The Type Two Word

Do you like word games? Here's one: I'm thinking of a word, a word that may be the most important word about Type 2 diabetes, and yet I suspect that it's a word that most people, including too many T2 diabetics themselves, don't really understand.

Give up?

The word is "progressive". And I'm not trying to sell you car insurance.

See, type 2 diabetes changes, or at least always has the potential to change. It doesn't suddenly appear: most T2s, whether they've known it or not, go though a condition now being called "prediabetes", in which insulin resistance has begun but has not yet seriously outpaced the pancreas's ability to regulate blood glucose. Eventually, for those diagnosed with type 2, the pancreas can no longer keep up - the insulin needs are too great, and at the same type the pancreas has become damaged. (The traditional view has been that the pancreas has been "worn out" trying to overcome the body's increasing insulin resistance. As I understand it, there's now doubt about that.)

The diabetes has progressed, has moved from a normal metabolic state through prediabetes to diabetes.

And, for many people, the disease continues to progress from there, requiring more aggressive treatments and posing greater danger to the body. The danger lies in pretty much the same set up complications as exist for Type 1 PWDs, because the feet, kidneys, eyes, and arteries don't care about the clinical reason for the blood glucose being too high.

For some people, good control and a healthy lifestyle slow, stop, or even (for a time, anyway) reverse the progression of the disease. My own father has had T2 for around 25 years and is still (I believe) being adequately controlled by the same medication I take. To the best of my knowledge, he has experienced almost none of the commonly-known complications. (He does have another rather nasty condition that MAY be a complication.)

Will I be so blessed as to be like my dad and prosper so long without major progression in the disease? I don't know, and I can't know. Even if the genes are the same, some of the other factors are different. It may be that I will go down a road requiring additional oral medications, then injected medications, then basal insulin, then full insulin therapy. If I'm to travel that road, I have no way of knowing how long it may take.

If anyone ever wonders why I hold so tightly to the online community when diabetes as I currently experience it is so much less of a problem than it is for many others, the answer is simple:

Type two diabetes is a progressive disease.

(And also, of course, that I love y'all dearly.)

The things I learn from my friends on insulin about insulin and insulin dependency are things I may need someday.

For all of the people who teach me, I thank you.

I Will Lay Me Down

"When you're weary, feeling small..."

I don't listen to music very often, actually. When I do, my tastes are somewhat eclectic - cool jazz, some "early" music, symphonies. And, though I quit listening to current pop a long time ago, I continue to love some of the music that was important to me when I was younger.

Yesterday was a terrible day. I'd slept very poorly, and I began the day with a flurry of stupidities on my part that resulted in missing an all-day seminar. (This may wind up costing me $180.) I then had to go back to my job and explain to my less-than-pleased boss what had happened. And, some folks from the DOC that I value seemed to be having tough days as well.

"When tears are in your eyes, I will dry them all..."

All of this had me pretty down, depressed almost to the point of being incapacitated. As I sat at my desk, the podcast I was listening to made a reference to the song "Bridge Over Troubled Water" by Simon and Garfunkel. I happen to love that song. It's my opinion that Garfunkel's singing on that is the greatest performance in pop music history: no other nominations will be accepted. (Do I have anywhere near the expertise I need to make such a statement? Absolutely not.)

So, I interrupted the podcast to give "Bridge Over Troubled Waters" a listen. "A listen" is a bit of an understatement - I listened to the song time six or seven times, one after the other. In the song, the singer is offering unconditional support to the person he's singing to: the lyrics feature the line "Like a bridge over troubled water, I will lay me down."

In that moment, I found the song incredibly moving, and struggled to keep from crying. As I listened, I alternated between feeling myself in the role of the singer and feeling myself in the role of the person being sung to. After a time, I could no longer stay seated. I went downstairs and chatted with a coworker for a moment, than I went and got a soda.

"Sail on silver girl, Sail on by.
Your time has come to shine. All your dreams are on their way."

By the time I got back to my desk, I was starting to feel better. I listened to the song one more time, then resumed my work. A little later, I had a nice chat with my boss, and even got a small project done. I was still very glad when the work day ended, but my mood had improved considerably.

