October 31, 2008

Diabetes Diagnoses Have Doubled

You've probably seen the headlines or the TV news stories about how the incidence Diabetes has Doubled in the past ten years.

Here, from U.S. News and World Report is a typical version of this story:

Rate of Diabetes Cases Doubles in 10 Years: CDC--The obesity epidemic is fueling the type 2 disease epidemic, officials say

As is the case with just about all reporting about Type 2 Diabetes this story neglects to mention some very important facts that explain some of this rise as being in truth a rise in diabetes diagnoses which is NOT the same as a rise in the actual incidence.

The Diagnostic Criteria were Improved in 1998

In 1998, before the ADA revised its document setting out the Diagnostic Criteria for Diabetes Mellitus, most doctors only diagnosed diabetes when people's fasting blood
sugar was over 140 mg/dl.

In 1998, the fasting cutoff was changed to 125 mg/dl.

This change resulted in people getting earlier diagnoses and earlier treatment. This is good, not bad!

Doctors are Screening More Aggressively

There are a lot more drug companies pushing a lot more diabetes drugs now than there were in 1998, and one side effect of this is that doctors are being urged to screen patients more aggressively. In 1998 many doctors were still screening patients for diabetes with a urine dip test which often misses evidence of high blood sugars.

Back in 1998, I did not test positive on a urine dip test until my blood sugar was 240 mg/dl three hours after eating (and that reading was taken with a blood calibrated meter, so the actual plasma reading would have been 12% higher.)

More Doctors are Finally Taking "Pre-Diabetes" Seriously

Fifteen years ago I was told that "pre-diabetes" was a "fad diagnosis" even though I'd been diagnosed years before with "pre-diabetes" on a glucose tolerance test. Even when she learned that my blood sugars were going into the 200s after ever meal, my doctor back in 1998 told me it was "nothing to worry about" because the blood sugars eventually came down to around 100 mg/dl by the next morning.

Since then, many, though not all, doctors have come to realize that pre-diabetes and what they used to consider "Mild" diabetes imply the presence of blood sugars high enough to cause "diabetic complications" and need to be diagnosed and treated.

The Baby Boom is Aging

The incidence of Diabetes rises as people get older. It always has. Women, in particular, become much more insulin resistant after menopause, unmasking blood sugar abnormalities that were hidden until then.

What is changing is that there are a lot more people now in the age group where these diagnoses start to rise since the huge population mass we call the "Baby Boom" is now mostly in its 50s.

So we might just as honestly ascribe the increase in diabetes to an "epidemic of menopause" as to the "obesity epidemic." This isn't a real epidemic, it's a well-understood demographic change.

Given these facts, the increase in diabetes diagnosis may be good news, because it means people are getting diagnosed earlier and with blood sugar levels that were ignored in the past to the point where many a person died of a diabetic heart attack without ever learning they were diabetic.

In addition, earlier diagnosis makes it possible for people with diabetes to avoid the horrible complications that were the fate of people a generation ago who were diagnosed only after they had already developed neuropathy, retinopathy, and early signs of kidney damage.

The growth in the incidence in Type 2 diabetes that is not accounted for by the above factors is probably explained by these:

1. There is a huge, not well-understood explosion in the incidence autoimmune diseases of all kinds. A surprising number of those diagnosed with "Type 2" diabetes have antibodies characteristic of autoimmune diabetes.

2. Toxic chemicals like the Bisphenol-A that lines our tin cans are now known to promote insulin resistance and obesity. Other chemicals known to cause diabetes are PCBs and pesticides, both of which are found in human bodies at alarming rates. The chemical industry would prefer that you keep blaming people for causing their obesity and their diabetes through gluttony because it would be very expensive for them to remove these chemicals from our environment.

3. The Drugs Used to Treat Depression Cause Weight Gain, Insulin Resistance, and Diabetes. The overmarketing of psychiatric drugs to people with normal, if unpleasant, human emotions is a major, unexplored, cause for our current "obesity" epidemic. If the people reporting about health in the media ever did anything more than read press releases you'd learn about this. But because these drugs are so profitable, the drug companies have kept this information out of the news.

October 29, 2008

Why This Election Matters: The FDA

There's a reason we pay taxes and support a Federal government. It's because there are things we need done that none of us has the resources to do alone.

One of them is to ensure the safety of our food and drug supply. Progressive Republicans under the leadership of Teddy Roosevelt created the modern FDA in 1906 after some high profile cases hit the news where people had been blinded or poisoned by drugs, foods, and cosmetics sold to the public in a hitherto unregulated "free market".

Testing our food and drugs for poisons is expensive. You and I can't do it, nor can local government. That is why it is just the kind of function that our Federal government, funded by our shared resourced--a.k.a. tax dollars, should do. And for more than a century, we have been relying on the Federally funded FDA to do this testing for us.

Unfortunately, the Republican love affair with deregulation has hit particularly hard on the FDA. For the last decade, at a time when the number of new drugs and new food threats has risen its budget has been slashed. Even more troubling, the Bush administration has appointed leaders to the FDA based on their adherence to right wing ideology, not their familiarity with science.

This should not surprise anyone. Bush insider Donald Rumsfeld spent some of his years out of power heading up drug company Searle. Among his accomplishments? Pushing for the legalization of direct to consumer drug marketing--the marketing that has let drug companies make what they know are false claims for their drugs that sell millions of prescriptions in the interval between when the ad appears and when regulators finally get around to pushing them off the airwaves.

Once Bush got into power he appointed industry insiders and Republican ideologues to run the FDA. These were people with strong ties--i.e. people receiving huge amounts of money from--the industries they are supposed to be regulating. They have, as a result, ignored strong scientific evidence when the evidence might lead to an outcome that impacted the profits of their industry buddies.

The refusal to face the truth about Bisphenol-A is only one of many decisions that the FDA has made by relying on "experts" who are in the pay of the very industry under scrutiny.

Putting the fox in charge of the hen house has also led to FDA to pretty much give up inspecting more than a tiny fraction of foreign food imports or to enforce existing regulations that could prevent e coli and Mad Cow Disease from being spread by slaughterhouse operations run by a few politically well connected food processors. In fact, the FDA has worked to weaken oversight of the meat we eat at the behest of cattle producers.

Finally, and most importantly for people with Diabetes the FDA has shortened the approval cycle for new drugs and then completely given up any attempt to follow the safety of these drugs once they are in the marketplace. Though the FDA orders companies to do followup testing, they have never enforced these orders, and as a result most companies have not done the studies they were ordered to do. The only true system we have for tracking the safety of drugs in the marketplace is a "voluntary" system which most doctors ignore, as it involves them in paperwork. And from what I have been told by doctors who have reported problems with new drugs to the FDA, the usual response is an assurance that the drug is safe--based on pre-release testing.

The current FDA drug testing criteria are a joke. They do not require that a drug be shown to be more effective than an existing drug. All they ask is that a drug be more effective than no drug at all.

