November 29, 2007

Lessons for the Diabetes Community from the Cancer World

I just read a very disturbing book, The Secret History of the War on Cancer by Devra Davis. Suffice it to say that if you are easily scared, you should not read this book.

Dr. Davis is a distinguished epidemiologist. Her subject in this book is how the companies that profit from selling cancer causing products coopted the very organizations and government organs set up to "fight cancer." She describes how the American Cancer Society was taken over by people from the tobacco industry who used the mantra, "This needs further study" to keep the organization from letting the public know that as early as the 1930s scientists had proved very conclusively that cigarettes caused cancer, and that the more a person smoked the more likely they were to develop cancer.

The tobacco industry provided a great deal of funding for the American Cancer Society and one way it kept the public from learning how dangerous their products were was to fund research into other obscure causes of cancer, which was done to downplay the role their product was playing in the huge rise in lung cancer that followed the addiction of millions of soldiers to cigarettes in World War I.

An even more disturbing finding that Davis documents is the way that industries that produce cancerous chemicals have for decades paid researchers to research the cancer causing properties of their products and the chemicals used to make their products, but kept their results hidden from the wider scientific community. Companies have known for decades that workers in their plants were dying horrible deaths from exposure to chemicals used in their workplace, but kept this secret. In some industries, chemicals were used that caused 100% of all workers to get cancer after 25 years on the job. Nevertheless though scientists working for these companies knew this, the information was kept completely secret, because revealing it would reduce corporate profits. That people died because of the secrets they kept was just too bad.

What does this have to do with diabetes?

Well, the ADA has had the same role in the diabetes world that the ACS had in the cancer world. Funded largely by companies that make the high carb products that worsen blood sugar and the drug companies that profit mightily when people eat those products, the ADA has fought for decades against letting the public know that it is carbohydrates that raise blood sugar and that people with diabetes can control their diabetes by lowering their carbohydrate intake substantially.

Any time research proves that cutting out most carbohydrates from your diet--especially those supposedly "healthy whole grains"--improves the health of people with diabetes, the ADA says, "More studies are needed." Meanwhile they put their stamp of approval on high carb junk foods made by companies like Campbells "One gram of salt per serving" Soup.

The ADA has put millions of dollars into convincing people with diabetes that sugar is good for them. Not so coincidentally a top ADA sponsor is Cadbury Schweppes, the candy and soda maker. Check out the annotated list of ADA sponsors as of August 2006 . The company has removed the list of sponsors from the page linked on that entry, probably because it was so damning. But their sponsors continue to be companies that sell you food that makes you more diabetic or expensive drugs you will need if you eat that kind of food.

Like the American Cancer Society, the ADA raises huge amounts of money from the victim of the disease their policies have made more widespread. These donors do not realize that just as the ACS's leadership was full of chemical industry and cigarette company lobbyists, the ADA's leadership is not made up of people with diabetes or of doctors, but of laymen whose corporate connections are not made public, but who probably have long histories of connections with the drug and junk food companies.

Just as the ACS kept the public from knowing for 20 years that cigarettes caused cancer, the ADA has fought to keep you from knowing that it is carbohydrates that raise blood sugar and that a "healthy diet" for a person with diabetes is one that does not raise the blood sugar over normal limits.

Recently a news release went out to say that the ADA has decided to soften its long held hostile stance against recommending low carbohydrate diets for people with diabetes. Well, don't get your hopes up. The outcry against their dangerous and outdated dietary advice has gotten so loud they have to do some kind of spin control. But a "diabetes" organization that in 2007 still defines "tight control" as a blood sugar that drops to 180 mg/dl (10 mmol/L) at 2 hours after eating, and does not mention the word "carbohydrate" once on their Tight Diabetes Control web page is not about to tell anyone to stop eating the diet that is killing them. Not when the funds that pay the salaries of the mystery people who run the organization are paid by huge corporate junk food and drug makers.

The venality documented in Davis' book is terrifying. I had naively thought that the mess that is diabetes treatment was the result of our having a non-glamorous disease people think is caused by our own bad habits. Davis' book makes it clear that callous disregard for the public, deceptive advertising, and cooking the research to hide results that might cost some company money are standard operating procedure throughout the health establishment.

The end-of-life repentances of the cigarette and chemical executives who spent their lives misleading people about the safety of their products do not begin to atone for the hundreds of thousands of people they killed. Will the ADA executives and their self-serving sponsors who fund the organization to ensure that their products continue to find a market, ever come to grips with the way they have caused generations of Americans to go blind, lose their feet, and go on dialysis?

Probably not. After all, unlike those cigarette industry folks who eventually got cancer from their own product, the ADA denizens don't have diabetes, they only profit from it.

