This is cool. Not in a having-it way, but a knowing-about-it way.
My professors here usually say 'doctors back in the fifties' for diagosing diabetes mellitus. I'm not sure if it's true or if they just think college students don't know the difference between the two eras.

Posted November 19, 2005 5:13 PM by Cassie Krahe

Veering ever so slightly off-topic -- how does thiamine work to counteract alcohol?

Posted November 19, 2005 5:34 PM by Victor S.

One point: if you've got these symptoms, go talk to a doctor -- but don't assume that it is diabetes until they've checked your blood glucose. Blood glucose is the gold-standard diagnostic test for diabetes. While diabetes is the commonest reason for having a bunch of these symptoms, they may be the result of some other underlying pathologies, unrelated to one another. If in doubt, see a doctor.

Posted November 19, 2005 5:43 PM by Charlie Stross

Thiamine doesn't work to counteract alcohol, but alcoholics often have thiamine deficiencies, which also makes it difficult for them to metabolize glucose.

Posted November 19, 2005 5:44 PM by James D. Macdonald

Note that the last item in your list of points is actually out of date. The fasting blood glucose level that defines diabetes has been redefined in the past couple of years downward to 126 mg/dL.

Posted November 19, 2005 6:11 PM by ralph

In my EMT class, we were told that one sign of untreated diabetes was an ant problem in the bathroom. The ants are attracted to the glucose in the urine that splashes onto the rim of the toilet. I filed it away as a bit of trivia, because how often do you suppose that actually happens? It never did come up when I was working on the ambulance.

Flash forward to a few years later, in my present job managing apartments. I am in the bathroom of an apartment where two developmentally-disabled middle-aged guys live with their aides, looking at the toilet the aide says is wobbly. "It rocks, it leaks, and what with the ants all over the place in here lately, things are a real mess." "Ants?"

Yes, it turned out that one of the men had developed diabetes since his last check-up (the aide wasn't supposed to disclose this to me, but she wanted to thank me afterward for the weird tip). You never know when this kind of stuff will come in handy.

And Jim, we were allowed to give glucagon at an Basic level. Our county medical director was very aggressive about getting us as highly trained as possible, because the we volunteer EMT-Bs covered rural districts with long transport times. I am normally a lurker here, but I wanted to mention how much I enjoy your posts on these topics.

Posted November 19, 2005 6:14 PM by Carrie

Well, the ancient physicians observed that the urine of certain ill persons drew flies (more than, say, an equal quantity of vinegar). And indeed, the word is Greek, because diagnoses go back that far -- about 3500 years, in fact -- though the etiology came long afterward.

But by the Middle Ages, of course, not only had much of the earlier medical knowledge been misfiled, burned, or eaten, uroscopy -- the technical name for "doing odd things with other folks' wee with vaguely medical intent" -- had become practically its own specialty, not to be confused with "urology," which can involve getting a live TV feed from inside your bladder. Technology is swell.

I will note, because this does lead to some confusion, that there are two types of diabetes mellitus, creatively named Type I and Type II. Type I is usually diagnosed in childhood -- it used to be called "juvenile diabetes" -- and is (at least by current understanding) an autoimmune disease in which your body turns nasty on the insulin-producing cells in the pancreas (the beta cells, or islet cells). Eventually almost everyone with Type I completely loses the ability to make insulin, so replacing it is always necessary, by injection or subcutaneous catheter. (Exercise can lower blood sugar without insulin, but not enough to completely replace it.) Beta-cell transplants, which are an actual cure (though you have the problems of any organ transplant) are still experimental, but have had some success, and will likely only get better.

In Type II, "adult-onset" diabetes, insulin production is inadequate, but usually doesn't completely disappear. Most of the symptoms are the same, though ketosis -- the exciting transformation of your blood into paint thinner -- is less common. Also, Type IIs tend to be overweight-to-obese, while Type Is at time of diagnosis are generally underweight. Some Type II patients can get by with dietary control and exercise. Some can take the various oral meds, most of which work by stimulating the beta cells to produce more (so obviously they're useless in Type I). Some people still require insulin, usually in combination with the other therapies.

It is a disease whose therapies and outlook have changed a whole lot in the last few decades. Not very long ago, we didn't have any remotely convenient way of doing blood glucose readings at home, never mind pocket-sized gadgets that would produce a quantitative reading in five seconds. (What you had was urine tests, which were always time-delayed and worthless for checking low sugar.) The variety of insulin mixtures available was much smaller, and they were all of animal origin,* rather than being recombinant human product from trained bugs. Even the needles for injection were a few gauge sizes larger. If you're gonna get it -- and if you have the option, I would recommend that you rent some Ed Wood movies instead -- you now have a pretty decent arsenal to fight it with, and a lot more knowledge of the enemy.

*Made by spinning down pancreases from slaughterhouse cows and pigs. I sometimes wonder if Niven & Pournelle knew this when they let "Dan Forrester" croak so heroically -- and have no doubt whatsoever, fighting hyperglycemia with your bare hands is a wretched way to go. Maybe they didn't think to ask Dan Alderson.

Posted November 19, 2005 6:40 PM by John M. Ford

Well, I scored a 14 on that quiz. For a few months now, my left eye has been a little blurry. I thought it was just my glasses needing a fine tuning. Perhaps I should see a doctor, now that I have insurrence again...

Posted November 19, 2005 6:44 PM by Keith Kisser

Dan didn't fight nearly as hard as he should have. (He's the primary reason why the boxes of cold at LASFS had - and probably still have - a rule that Insulin Is Always Private Stock.)

Posted November 19, 2005 6:47 PM by P J Evans

You do have to temper the list with your personal knowledge. I scored 12 total from four items, all related to renal disease. We check my blood glucose twice a year and it's always fine.

Posted November 19, 2005 8:06 PM by Marilee

Most of this is quite familiar. My maternal grandmother and great-aunt both had Type I diabetes, and one or the other of them lived in the house next door to my parents' for much of my childhood.

So there were a lot of ambulance visits at odd hours due to insulin shock or diabetic coma--this was in the '70's when the available self-treatments (and glucose measurements) were rather less precise, so it was pretty easy to mis-gauge (or mis-administer) your insulin dose.

A can of Coke was the standard whack-your-blood-glucose-up-a-few-notches method for relatives when one of them was too loopy to think of that herself, but sufficiently coherent to drink it (unfortunately a narrow window). It's harder to match doses, but even if you give too much sugar, it gets you outside the insulin shock domain, and then you have time to get the glucose levels under control. Outside that window, we were definitely looking at an ambulance visit, and possibly a hospital stay for blood work.

Fortunately, the EMTs who had been out before were generally willing to listen when my mom suggested D50 (or rather, to act more quickly on the suggestion). I never heard of any of them trying the hard candy trick, but that's probably not be the sort of treatment you should discuss with a boy of six ;-)

My family has the odd pattern that Type I diabetes hits people in their mid-to-late fifties, which is pretty far from the standard age of onset. So I used to be confused about which form was meant when people talked about juvenile diabetes--I mean, most people with Type II develop it younger than my family develops Type I...

Posted November 19, 2005 8:59 PM by Stephen Sample

A can of Coke was the standard whack-your-blood-glucose-up-a-few-notches method for relatives when one of them was too loopy to think of that herself, but sufficiently coherent to drink it (unfortunately a narrow window).

Yep, it sure can be narrow.

Around here, the drink of choice is orange juice. Still, anything with sugar will do in a pinch. A person has to be able to drink it, though.

The lowest blood glucose reading I have ever seen in a conscious person is 18. Mind you, this was conscious, not coherent. Fortunately, there was good help at hand.

paramedic level providers can give intermuscular (IM) shots of glucagon

So can significant others who have been trained in doing so, at least in this state. That's why there's always a little red case in my purse. The pep talk from the paramedics helped a lot, and the next time it happened and the glucagon was needed, things went just fine. (I was mostly scared of getting things wrong and making it worse; the pep talk addressed that very well by telling which spots were good choices for IM injections -- outer thigh is good, outer upper arm if outer thigh isn't handy, is what I was told.)

I am glad we have had it when it was needed.

I suppose if the blood glucose test they do on me in a few weeks says I'm part of the happy throng that I will become a person that people follow around with little red cases too. (Blurred vision, increased this and that, lots of family history. Not usually until later in life, though, in my family. That's what I am telling myself.)

It really is amazing to see glucose or orange juice or glucagon work, though. It's so fast, and such a big change.

