August 28, 2008

Why This Election Matters to People With Diabetes

The media are touting the "good" news that the rate of uninsured in this country dropped to "only" 47.7 million people.

I don't know about you, but 47,700,000 people looks like a lot of folks to me. Especially when you realize that many of them are the people who most need health coverage--people in their 40s who have lost good professional jobs and may never find anything but part time work without benefits, people who because they have a preexisting condition, like cancer, or asthma cannot buy health insurance no matter how much money they have. And, of course, many, many people with diabetes.

There are heartrending stories all over the blogs of people with diabetes who have lost their jobs and with it not only their health insurance but their ability to buy health insurance on their own. I get mail from Type 1s who cannot afford test strips. I get mail from Type 1s who have to choose between insulin or being homeless.

There is a feeble so-called "safety net" in our system, but what most people don't realize until they lose a job is that if you own any assets--a college fund for your child, a home, the savings you have accumulated to tide you over until you find that next job, you won't qualify for that safety net. If you have any equity in your home or any savings, if you have a health crisis without insurance you are SOL.

The system we have in the U.S. today expects you to spend every dollar you have on your health expenses before it will offer you any help. Then, to add to the unfairness of the system, drug companies and hospitals charge FAR MORE to people without insurance for every prescription, treatment, hospitalization, and doctor's visit than they charge to those with insurance.

The insurers can bargain down the price of test strips. The day you lose your insurance, you will pay the full $103/100. Insurers have certain insulins they will pay for at a lower copay because they have negotiated discounts with the pharmaceutical companies. But if you are paying for that same insulin they pay $50 for, you will pay $83. It's the same for all the rest of your prescriptions.

Conditions are not all that much better for many people who technically HAVE insurance and don't show up in that 47.7 million "unemployed" figure. Over the past 8 years, insurance plans have cut back drastically on what they will cover while raising the copays for everything. Where I used to pay $5 for each prescription, I now pay a $50 for each vial of insulin I buy. Where a doctor appointment with my PCP used to be free and then rose to $5 it is now $20. Lab tests used to be fully covered. Now there is a $500 copay before my insurer will pay for a single lab test. And that is after I pay a monthly insurance premium that is a lot more than I used to pay for monthly rent when I was in my 30s.

Still, I am one of the very lucky ones. I can buy health insurance despite a diabetes diagnosis, because I live in the great state of Massachusetts where Liberals have made it against the law to refuse insurance to anyone because they have a pre-existing condition and where a liberal legislature, disgusted with our Federal government's refusal to do anything about health care, passed a landmark law two years ago (despite then-Governor Romney's opposition to it) that offered coverage to all and dramatically raised the number of insured in our state. We could all do with a bit more of that kind of liberalism. Texas, that bastion of conservatism,, now has the highest rate of people without health insurance of any state in the union.

And that is why this election matters.

The Republicans will tell you they are going to do something about health care. But they had complete control of congress, the White House and the courts for six year, and throughout that period they did nothing about changing the way our health care system works except to attempt to ban the import of cheaper pharmaceutical drugs from Canada and to set up a Medicare drug benefit for the elderly that explicitly banned Medicare from negotiating with drug companies for better prices. Their plan was a huge gift to the pharmaceutical companies and big insurers. It was a tragic rip off of America's older population.

The Republicans appointed people to the FDA who had contempt for science and used ideology to approve or disapprove drugs. FDA leaders with strong financial ties to the drug companies repeatedly approved dangerous drugs over the protests of the experts whose advice they are supposed to rely on. Throughout the years of Republican rule, drug company lobbyists have gotten everything they have asked for. The American people, well, they get what trickles down. [Supply your own barnyard image here.]

Wrapping themselves in the banner of "religions faith" the Republicans have done all they could to block the stem cell research that could lead to Type 1 diabetes cures. They have cut way back on all funding for the basic research that might heal all of us.

So they've had their chance. The Republicans will make the usual election year promises but over the past eight years they've shown you what their priorities are and whose bidding they will serve if they get back into power.

And because they can't point to their record, or offer you a real health plan solution, their current campaign relies not on ads that explain their positions to your or describe the policies they will follow. Instead they are trying to distract your from the real issues at stake in this election by bombarding you with smear ads, silly insult ads, and downright lie ads, intended to work on your emotions, frighten you, and to making sure nothing really changes.

The Democrats have tried. Sixteen years ago, they tried to do something about our health care system. But the Republicans came up with the Harry and Louise scare ads and we squandered that golden opportunity.

Well, the chances are good that Louise has Type 2 now, but can't afford test strips. Harry's probably working part time at Home Depot and has no health insurance. Neither has seen a doctor in two years because they can't afford to.

And how about you? Is your health care better now than it was in 1992? Could you have been worse off under "socialized medicine?" Health care in American now costs more than health care anywhere else in the world while the health of our population as a whole is far worse than that of people in other industrialized nations.

I'm ready for a change. I may not agree with all the policies the Democrats will put in place, but I know they are going to give it a hell of a try--which will be a lot easier to pull off if you also elect Democratic Senators and Representatives. And I know for a fact based on the last eight years that four more years of Republican rule is a huge "risk factor" for bad health consequences for all of us.

