KosAbility is a community diary series posted at 5 PM ET every Sunday by volunteer diarists. This is a gathering place for people who are living with disabilities, who love someone with a disability, or who want to know more about the issues surrounding this topic. There are two parts to each diary. First, a volunteer diarist will offer their specific knowledge and insight about a topic they know intimately. Then, readers are invited to comment on what they've read and/or ask general questions about disabilities, share something they've learned, tell bad jokes, post photos, or rage about the unfairness of their situation. Our only rule is to be kind; trolls will be spayed or neutered.
This KosAbility diary, which is a repost with additions at Nurse Kelley's request, is dedicated to the one I love, a person with Type 2 diabetes (PWD for short, something you'll commonly see used these days). I too am a person with Type 2 diabetes, and this diary will share the things I've learned since I was diagnosed in 1995 about living well with Type 2 diabetes.
So let's get started. Be warned; this is a very long diary.
If you are at risk (I'll go through some risk factors below), please, please, go to your doctor or find a screening event (they're offered as a community service in many places) and get yourself screened for Type 2 diabetes. The things I talk about are also applicable to just about anyone who has been diagnosed with impaired glucose tolerance, aka prediabetes, or has been told they are at risk unless they do something about it. Some of it may be applicable to Type 1 PWDs, but I'm focusing on Type 2 because that's what I know and live with.
The Basics of Diabetes
What is diabetes, particularly Type 2 diabetes? It's when your body doesn't use its own insulin well, makes less (sometimes none), and the beta cells of your pancreas decrease to little or nothing. Your body then cannot correctly process the food and beverages you take in, all of which eventually turn into glucose in some amount. Carbohydrates, including sugar and starches, turn into glucose quickest. Protein takes the longest. But all of it - every bit - eventually turns into glucose so that your body can use it as fuel. With your beta cells diminished and your insulin not properly utilized, the glucose can build up in your system as you digest your food and your body cannot process it fast enough. That causes high blood glucose - just what it sounds like, a high level of glucose in your blood - and that is the hallmark of diabetes. High blood glucose leads to diabetes complications such as diabetic retinopathy (messing up your eyes), diabetic neuropathy (generally messing up your feet - you can be in constant pain from this), diabetic nephropathy (kidney disease), clogging your arteries, screwing up your brain, sexual dysfunction, and stuff like that. These can lead to amputation, blindness, and being stuck in the dialysis chair. They are all very good reasons to work to achieve good BG control.
Sometimes, if you don't eat a meal or a snack for a long time, your blood glucose can also drop to a dangerous level. Low enough BG for long enough can lead to coma. It makes you whacked out, as I know from personal experience. If your BG drops to a low level, it can really impair your driving. Some of the things that have happened to me because I had low BG include rear-ending someone on a city street and getting lost 6 miles from my own home on an artery that I have taken often for years. If you plan to drive, it's a good idea to check your BG first (more on that below) and eat something if you need to bring it up. If you eat something that will raise your BG to where it should be pretty fast, still allow 15 minutes for it to work before testing again, and don't drive until you know you are OK as far as BG goes. This is all part of living well with diabetes, and avoiding low BGs is another very good reason to achieve good BG control.
Once you have it, you have it for life. You don't get over diabetes, but it is definitely possible to keep it under good control, and that's how you live well with this condition. It's how you avoid complications of diabetes, and there are quite a few. The better your blood sugar (blood glucose, often abbreviated BG by PWDs) control is, the better chance you have of avoiding any of them.
People without diabetes don't go too high or too low. They can eat five really sugary donuts and be just fine. I have to look at the donut's nutritional information, see how many carbohydrates it has, and determine if it fits into my carbohydrate allowance for that time of day. I cannot just blithely eat even half a donut without doing this, and I can never eat five. I am a PWD.
That said, I want to point out the fallacy of the common myth that PWDs cannot eat sugar. The truth is, I can eat what I want, and I can eat anything. But it has to be in moderation, and I have to watch my carbohydrate intake carefully. I am allowed a certain amount of carbs at each meal and snack, and to keep my BG under control, I shouldn't exceed that. But I can use that "carb allowance" for any kind of carbs there are. I tend to choose complex carbs over simple carbs (like things made with white flour) because they have more nutrients, take longer to digest and turn into glucose in my blood, and are overall better for me. It's what I've spent years teaching myself to do, as a PWD.
