour USB performed pretty poorly (it was by no means the worst on the list but it is surprising because it's one of the pricier ones on the list). Bayer Contour USB was within 5% only a third of the time. It was more than 10% off  about a third of the time. It was more than 20% off in 4% of tests- which I think is a lot. I mean, if my bg is actually 200, it only would guess between 190-210 a third of the time. And it would guess outside the 160-240 range for 1 in 25 tests. That's a couple times per week if you're a 7x per day tester. The iBGStar did similarly poorly.

Two meters were within 10% on all 200 tests. Those were the Accu Chek Active  and the Freestyle Lite. Of the two, the Freestyle Lite was within 5% a larger portion of the time. That means, if your blood sugar was 200, it should tell you a number between 180 and 220 every single time. At least 4 times out of 5, these two would give you a number between 190 and 210. That's pretty good.
The Accu Chek Active is so old that the strips change color depending on your blood sugar, and it takes a 1 microliter blood sample.
The Freestyle lite takes 0.3 microliters and has the modern standard of a 5 second wait time.

The way I see it, if you want to think about what accuracy is okay, corrections are what's most important. I'm gonna correct for the number I see. I need to be pretty sure that the number I see represents a narrow enough range that if I aim for a blood sugar of 110 with my correction, I'm not likely to go lower than 70- that means the range that the bg I see might actually represent would ideally be less than 40. At a blood sugar of 200, a 10% error means a 40 point range in blood sugar possibilities. The meter I use, the Accu Chek Aviva, missed this mark 9% of the time. That's 1 in 11 tests.  If you test 7x per day, that's about 4 times per week.

Actually, that's just what their stats suggest. If you look at the graphs, you can see it even better. The accu chek aviva was actually off by more than 40 mg/dl in a few of their tests, and all the tests they did where the Aviva was off by more than 40 mg/dl, the Accu Chek read lower than the real value. This means that there isn't really as much risk of over correcting as I might worry; there's a much bigger risk of undercorrecting.
Bayer Contour, on the other hand, did read more than 40 mg/dl higher than the actual value in multiple instances in the study. The Freestyle Lite had a tendency to read low and didn't once read more than 15 mg/dl higher than the actual value. At very high values it tended to really under read numbers. That's something I'd be comfortable correcting off of. At blood sugars like 300, the iBGStar read more than 60 mg/dl high. Not cool.

There's also a chart in this study about the percentage bias different meters tend to have.

Like I said, a must read. Please click on that link!

Tuesday, October 09, 2012

G4 Platinum

The big news in the US diabetes online stuff is that the FDA approved the Dexcom G4 Platinum. It's shipping now, and I can order one as soon as my warranty on this one is up (in two days). I'll be waiting until I use up my sensors for the 7+ though, 'cause they won't work with the new system, and hoping my 7+ receiver works that long.

