Collection of Internet/Collection of Internet.iso/faq/misc/diabetes/general

Internet Message Format | 1994-03-20 | 52KB

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From: [e-mail] (Edward Reid)
Newsgroups: misc.health.diabetes,misc.answers,news.answers
Subject: misc.health.diabetes FAQ (general)
Date: Sun, 20 Mar 94 16:20:35 PST(-0800)
Organization: Paleolithic Refugia
Message-ID: <[e-mail]>
Reply-To: [e-mail] (Edward Reid)
Approved: [e-mail]
Expires: Sun, 1 May 1994 00:00:00 GMT
Summary: Answers questions which have been asked frequently in
    misc.health.diabetes. Likely to be of interest to anyone who has
    diabetes or a friend or relative with diabetes, especially if
    newly diagnosed or if a new problem has just arisen.
Supersedes: <[e-mail]>
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Xref: bloom-beacon.mit.edu misc.health.diabetes:4457 misc.answers:496 news.answers:16620

Archive-name: diabetes/general
Last-modified: 12 Mar 1994

Changes: Minor edits (12 Mar)

Copyright 1993-1994 by Edward Reid. Re-use beyond the fair use provisions
of copyright law and convention requires the author's permission.

CONTENTS
========

GENERAL
  Where's the FAQ?
  What's this newsgroup like?
  What is glucose? What does "bG" mean?
  What are mmol/L? How do I convert between mmol/L and mg/dl?
  What's type 1 and type 2 diabetes?
  Is it OK to discuss diabetes insipidus here? What is it?
TESTING
  How accurate is my meter?
  Ouch! The cost of test strips hurts my wallet!
  What do meters cost?
  How can I download data from my One Touch II?
  I've heard of a non-invasive bG test -- the Dream Beam?
  What's HbA1c and what's it mean?
TREATMENT
  My diabetic father isn't taking care of himself. What can I do?
  Managing adolescence, including the adult forms
  So-and-so eats sugar! Isn't that poison for diabetics?
  Insulin nomenclature
  Injectors: Syringe reuse and disposal
  Injectors: Pens
  Injectors: Jets
  Insulin pumps
  Beta cell implants, pancreas transplants, future cures
  What's a glycemic index? How can I get a GI table for foods?
  I beat my wife! (and other aspects of hypoglycemia) (not yet written)
  Does falling blood glucose feel like hypoglycemia?
  Alcohol and diabetes (not yet written)
SOURCES
  Where can I mail order XYZ?
  How can I contact the American Diabetes Association (ADA) ?
  Could you recommend some good reading?
DCCT
  What is the DCCT? What are the results?

Subject: Where's the FAQ?
=========================

Millions of volunteers are working on drafting the FAQ in their Copious Spare
Time (tm). Needless to say, this isn't moving very quickly. If you want to
volunteer to research and/or write, contact Steve Kirchoefer
([e-mail]).

This brief FAQ attempts to answer the questions which have been most
frequently asked in misc.health.diabetes (m.h.d). This is not a complete
informational posting. My only criterion for inclusion is that the question
has been frequently asked in m.h.d, either explicitly, or implicitly by
posting a related question or a common misconception.

An informational posting on insulin pumps is maintained and posted regularly
by Jim Summers ([e-mail]), with lots of help from Joan Stout
([e-mail]).

Other informational postings will, we hope, appear as volunteers find the
time to write them.

I've used ideas and information from many people in writing this FAQ. I haven't
attempted to identify them, but I thank them all. The words herein are mine
unless otherwise credited.

If you read this and it helps you, please let me know what part helped, and
why. If you read this and can't find what you want, let me know that too.
Such comments will help me and the other volunteers decide what is worth
working on, and whether. You'd be surprised how little feedback we get.

This document is available from the news.answers archives at rtfm.mit.edu.
Using anonymous ftp, get the file:

   /pub/usenet/news.answers/diabetes/general

or send an email message to [e-mail] containing:

   send usenet/news.answers/diabetes/general

Subject: What's this newsgroup like?
====================================

Posting topics range through emotional support, treatment techniques,
psychological factors, health care practices, and insurance. The atmosphere
is generally a highly supportive one, and most participants believe strongly
that this is an important aspect. As in other parts of the net, there are one
or two regular participants who believe that it is important to question the
motives and/or knowledge of anyone posting a new problem. If you find that
the first response is antagonistic, please wait a few hours. Every
antagonistic response will elicit a dozen sympathetic responses.

The same caveat applies here as in all newsgroups: the advice is worth what
you paid for it. This applies in spades to a critical health topic such as
diabetes. Never substitute informal advice for a physician's care. Advice
given in m.h.d is *never* medical advice.

The variety of individual responses to diabetes is exceeded only by the
variety of individual responses to life. No two patients respond alike, and
many respond *very* differently from others. These differences are
physiological, not just psychological. They reflect not only varying
responses, but the fact that diabetes itself probably has many causes, many
more than the few types currently recognized (see section on types). When you
read advice, realize that what works (or doesn't work) for someone else may
not work (or may work) for you. When you give advice, try to remember that
most advice is relative to the individual, not absolute. Recognize that you
can't treat your own diabetes by a set of rules, but only by knowing how your
own individual body and physiology work and by adjusting to your own
mechanisms.