Lifestyle Factors and Diabetes
What leads to Type 2 diabetes? Most often, it's your body's condition and what you do with it and to it. There are other factors: if you've had gestational diabetes, you're at higher risk. If you have a family history of it you're at risk, as happened to my partner. If you're older, you're at risk. African Americans are in high-risk categories for both diabetes and kidney failure. Part of it is due to the shameful disparity that exists in U.S. healthcare, a large part. Part is due to poverty and grocery deserts leading to only being able to make bad food choices - carbs are cheap and widely available. (We subsidize them, too.) The whole leads up to diabetes. A screener or your family physician can run the risk factors down for you and tell you which ones put you personally at risk.
(Aside: Type 1 is wholly different, by the way; it is an autoimmune disease. Type 2, though, is largely caused by lifestyle factors. The two types used to be called Juvenile (Type 1) and Adult Onset (Type 2) diabetes, then it was IDDM (Insulin Dependent Diabetes Mellitus) and NIDDM (Non Insulin Dependent Diabetes Mellitus). Now some kids are being diagnosed with Type 2, and Type 1 and Type 2 are commonly used for the condition in people of all ages.)
Lifestyle factors include your weight, how much or little exercise you get on a regular, frequent basis, your stress level, and how much of what kinds of foods you eat. Your weight is important, because obese people are much more likely to lose glucose tolerance and become PWDs. Even people who are overweight but not obese have a higher tendency to diabetes than people of a hormal weight. If you're overweight or, especially, obese, then check with your doctor about losing weight and get her suggestions about lifestyle modification.
Lifestyle modification includes exercise. A lot of people who are overweight or obese don't get enough regular, frequent exercise. For people who are, more than the half hour five days a week is required to lose weight. Half an hour five days a week is barely enough for weight maintenance, and you're going to need to burn those excess calories that have been stored as fat. If you can't or won't join a gym, get out your bike and start riding, or hit the sidewalk and start walking. (If your streets have no sidewalks, hit the shoulder, or drive to a nearby park and walk there.) Adding to the amount of regular, frequent exercise you get is a lifestyle modification that can help you avoid Type 2 diabetes.
Lifestyle modification also includes finding ways to lower your stress level, something easier said than done. You might want to start sending out resumes if your boss is an asshat, for instance, because doing that seems to lower work stress a bit (to me, I've been there) all by itself. Taking up something like yoga or a meditation practice is another good way to lower stress. Figuring out where you're getting stress at home and talking with those involved about your need for lower stress for your physical health is good. So's adjusting the physical factors around your home that are causing you stress. Find out by studying yourself where your stresses are coming from and take steps to lower these stresses to a more manageable level. Your body will thank you.
Another one, of course, is what you eat. Eat a lot of non-starchy vegetables; they're lower in calories than a lot of other stuff (as long as you steam them or eat them raw) and will help you feel full. They're full of awesome nutrients, antioxidants, and fiber, too. Eating a largely plant-based diet is a common recommendation for both getting to a normal weight and avoiding diabetes. If you find out the amount of protein you actually need in a day, you'll learn that it's a whole lot less than most of us who eat a Western diet eat now, so try to make your protein lean and healthy (poultry with the skin off and fish are great) and more of a condiment than what your meal is based around. Carbohydrates are something to watch out for if you've been told you're at risk for diabetes and need to modify your lifestyle. Eat a limited amount of carbohydrates; find out from a dietitian or medical professional what you need to keep going and limit it to that. That includes breads, sweets of any kind, starchy veggies like corn and potatoes (try sweet potatoes instead!), jam, and fruit. You're welcome to enjoy fresh fruit, too, but make sure it's whole fruit, not juices, that you take in. Many fruit juices have a lot of calories, fructose (which turns right into glucose in your system), and lack the good fiber of the fresh fruit which will help you feel more full on fewer calories. And there's the other point here with regard to lifestyle modification: you're going to have to eat fewer calories if you're overweight or obese and want to get some weight off. Losing weight is really key to avoiding diabetes!
