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).

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.

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).

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.

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. 

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.

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.

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: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2680737 (I have also read through the studies linked to in this article, but the article I am linking to is my main source).

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.

Endocrinology

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.