Posted November 19, 2005 9:25 PM by elise

Stephan - have your family members been told what possibly contributed to their late development of TypeI? My mother was diagnosed Type I at 51 yrs. She is an adoptee, so we have no family medical history for her. She was misdiagnosed as Type II and treated as such for 1yr. She is now having liver function issues as well as vision changes and numbness in her limbs. She has been on several varieties of insulin, and nothing really controls her blood sugar. I am of course concerned for her, but for myself as well. My father was diagnosed Type 1 40 years ago. Her doctors think that perhaps she was born with an inadequate pancreas and liver- but no one knows.

Posted November 19, 2005 10:02 PM by LeeAnn

I'm not diabetic, but I am hypoglycemic - and the effects of a glass of orange juice with a few tablespoons of sugar in it are amazing.

It's equally amazing to see what happens if you walk to the front of a buffet line in Vegas and explain that you -really- need something with sugar in it to drink -now-.

Posted November 19, 2005 10:34 PM by xeger

I've been a type II for about six years and this is the best and most concise explanation of the disease I've ever read. I'm particularly glad you published the long list of warning signs since the classic ones -- excessive thirst and urination -- didn't begin to apply to me until my glucose was well over 300.

Anyway, thanks for posting.

Posted November 19, 2005 10:50 PM by dargie

This caught my attention because I work in a diabetes lab, and because a colleague of ours died of insulin shock last week (less rare than people think, sadly).

First, one quick correction on the article - there's quite a lot of research to show that type 1 diabetes actually develops over quite a long period; antibodies indicating the presence of an autoimmune response can be detected months or even years before onset of clinical symptoms. We've actually used this knowledge to screen family members for antibodies so that we can conduct studies in people at-risk for type 1 diabetes who still have relatively normal pancreas function.

To the person who was wondering about type 1 diabetes at 51, look up 'Latent Autoimmune Diabetes in Adults' (LADA) - it's a form of type 1 diabetes where the autoimmune response progresses very slowly, and seems to have some features of type 2 diabetes, such as insulin resistance and obesity. These people often have a small number of the risk genes for type 1 diabetes; the more you have, the earlier you are likely to get it. They also sometimes have T2D genes as well.

Some research by S Fourlanos et al indicates that even in classic type 1 diabetes, insulin resistance is a risk factor - and I believe other researcher are now finding evidence of autoimmunity in people who have had T2D for a long time. So the two diseases may be more closely related than we had thought.

Catherine, not a scientist, but plays one on TV (or rather, is helping administer a clinical trial and has typed up far too many papers on this subject for it not to have sunk in)

Posted November 19, 2005 11:03 PM by Catherine McLean

Emma came down with Type 1 at the age of 47 or 48. She's 5'11" and was around 140 pounds at the time. Despite that, her doctor was schooled in the days of "juvenile-onset diabetes" and "adult onset diabetes," so it took about a year to get it properly diagnosed. Which had more to do with Emma's research than the doctor's.

Exact factors aren't known, but some people theorize that stress can be a trigger. Emma had broken both elbows some months earlier. One was a simple break; the other was a mess that called for a plate and a lot of physical therapy. We didn't have medical insurance and were deeply in debt. I'm comfortable with the notion that stress can be a trigger.

Emma lost 20 pounds before we quit trying to treat her diabetes as Type 2. Now she uses insulin, Humalog and Lantus, and all seems to be good.

Posted November 19, 2005 11:12 PM by will shetterly

Thanks for this Mr. Macdonald. Type 2 diabetes is one of my personal paranoias. My mother died at 62 as a result of badly managed adult onset diabetes, which ultimately led to kidney failure, liver problems and a massive stroke.

Several months ago, I had an unusually high fasting glucose reading (110), which launched me into a bit of a panic and right into the clutches of the medically supervised diet and exercise program heavily subsidized by ReallyBigCorp, Inc. After 4 months of 5 workouts a week and a pretty strict diet, I've lost about 35 pounds (from 240 to 205) and feel a lot better. I can now run for half an hour without feeling like I'm gonna die.

BUT, my fasting glucose last week was still 110. So, it's off to the doctor to see what he says. Dang. Maybe I should be shooting for the 185 that the BMI index says is the max weight for my height. (I somehow don't thing that that would be maintainable, though.)

The thirst point is an interesting one for me. Many years ago, I went on weight watchers and got into the 8+ glasses of water a day habit, which has stuck for the past 15 years. Now, if I fall short of that, I feel thirsty. I discount that as a warning symptom for me, anyway.

I'd really hate to have to manage my diet the way a diabetic does. I'm in NYC for the next 10 days, and I just had dinner at Plataforma with some friends. This was my biggest fall-off-the-diet event, and I planned for it. If I have to start eating like a diabetic, a meal like the one I just ate wouldn't be possible.

My hotel does have a gym, though, and I'll be down there tomorrow running.

Posted November 19, 2005 11:43 PM by Larry Brennan

I've got one of those little red cases with glucagon right here on my desk. It's for one of my neighbors. If I respond as a neighbor and friend, I can use it. If I respond on the ambulance as an EMT, I can't. Regulations are funny things.

If your Medical Director gives you permission, though, you can do anything. It's his or her license on the line. That's what Medical Control is for in the EMS system.

I'm not a doctor, nor am I a researcher. I'm just a wildnerness EMT who likes to talk about some stuff. (Oh -- if anyone's wondering, my little sea story up there had details changed to preserve patient confidentiality.)

Yo, Keith -- why not chat with a doctor? Rule some stuff out, figure out what the situation is. As Charlie pointed out, all of those signs could have a lot of causes. Only someone who passed medical school and is looking you in the eye can tell you what's actually up. Could be your glasses need fine tuning. Could be a lot of things. It's worth checking.

Speaking of movies (as we were on another thread), in Silly Diabetes Movies we find Con Air, with Nicholas Cage. Who would have suspected that the average junkyard can be assumed include a fully-stocked first aid kit in some random junked truck, and that when you found the first aid kit you could expect it to include a full hypodermic setup?

Posted November 19, 2005 11:44 PM by James D. Macdonald

I was diagnosed with Type II some years back; recently added glyburide to metformin and we'll do the 3-month blood tests on the new drug combination in a couple of weeks. Stick tests are very encouraging.

pk

Posted November 20, 2005 12:06 AM by Paula Kate

This is interesting, but a little confusing.

In one place you list overweightness as a warning sign of diabetes. In another place you say that diabetes causes unexpected weight loss.

You say that a quick sugar hit is the solution for insulin shock. Yet I have read diabetics saying that candy is deadly to them.

Trying to make sense of all this.

Posted November 20, 2005 12:43 AM by Simon

In one place you list overweightness as a warning sign of diabetes.

Often associated with Type II diabetes.

In another place you say that diabetes causes unexpected weight loss.

Often associated with Type I diabetes.

You say that a quick sugar hit is the solution for insulin shock. Yet I have read diabetics saying that candy is deadly to them.

Is in insulin shock: Yes/No. If yes, give sugar. If no, do not.

I'll bet the person who posted that piece over at Monkeys In My Pants carries a roll of Lifesavers in his pocket every day, just in case his blood sugar starts to bottom out.

If the patient is in balance, adding sugar is contraindicated. If the patient is out of balance to the low side, adding sugar is necessary.

Posted November 20, 2005 1:11 AM by James D. Macdonald

Thiamine given with D50 because of Wernicke-Korsakoff syndrome

Posted November 20, 2005 2:06 AM by Tae

Another common warning sign of long-standing diabetes is periodontal disease. Dentists diagnose a surprising number of people with diabetes -- or at least refer them for further testing. I know a periodontist who says he identifies two or three likely cases of diabetes a month.

The list of warning signs in your quiz is a little misleading, in that some indicate current high blood sugar and others indicate long-standing vascular damage. Non-healing ulcers, neuropathy, erectile dysfunction, gum disease, etc. are generally due to longterm damage; thirst and unexplained weight loss are immediate signs of hyperglycemia. Blurred vision, oddly, can be either one, depending on whether it's due to diabetic retinopathy (damage to the blood vessels on the retina) or diabetic lens osmosis (a temporary effect of high blood sugar). Having long-term complications before having a diabetes diagnosis is more typical with type 2's, since they can survive longer without being diagnosed or treated -- sometimes decades -- while the vascular damage is accumulating.