If you have been diagnosed with impaired glucose tolerance, it's even more important to follow the recommendation of your doctor or other healthcare provider, and make sure you talk to this person before starting an exercise and diet program! But do it, and do it now. Make a firm resolution that you're going to avoid the impaired glucose tolerance turning into full-blown Type 2 diabetes, and do something about it.
Alive, Well, and PWD
Suppose you've already been diagnosed with diabetes. It comes as a shock to most people. People tend to think that they're invulnerable until something like this hits them over the head. And being diagnosed as a PWD is a hit over the head with a 2x4 from the universe! You now know that your lifestyle and what you do and do not do, from food to exercise and the amount and kinds of each, is what generally leads to Type 2 diabetes. And you know you're going to have to do something to avoid complications and keep your blood glucose under control.
Fortunately, there's help available to you, under many health insurance plans including Medicare. You can go to diabetes education. I can't recommend doing so strongly enough. In diabetes education you'll learn what you can eat, when you should eat, how much you should eat - you'll be given an individualized dietary prescription that will tell you how much carbohydrate you can eat for each meal and snack, which will help you plan your meals. And you will be told, over and over again, that exercise is not just a good idea, it's a prescription for PWDs. Think of it like something your physician wrote a prescription for. Some actually do so. And then make a plan to ramp up the amount and vigor of the exercise you get, because for us, it's really that important.
In diabetes education, you'll learn about having a whole health care team and that you are the captain of your own health care team. You will learn why you need a podiatrist, a good eye doctor, and usually an endocrinologist. You'll learn a lot about diabetes complications and how to avoid them and you will learn what I am about to say:
The best way to avoid diabetes complications is to keep your blood glucose under control.
You'll learn how to use a glucometer, a device that measures your blood glucose. You'll learn how to keep a glucose log and the things that go into one. You'll learn how different types of foods affect your blood glucose. Would you believe that eating some starchy foods can raise your BG as fast as eating white sugar? It's true. You will find out why! You'll be taught by a Certified Diabetes Educator (CDE) or a team of CDEs, who have either a degree in nursing and a lot of experience educating PWDs, or have a degree in nutrition and a lot of experience educating PWDs. It's a hard certification to earn and a CDE is worth paying full attention to the entire time. You will learn how diabetes works and how high and low blood glucose affects your body.
The first thing your physician may do is refer you to an endocrinologist, a specialist in the endocrine system, who is well-versed in dealing with diabetes. The first treatment for diabetes these days is usually a recommendation for intensive lifestyle modification coupled with an oral medication like Metformin. It is important to take all medication when you're supposed to, in the amount you're supposed to. You'll probably get a recommendation to lose at least 10% of your current body weight. Unfortunately, for us it's easy to say that, a heck of a lot harder to do. I'll be honest, PWDs with Type 2 have a lot harder time losing weight than other folks, and the more out of control your BG is, the harder time you'll have. Keep your BG under good control and test often with your meter. Keep it with you wherever you go.
The next step these days, if the lifestyle modification (assuming you do it) and the Metformim don't work well enough and your BG is still too high, is to put you on insulin. It is not indicative of a fault, especially a character fault, if you need insulin. A lot of PWDs simply don't have enough any more, or they need to add more because their bodies are no longer sensitive enough to the insulin they make naturally. Needing insulin doesn't mean you're a failure as a PWD. It just means you need a different medication. Insulin has to be injected subcutaneously. If you don't know how to inject yourself, you'll learn that from a CDE, who will usually have you practice on something other than your own body or anyone else's. Injecting yourself with insulin is really not that bad. You can buy little, thin-needled syringes to draw up your insulin dose, or use a pen if it's available and fit it with a little tiny needle. The needles for pens come as small as 30 gauge, I believe, which are really small and thin and do not hurt much compared to larger ones.