Subject: What is glucose? What does "bG" mean?
==============================================

Glucose is a specific form of sugar, one of the simplest. It is the form
found in the bloodstream. "Blood sugar" always refers to blood glucose, and
is abbreviated bG. All bG meters are specific for glucose and will not
respond to other sugars, such as fructose, sucrose, maltose and lactose.

Subject: What are mmol/L? How do I convert between mmol/L and mg/dl?
====================================================================

mmol/L is millimoles/liter, and is the world standard unit for measuring
glucose in blood. Specifically, it is the designated SI (Systeme
Internationale) unit. "World standard", of course, means that mmol/L is used
everywhere in the world except in the US. A mole is about 6*10^23 molecules;
if you want more detail, take a chemistry course.

mg/dl (milligrams/deciliter) is the traditional unit for measuring bG (blood
glucose). All scientific journals are moving quickly toward using mmol/L
exclusively. mg/dl won't disappear soon, and some journals now use mmol/L as
the primary unit but quote mg/dl in parentheses, reflecting the large base of
health care providers and researchers (not to mention patients) who are
already familiar with mg/dl.

Since m.h.d is an international newsgroup, it's polite to quote both figures
when you can. Most discussions take place using mg/dl, and no one really
expects you to pull out your calculator to compose your article.

Many meters now have a switch that allows you to change between units.

To convert mmol/L to mg/dl, multiply by 18.

To convert mg/dl to mmol/L, divide by 18 or multiply by 0.055.

And remember that reflectance meters have a 10-15% error margin at best, and
that plasma readings are 15% higher than whole blood, and that capillary
blood is different from venous blood.  So round off to make values easier to
comprehend and don't sweat the hundredths place.  For example, 4.3 mmol/l
converts to 77.4 mg/dl but should probably be quoted as 75 or 80.  Similarly,
150 mg/dl converts to 8.3333... mmol/l but 8.3 is a reasonable quote, and
even just 8 would usually convey the meaning.

Actually, a table might be more useful than the raw conversion factor, since
we usually talk in approximations anyway.

   mmol/l     mg/dl     interpretation
   ------     -----     --------------
     2.0        35      extremely low, danger of unconciousness
     3.0        55      low, marginal insulin reaction
     4.0        75      slightly low, first symptoms of lethargy etc.
     5.5       100      mecca
    5 - 6     90-110    normal preprandial in nondiabetics
     8.0       150      normal postprandial in nondiabetics
    10.0       180      maximum postprandial in nondiabetics
    11.0       200
    15.0       270      a little high to very high depending on patient
    16.5       300
    20.0       360      getting up there
    22         400      max mg/dl for many meters and strips

Preprandial  = before meal
Postprandial = after meal

Subject: What's type 1 and type 2 diabetes?
===========================================

The term diabetes mellitus comes from Greek words for "flow" and "honey",
referring to the excess urinary flow that occurs when diabetes is untreated,
and to the sugar in that urine.

Diabetes mellitus (DM) comes in four classifications (which some will argue
don't really represent the actual types very well):

   type 1 -- characterized by total destruction of the insulin-producing beta
             cells, probably by an autoimmune reaction. Onset is most common
             in childhood, thus the common (but now deprecated) term
             "juvenile-onset", but the onset up to age 40 is not uncommon and
             can even occur later. Patients are susceptible to DKA (diabetic
             ketoacidosis). There seems to be some genetic tendency, but the
             genetic situation is unclear. Most patients are lean. Always
             requires treatment by insulin. Not sex-linked. Also referred to
             as IDDM (insulin dependent diabetes mellitus).

   type 2 -- characterized by insulin resistance despite adequate insulin
             production. A large majority of patients are overweight at onset,
             and a majority are female. Most are over 40, hence the common
             (but now deprecated) terms "adult-onset" or "maturity-onset", but
             onset can occur at any age. Patients are not susceptible to DKA.
             There is a strong genetic tendency, but not simple inheritance.
             Depending on the individual, treatment may be by diet, exercise,
             weight loss, oral drugs which stimulate the release of insulin,
             or insulin injections -- and usually a combination of several of
             these. Also referred to as NIDDM (non-etc) *even when treated
             with insulin*.

   type 3 -- a catchall for forms not covered by the other types,
             including loss of the entire pancreas to trauma, cancer,
             alcohol abuse, or exposure to chemicals.

   type 4 -- gestational. Occurs in about 3% of all pregnancies as a result of
             insulin antagonists secreted by the placenta. It is recommended
             that all pregnant women receive a screening glucose tolerance
             test between the 24th and 28th weeks of pregnancy to detect
             gestational diabetes early if it occurs, as diabetes can cause
             serious difficulties in pregnancy. Usually requires insulin
             treatment. Not DKA-susceptible. Usually disappears after
             childbirth, but not always. Most authorities state that the
             typical patient is female ...

About 90% of diabetes patients are type 2 (some 12 million in the US), and
about 10% are type 1 (some 1 million in the US). Discussion on m.h.d tends to
run about 2/3 type 1, I'd guess. This probably reflects the fact that type 1
diabetes is harder to ignore, and that type 2 seldom strikes the younger
people who are more likely to have net access. Type 2 is *not* less serious.

"1" and "2" are often written in Roman numerals: type I, type II. Because
typography is often unclear on computer terminals, I've stuck with the Arabic
numeral version.

Diabetes accounts for about 5% of all health care costs in the US, some
US$90 billion per year.