They do not require that the company selling the drug investigate what it is that the drug actually does as long as it affects some surrogate marker. So Vitorin, a drug that lowers LDL cholesterol can be marketed as preventing heart disease, even when the evidence suggests it has no positive impact on heart attack incidence and may actually increase heart attacks.

Most importantly they FDA not only does not force drug companies to show that their drugs do what they say before the drug is approved, they do nothing to prevent drug company representatives and advertisements from making unsupported claims for the drug's effects after they are released into the marketplace.

This is why statin drug manufacturers can claim their drugs prevent heart attacks, while the data only shows that they lower LDL cholesterol and that if they do prevent heart attacks at all, it is only in one subgroup: middle aged males who have already had heart attacks and that that they have no impact on heart attack incidence in women, as documented exhaustively in Good Calories, Bad Calories, by Gary Taubes

This is also why companies selling SSRIs can claim that their drugs prevent depression because boost serotonin levels, when in fact it turns out that this effect is transient and what these drugs really do is remodel neurons in hippocampus, the part of the brain responsible for storing memories.

The lax FDA drug approval process combined with virtually no oversight of drug company marketing practices is also why the costs for treating diabetes have doubled in the last eight years.

The companies selling expensive and unproven new drugs like Avandia, Januvia and Byetta have been marketing these incredibly expensive drugs to PCPs claiming--based on flawed evidence--that they cause beta cell mass to rejuvenate. These claims have been debunked for the glitazone drugs like Avandia and Actos--though they were marketed to doctors on that premise for almost a decade. These claims will probably be debunked in time for Januvia and Byetta, too, as the evidence supporting these claims is seriously flawed. But meanwhile millions of people will buy and use them, even though these drugs may be doing them harm.

Because the FDA does not require rigorous post-marketing testing but relies on the drug companies themselves to police the safety of their products, we may never know the toll the newest drugs are taking on our health.

We only learned of the dangers of Avandia and Vioxx from the drug companies' own studies which were intended to increase the market for their products. We can assume that the drug companies learned from these fiascos never to test the health benefits of any drug already approved for sale. So we are not likely to ever learn the long term dangers of Januvia--with its dangerous shut down of the immune system mechanism that kills metatastic cancer cells or of Byetta.

This is why we desperately need leaders in Washington who will appoint aggressive regulators to watch over the safety our food supply and of the drugs being marketed directly to us on TV and to our doctors. We need regulators whose primary allegiance is to we, the people, not to the corporations they regulate. We need stronger disclosure rules to make sure that drug companies can no longer cherry pick the studies they run and publish only those that show positive outcomes for their drugs while suppressing those that show the drugs to be ineffective or dangerous.

We also need to know who is paying the "experts" who evaluate the safety of new drugs and who determine which chemicals in our environment are safe.

Most importantly, we also need regulators who are familiar with and respectful of the principles that drive Science. It is hard to believe anyone would need to state such an obvious principle. But the Right Wing of the Republican Party has made it crystal clear that they consider science to be an elitist frill.

Whether it is Sarah Palin proclaiming that dinosaurs and humans lived on earth at the same time and citing fruit fly research as a waste of money--though any person familiar with science knows that fruit fly research continues to be where the vital first steps are taken towards understanding many of the genes that operate in humans, or Bush's stopping of funding to stem cell research, or the way that the release of a vaccine that could prevent our daughters from cancer was blocked for years on ideological grounds, the Republicans have made their priorities clear.

And those priorities are indeed faith based: because as long as people with those priorities are running things, you are going to have to pray to God to keep you safe and healthy, because the FDA sure isn't going to.

Bottom line: We can't afford four more years of the same old thing.


Note: As has been my practice in previous posts involving politics, I welcome comments that address the topic discussed in the post but will delete any hate posts and generic diatribes from anonymous posters which do not relate to the actual topic under discussion here.

October 28, 2008

Safe Surgery with Diabetes

If your doctor is honest he or she will have told you that people with diabetes have a very high risk of developing a serious infection or other complication after surgery. But having diabetes also makes it likely that a person will need surgery. So with that in mind let's look at what you can do if you are a person with diabetes to make sure that you emerge safely from any surgery you might have to undergo.

1. People with Diabetes and Normal Blood Sugar Fare as Well as Normal People. I can't point you to a study that proves this, because, sadly, there are no studies that involve people diagnosed with diabetes who maintain normal blood sugars. The only data we have is anecdotal--i.e. reports of people who have normalized their blood sugar despite a diabetes diagnosis. And the news from them is very good.

This makes sense. There are two reasons that people with diabetes have such poor outcomes in a surgical setting. One is because uncontrolled high blood pressure destroy the tiny capillaries that should bring immune cells to healing tissues, which allow bacteria to grow unopposed.

The other thing high blood sugars do is destroy nerves. Early in the process these high blood sugars kill the smaller nerve, then then later on, the larger nerves. This has a huge impact on the body's ability to fight infection because we now know thanks to Kevin Tracy's ground breaking research about the immune system published in Nature in 2002 that the nerves play a major role in sensing and then triggering the immune response to invasion. So when the nerves are damaged by high blood sugars, the immune system may not learn that an infection is taking place. This may be a major reason why neuropathy leads to the uncontrollable infections that lead to amputation.

But if you keep your blood sugars within normal limits--under 140 mg/dl (7.7 mmol/L) at all times or as close to that as you can manage--your capillaries and nerves should remain functional, and if that is the case, there is not reason why you should have any more exposure to infection than a normal person.

Family doctors don't know this, but I was very heartened when I had surgery last spring that my young surgeon did. In fact, when I asked if I might need to raise my carbohydrate intake to promote healing (a concept that I recalled reading in the book Protein Power years ago) the surgeon told me that a low carb diet was better, not worse, for healing, especially in people with diabetes.

I followed her advice and followed a stringent very low carb diet--no more than 10 grams per meal--for eight weeks--two weeks before the surgery and then six weeks after--and healed so quickly that the surgeon told me that she wished the rest of her patients would do whatever it was that I'd done.

2. MRSA is a Huge, New Threat to All People who Have Surgery. MRSA is a "superbug" form of staphylococcus bacteria which is resistant to most antibiotics. It has spread through hospitals at an alarming rate and is causing an epidemic of terrible wound-related complications. Hospitals have been very slow to respond effectively to it. There has been no requirement that hospitals report when they have MRSA infections and the steps needed to eliminate MRSA from a hospital once it has been contaminated are time consuming and expensive. As a result, many hospitals have not taken the steps they should take to prevent this infection from spreading and as a result MRSA has become a huge threat to all hospitalized patients.

Most people don't realize this, but it turns out that hospitals do not get the visits from the health departments that restaurants get. No outsider tests hospital surfaces for bacteria the way they test the counters in all restaurant kitchens. Hospitals are left to police themselves--a strategy we have seen in all sectors of society usually means that no policing occurs.

Because of this, if you are going into a hospital for surgery you should take steps to protect yourself.

