Friday, November 30, 2012
Cyclosporine
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: http://www.accessdata.fda.gov/cdrh_docs/pdf5/P050012c.pdf
-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.
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: http://www.accessdata.fda.gov/cdrh_docs/pdf5/P050012c.pdf
-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.
http://diabetes.diabetesjournals.org/content/61/8/2066.long
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.
http://diabetes.diabetesjournals.org/content/61/8/2066.long
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.
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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.
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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.
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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.
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.
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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.
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.
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.
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: http://dvd.sagepub.com/content/8/2/55.full.pdf
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
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.
http://www.sciencenews.org/view/generic/id/56441/title/Dolphins_may_offer_clues_to_treating_diabetes
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
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.
Source:http://www.statehealthfacts.org/comparemaptable.jsp?typ=2&ind=70&cat=2&sub=22
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
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.
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.
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.
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.
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).
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.
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.
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.
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.
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: 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).
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).
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
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.
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
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:
Jazz
Presto
Keynote
Keynote Pro
As well as two that it makes in partnership with Sanofi:
BGStar
iBGStar
Bionime advertises five meters, sold with and without the word "Rightest" in front:
GM100
GM210
GM300
GM550
GM700
But makes a handful more, such as
Pura
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:
G20
G30a
G31
G71a
G90
Premium V10
V12
V20
V22
V30a
D10
D15
D20
D30
GlucoCom sells the GlucoCom.
Infopia sells three monitors:
Element
Evolution
Eclipse
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:
True2Go
TrueResult
TrueTrack
TrueBalance
TrueRead
Sidekick
Oak Tree International sells thirteen meters, but only one is FDA approved (they mostly, from what I can tell, sell in Asia):
EMV2
EasyMax15
EasyMaxN
EasyMaxV
EasyMaxT1
EasyMax L
MasterDriver
EasyPlusT2
EasyPlus R2N
GlucoDock
Android APP
Omnis makes two
Embrace
Victory
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
Value+
SmartCare
SmartCare Mini
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
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:
Jazz
Presto
Keynote
Keynote Pro
As well as two that it makes in partnership with Sanofi:
BGStar
iBGStar
Bionime advertises five meters, sold with and without the word "Rightest" in front:
GM100
GM210
GM300
GM550
GM700
But makes a handful more, such as
Pura
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:
G20
G30a
G31
G71a
G90
Premium V10
V12
V20
V22
V30a
D10
D15
D20
D30
GlucoCom sells the GlucoCom.
Infopia sells three monitors:
Element
Evolution
Eclipse
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:
True2Go
TrueResult
TrueTrack
TrueBalance
TrueRead
Sidekick
Oak Tree International sells thirteen meters, but only one is FDA approved (they mostly, from what I can tell, sell in Asia):
EMV2
EasyMax15
EasyMaxN
EasyMaxV
EasyMaxT1
EasyMax L
MasterDriver
EasyPlusT2
EasyPlus R2N
GlucoDock
Android APP
Omnis makes two
Embrace
Victory
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
Value+
SmartCare
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.
http://www.ncbi.nlm.nih.gov/pubmed/22925225
http://www.ncbi.nlm.nih.gov/pubmed/22925225
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.
http://www.ncbi.nlm.nih.gov/pubmed/20424230
When age at diagnosis is the same, type 2 diabetics are at much higher risk of kidney disease and failure than type 1 diabetics.
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.
http://www.ncbi.nlm.nih.gov/pubmed/20424230
When age at diagnosis is the same, type 2 diabetics are at much higher risk of kidney disease and failure than type 1 diabetics.
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