Subject: Is it OK to discuss diabetes insipidus here? What is it?
=================================================================

Diabetes insipidus (DI) results from abnormalities in the production or use
(two main types) of the hormone arginine vasopressin. The excess urine flow
is devoid of sugar. There are no blood glucose abnormalities, and in fact
there is nothing in common with diabetes mellitus except the excess urination
when untreated. Diabetes insipidus can be treated with hormone replacement
(by nasal spray or injection). DI is much less common than diabetes mellitus,
though a few people have discussed it on misc.health.diabetes and are reading
m.h.d. Such participation is certainly welcome, but because the number of DI
patients is only 1 or 2 per 10,000 population (25,000-50,000 in the US),
there probably isn't a critical mass for discussion on Usenet. One possible
resource for DI patients is

    Diabetes Insipidus and Related Diseases Network
    Route 2 Box 198
    Creston, IA 50801

Subject: How accurate is my meter?
==================================

bG (blood glucose) meters are not as accurate as the readings you get from
them imply. For example, you might think that 108 means 108 mg/dl, not 107 or
109. But in fact all meters made for home use have at least a 10-15% error
under ideal conditions. Thus you should interpret "108" as "probably between
100 and 120". (See above for conversion to mmol/L.) This is a random error
and will not be consistent from test to test. You cannot expect to get
exactly the same reading from two tests done one after the other, nor from
two meters using the same blood sample.

This is generally considered acceptable because variations in this range will
not make a major difference in treatment decisions. For example, the
difference between 100 and 120 may make no difference in how you treat
yourself, or at most might make a difference of one unit of insulin. With
present technology, more accurate meters would be much more expensive. This
expense is only justified in research work, where such accuracy might detect
small trends which could go undetected with less accurate measurements.

This discussion applies to ideal conditions. The error may be increased by
poor or missing calibration, temperatures outside the intended range,
outdated strips, improper technique, poor timing, insufficient sample size,
contamination, and probably other factors. Contamination is especially
serious since it can happen so easily and is likely to result in an overdose
of insulin. Glucose is found in fruits, juices, sodas, and many other foods.
Even a smidgen can seriously alter a reading.

When comparing meter readings with lab results, also note that plasma readings
are 15% higher than whole blood, and that capillary blood gives different
readings from venous blood.

Visually read strips are slightly less accurate than meters, with an error
rate around 20-25%.

By "error rate" I mean twice the standard deviation from the mean. An error
rate of 15% says that about 97% of the readings will be within 15% of the
actual value.

Subject: Ouch! The cost of test strips hurts my wallet!
=======================================================

The cost of test strips is a complex interaction of R&D costs, manufacturing
costs, marketing strategy, insurance practices, and undoubtedly other
factors. You can ask on the net if you want; you'll get lots of comments but
no answers.

There are a couple of ways of reducing the cost of testing. One is to seek out
the best price for the strips; large stores such as FEDCO often have good
prices, as do some mail order suppliers (see mail order section).

A second way is to use visually read strips (Chemstrip bG and a couple of
lesser known brands) and cut them in half or even in thirds. Do the cutting
carefully with a pair of strong, *clean* scissors, and get the strips back
into the vial as quickly as possible. There have been reports that some
manufacturers claim this procedure will cause problems, but those who have
used the technique report that it works well. Visually read strips are
slightly less accurate than meters.

Do *not* cut strips when using them in meters. The results will be totally
incorrect.

Most discussion on m.h.d of the cost of test strips has centered on the US.
I'm not sure why, though a good guess is that differences in health care
systems and national policies make this issue more critical to the individual
patient in the US. There is no dearth of non-US participants on m.h.d.

Subject: What do meters cost?
=============================

The flip side of expensive test strips is that the manufacturers virtually
(and sometimes literally) give away the meters to hook you on their test
strips. Don't pay full price for a meter; look for discounts, rebates, and
giveaways. For example, as of this writing I'm looking at a catalog that
shows a Glucometer 3 for US$45, with a US$30 manufacturer's rebate *and* a
US$30 trade-in allowance if you already have a competing meter -- which means
you make US$15. There are similar deals on other meters. But make sure you
consider the cost of strips as well as the cost of meters, and find out which
your insurance will pay for. The most fully featured meters, such as the One
Touch II, don't have such widely advertised deals, though you can probably
find ways of getting them at discount.

If you have insurance that pays for strips but not for the meter, it may be
worth calling the meter manufacturer and trying to persuade them to give you
a meter. If anybody has actually tried this, let us know whether or not it
worked.

As with strips, this discussion of costs applies to the US, and there has been
little discussion of meter costs outside the US on m.h.d. An Australian
correspondent notes a much narrower choice and higher cost of meters there,
but subsidized (pardon, subsidised) test strips. Elsewhere? Please post.

Subject: How can I download data from my One Touch II?
======================================================

You can get a cable to hook the One Touch II to a PC from the meter
manufacturer, LifeScan. The cable includes some electronics, not just a
cable, so you probably don't want to make your own. In the US the cable is
free. Elsewhere, LifeScan lets each international office set its own policy
on cable distribution, and some are charging substantial fees. North American
telephone numbers are:

    U.S.A.    1-800-227-8862
              [phone]
    Canada    1-800-663-5521
    elsewhere (If you have trouble locating a phone number for your
               international office, let me know. If this problem is
               recurrent, we will add the list of offices here.)

LifeScan provides some software for downloading the data. According to a
recent posting, it is minimal download software, and you must use other
software (for example, a spreadsheet) for analysis. Vic Abell's freeware
TOUCH2 (described below), by contrast, has received rave reviews from its
users for its analysis features.