August 26, 2008

The Silver Lining on the Heart Disease/Diabetes Connection

A report about a newly released study, clearly meant to terrify us,is headlined, "Heart Disease Soars to 90% with Obesity."

But before you reach for the Prozac, take a look at the details of actual finding:

"...women who were obese and diabetic had a nearly 80 percent chance of developing heart disease at some point. For their male counterparts, that figure was nearly 90 percent.

"Lifetime risk was based on the likelihood that a 50-year-old would develop heart disease in the next 30 years."

This sounds terrible if you believe that the alternative to developing heart disease by age 80 is living forever in perfect health.

Unfortunately, it isn't. Though the supplement industry would like you to believe that consuming their pills will make you live forever, and the diet & exercise industries want you to think that losing weight and keeping fit will keep you in perfect health to age 120, all the research about longevity suggests that unless you have been fortunate enough to inherit a couple of very powerful genes, by the time you hit 80, it is almost certain you will have something serious wrong with you.

And if it isn't heart disease, it is likely to be cancer, painful arthritis, a neurological disease like Parkinsons, brittle bones, or dementia.

Dr. Barzilai's ongoing research about centenarians found that a handful of genes appear to determine who lives very long, not lifestyle choices. Analyzing his data about his centenarians, he found that fully 30% of them were obese in their 50s. He also has found no vegetarians among his survivors. My dad, who was one Dr. Barzilai's centenarians, smoked cigars and pipes until he was 98.

But most people do not have these genes, and with every passing year as they age their chances of developing some disorder goes up.

Cancer is the disorder they are most likely to contract, and what most people don't know, but I have seen happen first hand, is that any adult who has chemotherapy after age 70 is very likely to develop dementia as a result of that chemotherapy, even if it "cures" the cancer. The "chemo brain" that younger women suffer after breast cancer--which doctors denied for many years was real, but which has recently been substantiated--is devastating to older people, no matter how healthy they were before chemo.

If you don't develop cancer, you have a good chance of having a stroke. In fact, stroke develops more frequently than heart disease in thin people and results in horrible, permanent changes ranging from "locked in syndrome" to paralysis, to inability to speak, to severe mobility impairment. Strokes may be influenced by lifestyle factors, but they also occur in people who do everything right. As the vascular system ages blood vessels become more fragile.

If you don't have a stroke, there is Parkinsons, the cause of which which no one is quite sure of, but which is common among older people. Or COPD, which though most common in smokers, also occurs in people who breath polluted city air too long.

Avoid that, and there are a whole menu of Dementias to chose from starting with Lewy Body, moving on to Alzheimers, and concluding with Vascular Dementia which like stroke appears to be the result of fragile blood vessels in the brain giving out. Though there is much speculation about what causes dementia, more honest doctors will tell you that the single greatest "risk factor" for dementia is living to be over 80.

And if you should be lucky enough to keep your mind intact to 80, there are still dozens of other metabolic breakdowns waiting for you. Kidney disease, liver disease, malnutrition syndromes, and of course, brittle bones which along with falls are the most common killers of otherwise healthy old people.

Our bodies wear out. All of them. Even if we eat "right", exercise, and pray to powerful deities.

So this is why though I have seen much to worry me about getting older--and I speak as someone in her early 60s who has watched an entire generation of family and friends age--heart attack looks to be a swift and merciful end, and one that I would gladly choose if the alternatives to it would be the prolonged agony of a death by a cancer that has metastasized to the bones or years of the humiliating confusion, dependence and deterioration that are dementia.

To me, the really scary thing about diabetes, is not that it causes heart disease--especially in people in the latter part of life. It is that it causes blindness, kidney failure, and amputation in people who are relatively young. And that even before we get these terrible complications, uncontrolled diabetic blood sugars cause exhaustion, depression, and a generalized feeling of malaise that can rob life of much of its brightness.

The research data is confusing about whether blood sugar control can prevent heart disease, but it is crystal clear on the subject of whether tight control can prevent these other, more clearly diabetic complications. Blindness, kidney failure and amputation can all be prevented by bringing our blood sugars down to levels that do not require monk-like abstinence to achieve.

It is possible, too, that lowering blood sugars to normal may prevent heart attacks at a relatively young age. (The definition of "young" of course, changes with each passing decade that we age. 50 is looking pretty young to me of late.)

But every now and then, it is a good idea to stop and to contemplate the truth of our existence--that we all do have a limited lifespan and that each of our lives will end some day--and that "some day" may be closer than we think.

Ask yourself: Are you living in a way where you would be happy with what you have done with your life, should it end this week? Have you deferred too much of what you dreamed of doing to a "someday" that may never come?

I find it very helpful to do a life review every few years and to ask myself these questions in a probing and honest way. I have done my best to live so that I like the answers I come up with. I control my blood sugars and do what I can to stay in good shape, but when confronted with the fact that I am going to die someday, I continue to hope that when my time comes it will be swift and merciful, not painful and prolonged. And because of that, though there is much about aging that does worry me, heart disease is very low on my own personal list of worries.

August 21, 2008

Getting Fat? Maybe it is the Hidden MSG in Your Food

Scientists already knew that adding MSG (monsodium glutamate) to their feed causes weight gain in rodents. Now an interesting study done by scientists at the University of North Carolina quantifies JUST how fat MSG makes humans. More importantly, it finds that the effect of dietary MSG on weight gain is independent of how much you eat or exercise.