I just downloaded and watched the entire G4 Platinum tutorial (ugh) and here's what I learned that I didn't get from just looking at the press release and website:
- It is still only approved for belly sites, still has a problem with acetominophen, sensors still have the same storage recommendations, still can only be calibrated in the 40-400 mg/dl range (I am in the 30s often enough to be annoyed by this), still need to be calibrated every 12 hours, have a 2 hour warm up, and want two readings at that point, and still continue to provide readings if you miss a 12 hour calibration point. It also still has a 55 mg/dl low alarm you can't turn off, and still vibrates before beeping no matter how you set the alarms.
The transmitter is now expected to die after 6 months. Minimed has a transmitter it warranties for only 6 months and the 7+ transmitter is warrantied for a year; for me that was one of the selling points of Dexcom. But the tutorial says the transmitter will last roughly 6 months and that the receiver will give you a warning that your transmitter battery is dying, after which the transmitter is expected to last only one more week.
The range is now advertised to be 20 feet rather than 5 feet. Which is great, but apparently that 20 feet thing is only when you're out of water. Which means it might not help me in the swimming pool. It is still true that the sensor and transmitter (when attached to a sensor) are waterproof but the receiver is not even splash resistant.
Although the website says (in the for professionals section) that you can calibrate no matter how fast blood sugar is changing, in the tutorial it says not to calibrate when blood sugar is changing at a rate of 2 mg/dl/min or more. Since mine is doing that what feels like most of the time, that's an issue.
While watching the set up thing in the tutorial, I noticed that the settings for the low alert now offers an option of a low alert at 85 mg/dl (currently Dexcom only offers these low alert options: OFF, 60 mg/dl, 70 mg/dl, 80 mg/dl, 90 mg/dl, and 100 mg/dl). Hopefully this means that there are now more options to choose from for both high and low alerts.
For alert settings, there are now alert "profiles". Rather than being able to individually set each alarm to off, vibrate only, or vibrate then beep, you now choose from one of five profiles, which are: Vibrate only, Alarm Softly, Normal, Loud (they have a special name for loud), and Hypo Repeat (which is Normal, except the hypo alarms get louder and louder). You'll notice there doesn't seem to be an off option. Except for the fact that there's a loud option (which it desperately needs) this does not strike me as much of an improvement.
The sensor looks the same. My guess is that it's really only different by the way that the transmitter attaches, because the transmitter is shaped slightly differently.

So now, I have a few questions in my mind.
 Question one is, what if my Dexcom 7+ receiver, which is almost out of warranty, breaks before I use up my remaining sensors (which will be in roughly 6 weeks)? Will I be able to pay for a new 7+ receiver without  having to pay the $400 upgrade price (which is what is being charged if you bought a 7+ system before September 2012 and want to upgrade).
Question two: There are three color options, pink, blue, and black. The pink doesn't look real macho. Should I get blue or black?
Question three: So, say my G4 transmitter dies. Will insurance really pay for two transmitters per year? Will Dexcom really replace it for a reasonable price?
Question four: Is the system really as basic as it looks in the training video???

Friday, October 05, 2012

Funny Song; I Got to Poke My Finger Every Day

  • I got to poke my fingers every day
    I got to poke my finger, got to poke my finger, got to poke my finger, every day.
    I got to get that needle and put it inside the device.
    An then I got to pull the thing back.
    An then put the device on my finger and push the button and then I go
    I go to check that sugar every day.
    I got to check that sugar every day.
    I got to check that sugar, check that sugar, check that sugar every day.
    That's why I poke my finger every day.
    That's why I poke my finger every day.
    That's why I poke my finger- poke my finger- poke my finger- reckon I do
    I stick the needle and POW and tek some blood
  • And I gotta poke my finger every day.
    I poke my finger, yes I poke my finger, yes I poke my finger every day.
    Every day I poke my finger, every day I draw some blood.
    I go to put the needle inside the device and put the device goes through my finger and then push the button and go POW WOW
    'cause I got to poke my finger every day.

Thursday, October 04, 2012

That ADA Ad

... the one that says Diabetes Kills More than AIDS and Breast Cancer Combined! is showing up on practically every webpage I visit right now and it's bugging me.

Numerically speaking in the United States, diabetes is listed on more death certificates than AIDS or breast cancer, neither of which is a big killer. But diabetes isn't even close to being a bigger killer in terms of "years lost", because people dying of diabetes are on average 73. People dying of HIV and breast cancer account for more years lost as computed by the CDC because they are substantially younger than people dying of diabetes.

But even if that weren't the case I don't like that ad.

Wednesday, October 03, 2012

I just got my flu vaccine

and if you're reading this blog, you should too.
Vaccines are not totally effective at preventing disease (any disease) because not everybody's immune system will respond. To protect the people with the weakest immune systems, everybody who comes into contact with them needs to be vaccinated. That means you.