No comparable Macintosh software is known to be available. However,
downloading the raw data using a basic telecom program (such as Kermit or
ZTerm) is feasible. The meter responds to basic simple commands. LifeScan
will send you a list of the commands and responses. Call and ask for the
protocol specification, or FTP it from Vic Abell (see below).

Info from Vic Abell <[e-mail]>:

TOUCH2 is Vic Abell's freeware MS-DOS/PC application for downloading and
analyzing data from the LifeScan One Touch 2 blood glucose meter. TOUCH2
interfaces to the RS-232 data port of the One Touch 2, downloads the data on
command, and provides a variety of analytical displays. It's available via
anonymous ftp from vic.cc.purdue.edu (128.210.15.16) in /pub/touch2.zip or
/pub/touch2.tar.Z, with information in /pub/touch2.README. When ftp asks for
a password, you must provide your valid email address of the standard form
[e-mail].

The protocol specification is available from the same site, same directory,
filename lifescan.ot2.

If you do not have ftp access, you can get a copy of a TOUCH2
distribution by email by sending an email letter to:

[e-mail]

In the body of the letter put:

reply <your_email_reply_address>
connect vic.cc.purdue.edu anonymous <your_email_address>
chunksize 100000
binary
uuencode
get /pub/touch2.zip
quit

If you want touch2.tar.Z or lifescan.ot2 instead, put its name in place of
touch2.zip in the "get" directive. Multiple "get"s are allowed.
<your_email_address> must be in the standard form [e-mail]. If you
want btoa encoding instead of uuencoding, replace the "uuencode" line with
"btoa". If you can't receive email messages of 100K bytes, change the
"chunksize" line. Be patient; the server sometimes takes two or three days to
process the backlog, and recently up to a week.

Subject: I've heard of a non-invasive bG test -- the Dream Beam?
================================================================

There is at least one development project in hot pursuit of a bG test device
which operates by shining light through flesh (through the thumbnail in one
case) and analyzing the light that passes through. Glucose doesn't affect
light much differently from many other substances in the body, so this is not
an easy task. Some field trials have been done, but the developers have a way
to go to reach acceptable accuracy. A successful product is far from
guaranteed, and may be several years away if it arrives at all.

One estimate is that such a meter might cost about US$1000. Assuming the
testing is free, this would pay for itself in 1-2 years for many patients.
Look for the insurance companies to throw up some roadblock to achieving
these savings, at least in the US.

Subject: What's HbA1c and what's it mean?
=========================================

Hb = hemoglobin, the compound in the red blood cells that transports oxygen.

A1c is a specific subtype. (The 1 is actually a subscript to the A, and the c
is a subscript to the 1.) Glucose binds slowly but irreversibly to
hemoglobin, forming a stable sub-sub-type which is only eliminated by the
normal recycling of the red blood cells, which have a lifetime of about 90
days. In non-diabetic persons, the formation and destruction reach a steady
state with about 3.0% to 6.5% of the hemoglobin being the A1c subsubtype.
Since most diabetics have a higher average blood glucose (bG) level than
non-diabetics, the steady state level is higher in diabetics. The HbA1c level
thus is an indication of the average bG level over the past 90 days or so.

Interpreting HbA1c values is tricky because several different tests have been
introduced over the last 15 years, measuring slightly different subtypes with
different limits for normal values and thus different interpretive scales.
All are still in use in some places. When you get a lab result, be sure to
look at what the lab considers to be the normal range. Most discussion of
HbA1c values in m.h.d appears to be based on the most recent test, where the
normal range is approximately 3-6.5%. Caveat lector.

Subject: My diabetic father isn't taking care of himself. What can I do?
========================================================================

We'll assume your father has type 2 diabetes. See separate section for
definition of types.

Type 2 diabetics, and those who care for them, are in a difficult situation.
Type 2 strikes late in life, so personal habits and patterns are already
formed and solidly engrained. Yet in most cases those habits and patterns are
exactly what must be changed if a newly-diagnosed diabetic is to care
properly for his or her health. This is a difficult psychological problem.

The cornerstones for treating type 2 diabetes are exercise, weight control,
and diet. A high percentage of type 2 patients who apply these therapies
assiduously can control the disease with these therapies alone, without
requiring insulin or oral hypoglycemic drugs. Naturally these are also some
of the most difficult aspects of life to change. There can be no single or
simple answer of how to help or encourage a particular individual find a
combination of therapies which not only controls the disease but also is
psychologically acceptable and which can be incorporated as a lifetime
pattern. Helping depends on knowing the individual's habits, patterns,
motivations, desires, likes and dislikes, and working with all the existing
conditions and everything brought forward from past life.

Doctors and other health care professionals tend to treat type 2 diabetics
with drugs (oral hypoglycemics) and insulin rather than taking the time to
try to get their patients to make the difficult lifestyle changes described
above. This isn't true of all practitioners, but of many. They have good
reason for this tendency: they know all too well (often from painful personal
experience) that most type 2 patients aren't going to make many changes
anyway, and the doctors and other practitioners don't like wasting their time
and breath. So it's likely to fall to friends and relatives who care deeply
to educate themselves about type 2 diabetes and do what they can to encourage
their loved one to make changes. In particular, if the doctor has left the
impression that drugs and insulin are the only treatments, make sure to
counter that impression with information about the value of exercise, diet,
and weight control.

