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Monday, March 15, 2010

30 Years of Miracles - Diabetes

If you landed here first, go read my first post in this series, 30 Years of Miracles - Heart Disease.

It is a good bet that if you are reading this post that either you or some of your family members suffer with diabetes. If not you probably at least have friends that struggle with the disease.

Diabetes is a very common chronic ailment. Yours truly has had to contend with the disease since age 29. Actually diabetes care has come a long way in a very short time. Before 1922, most people with insulin dependent diabetes simply wasted away and died quickly. After 1922 when insulin became available, those who would have died before, ended up living longer, usually long enough to develop complications (vascular disease, kidney failure, neuropathy, blindness) down the road which would ultimately end up killing them anyway.

When I became a doctor, I was at first taught that it really did not matter whether or not someone's diabetes was aggressively treated. That person would still get complications and ultimately die from those complications. I wondered at first what was the point of treating the disease at all if the risk of complications would not be changed? As a young medical student though I remember reading an account of a subset of patients (several of them physicians) who preferred to give themselves multiple injections of regular (fast acting) insulin several times daily rather than using the more conventional treatments of mixtures of long and short acting insulin. According to accounts, these people generally had better outcomes, had fewer complications, and lived longer. I wondered how could this be???

When I was a new doctor, virtually nobody tested their own blood sugar. Most diabetics relied on urine testing to determine their diabetic control. The problem is that urine testing is pretty much worthless. Before you have sugar in your urine, blood sugar will have to approach about 200 milligrams-percent. Normal fasting is around 100. So back in the old days your sugar had to be about double the norm before you could tell it was too high. In the 1980's the idea of self testing of blood sugar took off. I remember the first test device I had. The blood letting device reminded me of something from an Edgar Allan Poe short story. It was a beastly thing that you cocked and launched at your finger. You could see the lancet coming at you. It kinda reminded me of a guillotine for the finger. I also had to extract a rather sizable blood drop and put it on a strip, wait a minute, and then manually read the color of the strip against a chart.

I coupled my blood sugar testing with use of multiple injections of regular insulin (I remembered reading about the diabetic doctors of old) and I was able to achieve near normal results.

Problem is that my efforts were time consuming, sometimes slightly painful, and very lifestyle intrusive. Many people would not endure the inconvenience of my method of controlling blood sugar. Eventually I was able to get off insulin with weight loss, diet, and exercise. For a while I took nothing for diabetes and then got on oral meds and eventually had to get back on insulin in 2001.
In the meantime, diabetes care progressed. The blood letting devices became much more user friendly and have now evolved into little penlike devices which are adjustable for comfort. The lancets are also hidden so that you can't see them coming at you. It's even possible to extract blood from the forearm rather than the finger which many people find a lot less painful. Instead of reading strips against a color code chart, high tech meters now allow for only a tiny amount of blood to provide a reading within about 5 seconds.

Regular insulin has been replaced by insulin analogs which act even faster than regular insulin and provide a more "physiologic" response than before. I use a device called a Novolog Pen which is a little cartridge containing insulin. It is convenient for someone on the go. Instead of drawing up medicine in a messy syringe, you just dial up a dose on the end of the pen.


Long acting insulins like Lantus have been developed which provide a slow, predictable, non-peaking, release of insulin to provide a baseline level for tight control of fasting levels.

New oral medicines have been developed which work in a variety of ways, from stimulating the pancreas to increasing the body' sensitivity to insulin to reducing the production of glucose by the liver to blocking absorption of glucose from the gut.

Some patients are candidates for insulin pumps, which deliver a continuous baseline dose of insulin to the patient while at the same time providing bolus doses to cover meals.

All of the above medicines and methods were unheard of when I first became a doctor.

To my relief, research finally revealed that tight control of blood sugar indeed was found to reduce or eliminate complications. It finally dawned on me that before blood sugar testing and all the new treatments developed over the past 30 years, that it was virtually impossible to obtain tight diabetic control. It just couldn't be done with urine testing and the medicines of old……..so, everybody got complications. Lousy control was about the best control that could be expected. It does not have to be that way now.

In spite of all these great new inventions, the sad fact is that tight control of diabetes requires some degree of intelligence and commitment. Even with all the new technology, some patients are just not teachable to the point where they will ever achieve good control. Others are simply not interested. Diabetes is a very intrusive disease and requires daily and continuous lifestyle modifications. Lots of folks prefer to eat their cakes and cookies and take their chances down the road.