The first thing you should do is read 15 Steps to Reduce Your Risk of Hospital borne Infection

My surgeon counseled me to wash with antibacterial soap for three days before surgery, which I did. I followed this up after surgery by washing my hands with antibacterial soap before doing any wound care. I had no problems and I suspect that this rigorous attention to decontamination helped.

If you are in the hospital for any period of time, the most important thing that your loved ones can do is to insist that anyone who attends you washes their hands before caring for you. This simple step has been shown in studies to prevent transmission of MRSA. Unfortunately, studies have also shown that most doctors and many nurses continue to neglect this step.

MRSA is taking a terrible toll. It killed the woman who was my roommate in the hospital last December. It looks like it may be destroying Tom Brady's knee. I am seeing more and more reports of terrible, nonhealing wounds in surgery support discussion groups, and from the treatments being used--repeated surgeries being used to open wounds and debride them, it looks like many people are being treated for MRSA without being informed by their surgeons that this is what is going on.

If you do develop MRSA it is very important to understand that you are infectious to others. Anyone with MRSA should be kept away from children who can pick up the bacteria and take them to schools or day care centers where they can enter broken skin and cause fatal infections. You must also insist that everyone who tends you follow rigorous decontamination techniques--like removing the shoes they wear in the sickroom--which you can learn more about on the hospitalinfection.org web site.

3. A Healing Diet is a Diet Rich in Greens and Colorful Vegetables. It is not enough to eat a low carb diet. To heal yourself, you will want that low carb diet to include a lot of fresh dark green vegetables as well as small portions of colorful peppers and tomatoes. Yes, these latter items have a bit of carbohydrate, but the value of the micronutrients they contain is well worth the very slight raise in blood sugar they may cause.

Vitamin K which is found in greens is extremely helpful to the healing process. You will also want to eat natural food sources of Vitamin C which have been shown over and over again in research to be far more effective than the vitamin taken in isolation in pill form. There are other micronutrients in fresh vegetables that are not found in pills. In addition, Vitamin C now all comes from China and is subject to the dangerous contamination that affects all Chinese products.

The juice of half a lemon or lime a day added to your surgery diet will give you all the vitamin C you need and be very helpful towards healing. Squeezing the juice of fresh lemons or limes into seltzer or tea is an easy way to get this valuable nutrient.

4. Start Your Surgery Diet Before Surgery. If you have advanced warning that you will be having surgery, start your surgery diet as soon as possible. Normalizing your blood sugar before surgery rather than just afterwards is very important, and building up body stores of micronutrients from fresh vegetables and greens is important, too.

5. Before the Day of Surgery Talk to your Surgeon about Keeping Blood Sugars Normal During the Surgery. Unfortunately, it is still common practice for anesthesiologists to start glucose drips before surgery. If you wait until the day of surgery (as I did) to ask that you not be hooked up to a glucose drip, you may find that the anesthesiologist does it anyway. So this is something you should discuss with your surgeon beforehand so that they can inform the anesthesiologist what protocol to follow. I was told that insulin is usually not administered during surgery, so if you are given a glucose drip and do not have the ability to lower your own blood sugars, you may end up with a very high blood sugar during surgery which will shut down your immune system and make it harder to heal.


UPDATE November 16, 2008: An article published in the Bellingham Herald written by investagative journalists from the Seattle Times describes in great detail how hospitals in one city ignore and downplay the MRSA epidemic, how doctors hide deaths by MRSA, and how dangerous this germ really is. Read this whole article before you check in for surgery. It might save your life or limbs. (The whole series also appears in the Seattle Times but this version is easier to read online.)

Unfortunately, this article is no longer available online.

October 23, 2008

The Retirement Crisis No One Talks About

Many of us have seen our retirement savings dwindle alarmingly over the past several months, and the press has covered that story. But when they mention people losing their retirement savings thanks to the stock market meltdown, journalists (who tend to be younger people) follow that up by saying, "People will have to work longer" as if working longer would solve the problems posed by losing most of your retirement income.

But many of us won't have the option of working longer.

Why? Because not everyone ages well. In fact few people over 70 have aged well enough to be able to work a 40 hour a week job that pays enough to cover their bills--even if they could find such a job, which is by no means certain.

Many older people do continue to work after retirement, usually part time and often in jobs that are far less stressful than the ones they retired from. But with advancing age several things happen that make it increasingly hard to hold the kind of job that earns enough to let a person live at even a level of genteel poverty.

Energy levels drop. This may be due to subtle metabolic problems, but even in the healthiest old people changes associated with normal aging may cause them to develop problems with sleep which prevent them from getting the rest that they need.

Hearing and vision begin to fail. This process might be accelerated for people with problems like diabetes, but even in the healthiest older people genetics seems to play a large role in age-related hearing loss and the likelihood of developing age related macular degeneration, which is the most common cause of blindness in the non-diabetic elderly.

Mobility becomes a problem. Joints wear out after 70 or 80 years of use and everything from walking to typing on a keyboard becomes more painful. Ironically, the popularity of running, biking, and other sports that hasten the deterioration of joints may make this an even bigger problem for the Baby Boom generation than it was for our elders whose idea of "exercise" was more likely to be a gentle stroll around the golf course rather than training for a marathon.

The brain deteriorates. This, when it comes to aging, is the elephant in the room which no one likes to talk about. Yes, there are those "wonderful" old people who are a sharp at 90 as they were in their teens, but they are a tiny minority. For most of us, the progress from our 50s to our 90s will involve subtle deterioration of our memory, our ability to think creatively, and most importantly, our judgment.

Most of us assume that we will know it when these changes occur and be able to ask for help. But those of us who have watched our parents age know that the exact opposite happens. As mental functions decline people rarely are aware that their ability to think is deteriorating. They may also develop paranoia and react very badly to anyone who tries to intervene--including an employer who may be troubled by evidence that the older employee is making mistakes that could harm the business.

These issues, a mix of which affect most older people to some extent, is why there comes a time when most people have to retire and why it is so important that there must be some way to support old people through the period--which is often a long one--after they are no longer able to earn their own livings.

We already knew that a major crisis is looming ahead in America as the Baby Boom population as a whole has never had the kind of savings that its parents accumulated. Some of this was due to people spending more than they should have, because of the Consumer Culture which urged them to buy things they really could not afford.

But I don't think this is the whole story. Many people of my generation have not been able to save because real wages have been stagnant for years and many hardworking people of my generation have never been able to earn more than it took to pay for housing, food, transportation, heat, health care, and eduction for their kids.

The loss of money invested in the "safe" vehicles that have been sold to us as ideal for our retirement nest eggs will force a lot of people of the Baby Boomer generation into the same needy situation they once thought would be the fate only of those who had been imprudent.

Social Security will help some people far more than others. Those who are winners are those who earned large salaries throughout their working lives. They may get payments in the $25,000 a year range which is enough to prevent poverty.

But for those of us who worked in the kinds of careers that do not produce large salaries or who took time out to raise children, or whose health problems made it hard to work full time in our younger years, Social Security may provide as little as $12,000 a year. And given that the median family income in our nation hovers around $42,000 a year, this is the situation most American workers fall into.