November 20, 2007


Khürt Williams from Honey Sweet tagged me with the meme going around with these rules:

1. Link to the person’s blog who tagged you.

2. Post these rules on your blog.

3. List seven random and/or weird facts about yourself.

4. Tag seven random people at the end of your post and include links to their blogs.

5. Let each person know that they have been tagged by posting a comment on their blog.
Seven Random and or Weird facts about myself:

1. My great-grandfather was born in the 1820s.

2. My daughter has appeared in music videos by Green Day and Kelly Clarkson.

3. I lived for three years on a farm that had no indoor plumbing.

4. I have written two completed novels set in the early 19th century.

5. I was a professional musician in Nashville in the late 1970s.

6. I sent and received my first email in November of 1980.

7. I've been involved in online discussion groups since 1987.
The folks I know online are pretty much tagged, so I'm going to risk whatever it is that happens if you don't pass on a meme and not pass this one on.

November 17, 2007

Great Diabetes Gift!

I just got the diabetes bag I ordered only two days ago from Rickina at Stick Me Designs.

It is even nicer than I expected it to be. I can stuff every possible diabetes supply I can think of into this bag and still get it shut.

Here's a photo:

Needles, pen, pen needles, insulin vial, meter, lancet, strips, even my handy dandy needle snipper, all fit in. And with all this stuff in the bag, it still closed:

Rickina, who recently went through a diabetic pregnancy which made her realize the need for this kind of bag, makes these herself. I also sew, and I can tell you, her work is beautiful.

You could also put your glucose in one of the zippered compartments, or your house keys wallet and money, for that matter. It would also be perfect for putting in a larger handbag or for when you travel and want to be sure you have all your stuff with you as carry on.

Most of all what I love is how jaunty it is.

Way to go Rickina!

November 16, 2007

When to Test Blood Sugar in Type 2

One of the topics that comes up a lot in the email I get from visitors to my What They Don't Tell You About Diabetes web site is the question of when is the best time to test your blood sugar.

A lot of doctors still tell people with Type 2 to test first thing in the morning and before meals. That was what I was told at diagnosis in 1998. People who test using this schedule may tell you their blood sugar is usually 120 mg/dl, which sounds pretty good, except that since this is a fasting number it usually hides the information that the person's blood sugar maybe going to 250 mg/dl or higher after every meal.

Research has shown that for people with Type 2 diabetes--especially those who have been diagnosed recently and still retain some beta cell function--it is the high spikes after meals that contribute most heavily to raising the A1c and causing complications. If you only test your fasting blood sugar, you will not know anything about how high your blood sugar is spiking after meals, so you won't know which foods are toxic to you because they cause dangerous spikes.

If you are like most people with Type 2 your access to the very expensive blood sugar testing strips is limited. You may have to pay for strips yourself or your insurance may pay for a single box each month. That means that you need to use each strip as efficiently as possible. Here are some strategies that you can use to get the information out of your blood tests that will let you drop your A1c back into the healthy zone.

  1. Keep a written log that matches what you eat with the test result you get.
    Even though your meter may keep a list of your readings, these readings are meaningless unless you know what food you ate that resulted in each particular reading. If you write down what portion size of which food you ate and match it to the blood sugar you saw after eating it, you will accumulate the information you need to eliminate toxic foods and replace them with those that do not raise your blood sugars.

  2. Determine when your blood sugar reaches its highest point after eating.
    Your goal is to bring your blood sugar peaks below the level that we know cause complications. To do this, you need to learn when your blood sugar hits its highest level. Research studies show that the average person sees a blood sugar peak 75 minutes after eating carbohydrate.

    But you're not average, you're you. So the first thing you need to do is determine when your own blood sugar peak occurs. Start out by testing at 1 hour, 1.5 hours, 2 hours, and 3 hours. Do this for three meals. You should start seeing at which time the highest reading occurs. That's the time you should plan to test in the future.

    Don't test at 30 minutes after eating. Though many people see a high at this point, research has shown that brief peaks at 30 minutes after eating do not correlate with an increased incidence of complications. The one hour reading is the earliest that you should concern yourself about.

    If you eat pasta which digests very slowly you may see a peak much later than usual. You should test for peaks from pasta 4 or 5 hours after eating if you don't see them in the first 3 hours.

  3. Eliminate the Foods that Cause Unacceptable Spikes.
    You can test all you want, but if you don't use the test result to eliminate the foods that cause blood sugar spikes, you might as well not test at all. Testing is the most powerful tool you have as a person with diabetes to regain your health, but you must act on the information you get from your testing.

    If you see an unacceptable high blood sugar reading, the only way to bring it down is to cut back on the amount of carbohydrate in your meal. Carbohydrates are what raise blood sugar, and despite what you may read in books written by people who do not have diabetes, every gram of carbohydrate you eat will raise your blood sugar no matter whether it is supposedly "healthy", "low glycemic" or the label says it is magically treated to keep it from raising blood sugar.

    So if your blood sugar is too high after eating a meal, determine where the carbs came from that raised your blood sugar in that meal, and cut back on the carbohydrate food or eliminate it completely.

