The relationship between people and food is complex enough to begin with, and it can be a little overwhelming if you're diabetic. In this post, after giving an overview of type one diabetes mellitus, I'm going to talk a little bit about the additional complexities that diabetics have with food.
A non-diabetic person has a working endocrine system that responds to natural increases in blood sugar levels by having portions of the pancreas produce insulin, which causes muscles and especially the liver to store the sugar. The liver acts as a buffer or gas tank; when you eat, it is like putting fuel in your body. The hormone glucagon has the opposite effect of insulin. Glucagon causes the liver to release sugar into the blood. A normal person always has trace amounts of glucagon or insulin in his/her blood. There is a good graph at Wikipedia that illustrates how insulin levels in a normal person's body react to sugar levels caused by eating and activity.
Keeping the blood sugar level below a particular value is important for many reasons that I do not fully understand. When the blood sugar goes too high, above about twice the normal value, the kidneys are overworked from removing all the sugar, and kidney damage can result. There are additional problems with blood vessels being weakened by high blood sugar. Keeping the blood sugar above a certain value is important because otherwise your cells would starve (leading to death). The combination of insulin, glucagon, intaking food, and the energy stored in your liver are all critical to keeping the blood sugar levels at a normal value.
A person with insulin-dependent diabetes mellitus (IDDM or type one diabetes) lacks the ability to produce sufficient insulin. A T1 (I will use this as short-hand for a type one diabetic, and it also makes me sound like a terminator) has the problem that his/her blood sugar would naturally go too high after meals, which can (over a period of years) cause kidney and blood vessel damage. T1s have the short-term problem that their energy reserves are too low. If a T1 performs vigorous physical activity and doesn't eat, the blood sugar will plummet, causing problems.
The way T1s normally solve these problems is by injecting insulin. There are two types of insulin: long-acting (basal) and short-acting (bolus). Long-acting insulin works over a period of roughly 18 to 24 hours, counteracting the "background" stream of sugar from the liver. Long-acting insulin is normally taken once or twice a day; in the Netherlands, doctors only prescribe it before sleep, though in America the dose is usually split between the morning and the night.
Short-acting insulin is taken at the same time as food. The short-acting insulin works over a period of roughly 4 hours. The amount of short-acting insulin I take is related to the amount of carbohydrates (sugars) in the food I eat. Right now I use about 4 units of insulin when I have less than 100 grams of carbs at a meal, 5 units when I have 100 - 110 g, and 6 units when I have above 110 g of carbs (I don't eat more than 110 g of carbs at a meal). This amount of insulin will increase over time, as my pancreas shuts down. Right now my body appears to produce enough insulin to cover about 60 grams of carbs; I need to inject insulin to make up the difference.
Unfortunately there are two big drawbacks to using the short-acting insulin. The first drawback is that the "response curve" of the insulin is set. The sugars in different foods take different amounts of time to absorb, but how and when the insulin acts is not variable. For example, when a T1 drinks 100 grams of caramelized dextrose, which the human body digests very efficiently, the blood sugar increases quickly and rapidly. In comparison, if I drink about 130 grams high-fructose corn syrup (which contains about 100 grams of sugar), my blood sugar would take about twice as long to rise. This is because the human body is less efficient at processing fructose than dextrose. How quickly a food is absorbed is known as the glycemic index, though this varies from person to person. The long and short of this is that foods with easily absorbed sugars (high glycemic index foods) will cause spikes in my blood sugar, which are bad. This is actually true for people in general; the South Beach Diet is a diet that partially focuses on eating low glycemic index foods, causing a lower variation in blood sugar. This type of diet is supposed to be better for you (you can also use it to lose weight, but that isn't the primary purpose of that diet).