This has been a public service announcement from Jonah.
What the CDC wants you to know about diabetes and influenza:
Evidence that diabetes is a risk factor for flu infections severe enough for hospitalization: (9 out of 162 people hospitalized for swine flu had type 1 diabetes in this one hospital study- I don't have to tell you that 9/162 is way more diabetics than you'll find in the general population)
What the ADA has to say:

Monday, September 24, 2012


On September 2nd, I left my Dexcom receiver on the el. No worries, I got it back... on September 12th. In the meantime I did a lot of worrying. I called the lost and found about four times before they said they had it. I called Dexcom to ask how much a replacement receiver would cost. The answer was: $199 for a receiver as long as I have one in warranty, which means that if I want to buy one for whatever reason (lost, backup) I can do that by October 11th. If I want to do it later than that, too bad, out of warranty, must buy new system. I'm trying to figure out if I should do that (or even just send this one back on grounds that its broken because the backlight, which I didn't like anyways, no longer works). I'd read some rumors that the Dex G4 was coming out in the US in December, but the person on the phone said they'd just submitted to the FDA and I shouldn't count on it. However, I'm hopeful anyways that it will be out by the time I next need to order a new system.

It's These Kinds of Weeks That Make Me Wonder

According to my Dexcom data, in the last seven days, my blood sugar has been below 200 mg/dl 97% of the time. I haven't had a real low (I've been down to 58 and no lower). My average for the week is 124. My standard deviation for the week is 36. I stayed below 200 on five days.

Over the last three months, I've spent only 90% of the time below 200, and have been above 200 about 5 days per week. My average is 134, I spend 3% of the time above 240, I go below 55 on the majority of days, and my standard deviation is 48.

That means that this week, my rate of the kind of hyperglycemia that gets you warned about ketones- numbers above 240- has fallen from being something I experience for an average of 45 minutes per day, to none. My rate of real hypoglycemia (below 55, say), fell from being something I experience for an average of half an hour per day, to none. The amount of time I spend in the 80-200 range went from 80% to 91%. My average fell ten points.

Did I do anything differently? Nope.

By the way, the title says "these kinds of weeks" but the last one as good as this was probably September 2011.

Sunday, September 16, 2012

Complete (if vague) 1 week food log (does not include water)

Sunday, breakfast:
1 1/2 cups soymilk (365 brand, "normal", sweetened)
1 tbsp Brewer's yeast
1 cup honey bunches of oats, honey roasted flavor (cereal)
1 small banana (I estimated it at 15 grams of carbs)

Sunday, midmorning:
25 jelly beans

Sunday, lunch:
pizza bread (basically white bread with tomato sauce, onions, mushrooms, and olives)

Sunday, while out walking:
granola bar (Nature Valley, Oats n' Honey flavor)

Sunday, supper:
Garlic bread (three types of bread with lots of garlic and some oil)
more jelly beans

Monday, breakfast
lentils with bits of sweet potato, onion
spelt noodles
little bit of bread

Monday, early lunch
lentils with bits of sweet potato, onion,
spelt noodles

Monday, later lunch
1 cup unsweetened Edensoy (this is actually the stuff Bernstein recommends drinking but I drank it even before I read his book, because my mother likes it)
2 tbsp Brewer's Yeast
extremely thin slice of pizza bread, with hummus

Monday, hypotime
1/3 cup applesauce
1 dum dum

Monday, still not suppertime
1/2 cup tomato juice, RubyKist brand

Monday,  suppertime
1 large white potato (boiled) with lentil dish

Monday, bedtime
2 dum dums

Tuesday breakfast
1 microwaved red potato (raw weight 120 grams)
1 cup unsweetened soy milk

Tuesday lunch
1 packet of instant oatmeal- raisin and walnut flavor

Tuesday afternoon
1 big gulp honey
1 dum dum

Tuesday on the way home
1 dum dum

Tuesday late afternoon snack
1 bowl stir fried vegetables- onion, eggplant, zucchini, cauliflour with soy sauce
about 1/4 cup sticky rice
boiled cabbage