  4. Nutritional Software Can Help You Discover Where The Carbs Are
    I like LifeForm. Others use Fitday. Find a reliable source of nutritional information and look up the foods you eat to see where the carbs are coming from. Read the labels on the prepared foods you buy and be careful to note the portion sizes which are almost always much less than you eat. For example, have you ever gotten "2.5" servings out of a can of Campbell's soup? No. I didn't think so. But that's the portion size given on the label, so if you eat half the can, you're getting 20% more carbs than are listed on the label.

  5. Shoot for Healthy Blood Sugar Targets
    These are the targets that will give you an A1c in the 5% range no matter how high your A1c is now. If you don't believe me, check out THIS PAGE of reports from people who have used these targets to dramatically lower their A1cs.

    One hour after eating: under 140 mg/dl (7.8 mmol/l)

    Two hours after eating: under 120 mg/dl (6.7 mmol/l)

    If you can do better than this, go for it. Normal people rarely go over 120 mg/dl ever and are usually under 100 mg/dl at 2 hours after eating.

  6. Use Generic Meters and Strips if Access is Limited

  7. Wal-mart sells the Relion meter for $8.88 and the strips are less than half the price of the name brand strips. They work just as well. The drugstore brand meters made by TrueTrak are also much cheaper than the brand name strips, though the strips may lose their accuracy over time, once the vial is opened. Companies give away "free" meters only to get you using their overpriced strips. Don't pay full price for name brand strips. It isn't necessary. You can sometimes get good deals on strips on eBay but check the expiration date. Don't buy expired strips and don't buy strips by mail when it is hot as the heat can destroy them.

November 13, 2007

Study: Studies funded by Drug Makers Underestimate Problems

Today's New York Times drew my attention to this study:

Adverse Effects of Inhaled Corticosteroids in Funded and Nonfunded Studies

It looked at studies of inhaled drugs and found two phenomena that should surprise no one who follows the news about any new drug.

1. Studies paid for by the company making the drug found far fewer side effects than studies of the same drug paid for by organizations that had no financial stake in the drug. The drug maker's studies were much more likely to describe a drug as "safe" or "effective" than were other studies.

2. The reason for this lay in the way that the studies were designed which appeared to make it easier to hide the side effects.

What's crucial here is that the misleading studies funded by the drug makers included the clinical trials used to get approval for the drug.

This should remind you that all the studies done to get approval for a drug are paid for by the company who will profit (greatly!) from the drug's sale. But this system ensures that the studies will be cooked as far as possible.

What does this mean for you? Simply this: for chronic conditions it makes sense to avoid new drugs no matter how well hyped until they've been in the marketplace for enough time that their real side effects will become apparent.

And don't trust those company funded studies that "prove" that the drugs cause much-yearned for benefits like weight loss or beta cell regeneration. Almost always these benefits disappear when the drug is studied by someone who isn't going to profit from its sale.

November 11, 2007

Debugging the Highs: Update

Well, I went through my debugging sequence as I described in a previous blog entry and the news is not good.

I am responding completely differently to R insulin than I was just three months ago, which is the the last time I was not taking Metformin.

My response to the R insulin was so different from what it was 90 days ago, that I went so far as to drive to a Wal-mart pharmacy in a different state and buy a new vial of R there, just to make sure that the two week old-vial I was using didn't have something wrong with it. The previous vial I'd bought at my usual pharmacy was the same lot as the insulin I'd bought a couple months before and I wondered if perhaps it had weakened.

To test the potency of the new insulin, I ate the identical meal for dinner using the same dose of the new insulin as I had eaten the night before with the dose from the older vial. I ended up with a blood sugar reading only 5 mg/dl different at one hour from what I'd seen the previous night. Unfortunately, that reading was 178. And that was with 4 units of insulin, which is a lot for me. This was using a 1/12 insulin/carb ratio which was what I would have used before when not taking Metformin.

Yesterday tried using a 1/8 insulin ratio, and it worked okay at lunch with 25 grams of carbs, though not great. But when I tried it at dinner with 40. I ended up at 157 at 1 hour and 126 at two.

That doesn't sound too bad, but there's a hitch: Eventually the insulin IS kicking in and I'm going low. After my meals yesterday I ended up in the low 80s feeling shivery--and after eating more fast acting carbs I was still in the 80s an hour later.

This sounds like what happens when a person has developed antibodies to insulin. The insulin is bound by the antibodies for a while making it less effective, then the antibodies release it and it kicks in later.

If that is my problem, the only thing I can do is wait it out and hope it goes away. Needless to say, I'm going to have to cut way back on carbs because I am going too high after meals, staying high and then getting lows, which make me feel like crap all day long.

If any of you have had anything like this occur, let me hear about it.

November 8, 2007

Halle Berry: Poster Girl for MODY?

There's been a huge outcry online now that Halle Berry, previously a poster girl for Type 1 diabetes, has told the press that she has been able to wean herself off insulin.