(Lyrics taken from Simon and Garfunkel, "Bridge Over Troubled Water." Bridge Over Troubled Water. New York: Columbia Records, 1970.)

Motivational, My Left Kneecap

Motivational quotes are often genuinely motivational.  Sometimes they're silly, however, and sometimes I just find them depressing when they seek to inspire me to an attitude I can't seem to muster.

One time, a number of years ago, I was making my first visit to the office of a mental health professional.  The receptionists desk had a page-a-day calendar from the manufacturer of a psychiatric medication.  I don't remember the quote on the page, but I've always remembered it as "Stride Confidently Into Your Glorious Future!"

I chuckled to myself with an ironic, mirthless chuckle.  I called the quote to the receptionist's attention and said, "If I could do that, I wouldn't be here!"

Hunger

As a person who's been overweight since childhood, I've eaten a lot of meals for reasons other than hunger, the real, physical hunger by which the body signals that there aren't enough calories on board.  Studies have shown that many obese people have lost understanding of what actual hunger even feels like: this is true of me, mostly.  I was on a program once that asked participants to rate hunger on a one-to-five scale before and after each meal.  I found this a real struggle.

When I was diagnosed with Type 2 diabetes, I was put on Metformin. From the day after the first dose, my fasting numbers dropped to within or near the target range.  For the first time in who knows how many months, my blood glucose level was normal.

But nobody had told my metabolism that.

This is my understanding of what happened next: after many months of continually elevated blood sugars, my body had grown to consider those elevated levels to be normal, what it expected, where it would work to keep me. And, when my BG dropped, my metabolism sent out the signals that the level needed to be raised.

I got hungry.

This was real hunger, physical hunger, body-in-need of nourishment hunger.  Not boredom hunger, not emotional-emptiness hunger, not boy-that-looks-good hunger.  Hunger that I had only occasionally experienced.

I may appear to exaggerate.  Obviously, this was not the hunger of starvation.  But it was brain-says-FEED-ME hunger, and I didn't handle it very well.  I ate, and ate, and the Metformin and whatever's left of my pancreas diligently worked to keep me from getting too high, and, well, let's just say I ate a lot.

As it happens, I was a Weight Watchers member at that time, and I'd been losing significant weight.  (Ironically, having changed my diet and lost some weight, I was symptom free at diagnosis.  Heaven knows what my A1c would have been if taken a month earlier.)  But within two weeks of beginning treatment, I had regained almost all the weight I had lost.  And, even though the feeling that I could clean out a buffet subsided after a few days, it was quite a while before I again felt in reasonable control of what I ate.

The reason I share this is because I know I'm not the only T2 that's experienced this when beginning treatment: perhaps some Type 1 folks experience it as well.

So, although I often forget: yes, ma'am, I do know what physical hunger feels like.

(Next-to-last paragraph edited for clarity.)

Brief Review - OneTouch Delica lancing device

(2/3/11 - I'm editing this to remove a word that draws a lot of folks to this post, many of whom are probably disappointed. -BP)

So the pharmacy chain I use gave me a good coup** for the new Delica lancing device and lancets, which is supposed to be a less painful way to do blood tests.  I don't actually have a lot of problems with testing being too painful, except for the apparently random occasion when it hurts like a mother.  But, I thought I'd give it a try.

The device achieves (or not) its goal of reduced pain in three ways. The lancing device features "glide control". (If you know what that means, that makes one of us.  Maybe the flight path, if you will, is straighter?)  The device is designed to for less vibration, presumably meaning it's doing less damage inside the finger.  And the needle is the smallest (33g) OneTouch offers.

(The lancets are not compatible with the device I got with my OneTouch meter.  I tried.)

I did about five or six pricks.  And, I gotta say, the thing does seem more comfortable than either my other OneTouch device or my MultiClix.  The vibration thing may account for my needing to squeeze a bit to produce a sample.  On the other hand, I was able to get a sample at setting four out of seven, and my other devices need me to be at about the highest setting.  So, it could be that the Delica would be an improvement for folks needing a deeper jab to get a sample.