Tuesday suppertime
Roasted and salted sunflower seeds
More stir fry- onion, eggplant, zuchhini, cauliflour with Brewer's Yeast
1 cup rice
1 cup soymilk- vanilla slightly sweetened (365 brand)
1/8 cup cereal- granola
handful of popcorn, no toppings

Tuesday bedtime
one baked potato, larger than the morning's
2 dum dums

Tuesday later

Wednesday pre-prayers
unsweetened Silk with tomato juice

Wednesday breakfast
vanilla soymilk with shredded wheat and BreKewer's Yeast
roasted unsalted, already shelled, sunflower seeds

Wednesday on the way to work (roughly lunchtime):
16 tea biscuits (3 grams CHO each)
1 sandwich (2 pieces of 1/2 whole wheat bread, about 1 tbsp peanut butter- the kind that's nothing but roasted peanuts, and 1 small tomato)

Wednesday when I got home:
soymilk with multigrain cheerios

Wednesday supper:
soymilk with Kellogg's Crunchy Nut Golden Honey Nut cereal (it tasted like peanut brittle)
stir fry (cauliflower, eggplant, onion, and zucchini) with rice and with Newman's tomato sauce

Thursday before prayers:
1/4 cup vanilla soymilk (I mixed it with water)

Thursday brunch:
grits with raisins (a lot of it)

Thursday early afternoon:
chocolate wafers

Thursday late afternoon:
Stew- eggplant, flax, zucchini, carrot, onion, garbanzo beans

Thursday evening:
Cooking water and some lentils left over after cooking a pot of lentils for a house of mourning.
2 dried apricots

Friday breakfast:
Unsweetened Silk Soymilk, Brewer's yeast, and toasted oats cereal

Friday at work:
gulp of honey

Friday lunch:
one packet instant oatmeal, raisins and walnut flavor
2 rice cakes

Friday afternoon snack:
2 rice cakes
chocolate wafers

Sometime on the sabbath:
three types of soymilk, flaxmilk
boiled potatoes
some kind of stew with lentils and spinach
borsht- mostly beets but also some celery and onions
tea biscuits
2 medjool dates (these are supposed to raise blood sugar really fast but I have never noticed them actually doing this)
soy hotdogs
wheat germ
half of a zucchini muffin
two types of breakfast cereal
breaded eggplant sticks (they look like fishsticks)
semi sweet chocolate chips
apple juice (we somehow forgot to buy grape juice)
roasted sunflower seeds
one pear (juicy and ripe)
soy "sour cream" (this tastes absolutely nothing like I remember sour cream but my mother makes it from tofu about once a month and claims it's sour cream. It tastes more like kefir.)

Saturday evening:
one dum dum
one small baked potato
three rice cakes
another small baked potato

Wednesday, September 05, 2012

Research idea

I've been thinking for a while about the internet being a vast source of information, but how a lot of the information that I want isn't available. And I keep thinking, what if a hundred or two hundred diabetics decided to get together and submit their own questions and data to each other and monitor it for years and then share it.

I think the project would go like this:
First of all, the people I want data on are people who are or have been on insulin for a significant amount of time. I'm going to say 10% of your life. I also want people who are going to be available for follow up, so people participating have to be volunteering their own data, not their kids'. And they have to commit to continuing to participate, and that means also giving me or somebody else their name to find an obituary if they die. So that's the inclusion criteria.
I then would need a whole lot of people to volunteer, in order to collect much meaningful data. Like I said, I'm thinking at least 100. Each person joining would need to submit their contact information, some statement to the effect that they want to join, and if they want to, would have the option of submitting the question(s) that they want the other people to be asked. The questions should be quantifiable type questions- not, "How did you feel?" but "Have you seen a therapist?" or "Have you been depressed?" not, how does your skin look, but "Do you have scar tissue at your injection sites?"
Then at some point we'd start the study, and probably for anonymity, assign or ask for a code name or number for each participant. Send out all the questions that everybody's submitted. Everybody returns the survey, with somebody badgering them until they do. Publically shared is the percentage answering each question in different ways, and maybe some large analysis; private to the members are any linkages that anybody asks for. For example, a participant might ask, of people who answered X1 to question number 14, how many answered Z1 to question 23? Of people who answered X2 to question number 14, how many answered Z1 to question 23?s
We would send out the same group of questions to the participants every year, except for questions like when did you go on insulin and how old are you. Participants would continue to be able to ask for linkage on past questions. For example, of people who answered Z2 to question 23 in the first year, but answered Z1 later, how many answered question 14 with X1 the first year?