The study uses an elegant design. As reported in this Science Daily article MSG Use Linked To Obesity, what the researchers did was this:

"Researchers at UNC and in China studied more than 750 Chinese men and women, aged between 40 and 59, in three rural villages in north and south China. The majority of study participants prepared their meals at home without commercially processed foods. About 82 percent of the participants used MSG in their food. Those users were divided into three groups, based on the amount of MSG they used. The third who used the most MSG were nearly three times more likely to be overweight than non-users."

This is a nice design because the study population was not eating a diet containing other food additives as their food was home cooked traditional fare. Chinese traditionally use MSG as a seasoning in their home cooking.

Later the article says:

" 'We found that prevalence of overweight was significantly higher in MSG users than in non-users,' He said. 'We saw this risk even when we controlled for physical activity, total calorie intake and other possible explanations for the difference in body mass. The positive associations between MSG intake and overweight were consistent with data from animal studies.' "

If you are thinking, "Well, that is all very nice, but I don't eat Chinese food and I avoid foods with MSG on the label," it's worth considering that MSG is hidden in many if not all of the boxed, canned, and frozen foods you buy in the grocery store, including may "diet" foods. This is because manufacturers know buyers don't want to buy foods with MSG on the label, so they use another ingredient name for the component in the food that carries the monsodium glutamate molecule.

MSG can be hidden, legally, being listed on a label as any of the following:

Textured protein
Hydrolyzed protein
Yeast extract
Glutamic acid
Calcium caseinate
Hydrolyzed corn gluten
Monopotassium glutamate
Sodium caseinate
Yeast nutrient
Yeast food
Autolyzed yeast
Natrium glutamate

Other ways of hiding MSG are to call it "natural flavoring." Anything that contains soy sauce contains MSG, too.

With this in mind, take a look at lists of ingredients found on the foods in your pantry and fridge. You may be surprised at how many of them contain some form of MSG. Looking around my pantry and fridge just now, I found MSG in two salad dressings, mustard, barbecue sauce, and chicken broth.

If you are having a problem controlling your weight or your hunger, eliminating all MSG from your diet might be worth a try.

August 20, 2008

Is Diabetes an Eating Disorder - Take Two

An alert reader commented that she had expected the previous post to be on a very different topic than the one it turned out to discuss. That's because we people with diabetes who care about our health are forced to develop what may look very much like obsessive behaviors to keep ourselves healthy.

So many people--including some doctors--believe that those of us who commit to getting normal blood sugars do it by developing an eating disorder.

The arguments for that interpretation are these: Like people with eating disorders we obsess over our food. We count the grams of carbohydrate in every serving. Some of us weigh our food on high tech scales. We measure our blood sugar after eating and if it isn't within range, we stop what we are doing and devote our entire attention to raising or lowering our blood sugar until it is. If our blood sugar is too high after a bout of careless eating, we may feel strong emotion--anger, fear, or self-condemnation for eating whatever it was that raised our blood sugar too high.

Superficially these behaviors do sound a lot like those of a person with an eating disorder. Except for one huge difference: An eating disorder is a behavior that makes our health worse. It is a dangerous behavior that, if it is not stopped, will lead to serious disability or even death. These outcomes are what first brought the major eating disorders, anorexia and bulimia, into the public consciousness thirty years ago.

But with diabetes, it is eating "normally" that leads to disability and death.

People with diabetes who embrace the idea that they have a "right" to eat like everyone else and who don't obsess about their food are likely to be running blood sugars many hundreds of mg/dls higher than normal for hours after each "normal" meal they eat. Over time those high blood sugars destroy their nerves, their retinas, their kidneys and their cardiac health.

People with diabetes who engage in the so-called "obsessive" behaviors described above, in contrast, maintain the normal blood sugars that provide them with normal health. Their A1cs are closer to 5% than to the 10% that is the typical A1c of most people with diabetes in America.

So you have to realize that what gets defined as "obsessional" has a lot to do with context. Is a person who washes their hands twenty-five times a day suffering from Obsessive Compulsive Disorder? Not if they are a physician whose work involves examining patients in a surgical unit. In that case, it would be a sign of significant mental illness not to wash hands before examining each new patient, because it has been proven through rigorous research that handwashing in the hospital is the single most powerful way of keeping patients from acquiring hospital borne infections.

I hope for a high level of "obsession" in the people who fly the jets I board and the people who work at my bank. If these people do not pay obsessive attention to details the rest of us might ignore, people will be harmed.

By the same token, the nutrient-counting behavior and restricted eating that might make us rightfully concerned when it is practiced by a thin 13 year old girl with no diagnosed health problems is cause for celebration in a 50 year old woman whose blood sugar rises to 300 mg/dl if she eats a single piece of cake.

If you are recently diagnosed with diabetes or if you have only recently started eating in a way that will normalize your blood sugars, be prepared to run into this issue with your family and friends, because when you begin to adopt the behaviors that are necessary to control blood sugar some of them may respond to these new behaviors with concern.

They may think it excessive for you to test your blood sugar once or even twice after a meals or before you start driving your car. They may feel uncomfortable if you interrogate a waitress about exactly what ingredients are going to be in a dish you are ordering, of if you have a fit when the diet soda you ordered turns out to be a sugary regular.