Anyways, the important point is that if I'm not exercising (a different post entirely), then my doctor recommends eating food with a lower glycemic index, and eating it slowly. Foods that seem similar actually act very differently. Cherries have a lower index than raisins. Prunes are better for me than dates. Grapefruit is better than pineapple (but this is definitely only true from a glycemic index standpoint; in every other way, fresh pineapple is vastly superior to grapefruit). Anything made with processed, white flour is absorbed very quickly, so things like pancakes will cause spiky blood sugar.
The other drawback to the short-acting insulin is that there can be absorption problems long-term. Scar tissue builds up if a particular site is stressed repeatedly, and if a pocket of insulin isn't absorbed because of scar tissue, and the insulin is released quickly, a sudden drop in blood sugar can occur. Scar tissue is prevented by rotating injection sites; I use half of my body for a month, and then switch. During the month I also rotate within the site itself. I prefer to use the tops of my thighs in the mornings and the evenings, since the large surface area makes site rotation easy. However, it is a bit inconvenient at work, so I normally use my belly at work. Massaging the area before the injection (increases blood flow) helps a little bit, but massaging afterwards seems to cause bruising. Insulin can and does leak if the needle isn't held in the site; I normally count to 10 after injection.
Long-term, lowering the intake of insulin also prevents scar tissue problems. I am trying to eat a low-carb diet by using the Idaho Plate Method. In this method, you split your main plate into a half and two quarters; low-starch veggies occupy half, starch-heavy grains and veggies occupy a quarter, and protein sources occupy the other quarter. One piece of fruit can accompany a meal. The food has been a bigger adjustment than the shots or finger pokes. I ate a lot of pasta before learning I was T1, and right now if I tried to eat a meal with 250 grams of pasta and 500 ml of orange juice (both huge sources of carbs)...well, let's just say a meal like this is a bad idea at this moment. I could eat such a meal if I wanted to, but I'd need about two or three times as much insulin as a much healthier meal.
You'll notice there is no "dessert." Fruit is dessert right now. Sometimes I'll have a square of very dark chocolate with a meal or before I exercise, but right now I'm adjusting to eating less sugar. It isn't easy, but it reduces the amount of insulin I require and is going to be better for me long term.
Well, this post turned out a bit longer than I expected, but I hope it clears up how diabetics view food. We care more about the amount of sugar and how it is absorbed, in addition to the standard concerns about vitamin content and caloric content. All in all, the forced examination of my diet has turned out to be a pretty good thing. It wasn't a great idea to be eating a meal that was 300 g of spaghetti with 500 ml of orange juice as my primary source of energy.
In the next few posts I'll probably cover differences in vitamin sources from America to Europe (you'll be surprised, trust me), along with how diabetics approach exercise.
Showing posts with label type 1 diabetes. Show all posts
Showing posts with label type 1 diabetes. Show all posts
2011-02-01
2011-01-11
Diabetes FAQ
I'm getting a lot of questions about type 1 diabetes; I figured a blog post would be in order.
What is diabetes? What is the difference between the types?
The two types of diabetes mellitus are actually quite different, though both diseases relate to sugar and sugar metabolism. Type 1 diabetes mellitus, which I have, occurs when the immune system attacks the portion of the pancreas that produces insulin. Insulin is necessary for the body to metabolize sugar correctly. Type 2 diabetes mellitus occurs when the body doesn't respond correctly to insulin. Type 2 usually occurs in older, overweight individuals that have eaten a lot of sugar.
What's up with the mellitus at the end of diabetes mellitus?
There is another form of diabetes called diabetes insipidus, or DI. Mellitus means sweet, whereas insipidus means tasteless. The terms relate to the fact that urine from a person with diabetes mellitus, or DM, is sweet (due to the sugar flushed out of the body), whereas urine from a person with diabetes insipidus is tasteless, or tastes like whatever urine tastes like. My high school biology teacher once told me that to diagnosis whether problems were DM or DI, people drank the urine. Is it true? I have no idea.
The symptoms of DM and DI are similar, but the causes and treatments are very different. Diabetes, in general, usually refers to diabetes mellitus.