If you have hypertension, you'll be advised to control it and probably prescribed medication to keep it under control. Hypertension is the second biggest cause of kidney failure in the U.S.; diabetes is the first. When I say control your BG to avoid complications, it's because I have first-hand proof that uncontrolled diabetes and hypertension can lead to End Stage Renal Disease (ESRD) and needing to get either a kidney transplant or dialysis to stay alive. If you're a PWD, it's imperative that you have ongoing health care and build your health care team. You need a podiatrist because you need to take care of your feet, and one of the things you learn in diabetes education is how to do that. You need an opthamologist because you have to take care of your eyes. You need an endocrinologist because you have to take care of your messed-up endocrine system, and you need a good GP because you have to take care of the rest of your body. Avoid complication. Keep your health insurance current. Make sure you have it and use it! I lost mine because my employer stole my labor and I couldn't pay for COBRA without money, and went for a year and a half without being able to see a doctor or get my diabetes and hypertension medication refilled. I wound up with kidney failure and spend five nights a week doing home hemodialysis on myself. Dialysis sucks. It really is hell. DO NOT WIND UP LIKE ME.
Living Well with a PWD
I want to stop talking about being a PWD for now and talk about living with a PWD, and/or caring about a PWD. Well-meaning friends and relatives all too often turn into the Diabetes Police. There are few things PWDs dislike more than dealing with the Diabetes Police. These are the folks who continually ask "Can you eat that?" "Are you sure you are allowed to eat that?" "How's your diabetes?" "That has sugar in it, and you can't have sugar". I think the people who do this most are parents. This is just as applicable to parents of older Type 1s who can determine what they should eat for themselves as it is to parents of Type 2s. Do not be the Diabetes Police, especially not to adult Type 2s. It's not only not helpful, it's harmful to your relationship with the PWD and can lead to the PWD feeling diabetes burnout, or deciding to go off the rails with his or her diet and say the hell with it because he or she is sick and tired of getting bugged.
To help encourage a PWD to do what he ought to do, it's helpful to fix tasty food that meets the PWD's dietary prescription in appropriate portions for everybody eating at that meal. It's helpful, too, if you're a family that eats dessert, to fix one that is lower in carbohydrates, especially one based on fruit. Some of the non-caloric sweeteners like Splenda also come in a mix of half Splenda, half sugar that's terrific for baking. No, it doesn't taste 100% the same, but better to fix something the whole group can enjoy, including the PWD, than something that everybody BUT the PWD can enjoy. If needs to diet and lose weight, don't offer your family seconds but tell the PWD that he can't have it, especially in front of everyone. If the PWD needs to exercise (and he does), offer to go on a walk with him. A long walk can lead to some great time to talk and strengthen rather than harm your relationship with the PWD. Just don't talk about subjects that turn you into the Diabetes Police. Another thing not to do is ask the PWD "How's your diabetes?" when you call or visit. Ask her how she is, since she is not her condition. That goes for a lot of people who are dealing with chronic disease conditions, BTW, not just PWDs. None of us is solely defined by our condition. I do refer to myself as a kidney patient or as a dialysis patient since that defines so very much of my life, but that is my personal choice. When a family member, well-meaning, asks me how my diabetes is without asking me how I am as a person, that's defining me by my condition and I get mad.
Being a PWD is difficult enough without the Diabetes Police getting involved. Understand that each PWD is the captain of his or her own health care team, not you. Understand that you may have some old, erroneous information about diabetes and how it works, and that if the PWD has been to diabetes education, he knows more than you do and has more current information. Don't be the Diabetes Police.
A Very Important Number
You may be told this number in one of two formats: either as your A1c, or as your average blood glucose. If you're told your average BG, you'll probably be told a 2 or 3 digit number with no decimal point. If it's presented as your A1c, it'll be in decimal form. My most recent A1c is 5.9 and I would like to get it lower. Your physician's goal for you is to get that number down below 7.0 or 6.5, depending on physician. Lower is better, but not if it is achieved by getting dangerous low BGs. My lowest A1c was about a year and a half ago and was 4.9, but it's been in the 5s for years. That tells me that my blood glucose control, for the most part, is as good as a non-PWD, which is my personal goal. It may also be presented as average blood glucose over a period of time, and that will be a number like 120. It may be higher or lower depending on you and what you do. The A1c is a measure of your average blood glucose over time, too, but presented in a different numeric format. Either number is measured by a simple blood test in your doctor or other provider's office. (If you're a dialysis patient, whether home or in-center, they'll measure it at your clinic.) Some send the test out and wait for results, then notify you of what it is; some have a machine to perform the test in five minutes right there in their offices. For that, you get pricked with a little needle and they collect a drop of blood.