My plan is to pass the Delica along to a T2 friend who's complained about her lancing device being painful.

Bad to the Bone

This post has grown out of a number of things I've seen in the last couple of days, particularly a discussion about diabetes and depression on Twitter, a cool post by Allison Blass,  and also a posting on a forum from a self-described "bad diabetic".  I've posted along these lines before, but it's an important set of ideas.

One of the reasons that depression so often follows diabetes, I believe, is that diabetes constantly invites us to see ourselves as having made a mistake.  PWDs can be caused problems by factors entirely beyond our control or which couldn't have been anticipated.  Highs or lows can also result from simple mistakes, the kinds of mistakes everyone makes. Even if we're secure enough to not judge ourselves for those times, and not all of us always are, the people around us and even our physicians may not be so wise.  And, sometimes, we make choices that might have been wiser.

A few weeks ago, I had lab results that were MUCH better than what I had expected.  I've thought a lot about what could have created such a huge gap between my perception of how I'd been doing and the reality.  Clearly, much of the answer relates to how well my medicines work for me.  But I think I also constantly measure myself against a vision of PERFECT diabetes management, thus only allowing myself to see "mistakes" without taking credit for the better choices.

Consider the following sequence of statements:

1. A healthy diet has room for an occasional treat.
2. A healthy diet has room for ONLY an occasional treat.
3. A healthy diet is better off without any treats at all.
4. I shouldn't have the candy bar I want, because it's not part of a healthy diet.
5. I shouldn't have eaten that candy bar: that was a bad choice.
6. I had a candy bar yesterday, too.  I frequently make bad diet choices.
7. I take poor care of my health and my diabetes.
8. I am a bad diebetic.

Any logician would laugh at this list - most of the statements simply don't logically arise from the one before.  Statement #1 is true, but each of the succeeding statements is a little bit farther down a road toward harsh self-judgment.  But my mind takes off down the list so fast that I don't even notice #1 as I fly by.  I live by #7 way too much of the time, and a bad day has me sitting at #8.

Take another look at #5.  In my mind, anyway, that's where a key change occurs.  My choice to eat the candy bar has changed from a choice about nutritional balance to a moral choice. In other words, I'm not a person who made a non-optimal choice, I'm (in my mind) a bad person.

This is obviously not the way for a diabetic to maintain a healthy attitude.  But it's what I do, all too often, and from what I see in the forums and on Twitter, I bet I'm not the only one. 

A healthy lifestyle is about balance, and a healthy lifestyle with diabetes that much more so.  I need to learn to more consistently SEE it as a balance rather than as an unending series of challenges to my adequacy as a person.

Many of us seem to see our encounters with our care team along these lines.  We don't just go to get information and guidance: we go to get approval.  And, all to often, members of our care team encourage this attitude by granting or withholding approval.  No wonder we hate our appointments -- we're not going to the doctor, we're going on trial!  I confess: part of what I was so thrilled about at my appointment was that I felt my doctor's approval.  That's fine, as far as it goes, but what if the approval had not come?  It would be healthier not to grant my doctor that much power over my attitude.

Like everything else, it's a progress.  But I'm gonna work on living higher up on my list.

How about you?  Are you able to separate your sense of worth from the ups and downs of life with diabetes?

Lessons Learned

For me, the biggest enemy of good diabetes management is denial.  In my current situation, it's awfully easy to pretend my diabetes doesn't exist.  I suspect I could go weeks at a time pretending that no action, no change, was required of me.  Active participation in the online community of diabetics helps prevent that.

One day last week I had a meal that, while not ideal, I've had before without particular problems. (Can you say "five dollar footlong"?  Can you avoid singing it?)  Later in the evening, I found that I was thirsty.  No surprise, everybody gets thirsty now and then.  So I had a glass of water and went back to following the DOC on Twitter. 