Count me as another case of LADA: I was diagnosed with diabetes at age 33. Because of my age and because I was significantly overweight at the time, the assumption from the beginning was that I was type 2. Despite heroic efforts my blood sugar would not come into control with standard type 2 treatments; meanwhile, I lost 80 pounds in 9 months. I knew something was badly wrong after about 5 months, but it took me several more months to convince my doctors. (At one visit when I burst into tears of frustration over my out-of-control blood sugar and frightening weight loss, my doctor wrote me a prescription for tranquilizers; at another, I remember begging her to give me an insulin injection and being refused.) Eventually I got a new dotgor and started on insulin, and lo and behold I responded in such a way that it was clear that I was actually type 1. A C-peptide test later confirmed this. (C-peptide is a byproduct of insulin production, so it's a measure of how much insulin the pancreas is producing.) LADA is unusual, but not really rare, and it's surprising how few doctors, even doctors who treat a lot of diabetic patients, know anything about it.

A few years later, when I had some abnormal thyroid labs, I did some research on Graves' Disease (an autoimmune disease that causes the thyroid gland to become hyperactive), and realized that the "thyroid problems" that my mother and maternal grandmother had had were almost certainly Graves' Disease, even though the name was never mentioned. It turns out that a family history of Graves' is a risk factor for type 1 diabetes, and more generally a family history of any type of autoimmune disease (MS, lupus, rheumatoid arthritis, etc.) is a risk factor for developing any other type. Autoimmune diseases are not all that well understood, and the idea of treating them as a specific class of diseases is pretty recent, so doctors don't always understand the significance of this when taking family histories.

Posted November 20, 2005 2:45 AM by Janet Lafler

ralph said:

Note that the last item in your list of points is actually out of date. The fasting blood glucose level that defines diabetes has been redefined in the past couple of years downward to 126 mg/dL.

he didn't actually write "fasting blood glucose is >140 mg/dL". when you go into the doctor (or EMT) and get a finger stick, that's NOT fasting blood glucose. fasting means first thing in the morning when you haven't eaten all night. it's pretty common for nondiabetics to have a blood glucose level of 140 mg/dL after eating, or sometimes higher. even if it's higher, something else, other than diabetes, might be wrong. or you might've just visited starbucks and had a frappacino. all that sugar DOES go somewhere you know.

simon said:

In one place you list overweightness as a warning sign of diabetes. In another place you say that diabetes causes unexpected weight loss. You say that a quick sugar hit is the solution for insulin shock. Yet I have read diabetics saying that candy is deadly to them.

simon, being overweight CAN LEAD TO type ii diabetes (not type i) but isn't a warning sign of type ii diabetes. most overweight people don't develop diabetes. but if you are at risk for type ii because of your family history, you should avoid becoming overweight.

i know it's confusing but if an overweight person you know suddenly, inexplicably and rapidly starts losing weight, THAT'S a sign of diabetes. to oversimplify it: STEP 1: you have a tendency toward type ii diabetes; STEP 2: you become overweight; STEP 3: you develop type ii diabetes; STEP 4: you then lose weight rapidly.

type i diabetes is mostly (probably) not caused or triggered by overweightness.

the sugar/insulin thing confuses a lot of people but it's really quite simple: you need insulin to balance your sugar. you need sugar to balance your insulin. the diabetic's life is essentially a non-stop effort to keep the two in perfect balance: not too much insulin, not too much sugar. if you overbalance and have too much insulin, it's called "hypoglycemia" or insulin shock. then you take sugar to correct it. if you overbalance and have too much sugar, it's called "hyperglycemia" or diabetes. then you take insulin to correct it.

janet said:

turns out that a family history of Graves' is a risk factor for type 1 diabetes, and more generally a family history of any type of autoimmune disease (MS, lupus, rheumatoid arthritis, etc.) is a risk factor for developing any other type. Autoimmune diseases are not all that well understood, and the idea of treating them as a specific class of diseases is pretty recent, so doctors don't always understand the significance of this when taking family histories.

i'm a type-1, juvenile onset, and i've also developed hypothyroid (NOT hypERthyroid or hyperactive thyroid) as well as vitiligo. the thyroid and vitiligo are related to the type one diabetes in a fairly simple way: the isles of langerhans, the tissue of the thyroid gland, and the melanocytes (that produce melanin) are all attacked by the immune system and partially or completely destroyed.

Posted November 20, 2005 5:02 AM by anon

For those using mmol/L (why on Earth are you measuring per dL??), the fasting blood sugar cut-off level for diabetes is 6.1 mmol/dL.

Posted November 20, 2005 5:43 AM by Therese Norén

Thanks for this. My husband does a urine test abotu once a year or so because many members of his family including his mom have adult onset. In fact, it is really really common among older adults in Egypt. Really, really, common. I asked an Egyptian doctor about this and he first of all confirmed that my perception was true, said it was because Egyptians have moved from a diet of mostly whole wheat bread to a diet of mostly white rice over the past couple of generations and also that they use a lot of sugar (heavily sugar tea, condition kids to expect that drinks like orange juice, milk, and even Tang(?) be doctored with sugar, etc.) and also that they lead highly stressful lives (crowded, pollution, tension between neighbors, tension driving, many jobs in order to make ends meet, e.g.)

My mother in law has to take an insulin shot daily and at times she gets shaky and someone runs and gets her a glass of sugar water. She also has a variety of other health issues includign weird things like strangely misshapen ingrown fingernails that she sahs doctors have told her is a result of diabetes. (I defer to doctors here. My mother in law does not read and write and it is very possible that she misinterpreted something someone told her.)

Posted November 20, 2005 6:45 AM by Anna in Cairo

On the subject of deceptive symptoms, here's a very personal example: over the past few years I found myself getting up to go to the toilet in the middle of the night with increasing frequency. Naturally I was worried about diabetes, so I got myself referred to a urology consultant -- but no, no sign of diabetes. (Or any other cause they could think of -- in 20/20 hindsight they were over-specialized.) Then, eight months ago, I began having palpitations (irregular heartbeat) and went to see my GP in a hurry. It turns out that I have inherited hypertension -- untreated, my blood pressure was 250/150. Now that I'm being treated for it, my blood pressure is down 45% and I'm no longer emulating a broken fire hydrant.

(NB: it's a hereditary condition; men on my mother's side of the family tended to die suddenly between the ages of 45 and 60. It is completely treatable these days if diagnosed before the fatal stroke or heart attack. My elder brother dodged the bullet completely; I got it bad enough to be diagnosed in time. So I'm going to be okay, just as long as I keep taking the pills, for which reason I am very glad I live in the land of the NHS ...)

Anyway, back to the list of symptoms: Pissing like a fountain, check. Fatigue, check. Overweight, check. Crave extra fluids, check. Blurred vision can also be a symptom when your BP is into the malignant hypertension range (where mine was going) -- luckily in my case I didn't have any extra retinopathy.

The moral of this story is that it could be diabetes, or it could be hypertension, or it could be something weird and rare, but the main thing is, don't wait: go and see a doctor and get it diagnosed right now.

Posted November 20, 2005 6:57 AM by Charlie Stross

Sorry to go off-topic, but the post after this one seems to have vanished. Is this a problem on my end, or...?

Posted November 20, 2005 7:41 AM by KristianB

Great article with one of the clearest explanations I've seen about the effects of diabetes and the difference between Type I and Type II.

For the past 6+ years, I've been a subject in the Diabetes Prevention Program, a long-term study to see if Type II can be prevented or delayed. The study followed large numbers of people with "impaired glucose tolerance" (which means that our sugar levels were high, but not yet in the range considered to be diabetes), and divided them into 3 groups. One was a control, one used diet and exercise to lose weight, and one took a common type II diabetes drug.

The study showed that diet and exercise was extremely effective - reducing the incidence of Type II by 58% in they study group. The drug (metformin) was also quite effective, although not quite as good as diet and exercise.

The important point to make is that Type II diabetes comes on in a slow progression, especially if you gain weight as you get older. But you can take steps to keep it at bay. The diet and exercise group in the study lost only an average of 5% of their body weight, yet showed a dramatic reduction in the incidence of diabetes. This is really a situation where your fate is mostly in your own hands.

I join in urging everyone over 40 to get a fasting glucose blood test, especially if you are overweight or have a family history of diabetes.

Posted November 20, 2005 8:02 AM by Leslie Turek

A few words about diabetes blood tests. Anon very correctly points out that the interpretation of test results varies depending on when you have most recently eaten. That's why the more accurate blood test is taken as a fasting test, when you haven't eaten for 12 hours. For a fasting test, the normal range is 70-99 mg/dL, 100-125 is considered impaired glucose tolerance (where you should start thinking about diabetes prevention), and 126+ is considered to be diabetes.

An even more accurate test is the 2-hour glucose test. In this test (which I get once a year as part of the study), they take a fasting measurement, then feed you a measured amount of sugar (in the form of an icky sweet drink), and then wait and measure your glucose exactly 2 hours after getting the drink. This shows how well your body processes the glucose. In this test, normal is 70-139, impaired glucose tolerance is 140-199, and diabetes is 200+.