You will need far more information than is appropriate for a Usenet FAQ
panel. As a start, call the ADA (see ADA section), get a subscription to
_Diabetes Forecast_ (see journals), and visit a university library and browse
in the diabetes section in the stacks.

Beyond the generalizations above, a few specifics are usually of value:

   Set a good example in your own life. Exercise and eat a good diet.
   The recommendations for diabetics are healthy choices for anyone.

   Share your example. Serve a tasty, low-fat diet to family and friends
   when they are your guests.

   Suggest joint activities. Suggest a walk instead of watching a
   ball game.

   Make sure your diet and activities are visibly enjoyable so your
   guests will accept your invitiation to join you.

Subject: Managing adolescence, including the adult forms
========================================================

Adolescents have special problems in managing diabetes. These include a
variety of physiological problems related to puberty and rapid growth, social
problems related to growing up and the general social pressures of adolescent
life, and the psychological turmoil caused by the expectations of others. I'm
here today to talk about (hey, hold the eggs and tomatoes) expectations.

Actually, this all applies to adults as well, though the subtle points may
differ.

The most important thing to remember, for the adolescent, the parent, and the
health care provider, is


              All Blood Glucose Measurements Are Good.

              There Are No Bad Blood Glucose Readings.


If that doesn't sound right, then please take two steps. First, learn why it
is true. Then chant it like a mantra until you internalize it, so that you
never give off the slightest vibes to the contrary.

Why is it true?

There are two kinds of adolescents (to simplify life enormously): those who
rebel and those who want to please. Ironically, the rebellious are probably
easier to deal with in treating diabetes. "So my blood sugar is 350, so
what?" Bad? No, that's good: you know what's going on, and so does your
child. The point of blood glucose measurement is to respond -- not to be good
or bad -- and only with an accurate report can you and the patient respond.

  [Compulsory digression: 350 mg/dl = 20.0 mmol/L.]

Look what can happen to the eager-to-please child:

   Child: My blood sugar is 350.
   Adult: Oh, that's awful! You must try to be better!
      [next time]
   Child: My blood sugar is ... um [to self: I must be good] 140 ...
   Adult: Oh, that's great!

In short order, the log book looks great but the HbA1c doesn't jibe.

This all happens with the best of intentions from all parties. The child is
trying to please, and is behaving in exactly the ways that elicit approval.
The adult is trying to care for the child's health in the most natural ways.
And the result is one that neither desires.

Thus the positive mantra to replace the half-negative one above:


              All Blood Glucose Measurements Are Good.

           Responding To Blood Glucose Readings Is Good.


. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

There is an excellent article entitled "Insulin Therapy in the Last Decade: A
Pediatric Perspective", by Julio Santiago, MD, of the St. Louis Children's
Hospital and the Washington University School of Medicine in St. Louis,
Missouri, which appears in _Diabetes Care_, volume 16 supplement 3, December
1993, pp. 143-154. The article discusses many aspects of treating pediatric
diabetes. Santiago spends several pages discussing how to establish realistic
and honest approaches to self-monitoring. I highly recommend the article.

Subject: So-and-so eats sugar! Isn't that poison for diabetics?
===============================================================

This is asked from both sides: the non-diabetic who doesn't understand
diabetes, and the diabetic who gets tired of hearing "I won't put any sugar
on the table" etc etc ad nauseum.

Diabetics should eat a high-quality, healthy diet very similar to that
recommended for everyone. This will include some sugar, and research
indicates that obtaining a moderate amount of carbohydrates in the form of
sugar makes little or no difference in controlling blood glucose levels. There
isn't room here to describe all the aspects of diabetes treatment that make
this so.

No one has suggested a really good, uniformly satisfying answer to the public
know-alls who insist they know more than you do. Feel free to add to this
list:

   That was true before insulin was isolated in 1921.

   Fat is more dangerous than sugar because diabetics have a three-fold
   higher risk of heart disease.

   The whole point of injecting insulin is to balance carbohydrate intake.

   All carbohydrates are converted to sugar in the digestive tract anyway.

Subject: Insulin nomenclature
=============================

The major types of insulin have both generic designations and brand names
used by the manufacturers. Most of the brand names are close enough to the
generic ones that the correspondence is obvious. Novo uses totally different
names. In those parts of the world where Novo has most of the market, the
Novo brand names are used in place of the generic names. To facilitate
communication between Novo users and others, here is the correspondence:

   Generic      Novo
   -------      ----
   Regular      Actrapid
   NPH          Protophane
   Lente        Monotard
   Ultralente   Ultratard

Subject: Injectors: Syringe reuse and disposal
==============================================

Disposable syringes can be safely reused as long as you take reasonable
precautions. Recap both ends between uses, and discard the syringe if
dropped, dirty, or damaged (especially if the needle is bent). Discard it
when it becomes uncomfortable to use. This varies a great deal, being half a
dozen uses for some patients and several dozen uses for others. Comfort
depends far less on sharpness than on the silicone coating applied to the
needle at manufacture.

Syringe disposal has proven controversial. If you want to be conservative,
buy a needle clipper, get a hard plastic bottle designed for medical waste to
put the syringes in, and take the full bottle to a facility approved for
handling medical waste. Intermediate positions use one of these techniques.
At the least conservative, cap the needle carefully and discard in trash
which will not be subject to illicit searching and possible abuse. If you
have trouble capping the needle without sticking yourself, definitely get a
bottle to drop the uncapped syringes in; a bleach bottle may be adequate.

