October 20, 2008

Not Your Grandpa's Diabetes

Many people greet a Type 2 diabetes diagnosis with more than the usual dismay because they have already watched a beloved relative diagnosed with diabetes go through the horrors of amputation, blindness or kidney failure.

As an example of what I mean, a delightful lady who posts online under the nickname "Ozgirl" once explained that when she was a child she thought all people lost their legs as they got older because all her older relatives had diabetes and all had no legs.

If you have that kind of family history, and these kinds of memories are haunting you, you may well flee into denial and ignore your blood sugar completely until you, too, suffer these same terrible complications. Many people do.

But this is an avoidable tragedy. With the tools we have available today, no one, no matter what their blood sugar history might be, has to develop these terrible diabetic complications.

Here is a list of the changes that have taken place in the last decades that explain why you don't have to go through the horror that diabetes was for an earlier generation:

1. Much Earlier Diagnosis. If your relatives was diagnosed with diabetes in the 1970s or 80s, they probably had been living with dangerously high blood sugars for many years before anyone noticed.

There were no commonly agreed upon cutoffs for diagnosing diabetes until 1978. Then the ADA devised diagnostic cutoffs that were intentionally set very high--just before people began to go blind--because as they explained in print, there was no effective treatment for any but the most severe forms of diabetes, and having a diagnosis in their medical records might keep people from getting insurance coverage.

So by the time grandpa got diagnosed, he had significant complications--retinopathy, nerve damage, protein in the urine and advanced heart disease. (You can read the history of how diabetes diagnosis has changed HERE.)

Doctors who keep up with diabetes treatment diagnose people much earlier now. If you have a good doctor he will diagnose you in the very early stages of "prediabetes." If you catch diabetes earlier, it is possible to normalize blood sugars and completely avoid complications, no matter what your genetic heritage.

2. Much Better Blood Sugar Tracking Technology. It has only been within the last 8 years that most people diagnosed with Type 2 diabetes have been given blood sugar meters and taught to track their blood sugars with them.

Before that, most doctors only checked a patient's blood sugar with urine dips done once every couple months. In most people, the urine dip test is only able to detect blood sugars that have been over 180 mg/dl (10 mmol/L) for several hours before the test. Even if your blood sugar tested out well above 180 mg/dl on the urine dip, most doctors in the old days would tell you you were fine, though that level is high enough to produce significant complications. Doctors only worried about extremely high blood sugars then--those over 350 mg/dl. But we now know that prolonged exposure to blood sugars over 140 mg/dl causes complications.

I went through an entire diabetic pregnancy in 1985 without ever seeing a blood sugar meter until I was in the delivery suite. So you can be sure that if Grandpa was diagnosed between 1950 and 1995 he may never have seen one either. If he has an old doctor now, he may still not have one, or if he was given one, he may not have been taught how to use it properly.

The blood sugar meter is the single most powerful tool we have to help us regain blood sugar control. If you follow the advice given here (or here if you are in a part of the world that uses mmol/L measurements) you will have the information you need to lower your A1c to a level that prevents most diabetic complications.

3. Much Better Medications. The only drugs available for people with Type 2 diabetes until the mid 1990s were the sulfonylurea drugs and insulin injections. These drugs cause hypos and since they were being given to people who were not using blood sugar meters, the only way they could be prescribed safely was by giving doses low enough that the patient's blood sugar would stay in what the doctors thought was the "safe" range--200-300 mg/dl. That level, we now know, is high enough to cause significant complications. In addition, earlier versions of these sulfonylurea drugs turned out to promote heart attacks and caused hunger that led to weight gain.

Doctors now should be prescribing metformin to newly diagnosed patients with Type 2. Metformin does not cause hypos and it is protective against heart disease. Patients who are given insulin are also given blood sugar meters, and, if their doctors are up-to-date, modern insulin regimens which lower blood sugar to safe, near-normal levels.

4. Doctors Only Learned How Important Lowering Blood Sugars Was in the early 1990s. Until the DCCT study was published in 1993 doctors did not know that lowering blood sugar could prevent complications for people with Type 1 diabetes. Until 1998 they had no evidence that lowering blood sugar would prevent complications in people with Type 2 diabetes. Many doctors believed that complications grew out of some other underlying cause, not blood sugars, and hence they worried more about avoiding low blood sugar than avoiding high blood sugars. Grandpa's A1c was very likely way over 10% in the range that we now know guarantees complications.

Sadly, the average A1c in the U.S. is STILL around 10% which is high enough to cause complications, but as thousands of people with diabetes who are active online have learned, it is possible to lower A1c and avoid complications. We do it, and so can you!

5. There Were No or Few Effective Medications for High Blood Pressure Until the 1990s. High blood pressure is a major contributor to complications, especially kidney disease and blindness. Until the 1960s there were no drugs at all that could lower blood pressure. The early diuretic drugs helped, but they caused side effects that made many people stop taking them.

But today's ACE inhibitor drugs have been shown to be very helpful to people with diabetes. They are cheap and effective and will go a long way to prevent the kidney failure that carried off so many people with diabetes in the past.

6. The Diet They Gave Grandpa Made His Blood Sugar Worse. The low fat diet that was prescribed to people with diabetes from the end of World War II to only a few years ago in the mistaken belief that it could prevent heart disease, encouraged people with diabetes to eat the foods most likely to raise their blood sugar and worsen their diabetes.