Some questions I'd hope a study like this might answer are: what factors change the risk of lipodystrophy? What factors change the risk of scarring? How prevalent is lipodystrophy?
What questions would you want answered?

Friday, August 31, 2012

Am Dancing on the Inside

The A1c is 6.2%!
The microalbumin is 0.4!!
The serum creatinine and TSH and just about everything are NORMAL.
The total cholesterol is 104 with LDL and HDL both being about 40.
And did I mention? I gained weight!

Wednesday, August 29, 2012

Post Endo Visit

What we did:
- I got weighed in and my weight is up to 102 lb. Woot!
- Discussed my blood sugar trends. He thinks it's looking pretty good- suggested taking an extra shot of Regular around 5 PM to forstall the rise in blood sugar that I often see.
- Discussed my hands- he says it probably isn't diabetic neuropathy.
- Discussed injection methods. He told me a few stories about patients and people with diabetes he's known. I wonder if I'm a story he tells or will tell anybody. I love hearing his stories.
- Got prescriptions for Regular, test strips, and glucagon.
- Mentioned the cardiac issues. He mentioned a holter monitor. Didn't think it was necessary, but an option to keep in mind.
- Had blood drawn for blood chemistry, A1c and TSH. Gave a urine sample for microalbumin.

If anybody wants to guess my A1c, you have until he tells me the results. My one month average is 131, the previous month was 139, and the three month average is 134.

Saturday, August 25, 2012

The endo appointment is Wednesday and I've been looking at my numbers really critically the last few days. My average as far back as this Dexcom goes (which is between two and three months) is 134. My biggest blood sugar weaknesses are: night time, especially when I'm asleep, and suppertime. In order to get a good distribution chart of when my BG is in what range, I reset the range to each 10 pt interval and looked at % in range. For 10 pt ranges after the 260s, the percent in range always came out 0, but there really is 1 last percentage point if you look at all points 270+, which is why the numbers on this graph add up to 99%.

Online Graphing
Make a graph

Edit: None of the diabetes software I've used has ever offered "mode" as a stat, but you the term for the most common data point in a group is mode. In the chart above, 110s is my mode

Friday, August 17, 2012

Made an Endo Appt

It's been 5 months since I saw the endo, although it doesn't feel that long. I scheduled an appointment for the 29th, three days before my six year anniversary of being on insulin. I want to get my endo's take on what's going on with my hands.

I am going to put up lots of data between now and then about what my blood sugar's been doing and you all are once again invited to guess at my A1c.
For July, my Dexcom average was 139 with a standard deviation of 52. But it was really not being all that accurate, I don't know why. For August so far I'm averaging 132. But it's still being really inaccurate. For instance, of my last ten calibrations:

Dexcom v Accu Chek
224 v 150
98 v 60
209 v 168
189 v 153
243 v 181
64 v 98
148 v 191 (for this one, it should be admitted that my blood sugar was rising rapidly)
162 v 240
85 v 120
108 v 54

Pretty poor, yeah? None closer than 34 mg/dl apart. Compare this to a time when my sensors were doing much better, say, one month ago. Looking at my chart for July 17 and going back 10 readings, the accuracy is like this:

Dexcom v Accu Chekt
261 v 256
204 v 186
128 v 116
160 v 120
254 v 264
157 v 138
207 v 177
171 v 171
244 v 231
218 v 156

Which is worse blood sugars (really, yuck) but features one pair that was exactly the same, a lot of pairs really close, and only two pairs with a difference big enough to change whether or not I'd give insulin or eat (the fourth and last).