An hour or so later, I felt thirsty again.  I think that it's only because I was thinking about diabetes that I got the suspicion that perhaps I should should test.  I was 176 -- FIVE HOURS after eating, with nothing since.  Heaven know what it had been earlier. After I tested, I tweeted what had happened, indicating my frustration.  I was instantly reassured (thanks, Doug!) that bad BGs happen.

So, that night I learned that the five dollar footlongs need to be a part of my past -- unless maybe eaten at TWO meals. I also (re)learned that the support of the online community has become important to me. 

We all gotta keep learning, right?

Type Two Mythconceptions Affect PWDs of All Types

At Fault?

Many people in our society, if they know anything about type two diabetes at all, are under the impression that it is the direct result of obesity, poor diet, and a sedentary lifestyle.  This view is promulgated by people who want to sell books about "reversing" diabetes and those concerned with public health who hope to scare those most at risk into changing their ways.

 

I'm not a doctor or a scientist, but my understanding is that type two is believed to result from a combination of lifestyle, genetics, and other factors not yet understood.  Obesity is certainly a major risk factor, but it's neither a necessary precondition nor a guarantee: many type twos are not obese and never have been, and many many obese people do not have type two. 

 

While type twos feel the effects of the misunderstandings, type ones are also affected.  Many people know little or nothing about type one and mistakenly carry over their (mis)understanding of type two, when in fact lifestyle bears NO role in the development of type one. This can result in type one PWDs being harshly and unfairly judged.

 

Diabetics in Society

People with diabetes, like essentially everybody else, participate in society.  We have friends, family, coworkers, waiters, fellow bus-riders, neighbors, and garbagemen.  And very few of us are above being affected what these people think of us.  For people living with a dangerous and frustrating condition like insulin-dependent diabetes, I can understand it being frustrating (okay, enraging) to have the people around us express the notion that not only is the disease our fault but that we could cure ourselves by getting off our lazy butts.

 

A Credibility Problem

I admire the many different ways in which PWDs I know advocate.  I've sort of struggled to find my role in this: I'm not a fundraiser, and the notion of calling on congressmen makes me feel faint.  For right now, my small efforts involve trying to offer a bit of support for others and to maintain this type two blog in the hopes that I'm reaching at least a few who are helped.

In many ways, I would really like to be a voice in helping diabetics of all types, as well as people in the society as a whole, understand the roots of type two diabetes.  But I can't keep but feeling that I'm a very poor person to be front-and-center on this issue.  As many members of the online community know, at the time of my diagnosis I was an overweight, non-exercising, poorly-eating, sedentary-job-holding, sleep-apnea'ed embodiment of the stereotype we all struggle with.  (Alas, this is still too close to the truth, though I have made changes.) Thus, it seems to me that I have a real credibility problem: I'm sort of in the position of the little boy with the slingshot yelling that he didn't break the window -- it may be entirely true, but who's he going to convince?.  If someone who didn't like what I had to say on this issue accused me of just making excuses for myself, how could I respond?  That's not what the science indicates right now, but maybe it's the truth.

 

My own experience

I myself haven't had to deal much with the misconceptions about type two.  The people in my non-virtual life either know better, don't know I'm diabetic, don't much care, or are too polite to point fingers.  I have had a few (a VERY few, I'd like to stress) painful experiences online.  I read a comment on somebody else's blog from a type one who expressed very bitter resentment against type twos.  Another comment on another blog was from a type two who'd been able to diet-and-exercise himself off of medication and was quite confident that any type two who "took their lifestyle responsibilities seriously" could do the same.  Another time a community member tweeted resentment towards "fat diabetics" in quite graphic terms. This comment left me feeling hurt and angry, but also feeling hamstrung - I understand (in part, anyway) where the comment was coming from, and anything I could think of to say might be seen as whining self-justification.  

I, too, wish the public understood the differences between the types of diabetes.  I, too, wish that Oprah and Dr. Oz hadn't muddied the waters.  But I hold out little hope: we live in a complicated society, people lead busy lives, and not everybody gets good exposure to correct information about diabetes.  In the meantime, the best most of us can do is to try to be reasonably well-informed ourselves and to take advantage of the opportunities we have to educate.