Posted November 20, 2005 8:15 AM by Leslie Turek

Nitpickery
The derivation is more or less right: it's 'dia' plus the verb to straddle (the word for siphon (which always looked Greek to me, anyway) is similar to the word for compass or dividers). It's "diarrhea" that has the word for 'flow' in it (think 'rheology')...

[apologies for the fake email address - every address I've ever used here gets spammed within less than a day]

Posted November 20, 2005 8:53 AM by Steve Glover

I'm a childbirth educator, and while I don't want to get too deeply into the controversy over gestational diabetes, I'll say that many of the supposed cases just ... aren't. As Henci Goer points out in her excellent article Gestational Diabetes: the emperor has no clothes, GD criteria are highly arbitrary, and the management of supposed GD cases often causes more trouble than it prevents. Worth a read.

Posted November 20, 2005 9:47 AM by Ellen Seebacher

I'm not diabetic, but I am hypoglycemic - and the effects of a glass of orange juice with a few tablespoons of sugar in it are amazing.

I'm hypoglycemic, too--and unless my blood sugar is really, really low, it doesn't even take anything particularly sugary to cause an obvious effect. The number of times I've had people say, "Wow, you're really feeling better!" when I was in the middle of just an ordinary meal.... This is good, since for the most part I can't stand sweet foods. (Particularly cake. Childhood memories of being force-fed cupcakes because there was nothing else sweet in the house, I suspect.) I do tend to carry hard candy with me, though, especially when I'm travelling.

My boss has come to accept that if I don't get lunch on time, I rapidly become useless. More importantly, she accommodates my eating schedule whenever possible. I consider myself lucky, there.

Posted November 20, 2005 10:21 AM by Jennifer Barber

Thanks, Steve. I'll fix that.

Posted November 20, 2005 11:07 AM by James D. Macdonald

I'm not diabetic, but I am hypoglycemic - and the effects of a glass of orange juice with a few tablespoons of sugar in it are amazing.

It's equally amazing to see what happens if you walk to the front of a buffet line in Vegas and explain that you -really- need something with sugar in it to drink -now-.

=====

My husband is hypoglycemic. He must eat on a regular schedule or his blood sugar gets wonky, and his brain follows in short order. A common thread to this thread is that symptoms vary, people vary, treatment varies. Don't ever ever ever feed Jim sugar. He turns manic/depresssive with a four hour cycle, amplitude reducing over a period of days. Yes, days.

Shortly after he was diagnosed and getting used to the diet restrictions, he called me at work, and said in a panic-striken voice, "We're not going out tonight like we'd planned." The voice was the kind of voice one uses when one is making one's only call from the police department, or one is calling from the local hospital emergency room. My heart rate went up, and I asked, "Oh? Why?" "I think I had a donut with sugar on it!"

When I stopped laughing, mostly from relief, he explained he'd eaten what he'd thought was a plain cake donut. The upshot of all of this was the guys he worked with made damned sure there was a plain cake donut in the batch from then on, and that it didn't come in contact with anything else in the box. Jim went manic-normal-depressed-normal-manic over that four-hour cycle for five freakin' days. The amplitude went down, but you could still watch the cycle every four hours.

And Jim's emergency-feed-me thing is beer. It holds his blood sugar level until we can get real food into him. Ask the guys at convention who watched him chug three beers in a row without drunk-symptoms while I ran to the con suite to build him a sandwich.

Posted November 20, 2005 11:59 AM by Lin Daniel

Serendipitous article for me. 4 points on the quiz all my life, 11 points if you count the last year, 21 points since three days ago when my doctor ordered a lab for another reason and found a blood glucose level of 217, ugh.

So my doctor told gave me some dietary advice and some glipazide, and instructions on buying and using a home blood glucose meter. Whee, new medical adventure....

Posted November 20, 2005 12:22 PM by Dan

Three years ago I could have ticked the boxes for most of those symptoms, but didn't have a clue what they meant. I think it was a visit to Pizza Hut that made my ankles swell up, which finally persuaded me to go to the doctor (perpetual tiredness led to apathy, or I would have gone sooner). I left the surgery with orders to report straight to hospital with DKA. The insulin drip they stuck in my arm as soon as I got there made me feel so much better so rapidly that I almost didn't mind the diagnosis. Yep, type 1 diabetes. I was 24. Once I thought back, I realised I'd been having marked symptoms for at least three months, plus one that isn't on the list - sudden cramp in my feet in the middle of the night.

The tingling fingers and toes aren't necessarily a symptom of neuropathy - I had that, but it cleared up after diagnosis. Sometimes I could feel my fingertips tingle in rhythm with my heartbeat, which was weird.

Thankfully I've never had a hypoglycaemic attack (hypo) that I couldn't recognise and treat by myself before it became serious. If my hands start shaking, or I feel tired at a time of day when I shouldn't, or I start feeling as if the light in the room is too bright, I know what's going on. I carry dextrose tablets or jelly babies wherever I go, plus a muesli bar or two in case I need to eat something more substantial, and a few minutes later I'm usually fine again. I also carry a glucagon kit, but nobody's ever needed to use it.

Jim, are you sure about low-grade fevers causing hypos? In my experience it's the opposite - any illness causes my blood sugar to rise. Someone told me that it's because my liver releases extra glucose to power the extra work my immune system's doing. I add a unit or two to each insulin dose I take until I've recovered, and test more often to check whether I should still be doing it. Last year during a particularly bad cold I was taking extra insulin shots between meals to keep my blood glucose down. But so many diabetes symptoms are idiosyncratic that I wouldn't be surprised to learn I'm in the minority here.

Posted November 20, 2005 8:15 PM by Eleanor

I'm another of the Type 2s here. The medical profession lets diabetes progress too far before they diagnose it. Anyone whose blood sugar goes above 100 has impaired glucose tolerence. The EPIC population study in Europe has shown that someone whose blood sugar averages 120 (HgbA1C = 5.5) has more than double the normal risk of a heart attack.

There are metabolic abnormalities that are not on Jim's list that give advance warning of diabetes: high triglycerides, low HDL cholesterol, high blood pressure, high fasting insulin level. I began to manifest some of these 15 years before I developed diabetes. These, along with abdominal fat accumulation, are markers of what Gerald Reaven calls Syndrome X and is now more commonly called metabolic syndrome.

Hypoglycemia is another indication of failure in the control loop that regulates blood sugar. Have your doctor do a fasting insulin test to see how insulin resistant you are.

I kept my A1C in the low fives for five years using a low carb diet and no medications. This spring my doctor changed me to a different Statin (to Crestor from Lipitor) and my blood sugar control went to hell. I skipped all the oral meds and went straight to insulin.

The way to do well as a diabetic is to recognize that your doctor will not die for you if he gives you bad advice or fails to educate you. Learn everything you can. I recommend Dr. Richard K. Bernstein's The Diabetes Solution.

The ADA standards of care will kill you slowly. The limits they set are their response to the poor self care most diabetics give themselves. They feel is not realistic to expect better control.

Posted November 20, 2005 9:02 PM by Stuart

Jim, are you sure about low-grade fevers causing hypos? In my experience it's the opposite - any illness causes my blood sugar to rise.

You can get a monkey to pass medical school by teaching him to say "It varies." The monkey will graduate in the top half of his class if you can also teach him to say "We see that sometimes."

There are metabolic abnormalities that are not on Jim's list that give advance warning of diabetes...

Sure. There are lots and lots of things. But triglicerides aren't really something you can determine yourself at home. I wondered about putting in the glucose level, because that's something you can't tell without the machine. But the machines are more common, and cheaper, and more accurate these days. Anyone who wants to can probably find someone with a glucose tester and do a fast finger stick on themselves. I was of half a mind to add another couple of points to the quiz: 1 pt for female gender, 1 pt for age 70+. But ... I'm not trying to be exhaustive.

Lots of things have various signs and symptoms. The uncommon symptoms of common diseases are more common than the common symptoms of uncommon diseass.

(Y'all know the difference between signs and symptoms, don't you? A symptom is something only the patient can tell you about -- headache or nausea, for example. A sign is something a third party can determine -- heart rate or blood glucose for other examples.)

Everyone, be good to your body. It's the only one you've got. And you want the EMTs to be able to sleep in, don't you?

Posted November 20, 2005 10:12 PM by James D. Macdonald

I am oddly reassured--and Jim, you and your fellow EMTs can sleep in, I hope.