I really noticed the inaccuracy starting a couple of days after I injured my hand and suspect that the medication I took for the hand (Voltarin) was part of that, although I'm now off the Voltarin and the numbers don't seem better.
On Wednesday I met with an occupational therapist that the orthopedic surgeon had suggested. She did some testing, and didn't really find anything wrong, other than what I said was wrong. My grip strength and pinch strengths are normal. My range of motion is normal, and my flexibility is normal.
The OT doesn't particularly think I have carpal tunnel or diabetic neuropathy. She thinks I am generally overworked and carry too much stuff and don't get enough rest and it just happens to be manifesting in my hands.

Although most of what she said is somewhat disturbing, one of the things she said keeps niggling at me. I asked if she said I had diabetic neuropathy. And she said I could, I could not, and that it didn't matter- I shouldn't be thinking that that's the problem because, according to her, that would be too easy. That would let me say, it's not an issue of how much I'm overworking my body, or what I'm doing lifestyle wise.

Diabetic neuropathy, easy? It's a thought.

There is, of course, the larger issue that she does not believe occupational therapy would help me with my hands and that what I really need to do is figure out how to work less, and less intensively. Which is the sort of thing I feel like a person can better get away with she has been working for thirty plus years, and not so much when he is applying for jobs. Also, I don't really feel comfortable taking things easy.

Monday, August 06, 2012

I first flunked a neuropathy screening on my feet in 2009, which prompted me to reduce blood sugar testing on my toes, and I stopped testing on my toes altogether in 2010 when I started using Dexcom and reduced the total number of blood sugar tests that I was doing.

As it was three years from diabetes diagnosis to the first suggestion that I had neuropathy, it was three years from the suggestion of neuropathy to the suggestion that I had neuropathy not just in a foot, but in all four limbs. 

And now I wonder- my hands are being medicated. I have an NSAID goop on them. Should I go back to checking blood sugar on my toes? I mean... if I have neuropathy in my hands as well as feet, why favor the feet?

Saturday, August 04, 2012

You'd think being in pain and stressed out would raise my insulin needs but it hasn't. Instead I'm taking 7 units of Lantus per night and about 15 units of Regular per day.  My insulin needs really haven't picked up since I got back from vacation and I don't know why.

My orthopedic surgeon changed the diagnosis from diabetic neuropathy with carpal (tarsal) tunnel, to neuritis with carpal (tarsal) tunnel. I think that's because it's getting better, whatever the heck it is.

I'm having second thoughts about buying the jet injector because I'm not getting a person when I call (I did on my first couple of calls- why not now?) and because I keep thinking that it's a long term investment and what if something better comes along?

Sunday, July 29, 2012

Update on Me- Lots of Small Annoyances

 I got new glasses in June (I'm near sighted). My prescription changed a lot in one eye, and I decided I wanted totally new glasses. A couple of days after I got my new glasses, I walked past a door and did a double take- it looked totally warped into a C shape. When I looked at it head-on, it was fine. After that I couldn't stop noticing that everything in my peripheral vision was warped. I use my peripheral vision less than most people do (sensory processing dysfunction- had an OT work with me for a long time trying to get me to track things and look at things without turning my head- I feel safer when I don't see things in my periphery). I went to the optometrist, who did something to my glasses and told me to give it a few days. It's still just as bad.

A few days after I came from my vacation, I started walking into things a lot, and kept injuring myself. In one day, I racked up four scrapes, one bruise, and one burn. The rate of injury has dropped off since then but I'm not doing so great.