Instead of supporting you they may respond by telling you to ease up. Chances are they do this because to them these behaviors may look obsessive. Your friends and family care enough about you to want to protect you from developing a true mental disorder.

But in this case, their concern is misplaced. The people they should be worrying about are the people with diabetes who are eating "normally," who are not testing, who have no idea how much carbohydrate is in the portions of food they eat--people who are not doing anything but taking the inadequate drugs their doctors prescribe for them and who have no idea what their blood sugars are most of the time--people who have no idea what will happen to them if they don't keep their blood sugars beneath the level that causes complications.

So if someone close to you suggests, "Why not just forget all of that and just enjoy your dinner?" take it as an expression of love or concern. But then explain that you want to enjoy a lot more dinners--and that you enjoy your food best when you can see it and when you are able to walk away from the table on both feet. Let them know that the key to avoiding the most common diabetic complications is to keep blood sugar under 140 mg/dl at all times and even lower if possible.

Yes, it sucks that we people with diabetes have to pay so much attention to what we eat. All of us would love to be able to eat normally. But we can't. We got dealt this body and we have to live with it. We get no choice about that. The choice that is left to us is whether we want to just stay people with diabetes or if we want to become people with diabetic complications.

And if you choose to stay a person without diabetic complications, you need to put your eating into "order" and doing that requires giving unflagging attention to everything that you eat. To keep yourself healthy, in short, you must adopt intensive behaviors which have the opposite effect of harmful eating disorders.

August 18, 2008

Is Diabetes an Eating Disorder?

I have been watching the Amazon "Diabetes" bestseller list for the past couple months, tracking how well my book has been doing--which is a lot better than I'd been hoping it would do. Thanks folks!

In the process, I've noticed something very troubling. One out of three books on the Amazon "Diabetes" bestseller list is a book about eating disorders. The people who designed Amazon clearly believe that diabetes is caused by overeating caused by emotional problems. Top books on the "Diabetes" bestseller list include Breaking Free from Emotional Eating (#2 on the Diabetes list last time I checked) or "Shrink Yourself: Break Free from Emotional Eating Forever (#6).

This is not a trivial issue. Many people will check out top selling "Diabetes" books immediately after a diagnosis. Will they buy a book that teaches them what they need to know to prevent complications or will they buy a book that blames their emotional problems for their diabetes and perhaps even urges them to start taking an antidepressant medication to "treat" their emotional problems--despite the fact that many of these antidepressants are very well known to contribute to cause weight gain and increase the insulin resistance that promotes Type 2 diabetes?

My very strong belief is that the hunger and weight gain suffered by people with Diabetes has nothing to do with "emotional eating" and everything to do with what happens when glucose metabolism is disordered. Hunger is usually a symptom that blood sugars are rising too high, which is why so many people are shocked to discover that their "emotional eating" disappears when they cut the sugars and starches out of their diets.

But if a person recently diagnosed with diabetes is not taught that there is an intimate connection between carbohydrates, blood sugar level, and hunger--and most still are not--they won't learn what they need to know to control their eating. If their doctor tells them to lose weight and eat a "healthy diet" they are very likely to fall for the myth that eating fat is dangerous and that only a high carbohydrate, low fat diet is "healthy."

After a week or two of eating whole wheat bread, pasta and bananas--which is what the folder my doctor gave me three years ago told me I should eat as a "healthy diabetic diet"--they will be hungrier than before, no thinner, and convinced that their "emotional eating" is impossible to control. The next step after this is hopelessness, quitting, and a life shortened by the inevitable diabetic complications caused by high blood sugars.

This is so unnecessary!

Beyond that, there is another huge problem with treating diabetes as an eating disorder. If you believe that diabetes is an eating disorder, you undoubtedly also believe that people with diabetes are to BLAME for their diabetes: that they have caused their diabetes through reckless eating.

This belief, which is not backed up by any science, is continually hammered home by the media. It causes shame in people with diabetes who often are obese because of the underlying condition causing their diabetes, rather than diabetic because of their obesity. This shame gets in the way of doing what needs to be done to achieve normal health.

If you still believe that people with diabetes cause their diabetes through their eating patterns, please read this summary of what a lot of high quality research has found about the true causes of diabetes:

You Did Not Eat Your Way To Diabetes.

After you have read it, consider emailing Amazon and asking them to remove books about eating disorders from their "Diabetes" bestseller list. Point out that there are NO books about diabetes on Amazon's "Eating Disorder" bestseller list, though undiagnosed diabetes is a major cause of the raging hunger that leads to the uncontrolled eating that is now diagnosed as "eating disorder" and attributed to emotional rather than physiological causes.

By putting these eating disorder books on their Diabetes list Amazon is making a medical judgment about diabetes--that it is caused by emotional problems--a diagnosis that is not supported by science. To do this is as valid--and as offensive--as putting books about demon possession in the bestseller list for mental illness.

To complain to Amazon use this link: (You will have to sign in.)

I have already written to them and got a personal response, but no action. Perhaps if Amazon hears from a couple hundred people they'll reconsider this policy. It is hurting people, especially those newly diagnosed, by giving them the false message that diabetes is caused by untreated mental illness.