A lot of people with Type 1 diabetes are very upset with this for the very understandable reason that it is impossible to go insulin if you have Type 1 diabetes unless you get an experimental pancreas or beta cell transplant--and even those are iffy. So there are a lot of people with Type 1 who are feeling betrayed and that is making for a lot of anger.

In fact, what happened to Berry has happened to quite a few people who have emailed me over the years since I put up my web page about monogenic diabetes (MODY).

None of them are TV or movie stars, so their experiences didn't hit the media. But all of them were diagnosed with Type 1 diabetes in their late teens or early 20s only to find out years later that they actually had a genetic form of diabetes that keeps beta cells from secreting--a form of diabetes where it is possible to reestablish beta cell secretion using sulfonylurea drugs like Amaryl or, more recently, Byetta instead of, or in combination with, insulin.

While some forms of MODY, like the one I appear to have, are mild enough to be misdiagnosed as Type 2 diabetes, as mine was, others can be quite severe and easily confused with Type 1 diabetes. Here's a case history of just such a case:

Identification of MODY: the implications for Holly
Journal of Diabetes Nursing, Jan, 2004 by Jo Dalton, Maggie Shepherd

The main things hinting that MODY might be at fault here were that insulin doses remained in the "honeymoon" range, years after diagnosis and that the patient did not develop DKA. Note also that the patient's father was diagnosed with "Type 2" later in life, but actually had a much milder form of the same genetic diabetes. The virulence with which these gene express is modified by many environmental factors science does not yet understand.

Many doctors still believe, incorrectly, that a person cannot develop MODY unless one parent has been diagnosed with diabetes. But even though neither of Ms. Berry's parents was diagnosed with MODY it does not rule out that she might have inherited the gene from one of them. In addition, as in the case of Holly's father, the gene may spontaneously mutate and appear in a person with no relatives with diabetes.

That there are "silent" carriers of these genes scattered through the population was only realized recently when scientists started testing family members of people diagnosed with MODY via gene tests. They discovered that there were other people in the families who were carrying MODY genes but whose blood sugar abnormalities had escaped diagnosis--probably because, like mine, the gene defect affected only post-meal blood sugar levels and were not detectable using a fasting plasma glucose test.

It is also worth noting that scientists who study genetic diabetes believe there are many more genes out there causing insulin secretory disorders than the six that have been so far identified. So it is possible that there are a lot more people diagnosed as Type 1 diabetics who have one of these not yet diagnosed genes.

However, it is also very important to note that whatever the cause of the defect, these MODY forms of diabetes are every bit as capable of wreaking havoc on eyes, nerves, and kidneys as is Type 1.

As far as Ms. Berry's situation goes, I hope that she isn't settling for the 7%-8% A1c that so many doctors consider good enough for someone with Type 2. As exciting as it might be to be able to give up insulin, trading shots for blood sugars high enough to cause blindness, amputation, and dialysis is not such a smart idea.

Ms Berry still has diabetes, it still has the potential to ruin her life, and she still needs support from the rest of the diabetes community in learning how best to get her blood sugars down into the normal range so she can avoid developing complications.

And we all need to realize that Ms. Berry's situation points out how misleading are the current diagnostic criteria which lump hundreds of different genetic and metabolic disorders into one of two bins--Type 1 and Type 2.

November 7, 2007

"Overweight" is Healthiest Weight

This is not actually news, as there was a good study published some years ago that found the very same thing to be true, but a new study presented at this years American Heart Association meeting confirms the finding, and has led to some headlines on the topic.

The basic message here is that you are most likely to live a long and healthy life if your BMI is between 25 and 30, which for a 5' 4" woman means having a weight of 150-174 lbs and for a 5' 10" man is 175 - 208 lbs.

Here's a report on the finding from the New York Times.
Causes of Death are Linked to a Person's Weight

Here are some earlier large population-based studies that have found similar results:

From JAMA in 2005 based on NHANES III data

Here is a further review of the NHANES data that points out that over age 70, overweight AND obesity are more healthy than normal or underweight. Be sure to scroll down to Table 4.

Supplemental Analyses for Estimates of Excess Deaths Associated with Underweight, Overweight, and Obesity in the U.S. Population
by Katherine M. Flegal, Ph.D.

The current data does NOT break health down by decade, which is a shame, because the strongest signal in the NHANES study points to weight becoming increasingly healthful as we go through middle age. By not breaking mortality figures out by age, we may miss this vital point.

This data flies in the face of our society's obsession with thinness and its tendency to equate near-anorexia with moral superiority and overweight to sinfulness. However, as anyone who is over 50 knows, at middle age the body ramps up its weight gaining mechanisms to the point where it is almost impossible NOT to gain weight. Now this research suggests that there is a reason for it, and it is not that we suddenly become lazy, greedy slobs.