What does having type 1 diabetes entail?
Essentially I have to give myself insulin instead of relying on my pancreas to produce it for me. This means that before eating anything with carbohydrates I have to give myself insulin. Anything with sugar or starch is high in carbohydrates, so foods like potatoes, candy, and fruity drinks require giving myself more insulin than meat or low-sugar foods.
Do type 1s ever develop type 2 symptoms?
"Very rarely." is the response I've received from doctors.
Isn't type 1 called juvenile-onset diabetes?
Onset of type 1 can occur later than age 40, and thus the terms juvenile or juvenile-onset are no longer preferred. Type 1 is often called insulin-dependent diabetes mellitus or IDDM. I was 26 at onset, and I know another type 1 who was diagnosed when he was 29. Type 1 is actually "better" when it occurs later in life; when kids are growing it is difficult to find the correct amount of insulin to use.
You have to give yourself a shot before you eat almost anything? Does it hurt? How much insulin do you use?
I do have to give myself a shot before every meal. I also give myself a shot in the morning of long-acting insulin that stays in my system for about 24 hours. The shots hardly hurt at all, and I have very quickly gotten used to them. I have also gotten used to pricking my finger to check my blood sugar. Pricking my fingers was worse at first, but is no longer a problem.
Right now my pancreas is still producing some fraction of the insulin that would be expected. However, my body will continue to attack portions of my pancreas, and eventually it will produce only trace insulin. I'll have to inject more insulin at this point.
The amount of insulin I use depends on the amount of sugar in the food I eat. I have to match my insulin dose to the amount of sugar in the food I consume using a carbohydrate-to-insulin ratio. The ratio will change as my pancreas shuts down, but it should stay the same afterwards.
What are the symptoms of being type 1 diabetic?
The insulin shots are to keep my blood sugar at roughly the level of a normal person's blood sugar. There are no symptoms if my blood sugar stays in the normal range. Problems arise if my blood sugar is too high or too low.
If my blood sugar goes too low, I notice it immediately, and I have something that has a little bit of sugar in it. I'm trying to find something with sugar that I don't like --- giving myself a reward when I don't properly manage my blood sugar seems like a bad idea. When my blood sugar is too low, my head feels a bit weird and my muscles jerk instead of operating smoothly. If my blood sugar goes way too low, very bad things can happen, such as fainting. Having low blood sugar is dangerous short term.
If my blood sugar goes too high, then I usually have trouble focusing. If it stays too high, then I usually itch. The itching is a personal symptom, which many people do not have. If it stays too high for too long, I can develop more symptoms, from the mundane like increased acne and increased thirst to the severe symptoms of weight loss, muscle aches and very blurry vision. My body has acclimated to high blood sugar, so it is difficult for me right now to notice when my blood sugar is high.
If my blood sugar is too high long-term, there are many complications for my eyes, kidneys, heart and lungs.
How did you find out?
Over the past three months at work, I've had tremendous difficulty focusing. I've also noticed that I've had increased amounts of acne.
During winter vacation, I spent a week in Boston. My hands started to itch, and while I didn't think too much of it at the time I did see a doctor when I was home in Iowa a week later. I starting having the more severe symptoms, including increased thirst and blurry vision. I thought my vision was blurrier than normal, but I've also needed glasses for a while, so I didn't really notice it. Then my muscles starting being sore when I walked up the stairs. I searched for the symptoms using my search engine of choice and there it was: diabetes. I saw the doctor the next day. My blood pressure was normal, my heart rate was normal, and my blood sugar was 4x the value it was supposed to be. Based on my age, weight and blood sugar, it was an automatic type 1 diabetes diagnosis. I had also dropped 2.5 kilos (about 5 pounds) in the week between the two doctor appointments. The doctors said that the decreased exercise (I ride my bike / walk a lot in NL) combined with my root beer, birthday cake and chocolate diet caused a huge spike in my blood sugar.