Your Friend the Glucometer and How to Use It
Your physician may prescribe a meter for you, or you may be told to go out and get one. You can get them at most pharmacies, and there are lots of different models on the market. There are different models of lancing device to use to get a blood sample, too, but one will almost certainly come with your meter. Where the difference is greatest in getting a sample (pricking your finger or your arm, depending on lancing device and meter) is in the lancets themselves, the little disposable one-use needles that we use to prick ourselves and draw blood. Yes, it hurts. It is generally momentary and doesn't hurt too much, and using a smaller-needle lancet will make it hurt a little less. You can get lancets with needles as small as 33 gauge, and I am sure of this because I use those myself. The lancing device is spring-loaded. You put the lancet into it and push down so that the spring is compressed. When you use it to take a blood sample, you hold the lancing device against your fingertip and push a button. The spring is released and the lancet comes out and quickly pokes your fingertip. Then you squeeze your finger a little to get a large enough drop of blood out (most modern meters only need a little drop) and either drop it onto the test strip or cartridge, or the test strip or cartridge will wick it up into the test area. About five seconds later, you have your result and know how high or low your BG is right now. It's a good idea to test when you wake up in the morning, before you go to bed in the evening, and 2 hours after each meal, as well as if you feel weird. If you are on insulin, you may need to test more often than that, and your CDE or physician will tell you how often and when. That seems like a lot of testing and it can be, but when I started peritoneal dialysis, my endo told me to test 16 times a day and I did. I did it for a month, then went back with my results and he reviewed them. He told me I didn't have to test that often any longer and to go back to my regular testing schedule.
Carry your meter with you. Take it to work. Take it out with you when you're socializing. It's easy enough to hit the bathroom if you're in a social gathering and do a discreet test, so if you don't want to tell all your friends you are a PWD, your secret will be safe. Test at home. Test at work. Test anytime you eat. Remember when you ate and test 2 hours afterward (when your BG is highest) to get an idea of how whatever you ate is affecting your BG. When you do this regularly, you get a really good picture of what you can eat and what you really should limit or avoid, by keeping an eye on how your BG responds to your food. It's a way to customize your prescription diet for yourself.
Food, Glorious Food
What to eat, when to eat, how often to eat, how much carbohydrate to eat...it's all a big deal to PWDs for a good reason: everything about it affects the BG. Fortunately for all of us, there are really good diabetic cookbooks out there on the market, and some sites like dlife that have a sizable collection of diabetes-friendly recipes. The cookbooks and recipe collections will not give you a dietary prescription, but they will help you follow yours. You can also adapt your favorite recipes to accommodate your diabetes. For instance, using non-caloric sweetener instead of sugar, or figuring out ways to add something like applesauce to baked goods, or fixing just enough for that night's dinner in correct portions instead of extra, or figuring out how to reduce the overall fat and calories in the recipe and replace the less-healthy fats with healthy fats like olive oil.
There's also a lot of controversy about exactly what to eat. Some PWDs are low carbers (I'm generally one); some are low-fat fans. The one thing almost all of us have in common is counting carbohydrates, because there's a set number on our prescription diets that we shouldn't go above for our meals and snacks (and that number varies with the meal or snack). For example, my diet prescription says I should eat 30 grams of carbohydrate at breakfast, 45 at lunch, and 45 to 60 at dinner. I am allowed 15 grams of carbs each for two snacks a day. I've found out, because I've checked my BG with my meter, that eating half that many carbs at breakfast is all I can do without causing my BG to go high. I personally prefer to keep my BG at 80 to 140 at all times, even 2 hours after meals, and to keep it on that much of an even keel requires dedication and dietary stringency on my part. That 15 grams of carbs for breakfast means I can have, for example, a breakfast of one carton of non-fat, no-sugar-added yogurt, or some eggs and a single piece of toast. It's not much in the way of carbohydrates. But I've learned to count them over the years and that's what I propose to teach next.