Subject: Injectors: Pens
========================

A pen injector is a device that holds a small vial of insulin and a
retractable, disposable needle, and injects an amount measured with a dial.
Advantages include being compact, convenient, easy to use circumspectly in
public, and accurate and simple in dose measurement. The primary disadvantage
is cost. The special vials may be difficult to obtain in remote areas, but of
course falling back to a standard syringe is always an option. Pens are more
popular in Europe than in the US.

Subject: Injectors: Jets
========================

A jet injector uses no needles, but instead squirts the substance being
injected through a narrow orifice under high pressure, producing a fine
stream which penetrates the skin as easily as a needle. Obviously jets are
popular with anyone who is simply scared of needles, for any reason. The jet
disperses the insulin more than a needle does, which probably results in
faster absorption. This can be an advantage or a disadvantage, and requires
careful monitoring when first used. Technique is just as important as with
needles, so jets are no more appropriate than needles for small children. If
a jet is used to avoid needles, equipment failure forcing a fallback to
needles may be traumatic. High cost is a major factor.

[[[[[ I'm no expert on pens and jets. Better summaries are welcome.]]]]]

Subject: Insulin pumps
======================

An insulin pump provides a Continuous Subcutaneous Insulin Infusion, or CSII,
via an indwelling needle or catheter. That is, a small needle (similar to
those on insulin syringes) or tube is inserted through the skin and fixed in
place for two or three days at a time. The external box pumps insulin through
the needle steadily.

Pumps don't solve all the problems of treating diabetes for two main reasons:

  1) The infusion is still subcutaneous, so the insulin still must be
     absorbed before it can be used. Insulin from the pancreas goes directly
     into the bloodstream and takes effect much more quickly.
  2) Current pumps are open-loop -- that is, there is no feedback from blood
     glucose (bG) to the pump. The patient must still self-monitor bG and
     program the pump.

Nonetheless, many patients get much better results with a pump than from
intensive therapy without a pump, and those patients tend to be extremely happy
with the pump. It isn't clear at present how to decide whether a given patient
should use a pump. Different studies have obtained varying results, ranging
from 85% success to 85% dropout! [[[[[ I haven't had time to look up and review
these studies. ]]]]] A few important factors seem clear, though:

  1) Motivation. A meter takes extra effort and attention.
  2) Knowledge. If you aren't already familiar with intensive therapy,
     think more than twice before jumping for a pump. You should
     probably try intensive therapy with multiple injections first.
  3) Treatment team. Successful users are backed by teams of physicians
     and educators who are experienced *with pumps*. Don't try a pump on
     your own (the manufacturers won't let you anyway), and don't try it
     with inexperienced providers -- these are recipes for unnecessary
     failure.
  4) Funding. Pumps represent a nontrivial capital outlay. If you don't
     have insurance or other public programs that will pay for the pump,
     you will need personal financial resources.

Most or all pump manufacturers allow a trial period, so you can try a pump
without financial risk. You will probably know fairly soon whether you want
to continue with the pump.

A long discussion about many aspects of pumps is posted regularly to
misc.health.diabetes by Jim Summers ([e-mail]) with lots of help
from Joan Stout ([e-mail]). It covers many more detailed questions
about pumps.

Subject: Beta cell implants, pancreas transplants, future cures
===============================================================

Beta cells can be isolated and implanted, requiring only outpatient surgery.
But foreign beta cells are quickly rejected without immunosuppressant drugs.
Even with the recent advances in drugs, especially cyclosporin, using
immunosuppressants is much more dangerous than living with diabetes. As a
result, beta cell implantation is not currently used to treat diabetes.

Current research is investigating two general methods of implanting beta
cells without the use of immunosuppressant drugs. The first (immunoisolation)
encapsulates the beta cells within a barrier so that nutrients, glucose, and
insulin can pass freely through the barrier but the proteins which provoke
the immune response, and the cells which respond, cannot pass. The second
(immunoalteration) involves altering the proteins on the surface of the cells
which provoke the immune response. The first human trial began earlier in
1993 on immunoisolated beta cells, and human trials may begin late in 1993 on
immunoaltered beta cells.

Don't expect these treatments to be available on a standard basis any time
soon. I've been reading about this research for nearly 15 years, and the
results are always just around the corner. Serious problems remain to be
solved: safety of the immunoisolated implants, long-term survival, ability to
use beta cells from non-human species, perfection of both techniques -- all
these must be resolved before beta cell implantation moves beyond the
experimental stage. Other problems will likely be encountered along the way,
since this is cutting edge medical research. I'll be surprised if it gets out
of the lab before the year 2000; 2010 is probably a better guess. And it may
fail -- it's always possible that unsolvable problems will yet arise.
Finally, it's not yet clear that even completely normal bG profiles will cure
all the problems of type 1 diabetes. Some may be related to the autoimmune
reaction that is the immediate cause of diabetes. This question cannot be
answered until it is possible to normalize bG levels for a period of many
years.

