Living With Diabetes: Walking the Tightrope
---by Djinifer



This is something that I am growing more used to talking about as I get older. I am a diabetic. I was diagnosed with juvenile diabetes at the age of nine and immediately began injection therapy for treatment, taking two injections of insulin daily.

Why have I been hesitant to talk about it up until now? Well, I was very self-conscious about being perceived as "strange" or "different" by other kids when I was younger. As I got older, it was something that I just considered was none of anyone's business. I really think, though, that it was just my way of ignoring it. Ignoring diabetes can be very easy to do.....but it isn't very smart.

As I've gotten older, I've learned more and now I can see the value in studying my disease and its effect on my body. That's what has really helped to open me up. I'm just now learning to feel more relaxed in discussing my disease with others without feeling embarrassed or odd. In fact, I'm at my most enthusiastic when people show an interest in learning more about it. That, combined with the little tips of daily living that I've gathered over the years has prompted me to put this page up for those who are interested in learning more about diabetes and how to live with it. I'm a great believer in a two-way exchange of information, so let me know if any of you readers see anything I've missed or have corrections or additions to this information.


I'm going to approach this page from the standpoint that the reader knows absolutely nothing about diabetes. In that way, I hope not only to pass along the benefits of my experience, but I also hope to educate. No information in this page should be taken as medical advice. This information is anecdotal and is drawn from my own research, observations and experiences in dealing with diabetes. I am not a doctor and I don't work in any health-related field. If you have medical questions, please consult your specialist.



What is diabetes and how do you get it?

How Insulin Works

Types of insulin

Hypoglycemia

Hypoglycemic unawareness

Hyperglycemia

Multiple Daily Injection (MDI) therapy

Insulin pump therapy

Infections: why they're dangerous and what to look for

Blood glucose monitors - moving into the 21st Century

Support Groups - do they really help?





What is diabetes and how do you get it?


Diabetes is a disease in which the body has either stopped producing insulin entirely or the insulin produced by the body is no longer working effectively. There are two types of diabetes: Juvenile Diabetes and Adult-Onset Diabetes.

Juvenile diabetes (which is what I have) or "Type 1 Diabetes":
People who have juvenile diabetes no longer produce insulin naturally. Insulin must, therefore, be supplied by injection into the body. Type 1 diabetes is the rarer form of the disease. People with Type 1 diabetes are said to have a genetic predisposition to it. I have heard it claimed that if there is juvenile diabetes in a family, that it will often skip a generation. My maternal grandfather had juvenile diabetes, so this was true in my case. With both my grandfather and myself, the trigger that brought it on was a bout with a virus. Type 1's have a problem with overactive immune systems; the body literally attacks the pancreas and destroys its ability to produce insulin. The virus was the trigger because it was probably the last straw on the camel's back of an over-stressed immune system.

Adult-onset diabetes or "Type 2 Diabetes":
In adult-onset diabetes, the body produces insulin but it either does not produce enough insulin to meet the body's needs or the insulin produced does not work effectively in the body. Adult-onset diabetes can be controlled through diet in some cases. In other cases, oral medication or injections of insulin may be necessary. I'm not as familiar with the adult-onset, so I'm not really sure of the causes.....I know that diet plays a factor in it. My understanding of it is that the pancreas in these individuals works harder to produce adequate amounts of insulin and over time, wears itself out and no longer functions properly.

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How Insulin Works


Understanding the way that insulin works in the body is the key to understanding just what diabetes is all about. Insulin is a hormone secreted by the pancreas. When you eat food, that food breaks down into its most basic components in your body. When carbohydrates or fruit are eaten, they break down into sugar. This sugar passes into the bloodstream as it is digested. Insulin allows the sugar in your blood to pass through the body's cell walls so that it can be used as energy.

In a person without diabetes, the pancreas releases just enough insulin to keep the amounts of sugar in the blood at a normal and healthy level. A normal blood sugar ranges from 70 milligrams per deciliter (mg/dl) to 110 mg/dl. What a diabetic must learn to do is to gauge how much sugar they are eating in a meal and take enough insulin to counteract the sugar and keep the blood sugar levels from rising too high. If too much insulin is taken, this can cause a hypoglycemic reaction. There are many other factors which affect blood sugar levels (amount of exercise, time of day, illness, metabolism) and they must also be taken into account when injecting insulin into the body. As no two people function alike, insulin cannot be injected using a standard "formula" which will tell you how much to take. Each person has to discover and develop his or her own formulas. So, you can imagine how difficult it can be to effectively control diabetes.