The Basics of Counting Carbs
This is the method that will keep you on track with controlling your BG if you follow it and don't exceed your carb prescription amounts. You are often taught when you're first starting out that you're allowed a certain number of carbohydrate servings or "carb choices" at each meal and with or for each snack. Each carb choice counts as 15 grams of carbohydrate. So for me to eat 30 grams of carbohydrate at breakfast, I would need to eat 2 carb servings or choices. A choice might be a single slice of bread. Or it might be that carton of artificially-sweeetened yogurt (milk sugars count as carb choices, too - all carbohydrates have to be accounted for and counted in). It might be a piece of fruit, or some berries to put on top of the yogurt. With each selection, I need to know what the serving size is that will add up to 15 grams of carbohydrate, but I can look that up in reference guides (printed for just this purpose) or online.
For dinner, I might want some rice instead. Brown rice instead of white rice, of course, since I largely avoid the "four whites" like most low-carbers and carb-conscious PWDs (white sugar, white flour, white rice, and white potatoes, the latter three of which act on our bodies a lot like white sugar and just as quickly) and I want that good fiber if I'm going to eat a carbohydrate. I need to look up how much rice is in a serving of 15 grams of carbohydrate, and measure out what I can eat with a measuring cup. I know that brown rice has 44.8 grams of carbohydrates per cup; that means 1/3 cup is 15 grams of carb, and I can have three to four of those 15-gram servings with dinner if nothing else has any carbohydrates. But other foods have carbohydrates as well so I need to take those into consideration before I dish up my dinner.
A good rule of thumb for diabetes diets is to follow the "plate rule", but you will potentially have to modify it based on plate size and your carbohydrate allowance. The "plate rule" says fill half your plate with vegetables, a quarter of it with protein, and a quarter with carbs, but you may not be allowed as many carbs as will fit on 1/4 of your plate. This is why carb counters measure, especially at first; we want to be exact in how many carbs we get, not go sloppily over by guessing how much we are getting. After a while, you get so you can eyeball the amount and make a pretty accurate guess, but anything new needs to be measured. A gram scale to weigh things is another handy device that is highly recommended. If you use bolus insulin at meals, you need to learn how to count carbs for your own well-being because it is critical for insulin users. I personally think it is critical for all PWDs and practice it myself.
Practice, practice, practice. You need to keep doing this, measuring, weighing, looking up carb values and figuring out your serving sizes, every day so that it becomes ingrained. This is the key to keeping your BG under control and avoiding complications. It's a life skill for us. Here is a pretty good overview of it. To count carbs for more complex foods, look up the ingredients in the USDA Nutrition Database and figure it out based on how much of what is in the dish.
The Exercise Prescription
For most people, exercising regularly and frequently is a good idea. For us Type 2 PWDs, it is a lot more than a good idea. In truth, it really ought to be a prescription just like diabetes oral medication or insulin is. Because it is every bit as important to us as that medication is in controlling our BGs. And it's the other vital component of good diabetes management. We've gotten into the basics, into measuring your BG and counting your carbs, but we have so far only skimmed over exercise.
The Components of Good BG Control
- Food Choice and Amount
- Medication
- Lifestyle Modification
- Regular, Frequent Exercise
What sort of exercise is recommended? Whatever you want to do, as long as you do it regularly and frequently. It's often recommended to people who don't already have an exercise plan that they begin by walking. Some people choose to take that into running, others build up the time and distance that they walk briskly. Still others say "the heck with that!" and find other things they like to do: dancing, swimming, kayaking (a personal favorite of mine), rock climbing, hiking, going to the gym, biking, house cleaning (you'd be surprised how much you can burn doing some good, vigorous vacuuming), gardening and working in the yard, skiing, snowboarding, volleyball, you name it. The list is long and as individual as the person who is performing the activity. I might not enjoy house cleaning but love swimming, for instance. It's all exercise, believe it or not; if it involves movement and moderate to vigorous activity, it counts. You can break up an hour a day of exercise into six ten-minute breaks, and it still counts as an hour. And we need quite a bit of exercise; check with your own physician, but most of us need an hour to two hours of moderate to vigorous activity in order to help manage BG control. Just pick something you'll enjoy and stick with, which is why I can't tell you what kind of exercise to do. The very best kind of exercise to do is the kind you will do, regularly. If that's walking, great. If it's something else, great, but do something. Do not refuse to exercise. It's like refusing to take your prescribed medication. You need this medication to deal with your condition and exercise is another medication, albeit one you can't take by mouth or inject into yourself. And making plentiful use of your exercise prescription may make it possible to lessen the amount of oral medication or insulin you're using. Ask your doctor. It's not true for everyone but is true for many.