The last time I was at my doctor (for the follow-up manual breast exam after a mammogram) she drew blood for general-purpose testing, since it had been 18 months. She was vaguely irritated that I'd eaten breakfast, but nobody had told me not to, and I hadn't made the appointment for bloodwork. (She was mollified that it was yogurt and fruit, not bacon and eggs.)

When I called for the test results, they just said "it's all fine", but I had them mail me the report. Some of it means nothing to me--I don't offhand know what eosinophils are (since I doubt it actually means people (or things) that like Chinese dawns). Those I could at least google for; there are lots of TLAs that would be harder. But while my triglycerides are a little high, my glucose is quite happy, as are the blood pressure and cholesterol.

Posted November 20, 2005 10:32 PM by Vicki

Eosinophils? They're a kind of white blood cell. (There isn't just one kind of white cell-- there are several different kinds, each with a special purpose.)

Eosinophils are the kind of white cells that deal with parasites. So a higher eosinophil count might be associated with parasites. You also see high eosinophils associated with some lung diseases. And sometimes you see more eosinophils for no reason at all.

Posted November 20, 2005 10:46 PM by James D. Macdonald

Usually, you see this in your older folks, particularly sedentary, overweight people. Oftentimes even a modest weight reduction (5 kilos) will be enough to get the cells to start accepting insulin again and start passing that glucose.

Sometimes this works, and sometimes it doesn't (yes, I saw the comment about the monkey); a friend worked her weight down through multiple sizes of clothes, started feeling poorly near her target weight, and was told -"we don't like your blood sugar; lose 10 pounds."- She spent most of the next year in bed, due to the amount of tissue loss (muscle and nerve) that happened before the doctor got serious. As some of the experiences above show, getting the doctor to think (and to react usefully) can sometimes be most of the battle.

But losing weight is often a good idea. (Best if you have a reasonable measure to work toward -- some of the old tables date from Depression-era studies of people who were malnourished, BMI doesn't allow for skeletal build, and Jim's waist/height ratio is a little tight for men -- but it's worth checking where you stand.)There have been a lot of reports that the "epidemic of obesity" is being tailed by a rapid increase in Type II.

Posted November 21, 2005 12:48 AM by CHip

As several folks who post here know, I am the caregiver for my 86 year old mother; she has been a type 1 diabetic for 31 years. She was diagnosed at age 55. (Stephen; I have the feeling such cases are not as rare as once was thought.) They thought she was a type 2, of course, since at that time type 2 meant "adult onset," but she had to go on insulin almost immediately.

I have managed her diabetic care for the last 8 years. Yes, she has doctors, pretty good ones. But most diabetes has to be managed by the person who has it, or in my mother's case, by me and the staff of the assisted living facility in which she resides. (I'm 5 minutes away from her. I am often there 3 or 4 times a day, sometimes for hours...) I am not going to go into specifics, but I will say it's not an easy disease to have, especially for a long time, especially if you come from a family with some very tough genes. (My maternal grandmother had 5 serious heart attacks, and still lived to be 89.)

One week last month I had to call the EMTs 3 different nights to take her to the local hospital. The third night they finally admitted her with a raging kidney infection.

Have I mentioned she's a "brittle" diabetic? Jim (or maybe Janet, hi, Janet) can go into what that means, if he wishes. I'm too tired.

Okay, enough venting. Sorry, sorry all. How interesting, however, to have an intimate and omnipresent topic in my very own personal life show up on one of my favorite web hang-outs.

Posted November 21, 2005 12:49 AM by Lizzy L

The way to do well as a diabetic is to recognize that your doctor will not die for you if he gives you bad advice or fails to educate you. Learn everything you can.

There was only one Great Physician who specfically died for the patients, though a few did highly risky experiments on themselves.

But y'know, there are actually good doctors in the world. I have several, but keeping to the topic, my endocrinologist is intelligent, knowledgeable, and is willing to talk about any aspect of the disorder (not just my variation) -- in fact, he likes it. (It's true that I have a fairly large medical vocabulary, so he doesn't have to translate for me.) If we're going to change something, we talk about it -- by which I mean I have input, not that he tells me what's gonna happen. It took him a while to talk me into the pump, but that was me being skeptical -- I have seen a great many changes in therapy, not all of which proved as good as they looked -- and now I love my hip-mounted R2D2.

He also likes my work (the doctor, not the pump), but maybe I'm just lucky.

In fact, I probably am, and not just for still being above ground. My cardiologist also likes to discuss stuff, and also happens to be one of the top guys in the country for renal-cardiac patients. The transplant clinic wants to fiddle with my drugs, and the nephrologist's approach to this was to have a long discussion about the options and their pros and cons, and then show me where to get the docs online so I could make my own decision (which I will naturally discuss with her).

I'm quite aware that there are also rotten doctors, but fortunately I've only observed the worst ones I've (*mutter*certain male gynecologists*mutter*).

And long ago, I developed the Talk To Nurses mutant ability (a certain amount of Danger Room practice was involved), and if you want a hospital survival trait, this is on the short list.

Posted November 21, 2005 12:53 AM by John M. Ford

You can get a monkey to pass medical school by teaching him to say "It varies." The monkey will graduate in the top half of his class if you can also teach him to say "We see that sometimes."

However, when you hear hoofbeats you think horses - not zebras.

An elevated eosinophil count is most commonly associated with antigen-antibody responses - such as asthma and allergic reactions. Including 'parasites' too high up in the list of differential diagnosis will net you a harsh pimp session and a required presentation on liver flukes.

Posted November 21, 2005 1:41 AM by Tae

Including 'parasites' too high up in the list of differential diagnosis will net you a harsh pimp session

Unless you're living in the tropics where microfilarians are a major problem.

Posted November 21, 2005 1:45 AM by James D. Macdonald

Unless you're living in the tropics where microfilarians are a major problem.

Agreed. Let's just hope Vicki doesn't live in the tropics, or the albuterol MDI she just got isn't going to do spit for her.

Posted November 21, 2005 1:57 AM by Tae

My last duty station was in the tropics, where I picked up a lovely case of leptospirosis. Not as much fun as everyone tells you it is.

That isn't the reason I'm permanently deferred from donating blood, but it's certainly more interesting.

Posted November 21, 2005 2:07 AM by James D. Macdonald

That isn't the reason I'm permanently deferred from donating blood, but it's certainly more interesting.

Uh uh, not gonna touch that. The exclusion criteria can get ... personal.

Posted November 21, 2005 2:21 AM by Tae

The Art of Pimping

Posted November 21, 2005 2:27 AM by Tae

I spent too much time floating around off the coasts of Europe, eating food brought aboard from European vendors. It worked out to more than two years in Europe, only without the fun of actually spending, y'know, more than two years in Europe. That's why the ARC doesn't love me any more.

I told you the lepto was more interesting.

Posted November 21, 2005 2:47 AM by James D. Macdonald

Well, I've just got about ten different drugs in my bloodstream at any given time (all prescribed, I assure you), and right after an injury or surgery serious enough to require transfusion is not when you want to get off the bed and mambo. (And I tried that, twice, but it's at least as dull as leptospirosis. Which I make no claims to having had.*)

I spent many years with the ARC, though, helping take it away from other nice people. Attempt to balance the books, I guess.

*One of the Discover Channels has a show about grim survival experiences called "I Shouldn't Be Alive," which causes me to want to put together a show titled "I Shouldn't Be 120/80."

Posted November 21, 2005 3:09 AM by John M. Ford

>Overweight (waist size > 1/2 height)

Really? I'm not overweight by that measure (72" tall, 32" around the middle) but I am skinny. I would think most adults I know are overweight according to that rule.

Posted November 21, 2005 5:45 AM by Niall McAuley

Clarification: my eosinophil numbers are in the normal range (as printed on this lab report); it's just the most interesting name of the things-I-didn't-recognize.

Thanks for the information, all. And yes, if you hear hoofbeats in New York, California, or Germany, think horses--there are parts of Africa where it's entirely logical to think zebras.

Posted November 21, 2005 9:40 AM by Vicki

My boyfriend has had blood sugar issues for most of his life, and when I started dating him three years ago there was a list of things Liam Didn't Eat.

Then his feet started cramping up a lot, and his vision was going weird. He went off to the doctor and had his blood sugar tested. It came out at 586. As another person inquired when told this number, "Is blood still liquid at that point?" Now that they've got him on Avandamet, these problems have cleared right up, thank heavens, and it's a good thing he figured out the problem before permanent damage set in.

Liam's weird, though, in that he starts getting the low-blood-sugar shakes at about 80. And his preferred stopgaps are cheese and milk.