So what happens when you have many tens of millions of aging Baby Boomer people who do not have the physical ability to work at jobs that could pay enough to cover their costs for shelter, food, heat, and health care? How far are they going to get living on $1200 a month? Who's going to be looking out for them? What can government do now that so much of our national assets have been squandered on unnecessary wars and bailing out the super rich who have paid for the lobbyists who have written our national tax policy for so long?

One thing is certain: We're going to find out.

October 20, 2008

Not Your Grandpa's Diabetes

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

1. Educate yourself about diabetes.

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

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

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

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

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

October 16, 2008

Joe the Plumber and McCain's Health Plan

We now know more than we ever wanted to know about Joe the Plumber (who, it turns out does not actually have a plumber's license.)

I am, personally, puzzled by the fact that the McCain campaign has made this guy the poster boy for the working class. We have some plumbers in our extended family, including one who runs his own business, and though they too often work 10 hours a day--that comes being in with the plumbing business--their income is far under that $250,000 level where a 3% tax increase Obama is suggesting would kick in.

That the Republicans consider a taxable income of $250,000 to be even "middle class" suggests to me just how out of touch they are with the financial realities of the lives of the true middle class. To have a taxable income of $250,000 you have to have a gross income of at least $300,000. If you are a small business owner who can deduct expenses, you would need to have a gross income somewhere near $380,000.

But since McCain wants us to consider Joe Not-Really-A-Plumber as an important part of this election, it is worth taking a moment to consider what happens to Joe under Senator McCain's proposed health plan.

Right now, despite his much vaunted dream of buying a business, Joe is an employee. Under McCain's plan, the cost of the health insurance his employer gives him now will become a part of his taxable income. The tax exclusion McCain has touted means that a portion of the cost of the policy will be excluded from taxes. $2,500 for an individual or $5,000 for a family.

But any amount of insurance he is getting from an employer that costs more than that is going to be taxed as income. Since most employer-sponsored family plans cost about $12,000, the day McCain's plan becomes law, Joe will have $7,000 more taxable income.

If Joe really does make $250,000, he is already in the 33% tax bracket. So under McCain's plan he will have to pay an additional $2,300 in tax on his existing health benefit.

Now Joe's whole objection to the Obama tax plan was the additional tax he'd be paying on his taxable income over $250,000 would make it impossible for him to buy the business of his dreams.

Sot it looks like Joe is not too good at math, because it is clear he's going to be paying a lot more new taxes under McCain's plan, with that newly taxable health benefit which raises his taxes no matter what he earns, than he is under Obama's plan which only raises taxes 3% on the taxable income he earns that is over $250,000.

And of course, none of this even gets into the issue of what happens to Joe's income stream if he, Mrs. Joe, or Joe Jr. are diagnosed with any form of diabetes. Nothing in McCain's plan guarantees that he or his employer will be able to find affordable insurance that covers pre-existing condition or that covers things like the pump or CGMS Joe Jr. might need.

The Chamber of Commerce and Business Roundtable, two highly conservative business lobbying groups, have both stated that they believe McCain's health plan to be deeply flawed and likely to increase the number of the uninsured, not lower it.

Rather than repeat the reasons why, I'll give you the link to the article that reports on why they feel this way:

New York Times: Business Cool Towards McCain's Health Coverage Plan

One last thought: McCain has claimed a couple times during the debates that the best thing about his plan that it will allow people to buy insurance across state lines.

Well, crossing state lines to buy insurance sounds like a great idea, until you realize that the affordable plans that actually cover what people need to get covered almost always are HMO or PPO plans. These plans are able to save money and lower costs by limiting the doctors, pharmacies, and hospitals you can use to those in a certain geographic area with whom they have negotiated hefty discounts.

And that's why out of state plans are not a solution: If Joe buys into the excellent plan I can buy in Massachusetts (which will cost about $12,500 for his family and still have some hefty deductibles he'll have to meet) he will have to cope with the fact that the plan obliges him to use doctors or visit hospitals in the Western part of Massachusetts which might be a bit of a drive from his home in Central Ohio.

If he buys a cheap plan sold in TX where there is, in effect, no regulation of health insurers, he may be able to see a local Ohio doctor, but he better be sure he or his family do not have any preexisting conditions because the plan won't pay for treatment for any condition that they can in any way link to a preexisting condition. And he better realize that the way they define "preexisting condition" in TX can be very broad.

Years ago, when I was running a Forum for computer consultants I heard from one man who had bought a Texas plan marketed to the "self-employed" that would not pay for the expenses of his wife's stroke simply because she had been diagnosed with mitral valve prolapse, a usually benign condition that affects 17% of all young women which has never been shown to cause stroke.

And I myself years ago was stupid enough to buy a health policy from a company that sells mainly to the self-employed. The premium was quite affordable. Unfortunately when I had claims, though the policy said it would pay 80% of my claims, the company refused to pay more than 50% of any claim I submitted.

I later learned, by reading an article about that company in the Wall Street Journal, that it remained profitable by pursuing a policy of refusing to pay claims in full knowing that most policy holders could not afford to go to court to force payment. That company, Golden Rule, is still in business and still marketing to small business owners.

That is why a simplistic solution like letting people cross state lines to buy insurance is not going to solve the health insurance crisis.


Update 2:52 PM: The NYTimes reports that Joe the not-a-Plumber is not only not a licensed plumber, though he is working as a plumber in a town where a valid license is required, he's fraudulently claiming to be a member of a union he isn't a member of, he hasn't paid the taxes he already owes, and he is registered to vote under another name than the one he uses in daily life.

Once again, it is clear McCain doesn't have staffers able to check out anyone's background before making them the centerpiece of his campaign.

New York Times: Joe in the Spotlight

McCain may have ruined this poor schnook's life, by cynically and very clumsily trying to use him to score political points. Shame on him!

October 14, 2008

Blood Pressure Control: As Important as Blood Sugar Control?

Several recently published studies remind us that high blood pressure plays an important role in causing several of the classic diabetic complications and that controlling high blood pressure may be nearly as important as controlling our blood sugar.

Blood sugar and blood pressure are not unrelated. In fact, there is some evidence that suggests that high blood sugars cause high blood pressure. Many people who have cut the carbohydrates out of their diet find that their blood pressure drops--sometimes dramatically--after making this change. Some people attribute this to the fact that for an insulin resistant person with Type 2 diabetes, cutting the carbs will lower the amount of insulin that is secreted, and suggest that insulin itself raises blood sugar. Others think it might be related to the diuretic effect of the low carb diet.

But it is more likely that high blood sugars themselves cause high blood pressure. That this might be the case is suggested by the findings of the 15 year follow-up to the DCCT study.

DCCT was the landmark study where people with Type 1 diabetes were given more aggressive treatment with the goal of lowering their A1cs to 7%. Before this study, most doctors did not believe that lowering blood sugar could prevent diabetic complications. The DCCT proved them to have been very wrong as blood sugar in these Type 1s lowered the incidence of their diabetic complications dramatically.

