Edward Reid
Archive-name: diabetes/faq/part1
Posting-Frequency: biweekly
Last-modified: 21 May 2003 (excludes change list and Table of Contents)
Changes: change URL on A1c variability (4 Jan) update A1c by
mail info (28 Jan) update links to ADA Clinical Practice
Recommendations (30 Apr) change attribution for software FAQ
(now Rick Mendosa) (20 May) remove outdated insuline pump
discussion (21 May)
------------------------------
Subject: READ THIS FIRST
Copyright 1993-2003 by Edward Reid. Re-use beyond the fair
use provisions of copyright law and convention requires the
author's permission.
Advice given in m.h.d is *never* medical advice. That
includes this FAQ. Never substitute advice from the net for
a physician's care. Diabetes is a critical health topic and
you should always consult your physician or personally
understand the ramifications before taking any therapeutic
action based on advice found here or elsewhere on the net.
------------------------------
Subject: Table of Contents
INTRODUCTION (found in all parts) READ THIS FIRST Table of
Contents GENERAL (found in part 1) Where's the FAQ? What's
this newsgroup like? Abuse of the newsgroup The newsgroup
charter Newsgroup posting guidelines What is glucose? What
does "bG" mean? What are mmol/L? How do I convert between
mmol/L and mg/dl? What is c-peptide? What do c-peptide
levels mean? What's type 1 and type 2 diabetes? Is it OK to
discuss diabetes insipidus here? What is it? How about
discussing hypoglycemia? Helping with the diagnosis (DM or
hypoglycemia) and waiting Exercise and insulin BLOOD GLUCOSE
MONITORING (found in part 2) How accurate is my meter? Ouch!
The cost of blood glucose measurement strips hurts my
wallet! What do meters cost? Comparing blood glucose meters
How can I download data from my meter? I've heard of a non-
invasive bG meter -- the Dream Beam? What's HbA1c and what's
it mean? Why is interpreting HbA1c values tricky? Who
determined the HbA1c reaction rates and the consequences?
HbA1c by mail Why is my morning bg high? What are dawn
phenomenon, rebound, and Somogyi effect? TREATMENT (found in
part 3) My diabetic father isn't taking care of himself.
What can I do? Managing adolescence, including the adult
forms So-and-so eats sugar! Isn't that poison for diabetics?
Insulin nomenclature What is Humalog / LysPro / lispro /
ultrafast insulin? Travelling with insulin Injectors:
Syringe and lancet reuse and disposal Injectors: Pens
Injectors: Jets Insulin pumps Type 1 cures -- beta cell
implants Type 1 cures -- pancreas transplants Type 2 cures
-- barely a dream What's a glycemic index? How can I get a
GI table for foods? Should I take a chromium supplement? I
beat my wife! (and other aspects of hypoglycemia) (not yet
written) Does falling blood glucose feel like hypoglycemia?
Alcohol and diabetes Necrobiosis lipoidica diabeticorum Has
anybody heard of frozen shoulder (adhesive capsulitis)?
Gastroparesis Extreme insulin resistance What is pycnogenol?
Where and how is it sold? What claims do the sales pitches
make for pycnogenol? What's the real published scientific
knowledge about pycnogenol? How reliable is the literature
cited by the pycnogenol ads? What's the bottom line on
pycnogenol? Pycnogenol references SOURCES (found in part 4)
Online resources: diabetes-related newsgroups Online
resources: diabetes-related mailing lists Online resources:
commercial services Online resources: FTP Online resources:
World Wide Web Online resources: other Where can I mail
order XYZ? How can I contact the American Diabetes
Association (ADA) ? How can I contact the Juvenile Diabetes
Foundation (JDF) ? How can I contact the British Diabetic
Association (BDA) ? How can I contact the Canadian Diabetes
Association (CDA) ? What about diabetes organizations
outside North America? How can I contact the United Network
for Organ Sharing (UNOS)? Could you recommend some good
reading? Could you recommend some good magazines? RESEARCH
(found in part 5) What is the DCCT? What are the results?
More details about the DCCT DCCT philosophy: what did it
really show? IN CLOSING (found in all parts) Who did this?
------------------------------
Subject: Where's the FAQ?
This FAQ attempts to answer the questions which have been
most frequently asked in misc.health.diabetes (m.h.d). This
is not a complete informational posting. My only criterion
for inclusion is that the topic has frequently appeared in
m.h.d, either by an explicit question, or implicitly by
posting a related question or a common misconception.
This FAQ is posted biweekly to the Usenet newsgroup
misc.health.diabetes. If you obtained this article by some
method other than reading Usenet, refer to the section on
"Online resources: diabetes-related newsgroups" for brief
information on how to obtain access to Usenet newsgroups and
misc.health.diabetes in particular.