As we age, the metabolism slows down at a predictable rate. The result of this slowing is that at 59, I can now gain weight eating the same diet that I would have lost weight on at age 40. A diet, by the way that has the same number of calories used to induce starvation in men who averaged a weight only 10 lbs more what I now weigh during Ancel Keye's famous WWII Starvation Experiment.

This is not because I am less physically active than I was at 40, which is the usual excuse given for middle age weight gain. No, my body has clearly decided that I need an extra 20 lbs and the more I fight it the harder it fights back.

So what a sudden revelation it is to realize that maybe my body is doing this because it is trying to keep me alive!

There is a predictable backlash to this data from people who know it has to be wrong. But as the analysis of the NHANES research linked above shows, their belief that overweight is unhealthy may derive from studies that cherry-picked the data in such a way as to achieve the result that the researchers already believed to be true. Taubes' work has made it very easy to see how common this is in so-called scientific studies.

And it's also worth remembering many of the claims of excess mortality linked to weight, like Julie Gerberding of the CDC's famous discredited estimate of mortality due to overweight, were pulled from thin air.

Does this mean you should rush out and gain weight? Of course not. Does it mean that carrying an extra 100 lbs is good for you? Again, of course not. The health benefits of weight drop off significantly at a BMI of 35--204 lbs for a 5' 4" woman and 244 for a 5' 10" man.

In addition, the BMI as an index to health has to be taken with a grain of salt, because it completely the two Bs: boobs and brawn. I'm carrying 6 lbs of boob, which do not go away even if I weigh 108 (I've tried it.) That raises my BMI by 1.1. Does this mean I'm much less healthy than a completely flat chested woman of my size? I doubt it.

In a similar manner, when my son was playing on his college football team, he had a BMI well into the "obese" range, based on his height and weight, though he was measured as having a body fat percentage of 17% which is normal for a male. This discrepancy was because he was carrying an enormous muscle mass which the BMI calculations treat as if they were body fat.

One of the things doctors always tell people with diabetes is that if they could lose as little as ten pounds, they could lose the diabetes. Hundreds if not thousands of you reading this blog have probably tried this and found it to be nonsense. Some of us, like, say, me, have lost over 15% of our body weight and found it to have zero impact on our blood sugars.

Well, heave a sigh of relief. Your weight is not going to kill you. Then take another deep breath because no matter WHAT you weigh, your blood sugars might: the connection between blood sugars rising over 140 mg/dl after each meal and heart attack is very well documented with more research confirming it every year.

So concentrate on getting those blood sugars down. Get your A1c as close to 5% as you can, and once you do look forward to having long debates about "healthy eating" with your grandkids and great grandkids!

November 6, 2007

More Problems with Galvus the Other DPP-4 Inhibitor

UPDATE (April 2, 2013): Before you take Byetta, Victoza, Onglyza, or Januvia please read about the new research that shows that they, and probably all incretin drugs, cause severely abnormal cell growth in the pancreas and precancerous tumors. You'll find that information HERE.

Original Post:

There's a new and troubling problem connected with DPP-4 inhibition. Read about it here:

New Safety Warning Delays Norvartis Diabetes Drug

Galvus is the other drug that uses the same mechanism to lower blood sugars as Januvia does. It is a DPP-4 inhibitor which has been approved for use in Europe and Latin America, but so far, not in the U.S.. It came up for approval around the same time as Januvia, but the FDA refused to approve it citing vaguely described "skin-related findings."

The chances are very good that these skin related findings are the same ones that have recently been discovered to occur with Januvia, including the potentially fatal Stevens-Johnson syndrome, where your skin separates from your body, as well as other allergic skin reactions including severe rashes and swelling.

There's no mystery why Januvia and Galvus cause such problems. Both suppress DPP-4 which, besides having a role in eliminating GLP-1 from the body, are major players in the regulation of the immune system. Stop DPP-4 from doing its job, and the immune system will start displaying subtle changes like rises in some white blood cells and not so subtle changes, like major allergic skin reactions.

The recent discovery of these Januvia side effects is detailed in this Reuters news story:
(Merk's Januvia Wins New Uses but Risks Outlined.).

Now a new problem has emerged with Galvus. When prescribed in the dose needed to make it a once a day pill, like Januvia, it can elevate liver enzymes to an unacceptable level. Elevated liver enzymes tell you that liver cells are being damaged or killed. Kill enough of them and you are looking at a liver transplant or death.

It was high liver enzymes that first warned of the toxicity of an earlier diabetes drug, Rezulin. Unfortunately few doctors paid any attention to the warnings about elevated liver enzymes with Rezulin. So for several hundred patients on Rezulin, by the time they learned they had elevated liver enzymes it was too late and they died, several hundred of them.

The solution that Novartis has come up with to pretty up Galvus is to cut the recommended dose in half. Supposedly at the lower dose, taken twice a day, the liver enzymes signal disappears in the study pool. However, this does NOT mean that the drug isn't causing liver damage. Only that it may take longer for the tiny bits of damage to accumulate.