The EDIC study which was a follow up involving the DCCT subjects after the original study was over found that, "However, intensive therapy during the DCCT reduced the risk of incident hypertension by 24% ... . A higher hemoglobin A1c level, measured at baseline or throughout follow-up, was associated with increased risk for incident hypertension..."

Subjects involved in the DCCT study used more insulin, not less than controls with higher blood sugars, and they were eating a high carb/low fat diet so no diuretic effect would have been involved. Even so, the follow-up study found that the lower the A1c the better their blood pressure was.

Insulin Therapy, Hyperglycemia, and Hypertension in Type 1 Diabetes Mellitus Epidemiology of Diabetes Interventions and Complications. (EDIC) Study Research Group. Arch Intern Med. 2008;168(17):1867-1873.

The UKPDS, was an attempt to duplicate the DCCT study using a population of people in the UK diagnosed with Type 2 diabetes rather than the Type 1 that had been studied in DCCT. It found that lowering both blood sugar and blood pressure greatly decreased microvascular complications.

The follow up to the UKPDS study found a more sobering relationship between blood sugar and blood pressure.

Long-Term Follow-up after Tight Control of Blood Pressure in Type 2 Diabetes New England Journal of Medicine. Volume 359:1565-1576. October 9, 2008. Number 15.

Unlike the Type 1s studied in the DCCT follow up study, the Type 2s involved in the UKDPS follow up study did a wretched job of controlling their blood sugars. This wasn't their fault. The study design says it all. "The 884 patients who underwent post-trial monitoring were asked to attend annual UKPDS clinics for the first 5 years, but no attempt was made to maintain their previously assigned therapies."

In short, once the study was over, were offered only the standard UK NHS treatment which meant they were told to eat a high carb/low fat diet, given sulfs or metformin, and, if they were given insulin at all, they were given the extremely outdated one or two shots a day 70/30 NPH regimens that were standard NHS treatment until very recently.

They were not encouraged to lower their blood sugars to the feeble 7% A1c that the UKPDS researchers had striven for, and it is not even clear if they were ever informed that there were any health benefits to lowering their A1cs to the 7% level.

What happened to these people was sobering. Not surprisingly, their blood sugars soared. And so did their blood pressures. As reported by the researchers, "Significant relative risk reductions found during the trial for any diabetes-related end point, diabetes-related death, microvascular disease, and stroke in the group receiving tight, as compared with less tight, blood-pressure control were not sustained during the post-trial follow-up."

Saddest of all, the improvement in microvascular complications that had been seen during the "tight control" phase of the study ("tight control" here was defined as a 7% A1c) disappeared as blood pressure rose along with blood sugar.

The researchers conclude "Early improvement in blood-pressure control in patients with both type 2 diabetes and hypertension was associated with a reduced risk of complications, but it appears that good blood-pressure control must be continued if the benefits are to be maintained."

I will restrain myself from ranting and raving about the ethics of a study where patients who had achieved significant improvements via tighter blood sugar control were completely abandoned once the researchers had their data in the can. Instead, I wall point to the take away message here: Lowering blood sugar lowers blood pressure and decreases microvascular complications. If you let blood sugar go back up again, blood pressure will go up too and you see a lot more microvascular complications.

Microvascular complications include retinopathy and nephropathy--in English, blindness and kidney failure. The kidney is particularly sensitive to damage from high blood pressure, which appears to destroy its glomeruli--tiny filtration units.

A sub-study connected with UKPDS found a dramatic drop in retinopathy and stroke in a group of people with Type 2 who were given either an ACE inhibitor or a beta blocker to lower their blood pressure. Their target blood pressure was one that today's doctors still consider too high: 150/85, but even so, achieving that target produced a dramatic lowering of stroke and retinopathy.

Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. UK Prospective Diabetes Study Group.

So there are two lessons here:

1. Lowering blood sugar should help control blood pressure and that may be one reason why lower blood sugars help prevent diabetic complications.

2. Lowering blood pressure independent of blood sugar can also help prevent serious diabetic microvascular complications.

This should motivate you to keep an eye on your blood pressure as well as on your blood sugar. Just relying on the blood pressure measurement your doctor does every couple months--or perhaps once a year--is not enough to prevent high blood pressure from creeping up and causing microvascular damage.

Fortunately, blood pressure monitoring is a lot cheaper than monitoring blood sugar. For about $60 you can buy an automated blood pressure meter that you can use at home. The Omron meters sold on Amazon for $50 - $60 (Shipping is free) are highly accurate and well worth the investment.

When shopping for a blood pressure meter, avoid the wrist models--they tend not to be as accurate. Also, look for one that plugs into the wall with an AC adapter rather than one dependent on batteries.

Once you have your monitor, check your blood pressure every couple days, following the instructions that come with your meter. Expect your blood pressure to fluctuate from day to day and at different times of day. But if you see repeated blood pressures where the first measurement is over 140 or the second measurement is over 90 give your doctor a call and make an appointment to discuss treatment.

If you see repeated blood pressure measurements over 180/100 you should demand to see a doctor immediately. Sustained exposure to blood pressures that high can damage your organs.

Some people find that exercise helps them lower blood pressure. A subgroup of people--this depends on genetics--are very sensitive to salt and for this group, cutting salt out of the diet can lower blood pressure too. For people not in this group, salt has no impact on blood pressures. You will only know what group you fall into by cutting your sodium intake and seeing if it has an impact on your blood pressure.

Doctors do not really understand all the reasons people develop high blood pressure. Other forms of kidney disease may play a part. So do fluctuations in the levels of many different hormones--sex hormones and cortical hormones in particular. But whatever the cause, untreated high blood pressure is very dangerous and a major contributor to stroke, heart attack, heart failure, kidney failure, and blindness. Lowering it can help prevent all these unpleasant conditions.

October 8, 2008

In Praise of the "Difficult Patient"

An essay originally published in the journal Health Affairs and reported in Science Daily last month raised an issue that needs a lot more discussion both among us folks with diabetes and within the community of doctors who treat us.

The report is here: Science Daily: Survival Instincts Propel 'Difficult Patient' To Insist On Quality Care.

"Difficult patients" turns out to be patients who do not accept mediocre care from unconcerned doctors. They are patients with serious symptoms who want a better diagnosis than a shrug of the shoulders--patients, in short, who demand that doctors do the job they are being so very well paid to do.

Doctors loathe these "difficult patients." They are quick to label any patient who challenges the level of care they receive with an unpleasant psychiatric label. One such label is "hypochondriac." This term is used to describe a person who imagines they are sick when they are not. If you are labeled with this label, your chances of getting decent care from the doctor applying the label drops to zero.

Many of you have been labeled hypochondriacs. I certainly have. Around the time I discovered my blood sugars were extremely high, I had a doctor who told me that blood sugars that rose into the middle 200s after every meal were "nothing to worry about" and that it was "obsessive" for me to test my blood sugar after eating. Because she refused to diagnose me correctly as having diabetes, I was unable to get any insurance coverage for the blood testing strips I needed to start learning how to control my blood sugar.

