A Modest Proposal* on Diabetes Detection and Control

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Self Management of Early and Silent Diabetes or Pre-Diabetes

Colonet is an inland town of about 2500 in Baja California. I have gone there four times with my daughter Amy and the Los Gatos Methodist Church to build small houses. They have now built more than 40, generally during Easter vacations so school children can participate. There are two doctors offices and two pharmacies in the tiny  town but it serves a wide local area; ‘universal care’ is available at a government clinic staffed – in a common South American way –by a recent medical school graduate who must pay back year for year of medical school by staffing several remote rural clinics; he is there only a few hours each week, so people line up at 4 AM for one of the few openings. Otherwise they must see a private doctor at about US$35 a visit. For those who have a job, the average daily income is about US $10 per day, but work is not available year round. The nearest hospital is 60 Km distant.

It may seem surprising, but the area is highly agriculturally productive. The largest tomato grower in the world is nearby. The Driscol strawberries we buy here are grown in the region. Why? It sits between the ocean and the Sierra de San Pedro mountain range that reaches up 10000 feet to suck in winter  rain, allowing for irrigation like a tiny San Fernando Valley; water and sun and hard work make it productive. Migrant workers, often speaking no Spanish, invade for harvests. This year it rained a great deal and the area is lush with small blossoming plants and green with bushy growth.

The local Christian Church has been very helpful in building the small homes. They often help people to acquire a tiny  plot of land, which is a required, as well as someone in the family with a job. The pastor’s wife has diabetes as does her mother and their four year old  daughter;  they assisted in preparing for a series of evening diabetes screening clinics during my week there. The disease is so  common that among the first 20 people screened ( excluding the pastor’s family)  9 had diabetes or pre-diabetes.  Below is the translation from Spanish of the written introduction  and information that was given to people who attended the screenings. Of course, the problem is obvious: When you find a person with diabetes, under these circumstances what do you do? I believe self management is the only realistic, timely, and practical option. To make that sort of thing work, it is best for small groups of people with diabetes to work together over time to solve problems like Where to find medications and supplies most reasonably; How to measure and keep track of glucose levels; How to safely adjust medication in view of the results. The pastor  has an internet connection. It is a long and twisted road, but one that otherwise most Colonet people with diabetes travel alone. What follows below is information  provided at the screening clinics, addressing the screening process, the general nature of the disease, glucose self monitoring, and possibilities for  self treatment. It is translated and redacted  from a Spanish blog.

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RAPID SCREENING FOR DIABETES AND PRE-DIABETES

Blood glucose is measured about two hours after a sugar or starch rich meal.

Diabetes Positive Screening test:

  1. Any blood glucose level above 200 mg/dL at any time, including the
  2. Challenge test: Blood glucose above 200 mg/dL 2 hours after a sweet or starchy meal
  3. After 10 hour fast: any blood sugar over 125 mg/dL

PreDiabetes Positive Screening test:

    1. after a  10 hour fast: blood sugar 100-125 mg/dL
    2. 2 hours after sweet or starchy meal blood sugar 140-199 mg/dL

 Conversions between mmol/dL  and mg/ dL  here

Screening tests are highly suggestive but not diagnostic. When positive, reconfirm whenever possible, with a qualified laboratory and physician.

 These screening tests are valid at all ages.

Diabetes has serious complications, all caused by elevated levels of blood Glucose (sugar). In early years the disease is silent. One feels fine while high glucose levels destroy the most delicate but critical circulation in the kidneys, retina of the eyes, feet, and elsewhere.Fortunately we live in a time when prevention of that damage can be  effective, and simple. But only those who have or who discover their  disease can successfully treat it; especially those with the most common kind:  silent diabetes. To do that the disease must be revealed… diabetes diagnosed if present,. , and then controlled by:

      1. Using a personal glucose monitor to keep track of blood glucose levels
      2. Measuring and recording glucose levels
      3. Learning to manage the illness… i contend that is best done as a member of a small group who regularly share their experiences and information.

Some may wonder why it is essential or practical to self control and self manage this particular illness. Although it can best be done with the help of a physician, only the person who has this disease can do so. Physicians cannot hang around 24/7. The time a physician can actually help most is after the disease had done so much damage that a foot has to be cut off, or a kidney replaced: too late for prevention. A competent physician welcomes self management of early or silent disease. All this may seem complicated, but it becomes quite natural quickly when the diabetic can:

  1. measure, blood glucose, record the result, and then
  2. use the results to manage and control the disease
  3. share results and experience with others who have diabetes for: a) interpretation of results; b) finding sources for test strips, medications or professional advice;c) understand medications and ways to manage it. For example, glucose monitoring is crucial, but very expensive. However, an hour drive away is a large international chain store where  costs for glucose monitoring supplies are: ( US$):  Monitor $  9.00; 100 test strips $17.88; one time cost of lancing device $5.84; 100 lancet needles, $1.84 Total $34.24 , adequate for about 6 months monitoring– $0.19/day! By comparison,  costs where test strips alone are $ .50-.75 each, are many times that depending on how many strips are required.

The personal glucometer (glucose measuring device or meter) is inexpensive, accurate and lasts for years. One must learn to use it, use it regularly and record results and circumstances affecting each  test. . At first it is advisable to measure glucose levels often in order to better understand the illness. Yet because test strip use can often gradually be reduced to as little as 5 or six times weekly, plus anytime a concern arises. For example, one might suspect, for whatever reason, a blood glucose is low, and eat “just in case.” That should not be done: measure, don’t guess!  

