Diabetes

TCOYD “Take Care Of Your Diabetes”

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This is to suggest that when there is a “Take Care Of Your Diabetes” conference nearby it is worthwhile for those with, or at risk of, diabetes; likewise for medical professionals. I attended the TCOYD conference here in March 2018, though I had never done so before; it was offered for about the 6th time in Sacramento, and many hundreds of times in the nation. For professionals at this session the conference cost was $30, and less for others. It was held at the Convention Center, attended by at least a thousand people. There were no openings for walk- inns. The general idea is this: People with an inherited predisposition, or diabetes, or abnormal diabetes screening tests of any sort, are encouraged to do simple things themselves to prevent later problems. Moreover medical providers may discover more about ways technology promotes patient personal involvement in the care of chronic disease; and, I believe, about the direction and future of medicine. Joan Borbon clued me in to TCOYD. We volunteer at a local Student Free Clinic. So I signed up. For me, personally, the whole day was a triple delight.

First, because the general thrust concurs with one I have long practiced: That in chronic disease treatment and prevention, people must be their own principle care-givers and managers. Diabetes is the perfect example. Why? No one can manage the illness without the direct personal understanding and involvement of the diabetic or pre diabetic; no Doctor, Legislator or friend or family member. But technology places the means to do so in the hands of the individual. For example, in diabetes, the personal Blood Glucose Monitor allows people, 24/7, to measure and control their own disease. No more time consuming lab or office visits, days long waits for test results. Moreover, in the forseeable future, access to reasonable, personal technology and information will make self care ever more practical and efficient. In my own little lifetime, it seems to me the most significant development in diabetes care has been the personal BG monitor, which has become acessable, reasonable, and simple to use.

Second, because I, a stubborn, arrogant macho man, ignored my own clear symptoms and family history for at least 15 years before discovering my own diabetes…never listening to my life, never thinking about it.* Maybe signs of diabetes were so easily overlooked because my routine screening tests were always normal; my doctors and I relied on them without another thought. But if we had considered my family history, or even listened to the voice of my body, we could have discovered my type 2 DM much earlier.

Many people with an interest in diabetes attend the conferences over and again, gradually learning more and more about the disease. And yet, while the conferences are very informative, perhaps it's wise to keep some things in mind: 
  1. Even if addressed mainly to the general public, these are medical conferences; they are funded completely by people who want to sell stuff–caveat Emptor — Buyer Beware.
  2. The eloquent and impactful speakers, aided by great media, are partially bought and paid for.
  3. The literature is as skillfully crafted to subtly mislead as are magazine or TV ads.
  4. The booths are staffed with highly trained professional salespeople. Beautiful, engaging people.

Third, The program is varied and relaxed enough to allow for casual unhurried conversation. A personal note: I like to run and sniff the world like an escaped hound dog. But always, even in childhood, Northern California has been the home where I return ever, where my family history and heart and dearest memories also live; as a physician, it’s been my medical home since 1959. Therefore in this broad focused meeting I often met up with old colleagues or friends who share an interest in diabetes. Steve Edelman, who many years ago concieved and organized TCYOD, was a Med student at UCD when it was still on the Davis Campus where I occasionally lectured; Demo Pappagiannis who coached and wrote several papers with me on coccidioidomycosis, was there. There were many other friends, colleagues, and physicians from Kaiser, UCD, Woodland, Davis, and Sacramento. And nurses; perhaps most of all. .

Nurses and P As are the Hands and Heart of medical care. Brooks Smith and I were the first lecturers for the UC Davis Rural Family Nurse Practitioner training program. It was in the Dept of Family Pracitce headed by Hughes Andrews, and managed by Mary Fenley and Leona Judson. Since then,– 45 years ago– it has evolved fast, grown, changed names, and fled the skirts of the Med School into the arms of Nursing. At the conference every local Nurse Practioner and PA I spoke with was a graduate of that particular program.

TCYOD is based in San Diego) at the center of a world of Spanish speaking folk with diabetes and prediabetes. Therefore A Cuidese Su Propio Diabetes– CSPD– is needed. If I were still crazy I would volunteer; but I am less insane now. Maybe someone can use material in Spanish I wrote for diabetics in Colonet, Baja CA. ¡Quizas!