Fortunately for me, by the time this happened, I already had a lot of experience with mediocre doctors whose misdiagnoses had hurt both myself and my kids. I was also lucky enough to stumble upon Dr. Bernstein's "Diabetes Solution" book, which made it very clear to me how abnormal my blood sugars really were. So I found different, better doctors and have pushed them ever since for the treatments I needed to keep my blood sugars in the healthy range.

But most of my first doctor's patients who had blood sugars like mine probably were relieved to learn they were "fine" and did not take it any further. I'm sure that the doctor liked them a lot more as patients than mine do. But I'm also sure I'm in much better shape a decade later.

I'm far from being alone in this. Many of you have written to me about doctors who refused to diagnose you, even when you had demonstrably abnormal blood sugars. You write me about doctors who refused to refer you to specialists when they were clearly out of their depth dealing with your diabetes. And many of you complain about doctors who implied that you were a bit "mental" because you won't settle for an average blood sugar of 180 mg/dl and an A1c high enough to guarantee complications.

Now a study published in a psychology journal, Psychosomatic Medicine, quantifies the damage done by doctors who write off "difficult patients" as hypochondriacs.
Anxious Temperament and Disease Progression at Diagnosis: The Case of Type 2 Diabetes

To fully understand this study, you have to understand that the term "anxious" when applied by a psychologist is a loaded word which suggests that the patient is not mentally healthy. If you are diagnosed with "Anxiety", most psychiatrists will prescribe a powerful psychoactive drug. In addition, it is one of those diagnoses which is much more likely to be applied to females by male practitioners.

What this study found was that "anxious" patients had much better A1cs at time of diagnosis than did those who were supposedly more well-adjusted. As Diabetes in Control (who had access to the entire publication, not just the abstract) reports, "those with more anxious temperaments were diagnosed at an earlier stage compared with their more relaxed peers. The relationship was particularly strong among younger people, who do not normally undergo routine screening for diabetes. The patients who were diagnosed early were also more likely to have better control of the diabetes, regardless of their age."

Lower A1cs translate into fewer complications and heart attacks. This is good. But the doctor who dismisses the "anxious" i.e. concerned patient--often female--as a hypochondriac will miss the diagnosis in these patients or will ignore it, depriving them of the care that could help them keep those A1cs low over time.

So here's a thought to keep in mind: if your doctor only diagnoses or treats diabetes in patients who arrive in his office with neuropathy and retinal changes, who are peeing all the time and losing weight because their blood sugar is always above 300, you would do well to be as anxious as possible. And you should also do what you can to make sure that kind of mediocre doctor continues to think you are a hypochondriac, because the only time that kind of doctor will take you seriously is when his poor doctoring has led to your developing undeniable diabetic complications.

Many people with diabetes who were not sufficiently anxious get their first diabetes diagnosis in intensive care, after their heart attack. Even more tragically, some get that diagnosis when they suffer a serious wound that won't heal, which may even require amputation.

You do not want to be one of those people. It is much better to be labeled "Difficult" or "Anxious." And it is even better when you have been labeled (and treated) that way to find a new and better doctor who will work with you to make sure that you never develop the complications that make diagnosis so easy for out-of-date doctors.

October 3, 2008

The dreaded words: "in mice"

Not a week goes by that someone doesn't email me with a news report about some food or supplement that cures diabetes. Invariably, the punchline of this report includes the words, "In mice." Trust me, folks. after ten years of following the diabetes racket all it takes to get me to stop reading any further are those dreaded words, "in mice."

Over this past decade I've seen diabetes dramatically improved in hundreds if not thousands of rodents. Mice have regained healthy blood sugars after being fed chamomile tea, red wine and curry spices. They've made dramatic recoveries after being dosed with amino acids. Hormones have made them slim and frisky. But those of us with blood sugar meters who have tested our blood sugar after testing substances that have done such wonders for mice continue to remain uncured.

There are reasons for this. One of the most important is that mice have bodies completely different from ours. They are tiny creatures adapted to living on a diet of seeds very different from the omnivore diet of us massive humans. They are also a prey species that uses the common prey species strategy of living fast, dying young, and leaving a lot of offspring. So their bodies that don't repair tissue the way ours do. Their metabolisms are much much faster, and not surprisingly, their pancreases, while sharing some similarities with ours, have major differences.

Finally, mice do not in any appreciable way, get old. They age quickly--a 2 year old mouse is a mouse methusalah. In the wild they rarely live for more than a few months. Any cat would be happy to explain why. This means that rodents cannot be a truly good research model for any of the long term diseases that emerge with aging , especially Type 2 diabetes.

And indeed, when we look more closely at the mice used in diabetes research we see how true this is. The researchers doing rodent diabetes research usually use special strains of lab mice that have been breds to exhibit some specific genetic makeup that is considered to be a "model" for diabetes.

If they are a model for Type 2 diabetes, these mice are invariably fat. For example, much Type 2 diabetes research has been done with the OB mouse. This is a monster of a mouse which is obese because it is unable to produce leptin. These mice breed true. Buy an OB mouse, and you can be sure it will grow extremely fat and develop diabetes. But that is where the similarity with diabetic people ends. Because while people do grow fat and develop diabetes, it is not because they are leptin deficient. The number of humans around the world who have been found to be obese (or diabetic) because they lack the gene needed to make leptin is less than ten.

Scientist are constantly breeding new mouse models for Type 2 diabetes--and patenting them--but as is with the case with the OB mouse, though these mice are indeed obese and prone to get diabetes, the gene defects that cause them to do this are not those that have been so far identified in people diagnosed with Type 2 diabetes.

Scientists also breed mice that have been given intentionally disabled genes--the so called "knockout mouse" because in these strains of mice a specific gene has been destroyed or "knocked out." Breeding knockout mice can be helpful way of examining what a specific gene does. DPP-4 knockout mice have been used to see what the impact of inhibiting DPP-4 would be. These mice do not produce DPP-4, they have low blood sugars, and they seem--as far as you can tell with a mouse--to go about their daily lives untroubled by the lack of DPP-4 which gave researchers the idea that inhibiting DPP-4 in humans might be okay. Since these mice don't live long enough to develop most human cancers, alas, the researchers also may have missed the fact that inhibiting DPP-4 would, over time, allow slow growing cancers to metastasize that would have not survived in a creature that was making DPP-4.

It is because studies with mice are done with these genetically selected or modified pedigreed mice that they often prove so disappointing when applied to people.

People with diabetes are not a single breed. Your diabetes is almost certainly NOT caused by the same gene defect that causes mine. Nor is it caused by the gene that predisposed your neighbor down the street to get diabetes. Furthermore, if you go to a distant country where people come from different stock than you do, the people there with diabetes are likely to have yet other kinds of genetic forms of diabetes than you and your neighbors.