August 15, 2008

What did that blood sugar test mean?

There's an interesting study that was reported on Science News today which illuminates the very poor way in which doctors communicate the results of medical testing to their patients.

Wide Variety Of Errors Found In Testing Process At Family Medicine Clinics.

What this study found was that "...medical testing errors led to lost time, lost money, delays in care, and pain and suffering for patients, with adverse consequences affecting minority patients far more often. ...The most common errors involved failure to report results to the clinician, accounting for one out of four (24.6%) reported mistakes. Test implementation (17.9%)[i.e. people not getting the test that was ordered] and administrative errors (17.6%) were the next most common. ...A quarter of the errors resulted in delays in care for patients, and 13 percent caused pain, suffering or a definite adverse clinical consequence. Eighteen percent resulted in harm."

This really leapt out at me because I've been hearing from a lot of people whose emails bring to life what these kinds of testing errors really mean for people with diabetes.

Typically the person who is experiencing what sound very much like diabetes symptoms will write, "The doctor gave me a blood test but I didn't hear anything back, so I figured it was okay."

As this study shows--and as I have experienced in my one case--not hearing from your doctor often does not mean that the test was fine. It means that the result never got to your doctor.

Today's doctors' overworked staff do not have the time to double check that a lab test that was ordered came through from the lab. As this study shows about one in four tests never get reported by the lab at all. And whether the report gets through or not has nothing to do with whether the results was normal or not.

So if you were tested for diabetes, and don't hear from your doctor, you need to demand that your doctor's office sends you a copy of the lab result. It is only when they go looking for your lab test that the staff will discover they don't have a copy.

But the problems with lab tests go beyond this. Even if the doctor says, "your test came back fine" you STILL need to demand a copy of the lab results. Why? Because of what this study calls "Administrative errors."

What this means is that when the test comes in to your doctor's office some LPN whose total medical training was a one year certification course at a Junior College looks at the lab sheet and unless something is flagged "abnormal" puts the test into your folder or adds it to the pile of unimportant stuff the doctor doesn't have to look at unless he has nothing else to do.

If you call to ask about the result of this test that was not flagged abnormal, the LPN "Nurse" will tell you it was "fine." But often with diabetes blood tests, the word "Fine" can hide a world of hurt.

Consider the fasting blood glucose test that comes in at 124 mg/dl. This is officially "not diabetes." The ADA defines a diabetic fasting blood sugar as being over 125 mg/dl. So there are, sad to say, LPNS and even doctors who will tell you that you don't have diabetes when you have a fasting blood sugar of 124 mg/dl.

Yes, I know it is crazy. But it happens, though any rational person can see right away that a blood sugar of 124 mg/dl is so close to 126 mg/dl as makes no real difference. Test two days earlier or later and you might very well have seen a fasting blood sugar of 127 mg/dl or more.

By the same token, a lot of family doctors still consider "pre-diabetes" to be a fad diagnosis and will not even mention to you that you have pre-diabetes when your fasting blood sugar is over 100 mg/dl.

This is a huge problem because a lot of research has made it crystal clear that the fasting blood sugar test remains near normal in many people with Type 2 diabetes, until several years after their post-meal blood sugar is going up over 200 mg/dl after every meal. And other research is finding that into a whole slew of diabetic complications from heart disease to nerve damage to early retinal changes leading to blindness begin to occur when these post-meal blood sugars are high, long before the fasting blood sugar is high enough to earn you a diabetes diagnosis.

If you are already diabetic and doctor does an A1c test to check on how your blood sugar is doing, you may also be told you are "fine" when your A1c is hovering around 7.0%. Again, that's because of the way labs report the A1c result.

My lab--at the county hospital--lists an A1c of 6.0 to 6.9% as "VERY GOOD". It lists the A1c of 7.0% to 7.9% as "GOOD." If your doctor mails you a postcard that says "your A1c test result was good" you really need to call up and ask them to mail you a copy of the actual test result, because if that "good" A1c turns out to have been 7.9% it is high enough that you have a thee and a half times higher risk of having a heart attack or stroke than you would have had if your A1c had been between 5.0% and 6.0%. That doesn't sound good to me at all.

In today's environment of PCP doctors who have so many patients they can't remember who you are or what treatment they prescribed for you the last time you visited, you can't assume that the doctor ever saw your lab result unless it was highly abnormal.

Even worse, if you change doctors, don't assume that your old lab results will be forwarded with your "medical records" to your new doctor. Often they are not. Labs often don't keep copies of your old tests for more than a year or two, either.

That's why it is a very good idea to get a copy of every lab test you ever have had done and keep it with your important personal records. Often the real meaning of a medical test does not become crystal clear for a few years, because it is part of a developing pattern. Without previous lab results it is hard for a doctor to know if a borderline finding is significant or not. And in today's world of sloppy medical care, those past lab results may no longer be available.

Your lab results are yours and you have a right to a copy of every lab result you or your insurance has every paid for. When you go in for a lab test, ask exactly what you have to do to get a copy of your test result. Sometimes you will have to fill in special forms. Other times you will have to fax a letter to some functionary. Whatever it takes do it. Get a copy of your labs and if they are blood tests, call on the very helpful people involved in the online diabetes community to help you understand what they mean.

