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: http://dvd.sagepub.com/content/8/2/55.full.pdf

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.

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.
http://www.sciencenews.org/view/generic/id/56441/title/Dolphins_may_offer_clues_to_treating_diabetes

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.

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.

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.

Source:http://www.statehealthfacts.org/comparemaptable.jsp?typ=2&ind=70&cat=2&sub=22

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.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3214300/ - about children in Iran
http://www.ncbi.nlm.nih.gov/pubmed/23150692 - about adults in Brazil
http://www.indianpediatrics.net/jan2005/jan-15-21.htm - about Sudanese children (with poor metabolic control)
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3120175/ - 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.

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.

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.