The First Year: Type 2 Diabetes

DAY 1

living

It’s Not Your Fault

YOU’VE JUST been diagnosed with type 2 diabetes. If you’re like most people, you’re probably in a state of shock. At the first consultation, your doctor probably told you a lot of things about diets and drugs and insulin and glucose and carbohydrates and blood tests and avoiding this and doing that, and you probably came out of the office with your head spinning, not remembering much of what the doctor said.

Don’t worry, you’re not alone. Most people feel that way.

If no one in your family ever had diabetes, and especially if you’re thin and thought diabetes only happened to fat people, you’re probably especially puzzled. ‘What did I do wrong? Why is this happening to me?’

Sometimes a diagnosis comes like a thunderbolt on a sunny day. Sophie C. consulted a doctor about a toenail fungus, and he drew some blood for routine tests. ‘Next day the phone rang, and my doctor informed me quite bluntly that I was diabetic,’ she said. ‘Talk about a slap in the face! I was scared out of my mind. There must be some mistake here. I wasn’t blind, my feet weren’t gangrenous. No family history of the disease, no warning signs (that I knew of at the time), not a clue.’

Or maybe you were expecting a diagnosis someday. You’ve got relatives with diabetes: your grandmother had diabetes and died from gangrene in her foot. Your father got it when he was 65 and died from a heart attack a few years later. If you’re also overweight, maybe you figured someday you’d get diabetes yourself. But you probably figured ‘someday’ would be far in the future, when you were old. Not today. Not now. ‘I’m not ready yet.’

Whether you expected it or not, a diabetes diagnosis is a shock.

Getting diabetes is not your fault

There’s so much to learn, but you can’t learn it all at once. Trying to accept the diagnosis is enough for your first day. Here’s what you should remember as you deal with this: Getting diabetes is not your fault.

A lot of people may tell you that if only you’d eaten less sugar, or eaten less fat or exercised more, or eaten more fibre, or smoked less, or done none of the things that 95 per cent of people do, you wouldn’t have got diabetes. Especially if you’re overweight, since most people with type 2 diabetes have a problem with weight, people will suggest that it’s your fault that you got diabetes because you let yourself get fat.

There is no question that type 2 diabetes is associated with obesity. Therefore, most people assume that the excess weight causes the diabetes. But here’s something to think about: It’s possible that diabetes causes obesity.

You need the genes

To get diabetes, you need to have diabetic genes. One of the causes of your diabetes is a poor choice of ancestors. People without those genes can spend their lives lying around eating chips and watching TV and they’ll probably get fat. But they won’t get diabetes.

Having the genes, however, isn’t enough to give you the disease. Even if you have diabetes genes, if you live in an environment where you don’t get a lot to eat and you do hard physical labour all day, you still probably won’t get diabetes. Some people think the diabetic genes are thrifty genes that make your body use its food more efficiently, meaning that you can gain more weight with less food. In times of famine, this comes in handy, and when food was extremely scarce, your ancestors probably fared better and had more children than other families who didn’t have those genes.

But when your family moved to a different country or into a different type of lifestyle where food was plentiful and machines did all the work, those diabetes genes weren’t so handy after all. When food is limited, it doesn’t matter how hungry you are. You can’t eat enough. When food is readily available, having a good appetite can be a disaster.

Diabetes may cause hunger

Having diabetes genes may affect the appetite. Alex E. described the time someone brought some scrumptious pastries to work. A thin person walked in, looked at the pastries, and said, ‘Oh my, those look good. I wish I were hungry so I could try one.’ Alex was flabbergasted. He was hungry all the time and thought everyone else was too. Only after he learned to control his blood sugar levels did his hunger abate and he learned what normal hunger is like.

Some people find that they get ravenously hungry when their blood sugar is fluctuating rapidly. You may have had poor blood sugar control for years before you were diagnosed with diabetes. This means that after every meal, your blood sugar went abnormally high. Then it came down again. This may have triggered intense hunger, which would make you eat again. Then the roller coaster would repeat. No wonder you put on a little weight.