You can find help understanding your test results by posting messages at, and

BOTTOM LINE: If you have a test, find out what the result was, learn what you can about what the test result numbers mean, and make sure your doctor spends the time to interpret the test appropriately. Especially if it is a blood test that relates to diabetes.

August 14, 2008

Why I LOVE Apidra

Apidra is the brand name of yet another fast acting insulin. Its generic name is "insulin glulisine" and that is the name you will see it referred to in medical research studies.

I had been doing quite well with Novolog, but was curious to try Apidra as I had heard it was even faster and more physiological in the way it acted than Novolog. So at my last endocrinologist appointment I asked the doctor about it and she offered me a free sample.

The sample came in the form of a cartridge which had to be inserted in the Opticlick pen. At first I did not think I was going to like it. The Opticlick pen is reusable and is more bulky than the disposable Novolog pens I was used to. It comes in a case that looks like an eyeglass case and barely fits in my purse.

The Opticlick pen also features some electronics that keep track of the dose and the instructions say that if you put it in the fridge that will ruin the pen. Since I have always kept my pens in the fridge to preserve the potency of the insulin and we were headed into summer--the time of year when I traditionally cook a pen or two just walking around with it in my purse on a hot day--I figured my Apidra trial would be short.

Was I wrong! The Apidra cartridge I opened on April 11 dispensed its last unit last week.

The extra long life was due to two factors. The first is that I was eating extremely low carb 2 of the past 4 months at the urging of my surgeon, and when I eat less than ten grams of carbs per meal I only need to use my Levemir.

The other reason was that the Opticlick pen only requires that you shoot one unit to prime the pen, rather than the two units you have to shoot to prime the Novolog pen. When your usual dose is two units, as mine is, having to waste two units every time you take a shot makes the insulin disappear pretty quickly. (My carb insulin ratio right now when I am also injecting Levemir is 1 unit to 20 grams of carbs.)

The last few units of Apidra I injected were just as powerful as the ones I shot the first day I tried it. When I opened a new cartridge I was able to keep using the identical dose to cover the same amount of carbs, which is proof that there was no gradual fade with the previous cartridge. And that was true despite the fact that the Opticlick pen has been sitting in an un-airconditioned kitchen cabinet for the past 4 months--when it hasn't been traveling to restaurants on hot summer days in my purse.

This stuff is ROBUST!

But that's only the beginning of why I love this insulin. The other reason is its activity curve. Now please note, various insulins may perform differently in different people's bodies, so my results might not be your results. But my experience with Apidra is that if I inject it right before my first bite it covers fast carbs perfectly.

What do I mean by perfectly? I mean that if I cover an ear of fresh picked sweet corn with 1 unit right before my first bite, at 1 hour I am at 104 mg/dl and I'm back in the 90s at 2 hours. Since at 2 hours it has just about stopped working, I do not see delayed hypos when I get those good numbers at one hour.

The only potential downside with this kind of activity curve is that if you are eating really slow carbs you may have to split your doses for the meal and inject a second dose at 1 or 2 hours after eating. Otherwise the insulin may peak before your food is digested. I have mainly seen this happen with a slice of pizza eaten with the whole crust and a enchiladas/bean dinner.

But it's a lot better to have to give yourself a booster shot at one hour than to reach that one hour with your blood sugar unacceptably high, or to have to wait for a half an hour after you inject before you can start eating.

I had been concerned because I'd read that if something happens to the Opticlick pen the only place you can get a new one is from the endocrinologist. They aren't sold at pharmacies. But so far this hasn't been a problem. My pen is still working well.

What I really love about the pen is that it has an LCD display that retains the number of units you have injected. So if you are scatterbrained like I am, and inject without giving the dose quite as much attention as you should have, you can look at the pen and for a few minutes it still displays what dose you injected. That's very helpful.

It turns out that the company that makes Apidra (which is the same company that makes Lantus)is going to be selling Apidra in the Solostar disposable pen. They already have switched to selling Apidra in Solostar pens in Europe. That will make Apidra more competitive with Novolog and Humalog which both come in disposable pens. No one can tell me when this will actually happen, but supposedly it is scheduled for sometime in 2008.

I have tried the Solostar pen as my doctor gave me a Lantus Solostar sample last fall when they came out. It is pretty much identical to the Novolog pens and does not track the dose used. Unfortunately, the Solostar requires you to use 2 units to prime the pen, unlike the Opticlick which only uses one. This means the pens will not be lasting anywhere near as long for me. When I am not low carbing my Novolog pens usually last six weeks to two months--if I don't cook them first, a big IF.

I'm told a lot of pump users use Apidra, which given how stable and fast acting it is makes a lot of sense. But if you inject fast acting insulin and are still seeing highs at one hour, you might want to ask your doctor about trying this newer insulin and seeing how it works for you.

If you do test it, start with a low dose and expect it to work faster than the insulins you are used to.

August 11, 2008

Strange Readings? Check Your Meter Battery

They say a man with two watches never knows what time it is. If you have two meters you may sometimes feel the same way about your blood sugar readings.

This past weekend I was seeing some really odd readings with my usual Ultra 2 meter--I was low carbing and using my usual dose Levemir but my fasting blood sugar was much higher than what I expected to see--113 mg/dl rather than low 90s or 80s.