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Types of Insulin


There are several types of insulin that can be used to treat diabetes. They basically all fall into one of two groups: long-acting and fast-acting. Long-acting insulins that I have taken include NPH and Ultralente. These insulins are absorbed slowly by the body and help to keep the blood sugars at manageable levels throughout the day and night. Fast-acting insulins that I have taken are R and Humalog. These insulins are taken to counteract any sugar that is eaten with meals.

When I was first diagnosed, I was prescribed a combination of R and NPH insulins. I only recently switched to Humalog, and I really recommend it. Whereas the R insulin takes 30 minutes to act and up to 4-6 hours to peak, Humalog starts working in about 5-10 minutes and in my system it peaks at about 1 to 1 1/2 hours. I had to inject R insulin 30 minutes before eating in order to match the action time of the food I ate. And, after the injection was taken, I had to eat thirty minutes later, or my blood sugar would drop too low. Humalog allows me more freedom in that I can inject it as I begin to eat. Since it works so quickly, I take the added precaution of not injecting it until I have a plate of food in front of me. The action time of Humalog for me, most closely matches the digestion of the food. A word of caution with Humalog: it IS stronger than R. When I made the switch to Humalog, my doctor instructed me to take as much Humalog as I had been taking of R insulin. That was way too high of a dose. Since Humalog works much faster, I was able to reduce my overall injection of fast-acting insulin by about 25%.

The combination of both Humalog and NPH was too strong for me, so I was switched to Ultralente which has a much slower absorption time (it can last anywhere from 18-24 hours in the system).

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Hypoglycemia


Hypoglycemia means "low blood sugar". Low blood sugar occurs when too much insulin has been taken and not enough sugar is left in the blood for the body to function normally. If left untreated, it can result in loss of consciousness and coma. I've also heard of some diabetics who seizure when blood sugar levels drop too low.

Hypoglycemia can make the diabetic feel and act drunk. Other symptoms are shaking hands, sweating, increased heart/pulse rate, loss of balance, and there can be a slight distortion in vision. Hypoglycemia can (most of the time) be very easily treated by eating something with sugar for a quick boost. I have noticed that I tend to bounce back quickly from a low when I drink orange juice or a drink sweetened with high fructose corn syrup (such as Snapple or Gatorade). Other options are eating glucose tablets, which are sold in any pharmacy. I usually eat about 15 carbohydrate grams worth - that's 4 or 5 tablets---or I drink one-half a can of sweetened soda. However, anything with sugar will do---even frosting. I've been known to use plain granulated sugar dissolved in a glass of water....and once in an emergency, I had to make do with maple syrup. Another bit of advice: low blood sugar can make it difficult to chew, so I prefer to have something liquid on hand.

Above all, it's very important that a diabetic ALWAYS carry something with them. I can't tell you how frightening it is to be sitting in a traffic jam at dinnertime and watch your blood sugar dropping, knowing there's nothing you can do about it. So, take my advice and please do carry something. It doesn't have to be conspicuous......I keep glucose tablets with me at all times in my purse and also have a can of sweetened carbonated drink in my car.

In cases of severe hypoglycemia, it may be necessary to inject glucagon. Glucagon is produced by the pancreas and it works as an antidote to insulin. I'm told that it raises blood sugar quite rapidly. Glucagon kits are available only by prescription. These glucagon kits are usually the kind where you must mix up a powder and then inject it, but I hear that there are pre-mixed kits available. These kits do have an expiration date, so instead of throwing the kit out when it expires, use it to practice mixing the glucagon. I have personally never carried glucagon with me. Glucagon is used when the diabetic is too far gone to be able to help themselves during a hypoglycemic episode. Luckily, my blood sugar has never dropped so low that I have been unable to assist myself.

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Hypoglycemic Unawareness


If you've had diabetes for a long period of time, there is a risk that you will develop hypoglycemic unawareness, as I have. To me, this is one of the more dangerous conditions that you can develop with diabetes. The name is pretty self-explanatory, but I'll explain anyway :) .