So far, scientists have found specific genes that color the way that diabetes arises and behaves in Pacific Islanders, Pima Indians, Danes, Ashkenazi Jews, people from West Africa, and Japanese. While there are also genetic differences between individuals in these populations, each population has different sets of busted genes that are more likely to turn up in people with diabetes in that population than they are in others.

The members of these discrete populations have different patterns of onset of Type 2 diabetes and they also usually have different likelihoods of developing specific diabetic complications. Some populations are more prone to develop kidney failure where others are more apt to go blind or need amputations. People with these different underlying genetic profiles also respond differently to various diabetes medications.

Given this diversity among people with Type 2, the usefulness of the purebred "obese diabetic" mouse is limited. It may be able to answer some questions for researchers, but the question they can't answer with any authority is, "Did I just find a substance that cures human diabetes?"

When we move from Type 2 diabetes to Type 1, we run into another mouse model. Research on autoimmune Type 1 diabetes is almost always done with the the NOD (non obese diabetic) mouse, which is a strain of mice that breeds true for a susceptibility to a mousy kind of autoimmune diabetes that shares some antibodies with human autoimmune diabetes.

Dr. Denise Faustman's current research that has raised such hopes in the Type 1 community is based on her results curing NOD mice. But while we hope that the techniques which were so helpful to these mice work for people, that they will make the transition from mice to humans is not guaranteed. Because while the mouse model is similar to human Type 1 diabetes, it is still a mouse, and there are still significant differences between a Type 1 mouse and a Type 1 person.

Beyond that, the genetics underlying Type 1 are not all that uniform either. While there are certain genetic markers that have been identified as being more common among people with Type 1 diabetes, genes alone do not explain the disorder and there are significant genetic differences between different people with Type 1.

Sometimes rodent research is done with "streptozotocin-treated" rats or mice. Streptozotocin is a poison that is specific to the beta cell. Give it to a normal rat and you end up with a rat with a dead pancreas. This is useful if you want to see what life is like for a critter with a dead pancreas, and these animals can be useful if all you want is an animal that cannot control its blood sugar without help. But again, a poisoned mouse, like any mouse is only of limited value in studying the impact of treatments on humans with diabetes.

Because when you give a mouse that healing substance --no matter what its impact on blood sugar--you can't ask the mouse if its tummy hurts. You can't ask if it has a headache, if its little nerves are tingling, if it can still remember where it put its car keys. When you give a mouse a healing substance, you also can't discover whether ten years later the mouse will develop a serious cancer of a type that takes ten years to develop or if it will end up with a damaged heart muscle. Mice cannot not really model any disease that takes a long time to ripen in a long living animal designed to preside over the top of the food chain--as we are.

The strength of mouse studies is that they are are a quick way of testing an idea to see if it has any plausability at all. A lot of medical ideas turn out to kill mice or leave them with such obvious problems that you wouldn't want to waste any more time on them--though it is not impossible that there are things that might work very well in people that get lost because they don't work in the very different physiologies of mice. But if something does work in a mouse, there is a lot of work ahead to see if it works in other larger mammals, and eventually in people. Most things that look good in rodents, don't.

Which is why people with diabetes are drinking red wine, slurping down chamomile tea, supplementing with hundreds of expensive minerals, amino acids, and herbal extracts, each one of which has done great things for rodents, but they are still running blood sugars much higher than normal.

And why I really wish the media would stop publishing these articles with those dreaded words, "In mice."

October 1, 2008

Making Insulin Work

As you all probably experience in your own lives, it often seems like things come in waves. And this past week the wave I have been experiencing has been full of worried emails from people who report that they or a loved one have recently started insulin but that it isn't working.

In every case, the insulin is a slow acting insulin, Lantus or Levemir, and there's a good reason why the insulin isn't working. It is because the dose being used is far too low to have an impact on an insulin resistant Type 2.

When doctors intially start a person with Type 2 diabetes on a slow acting insulin they start out with a very low dose, usually 10 units. This is prudent. One in ten "Type 2s" is not really a Type 2. Most of these misdiagnosed "type 2s" turn out to be people in the early stages of LADA, Latent Autoimmune Diabetes of Adults, which is a a slow onset form of autoimmune diabetes. People with LADA usually have normal or near normal insulin sensitivity and for them an injection of ten units is a LOT of insulin.

One or two percent of people diagnosed as Type 2 turn out to be people like me who have other oddball genetic forms of diabetes that also make them very sensitive to insulin. So starting everyone out at a low dose of insulin makes sense since this way the misdiagnosed people who turn out to have normal insulin sensitivity will avoid hypos caused by too much insulin.

But once it is clear that a person really is a Type 2--since they see no response at all to a dose of 10 units of insulin, the doctor is supposed to raise the dose until it gets to the level where it will drop the fasting blood sugars. But many doctors do not explain this to their patients and quite a few raise the dose so slowly that it does seem to the poor patient that insulin won't solve their problems.

For example, I have heard from obese Type 2s people whose doctors started them at 10 units and have instructed them to increase that dose by 2 units every three days. That means that after a month of "using insulin" they will be using 30 units.

But as many of you have learned in your own exploration of insulin, the dose that works for most obese Type 2s is closer to 100 units than 30. In fact, the only Type 2 I know who uses a dose of basal insulin anywhere near 30 units weighs about 125 lbs and eats a strict low carb diet. All the rest, including several people who eat carb restricted diets, are using anywhere from 80 to 110 units.

No wonder these people are frustrated! They've overcome significant fear to take that step into using insulin but when they have done it, nothing has happened.
And what is really sad, is that I know that for everyone out there that contacts me, there are thousands who "use insulin" for a month, conclude it isn't working, and stop--which means that they continue to live with fasting blood sugars in the high 200s or worse. If these people don't have health insurance and are paying $85 a vial for the insulin that "doesn't work" you can well understand why they give up.

If we had a system where doctors followed up on their patients, this wouldn't be so big of a a problem, but in today's environment of overworked family doctors, most are too busy to follow up with patients and it takes a lot of hard work on the part of the patient to reach anyone at the doctor's practice who can help adjust their insulin dose to where it actually does something to lower their blood sugar. If a patient is not capable of harassing the doctor until they get some help they may be out of luck.

So it's crucial that if you or a loved one has diabetes you understand how insulin should be used so that you can make those phone calls to the doctor that it will take to get help setting insulin dosages to where they really work.

With that in mind, here is a very brief summary of how insulin works.

1. Long Acting Insulins Lower Fasting Blood Sugar. They Cannot Cover Carbohydrates in Meals. Lantus, Levemir, and to some extent NPH are slow acting insulins. They are used to lower your fasting blood sugar level. They are also called "basal insulins". After they are injected they release insulin molecules into your blood stream very slowly over a course of anywhere from 8 hours (for NPH) to 24 hours.