‘All my life I was hungry! The more “healthy” my diet, listening to all the diet gurus, the more hungry I became,’ said Linda C.

You can’t change your genes

So it may have been those diabetes genes that made you hungry. The hunger made you eat. The thrifty genes were especially efficient in turning that food into fat. And the fat made it harder for you to exercise. So you had another snack instead.

I’ve probably already told you more about diabetes than you wanted to know right away. But for now, just remember this. To get diabetes, you need to have diabetes genes. There’s nothing you can do to change your genes.

Your diabetes is not your fault.

IN A SENTENCE:

learning

What Is Diabetes?

DIABETES IS an incredibly complicated disease that comes in many flavours. Later, we’ll discuss some of those exotic flavours. But for now, we’ll stick with the two basic groups, called type 1 and type 2 diabetes.

Type 1 is autoimmune

Type 1 diabetes, which used to be called juvenile diabetes, or insulin-dependent diabetes mellitus (IDDM), is usually, but not always, diagnosed in children and young adults. It is an autoimmune disease, meaning that for some reason, the immune system has mistaken its own pancreas for foreign tissue and destroys the cells that produce insulin, which is a hormone. As a result, people with type 1 diabetes produce almost no insulin and must take daily insulin injections.

Type 2 means insulin resistance

Type 2 diabetes, which is what you have, used to be called adult- or maturity-onset diabetes, or non-insulin-dependent diabetes mellitus (NIDDM), sometimes popularly called old-age diabetes, because it is usually, but not always, diagnosed in older people. Today, more and more younger people, even children, are being found to have type 2 diabetes. Because this book is about type 2 diabetes, whenever I say just diabetes, unless I specify otherwise, I am referring to the type 2 variety.

Type 2 diabetes is probably not an autoimmune disease, and you probably don’t have less insulin than normal. In fact, you may have more insulin than normal. The problem is something called insulin resistance (IR).

Insulin lets glucose into cells

Before we discuss IR, let’s go back and try to understand what insulin does. Like a car that needs energy to run and uses petrol as an energy source, your body also needs energy to function and uses a sugar called glucose. When you eat food, the body converts much of that food into glucose. The glucose is taken up by the brain and the muscles to make you think well and run fast, both useful characteristics if you’re trying to avoid being eaten by a sabre-toothed tiger or hail a taxi in London.

The brain doesn’t need insulin to take up that glucose, but the muscles do. In the presence of insulin, the muscles produce what are called glucose transporters – which you can think of as little boats that carry glucose passengers – to ferry the glucose across the cell membrane into the cell. Without enough insulin, the cell doesn’t produce enough transporters, so a lot of the glucose can’t get into your muscle cells. The glucose just builds up in the bloodstream and causes all kinds of problems.

If you’re thin, you may be one of the minority of people with type 2 diabetes who for some unknown reason simply don’t produce enough insulin. In this case, your IR may be normal.

If you’re overweight, it’s more likely that you’re producing plenty of insulin, but you’ve got IR. For some unknown reason, the insulin just doesn’t work very well. The body (which is generally much more intelligent than we are) recognizes this and produces more insulin to compensate for the IR. But after many years, the cells in the pancreas that produce the insulin (called beta cells) can’t keep up with the demand and eventually get ‘exhausted’, not able to produce all the insulin you need. Then your blood sugar (blood glucose) level rises, and that’s usually when you’re diagnosed with diabetes.

The drinks machine analogy

If you like analogies, think of muscle cells as drinks machines. If you want a drink, you put money (insulin) into the machine and a can of fizzy drink (glucose transporters) comes out.

Thomas is a single father who just got fired from his job. He’s thirsty and he finds a functioning drinks machine, but he simply has no money to put into the machine, so he can’t get a drink. Thomas is like the thin person with type 2 who just isn’t producing enough insulin (money), even though the glucose-transporter factory (the drinks machine) is working well.