 

The blood glucose monitoring record: ( for one month…the first of 30 spaces appear) below)

Date mo/day Time 24 hr Level before meal 2 hours later Useful details like: what was eaten, an unusual event like illness, or any other comment

 

How food affects blood glucose:

Carbohydrates fats and proteins can all be converted to glucose…which  is vital to the human body even if too much is harmful. Some carbohydrates convert to glucose very quickly and therefore are a problem for people with diabetes:

Fast: processed or refined bleached grains like white wheat flour, and white rice; processed fruit sugars (fructose) like corn sugar and beet or cane sugar; starchy vegetables like potatoes and some sweet fruits like peaches, apples, bananas, oranges.

Slow: beans, seeds like most  nuts, peas, lentils, meat, fish, chicken, cream is less fast than milk because less lactose, milk sugar.

Take control of your diabetes when  it is silent and serious irreversible complications are most easily prevented.

You are the only person who can control your disease!

Note 1) Insufficient insulin was discovered to be present in diabetes nearly 100 years ago. Insulin is made in the pancreas; in the most common sort, Type 2 diabetes, the pancreas still can make some insulin, but not enough to meet the body needs; so glucose accumulates. The disease  usually gets worse with time– especially if not controlled well. In type 1 diabetes almost no insulin is produced, and that is a different but related illness.

Note 2) Fasting blood sugar— after not eating for about 10 hours– can be deceptive in Type 2 diabetes because the pancreas has been resting (usually overnight) making enough insulin to keep blood glucose levels normal or nearly so.

Note 3) Hemoglobin A1C test: Red blood cells are not alive. They were grown in the bone marrow, and when growth is complete, they are delivered to the blood where they act as tiny carriers of Oxygen. That Oxygen is delivered to the tissues, and the empty red blood cells are sent back for more. They live about 90 days and are then discarded. But when they were being formed they took in the amount of glucose that was in the blood at that time. Therefore, the average glucose level in those red blood cells is a measure of the average blood glucose during the previous 90 days. Problem: both high blood sugars and low blood sugars can be seen in early type 2 diabetes because the pancreas can over react to high blood sugars and therefore over-produce while trying to catch up at night. So an average of high and low glucose can be deceptively normal. Conclusion: a challenge test, similar to the old glucose tolerance test, is superior to looking at averages or fasting blood glucose level. This screening test is significant because it offers a fast, and economical screening that can be done by anyone with a glucose meter.

Note 4) The personal glucose meter was pioneered by Richard K Bernstein, an engineer with severe diabetes working on a glucose monitor for physician offices. His diabetes became so advanced he  began to control his own blood glucose very tightly and began to improve; then he did his own study among students, which suggested a personal glucose monitor was the key to diabetes control.   What happened is classic:The study results were rejected by the academic  medical profession. So he went to medical school and began to practice immediately as a diabetes specialist. His book –The Diabetes Solution- is largely viewable on line

Dr. Bernstein completely recovered on a very low carbohydrate high protein diet and tight glucose control; he suggests an average blood glucose of 81 mg/dL;  he is alive, and lively, over 80 years old. He participates regularly in Teleseminar Webcasts. The March 29 2017 event can be seen  here.

* A Modest Proposal is a 1729 satire by Jonathon Swift: For preventing the Children of Poor People From being a Burthen to Their Parents or Country, and For making them Beneficial to the Publick’. He outrageously suggests newborns be harvested for food to reduce the numbers of poor and also feed the rest. Perhaps the only bearing of Swift’s satire to this little essay is the focus on the millions of poor we seem willing to sacrifice to diabetes, even though it’s cruel, and irrational. and avoidable.

 By working together outside a system that tends to sacrifice the good to the perfect, and by self managing their own disease, people can at least greatly improve their lives and well being. Yet for our world’s millions of unsuspecting pre-diabetic and diabetic people, only those who discover their disease early and begin to self control it can easily limit its ravages. I believe that worldwide– and even in the USA– there are tens of  millions who could benefit from a similar process  until something more academically perfect comes along.

 Even privileged, idealistic and committed people can  become  insensitive, intolerant, and dismissive, based on disagreement about dogma, about the meaning of ideas and words. Words are, after all, only symbols; like metaphors they represent things or ideas usually unseen. When we hear or  read a word, we rewrite it in our own minds. We interpret and give it our own personal twist. When one half of our nation cannot stand to hear or see the other half, because of ideas or words, it would seem wise to ask ourselves Why do  Words Hurt? Why are we so willing to wound  one another? Or to  put another way, Why so terribly thin skinned? Who ever said ‘sticks and stones will break my bones but words will never hurt me’ was from another era; like Swift.

It seems to me more appropriate to think about deeds rather than only  words. So in Colonet this year, I wore a baseball cap with a silent modest proposal written on the face to imply  that :

We are in this together. In this place, this nation, this world. We should try to ‘read’, or value one another for what we DO, not what  we appear to BE: Not color of skin or political affiliation; or religion; or citizenship, or age, sexuality or gender— but rather, our behavior; our acts; and judge ourselves and others as reasonably as our acts allow.

“THNIK”

 

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