Then I remembered something: when I had been out on a long walk the previous day and tested my blood sugar with the Ultra I keep in my purse, it had been 80 mg/d, but when I tested at home a few hours later without eating anything, it was back into the low 100s.

Finally I got the bright idea of testing my blood sugar simultaneously on both meters, and yes. The Ultra 2 was reading 113 and the purse Ultra read 90. In the past when I have tested the same draw on both meters they have matched within 3 mg/dl.

I did a control solution test (though I have NEVER yet had a control solution test identify a faulty meter, even when the meter has been found to test 50 mg/dl higher than a lab reading.) The control solution test showed the one meter reading considerably lower than the other when tested with the test solution, but both meter readings were within the ridiculously wide range supplied by the meter manufacturer.

Then I remembered that I had read somewhere that a battery is only good for about 1000 readings. Since I test about 5 times a day, that is not even a year's worth of tests. So before I went out to get a new meter and then had to wait months for the rebates involved, I figured it would be worth investing $2.49 in a new battery to see if it made any difference.

I installed the new battery and tested again. This time my two meters matched within 1 mg/dl. And they matched at the low reading, not that baffling high reading.

Problem solved.

But once again I was disgusted at this latest proof of how poorly designed these meters are. The weak battery had caused my meter to read 24% higher than it should have read, but there was no "low battery" message on my meter though the manual tells me there should be one when the battery is running low. I had definitely run more than 1,000 tests on this meter, but obviously the meter will continue to provide test results--erroneous test results--long after that number of readings has been exceeded.

Even worse, had I not had a second meter with a newer battery, I would not have discovered this problem and I might have ended up using too much insulin as I tried to get my fasting blood sugar down from the "high" of 113 to the normal middle 80s range I shoot for. Since my 113 really was 90, lowering my fasting blood sugar by another 20 mg/dl would have put me at risk of hypoing.

From past experience, I know that calling the meter company to complain would have only resulted in the phone-clone demanding that I do a control solution test and when the value fell within the 35 mg/dl wide range given on the vial of strips, they would have told me there was no problem.

But if there is a 35 mg/dl difference between what your meter says your fasting blood sugar is, and what it really is, there IS a serious problem. Not to mention the 7 expensive expensive strips I wasted on debugging this latest problem.

In a world where every other piece of electronic technology drops in price every three months, and where one out of every U.S. four adults over age 50 has diabetes and is hence a customer for the blood sugar meter companies, there is no excuse for the combination of poor performance and rising prices we continue to experience with these meters.

The meter is the single most powerful tool we have at our disposal to help us for achieve normal blood sugars. Isn't it time to demand that they work properly and that the companies charge a fair price for the strips?

August 6, 2008

More Evidence That Weight Loss After 65 is Dangerous To Your Health

We already knew from analysis of NHANES data that after age 70 any weight loss, including weight loss from intentional dieting, correlates with a higher risk of death. This was true even when controlling for the presence of diseases that might have caused weight loss like cancer. You can review some of the research that established this in this earlier blog post: Overweight is Healthiest Weight.

Now an intriguing finding about the hormone adiponectin may hint at why this is. The study is described in this week's issue of Diabetes in Control. Read the summary here:

Adiponectin May Increase Risk of Heart Attack.

Diabetes in Control's article reports: "This study examined a sample of 1,386 participants of the population-based Cardiovascular Health Study from 1992 to 2001. Participants consisted of adults aged 65 to 100 years and were recruited from four field centers in the United States. Subjects underwent physical examinations and laboratory testing. Of these participants, 604 experienced a heart disease event. Those with the highest levels of adiponectin were most likely to suffer a heart attack."

The kicker is this: Weight loss causes adiponectin to rise.

The researchers from this study speculate that "higher adiponectin concentration may reflect underlying disease processes in the body, or even have direct harmful effects, which may be amplified in the elderly. Adiponectin has been shown to increase energy expenditure through direct actions in the central nervous system in mice, and if this effect were also present in humans, it could be significantly harmful in older adults by accelerating the loss of skeletal muscle, a condition called sarcopenia."

Given that repeated analysis of the huge volume of NHANES research found a similar increase in death with weight loss even when people's underlying health conditions were screened out, I doubt that underlying conditions are the explanation for the correlation here. Indeed, there may very well be a reason why our bodies start to pack on weight at middle age and that reason may be that the fat we pack on helps keep us alive.

It is worth noting, again, that despite all the demonization of obesity in the media, Dr. Nir Barzilai's research about people who lived to be 100 years old or older found that fully one third of them were obese in their 50s.

So what does this latest finding mean for you? My guess is that it means that the best time to work on your weight is long before you hit your 60s. From then on your focus should be on blood sugar control and that your dieting efforts should be directed to maintaining your current weight rather than losing weight.

Certainly the body helps us out on this one. It gets tougher and tougher to drop a pound with each passing year and just maintaining our weight may take more self-restraint than we expended dropping 30 lbs in our 30s.

Vanity fanned by a media culture that makes people believe that we all should have bodies like liposuctioned, breast-augmented 20-year-old actresses makes it very hard to accept the idea that a healthy older person is a plumper older person.