Hypoglycemic unawareness is a condition where the body's signals that the blood sugar are too low have become "muted", so that you are unaware that your blood sugar may be too low. For instance, when I first got diabetes, I was very aware of my hypoglycemic episodes. I would have severe "shakes", sweating, and increased heart rates. This is your body's warning that your blood sugar needs to be raised. Over time, these signals have become less obvious to me. The signals are still there, but they are much more subtle. When this first began happening to me, I didn't realize that my problem was hypoglycemia, because hypoglycemic unawareness can give you symptoms very similar to an anxiety attack. What you think is just a case of nerves is really not sometimes. However, there are other signals that I still get which clue me in to the fact that the problem is hypoglycemia: I will first notice feeling abnormally weak or tired, along with a slight increase in heartbeat. I also get a weird visual distortion...I see "wavy lines" when staring into a bright light. That is a definite tip-off. However, if I'm not sure, I always check my blood sugar just in case....particularly if these symptoms occur around mealtimes.

I'm not sure if anyone knows what is the cause of hypoglycemic unawareness. I've heard that it may be the synthetic insulins that diabetics take that make the difference in the body's response. I have a suspicion that it is probably a form of neuropathy (nerve damage) that occurs over time.

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Hyperglycemia


Hyperglycemia means that the blood sugar is too high. Consistently high blood sugars over time will damage the internal organs. Dangerous levels are anywhere from 240 and up. High blood sugar is dangerous because it means that sugar is building up in the blood; the body does not have enough insulin to absorb it into the cells. Since the body cannot burn off the sugar, it starts burning off body fat as an energy source. The body fat (ketones) that is burning is dumped into the blood in increasing amounts. This condition is called "ketoacidosis" and is quite serious. Ketoacidosis changes the pH levels of the blood. Eventually, the body will shut down and the diabetic will become comatose. Symptoms are extreme thirst, increased heart rate, dry or "cotton" mouth, blurry vision, rapid weight loss (I've been known to lose up to five pounds in one day!) and nausea. The only solution to this problem is to immediately increase your dose of fast-acting insulin (Humalog or Regular insulins). If I suspect that my body is producing ketones, I test for it using Ketostix. These can be purchased at any pharmacy. It is a good idea to test for ketones anytime your blood sugar gets to 240 or above. I've also been told that if you develop nausea with high ketones, it's very important to get medical assistance as quickly as possible.

One thing that I have noticed from personal experience is that once you have ketones in your system, it takes a larger than normal dose of insulin to bring the blood sugar back down. I always have to keep this in mind when I dose myself to resolve high blood sugars and ketones.

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Multiple Daily Injection (MDI) Therapy


When I first developed diabetes, the course of treatment was pretty simple: two injections of insulin daily, one in the morning and one in the evening. More or less insulin was taken depending upon the blood sugar levels (which weren't measured using an actual blood test, but were instead measured by urinalysis).

As you can imagine, this left the field wide open for fluctuations in blood sugar during the daytime. I wasn't very consistent about seeing a doctor then, and I became very comfortable with my old regimen of two injections per day. I felt fine, but my blood sugar levels were often high. Eventually, when I discerned that my twice-a-day dose wasn't doing the job it should be, I began to focus in on bringing my blood sugar levels as close to normal as possible. My regimen still incorporated morning and evening doses, but I also began giving myself an injection prior to lunch, and basically at any time I felt that I needed more insulin in my system to cover food I had eaten.

Using the method of multiple daily injections, I was able to keep my blood sugars under 200 for the most part, and my Hba1c results dropped from a 9 to a 7.1. Multiple daily injection is currently the preferred method of treatment for diabetes. The goal is to keep your blood sugars as close to normal as possible. However, keeping your blood sugar closer to normal levels has some increased risks. On one hand, you are hoping to stave off the complications of diabetes which are caused by long-term hyperglycemic levels of sugar in the blood; on the other hand, keeping the blood sugar lower takes more discipline and it increases your risk for hypoglycemic episodes. In turn, that means you may need to increase the number of times per day you test your blood sugar. I now test mine anywhere from 8-10 times daily.

In early 1999 I began treating my diabetes using an insulin pump.

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Insulin Pump Therapy


Insulin pumps have been around for quite some time (I've known diabetics who have been on them for up to 15 years), but they are only recently gaining real popularity amongst the diabetic community. What the insulin pump does is to administer a constant flow of insulin into the body through a small catheter that is inserted into the abdomen. It is meant to be an "electronic pancreas" as it most closely mimics the type of insulin delivery that the pancreas provides naturally. The pancreas in a non-diabetic delivers small doses of insulin into the system throughout the day in order to keep blood sugar levels stable. The insulin pump does the same thing.