Galvus is a different molecule than Januvia, but we don't know whether the damage was caused by something specific to the Galvus molecule or by fiddling around with DPP-4 and GLP-1. There is no requirement for drug companies to study and explain WHY a certain dangeous side effect occurs with their drug.

Since the two drugs appear to be pretty similar in their effect on the body. It would probably be a very good idea to get your liver enzymes checked every year if you are taking Januvia and if you see any sign that your liver enzymes are rising, get off the drug.

If your doctor pooh-poohs your concern, remember that busy doctors are very unlikely to know about newly discovered side effects. Your doctor probably also doesn't know about the immune system and skin problems that FDA just discovered with Januvia and added to the prescribing information. The drug company reps who give doctors 99% of their "education" about new drugs are not legally required to inform doctors about new warnings put into the Prescribing Information doctors rarely read.

November 4, 2007

Debugging Unexpected Blood Sugar Highs

Every time I get things working, as far as balancing food and insulin, something changes and I get knocked back to square one. And, surprise, surprise, it has happened again.

Out of the blue, last week, I started seeing highs after meals using doses of insulin that up until then had matched specific food inputs perfectly. Over the week they've gotten worse until yesterday I spent most of the day well over 150 mg/dl and partly over 200, though I used more insulin yesterday than I've ever before used in one day.

I checked the Usual Suspects that I always consider when my blood sugar goes blooey on insulin, which I'll list here:

1. Meter problem: I tested highs on two different meters with strips from two batches and they matched within 4 mg/dl. No meter problem. (Of course, I washed my hands after seeing the first high, to make sure I didn't have sugary fingers.)

2. Insulin problem: Because I use very small doses of insulin, one vial or pen can last me a very long time. But over the past two years I've learned that any vial of insulin that gets used 3 times a day can deteriorate after six weeks, even if I've only used 100 units out of the 300 in the bottle. Sometimes I can see tiny crystals in the previously clear insulin. Sometimes I can't see anything, but replacing the vial or pen solves the problem of mysterious highs.

I replaced both my R and my Novolog pen with new ones. The problem did not go away.

3. Getting Sick? Sometimes we see rises in blood sugar days before we get sick.

I did end up developing a nasty viral outbreak in my mouth this past week, which is something I get from time to time. But I'm not sure that would be enough to cause the dramatic deterioration I'm seeing. I've had it before without seeing highs. And the outbreak is clearing up while the blood sugars are getting worse.

4. Carb Creep/Wrong Carb Insulin Ratio: Is that 30 grams of carbs really 60? Sometimes we get sloppy with our carb counting.

I thought that might be the problem, but yesterday I weighed portions and had a very good idea of what I was eating and saw crazy high numbers. More importantly, the timing of the highs was really strange--with the highest reading almost 3 hours after eating and injecting Novolog. When I did a Novolog correction at 3 hours, I ended up with a wicked low an hour later. This is NOT the usual pattern I see at all, but it does require further investigation.

5. A Change in Meds or Supplements: Any medication or supplement we take, whether for diabetes or not, can impact on our blood sugar.

In this case there were two obvious suspects. The high blood sugars started before I stopped taking Metformin again, and ideally I should have NOT stopped taking metformin when I developed highs, because my blood sugar will go up a bit without metformin, though not a lot. But I had no choice, as the Metformin was giving me continual burning stomach pain and I was also feeling very exhausted after taking it, which is something that had gone away when I stopped taking it before. So I decided that I had to stop taking it, because it was clearly not helping me out anymore.

But that said, I had stopped taking Metformin for several months only a few months ago without seeing dramatic highs. Usually I see a rise of about 10 mg/dl in fasting blood sugar and maybe of 20 mg/dl after eating when I am not taking Metformin. In the past, to correct for this I had only had to add another unit or so to my dose at meals, and 1.5 unit of NPH at night to knock down the fasting blood sugar. This was nothing like the 50-70 mg/dl rise I have been seeing this past week.

A I blogged earlier, I have also recently started taking 1000 IU of Vitamin E, which initially was causing lows which stopped after a week or so. Then after reading up about Vitamin E I added 2 Calcium/Magnesium supplement pills to my daily regimen, since it turns out that without available Cal/Mag Vitamin D may store metals in your bones. Hmmmmm. Needs further investigation!

6. Too Much Insulin Causing IR? It's one of the ironies of insulin use that if you use too much insulin the body may get into a counter-regulatory mode where surges fight and flight hormones push blood sugar up out of the low range and the body becomes more insulin resistant out of self-protection. I have always had a huge problem with unwanted counter-regulation in the past, which is characteristic of MODY-2, the kind of genetic diabetes I'm currently being tested for.

So this idea isn't so far fetched. When I figured out the right dose of Lantus to use to avoid hypos last year, I saw very high post-prandial numbers--and that was why I stopped the Lantus. I have been using increasing doses of NPH for the past month to try to get my always high fasting bg down and had added a unit or two every morning, too. Requires investigation.