A week ago Friday, in the evening I wanted to lie on my side and tried to prop myself up with my left hand. There was an excruciating pain across the top of my hand and I fell. I thought it was yet another stupid joint issue and didn't think too much of it, tried to just use my right. Kept hurting the left everytime something bumped it. Monday night, the hand started feeling the way it did when I had an IV infiltrate- tingly and swollen. So on Tuesday I went to see an orthopedic surgeon, figuring I had a sprain or a fracture. But he took a look at my hand and said, "Interesting- this is acute tarsal carpel tunnel syndrome".  He says his tentative diagnosis is diabetic neuropathy with carpal tunnel syndrome. That is really depressing. I think he's wrong though- I wouldn't be surprised if I do have neuropathy (both  hands and feet have been tingling in a non-painful way) and there's clearly some nerve involvement. But it's the wrist that's really been hurting and it's across the top of my hand, and it's as much on both sides of the hand (thumbward and pinkieward) and plus, I'm only 23 years old.

I'm now wearing a splint and applying a topical NSAID. My Dexcom has been performing pretty erratically and I wonder if it's the NSAID, which is Voltaren Gel (diclofenac sodium topical gel). I'm having a little difficulty in doing shots- I can easily do an injection one-handed, the hard part is drawing up the insulin. And taking the caps off the syringe. Tips welcome.

I'm also having an issue with extreme, sporadic, dizziness. Like everything around me is spinning, but I'm not hypo.

Also, on Friday morning I woke up a little high (218 mg/dl) and tested urine ketones, which were moderate. I tested blood ketones and got a 2.0!!! Unfortunately the strip was a month past the expiration date and I don't have anymore of them, so I couldn't confirm or disprove the result. I took a lot of insulin for breakfast and supper, and my urine was ketone free by evening.

My computer, a little Eee PC, is also having some issues and was giving me blue screen deaths. It works okay as long as I keep it in safe mode (with networking) but the sound won't work and if I go out of safe mode, it restarts.

Despite all that, I'm feeling okay. Have been enjoying finding work arounds, but hoping to return to the state my body was in a month ago.

Tuesday, July 24, 2012

Side Effects

 A while back, I got a comment on here asking if I'd accept guest posts. I said yes, if the guest post was relevant. This is the article written for this blog from, a website that focuses on the risks in medications, and especially those that have been recalled. Although us type 1s do not really have much choice about taking insulin, I sometimes think we can use the reminder that it's not always a good idea to take other medications, or to advocate the use of medications in type 2 diabetes, even when it lowers blood sugar- there are worse things than high blood sugar. Anyways, here's the article. Please leave a comment if there's something you think somebody who is calling attention to the downsides of medications should know about diabetes.

The Benefits and Risks of Diabetes Medications

People with type 1 and type 2 diabetes have similarities and differences when it comes to their medications. People with type 1 diabetes rely mostly on insulin injections, and people with type 2 diabetes are usually prescribed oral medication to help manage the insulin their bodies still produce.
Type 2 patients may require insulin at some point, as well. And people with type 1 diabetes might use an oral medication like an alpha-glucosidase inhibitor to slow the flow of sugar into the bloodstream after a meal.
No matter which medication they take, people with diabetes must be familiar with the drug and possible side effects.
Many diabetes drugs are effective at controlling blood sugar. But they may be too effective, causing hypoglycemia. Both type 1 and type 2 patients need to be on the lookout for low blood sugar. Symptoms include:
* Hunger
* Shaking or trembling
* Blurry vision
* Rapid heartbeat
* Tiredness
* Nervousness
* Headache
* Sweating
* Tingling
If left untreated, hypoglycemia can lead to fainting, seizure or coma. When blood sugar drops, the best thing to do is to eat a piece of candy or drink some regular soda.
Many patients require insulin, which is one of the most powerful reducers of blood sugar. But when it is used in higher amounts than it should be, it can lead to hypoglycemia.
If a person fails to take enough insulin, however, their blood sugar levels can rise dangerously high — a condition known as hyperglycemia. Symptoms include: thirst, tiredness, frequent urination and an upset stomach. It is often treated by exercising, but a doctor would know the best treatment.
Actos is one of the most popular type 2 diabetes medications, and can lower long-term blood sugar (measured by glycated hemoglobin) by about 1.5 percent. It does this by making the cells more receptive to insulin.
Unfortunately, Actos (pioglitazone) also has been linked to serious side effects, including congestive heart failure, bladder cancer and liver disease which has led some patients to begin to file lawsuits. It has carried a black-box warning from the Food and Drug Administration (FDA) since 2007.
The positives and negatives of diabetes medications aren't always clear cut. It's important for people with diabetes to look at medical studies about diabetes drugs before they begin taking them. Look on to find a drug's warning labels to fully understand its risks.