How does exercise work?
Blood glucose levels drop automatically during exercise, so I am supposed to only give myself a half dose of insulin at meals before I work out. After I get my levels stabilized I think I am going to join a gym.
Can you still drink alcohol?
Yes, but alcohol is tricky. Most alcoholic drinks are just fermented sugar, and consuming small amounts of sugar over a long period of time does not match giving a single injection of insulin, which works well for a meal. Additionally, being intoxicated is much more dangerous now than before. I didn't consume alcohol in large quantities before, just a beer every now and then, but I think I am going to consume even less now.
This all kinda sucks.
That is not a question, but yes, it is unfortunate. However, it turns out that people can adapt very quickly to adverse circumstances. I can tell that I am going to be able to live a normal life sans some special things required for eating food and exercise.
How common is type 1 diabetes?
In northern European populations, the rate is almost 1%, or 1 in 100 people (see the study in the next question). In America the rate is probably closer to 1 in 200 or 250 people (see the Wikipedia article). I haven't found great information on the rest of the world.
Is the disease genetic?
There are some very interesting studies on this question, particularly a study on Finnish twins. When a twin of an identical pair had type 1 diabetes, there was roughly a 50% chance that the other twin would also have the disease. There are multiple genes involved, which make occurrence complicated to predict. The 23andMe page on type 1 diabetes is actually a really good resource on the genes and appropriate studies.
Type 2 is also somewhat genetic, but is much more influenced by the environment, especially diet and exercise.
If your pancreas isn't working does that mean you don't need it? Can I stab it?
Only a portion of my pancreas isn't working; I still need some of the other portions. No, you may not stab my pancreas.
Do you expect that anyone is going to develop a cure in your lifetime?
No. It wouldn't surprise me if someone came up with a vaccine, but I doubt there will be a cure. Drug companies aren't very interesting in curing things, they care more about treating symptoms, which is a better income stream.
What was treatment like before insulin?
Controlled starvation was the "treatment" before insulin. I use quotes because nothing was actually treated, symptoms existed, but people would live longer. The life expectancy after diagnosis without starvation was about six months; it could increase to a few years with controlled starvation.
After insulin was successfully extracted in 1921 (the extraction technique's inventors won the Nobel prize in 1923), treatment was an insulin injection before any meal. I would recommend reading the book Breakthrough, though make sure you read the book's afterword to understand that some of the non-scientific portions of the book are fictionalized.
What can I do?
The most important thing you can do is take care of yourself so that you are less likely to develop type 2 diabetes. Eating foods with less added sugar, eating lots of fruits/veggies, having a balanced diet, and getting enough exercise are very important.
If you like you can donate money to a foundation like the JDRF or ADA, but I think being supportive of scientific research and politicians who support research is more important.
Finally, just treat anyone who is diabetic just like a normal person with specific dietary restrictions. Try not to confuse type 1 with type 2; while both types share the label of diabetes mellitus, the two types can be very different. If a diabetic suggests eating at a different time or a different place please accept.
Oh, and be very careful about brunch. We the type 1 diabetics hate brunch. Well, mostly hate brunch. It is too much food of the wrong type at the wrong time.
This is all really interesting, where can I find more information?
I would suggest browsing the JDRF website first, then maybe the ADA website. There is always the Wikipedia.
What is diabetes? What is the difference between the types?
The two types of diabetes mellitus are actually quite different, though both diseases relate to sugar and sugar metabolism. Type 1 diabetes mellitus, which I have, occurs when the immune system attacks the portion of the pancreas that produces insulin. Insulin is necessary for the body to metabolize sugar correctly. Type 2 diabetes mellitus occurs when the body doesn't respond correctly to insulin. Type 2 usually occurs in older, overweight individuals that have eaten a lot of sugar.
What's up with the mellitus at the end of diabetes mellitus?