* But during the first years of symptoms I was working day and night 7 days a week, rather doggedly doing My Thing with migrant worker night clinics, and Regional Rural Health which they grew to be, and Salud, an inner city clinic in Broderick, CA. At the same time I worked at UCD to establish an Occupational Medicine Program, and took on many consultant jobs in order to provide for my family, 6 people whom I supported but otherwise mostly left on their own. I was Sick, Out of My Mind. Over time I gradually developed severe bilateral lower extremity neuropathy. As my usual diabetes  tests were normal, neither I nor my doctors explored diabetes further. A neurologist confirmed the neuropathy, but asked: Do you drink? Yes occasionally. Well! He said, Don’t. A podiatrist ordered some $400 shoes. I had had a laminectomy in 1975 for and acute disc with foot drop, with lipiodol studies, so a CT was done. Nada. I ignored some other things: that my neuropathy was better when backpacking – and burning a lot of glucose. That the cold bothered others it didn’t trouble me. That my balance was slaightly off. Only after several years of worsening neuropathy did I order an old fashioned four hour Glucose Tolerance test. Bingo! Ironically, today anyone with a personal blood glucose test kit can do that home alone. I”m happy to say that the neuropathy has receded with control of my disease.. like many people, I detest initialisms and acronyms but they are epidemic;; as they say, It is what it Is. IIWII. So, TVOYD; Listen To Your Body. LTYB; Listen To Yor Family, their words acts, troubles, and History. LTYF; Hear, Think, And Do. HTAD.

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”

 

Wheed Machey

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I have diabetes and use a long acting repository insulin that slowly is released over about 24 hours. At night, if my blood sugar is very low  I sweat and awake.* That can happen if I forget to eat at all  after mid day because of mild 
gastroparesis;  my slovenly slouch stomach just sits there silently doing-nothing. I don’t get hungry.  see https://nwalmanac.wordpress.com/2016/07/28/a-90-hour-fast/  

For the same reason, lazy stomach,  I don’t like to eat much before lying down to sleep; a meal will stagnate acidly while   waiting for attention like a supplicant at The Department of Motor Vehicles.

By contrast,  mildly low  levels during sleep can spin off splendiferous dreams. At night when my bed is toasty warm the little lake of repository insulin warms up  too, and that heat causes a faster release of insulin. Last night I had such a dream based on the following real life situations:

My daughter, a well known free lance writer, has been waiting during several years for an eminent national  U S newspaper to be granted a visa to send her to Cuba for an interview with their most popular TV personality; he has, in effect, become too big to fail; he gently but sharply lampoons the average Cuban’s encounters with the dictatorship.

Yet it is unlikely a visa will be granted for an interview in the near future because of the  politics and economic circumstances of the two countries. The Cuban government fears calling more attention the embarrassingly popular TV show magnate. Our government– while grandly announcing an historic breakthrough in  diplomatic relations, tourism and commerce– fears voters.  Long after the hoopla, no average citizen can visit freely, independently, economically, and legally.

The two governments have quietly collaborated on restrictions which give each what they want, but pitifully little to the average would be visitor who hopes to travel freely and communicate freely with average Cubanos. The restrictions  and process remain obscure, but effectively make it impossible to visit except under conditions imposed by cooperating tour agencies and privileged Cuban groups that can profit nicely from the  great interest in Cuba travel. It is as usual: profit and  politics rule.

But last night was different. In a low sugar moment, L’s visa was approved. After a long and involved series of preparations too detailed to recall or understand, she left. Shortly afterward, a mysterious person called to ask me to remind her to look up Wheed Machey in Havana. At that point I awoke, recalling that I had not eaten much supper. Blood sugar 73; half a banana and a quarter of an apple took care of that nicely.

But what to do about Mr. Machey? Afraid to forget details as in most dreams, I wrote down his name and slept on it. Today I called L, but she didn’t know how to reach him, so I am posting, emailing and Face-booking this open letter, hoping it will be shared, and ultimately reach Wheed Machey H:

Muy estimado Sr. Machey,

Le saludo cordialmente. Lamento la nececidad de intentar conectarme con Ud. de esta manera tan extraordinaria. Creo que posiblemente somos parientes. Mis tatarabuelos vivian en Matanzas ,  pero no se nada de ellos. Por la situacion internacional creo que no voy nunca poder viajar a Matanzas antes que me muera.   Con la esperanza que me pueda responder lo mas luego posible,

Atentamente,

Juan Heriberto Huachuca  Machey

 

*Long ago I used both insulin and two oral medications for diabetes; after 45 minutes sweating in a very hot sauna, which always delights me, I felt weak; thanks to the combination of oral medications and long acting insulin my blood sugar was 10! But since stopping all medication except insulin I have never had a similar problem.