Rhoda, on the other hand, is wealthy. She has all the money she needs, because she prints her own money on a machine in her basement. She’s thirsty, finds a drinks machine, puts in some money and discovers that the machine is broken; no can comes out. But Rhoda is in luck for today. She discovers that if she puts in £25, she can get a drink out of the machine. Getting money is no problem for her, so she keeps using the drinks machine because it’s near where she works.

Rhoda is like the overweight person with IR. She can produce plenty of money (insulin), but the machine (her glucose-transporter factory) is broken. For a while, things work all right for Rhoda. When she needs a drink, she just prints more money.

Then one day, Rhoda’s money-printing machine (her insulinproducing beta cells) starts wearing out. Every day, she’s got less and less money (insulin). Finally, she doesn’t have enough money for even one drink. Now she’s like the person with IR whose beta cells are exhausted.

Focus on the basics

No one yet understands exactly how all these processes work, but scientists are working hard on the problem. Later, we’ll discuss some of the details. For now, it’s enough just to understand the basics: Diabetes is a disease of insulin deficiency, in either quantity (the beta cells don’t produce enough) or quality (you’ve got plenty of insulin, but it doesn’t work very well). As a result, your blood glucose levels are too high.

There are many ways to treat type 2 diabetes. For now, trust your medical team to make the best choice for you and don’t worry about all the whats and whys. You’ve probably gone for many months, maybe even years, with high blood glucose levels, but with no treatment at all. Now almost any treatment will improve your situation. You’ve got a lot to learn in the days ahead, so concentrate on becoming informed and let your medical team lead the way.

IN A SENTENCE:

DAY 2

living

Is It All a Mistake?

I SUSPECT most people with diabetes have the same fantasies.

In the first fantasy, you’re sitting at the kitchen table surrounded by diabetes paraphernalia and lists of food choices called exchanges that you got from the nurse. You’re trying to understand what insulin resistance (IR) is, and you can’t remember if your doctor said you had too much of it or too little. You’re wondering if you’ll have to have injections.

Then the telephone rings.

‘Hello? Is this Mr Bigappetite? This is Dr Birdwhistle’s receptionist. There’s been a mistake here at the lab. They mixed up your lab results with Mr Bigape E. Tight’s. Your blood sugars were fine. You don’t have diabetes after all.’

Unfortunately, that fantasy is not likely to come true. Your diabetes is real. And it’s not like the flu or a bad case of bronchitis. It doesn’t go away. Someday in the future, they’ll discover how to cure diabetes. But that day isn’t here yet. Your diabetes is going to be with you for a long, long time.

You want it to go away

Diabetes doesn’t show. You don’t have any obvious outward signs like a high fever or black warts on your nose or joints that scream when you move. Many people feel perfectly healthy once they’ve got their blood glucose levels under control. So it’s easy to fantasize that your diabetes might have gone away. In this fantasy, you’re standing at the checkout in the supermarket. You smile as you see a copy of the latest edition of your local newspaper, with your picture on the front. The cover story says, ‘Middle-aged diabetic miraculously cured.’

There is a picture of you, eating a chocolate fudge sundae. ‘It was the oddest thing,’ you are quoted as saying. ‘After dinner last night, I had a bite of this strange Tibetan chocolate, and the next day my blood sugar stayed normal no matter what I ate. Then this morning, I discovered I’d lost weight.’ Doctors confirmed your recovery. ‘We can only say it’s a miracle,’ says Dr Charge A. Lott.

This second fantasy never comes true either. Unfortunately, your diabetes is here to stay.

You can be diagnosed with or without symptoms

You may have been diagnosed because you weren’t feeling well. Many people feel tired when their blood glucose level is high. High blood glucose levels can cause constant thirst and frequent urination. It can cause recurrent yeast infections. It can also cause problems with the lens of your eyes, so that you have to change the prescription for your glasses too often. Some of you may have had elevated blood glucose levels for five or ten years before you were diagnosed. If that is the case, you may have had more severe symptoms, such as sores that wouldn’t heal, numbness or tingling in your arms or legs, problems with your kidneys or damage to the retina of your eyes. You may even have had a heart attack before you were diagnosed.

If you’ve had any of these symptoms of diabetes, it may be easier for you to believe that you do, in fact, have this disease, especially when the symptoms disappear, or at least stop getting worse, after you get your blood glucose levels under control.

But you may have been diagnosed on the basis of a random blood glucose test during a physical exam or screening at a health fair when you were feeling perfectly fine. Then someone pricked your finger and tried to tell you that you’ve got diabetes.

How can you believe that when you’re feeling so good? Surely it must have been a mistake. No one in your family has diabetes. You’ve always eaten healthily. So admittedly, you don’t run the London Marathon every year, and you don’t lift weights every day. But you’re reasonably fit and reasonably active. You thought diabetes only happened to overweight people who never went far from the TV remote control. How could this happen to you?

It must be a mistake. Maybe the machine was broken. Maybe that nice woman doing the test wasn’t properly trained. Or maybe it was just because you had been eating sweets before you took the test and probably when you eat regular food again everything will be back to normal. Right? Unfortunately, wrong is the right answer here.

Acceptance is difficult

Accepting that you have diabetes is difficult for anyone, even if you had obvious symptoms when you were diagnosed. One day, you’re just like everyone else. Then suddenly everything is changed. You’re different. Simple things that you’ve always taken for granted are now suddenly forbidden to you – probably forever.

How do you deal with this sudden curtain falling down on the world as you knew it? The easiest way is to deny it. They think you’re going to stop eating almost everything that tastes good? No way.

Taking tablets is easy. But changing your entire way of living is more difficult. ‘I went through the various phases of being unable to imagine giving up my favourite foods, or feeling cheated that certain foods would be taken from me, or that I had a right to these foods and it was unfair for this disease to treat me this way and even a little, “I’m strong, these high blood glucoses won’t hurt me,” ’ said Edward A.

But acceptance leads to control

Accepting your diagnosis as soon as possible is absolutely the best thing you can do for your control of this disease, because there’s both bad news and good news about type 2 diabetes. Diabetes is incurable. That’s the bad news. The good news is that it is controllable. And the most important agent in that control is you.

Of course it’s not easy. Acceptance takes time. But once you are able to accept the fact that you really do have type 2 diabetes, a condition that won’t ever go away, you can start taking control. In many cases, you will eventually feel healthier and more energetic than ever before.

That first step may be one of the hardest to take, and it normally takes a while to fully accept this new way of life. The front page of the newspaper fantasy will probably be with you for years to come. But acceptance is the key. Acceptance allows you to dump all the unnecessary baggage of pretending and blaming and resenting and wasting your energy looking for medical mistakes or miracle cures.

You know that diabetes is not your fault. It’s simply one of those bad breaks. You’ve got it, and it’s not going to go away. Now you can focus on learning more about this complicated disease so that you can control it well and lead a happy, rewarding life.

IN A SENTENCE:

learning

Measuring Your Blood Glucose Levels

THE BEST thing you can do is to get a blood glucose meter. Right away. Now. There are many different kinds of meters and subtle differences among them that I’ll discuss later. But for now it doesn’t really matter what kind of meter you get. What matters is that you get a meter and that you use it.

A simple meter may be best to start

Strips are available free on a National Health Service (NHS) prescription but you will have to buy a meter. Adequate ones will cost less than £25 and they are available in all good chemists. Alternatively the practice or hospital diabetes nurse will advise you.

Some meters offer fancy extras. If you’re a gadget freak, you’ll want to check these out right away. If you’re visually impaired, look for a meter with a large display. There are also talking meters as well as little gizmos that help you aim the drop of blood onto the strip when you can’t see it very well.

Otherwise, a simple meter is just as good, especially to start with. The important thing at this point is not the bells and whistles in the meter. The important thing is to get a meter, learn how to test and do it every day.

Every meter operates slightly differently, so of course you’ll need to read the instruction manual for your own particular meter before you actually do a test. Or your doctor, nurse or diabetes educator may show you how to use it.

Pricking your fingers is a minor annoyance

Some aspects of testing are pretty much the same no matter which meter you have. Testing your blood glucose (which from now on I’ll call BG) requires you first to obtain some blood. This means that you must puncture your skin. Ouch. Yes, it does hurt a little. And yes it does take a few days before you stop worrying about the pain. I remember the first time I tested my blood. I knew that all I had to do was press this little button on my finger-pricker and it would do all the work for me. I did a few dry runs pricking imaginary fingers in the air. Then I put the pricker on my finger and . . . and . . . finally I closed my eyes and clicked, and ouch, a little hurt and then it was done.

It doesn’t take long to realize that pricking your fingers is one of the minor annoyances of having diabetes. When you’re starting out, it’s the anticipation that hurts the most. And certain types of finger-prickers hurt more than others. The best kinds are the ones you can adjust for different depths. At the lowest setting, you hardly feel a thing.

Blood is usually easy to get

But wait. Let’s go back a minute. Before you prick your finger, wash your hands in warm water. This not only reduces the number of germs on your fingers, but it ensures that you don’t have any traces of sugar on your fingers that might interfere with the test, and it’s also easier to get blood from warm hands. Then dry your hands thoroughly. Extra moisture on the skin could dilute the blood and give a wrong result. Don’t use an alcohol wipe. If you don’t get it all off, the alcohol might interact with the test materials and cause false results.

After you’ve pricked your finger, wait a second or two, and then gently squeeze out a little blood and let it drop onto the test strip. Your meter will start working, and in less than a minute you will know what your BG level is.

The best place to prick your fingers is on the side of the tips, close to the nail (but not too close, or the blood will run all over the nail and won’t drop onto the strip). The fingers are less sensitive there.

Many people rotate their fingers, using a different finger every day, so each finger has several days to heal before being used again. This is a sensible method, but I find that my ring finger and little finger are the easiest to get blood from, and I tend to use them day after day.

The instructions to your meter will tell you to make sure to use a fresh lancet every time you test, but many people use the same lancet for days, weeks or even months without changing. It seems that people usually build up immunity to the germs on their own skin, and infections from used lancets are rare although they can occur. For the same reason, it’s not absolutely essential to wash your hands before lancing your fingers to test, but if you’re near a bathroom, it certainly doesn’t hurt and reduces the chances of contaminating the blood sample with something on your fingers that might affect the test. Of course, to avoid getting infected with hepatitis, AIDS or other viruses, you should never use a lancet that has been used by anyone else.

Use a few tricks when the blood won’t flow

Sometimes blood is easier to get than other times. Anything that increases your circulation, such as exercise or a hot bath, makes the blood run out more easily. That’s a good time to use your ‘bad’ fingers – the ones that don’t bleed as well. Sometimes you may have difficulty squeezing a drop of blood out, especially if your hands are cold. If this happens, try warming your hands in hot water. If that’s not enough, try swinging your arms to push the blood into the fingertips. Then, after you’ve pricked a finger, hold your hand well below your heart, the lower the better, and relax your hand for a few seconds before you try to squeeze some blood out. Don’t worry. You’ll get the hang of it pretty quickly.

Although ‘milking’ the finger by grasping it at the base and squeezing towards the tip can help, it’s best to avoid getting blood this way if you don’t have to, as it can force nonblood fluids (called interstitial fluid) into the drop, and this sometimes affects the results. If all else fails, try putting a rubber band on your finger like a tourniquet to build up pressure at the tip. Needless to say, you’ll want to take it off as soon as possible.

Test as often as you can

Once you’ve learned how to measure your BG level, you’ll want to do it (OK, you should do it) frequently. This is especially important early on, when you’re learning how your body reacts to various things like the foods you eat and the exercise you get. We’re all different, and we all live under different circumstances. No book and no doctor and no diabetes nurse can tell you exactly how your particular body is going to react to your particular diabetes treatment plan. Only by testing as often as you can will you be able to learn about your own particular physiology.