There is another form of diabetes called diabetes insipidus, or DI. Mellitus means sweet, whereas insipidus means tasteless. The terms relate to the fact that urine from a person with diabetes mellitus, or DM, is sweet (due to the sugar flushed out of the body), whereas urine from a person with diabetes insipidus is tasteless, or tastes like whatever urine tastes like. My high school biology teacher once told me that to diagnosis whether problems were DM or DI, people drank the urine. Is it true? I have no idea.
The symptoms of DM and DI are similar, but the causes and treatments are very different. Diabetes, in general, usually refers to diabetes mellitus.
What does having type 1 diabetes entail?
Essentially I have to give myself insulin instead of relying on my pancreas to produce it for me. This means that before eating anything with carbohydrates I have to give myself insulin. Anything with sugar or starch is high in carbohydrates, so foods like potatoes, candy, and fruity drinks require giving myself more insulin than meat or low-sugar foods.
Do type 1s ever develop type 2 symptoms?
"Very rarely." is the response I've received from doctors.
Isn't type 1 called juvenile-onset diabetes?
Onset of type 1 can occur later than age 40, and thus the terms juvenile or juvenile-onset are no longer preferred. Type 1 is often called insulin-dependent diabetes mellitus or IDDM. I was 26 at onset, and I know another type 1 who was diagnosed when he was 29. Type 1 is actually "better" when it occurs later in life; when kids are growing it is difficult to find the correct amount of insulin to use.
You have to give yourself a shot before you eat almost anything? Does it hurt? How much insulin do you use?
I do have to give myself a shot before every meal. I also give myself a shot in the morning of long-acting insulin that stays in my system for about 24 hours. The shots hardly hurt at all, and I have very quickly gotten used to them. I have also gotten used to pricking my finger to check my blood sugar. Pricking my fingers was worse at first, but is no longer a problem.
Right now my pancreas is still producing some fraction of the insulin that would be expected. However, my body will continue to attack portions of my pancreas, and eventually it will produce only trace insulin. I'll have to inject more insulin at this point.
The amount of insulin I use depends on the amount of sugar in the food I eat. I have to match my insulin dose to the amount of sugar in the food I consume using a carbohydrate-to-insulin ratio. The ratio will change as my pancreas shuts down, but it should stay the same afterwards.
What are the symptoms of being type 1 diabetic?
The insulin shots are to keep my blood sugar at roughly the level of a normal person's blood sugar. There are no symptoms if my blood sugar stays in the normal range. Problems arise if my blood sugar is too high or too low.
If my blood sugar goes too low, I notice it immediately, and I have something that has a little bit of sugar in it. I'm trying to find something with sugar that I don't like --- giving myself a reward when I don't properly manage my blood sugar seems like a bad idea. When my blood sugar is too low, my head feels a bit weird and my muscles jerk instead of operating smoothly. If my blood sugar goes way too low, very bad things can happen, such as fainting. Having low blood sugar is dangerous short term.
If my blood sugar goes too high, then I usually have trouble focusing. If it stays too high, then I usually itch. The itching is a personal symptom, which many people do not have. If it stays too high for too long, I can develop more symptoms, from the mundane like increased acne and increased thirst to the severe symptoms of weight loss, muscle aches and very blurry vision. My body has acclimated to high blood sugar, so it is difficult for me right now to notice when my blood sugar is high.
If my blood sugar is too high long-term, there are many complications for my eyes, kidneys, heart and lungs.
How did you find out?
Over the past three months at work, I've had tremendous difficulty focusing. I've also noticed that I've had increased amounts of acne.
During winter vacation, I spent a week in Boston. My hands started to itch, and while I didn't think too much of it at the time I did see a doctor when I was home in Iowa a week later. I starting having the more severe symptoms, including increased thirst and blurry vision. I thought my vision was blurrier than normal, but I've also needed glasses for a while, so I didn't really notice it. Then my muscles starting being sore when I walked up the stairs. I searched for the symptoms using my search engine of choice and there it was: diabetes. I saw the doctor the next day. My blood pressure was normal, my heart rate was normal, and my blood sugar was 4x the value it was supposed to be. Based on my age, weight and blood sugar, it was an automatic type 1 diabetes diagnosis. I had also dropped 2.5 kilos (about 5 pounds) in the week between the two doctor appointments. The doctors said that the decreased exercise (I ride my bike / walk a lot in NL) combined with my root beer, birthday cake and chocolate diet caused a huge spike in my blood sugar.
How does exercise work?
Blood glucose levels drop automatically during exercise, so I am supposed to only give myself a half dose of insulin at meals before I work out. After I get my levels stabilized I think I am going to join a gym.
Can you still drink alcohol?
Yes, but alcohol is tricky. Most alcoholic drinks are just fermented sugar, and consuming small amounts of sugar over a long period of time does not match giving a single injection of insulin, which works well for a meal. Additionally, being intoxicated is much more dangerous now than before. I didn't consume alcohol in large quantities before, just a beer every now and then, but I think I am going to consume even less now.
This all kinda sucks.
That is not a question, but yes, it is unfortunate. However, it turns out that people can adapt very quickly to adverse circumstances. I can tell that I am going to be able to live a normal life sans some special things required for eating food and exercise.
How common is type 1 diabetes?
In northern European populations, the rate is almost 1%, or 1 in 100 people (see the study in the next question). In America the rate is probably closer to 1 in 200 or 250 people (see the Wikipedia article). I haven't found great information on the rest of the world.
Is the disease genetic?
There are some very interesting studies on this question, particularly a study on Finnish twins. When a twin of an identical pair had type 1 diabetes, there was roughly a 50% chance that the other twin would also have the disease. There are multiple genes involved, which make occurrence complicated to predict. The 23andMe page on type 1 diabetes is actually a really good resource on the genes and appropriate studies.
Type 2 is also somewhat genetic, but is much more influenced by the environment, especially diet and exercise.
If your pancreas isn't working does that mean you don't need it? Can I stab it?
Only a portion of my pancreas isn't working; I still need some of the other portions. No, you may not stab my pancreas.
Do you expect that anyone is going to develop a cure in your lifetime?
No. It wouldn't surprise me if someone came up with a vaccine, but I doubt there will be a cure. Drug companies aren't very interesting in curing things, they care more about treating symptoms, which is a better income stream.
What was treatment like before insulin?
Controlled starvation was the "treatment" before insulin. I use quotes because nothing was actually treated, symptoms existed, but people would live longer. The life expectancy after diagnosis without starvation was about six months; it could increase to a few years with controlled starvation.
After insulin was successfully extracted in 1921 (the extraction technique's inventors won the Nobel prize in 1923), treatment was an insulin injection before any meal. I would recommend reading the book Breakthrough, though make sure you read the book's afterword to understand that some of the non-scientific portions of the book are fictionalized.
What can I do?
The most important thing you can do is take care of yourself so that you are less likely to develop type 2 diabetes. Eating foods with less added sugar, eating lots of fruits/veggies, having a balanced diet, and getting enough exercise are very important.
If you like you can donate money to a foundation like the JDRF or ADA, but I think being supportive of scientific research and politicians who support research is more important.
Finally, just treat anyone who is diabetic just like a normal person with specific dietary restrictions. Try not to confuse type 1 with type 2; while both types share the label of diabetes mellitus, the two types can be very different. If a diabetic suggests eating at a different time or a different place please accept.
Oh, and be very careful about brunch. We the type 1 diabetics hate brunch. Well, mostly hate brunch. It is too much food of the wrong type at the wrong time.
This is all really interesting, where can I find more information?
I would suggest browsing the JDRF website first, then maybe the ADA website. There is always the Wikipedia.
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