And Speaking of Prescriptions...
Chances are, if you're a PWD or have impaired glucose tolerance, you'll be given a prescription for at least one medication. There are differing philosophies among physicians and diabetes professionals as to the right medication approach. The standard right now is to start a PWD or person who needs medication to lower blood glucose on Metformin, which doesn't have a tendency to bring about low blood glucose (a very dangerous condition), and if that doessn't do the trick, to start the person on at least a basal daily dose of long-acting insulin, adding more doses (this time bolus doses) of insulin at mealtimes if needed. Insulin most certainly can bring about low blood glucose and if you are prescribed insulin, make sure you have your meter with you at all times. Insulin also has an unfortunate tendency to help the body store fat, so a PWD may gain weight easily if she's on insulin. If you're prescribed insulin, my personal recommendation is to keep your meter with you, count carbs like a fiend (they get stored as fat most quickly), and keep yourself on the right track to lose weight by following a calorie-restricted diet. Talk to your diabetes educator. You'll probably have an appointment scheduled with one anyway if you're prescribed insulin, because chances are good that the diabetes educator will be the one teaching you to load syringes and inject yourself with your insulin. The only way to administer insulin is to inject it. You can get many insulins in a "pen" form, for which you can get little tiny needles that hardly hurt at all. Insulin is injected subcutaneously, i.e. under the skin, usually in your abdomen. The other way to inject insulin is with insulin syringes, which are small syringes with fairly small needles. The needles on insulin syringes are usually a little larger than the ones you can buy separately for the pens. Most of the time, insulin has to be stored in the refrigerator or otherwise kept cold, and you can purchase insulin coolers just for this. There are many, many sites selling these coolers and they're small and highly portable, so you can take your bolus dose insulin to work with you and inject at lunchtime.
Some physicians, though, follow a different philosophy when it comes to treating PWDs. My GP, who is trained in this and does all my diabetes care, is one of them. He believes that a PWD needs to keep her A1C below 6.0 and the closer to non-diabetic normal, the better (as long as it's on an even keel, without lows). He thinks that using multiple oral medications to achieve this is a good way to treat a patient, and he has me on three diabetes medications at this time. None of them is insulin; all are oral. Most of them are pretty new and treat blood glucose in innovative ways. One's called Glyset, and it's not available in a generic form. Another's called Januvia, and it's not available in a generic form, either. The last one is called Starlix, and it became available in a generic form just last year; the generic form is called Nateglinide. That last can cause lows if I'm not careful. I've been on many, many oral medications. I was on Avandia for two full weeks and insisted that I be taken off it, because in those two weeks, with no diet modifications whatsoever from my already calorie restricted diabetes diet, I gained ten pounds. That medication has turned out to cause heart problems, so it's a good thing I went off it quickly. Another one I've been on but am not on right now is an injectable called Byetta, which is still pretty new and not available in a generic form. It's also known colloquially as lizard spit, because the idea for it came from a property found in gila monster saliva. No joke! That one comes in a pen form only, and it's an injectable. It helps lower your blood glucose and for many people, also helps induce weight loss. This has been seen and studied, and it's documented; it's not just anecdotal. Another injectable, one that comes in a bottle and must be drawn and dosed with an insulin syringe, is called Symlin, and that didn't work for either Charles or me at all. In fact, it raised our blood glucose, and we were off that medication within a month. Glyburide, a generic, is often prescribed, and that medication is specifically designed to lower blood glucose. It may cause dangerous lows, so again, always have your meter with you. That's actually a good idea anyway for every PWD, because many PWDs experience lows when they haven't eaten for a while.