Long acting insulins are started at a low dose and then the dose is increased every few days until the fasting blood sugar has reached a target. This target should be a normal blood sugar, but doctors who don't have the time or resources to educate patients often settle for a dangerously high fasting blood sugar level--often around 170 mg/dl (9 mmol/L) because patients maintained at that level run zero risk of having a dangerous hypo. Unfortunately, they also run zero risk of avoiding complications.

The daily dose of a long acting insulin that will give a normal fasting blood sugar varies from person to person. For a person with Type 2 diabetes, it may be anywhere from 30 to 120 units. To learn what dose works for you you will have to slowly raise your dose--pausing a few days to let the insulin reach its potential, and test your blood sugar first thing in the morning and before meals to track how well the slow acting insulin is working. Your blood sugar will often be higher first thing in the morning than before meals. The before meals number is the one you should be the most concerned about.

If you need more than 110 units of insulin you should demand to see an endocrinologist because there are tricks that specialists know that can help you lower that dose.

Because the absorption of long acting insulins is so slow, you cannot use them to get normal blood sugars after meals. Blood sugar rises very fast after a meal, and if you inject enough long acting insulin to cover the mealtime rise you are very likely to experience a low blood sugars--possibly dangerously low blood sugars-- hours later when there isn't glucose from a meal in your body.

Many doctors prescribe doses of long acting insulin that are a bit too high and then counsel their patients to eat steadily through the day to avoid hypos. This, not surprisingly, leads to weight gain, and may be one reason why many doctors believe that injecting insulin causes weight gain.

If you are using too much long acting insulin, the time you are most likely to feel it is at 3-4 AM when many of us are prone to hypo. Signs you are hypoing are waking up suddenly at 3 or 4 AM from a sound sleep, nightmares, sweating, and experiencing fast heart beat. By the time you test after waking up this way may already have had a release of hormones that pushed your fasting blood sugar back up. If you keep experiencing the symptoms of 3 AM hypo talk to your doctor about cutting back on your long acting insulin to see if that improves matters.

2. Fast Acting Insulins are intended to cover the carbohydrates that come in with a meal. They must be matched to the amount of carbohydrate you eat to work properly.

Fast acting insulins include Humalog, Novolog, Novorapid, Apidra and the slightly slower Humulin or Novolin R insulins. These start working as soon as you inject them. Each one has a slightly different speed with which it kicks in and that speed varies from person to person. If you have trouble matching a fast acting insulin to your meals, ask your doctor if you can try another version. There really is a difference.

To use these insulins correctly you have to learn, by trial and error, how many grams of carbohydrates one unit will "cover". For many Type 2s that number is somewhere around 5 grams, but exactly how much depends on your body size and your degree of insulin resistance. You can only tell how well your insulin is controlling your meals by testing your blood sugar 2 or 3 hours after a meal and noting how much insulin you used, how much carbohydrate you ate, and what the resulting blood sugar was.

To make mast acting insulin cover the carbohydrates in your meals you need to know exactly how much carbohydrate is in the portion of food you eat. This involves study and careful weighing of portions until you get the hang of it. If you aren't willing to do the study and learn the carbohydrate content of your food, you run a very real risk of using too much insulin and causing a hypo. If you are willing to do the work, you can get excellent blood sugar control.

Because there is work involved in using fast acting insulin correctly, many doctors are reluctant to prescribe these fast acting insulins to people with Type 2 and when they do prescribe them, they prescribe them at set doses low enough to guarantee that you won't lower your post-meal blood sugar anywhere near normal. This prevents hypos (attacks of low blood sugar) but promotes complications.

The sign that your doctor is not up-to-date on how to use insulin is if you are told to inject a set amount of fast acting insulin based on your blood sugar before a meal. This is called "sliding scale" dosing and it is considered by endocrinologists to be out of date and ineffective. Sadly, it is also still widely in use because so many doctors got their training in how to use insulin while they were in training decades ago.

There are many of us in the online diabetes community who have figured out how to use fast acting insulin. So if you are considering using insulin or having trouble with it after it has been prescribed, it is worth visiting one of the online diabetes support communities and participating in discussions on the topic.

People with Type 1 diabetes get much better training in how to use insulin, so they can be extremely helpful in explaining how it works, though the doses they use will be very different from those that Type 2s need. The point of any support group discussion should be to learn the theory behind using insulin. Do not ask for or accept dosage recommendations. Suggesting doses is the job of your doctor or a trained diabetes educator. If they aren't doing that job, you need to find a competent doctor or educator who will do it.

You can also learn a lot from books that explain insulin usage. Several books that are often recommended in online support groups are, Think Like a Pancreas by Gary Scheiner, Using Insulin by John Walsh, and Dr. Bernstein's Diabetes Solution by Dr. Richard K. Bernstein. These books all take different approaches but if you read them all you'll get some idea of how to start thinking about using insulin. Your public library should have copies. If not, ask that they purchase them.

If your doctor is not helpful and books don't give you the information you need to tailor your insulin doses so that they give you normal healthy blood sugars, you will have to demand to see an endocrinologist.

3. Premixed insulins combine fast acting and slow acting insulin and therefore guarantee mediocre control. Insulins that have 70/30 in their names are a mixture of 70% slow acting insulin with 30% fast acting. They are most likely to be prescribed by doctors who don't have the resources to teach patients the correct way to use insulins.

By mixing the two kinds of insulin in one injection you make it impossible to match the fast acting part of the insulin to the carbs in your meals as well as making it impossible to match the slow acting part of the insulin to your fasting blood sugar. These insulins may give patients slightly better blood sugars than a regimen of only slow acting insulin--which is the only insulin they are compared to in studies. But that is only because slow acting insulin alone cannot give most people anything near a normal, healthy blood sugar.

Because for most people these 70/30 insulins they make it very hard to lower blood sugar anywhere near normal they are likely to produce the much too high blood sugars that lead to complications.

4. Brand Name Insulins are expensive. If you do not have insurance you will probably not be able to afford the newer brand name insulins which run about $85 for a vial that contains 1000 units or $185 for five pens that contain a total of 1500 units.

Fortunately, you can still get excellent control using the older insulins that are based on R insulin. These are NPH (for slow acting) and Humulin or Novolin R (fast acting) insulin. You will need to use two or three shots of NPH a day to cover your fasting blood sugars as NPH only lasts about 8 hours. R insulin needs to be injected 45 minutes to an hour before eating and it will last 3-5 hours.

However, once you get the hang of how to use these older, cheaper insulins you can get safe blood sugars with them. They are much cheaper at Wal-Mart than anywhere else, so if you are strapped for cash, that is where to buy your insulins.

5. Pens are more convenient than vials but much more expensive. Insulin comes in vials containing 1000 units and pens that contain 300 units each and are sold in packs of 5. If you buy vials you will also need a prescription for syringes with which to inject the insulin. If you buy pens, you will need a prescription for pen needles.

The pen is easier to use, but it is really not necessary if you are only doing one shot a day of long acting insulin. If you are using fast acting insulin in public places, a pen is much less confrontational than a syringe and many people prefer it for that reason. If cost is an issue, the vials are a much better deal.