The Gumption Meter

I want a meter, just like my glucose meter, only one that checks for gumption. Yes, gumption: if you don't know or don't like the word, you can use "pluck" or even "courage". But "pluck" in this sense is pretty passe, maybe even archaic. "Courage" is accurate, but seems to fit more in the context of military personnel, police, fire fighters, and junior high school teachers.

"Gumption" is simply the ability to face up to what one has to do in everyday life. And tonight, my levels are pretty low.

My gumption meter would look a lot like my glucose meter, and would work pretty much the same way. If the target range was the same for my blood glucose, a check tonight might read "43 mg/ml. Check for depression." Then, I might go to my bathroom to take a second test to get a reading as to where a more fundamental reading of my current mood stood.

Tonight, I think I'm basically okay. I'm in a situation that has me outside of my comfort zone, trying to fix a situation that I brought on myself, and needing to call on good friends (bless 'em!) to help me out of it. I've been unable to sleep on a regular schedule for a few weeks: that doesn't help. Anxiety, stress, guilt, fatigue: a perfect scenario for low gumption.

For tonight, I'm going to go care for my neighbor's pooch, and try to go to bed. Tomorrow, the plan to get me out of my situation moves into action: mostly what I need is a little luck, and I'll be past it by the end of the week. My friends are gracious and genuinely willing to help.

A little sleep, a little friendship, a little resolution. I think my gumption meter will be showing target readings really soon.

D-Feast Friday: Getting Started with Fresh Chiles

Cooking with fresh chile peppers is an easy way to add heat - but not necessarily too much heat - to your food. I'm a long, LONG way from an expert on this, but maybe what I do know can help you get started.

I was scared off of using chiles for a long time, because chiles to me meant jalapenos, and I don't like jalapenos. I eventually learned that different chiles carry different flavors as well as different heat levels, and that I just don't happen to care for jalapenos.

One other note: I am not a fan of really spicy foods. I do not use hot sauces with names like "Instant Death". I use chiles in moderation. In short: respect the chile, but do not fear the chile.

Here are some tips from what I've learned:

* I AM NOT KIDDING: when using anything stronger than a bell pepper, WEAR GLOVES. If you don't, you will eventually get a little of the oil that makes a chile hot into your eye, and you will be VERY UNHAPPY. I have done this twice, because I am a moron.
* Generally speaking, the smaller the chile is, the hotter it is. The varieties usually available here, from mildest to hottest (and from largest to smallest) are poblanos, Anaheims (also, I think, called New Mexico), jalapenos, serranos, and habaneros. Habaneros dang well mean business. (You may find "Scotch bonnets" in your stores: I've seen different stories on whether or not these are the same as habaneros.) The stores here also often carry the skinny little dried peppers you may have seen in Chinese food: these also mean business.
* Speaking of dried peppers, although I'm mostly talking here about fresh varieties, it's useful to know that the dried form of a chile often has a different name. Thus, a chipotle is a dried, smoked jalapeno.
* Most of the heat in a chile is in the seeds and the light-colored membranes inside the pepper. Removing some or all of these gives you a lot of control over the heat of a final product.
* I've seen soups prepared on TV that included making a slit in a really hot variety, such as a habanero, and cooking it with the other ingredients, then removing it before serving. I've done this once, and it was good.

A couple of suggestions:
* Find a recipe on the Internet (or in a cookbook, if one of yours has it) for "New Mexican Green Chili". Cook and eat. You're welcome. You owe me one.
* If you ever do a small roast in a slow cooker as I do, chop up some poblano, Anaheim, or jalapeno into the cooking liquid. It will add a lovely (but controlled) spiciness to the meat, and you'll be able to do something interesting with the cooking liquid afterward.
* Try substituting some seeded, demembraned, and finely diced Anaheim into a tuna or chicken salad. A few experiments with this will start to teach you about the spice tolerance of you and the folks you cook for.

It's official!

It's hardly a unique experience, and others have written about it. But it's the first time it's happened to me, so I'm gonna write about it.

When I cleared out my mailbox tonight, I saw the envelope and knew immediately what it was and what it meant.

The letter was from the AARP, formerly known as the American Association of Retired Persons.

It was an invitation to join.

I'm officially old.

This does not traumatize me: the evidence has been mounting for some time. But I turned fifty a few weeks ago, and so my name popped up on some AARP computer, and the letter got sent.

I may well join. I think it's a good organization, and the magazine is pretty good.

Get off my lawn.

A Toast to Fleeting Friendships

I'd like to raise a toast (Coke Zero, if you'd like to join me) to those people who have touched my life for just a little while, be it a few months or even just a few minutes. I'm not talking about romantic relationships, but they've been no less special for that.

Here's to seatmates on airplanes or buses with whom I've had conversations that I think about to this day. It won't surprise my friends to learn that I usually keep to myself, but have still had some splendid opportunities.

Please join me in thanking the people in the short-lived depression support group I attended, who showed me so much about life I'd never suspected.