The insulin pump does not, however, automatically know how much insulin to deliver into your system. Once on the pump, the diabetic switches from taking both long-acting and short-acting insulins to taking small doses of short-acting insulin throughout the day. I use Humalog exclusively with my pump. When first starting on the pump, you have to determine what is called your baseline dose of insulin. The baseline dose of insulin is an amount of insulin that will be constantly delivered into your body and is measured in number of units of insulin per hour. This baseline should keep your blood sugar stable....neither rising too high nor falling too low. Extra doses of insulin (called boluses) are taken at mealtimes to cover any carbohydrates or sugars eaten. Check this page at Diabtrends.Com for tips on using Humalog with the pump.

The baseline dose of insulin can be programmed to change at certain times. For instance, many juvenile diabetics suffer from what is known as the "dawn effect". The dawn effect is a sharp rise in blood sugar that naturally occurs during the early morning hours. This can cause the diabetic to awaken with elevated blood sugar levels. Before starting on an insulin pump, it was not unusual for my morning sugar levels to be at 300 or more. With the pump, I can program in an increase in my insulin dosage during the early morning hours to counteract the rise in blood sugar.

There are also drawbacks to using the pump. You have to be connected to it 24 hours a day, seven days a week. I can disconnect from my pump for any water activities (including daily showers), but at the most, I can only remain disconnected for 30 minutes or so. Since the pump delivers insulin into the body in very small amounts, there is less insulin reserve for the body to draw upon. Under these conditions, it is much easier to slip into ketoacidosis if you remain disconnected for too long.

The catheter can be a pain in the neck-especially when changing clothes! I have to point out that the catheter is not permanently placed into your body. It must be changed out every three days and a new site used each time. Having a catheter does not mean that I have a needle sticking into me at all times. A needle is used for insertion, but only a thin piece of flexible tubing (called the cannula) remains beneath the skin. The cannula produces little or no discomfort to me....only some minor itching. However, I have heard of diabetics who are allergic to the tape adhesives that you must wear with the catheter, to keep it from pulling out.

Wearing the pump with various clothing presents its own challenges! The pump itself is no larger than a pager and is relatively inconspicuous. There have only been a few instances when people have noticed it and asked me about it. I use the Minimed 507C pump. It comes with a leather case and a clip so that you can fasten it to the waistband of your pants or skirts. The catheter tubing is tucked into your clothing. You can take the leather case and clip off and wear the pump in a spandex thigh pouch attached to your thigh (with dresses) or clipped to your bra or underneath your arm. For other interesting options in wearing the pump, please see Minimed's site for Pump Cases and Other Conveyances.

Minimed is one of two major manufacturers of insulin pumps. The other is Disetronic. Each have their own advantages and I've noticed a fierce brand loyalty amongst the diabetic community.

The main differences I've noted are these: while the Minimed pump is water resistant (it can survive brief dunkings), the Disetronic is supposed to be practically waterproof-you can even wear it into the shower. Anyone who participates in water activities/sports would definitely want to consider the Disetronic pump. The Minimed pump has several features that I like: backlighting so that you can read the pump's display in the dark, an automatic shut-off feature (in case you fall unconscious due to hypoglycemia), and dual and square wave bolusing. The dual and square wave boluses deliver bolus doses over a prolonged period of time. This helps when you're eating food that is high in fat, which takes longer to digest. Another great benefit with the pump is that I can pull out of hypoglycemia much more easily. Since I have less insulin hanging around in my system, it takes less time to raise my blood sugar levels!

If you have a pump, or are thinking of getting one, I highly recommend that you do two things in your research. Visit the Insulin-Pumpers website, and purchase a copy of Pumping Insulin. "Pumping Insulin" is considered by many to be the Bible of insulin pumping. You can either purchase it from Amazon.com (they offer a great discount on it!), or you can order direct from the publisher:


Torrey Pines Press
1030 West Upas Street
San Diego, CA 92103-3821
FAX: (619) 497-0900


Cost from the publisher is $19.95 plus shipping.


The Insulin-Pumpers.Org site has a mailing list, which I really recommend as well. I subscribe to it, and I have gotten a lot of great information and support from other pumpers around the world. The list contains around 1,300 subscribers and is still growing!