7. Deteriorating Beta Cells: While this is not a likely explanation, we can't rule out that something may have caused my beta cells to shut down or otherwise misbehave. I don't think this is likely, because the last time I stopped using insulin (with a very low carb diet) my post-prandial control was a lot better than it had been 2 years ago when I started insulin, suggesting that beta cell rest had given me more function in my beta cells, not less.

Into Debugging Mode!

Since I come from a computer engineering background, I'm familiar with the techniques used to debug problems that develop in large, complex, poorly documented systems. So now it's time to sort out what might be causing these highs.

Key to doing this is the basic debugging concept: When there are multiple possible causes for a poorly understood problem, go back to something that works (if possible) and then change one thing at a time and see if you can reproduce the problem. Start with the most likely and work back to the least likely.

So here's what I'm gong to do:

1. Cut out everything that looks like it might be causing the problem: the Vitamin E/Cal/Mag supplementation, carbs, and NPH. I can do this because I am fortunate to still have some natural insulin production left. A Type 1 could not cut out a basal insulin, because cutting out the basal could make them very, very sick.

2. Cut carbs way, way down and stick to foods where I'm certain about the carb count. My most recent stint of low carbing wasn't that long ago. I was able to stay between 95-120 most of the time if I kept my carbs under 12 grams per meal and 6 at breakfast, a la Bernstein diabetes diet. I have some other problems that this diet makes worse, but for now I'm going to eat that way to get to an acceptable baseline. It mostly eliminates the problems caused by mismatching insulin to meals.

3. Add back one suspicious element at a time to see if I can determine what is causing the problem. Here's my thinking:

a. Add nighttime NPH. I started using NPH at night when I was off Metformin before because without Metformin my fasting blood sugar is always around 100 or more. It did not seem to cause a rise in my day time blood sugars. Because my fasting bg on a Bernstein diet will quickly go up to 110-120 mg/dl I want to address the high fasting value first before doing anything else.

If after doing this I don't see daytime highs:

b. Raise the number of carbs I eat in each meal gradually using my old reliable R insulin and my usual Non-Met carb/insulin ratio (1:10-1:12). Use measured portions of foods I'm familiar with. This should quickly tell me if using the wrong carb/insulin ratio was the problem.

If this solves the problem of daytime highs:

c. Add back the Vitamin D and Calcium/Magnesium.

If this doesn't cause daytime highs:

d. Add back the morning NPH dose.

Obviously, if one of these elements DOES cause the daytime highs, I'll have to stop using it.

I should wait a couple days before introducing each element.

Obviously, this is all a pain in the neck, but when I'm done, I should have a better idea of what is going on. I hope! If the problem was that I'm really about to come down with a cold, I might add everything back in and not reproduce the problem, but that works too.

Any other debugging suggestions from you folks who live with this crap day in and day out?

November 1, 2007

Good Germs, Bad Germs

No, this is not a pun on the title of Gary Taubes' new book. It's the name of a completely different book which should be of great interest to anyone whose diabetes is autoimmune in origin.

Good Germs, Bad Germs: Health and Survival in a Bacterial World by Jessica Snyder Sachs, is an up-to-date summary of what we know about how bacteria interact with humans.

It's a fascinating story, because after a lifetime of "fighting germs" it seems that scientists are coming to learn that the interaction between bacteria and our bodies is far more complex than was ever realized and we have to work with germs and make alliances with "good germs" in order to survive.

Why this relates to diabetes is that the book starts out with several chapters that explore in greater detail than I've seen elsewhere, the research that has been establishing "The Hygiene Hypothesis." This is the idea that the huge rise in autoimmune disease we are currently experiencing is being caused by too much cleanliness.

It is starting to look like we are not being exposed to enough of the right bacteria very early in life or as we go through our daily lives, thanks to changes in water treatment, how we get our food, how we medicate illness, and how we clean our homes.

It turns out that our bodies are complex ecosystems in which maintaining populations of billions of bacteria of various kinds is essential for preserving our health, particularly in the digestive system, where, if our population of bacteria are killed off, the digestive system fails to function properly. Children absorb the good bacteria they need to have populating their own digestive tract from birth on. A caesarian birth, for example, results in a baby who is not exposed to the bacteria found in the mother's perineal area, which raises the risk of developing autoimmune problems like asthma and Type 1 diabetes.

Children who are given antibiotics early in life which kill off the developing populations of healthful bacteria also develop more autoimmune diseases, particularly asthma.

And all of us who drink filtered water (which the book mentions was not common until the last 25 years of the 20th century) and eat packaged, preservative-filled foods, may not be maintaining the colonies of soil and fecal bacteria which our bodies depend on to regulate our immune systems and fend off dangerous bacterial invaders.

An important point that Sach's raises in Good Germs, Bad Germs, is that while in the past many people, including those opposed to vaccination, have argued that exposure to disease is required for the development of a healthy immune systems this is not, in fact, true. More recent research suggests that it is not infection with disease that protects children. Disease, is NOT good for people.