The real tragedy is juvenile diabetes that strikes children at very young ages. Many of these kids have a very poor prognosis. Sometimes the kids and the parents are just not teachable to the point that long term good results can be expected. The disease robs kids of their very existence. Kids should only worry about being kids, growing up, laughing, playing…..not worrying about testing blood sugar, not eating candy and cookies, not worrying about taking shots. I've never seen a kid yet that liked to take a shot. What a terrible disease this is for a young person.

A lot of work remains for the future. I'd like to see a noninvasive way to test blood sugar. Work is being done here but results so far have been sporadic. It would be so cool to have a device that could read your glucose level through your skin and at the same time be coupled to some kind of pump that could provide continuous regulation.

The ultimate would be perfecting a way to cause regeneration of the beta cells in the pancreas or teaching other cells to produce insulin. Every cell in our body contains the genetic code for each and every physiologic process. All we have to do is to figure out how to unlock the secret of what causes a beta cell to become a beta cell. When this discovery is made, I can envision people growing their own replacement beta cells, kidneys, or hearts, or livers. Science fiction? Nope, I have every confidence the answers are out there.

A lot of miraculous discoveries have been made in diabetes care in the last 30 years. Who knows what the next 30 years may bring?

9 comments:

  1. I remember your early testing devices and how painful they were. It's hard to believe some physicians didn't believe strict testing and treatment would help patients live longer, healthier lives. Almost archaic.

    I'm so thankful you are one of the serious diabetics who eats properly and takes strict care of your blood sugar levels.

    Debbie
    Right Truth
    http://www.righttruth.typepad.com

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  2. A year and a half ago I was diagnosed with Type II diabetes. The doctor wanted to put me on meds right away. I told him I'd research it and get back to him. He gave me two months. I found quite a bit of info on low carb diets and decided to try it. I went on under 40g of carb a day and when I went back I no longer had diabetes. My doctor said he tries to tell patients to try this but he hasn't had much luck with people sticking with it. I have been doing it for 1.5 years and lost 35 lbs, feel great and have just changed my way of eating. I don't feel like I'm on a diet. Dr. Eric Westman of Duke University has done a lot of research on this. There are many doctors blogging about this with tons of information and recipes. I gave up all grains - I make bread out of almond meal. I make spaghetti out of julienned zucchini and I make my own almond joy bars out of dark chocolate (90%) Lindt bars and unsweetened coconut, coconut oil and coconut milk. All the info is out there if you google it!

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  3. Anonymous,

    There is no doubt that many type 2 diabetics can be managed by diet alone, but as I said in the post, even diet control requires some degree of intelligence and commitment.

    Some are not smart enough to learn to eat properly. Others just don't care.

    Grouch

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  4. You are so right. I have shared my experience with people and most of them say they just couldn't do it. I'm not sure I could have had my success if it weren't for my wonderful husband who said he would eat this way too so I wouldn't have to cook things for him that I couldn't eat. He is now at his high school weight as the extra weight dropped off him. It really helps not to have anything in the house that I can't eat!

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  5. Being one of those lucky ones with good sugar/blood, I don't worry about diabetes, but my wifey does. I know and realize the burden it can be. I sympathize with you, but I'm counting on my heart to kill me off. Just think, if we ever whip heart disease and diabetes, we will be run over by a candy cigarette truck!
    73,
    Lizzard

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  6. Yeah, Lizzard,

    Who is Deanna? What time are you and Booger gonna pick me up?

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  7. Hey Grouch, I"m also an ER physician, in the great (as in greatly broke and corrupt) state of Illinois; I also have a daughter with Type 1 since age 3 (now 18).

    I've talked to long-term diabetics who had the disease for >50 years. They remember the huge syringes they had to sharpen themselves, and boil to sterilize...and now, it really is amazing what we have available.

    I just hope that Obamacare doesn't, among its many possible horrific consequences, squelch the research that's needed to cure this and other illnesses. But I'm hoping and praying for the best, that a cure or much easier way to control sugars and complications are found.

    Is your ER as insane as ours lately?

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  8. Deanna is the XYL, I inadvertantly logged in under her name.
    The question is, what time are you gonna be here!

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  9. Mo, Thanks for visiting. I am afraid BHO's health plan will end up forcing us into mediocrity. We'll all be sharing the misery together. Best wishes to your daughter.

    Our ER has actually been a little quieter than usual for the last couple weeks. Got a feeling the storm in on the way.

    Grouch MD

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