William Richards researches and writes about prescription drugs and medical devices for

Wednesday, July 11, 2012

I was on vacation July 1-8; left on the first and came back to Chicago on the 8th. I reduced my Lantus from 8u (which I'd been taking for the last week of June) to 6u, which I took on the evenings of July 1-6. I took 4 1/2 u Lantus on the evening of the 7th because the 8th was a fast day.
This was my first vacation with diabetes in which I managed to avoid severe, symptomatic, scary hypoglycemia. I did run a lot of lows in the 40s, but I didn't have any lows that made me woozy, panicky, or disoriented, and I didn't go lower than the 40s.

This was also the first time I tried packing a sensor. I've had two vacations in the past where I had been wearing a CGM; in one, I just left the CGM at home and took a sensor break, and in the second I changed sensors right before leaving. This time I took a sensor in the bag but not the box and put it in with my clothes. When I got where I was going the bag looked pretty beat up but the sensor looked okay, and two days later I changed sensors. It performed beautifully. Unfortunately, I'd forgotten to bring scissors to cut my hairs before applying the sensor, and it was a really hot week, so after a week I pulled the sensor because I didn't think it would stick on much longer. But it worked just fine. I will be less hesitant to pack sensors in the future.

One thing I must've done a bad job packing: pen needles. I currently use syringes for the Novolin R and testosterone and pen needles for Lantus. That means that on an 8 day vacation, I expect to use 7-8 pen needles and anywhere from 20-50 syringes. So I packed a box of a 100 syringes and counted out ten pen needles which I put in the box. Well, I guess that's not a good place to put them, because I had trouble finding the darn things. In the end I only could find five pen needles. I reused one of them and did the last Lantus shot by syringe. I guess if you have enough syringes, not having pen needles isn't really such a big deal.

I recently read a study that's made me think about how I store my insulin, even those vials in use. This study looked at Regular and 70/30 insulins made my Novo, Lilly, and Biocon (Biocon insulin is not available in the US and is a U-40 insulin for sale in India). So that's 6 types of insulin. They stored them in unopened vials in 5 different storage conditions (now we're looking at thirty different situations). They wanted to compare how the storage conditions affected degradation of the insulin over a period of two weeks, and over a period of one month.
They injected the insulins into rabbits to see how much the insulin lowered rabbits' blood sugar after being stored in different ways. The rabbits started out with blood sugars in the range of 100-108 mg/dl (apparently that's normal fasting blood sugar for rabbits). The insulin then made them hypo. It lowered blood sugar into really tight and predictable ranges with little standard deviation. It lowered blood sugar significantly less when the insulin had been stored at temperatures of 32 and 37 degrees Celcius (89.6 and 98.6 degrees Fahrenheit), as compared to when it had been stored at temperatures of 5 to 26 degrees Celcius (41 to 78.8 degrees Fahrenheit).

This strongly suggests, at least to me, that a person who carries around his short acting insulin during hot temperature days should carry it in something that will keep it at a temperature that is at least below 89 degrees Fahrenheit, lower if possible, unless the insulin will be used up in less than a two week time period. The Frio may be a good idea.

The full text of the study is available here: