If you like rice and recognize that brown rice might be better for you, but find that you don't like the texture, check to see if the market where you shop has medium-grain or short-grain brown rice available. The different "lengths" of rice are actually quite different, and cook up differently. I find that the short and medium grain brown rices much have a softer texture than the long-grain when cooked. It's still not as soft as white rice, but nearly so. And, in my experience, short and medium grains don't get hard in the refrigerator. (I can even enjoy it cold, but I'm a little weird that way.)
As with beans, you can create some great-tasting dishes by adding spices or other flavorings to the cooking liquid. I love using reduced-sodium chicken stock for this.
Friday, August 06, 2010
Thursday, August 05, 2010
Intermission
"Gee, Dad, this blogger has sure been serious lately"
"Yes, son, he has."
"He's not usually this stuffy for this long!"
"Well, you see, son, his friends in the Diabetes Online Community have given him some great post, and they've all been things he feels strongly about. He's writing deliberately because he really wants readers to understand, whether they agree or not."
"I guess. But the posts have been so LONG!"
"Well, he's got a short one in mind for tomorrow, a D-Feast Friday post. And he's hoping to inject some humor over the weekend."
"He's going to do a dfeast post? Last week he wrote about cooking beans, and he ruined a whole batch the other day!"
"Well, son, he just didn't know that the citrus just in the cooking liquid would keep the beans from softening."
"I think he's softening in the head, Dad!"
"Shh, son, that's just not nice."
"Yes, son, he has."
"He's not usually this stuffy for this long!"
"Well, you see, son, his friends in the Diabetes Online Community have given him some great post, and they've all been things he feels strongly about. He's writing deliberately because he really wants readers to understand, whether they agree or not."
"I guess. But the posts have been so LONG!"
"Well, he's got a short one in mind for tomorrow, a D-Feast Friday post. And he's hoping to inject some humor over the weekend."
"He's going to do a dfeast post? Last week he wrote about cooking beans, and he ruined a whole batch the other day!"
"Well, son, he just didn't know that the citrus just in the cooking liquid would keep the beans from softening."
"I think he's softening in the head, Dad!"
"Shh, son, that's just not nice."
"Pre" but not Easy
I've seen several discussions recently in the Diabetes Online Community recently about the notion of "pre diabetes", a situation where a patient has blood glucose levels that are abnormally elevated without meeting the diagnostic criteria for Type 2 diabetes. Mike Hoskins wrote a thoughtful post about it not long ago, and it was discussed in the second Diabetes Social Media Activism session. It's come up one or two other times, as well.
By and large, the people I've seen weigh in don't care for it, either as a term or as a concept. And I have to say that I disagree, at least in regards to the concept. This post relates pretty heavily to yesterday's post about "reversing" Type 2.
The Analogy
I've seen a number of folks who argue against the notion of pre-diabetes by drawing an analogy to pregnancy. You can't be pre-diabetic, and you can't be a little bit pregnant. Once you're pregnant, you stay pregnant until the pregnancy is interrupted in some way or the baby is born. According to the analogy, either you're diabetic or you're not, and once you're diabetic you're always diabetic until death or such time as there's a cure.
In pregnancy, there is a pretty well-defined beginning, to the best of my layman's understanding: an ovum is fertilized by a sperm cell. It may be that the onset of Type 1 diabetes is comparable, if onset is considered to occur when the immune system starts trying to kill off the pancreatic beta cells. So, it may be that the pregnancy analogy would work for Type 1. (It's also a distasteful analogy, in my mind. Comparing the prospective birth of a child to a disease state? Really?)
But what's the analogous is/isn't point in Type 2 diabetes? Is it when insulin resistance rises above a certain point, and how wold this be measured? Is it when the observable measure of fasting blood sugar rises above a certain level, or a certain A1c, or a certain result from a glucose tolerance test? Is it when the ability of the pancreas to supply insulin begins to be impaired, through a mechanism that I don't believe is yet understood?
And, do we really know that no one who meets whatever criteria you choose ever stops meeting that criteria?
Ironically enough, I think the case against the pregnancy analogy ultimately falls when we consider gestational diabetes. Some significant percentage of women develop insulin resistance during pregnancy and need to be treated with oral medications or insulin. When the pregnancy ends, so does the diabetes. A woman who's had gestational diabetes is at significant risk of later developing Type 2, but for many the diabetes goes away and stays away.
The pregnancy analogy just doesn't work for Type 2.
The Concept
The next point I want to consider is whether the concept of pre-diabetes is meaningful or not, temporarily laying aside the choice of term. It may be that further research will allow us to dump it entirely, if the diagnostic criteria for T2 can be refined such that a patient is considered diabetic at one level (of whatever we're measuring), and those folks below that don't need to worry. But, given what we think we know now, this seems counter-intuitive.
As I discussed at length yesterday, there does seem to be a stage early in the development of T2 when lifestyle interventions may arrest the progression of the disease and development of symptoms. It makes sense to me that there would be a stage where there's sufficient insulin resistance to cause blood glucose levels to climb but precede (it is to be hoped) much in the way of damage to the pancreas' ability to produce sufficient insulin.
(Mike, in his post linked above, describes an experience his wife had being "diagnosed" with pre-diabetes in a health fair. It would be my hope that, if such a fair showed elevated blood glucose levels, the patient would not be "diagnosed" but rather encouraged to visit their physician for possible further testing and perhaps intervention.)
If there IS such a state, if significant lifestyle change can stop disease development (possibly for a lifetime), it seems to me that physicians have a strong obligation to watch for it. And there's another thing: we're used to Type 2 progressing pretty slowly, but that's not the case for everybody. A patient who doesn't quite meet diagnostic criteria at one checkup may, I'm guessing, come to the next checkup complaining of foot pain and blurred vision.
The Term
So I'm a fan of the concept of pre-diabetes, at least until it's shown not to be useful in helping people be as healthy as possible. However, I don't much care about the term itself. I don't doubt that there would be good candidates, and I'd be happy with any of them if the support for it is broad enough to minimize confusion.
So, if you hate the term, I'm not going to argue with you. If you hate the concept, though, I'd ask that you give the idea another look.
By and large, the people I've seen weigh in don't care for it, either as a term or as a concept. And I have to say that I disagree, at least in regards to the concept. This post relates pretty heavily to yesterday's post about "reversing" Type 2.
The Analogy
I've seen a number of folks who argue against the notion of pre-diabetes by drawing an analogy to pregnancy. You can't be pre-diabetic, and you can't be a little bit pregnant. Once you're pregnant, you stay pregnant until the pregnancy is interrupted in some way or the baby is born. According to the analogy, either you're diabetic or you're not, and once you're diabetic you're always diabetic until death or such time as there's a cure.
In pregnancy, there is a pretty well-defined beginning, to the best of my layman's understanding: an ovum is fertilized by a sperm cell. It may be that the onset of Type 1 diabetes is comparable, if onset is considered to occur when the immune system starts trying to kill off the pancreatic beta cells. So, it may be that the pregnancy analogy would work for Type 1. (It's also a distasteful analogy, in my mind. Comparing the prospective birth of a child to a disease state? Really?)
But what's the analogous is/isn't point in Type 2 diabetes? Is it when insulin resistance rises above a certain point, and how wold this be measured? Is it when the observable measure of fasting blood sugar rises above a certain level, or a certain A1c, or a certain result from a glucose tolerance test? Is it when the ability of the pancreas to supply insulin begins to be impaired, through a mechanism that I don't believe is yet understood?
And, do we really know that no one who meets whatever criteria you choose ever stops meeting that criteria?
Ironically enough, I think the case against the pregnancy analogy ultimately falls when we consider gestational diabetes. Some significant percentage of women develop insulin resistance during pregnancy and need to be treated with oral medications or insulin. When the pregnancy ends, so does the diabetes. A woman who's had gestational diabetes is at significant risk of later developing Type 2, but for many the diabetes goes away and stays away.
The pregnancy analogy just doesn't work for Type 2.
The Concept
The next point I want to consider is whether the concept of pre-diabetes is meaningful or not, temporarily laying aside the choice of term. It may be that further research will allow us to dump it entirely, if the diagnostic criteria for T2 can be refined such that a patient is considered diabetic at one level (of whatever we're measuring), and those folks below that don't need to worry. But, given what we think we know now, this seems counter-intuitive.
As I discussed at length yesterday, there does seem to be a stage early in the development of T2 when lifestyle interventions may arrest the progression of the disease and development of symptoms. It makes sense to me that there would be a stage where there's sufficient insulin resistance to cause blood glucose levels to climb but precede (it is to be hoped) much in the way of damage to the pancreas' ability to produce sufficient insulin.
(Mike, in his post linked above, describes an experience his wife had being "diagnosed" with pre-diabetes in a health fair. It would be my hope that, if such a fair showed elevated blood glucose levels, the patient would not be "diagnosed" but rather encouraged to visit their physician for possible further testing and perhaps intervention.)
If there IS such a state, if significant lifestyle change can stop disease development (possibly for a lifetime), it seems to me that physicians have a strong obligation to watch for it. And there's another thing: we're used to Type 2 progressing pretty slowly, but that's not the case for everybody. A patient who doesn't quite meet diagnostic criteria at one checkup may, I'm guessing, come to the next checkup complaining of foot pain and blurred vision.
The Term
So I'm a fan of the concept of pre-diabetes, at least until it's shown not to be useful in helping people be as healthy as possible. However, I don't much care about the term itself. I don't doubt that there would be good candidates, and I'd be happy with any of them if the support for it is broad enough to minimize confusion.
So, if you hate the term, I'm not going to argue with you. If you hate the concept, though, I'd ask that you give the idea another look.
Wednesday, August 04, 2010
Reversal of (Mis)Fortune?
The following is a response to a topic suggested by my friend Mike Hoskins. Thanks, Mike!
Point one: Type Two diabetes is a very serious illness.
I don't see this to compare it to Type 1, or to Type 1.5, or to any other condition. I don't say this as an editorial about research priorities or an argument for or against any particular public health policy. I just state it as an unassailable fact.
Let me say it again, and expand a bit:
Type Two diabetes is a very serious illness, and it becomes more serious over time. If uncontrolled, and sometimes even in spite of control, it can steal sight, destroy organs, calcify the heart, and rot extremities. Extreme hypoglycemia and hyperglycemia pose the same dangers to a Type 2 that experiences them as they do to any other diabetic.
Point two: Because Type Two diabetes is a serious illness that grows more serious over time, the possibility that patients may be able to delay either its onset or its more serious serious stages MUST be taken seriously by those patients and their physicians.
The development of Type 2 diabetes appears, as I understand it, to depend on:
1) genetics;
2) risks such as age and obesity that are usually present (but aren't always); and
3) other factors not yet understood which may include environmental exposures or something(s) else.
We can't do much about 1) or 3) at present, either as individuals or as a society. So that leaves 2).
Point three: With all this horse manure, there's got to be a pony in here somewhere!
There's an awful lot of nonsense being spouted about "reversing" Type 2 diabetes. A great plenty of this nonsense is coming from snake oil salesmen who want to go on talk shows and sell books. Some of it is coming from people who honestly (I think) hope to address T2 as a public health problem by trumpeting warnings about the diabetes risks of obesity, overestimating (I think) the power of fear to promote lasting healthy lifestyle changes. Both groups slide over points 1) and 3), and omit distinctions between types of diabetes almost entirely, in an effort to present the simplest possible message: obesity causes diabetes. Reduction to absurdity.
The damage from this approach is felt by diabetics of all types who wind up being blamed for their illness by those around them. This is probably most unfair, and screamingly frustrating, to PWDs of Type 1 and Type 1.5, and some of Type 2, who had NO role in the development of their illness. But it just might be most damaging to we Type 2s who DO (or did) have the lifestyle risk factors and therefore must carry the burden of the misconception, all too often in our own hearts.
But all the nonsense, all the lies, all the misunderstandings, all the snake oil should not be allowed to wash away a truth that's becoming pretty evident:
Point four: Many newly diagnosed Type 2s, and many of those with elevated blood glucose numbers that do not yet meet the current diagnostic criteria, can delay the onset or progression of their disease via good diet, exercise, and weight loss where appropriate.
I have no idea what percentage "many" represents in the previous sentence, but whatever that percentage is represents a lot of people. And that's why we can't dismiss this point, however corrupted and misused in the media and however often its used to bash us over our heads.
If your life is touched by diabetes of any type, wouldn't you have wanted to delay the onset of the disease, were it possible?
Point five: Just because many can, that doesn't mean everyone can.
Using diet and exercise to delay the onset or development of Type 2 diabetes doesn't work for everyone. Unfortunately, the ability of many Type 2 PWDs to produce insulin is already pretty damaged by the time of diagnosis. For those of us with serious lifestyle-related risk factors, even when diagnosis comes early, that diagnosis does not necessarily remove whatever barriers to healthy living existed before diagnosis. I am one that was unable to make serious change. I don't know what part of that failure is rooted in laziness or warped psychology, or to what extent the metabolic deck is stacked against me, but there you go.
Point six: "Reversal" is just a word.
In preparation for writing this post, I spent a few minutes trying to find responsible medical opinion on the subject of reversing Type 2 diabetes. I did find a WebMD article that made a pronounced distinction between "reversing" T2, which the author believed in, and "curing" T2, which is clearly not yet possible. I don't know, but I'm guessing that to a physician, "reversing" a disease may be something equivalent to my layman's understanding of putting a condition into remission.
I'm interested in linguistics, and you're never going to hear me say that words don't matter. But sometimes, particular words do more to disrupt understanding than they do to promote it. I think "reversing" diabetes has become an example.
So, in review, let's review what seems to be true and not true:
-- Nobody can currently say with any truth that any type of diabetes can be "reversed" if "reversed" means "cured".
-- Nobody can say with any truth that diabetes of types 1 or 1.5 can be "reversed" in any meaningful sense through ANY amount of diet or exercise.
-- However, it CAN be truly said that SOME type 2 diabetics or "pre-diabetics" can delay the onset or profession of their illness though good diet, good exercise, and weight loss where appropriate.
I don't like the term "reversing diabetes" because it sounds too much like "curing" to my ears.
But I LOVE the concept. Even though I couldn't make it work for me.
Point one: Type Two diabetes is a very serious illness.
I don't see this to compare it to Type 1, or to Type 1.5, or to any other condition. I don't say this as an editorial about research priorities or an argument for or against any particular public health policy. I just state it as an unassailable fact.
Let me say it again, and expand a bit:
Type Two diabetes is a very serious illness, and it becomes more serious over time. If uncontrolled, and sometimes even in spite of control, it can steal sight, destroy organs, calcify the heart, and rot extremities. Extreme hypoglycemia and hyperglycemia pose the same dangers to a Type 2 that experiences them as they do to any other diabetic.
Point two: Because Type Two diabetes is a serious illness that grows more serious over time, the possibility that patients may be able to delay either its onset or its more serious serious stages MUST be taken seriously by those patients and their physicians.
The development of Type 2 diabetes appears, as I understand it, to depend on:
1) genetics;
2) risks such as age and obesity that are usually present (but aren't always); and
3) other factors not yet understood which may include environmental exposures or something(s) else.
We can't do much about 1) or 3) at present, either as individuals or as a society. So that leaves 2).
Point three: With all this horse manure, there's got to be a pony in here somewhere!
There's an awful lot of nonsense being spouted about "reversing" Type 2 diabetes. A great plenty of this nonsense is coming from snake oil salesmen who want to go on talk shows and sell books. Some of it is coming from people who honestly (I think) hope to address T2 as a public health problem by trumpeting warnings about the diabetes risks of obesity, overestimating (I think) the power of fear to promote lasting healthy lifestyle changes. Both groups slide over points 1) and 3), and omit distinctions between types of diabetes almost entirely, in an effort to present the simplest possible message: obesity causes diabetes. Reduction to absurdity.
The damage from this approach is felt by diabetics of all types who wind up being blamed for their illness by those around them. This is probably most unfair, and screamingly frustrating, to PWDs of Type 1 and Type 1.5, and some of Type 2, who had NO role in the development of their illness. But it just might be most damaging to we Type 2s who DO (or did) have the lifestyle risk factors and therefore must carry the burden of the misconception, all too often in our own hearts.
But all the nonsense, all the lies, all the misunderstandings, all the snake oil should not be allowed to wash away a truth that's becoming pretty evident:
Point four: Many newly diagnosed Type 2s, and many of those with elevated blood glucose numbers that do not yet meet the current diagnostic criteria, can delay the onset or progression of their disease via good diet, exercise, and weight loss where appropriate.
I have no idea what percentage "many" represents in the previous sentence, but whatever that percentage is represents a lot of people. And that's why we can't dismiss this point, however corrupted and misused in the media and however often its used to bash us over our heads.
If your life is touched by diabetes of any type, wouldn't you have wanted to delay the onset of the disease, were it possible?
Point five: Just because many can, that doesn't mean everyone can.
Using diet and exercise to delay the onset or development of Type 2 diabetes doesn't work for everyone. Unfortunately, the ability of many Type 2 PWDs to produce insulin is already pretty damaged by the time of diagnosis. For those of us with serious lifestyle-related risk factors, even when diagnosis comes early, that diagnosis does not necessarily remove whatever barriers to healthy living existed before diagnosis. I am one that was unable to make serious change. I don't know what part of that failure is rooted in laziness or warped psychology, or to what extent the metabolic deck is stacked against me, but there you go.
Point six: "Reversal" is just a word.
In preparation for writing this post, I spent a few minutes trying to find responsible medical opinion on the subject of reversing Type 2 diabetes. I did find a WebMD article that made a pronounced distinction between "reversing" T2, which the author believed in, and "curing" T2, which is clearly not yet possible. I don't know, but I'm guessing that to a physician, "reversing" a disease may be something equivalent to my layman's understanding of putting a condition into remission.
I'm interested in linguistics, and you're never going to hear me say that words don't matter. But sometimes, particular words do more to disrupt understanding than they do to promote it. I think "reversing" diabetes has become an example.
So, in review, let's review what seems to be true and not true:
-- Nobody can currently say with any truth that any type of diabetes can be "reversed" if "reversed" means "cured".
-- Nobody can say with any truth that diabetes of types 1 or 1.5 can be "reversed" in any meaningful sense through ANY amount of diet or exercise.
-- However, it CAN be truly said that SOME type 2 diabetics or "pre-diabetics" can delay the onset or profession of their illness though good diet, good exercise, and weight loss where appropriate.
I don't like the term "reversing diabetes" because it sounds too much like "curing" to my ears.
But I LOVE the concept. Even though I couldn't make it work for me.
Monday, August 02, 2010
Is Insulin a "Failure" for Type 2 Diabetics?
My friend Jess asked a very interesting question on Twitter the other day. (I had requested suggestions for topics Type 1 diabetics might like to see a Type 2 address.) Why, I was asked, do many Type 2 diabetics feel that going on insulin therapy means that they've failed?
(It may be a good idea here to remind everyone that I'm not a doctor or a scientist and that the following is only my best understanding.)
It's an excellent question. First, from what I've read, it's certainly true that many Type 2's struggle when that transition becomes appropriate. It's so true, in fact, that many physicians delay making the recommendation because it's so likely to be poorly received. That's a shame, because when other therapies no longer work well, going on insulin will bring a dramatic improvement in blood glucose control and result in the patient feeling much better, immediately. I've read a couple of articles talking about how PWDs that have begun taken insulin often wish that they'd done so years before.
My speculation is that the problem is rooted in two ideas. They're both false, but they're both so seductive as to be nearly irresistible. The first of these false ideas is that insulin-dependent diabetes is "worse" than that treated in other ways. It's really hard to dismiss the notion that Type 2 "worsens" as it progresses - especially, I imagine, when it's happening to you.
The second of these false ideas is that Type 2 diabetes, its progression, and the complications we're all trying to avoid are the "fault" of the diabetic because of the lifestyle component in the development of insulin resistance. Science now knows that there's a genetic component as well - no T2 genes, no T2, no matter how many Twinkies you scarf. And, it's thought that there are other factors as well, perhaps in the environment.
But, that's not the message in the media. The bookstores are crowded with books on using a combination of diet (their special diet, of course) and a serious exercise regime will "reverse" Type 2 diabetes. As with all the best lies, there's some truth here. Many new T2s, or those with numbers that suggest a problem in the future, ARE able to use strict diet, weight loss and vigorous exercise to cause blood levels to go down and symptoms to disappear. I think (not sure here) that it's expected that this only delays full onset, but that delay may be a number of years.
Because of this partial truth, even many doctors with the best of intentions try to hammer home the notion that exercise and weight loss can "prevent" or "reverse" diabetes. But where does that leave those of us who are unable to make those changes, or whose pancreases are already too badly damaged for this approach to be effective? It leaves us feeling guilty and at fault for our diabetes. Society believes that we're diabetic because we're fat (even though many of us AREN'T fat) - our families believe that, our friends believe that, our insurance companies love to believe that, our employers believe it, and all too often WE believe it. It may even be that our doctors believe it.
So, if we accept into our hearts the lie that our diabetes is our own fault, even subconsciously or partially, then the progression of our disease also becomes our fault. Seen through that lens, the need for insulin becomes the scarlet letter "I" we wear on our inner selves that we have failed to prevent the progression of the disease.
If and when my current medications no longer work for me and I need to start climbing up the list of other available therapies, I hope very much I'm able to establish a relationship with a CDE or other medical professional that I can trust to recommend insulin therapy when it has become appropriate. I hope that I'll recognize that point myself and initiate the discussion, but the blizzard of medication options may make that tough.
I'm not afraid of insulin. I'm afraid of not knowing I need it.
(It may be a good idea here to remind everyone that I'm not a doctor or a scientist and that the following is only my best understanding.)
It's an excellent question. First, from what I've read, it's certainly true that many Type 2's struggle when that transition becomes appropriate. It's so true, in fact, that many physicians delay making the recommendation because it's so likely to be poorly received. That's a shame, because when other therapies no longer work well, going on insulin will bring a dramatic improvement in blood glucose control and result in the patient feeling much better, immediately. I've read a couple of articles talking about how PWDs that have begun taken insulin often wish that they'd done so years before.
My speculation is that the problem is rooted in two ideas. They're both false, but they're both so seductive as to be nearly irresistible. The first of these false ideas is that insulin-dependent diabetes is "worse" than that treated in other ways. It's really hard to dismiss the notion that Type 2 "worsens" as it progresses - especially, I imagine, when it's happening to you.
The second of these false ideas is that Type 2 diabetes, its progression, and the complications we're all trying to avoid are the "fault" of the diabetic because of the lifestyle component in the development of insulin resistance. Science now knows that there's a genetic component as well - no T2 genes, no T2, no matter how many Twinkies you scarf. And, it's thought that there are other factors as well, perhaps in the environment.
But, that's not the message in the media. The bookstores are crowded with books on using a combination of diet (their special diet, of course) and a serious exercise regime will "reverse" Type 2 diabetes. As with all the best lies, there's some truth here. Many new T2s, or those with numbers that suggest a problem in the future, ARE able to use strict diet, weight loss and vigorous exercise to cause blood levels to go down and symptoms to disappear. I think (not sure here) that it's expected that this only delays full onset, but that delay may be a number of years.
Because of this partial truth, even many doctors with the best of intentions try to hammer home the notion that exercise and weight loss can "prevent" or "reverse" diabetes. But where does that leave those of us who are unable to make those changes, or whose pancreases are already too badly damaged for this approach to be effective? It leaves us feeling guilty and at fault for our diabetes. Society believes that we're diabetic because we're fat (even though many of us AREN'T fat) - our families believe that, our friends believe that, our insurance companies love to believe that, our employers believe it, and all too often WE believe it. It may even be that our doctors believe it.
So, if we accept into our hearts the lie that our diabetes is our own fault, even subconsciously or partially, then the progression of our disease also becomes our fault. Seen through that lens, the need for insulin becomes the scarlet letter "I" we wear on our inner selves that we have failed to prevent the progression of the disease.
If and when my current medications no longer work for me and I need to start climbing up the list of other available therapies, I hope very much I'm able to establish a relationship with a CDE or other medical professional that I can trust to recommend insulin therapy when it has become appropriate. I hope that I'll recognize that point myself and initiate the discussion, but the blizzard of medication options may make that tough.
I'm not afraid of insulin. I'm afraid of not knowing I need it.
Sunday, August 01, 2010
Dear CDE...
(Saturday afternoon, I put out on Twitter a request for Type 1s to make suggestions about anything they might like to see a Type 2 address. Sarah, who is working towards becoming a Certified Diabetes Educator (CDE), responded "Everything!" I've chosen to write this post to the CDE I might work with someday.)
Dear CDE --
I don't know you yet, nor what circumstances caused me to need your services. But I'd like to tell you some things about me and my diabetes to give you the best shot of helping me. Because Type 2s rarely have Certified Diabetes Educators, your availability to me suggests that I'm having real problems.
First, I am a man in full. I am more than my metabolism, more than my BG log, more than what they scale says, even (despite the saying) more than what I eat. I have a sense of humor and am an incorrigible punster. I've read an awful lot of books. I have some hopes and a lot of fears. I am cranky and often inwardly judgmental, but my compassion and overriding desire to treat all people well are easily aroused and overcome the crankiness and judgment. I'm happy to live alone, but I am sometimes lonely. These details are not important for you to know. What IS important for you to know is that I, like all your patients, am a complete person.
Second, I need you to start with questions about who I am and what I already know about diabetes. If you start with a standard informational spiel, you're going to be wasting time for both of us. I don't doubt that there are many things you can teach me, but none of them would come up in your first session with a newly-diagnosed patient.
Third, you're not going to make me skinny. I've been seriously obese for four decades. In all likelihood, I've worried about my weight since before you were born. It's no longer a healthy goal for me. I need to you to assist me in my efforts to live a healthier life. If substantial weight loss happens as a result of that healthier life, that will be wonderful. But that isn't, and can't be, my goal.
Fourth, if I need changes in my treatment and your role includes making suggestions to my physician, I suspect that my needs as a Type 2 may be a little different than for your Type 1 patients. An experienced Type 1 may be able to be at least your equal in deciding changes in basal rates and so forth. However, it's not possible for me to really understand all the types of medication therapies that are available. However, I do expect you to solicit my strong participation in decisions about tradeoffs among alternatives.
Fifth, it's often said that insanity is doing the same thing over and over and expecting different results. Given the miniscule percentage of people who are able to make sudden dietary change, and the even smaller percentage of those who are able to stick it for the long haul, just what would be sane about your reaching into your desk and handing me a one-page meal plan? If I could make a "meal plan" work for me, it's overwhelmingly likely that I wouldn't be meeting with you. What I do need is information about smaller changes I can make or suggestions as to how I can circumvent the barriers I face. I also need help in sorting out which pieces of medical research I should be paying attention to.
Finally, don't try to "scare me straight" or scold me. Fear does enable to make some people to make changes. But my diagnosis was a long time ago, and I wasn't ignorant for long about what it meant. Frightening me won't make me skinny, it will just make me fat and scared. I don't consider that progress. As for scolding, I assure you that all the scolding that might be helpful, and more, has already happened within my heart. From you, I need respect and a little kindness.
Thank you for meeting with me. I respect you and your very significant attainment of education and training. I'm likely to be a little reserved when we first meet, but I do hope you can help me. I hope that very, very much.
Your patient,
Bob
Dear CDE --
I don't know you yet, nor what circumstances caused me to need your services. But I'd like to tell you some things about me and my diabetes to give you the best shot of helping me. Because Type 2s rarely have Certified Diabetes Educators, your availability to me suggests that I'm having real problems.
First, I am a man in full. I am more than my metabolism, more than my BG log, more than what they scale says, even (despite the saying) more than what I eat. I have a sense of humor and am an incorrigible punster. I've read an awful lot of books. I have some hopes and a lot of fears. I am cranky and often inwardly judgmental, but my compassion and overriding desire to treat all people well are easily aroused and overcome the crankiness and judgment. I'm happy to live alone, but I am sometimes lonely. These details are not important for you to know. What IS important for you to know is that I, like all your patients, am a complete person.
Second, I need you to start with questions about who I am and what I already know about diabetes. If you start with a standard informational spiel, you're going to be wasting time for both of us. I don't doubt that there are many things you can teach me, but none of them would come up in your first session with a newly-diagnosed patient.
Third, you're not going to make me skinny. I've been seriously obese for four decades. In all likelihood, I've worried about my weight since before you were born. It's no longer a healthy goal for me. I need to you to assist me in my efforts to live a healthier life. If substantial weight loss happens as a result of that healthier life, that will be wonderful. But that isn't, and can't be, my goal.
Fourth, if I need changes in my treatment and your role includes making suggestions to my physician, I suspect that my needs as a Type 2 may be a little different than for your Type 1 patients. An experienced Type 1 may be able to be at least your equal in deciding changes in basal rates and so forth. However, it's not possible for me to really understand all the types of medication therapies that are available. However, I do expect you to solicit my strong participation in decisions about tradeoffs among alternatives.
Fifth, it's often said that insanity is doing the same thing over and over and expecting different results. Given the miniscule percentage of people who are able to make sudden dietary change, and the even smaller percentage of those who are able to stick it for the long haul, just what would be sane about your reaching into your desk and handing me a one-page meal plan? If I could make a "meal plan" work for me, it's overwhelmingly likely that I wouldn't be meeting with you. What I do need is information about smaller changes I can make or suggestions as to how I can circumvent the barriers I face. I also need help in sorting out which pieces of medical research I should be paying attention to.
Finally, don't try to "scare me straight" or scold me. Fear does enable to make some people to make changes. But my diagnosis was a long time ago, and I wasn't ignorant for long about what it meant. Frightening me won't make me skinny, it will just make me fat and scared. I don't consider that progress. As for scolding, I assure you that all the scolding that might be helpful, and more, has already happened within my heart. From you, I need respect and a little kindness.
Thank you for meeting with me. I respect you and your very significant attainment of education and training. I'm likely to be a little reserved when we first meet, but I do hope you can help me. I hope that very, very much.
Your patient,
Bob
Saturday, July 31, 2010
Easier or harder?
This afternoon I put out on Twitter a request for Type 1s to make suggestions about anything they might like to see a Type 2 address. My friend Scott Johnson responded, "I often think you guys have it harder - depending more on willpower & dietary choices for BG control. Do you feel that way?"
It's a complicated question, or a simple question with a complicated answer. I've often thought about it, and I've been hesitant to address it. My basic reaction is "absolutely not!" However, I've rarely been angrier than the time I was listening to a podcast panel of Type 1 PWDs, and someone said that "Type 2 is easy!"
The first thing to remember, and I'll mention it again, is that Type 2 is a progressive disease. Type 2 covers people in many different situations: diet and exercise alone; a dizzying array of oral and injectable medication options, each with its own set of consequences; a combination of oral medication and basal insulin injections; and full insulin dependency. A Type 2 may be as healthy as a horse or a very sick individual indeed. A Type 2 may be dealing with the effects not only of diabetes itself but any or all the other conditions that tend to cluster with it: hypertension, elevated cholesterol, heart disease, apnea, and others.
I have to say that in my mind, it's the manner of treatment and how well it's working that affects what life is like far more than the disease mechanism. For the purpose of this discussion, by "Type 2" I'll be referring to someone on the diet/exercise regimen or oral medications.
I also want to note that my knowledge of what Type 1 is like to deal with is all second hand. I think I know more about it than most people, but I'm sure there are important things I don't understand. So, I hope my friends will forgive me if I'm missing something important.
I have some academic background in political philosophy, and it often helps me to go Aristotelian on the bit and break things down into parts. I see four areas to compare lifestyles for the two types: immediate health impact, daily management, complication avoidance, and the complications themselves.
Immediate health impact -- As I noted above, a Type 2 diabetic may be at many different places on the scale between healthy and sick on a day to day basis. In my own case, because I'm so fortunate in how well my medications work at present, I don't experience anything like the rollercoasters I see many of my T1 friends experiencing. I've never had a low, as I've noted elsewhere, and anything like reasonable choices in what I eat keeps me from getting too high to feel poorly in that respect. I do have days in which I feel ill because my metabolism hates me in general.
Daily management -- There are sort of two sides to this coin. There's absolutely nothing I currently have to do that's as intrusive as the daily routine of shots/pump management, diabetes arithmetic, many daily blood tests, etc. On the other hand, many of the folks that manage Type 2 without medication work vary hard, with very significant dietary restrictions and exercise routines that would make Richard Simmons blush. On the third hand (can you believe I'm not a lawyer?), Type 1's are not necessarily immune to the same genetic, lifestyle, and environmental factors that produce insulin resistance in Type 2 folks, and thus diet and exercise become critical for some of them, too. So, this one is kind of a toss-up to me, and depends on the individual's situation.
Some Type 2s feel a bit of envy for folks on basal/bolus regimens who "can just push a button" or "just take a shot" to prepare for a special meal or to treat a high. I'm not one who feels that way - I think it's way more complicated than that, and I don't want to minimize the difficulty and discomfort of managing boluses. Yes, it would be nice to have a tool (other than patience) to deal with a high that's beyond exercise being a safe option. But that might yet be down the road for me.
Complication avoidance
For people with all types of diabetes, the best chance of fending off the complications we can all list consists in good long-term control of blood sugar levels. (And, of course, complications may show up even when control has been good.) But, in order to achieve that control over the long term, many Type 2s must do their best to make very significant changes in their dietary and exercise choices. Most often, Type 2 is diagnosed in middle age or later, and habits have been built up over decades, and making those changes is very difficult. Plus, for those of us who are truly obese, there are often psychological issues that must be either addressed or somehow sidestepped for meaningful changes to occur. So, the challenges are considerable, and I for one am not even out of the foothills at the basis of this particular mountain. For most (I think) Type 1 PWDs, this is a set of issues that's not part of the equation. Again, however, Type 1 PWDs are not immune to this set of issues and may deal with them as much as anybody else.
(Mini-rant: I just about lost my temper during last week's #dsma session. A number of folks talked offhandedly about lifestyle choices, as if it was a simple thing, like upgrading your wardrobe and grooming yourself a little more carefully to get a better job. If losing weight is so freaking easy to do, how come millions of Americans (and countless others) are unable to do it? Do you really believe all of those people are stupid, or have deeply flawed personalities? Or, just based on your own experience with blood sugar management, don't you think that human metabolism is way more complicated than we currently comprehend, and that we simply don't yet know how to actually help people rather than just lecture them? *ahem* Sorry.)
The Complications Themselves -- I think it's important to note that the long term effects of diabetes do not much vary between the two major types. The organs of our bodies that rely on intricate networks of tiny blood vessels don't care why they've been assaulted by excess blood sugar for many years. They're not concerned about antibodies, or insulin resistance, or beta cells, or artificial ingredients, or even cheeseburger consumption.
So, in summary, my answer to Scott is no, I don't think that Type 2 is harder, although distinctions between the two types fade as Type 2 advances. On the other hand, that's not to say that Type 2 is "easy", and involves issues and complications not common to most of my Type 1 friends. All diabetes is hard, all diabetes sucks, all diabetes needs to be cured.
It's a complicated question, or a simple question with a complicated answer. I've often thought about it, and I've been hesitant to address it. My basic reaction is "absolutely not!" However, I've rarely been angrier than the time I was listening to a podcast panel of Type 1 PWDs, and someone said that "Type 2 is easy!"
The first thing to remember, and I'll mention it again, is that Type 2 is a progressive disease. Type 2 covers people in many different situations: diet and exercise alone; a dizzying array of oral and injectable medication options, each with its own set of consequences; a combination of oral medication and basal insulin injections; and full insulin dependency. A Type 2 may be as healthy as a horse or a very sick individual indeed. A Type 2 may be dealing with the effects not only of diabetes itself but any or all the other conditions that tend to cluster with it: hypertension, elevated cholesterol, heart disease, apnea, and others.
I have to say that in my mind, it's the manner of treatment and how well it's working that affects what life is like far more than the disease mechanism. For the purpose of this discussion, by "Type 2" I'll be referring to someone on the diet/exercise regimen or oral medications.
I also want to note that my knowledge of what Type 1 is like to deal with is all second hand. I think I know more about it than most people, but I'm sure there are important things I don't understand. So, I hope my friends will forgive me if I'm missing something important.
I have some academic background in political philosophy, and it often helps me to go Aristotelian on the bit and break things down into parts. I see four areas to compare lifestyles for the two types: immediate health impact, daily management, complication avoidance, and the complications themselves.
Immediate health impact -- As I noted above, a Type 2 diabetic may be at many different places on the scale between healthy and sick on a day to day basis. In my own case, because I'm so fortunate in how well my medications work at present, I don't experience anything like the rollercoasters I see many of my T1 friends experiencing. I've never had a low, as I've noted elsewhere, and anything like reasonable choices in what I eat keeps me from getting too high to feel poorly in that respect. I do have days in which I feel ill because my metabolism hates me in general.
Daily management -- There are sort of two sides to this coin. There's absolutely nothing I currently have to do that's as intrusive as the daily routine of shots/pump management, diabetes arithmetic, many daily blood tests, etc. On the other hand, many of the folks that manage Type 2 without medication work vary hard, with very significant dietary restrictions and exercise routines that would make Richard Simmons blush. On the third hand (can you believe I'm not a lawyer?), Type 1's are not necessarily immune to the same genetic, lifestyle, and environmental factors that produce insulin resistance in Type 2 folks, and thus diet and exercise become critical for some of them, too. So, this one is kind of a toss-up to me, and depends on the individual's situation.
Some Type 2s feel a bit of envy for folks on basal/bolus regimens who "can just push a button" or "just take a shot" to prepare for a special meal or to treat a high. I'm not one who feels that way - I think it's way more complicated than that, and I don't want to minimize the difficulty and discomfort of managing boluses. Yes, it would be nice to have a tool (other than patience) to deal with a high that's beyond exercise being a safe option. But that might yet be down the road for me.
Complication avoidance
For people with all types of diabetes, the best chance of fending off the complications we can all list consists in good long-term control of blood sugar levels. (And, of course, complications may show up even when control has been good.) But, in order to achieve that control over the long term, many Type 2s must do their best to make very significant changes in their dietary and exercise choices. Most often, Type 2 is diagnosed in middle age or later, and habits have been built up over decades, and making those changes is very difficult. Plus, for those of us who are truly obese, there are often psychological issues that must be either addressed or somehow sidestepped for meaningful changes to occur. So, the challenges are considerable, and I for one am not even out of the foothills at the basis of this particular mountain. For most (I think) Type 1 PWDs, this is a set of issues that's not part of the equation. Again, however, Type 1 PWDs are not immune to this set of issues and may deal with them as much as anybody else.
(Mini-rant: I just about lost my temper during last week's #dsma session. A number of folks talked offhandedly about lifestyle choices, as if it was a simple thing, like upgrading your wardrobe and grooming yourself a little more carefully to get a better job. If losing weight is so freaking easy to do, how come millions of Americans (and countless others) are unable to do it? Do you really believe all of those people are stupid, or have deeply flawed personalities? Or, just based on your own experience with blood sugar management, don't you think that human metabolism is way more complicated than we currently comprehend, and that we simply don't yet know how to actually help people rather than just lecture them? *ahem* Sorry.)
The Complications Themselves -- I think it's important to note that the long term effects of diabetes do not much vary between the two major types. The organs of our bodies that rely on intricate networks of tiny blood vessels don't care why they've been assaulted by excess blood sugar for many years. They're not concerned about antibodies, or insulin resistance, or beta cells, or artificial ingredients, or even cheeseburger consumption.
So, in summary, my answer to Scott is no, I don't think that Type 2 is harder, although distinctions between the two types fade as Type 2 advances. On the other hand, that's not to say that Type 2 is "easy", and involves issues and complications not common to most of my Type 1 friends. All diabetes is hard, all diabetes sucks, all diabetes needs to be cured.
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