Whole pancreas transplants have the same rejection problems as beta cell
implants, and also require major surgery. For these reasons, whole pancreas
transplants have only been used 1) in desparate cases in medical schools with
exceptional capabilities, and 2) in conjunction with kidney transplants.
Kidney transplants are (relatively) common in diabetics with advanced
complications. A kidney recipient is taking immunosuppressant drugs anyway,
and the same surgery that implants the kidney can stick in a pancreas with
little extra effort or trauma. As a result, the double transplant is now
recommended, at least for consideration, for any diabetic patient who
requires a kidney transplant. The only disadvantage would seem to be that the
pancreas donor must be dead; whereas a living kidney donor is feasible.
However, at some organ banks the double transplants get in a different queue,
and in some cases the queue for double transplants may be shorter. This will
not be true in all cases and may depend on whether the double transplant is
considered experimental at that institution. It is worth investigating which
choice would get quicker results.

Also note that these treatments apply only to type 1 diabetes. Type 2 diabetes
is the result of insulin resistance or other forms of improper use of insulin
within the body, not an absolute lack of insulin. Type 2 patients have normal
beta cells. There is no treatment of comparable promise on the horizon for
type 2 diabetes.

Subject: What's a glycemic index? How can I get a GI table for foods?
=====================================================================

The glycemic index, or GI, is a measure of how a given food affects blood
glucose (bG). Some complex carbohydrates affect bG much more drastically than
others, and some (such as white bread) even more than sugar. This was quite a
surprise when the research was first published around 1980 [[[[[need to check
date]]]]].

The problem with using the GI extensively in diet is that it is not additive.
That is, different foods interact to produce a combined GI that cannot easily
be predicted from the separate GIs. For example, a baked potato has a very
high GI (one of the famous, unexpected examples), but adding butter to it
lowers the GI greatly. Research is continuing, and eventually it may be
possible to predict the GI of a complete meal.

For now, the important thing is to understand that foods may affect your bG
profile in ways that you wouldn't expect from categorizations such as "simple
sugar" and "complex carbohydrate". Build your knowledge about your own
response to different foods and meals by monitoring and keeping records, and
avoid assumptions.

There have been requests for GI tables on m.h.d. To my knowledge, none is
available in electronic form.

Subject: I beat my wife! (and other aspects of hypoglycemia)
============================================================

(not yet written)

Subject: Does falling blood glucose feel like hypoglycemia?
===========================================================

Sometimes. Symptoms of hypoglycemia are divided into the adrenergic and the
neuroglycopenic.  Adrenergic responses are caused by increased activity of
the autonomic nervous system and may be triggered by a rapid fall in blood
glucose (bG) or by low absolute bG levels; symptoms include

  weakness
  sweating
  tachycardia
  palpitations
  tremor
  nervousness
  irritibility (sound familiar?)
  tingling of mouth and fingers
  hunger
  nausea or vomiting (unusual)

The autonomic nervous system activity also causes the secretion of epinephrine,
glucagon, cortisol and growth hormone.  The first two are secreted rapidly and
eliminated rapidly.  The second two are secreted slowly and remain active for
4-6 hours, and may cause reactive hyperglycemia.

Neuroglycopenic responses are caused by decreased activity of the central
nervous system and are triggered only by low absolute bG levels; symptoms
include

  headache
  hypothermia
  visual disturbances
  mental dullness
  confusion
  amnesia
  seizures
  coma

The above information is from Mayer Davidson's _Diabetes Mellitus: Diagnosis
and Treatment_.

Remember, as always, that individual responses vary greatly. The exact set of
symptoms encountered will vary. It's not impossible that some of the symptoms
will fall in the other category for some individuals.

Subject: Alcohol and diabetes
=============================

(not yet written)

Subject: Where can I mail order XYZ?
====================================

XYZ is most often test strips, especially for those who don't live near
discount pharmacies. Mail order prices are not always lower than local
prices. Remember that there is an advantage to going to a single pharmacist
for all your drugs, if that pharmacist is knowledgeable about interactions
and tracks all the drugs you use. Adjustments will be slower if you mail
order. Never mail order unless you are certain about what you need.

That said, here's a list of mail order firms specializing in diabetes
supplies. Aside from the one listed below, I've not heard of any outside the
US, perhaps because the health care systems elsewhere don't encourage the
practice. Some of these advertise in _Diabetes Forecast_ (see section on
journals). This list is presented with no recommendations, pro or con. Each
issue of _Diabetes Forecast_ also contains a column summarizing
recommendations for ordering health supplies by mail.

Chronimed                    1-800-477-6540 or [phone]
Source International         1-800-237-6696
Diabetic Warehouse           1-800-995-4308
Hospital Center Pharmacy     1-800-824-2401 (part of the Joslin Diabetes Ctr)
Diabetic Care Center         1-800-633-7167
Diabetic Express             1-800-338-4656
The Sugar Substitute         1-800-435-1992
Diabetic Promotions          1-800-433-1477
Thriftee Home Diabetes Care  1-800-847-4383
National Diabetic Pharmacies 1-800-467-8546

in Canada:

Diabetes Specialty Shop      1-800-465-3336 (Canada)

Subject: How can I contact the American Diabetes Association (ADA) ?
====================================================================

1-800-232-3472 or [phone]. This will reach all departments.

The ADA offers aid to diabetic patients, books, and journals ranging from
general to research. New patients and their families needing advice are
encouraged to call. They may be able to help in dealing with bureaucratic
problems. They can provide local contacts. [[[[[ let me know how they help
you ]]]]]

Subject: Could you recommend some good reading?
===============================================

You mean to curl up with on the sofa? Oh, diabetes ... OK.

My favorite book is Mayer Davidson's _Diabetes Mellitus: Diagnosis and
Treatment_. Though written as a medical text, anyone willing to plow through
an occasional dense passage and keep a dictionary handy will have no trouble
with it. (See below about medical terminology.) Being written by a single
person, it is much better focussed than the "committee" books which are so
common. And it's extraordinarily cheap for medical books, US$25 in 1989.