Posted November 21, 2005 9:59 AM by Carrie S.

Good to see a couple of people note that fasting glucose over 100 is a Warning Sign.

One problem with dealing with both types of diabetes is that the complications (which can be horrific and life-threatening) don't generally happen for a long time. Thus they are psychologically easy to put aside, and worse, there is a financial incentive for insurance companies to not care very much about preventive treatment. I have heard it said many times by people in the industry that since you will be insured by someone else when the complications hit, paying for prevention is wasted money. (I work on a project involving diabetes treatment.)

Another issue is that the general recommendations for "maintenance" glucose level and A1C level (this latter is a protein that essentially is a marker for how much glucose you have processed in the last three months) are set too high to be compatible with long-term complication-free management. The reason is doctors are desperately afraid you will screw up your insulin bolus and die if you actually try to keep it at the best level for long-term health.

Managing diabetes is extremely complicated; it gives one new respect for how well our bodies do the job when everything is working properly.

Eventually there will be closed-loop systems for Type I; there are already continuous-monitoring glucometers available and there are (in development) insulin pumps that could interface to them. However, Type II is another matter.

Posted November 21, 2005 10:25 AM by DaveL

Huh. 2 years in Europe (or, rather, nearby) and you are barred from donating blood for life? Why? Are they concerned you might have bioaccumulated high levels of Frenchness? (Hangs around in the fatty tissues, you know, like dioxin.)

I've spent almost my entire life in Europe. Suddenly I am worried.

Posted November 21, 2005 10:42 AM by ajay

I think it's the quarantine thing-- the UK is full of mad cow, for example. They don't know what you might have picked up over there, but they know we don't have it over here.
I always confuse the screeners because I've been outside the country so much. I usually just pick one of the countries that put me on the malaria deferral list or it takes forever. And two years in Honduras? They *hate* when I bring that up.

Posted November 21, 2005 11:20 AM by Cassie

20-50% of the women who develop gestational diabetes will go on to develop Type II diabetes in later life
I'm relieved to hear your statistic is lower than I believed. I read/heard somewhere that you had a 90% chance to develop type 2 if you had gestational diabetes. I really enjoyed reading this comment even though I feel pretty versed on the subject. I especially liked the line "don’t use a Red Hot Fireball cinnamon candy". LOL!

Xeger said "I'm not diabetic, but I am hypoglycemic - and the effects of a glass of orange juice with a few tablespoons of sugar in it are amazing." and another person mentioned that their hypoglycemia makes them manic. I have been hypoglycemic since I was 12 and I'm 48 now. I keep waiting for the other shoe to fall. My younger brother developed Type 1 diabetes at age 25. To complicate matters I am obese, have hypertension, Rheumatoid Arthritis, and some peculiar allergies. I suspect that our family may have some weird inherited auto-immune thing going on, but no doctor is going to figure this out so we have to live with our symptoms. The main problem I have in controlling my health is that sugar is to me as alcohol is to an alcoholic. I have a very difficult time staying away from it and I greatly abuse it hence the obesity which doesn’t help the other problems one bit.

Posted November 21, 2005 11:25 AM by Gigi Rose

Back to the original post, Jim mentioned Narcan as one of the things the paramedics use if someone is unconscious and they don't know why.

New York City has a relatively new program in which heroin users are being prescribed syringes of Narcan, to be carried in the same way as some people carry epinephrine or glucagon. The syringes are being handed out at the needle exchange programs.

They don't know how many of them are being used--not everyone who has them is comfortable coming back and saying "I think I saved so-and-so's life last week"--but they're confident that some lives are being saved. The next step they're considering is issuing them to city (as in, paid staff) EMS; I was startled, comparing to Jim's post, that our EMS don't already have them in their kits.

Posted November 21, 2005 11:33 AM by Vicki

Thanks for the timely information. Last month I was diagnosed with diabetes (significantly lower blood glucose than the woman you tested). I've given up refined sugar (and had recently started walking 20-30 minutes a day) and am negotiating with my body as to further adaptations.

Posted November 21, 2005 11:51 AM by Arthur D. Hlavaty

To all who have recently been diagnosed as diabetic or borderline diabetic, may I recommend exercise? It feels good (endorphins), and handled with common sense it can lower blood sugar and generally help keep your body on an even keel. Don't forget the common sense, though. Keep a candy bar or other sugar source nearby in case you drop low. Lows are more directly dangerous than highs -- they lead to convulsions, loss of consciousness, and death -- but consistent highs also lead to loss of consciousness and they do more sustained damage to organ systems. My mother has been conscious with a low of 29 (I was there, talking to her)and semi-conscious with highs of 680. You don't want to go to either of those extremes, ever.

Posted November 21, 2005 12:10 PM by Lizzy L

Joe Connelly's Bringing Out the Dead has a hilarious EMT story (not in the movie) involving a dose of Narcan, and it would be useful so often that I'm pretty sure they must have it along. It may just be that they're going to add the preloaded injectors to save time and fussing around with loading a syringe. It's not a terribly hard task, but it does require both hands. With a filled syringe one could, if the need required, flip off the guard and shoot.

Many years ago, in the Merck Manual's chapter on Psychiatric Emergencies, there was a discussion of dealing with berserk patients that had some lovely -- and doubtless experientially based -- lines, like "Adequate force should be gathered. In the case of a muscular young male wielding an ax, several policemen may be regarded as indispensable." This was followed by "Administer [a drug to subdue the patient] into the nearest available muscle without undue finesse." Later editions, sadly, lost this paragraph for one that carefully explains that proper restraint and injection procedures must be maintained at all times.

Posted November 21, 2005 12:13 PM by John M. Ford

I have just been reminded (by going over to check the film data) that Bringing Out the Dead was set during the era before the Fire Department took over EMS from the Hospitals Department. So maybe the drug rules changed, though if they did have to stop carrying Narcan, I can't imagine the EMTs were very happy about it.

Posted November 21, 2005 12:19 PM by John M. Ford

On the eosinophils: Some doctors don't know what they mean, either. I tried to get an answer for over a month after finally getting a doctor to order a blood panel before I googled it myself. Put together with the symptoms I had been presenting to them for over two years, asthma was blindingly obvious. (Eos count was over 20K, IIRC.)

On exercise: I'm happy for those of you who can jump up and exercise. I can walk into my current doctor and get a lecture about how I must immediately start exercising at least 20 and preferably 60 minutes a day, all in one go, when I'm pleased as punch that I managed to walk from my car to their office door without my cane.

Yes, I'm looking for a new doctor.

Mike: That revised paragraph looks like an anti-lawsuit vaccination to me.

Posted November 21, 2005 1:13 PM by OG

Thanks for the information. I was just diagnosed with Type II in October. :(

Posted November 21, 2005 1:52 PM by Adam Ek

The main problem I have in controlling my health is that sugar is to me as alcohol is to an alcoholic.

Yeah, I know that feeling. Two siblings with type 2 (one deceased).
Being on Atkins helps a lot, as well as letting myself indulge in very dark (minimum 72% cacao) chocolate to help from feeling deprived. But when I fall off low-carb wagon it's way too easy to lose control.
The Holiday season is hard. *sighs*

Posted November 21, 2005 2:33 PM by mayakda

Great thread with great info. I was lucky, when I had all the symptoms one associates with diabetes I went to my doctor, had her do a fasting glucose and a few other tests and the next morning was unsurprised to here my A1C was 15% and that I would be going directly to insulin. I already had an appointment for that afternoon set up at the Joslin (my SIL heads a dept. there)and I went from someone who "would never stick a needle in myself even if my life depended on it" to "show me where, how and how often". I want to see my kids grow up.

It's been an ongoing learning proces and I am not all that great a diabetic. My A1C's are fine (last one was 6.1% and I expect the next one to be lower), but that's because I use humalog and lantus with a vengeance. I am obese, which means I am insulin resistant but because of other issues don't produce insulin. It makes knowing how big a bolus to take tricky at times.

Except...it wouldn't be if I had the stones and the stamina to radically alter my diet and stick to it. I won't ever be able to say good bye to the needles or insulin (and because of liver problems can't take any orals), but I would be healthier and take far less. If I excercised daily, even a 30 minute brisk walk a day, my numbers would come down. I do my best and try to do better and remind myself that while diabetes isn't my fault I am responsible for my own choices in how to deal with it.

Having said that...to all you pump users, my docs want me to try it and I've been resisting for a year now. I have an aversion to being mated and attached to tubing and a box 24/7 and fear that it will be uncomfortable and unwieldly. Any thoughts?