That's just a few of the many, many diabetes medications that are on the market and may be prescribed. It's not even a complete rundown of everything I've ever been on. Metformin is prescribed for almost every Type 2 PWD, especially at first, but for people like me with Chronic Kidney Disease or who are on dialysis, it can be fatal and is contraindicated. That's why I'm not on it any longer.
Bulding your Health Care Team
Speaking of doctors, let's talk about building your health care team. As mentioned earlier, the team captain is you. You are the one who chooses the professionals you see, unless you're required to get a referral from another doctor. Even if you are, if you have a bad feeling about one of the professionals to whom you've been referred, ask for a different referral.
The other players on the team are your general practitioner (GP), who may or may not be the person who does your diabetes care. This physician can refer you to an endocrinologist, and preferably to one who is a diabetologist (a diabetes specialist), who will do your diabetes care if your GP does not. If you don't think your GP is doing a good enough job, or if you have other diabetes questions that you would rather address with someone else, ask for the referral to a good endo. Also ask for a referral to a podiatrist, because foot care is essential to avoid non-healing sores, foot complications, and amputation. Your feet are one of the places where a lot of things can go wrong. Many PWDs lose some or a lot of feeling in their feet and cannot necessarily tell when they have a sore that needs treatment unless they examine their feet with a mirror. Daily foot care is a must-do and it's your job. Not only are you the team captain, you're the masseuse and the health inspector when it comes to caring for your feet. And make sure you get a referral to a good eye doctor, preferably an opthamologist who has equipment like a retinal camera to study your retinas closely and monitor you for any signs of diabetic retinopathy.
You should also ask for a referral to a CDE. Your doctor may refer you to one automatically if you are diagnosed with Type 2, or may not. If not, make sure you ask for that referral, because going through a good diabetes education program will help you in many, many ways. You'll learn that you aren't alone, because the sessions are usually group sessions. You'll learn a lot about diabetes. I went into this in some detail above. And you'll almost certainly walk away with your own diet prescription, and some of what I wrote above will help you learn how to tweak it. If you are partial to your ethnic cuisine, there are books to help make that diabetes-friendly as well as books on more standard American fare.
That's your health care team. It takes more than one doctor to treat a PWD properly; it takes quite a few of them. You are the one in charge, though. You may have to make sure all these professionals talk with each other and keep each other in the loop. You do have to make sure that you follow what they tell you to do with regard to food, exercise, self-examinations, medication, rest, and generally taking care of your body. Nobody can force you to do it; it's up to you. A doctor generally is happier to work with a compliant patient who follows what she has been given rather than a non-compliant one, so be aware that being compliant can lead to better care from your doctors and a better working relationship with them. But you, not anybody else, are in control of your health care. And that is the way it should be.
Helpful Websites
Here are some I recommend and use:
dlife - Has videos, a TV show, forums, recipes, many articles by diabetes professionals of many kinds
SparkPeople - one of the best sites I've found for weight loss and accomodates diabetes diets to at least some extent. Forums abound! Exercise demo videos have helped me lots and they have more recipes than I could ever cook, even if I cooked all day for the rest of my life.
Diabetes In Control - Diabetes In Control newsletter, written for health care professionals but available to us for free. Superb and opinionated.
Diabetes Health - an online magazine. Also has a paper copy if you want to subscribe, and Diabetes Health Professional is a good magazine (also available online and on paper) for informed laypeople and diabetes professionals. Online availability to both is at no cost.
I'll be around for a while if anybody has questions, and if you feel a need to ask your question privately, my email's in my profile. If you made it this far, thanks for sticking with it through this lengthy diary; I hope you found it helpful.
And one last note: this diary (in its earlier iteration) has been nominated for a kOscar for Best Teaching Diary, as long as it survives the runoff voting. Only the top 9 diaries will survive, so if you liked it, I hope you'll find a kOscars voting diary and vote for it. Thanks.