Eventually we may have a full list of a variety of books. You'll have to make
do with the above until someone volunteers to put it together. The rest of
what I have to talk about is periodicals.

Several m.h.d readers have recommended _Diabetes Interview_. [[[[[ I haven't
read it; can anyone provide a summary? ]]]]] One year, US$14; two years,
US$24 (probably more outside the US).  Their address: 3715 Balboa Street, San
Francisco, CA 94121. Use Visa or MC and call 415-387-4002.

Everything else I have to recommend comes from the ADA (see section on ADA).

Here's what the ADA says about its own publications:

    _Diabetes_ -- the world's most-cited journal of basic diabetes research
    brings you the latest findings from the world's top scientists.

    _Diabetes Care_ -- the premier journal of clinical diabetes research and
    treatment. _Diabetes Care_ keeps you current with original research
    reports, commentaries, and reviews.

    _Diabetes Reviews_ -- the comprehensive but concise review articles in
    ADA's newest journal are a convenient way for the busy clinician to
    keep up-to-date on what's truly new in research.

    _Diabetes Spectrum_ -- translates research into practice for nurses,
    dietitians, and other health-care professionals involved in patient
    education and counseling.

    _Clinical Diabetes_ -- For the primary-care physician as well as other
    health-care professionals, this newsletter offers articles and
    abstracts highlighting recent advances in diabetes treatment.

    _Diabetes Forecast_ -- ADA's magazine for patients and their families
    features advice on diet, exercise, and other lifestyle changes, plus
    the latest developments in new technology and research. It is a
    valuable tool for patient education.

Now for my own opinions.

_Diabetes Forecast_ is the mass market magazine, intended to be readable by
most educated diabetics. For US$24/year you can hardly go wrong. DF may seem
low-level to those who've been to graduate school -- I'd guess it's written
at a 10th-12th grade level. But it contains much useful information and is
excellent at promoting self-care and a positive self-image for persons with
diabetes.

The remaining journals are of interest if you want to follow what is new and
under investigation in medical practice and research. The journals vary in
difficulty of reading. Though some knowledge of statistics and chemistry
helps, a general acquaintance with scientific method is perhaps more
important, and a smattering of familiarity with medical terminology helps
most. Luckily, medical terminology is basically simple -- it mostly consists
of putting together roots and affixes to make specific terms. Learn a few
dozen roots and you can make out most of it. Try to have a dictionary at hand
at first.

_Diabetes Care_ publishes papers on clinical research. I find many of the
papers to be interesting and applicable to my own management.

_Diabetes_ is the ADA's journal primarily for basic research. Some of the
articles are interesting, but they run much more toward biochemistry and
mechanisms of metabolism. As important as basic research is, few of the
reports say little of value directly to patients.

_Diabetes Spectrum_ is the ADA journal most oriented toward health care
practitioners. It consists of reprints of important articles (sometimes
several on a topic) and summaries of related articles, plus original
commentaries from other authors. As such, it provides a broad overview of
topics for readers who don't have time to track down lots of separate
original articles. If you only have time to read one technical publication,
_Diabetes Spectrum_ is probably the best choice.

The ADA has a multiplicity of price structures for nonmembers, regular
members, and professional members. I don't have a list of all the options,
and I'm not sure I'd want to reproduce it here if I did -- I haven't figured
it all out myself. A basic regular membership with _Diabetes Forecast_ is
US$24/year (in the US, I don't know the cost outside the US).

The ADA takes checks, money orders, Visa, Mastercard and American Excess.
Phone numbers

   1-800-232-3472
   [phone]
   [phone] fax

or write

   American Diabetes Association
   Subscription Services
   1660 Duke Street
   Alexandria, VA 22314
   USA

Subject: What is the DCCT? What are the results?
================================================

The DCCT was a large multi-center trial involving over 1400 volunteer
patients with type 1 diabetes. It began in 1983, ramped up to full speed by
1989, and ended early in 1993 when the investigators felt the results were
clear. The volunteers were all undergoing "standard" treatment when they were
recruited, meaning one or two injections per day. They were randomly assigned
to two groups. One group continued as before. The other group received
intensive treatment aimed at achieving blood glucose (bG) profiles as close
as possible to normal. The intensive treatment involved multiple bG tests per
day, multiple injections and/or an insulin pump, and access to and regular
consultation with a team of treatment experts.

The results show that the intensive treatment group did indeed achieve bG
levels closer to normal, and that they experienced far fewer diabetic
complications. In particular, patients who maintained HbA1c levels around 7%
appear to be much better off than those whose HbA1c hovers around 9%. (See
caveats in the section on HbA1c.) Though it is not possible to separate the
effects of all the aspects of the intensive treatment, it is reasonable to
believe that lowering average bG is effective even in isolation from the
other aspects of the intensive treatment. In its position statement, the ADA
says

   Patients should aim for the best level of glucose control they can
   achieve without placing themselves at undue risk for hypoglycemia or
   other hazards associated with tight control.

Though type 2 patients were not included in the study, it is generally
believed that the results showing the benefits of tight control apply to
type 2 patients as well.

The entire position statement is recommended reading.

--
Edward Reid          [e-mail]
PO Box 378           [e-mail]
Greensboro FL 32330  [e-mail]