Posted November 21, 2005 4:13 PM by amysue

regarding the question about fever causing low or high blood sugar: i'm surprised that jim didn't immediately affirm eleanor's experience, before going into the snarky commentary about monkeys. eleanor, illness is ALWAYS EXPECTED to raise your blood sugar. this is common and universally known. don't start doubting now! i think what jim was trying to say was that sometimes low grade fevers cause low blood sugar BUT that illness usually raises blood sugar. if HE wasn't trying to say that, I'M saying it now.

regarding docs who won't die for you: excellent point.

for all you new diabetics out there: don't stick with an internist. go find yourself a diabetologist or endocrinologist. insist on it. any doctor who doesn't specialize in diabetes simply will not know the things they need to know. i've been brought to the brink of coma, accused of epilepsy, and told all manner of suable things by internists who did not specialize in diabetes. don't do it to yourself.

on the other hand, don't think that a diabetologist is the answer to all your prayers. you need to do your own research (http://www.diabetes.org/home.jsp), you need to ask lots of questions, you need to ask for OPTIONS, and you need to get your doctor used to being your consultant, not being your decision-maker.

i've seen about 8 diabetologists in six different cities in three different countries and MOST of them want to fix you. that's right, they want to fix you, like most doctors want to fix people, even though they know that diabetes can't be fixed. so they have ONE fix for each problem and you take it or leave it and if you leave it, then you are blocking THEIR WORK and they get pissed off and yell at you.

don't assume that because everyone tells you that your diabetologist is the best in town, that you have to stick with that specialist. find the doctor who will listen TO you and work WITH you and talk WITH you. that's a good doctor, not the one with the best stats. the doc with the best stats is PURSUING good stats, and not helping you live your best life.

on the other side of the coin, pursuing a top-notch a1c is maybe not the best life you can live. it may be the heallthiest, but it may not be the best. you need to put your diabetes in the context of your entire quality of life, and i'm not talking about being able to eat cake, but about being able to stay up late to drink good wine and watch a meteor shower, or to not wear a pump so that you can go surfing or have wild sex in a hot tub, or choosing the simplest (not the complex best) system to work with so that you can travel easily through inner mongolia or volunteer for a year with orphans in soweto. maybe a decade of old age is a worthwhile sacrifice so that you don't have to stay at home, testing your blood sugar ten times a day.

also, type 1s should know that pancreas transplants ARE a viable option, but they're not one that most doctors will bring up to you. there used to be a website dedicated to this (http://www.diabetesportal.com/) but it's closed for now because the person in charge, a 38-year-old former type 1 diabetic who had a successful transplant, has had a baby. here's an article about the substance of her argument for transplantation:
http://www.mendosa.com/insulin_free.htm

and finally, no one ever wants to hear this, but, although there's no conspiracy or anything, diabetics need to be aware that there's no very strong will in the medical community to cure diabetes. diabetes care (not cure) is an exploding industry, and a great deal of research money, especially within the pharmaceutical industry, goes to finding better ways of maintaining diabetes, not curing it. the will to cure is more in the diabetic community, and in organizations like the juvenile diabetes foundation (which focuses on type 1)

just stop and think for a minute about all the doctors, nurses, educators, drug companies, clinics, physical therapists, hospitals, insurance companies, who benefit from diabetic clientele. think how many jobs would be lost if a cure for diabetes was found. think about that when new therapies and treatments come up and your doctor doesn't want to discuss them because they're "too risky". all i'm gonna say.

Posted November 21, 2005 4:26 PM by anon

carrie s: when my blood sugar gets low enough so that i start shaking, i also go for cheese (or other things containing protein). i will do sugar, but only if i'm really bad off and only to get me to a protein source. for me, my blood sugar seems to bounce back down quickly enough that i just end up with the shakes again pretty quickly.

Posted November 21, 2005 5:31 PM by betsy

It worked out to more than two years in Europe, only without the fun of actually spending, y'know, more than two years in Europe. That's why the ARC doesn't love me any more.

Anyone who has been deferred due to too much overseas time should check the revised standards; sometime last Summer a lot of the numbers were changed, e.g. time in the UK after 1996 doesn't count against the 3-month limit (that's the one I was watching as Interaction was my 6th UK convention), time in Europe is up (5 years?), etc.

Posted November 21, 2005 5:57 PM by CHip

OG, you sound like we can walk about the same amount -- on land. I can walk and exercise in water.

Posted November 21, 2005 6:40 PM by Marilee

Wyth Referrence to Ye Pumps.

With the understanding that this is just my experience; what works is what works for the patient.

First, you aren't permanently mated to the pump. There's a small, soft catheter, a few mm long, that you put in subcutaneously (the introducer needle is immediately removed, so there's no metal in you). This has a socket that connects to the pump with a quick disconnect. So if you want to take a shower, you disconnect the pump, put it on standby, and shower. (There are still plastic neck bags to tuck the pump in while showering, but I've never used one. Being disconnected for fifteen minutes is not a big deal for me, though I can see that for some very brittle folks it might be.)

Apart from this, yes, it is there all the time. In the daytime I wear it on my belt; since we now live in an age where darn near everybody has an electronic device on their belts, this is scarcely noticeable in public. In addition to the basic clip, I've got a neoprene pouch and a black leather model for dress wear.* It does have a length of tubing running to your catheter, which can get untucked and sometimes catches on things, but again, not a huge problem. At night I've got a soft fleece belt with a Velcro pouch, though sometimes I just tuck the pump in a pajama pock You change the catheter a couple of times a week, moving it around just like an injection site. I've only once had a problem with discomfort, and that was apparent as soon as it was installed; I pulled it and put in a new one, which was fine.

My pump has an RF link; it can receive BG data from my meter, which saves entering it manually, though that's not a huge nuisance. It also allows boluses to be set remotely, from a keychain-sized gadget. This means that if you really dislike having the pump showing, you can put it somewhere inside your clothes, and set it from the remote. (Another use of the remote is with small kids or impaired elderly: you lock out the onboard controls and give their boluses from across the room.)

It does take a while to properly tune the pump, and some of it is trial and error, though using the monitor usually makes the errors minor. The basal rate -- the constant trickle of insulin -- can be set to change during the day, and it takes some experimentation to match it to your schedule. On the other hand, once properly set, this means your BG remains relatively constant.

At mealtimes you calculate and deliver a bolus, and this is one of the pump's enormous advantages. You take the mealtime insulin when you're ready to eat; you don't take a slow of slow-acting and then have to cover it on its schedule. And the bolus is based on what you're eating, not what you took four hours ago. If you're having pizza, or something else high-fat (remember, this is not medical advice), you can set the pump to deliver, say, half the dose now and the other half spread out over the next couple of hours, so you're covered as that fat slowly metabolizes. This flexibility is a major improvement (and yes, for a while before changing over I was doing the Lantus/Novolog deal,** with five shots a day. It was better control than the previous two shots of regular/Lente mix, but still not as good, and certainly not as flexible as this.

Again, this is just my experience. But I was resistant too, and I'm not at all sorry I changed. (I don't miss shots, though after over twenty thousand of them they were not really a proble. And five a day, even with the nice portable pen injector, was a bit of a grind.)

*There's a fairly broad aftermarket in pump accessories for gracious living, including satin pouches on lace garters. Not my style, but I'm sure they look really sharp with a slit Mizrahi dress.

**For everyone else: Lantus is a long-acting insulin*** with a very long, very flat action curve; it's similar to the basal rate on the pump, though of course not adjustable. Novolog is an insulin with rapid and short action, which you use to cover meals. My pump is also loaded with Novolog.

***Ooh, nested footnotes. Natural human insulin loses its effect after about four hours. As this won't get you through the day, there are a number of modified insulins that are released more slowly, with various curves of action. A lot of people take one that lasts for 24 hours, with a hypergolic starting slug of unmodified insulin to cover until the long-acting kicks in; for a long while I was doing this twice a day, and before a particular metabolic change (different, long, not very interesting story) that worked pretty well.

Posted November 21, 2005 7:07 PM by John M. Ford

And anon, I am not going to quarrel with any of your observations, but leaving rude phony e-mail addresses is considered very poor form among the regulars here.

Posted November 21, 2005 7:13 PM by John M. Ford

Here's a stupid question:if you sleep in no clothes and don't want to wear a belt then what are your options for placement of the pump?

Posted November 21, 2005 7:48 PM by amysue

About exercise: I am aware that some people find exercise difficult. But as has been posted here, if you can't walk easily on land, maybe you can in water. If you can't walk at all, there are exercise bikes and if they are not appropriate, there are exercises for upper body strength and flexibility and even lower body strength which can be done sitting in a chair. Of course there are people for whom exercise is not possible -- but at the very least, breathing exercises are good for everyone unless you are suffering from lung problems, are in an iron lung, or are in such state of disability that this is all nonsense.