What is good for people is acquiring populations of benign non-disease causing bacteria that live on skin, on mucous membranes, and within the digestive tract. This is because these populations of benign bacteria do two things. One is that they fill up the ecological niche your body represents, making no room for the more dangerous bacteria which cause disease to move in.

The other, which is just starting to be understood, is that by their very presence, these benign bacteria send out biochemical signals that cause the immune system to respond by developing what is called "tolerance"--i.e. turning down the immune system. It is this tolerance that turns off the inappropriate immune attacks that cause asthma, diabetes, multiple sclerosis, etc. When the body is not populated by the bacteria it expects to meet, it does not develop tolerance, and instead seems to go on high alert, and unfortunately, this leads it to attack things like peanuts and pancreases.

Another interesting finding is that having the right bacteria established in your body causes changes in the cytokine mix which affect your mood. Sachs describes some research that finds that when levels of Interleukin-10, a cytokine that is secreted when tolerance develops, rise, serotonin levels surge too. The implication here is that the depression that is associated with autoimmune disease may not be psychological. Yes, it is a bummer having to deal with diabetes, but it may FEEL like a bummer because of the lack of calming chemicals in the brain.

This reminded me of one of the oddities of tuberculosis in the 19th century, which is that its victims were always described as being bizarrely cheerful especially as their condition worsened. One wonders if perhaps this had something to do with their immune systems having developed too much tolerance and pumping out serotonin happy juice. The book mentions that this kind of inappropriate tolerance can develop in the presence of some kinds of chronic infections that the immune system cannot take care of.

The good news reported in this book is that there are people working on using carefully cultured populations of benign bacteria to modulate the immune system. The bad news is that it turns out that bacteria can trade just about any trait you can think of with each other, particularly resistance to any antibiotic ever made, and they do it across species lines and very, very fast. A bad bug you pick up on your spinach can pick up a drug resistance gene from a "good" bacteria in your gut in the 3 hours it takes to hit your lower intestine.

This means that the most "healthful" bacteria in the world can go bad if you already have drug resistant bacteria haunting your gut. And unfortunately, most of us do. Much of the rest of the book is taken up with discussing the problems caused by the drug resistant bacteria that now fill our world.

One huge reason for the unstoppable growth of MRSA and other bacteria that do not respond to antibiotics is the overuse of antibiotics in animal feed. It turns out that the problem is not just residues that you might eat. The problem is that resistance genes that develop in livestock pass into the ground and get out into the world where the promiscuous bacteria trade them around continually. You don't need to eat meat to get bacteria in your gut that are resistant to antibiotics used only in cattle.

Another problem is the use of antibacterial soaps which kill off the friendly bacteria in our homes and leave a nice, big empty place for baddies to grow. Sachs compares cleaning your cutting board with antibiotic soap to nuking your lawn with Roundup without reseeding it, which ensures that you will end up ONLY with clumps of crabgrass and weeds.

There's lots more in this book that you should read if you are concerned about MRSA or worry about infection--a huge issue for anyone whose diabetes is not in excellent control.

For those of you who won't get around to reading it, here are a few "takeaway messages."

1. If you are serious about preventing autoimmune disease don't overprotect your baby from dirt. Throw out the antibacterial soaps. Let your kids get dirty. Let them play with the dog. Let them help diaper the baby. Eat fresh vegetables from local farms where possible.

2. Do not give your children antibiotics for viral diseases. If you do need an antibiotic, try to get the doctor to do a culture first so that the doctor prescribes a drug that is limited to attacking the kind of infection you have, rather than the "broad spectrum" antibiotics that also wipe out the bugs that are teaching your kids' immune system how to play nice.

3. Some autoimmune disease is caused by genetic flaws in the mechanisms that the body uses to develop tolerance. If that is the case, no amount of exposure to healthful bacteria will help. This may be what is going on in families that have long histories of autoimmune disease going back generations.

4. MRSA (antibiotic resistant staph) is probably the biggest health risk we all face. It is a direct result of the overuse of antibiotics in both hospitals and in animal feed. There is no easy solution to this problem. It is a huge killer of people who go to hospitals for other causes. It also produces a pneumonia that can be fatal very quickly, often in young people. Unfortunately, the U.S., alone in the Western World has no organized system for tracking hospital borne infections. So you will not know when there is an epidemic of MRSA in your local hospital. In fact, doctors at the hospital across town may not know about it.

5. If you have diabetes, the best thing you can do is avoid getting infections by keeping your blood sugar normal. People with diabetes who have high blood sugars are more prone to drug resistant infections than the rest of the population. These infections are a huge cause of amputation. Because drug resistant infections once established can be impossible to fight, take any infection no matter how small very seriously. If you are a diabetic with an A1c over 6.5% and your doctor does not treat a foot infection as an emergency, find another doctor who will.