Perhaps the next radical step the Baby Boom generation will have to take is to publicly challenge the fat-phobic media culture and start demanding that health authorities tell the truth about the relationship of weight and health in older people. That truth is simple: LOSING WEIGHT KILLS OLDER FOLKS.

Ignore it at your peril.

August 4, 2008

C-Peptide and Your Nerves

When a beta cell synthesizes insulin it creates a substance called "proinsulin" which splits into the actual insulin molecule and another substance--a chain of proteins called C-peptide. Details of this process are described in this Wikipedia article:

Most of us learn about C-peptide because testing its concentration in our blood is useful for determining if a person's beta cells are making insulin. This is especially true if a person is injecting insulin. That is because injected insulin only contains the actual insulin molecule not C-peptide. So the only way you get C-peptide in your blood is if your beta cells are making proinsulin, which then is presumed to turn into insulin.

For years C-peptide was considered to be inert, but it now turns out that C-peptide may play an important role in our body. There is some evidence that it is actively involved in the processes that fight oxidation in our blood vessels. This is important because damage to our blood vessels is what causes neuropathy. When tiny capillaries are damaged they do not supply blood to our nerves. Damage to blood vessels also leads to kidney damage.

A recently published study found one mechanism which may explain the effects of C-peptide on blood vessels. You can read the abstract HERE:

Human C-peptide antagonises high glucose-induced endothelial dysfunction through the nuclear factor-κB pathway

How important this could be is suggested by a very small controlled study where for three months human C-peptide was injected in people with Type 1 diabetes who produce no C-peptide of their own. Improvements were seen in neuropathy and kidney function in the group who received the C-peptide.

Beneficial effects of C-peptide on incipient nephropathy and neuropathy in patients with Type 1 diabetes mellitus

Another very similar study that lasted 6 months found a similar effect on nerves:

C-Peptide Replacement Therapy and Sensory Nerve Function in Type 1 Diabetic Neuropathy

It is important to understand that the process by which synthetic insulin is manufactured never produces C-peptide. There is a false belief floating around the internet that insulin manufacturers "throw out" the C-peptide. In fact, what they do is get genetically modified microbes to spit out copies of the final insulin molecule. Pro-insulin is never produced in the insulin manufacturing process. Pro-insulin was present in the old animal insulins but the process of purifying those animal insulins which was necessary to eliminate substances that caused serious allergic reactions in some people also eliminated the C-peptide, so you will not find C-peptide in any animal insulins sold today as they too contain only the actual insulin molecule.

The good news for those of us who are lacking C-peptide is that it appears that drug companies are working on producing synthetic C-peptide. If the initial, admittedly very small scale, research on the ability of C-peptide to prevent complications holds up, in a few years you might be able to inject synthetic C-peptide and lower your chances of developing microvascular complications.

But that said, it is very important to realize that there is just as much--if not more--research that suggests that you can also reverse and prevent microvascular complications by keeping your blood sugar within truly normal limits, and avoiding highs that go over 140 mg/dl for any significant amount of time. That level appears to be the level at which neuropathy first appears. You can read the research that shows this on this page:

Research Connecting Organ Damage with Blood Sugar Level.

One thing that makes me question whether C-peptide is a truly magical elixir is how many people with Type 2 who still produce insulin--often a lot of it--develop neuropathy and early kidney damage before they have blood sugars high enough to give them a diabetes diagnosis. Since these people are secreting proinsulin and often test with very high levels of C-peptide since they are primarily insulin resistant, not insulin deficient, one has to wonder how potent the effects of C-peptide really are. Clearly the presence of C-peptide in these people's blood streams does not prevent the microvascular complications.

Another question that rises in the minds of those of us who still can produce some insulin is whether we are suppressing our C-peptide secretion by injecting insulin and if we are, if this might make complications more rather than less likely.

The evidence, such as it is, suggests that injecting insulin early rather than late lowers the rate of microvascular complications--mostly because, as stated before, the benefits of lowering blood sugar to normal levels appear to outweigh any possibly helpful impact of C-peptide.

So if your own native--produced insulin is not able to keep your blood sugar in normal limits, any benefits you get from producing C-peptide are outweighed by the damage caused by the high blood sugars your inadequate insulin production creates. In any event, it appears that even when you inject insulin your body still produces some insulin. That is why doctors will give C-peptide tests to people with Type 2 who inject insulin and use the results to rule out Type 1 diabetes. Even when people with Type 2 diabetes are injecting large amounts of insulin, if some beta cells are still alive they will secrete detectable amounts of C-peptide.

Since there is clearly another big-selling diabetes product in the works here, if you start seeing a lot of studies promoting the value of C-peptide in the journals you should assume that some company is about to launch a blockbuster new, and of course expensive, synthetic C-peptide.

We won't know how effective it really is until we can see the results of some large trails with thousands rather than tens of subjects. My guess is that it will have some value, as does Symlin, another drug that replaces a hormone destroyed when the pancreas is the subject of immune attack. But is the case with Symlin, the value of an artificial C-peptide will be enormously enhanced if it is used in conjunction with a diet that cuts way, way down on the carbohydrates that raise blood sugar.

No magic bullet is going to prevent complications when your blood sugar is well over 200 mg/dl for hours at a time. And fortunately, we already know how to prevent that from happening. Cut back on the carbs!