Fortunately, scientific research has made it crystal clear that low fat diets do not improve health and that lowering your carbohydrate intake by cutting way back on starches and sugars not only improves blood sugar but also lowers your risk of heart disease.

You don't have to suffer the way your elders did. It will take some effort on your part, but you can do it. The keys to getting the best treatment possible are:

1. Educate yourself about diabetes.

2. Make sure your doctor's training in diabetes treatment is up-to-date and that he or she shares your commitment to achieving the normal blood sugars that prevent complications.

3. Use your blood sugar meter to help you understand what foods you can eat.

4. Select your medications with care and only use those that safely lower your blood sugar and promote your health.

5. Keep an eye on your blood pressure and keep it normal.

6. Interact with others in the online diabetes community who have been successful in controlling their own diabetes and preventing complications.

7 comments:

Pubsgal said...

Jenny, thanks so much for writing this article. I had no idea how much has changed within a relatively recent time. My grandmother had type 2 diabetes late in her life and suffered a pretty rapid decline afterwards. I don't know what her treatment was, nor how long she was probably suffering from it. But yes, having (albeit remotely) watched her decline, I did feel a lot of fear when I was diagnosed, but not quite as much now. I'm grateful that we have more knowledge and technology to help combat this disease.

Anna said...

Excellent post! The only thing I would add is that people don't have to wait until their doctor gets concerned to start using a glucose meter and monitoring their blood glucose, especially after meals. The meters and the test strips are available without a prescription at any drug store.

Yes, I know buying the test strips OTC is expensive (I bought them OTC for nearly a year, testing on average 2-8 times a day to really understand how food affected my levels). But treatment for diabetes and diabetic complications is a very expensive "habit" to develop, so some expense upfront to avoid diabetes and complications from progressing will actually save money (yours, mine, our insurance companies, and tax-payers). You know, penny-wise, pound-foolish (dollar-foolish on this side of the pond).

Lyrehca said...

Very interesting stuff.

I'm curious, though--how was your pregnancy in 1985? Complication-free? Was your child born healthy? As someone very interested in pregnancy and type 1 diabetes, I'm curious how undiagnosed type 2, as you say, affected you and your child. Feel free to email me if you don't want to post here (Lyrehca AT gmail DOT com). Thanks!

--Lyrehca
www.thesweetnesswithin.blogspot.com

Jenny said...

Lyrehca,

I turned out to have MODY not Type 2, but the effect of uncontrolled blood sugars on the babies was the same.

They were both 9 pounders and the main complication I had was very difficult deliveries due to their size, especially with the first who was lucky to be delivered alive after getting stuck.

Outside of that, though, they had no issues that could be blamed on diabetes.

Though they were both huge babies and weighed the same at birth, the one grew up very slim and the other became an enormous football player. But his grandfather (from the side without diabetes) was also a huge football player so that was more likely due to his genes than gestational diabetes.

Deborah said...

Thank you so much for this site and all your effort to make this information available.

I am one (of many I'm sure) who is a living example of both sides of this specific issue. My father died 25 years ago from diabetes related kidney failure. At the time of his death at age 68, he had been an insulin dependent, adult onset diabetic for 20 years. He also had severe retinopathy, and neuropathy, though he did have his legs! He basically kept his blood sugar "regulated" with alternating doses of insulin and candy. Talk about your blood sugar swings!

I have 4 siblings. In the late 90's my younger sister and I discovered Protein Power and Atkins for weight loss. each of us lost in excess of 30 pounds, and became educated as to the heathfulness of controlled carb eating. We both continue a lower carb lifestyle--basically meat, veg, some fruit, nuts and dairy, no veg oils (olive oil ,butter and lard, coconut oil and some nut oils only) very little grain, no starchy veg, and NO sugar.

we remain slender and healthy--both of us now over 50 years old. I do test blood sugar from time to time and do have very high readings if I eat high carb food. (With my current eating regimen I keep them below 100 most of the time with small spikes under 110.)

our 3 OTHER sibs-- 2 men in their 60's and a sister in her mid fifties--a re all overweight. My brothers both have heart disease and diabetes. sister is VERY fat and also has diabetes.
very good examples of Gene expression here and how it CAN be manipulated.

I have sent all of them to your site and have done considerable intervention with my sister but they remain entrenched in traditional thinking and "...my doctor knows best...blah blah."

I will NEVER understand--with examples right in front of them.
....sigh

Anonymous said...

I just finished reading Diabetes 101 and I learned alot.
I am not diabetic, but my a1c was 5.5 which my doctor says is "fine" and which I interpret as borderline prediabetic.
Do you have any tips on educating doctors that does not make them defensive?

Jeanne

Jenny said...

Jeanne,

"Educating" doctors is pretty much a lost cause. They do not respect patients' understanding of medical issues.

That is why it is much more useful to educate your friends who have diabetes about the simple principles that will keep them healthy.

Use your doctor as a resource for getting the prescriptions and tests you need. If they ask you how you are managing to do so well, tell them, but sadly, don't expect them to ask.

My eye doctor told me I was the only diabetic in his practice with an A1c in the 5%s, but did not have the slightest interest in hearing how I did it.

Sad.