I drink the health of the retired government official from Syria I found sitting on the front lawn of my apartment complex in my home town. My conversation with him, using scraps of three languages and some rough drawings, gave me hope for international understanding. I hope he, as he taught me to say, went in peace.

Further, I pay tribute to the two friends from a silly newsgroup who reached out to me in friendship after a family tragedy.

A further raise of my glass to the girl who played me a song on her guitar during a free period in high school. A precious gift from someone I hadn't otherwise really talked to, either before or since.

Here's to the Internet friends with whom a single conversation has created a precious sense of connection. There have been so many in the diabetes online community. I appreciate you, individually and as a group.

Yes, friendship can be eternal. But fleeting can be pretty good, too.

The Investment Paradox

I find life to be full of paradoxes, big and small. One of the paradoxes I find in the search for personal change is that to get more of something you want, you often have to give up some of what you have of that thing.

I find it useful to think of financial investments as an analogy. For most of us, part of increasing our financial stability is finding ways to build some savings, even if just a little bit, to get us through a rough patch or to secure a more comfortable retirement. But, few of us make the kind of income that allows us to save money without any pain. So, if we can't increase our income, we have to make the choices that allow us to cut our spending.

Exercise is a lot like that. Most of us know that exercise is good for everybody, and it's especially good for diabetics. It's most especially good for those of us with Type 2 (and many type 1 folks as well) because it reduces insulin resistance, sometimes dramatically. When I'm exercising regularly, my fasting numbers improve, I don't seem to spike as high after a meal, AND I seem to recover from the spike more rapidly.

I've been off the regular exercise pattern for a few months now. I'd recently been making some headway, but was derailed by the heat wave we've had here: the highs have been above 95 just about every day for a couple of weeks, and more exercise has just been out of the question for me. Perhaps as a result of the non-exercise, I'm just not feeling as well as I could be.

So, here's the paradox: in order to feel better, I have to "invest" some of my dwindling energy store into some aerobic movement. I can't buy exercise in a store, and I can't borrow some from a friend - I have to make that investment myself. Bummer, huh?

I suspect that sleep works the same way. I often have trouble sleeping, especially on Friday and Saturday nights. So, I sleep late on Saturdays and Sundays. But, I've often read that one of the best ways to improve one's sleep is to have a regular sleep schedule - that DOESN'T include sleeping until 10 on weekends. To improve, I'm probably going to have to give up sleeping in, even though it feels desperately needed, as an investment in better sleep.

What investments do you need to make?

'Chops', the Arts, and Diabetes

(I promise this will get to diabetes. I don't promise a short trip.)

I believe that ability in the arts - in most things, actually, but that's a broader subject - is composed of two major elements. The first is what is either inborn or perhaps gifted by the universe: talent, genius, soul, inspiration, whatever makes sense to you. The other is what I like to call "chops", borrowing a term some musicians use: the accumulated skills, experience, practice, and know-how that goes into producing the artistic work, whether that work is a dance, a sonnet, a song, a painting, or any other creative work.

The full role of talent, etc., is perhaps disputable. (I recently heard an interview with a psychologist who argues that talent plays little or no role in ability, which is really obtained through education and practice.) But the role of "chops" is not disputable: the cellist is the high school orchestra may have loads and loads of soulfulness to express, but that doesn't make him Yo-Yo Ma. No amount of talent will make a toddler with her fingerpaints into an instant Georgia O'Keefe. The five-year old in ballet class may have been gifted with a body perfectly suited to dance, but he's not (yet) Rudolf Nureyev.

It's my belief that we pay too much attention to the "talent" side of the equation. Many years ago, I read a weird and wonderful book called "Sayonara, Michelangelo", which was about many things, but mostly about Michelangelo's paintings on the ceiling of the Sistine Chapel and the restoration thereof late in the last century. At one point in the book, the author argues that in praising Michelangelo's genius, we wind up giving him insufficient credit for his ability, his experience, and his hard work.

I once read a memoir by the actor Alan Alda, most famous for his role in "M.A.S.H.". The real revelation for me from that book is the amount of the actor's craft that must be learned, from the ways to express certain emotions to successfully mimicking an accent. George Clooney's a great actor, I'm told, but he wouldn't be without his chops.

Earlier week, with considerable reluctance, I blogged a poem I'd written. I got some very nice comments on it, and I'm pleased it connected for some people. But, other than the schoolwork everyone's done, I've written maybe three dozen poems in my life. But I haven't written hundreds of poems, I haven't sat through critiques by fellow students knowledgeable and passionate about the craft, and I know very little about form and meter. While I did write a poem that expressed my idea, I'm not a poet - I just don't have the chops.

Chops plays a huge role in diabetes management, too, and we acquire them only with time and effort. Although our bodies continue to spring surprises on us, we do learn how to anticipate and deal with many of the individualities of our own diabetes. (Shredded Wheat is poison, diabetes? Really, diabetes?) We learn tips and techniques for a thousand things, from how to test our blood to the way we want to handle doing so in public. A person dependent on insulin are engaged in a lifelong process of learning how to be his or her own pancreas. (My hat is off to those who have mastered the "double wave bolus".) From time to time, we need to learn (or relearn) that the things we know HOW to do are important enough to actually do them.