Simply telling people who have never exercised, don't like it, and don't really want to do it to exercise is mostly useless. You have to tell them where to go and whom to talk to, which means you have to KNOW. Most doctors don't.

I was lucky. I fell in love with a particular physical activity when I was 25. In my previous life I weighed 105 lbs, and never did anything more strenuous than picking up a book. I am going to be 60 next birthday and am still doing it. It keeps me reasonably fit and contributes greatly to what sanity I have left.

And I don't, to date, have diabetes. I may yet get it: some of it is inherited, some not. No way to know. At least, if I do get it, I know how to manage it... though I'll miss the ice cream and the beer.

Posted November 21, 2005 8:08 PM by Lizzy L

(Giggle, guffaw, smirk.)
Hey, get your mind out of the gutter...

Posted November 21, 2005 8:19 PM by Lizzy L

amysue: It's not a stupid question -- it's the kind of thing that patients reasonably want to know, but the people who write the literature never think about.

When I stuff the pump in a breast pocket (and occasionally even if it's in the Velcro pouch), it sometimes falls out. This has never been a problem -- lying on top of it is unlikely to cause any damage (though the way I'm built, lying on top of a coconut cream pie might not cause that much damage), and any action that would change a setting or deliver a bolus requires at least two, usually three, button presses (and sometimes a menu access), so it would be pretty hard to mess up the settings (or worse, send a bolus) by rolling on it. (If this became a real problem, the keyboard can be locked out for the night, as I said above.) I suspect the worst thing likely to happen would be for it to fall on the floor, though they're built sturdy. And I suppose a really good yank could pull out the catheter, but the sticky pad that holds it is very strong -- it's supposed to last three days, with showers -- and I've never had that happen. It does tend to wander around the bed when it's loose like that, but you can always follow the tubing.

On the other islet of Langerhans, I can see that this could be troublesome, and it's worth taking into consideration.

Posted November 21, 2005 9:01 PM by John M. Ford

I went to Costa Rica and Peru a couple years ago; one of the girls on the trip had an insulin pump. It caused a fair amount of trouble getting through airport security, but we expected that. Her general doctors tend not to know what on earth it is. Somewhere in Peru, she and a group of friends went out for the night. Upon getting back to the hotel, she said, "I think my pump's gone."
A streetbrat had stolen it. It took somewhere around a hundred dollars and a lot of arguing, including explaining that it was not a pager and that she needed it, to get it back. Those are some pretty good pickpockets, I guess.

Posted November 21, 2005 9:30 PM by Cassie

Thank you for this good information. My mother has Type II (controlled by injections) and while I knew a bit about what caused it and what the results could be, I didn't understand WHY those results could happen. Now if only I could convince her to exercise. Ever. :(

Posted November 22, 2005 12:45 AM by zandperl

a word of advice is needed.
i've got a puzzle (caused by the Queen of Denial, my loving 80-year-old mom)

She told me her doctor advised her that her white count was low. Thanksgiving is going to be okay because my sister, Jim and I are all well right now.

What worries me is that we're ALL going to be there for Christmas, including my niece's three infection-bearing children (even though they're home-schooled, mom tells me they're 'always sick from somethiing.' )

Iis there anything safe (she's hypertensive and takes meds for that, but as far as I know, those and Tylenol are the strongest things she takes daily) that she can take/do to improve her immuity (replying to dragonet@kc.rr.com is okay, not to add to thread)

Thanks in advance for any advice.

Posted November 22, 2005 1:25 AM by Paula Helm Murray

eleanor, illness is ALWAYS EXPECTED to raise your blood sugar. this is common and universally known.

Hypoglycemia commonly occurs in sepsis (overwhelming blood infections), kidney and liver failure. The zebra in the differential would be an insulinoma (insulin-producing tumor).

Posted November 22, 2005 2:33 AM by Tae

Marilee, I went from all-day hikes to using a cane to go 50 feet overnight. My allergist thinks I had a form of bronchitis and has some choice things to say about the docs who tried to feed me prozac instead of giving me a referral.

Water exercises are no good for me. The underlying problem is pulmonary, and even the pressure of the water hinders my breathing too much. What progress I've made is thanks to an air walker with a sturdy "hand rest" that I can lean on, but every cold, flu, or round of hay fever sets me back to the beginning again. One step forward, 0.9 steps back.

And exercise is my key. Without it, I can gain weight on 1000 calories a day.

Posted November 22, 2005 6:54 AM by OG

Anyone who's interested in insulin pumps, how to get them and how to live with them should check out insulin-pumpers.org and its British and Canadian sister sites. Excellent sources of diabetes-related information (though skewed towards type 1) even if you don't pump.

anon: Thanks, I knew I wasn't the only one.

Tae: I didn't know that. But for the common cold and the like, I think my experience is normal.

Posted November 22, 2005 8:13 AM by Eleanor

Tae: I hope you don't mind my asking, but are you the author of the "Paramedic from Hell" series? If so, thank you -- I enjoyed those immensely.

Posted November 22, 2005 8:49 AM by Teresa Nielsen Hayden

John: Thank you for all the pump info. I am not a shy person and yet I feel funny telling my doctor that amoung the many different concerns I have about the pump a few are related to sleep and or sex habits. I'm also a klutz. If there is a way to pull, step on, fall over etc. a given object, I will find that way.
I think that ultimately it will come down to control and what I am comfortable with. I don't mind the 5-6 injections a day. I am not shy about using the needles in public (though occasionally I get asked to not do so). However, the control I have may not be optimal and I need to honestly look at that. The fact is that my children have not once but twice needed to intervene when I've gone low so fast I had no warning. (One time was at the Lowell Folk Festival this past summer and my daughter essentially walked me by the hand to a paramedic and told him I was dabetic and acting funny-he squirted that stuff in my mouth and it really works.) It makes me sad that a 7 and 10 year old are aware of such things and that they worry about me and if the pump will give me better control and lessen the chances of such events than I can suck up inconvienient aspects.

Thanks again for the insight.

Posted November 22, 2005 9:15 AM by amysue

I've been type II diabetic for years now (eight? ten?) and perhaps the most astonishing thing to me about the "diet and exercise" part of diabetic control is how totally different it is, and needs to be, from the weight-loss dieting I yo-yoed on for years. It has to be totally sustainable, a word tossed around much in weight-loss diets but much more the exception than the rule. It has to become a matter of actual habits, not a project. Experience with short-term weight-loss diets will be more a hindrance than a help, she said with epic understatement.

So while diabetics have to be emphatic and tenacious, because real damage is being done, we also have to be really forgiving with ourselves, because putting habits in place is always an annoying and tedious process that must incorporate steps backwards as well as forwards. Also, while nuitrition and exercise are both vital, psych studies show overwhelmingly that it works better to concentrate on building one new habit at a time.

Fortunately, any progress is better than none, and as Charles Fort said, to measure a circle you can begin anywhere. Most books about diabetic control for diabetics have a sane attitude towards habit change that I can only wish I had encountered before I went on my first weight-loss diet.

Another nice thing is that generally speaking, habits that control diabetes also are good for health in general. Everyone would be better off exercising regularly, eating a variety of vegetables every day, etc.; I just have more motivation than many. Which is good, because it sure is a pain in the ass.

Posted November 22, 2005 9:47 AM by Bernadette Bosky

AmySue, what you wrote is scary. I understand squeamishness about private details - but failure to discuss concerns with a doctor can have horrible side effects.

I urge you (and all the people who feel the same way and don't have the guts to say so in public) to do whatever you need in order to get over the squeamishness. Therapy, role-playing, voodoo dolls, lots of blushing... ANYTHING. Because giving one's doctor full information is the only way some things will get caught, noticed, and treated. Doctors aren't necessarily brilliant, but without full information they can be useless or harmful.

Whatever it takes - it's worth it.

Posted November 22, 2005 10:39 AM by Shunra

Tae: I hope you don't mind my asking, but are you the author of the "Paramedic from Hell" series? If so, thank you -- I enjoyed those immensely.

Ah yes, that was me, though I now cringe at my lack of writing and parsing style when I read some of the stuff today.

In my defense, I typed essentially one long paragraph and posted using my trusty Apple //e and my not so trusty dialup connection and hoped that it went through.

Never occurred to me that I could write using a word processor and post in a more lesiurely fashion.

Posted November 22, 2005 11:07 AM by Tae