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Infections: Why they're dangerous and what to look for


Basically, infections are dangerous to the diabetic because an infection causes the body to be increasingly resistant to insulin. You take your normal dosage, but it has little or no effect on your blood sugar levels. Once this happens it is, of course, very difficult to judge just how much insulin will work to bring your blood sugars down and how much is too much. Under these conditions, you can quickly go into ketoacidosis .

This is why it's important to catch an infection early on and get the proper treatment for it. As time goes on, the situation will only worsen. You can bet that you probably have some sort of infection or other illness if you experience the following:

An unexplained and sudden increase in the blood sugar
Resistance to insulin
Ketones
Fever
Sudden, rapid weight loss


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Blood Glucose Monitors - moving into the 21st Century


I switched from testing glucose levels by urinalysis to using a blood glucose monitor during my teens (1980's-ish). Blood glucose testing is superior because by the time the sugar is eliminated from your body, your blood sugar may have changed drastically. It is currently the most effective method used by diabetics.

I have used the One-Touch Basic glucose meter for the past 5-6 years. However, I recently upgraded to the One Touch Profile meter. This meter has the latest features such as memory retention of blood glucose readings, time and date stamping, ability to enter and save information on insulin dosages, plus you can purchase a computer program called IN TOUCH which allows you to download all the information you've stored into your computer and print reports and chart graphs of your readings. For more information about Lifescan and Lifescan products, visit their home page.

A similar meter to the One-Touch Profile is Accu-Chek's Accu-Chek Complete meter. Accu-Chek's Accutility software is made for use with the Accu-Chek Complete meter. For more information on Accu-Chek's products, visit their Product Information page.

I recommend upgrading to one of these meters if you're currently using the old method of keeping your blood sugar readings in a hand-written diary......or worse, if you're not keeping records at all. I received the One-Touch Profile meter free of charge from Lifescan (owned by Johnson & Johnson). I had been experiencing problems with their One-Touch Basic meters, so they offered to upgrade me to the One-Touch Profile. If you do experience meter problems, calling the company's 1-800 number (on the back of the meter) will often result in you getting a brand-new meter free of charge. Companies who manufacture the meters make most of their revenues from blood test strip sales (a box of 100 blood test strips costs around $60 retail), and they want to keep you happy so you'll continue buying their products. Don't be afraid about calling up and asking for a free meter. Odds are, you'll probably be successful!

The next step in blood glucose testing is currently underway! Minimed is currently developing a continuous glucose monitor. It is Minimed's goal to one day incorporate a continuous glucose monitor into an insulin pump to achieve a truly artificial pancreas. Minimed has received FDA approval for their product and it is now undergoing clinical trials. This glucose monitor will be similar in size and appearance to the insulin pump. It would be worn in the same manner, utilizing a catheter. The sensor at the end of the catheter would measure the glucose levels of the interstitial fluid under the skin of the abdomen. Glucose levels would be measured approximately 300 times daily and would allow the diabetic's specialist to more easily spot trends in the patient's glucose readings.

The only trouble I have with this is that this monitor will not display its readings to the wearer. The wearer must take the meter into the doctor after several days of monitoring and have the results stored into a computer program at the doctor's office. I think it would be far more useful if the diabetic were to have a display that would show the glucose readings as they were taken. Putting information into the hands of the diabetics can only help them! [I have to add that a sensor for patient use is being developed at this time, and it will include a low blood sugar alarm feature. I think that this meter will prove to be the more successful product by far!]

I have signed up for the Glucose Sensor Trials for testing of the glucose monitor. If chosen, I would be hospitalized and tested. I haven't been contacted yet, but.......we'll see!

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Support Groups - Do they really help?


I think that support groups can be a great comfort! It's wonderful to be able to talk to people who can relate to health issues that you are dealing with. However, it's important to me to be part of a group where you come away feeling informed, supported and uplifted. I think there is a danger that some support groups can bombard you with negativity, which can taint your attitude and outlook for the future. As in choosing a physician, it's important to be in a group in which you feel comfortable. Ask your specialist or contact a hospital in your area to find out about support groups!

For more information about diabetes, please visit the Juvenile Diabetes Foundation International web site. Thanks for your interest!



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As I said above, please feel free to contact me if you have any questions, comments, criticisms or additions to this page!

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