Then, there are the lessons that can be harder to learn because we don't entirely want to learn them, from maintaining our weight (for those with that issue) to avoiding those favorite foods that, although we CAN eat them, just aren't worth what they do to us. (I'm looking at you, white rice.)

I'm learning, and you're learning. We need to be gentle with ourselves about what we haven't yet learned, acknowledge and feel good about the things we have learned, and be open to the things we don't yet know that we need to learn.

Above all, there are no good or bad diabetics. It's all chops.

First Time Frightened

(Please note: I am aware that some of my readers have dealt for many years with diabetes being fare more intrusive than mine is at this stage. I am guessing that my reaction to what happened may seem silly, but I want to document this as I experienced it.)

Wednesday morning, my fasting test was in the 140s, higher than is optimal for me. So, though I don't to this often, I decided to test before leaving for my lunch hour and choose lunch based on the result. 132, so I decided to just have a salad for lunch.

I usually like to relax in the staff lounge over lunch hour and pick my meal up on my way back to my desk. I'm trying to do some pre- and post-testing to learn better meals, so I tested again. 82. I'd dropped 50 points in an hour of doing essentially nothing. That felt new, and as close as I was to the bottom of my good range, I was afraid that I was still dropping. And the meal I had chosen was pretty close to carb-free.

I admit it: I panicked a little. Was I going to go low, maybe seriously so? And what could I do to stop it? If something really bad was happening, a quarter cup of tomatoes wasn't going to slow it down. (Did I remember that I had glucose tabs for backup, sitting right in my desk? Noooooooooo.)

For the first time since diagnosis, I was scared about what was happening to me then. Sure, I've worried plenty about complications down the road, and about the significance of the occasional tingling in my feet, but that's a different thing. Even the time I was in the 400s, I knew what had caused it and I thought I knew the best thing to do about it (though I was wrong).

Even though the adult part of my brain kept trying to assure me that a problem was unlikely, I still felt frightened. And, I felt alone.

I calmed down some, and ate my salad. Half an hour later, I was at 87, so I was no longer dropping. At my 2-hour post test, I was nearly 100. The crisis, if there ever was a crisis, was over.

What's significant about that event to me is not what happened with the blood sugar, but how I felt about it. I'm not surprised that I was frightened, but I wouldn't have anticipated the sense of isolation. That sense of isolation might be telling me that I need a stronger emergency backup system. Maybe I need to remind my colleagues about my supply of glucose tabs and what to do if I need them. Maybe I need to decide how I would handle a real semi-emergency, one that didn't seem at a 911 level.

I'm not alone. I just need a plan.

English: a Love Affair

I am in love with the English Language, and have been as long as I can remember.

I love words. I like their sound, and I like their rhythm. Most of all, though, I love their meanings, the often subtle shades of connotation that make apparently interchangeable words just a little bit different.

I like the history of English. I love that English is a Germanic language that took a French lover. I love that this couple adopted Greek and Latin and loved them as their own children, and I love that this raucous, tumultuous family parties with every language on the planet. (Did you know that "ketchup" is Indonesian and "boondocks" is taken from the Tagalog? How can you not love that?)

I don't read much poetry, and I haven't read much literary fiction. Most of my reading is nonfiction and essays. But that doesn't mean the quality of prose doesn't matter to me. I love reading writers that love language as much as I do. Some of my favorite essayists are primarily poets: Donald Hall is the only person for who's autograph I've stood in line. I love the twinkle-in-the-eye elegance of E. B. White, the brittle beauty of Joan Didion, and the riotous combativeness of Tom Wolfe.

My interests are many, and I'm always open to a new one. So, I'm less concerned with a writer's subject than with his craft. I've loved Roger Angell on baseball, Lewis Thomas and Richard Selzer on medicine, Witold Rybczynski on architecture, and John McPhee on many different things. Years ago, the library where I work created a bookmark with titles I'd chosen from each of the ten classes of the Dewey Decimal System.

I love puns, the more groan-inducing the better, and I love them best of all when they contain a play on meanings as well as sounds. I love word histories, although most of the ones you see outside of reference works are bogus. I love how etymology can suggest connections between ideas and concepts that I'd never considered.

English makes me happy.

Discouragement: a Poem

Discouragement
can come upon me in a rush,
grasping at the throat of my peace --
choking off ambition
choking off change
choking off hope.

Discouragement,
more usually, however,
creeps in around the corners of my mind.
Knowing the way well, he requires no light,
Has no need to alert me to his presence
Before his bags are fully unpacked.

Discouragement
likes to wear disguises
to defer the moment of recognition.
Most often he borrows the solemn raiment of Realism,
but sometimes disgraces the sacred robes of Humility,
defiling the cloth with his lies.

Discouragement
is not invincible.
He can often be defeated
by laughter, by love, or by prayer.
But seldom can you dislodge him
Before you know who he is.

A Quick Tip on Brown Rice

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.

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."

"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.

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.

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.

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