Feel free to make copies of this FAQ for your personal use
or for a friend or relative, including to share with health
care providers. If you want to make this FAQ available to
others on an ongoing basis (for example, on a BBS), please
do *not* post or copy the entire FAQ. Instead, post only
this section, entitled "Where's the FAQ?". This will enable
others always to retrieve the most recent version.
I have removed the outdated informational posting on
insulin pumps.
An informational posting on diabetes-related software is
posted to m.h.d at the same time as this FAQ. See below for
retrieval information. It was developed and is maintained by
Rick Mendosa <mendosa(AT)mendosa.com>.
I've used ideas and information from many people in writing
this FAQ. With a few exceptions I haven't attempted to
identify them, but I thank them all. The words herein are
mine unless otherwise credited.
If you read this and it helps you, please let me know what
part helped, and why. If you read this and can't find what
you want, let me know that too. Such comments will help me
decide what is worth working on, and whether. You'd be
surprised how little feedback I get. If you are reading this
on the newsgroup, just reply to this article. If you found
this on the web, send email to <edward@paleo.org>.
These documents -- the FAQ and the software overview -- are
available from the news.answers archives at rtfm.mit.edu.
Using anonymous ftp, get the files:
/pub/faqs/diabetes/faq/part1 /pub/faqs/diabetes/faq/part2
/pub/faqs/diabetes/faq/part3 /pub/faqs/diabetes/faq/part4
/pub/faqs/diabetes/faq/part5 /pub/faqs/diabetes/software
or in web browser format:
ftp://rtfm.mit.edu/pub/faqs/diabetes/
If your net access is by email only, send an email message
to mail-server(AT)rtfm.mit.edu, subject ignored, body
containing:
send faqs/diabetes/faq/part1 send faqs/diabetes/faq/part2
send faqs/diabetes/faq/part3 send faqs/diabetes/faq/part4
send faqs/diabetes/faq/part5 send faqs/diabetes/software
If you are using the World Wide Web, you can reach a WWW-
formatted version of the FAQ and other documents via the URL
http://www.faqs.org/faqs/diabetes/
You can also retrieve the plain text by FTP from the
rtfm.mit.edu site mentioned above, which has long been the
most reliable source. However, it only offers the simplest
retrieval capability.
------------------------------
Subject: What's this newsgroup like?
Posting topics range through emotional support, treatment
techniques, psychological factors, health care practices,
and insurance. We talk about our problems, frustrations,
depressions and complications to find out how others handle
the same issues and for mutual support. The atmosphere is
generally a highly supportive one, and most participants
believe strongly that this is an important aspect. As in
other parts of the net, there are one or two regular
participants who believe that it is important to question
the motives and/or knowledge of anyone posting a new
problem. If you find that the first response is
antagonistic, please wait a few hours. Every antagonistic
response will elicit a dozen sympathetic responses.
Meta-topics include discussions of how to best convey health
information on the Usenet, ethical treatment of other
participants, what topics and information are appropriate
for m.h.d, where to find diabetes information, and what the
newsgroup should be like.
Betsy Butler says eloquently:
The positive posts of people who are in great control are
very motivating, but it is also helpful to hear from
people who don't find it so easy. I'm sure there are a
lot of people who struggle to keep control. The people
who are having trouble also need to know that there are
others who struggle, and that they are not alone. It can
be very intimidating, and a blow to self-esteem for
people to suggest that if you would just do X, Y and Z,
you will be in control. There are 100s of factors to
balance, and I think people need to be reassured that
"yes, it's hard to balance so many things, many of which
can't be measured or that don't act predictably."
Topics closely related to diabetes mellitus which do not
have their own place in Usenet are welcome. Examples are
diabetes insipidus, hypoglycemia, glucose intolerance, legal
and employment ramifications of chronic illness, effects on
family members, how family members can best provide support,
and so on. misc.health.diabetes tends to be inclusive of
anyone who needs it.
The same caveat applies here as in all newsgroups: the
advice is worth what you paid for it. This applies in spades
to a critical health topic such as diabetes. Never
substitute informal advice for a physician's care. Advice
given in m.h.d is *never* medical advice.
The variety of individual responses to diabetes is exceeded
only by the variety of individual responses to life. No two
patients respond alike, and many respond *very* differently
from others. These differences are physiological, not just
psychological. They reflect not only varying responses, but
the fact that diabetes itself probably has many causes, many
more than the few types currently recognized (see section on
types). When you read advice, realize that what works (or
doesn't work) for someone else may not work (or may work)
for you. When you give advice, try to remember that most
advice is relative to the individual, not absolute.
Recognize that you can't treat your own diabetes by a set of
rules, but only by knowing how your own individual body and
physiology work and by adjusting to your own mechanisms.
------------------------------
Subject: Abuse of the newsgroup
As mentioned above, a few participants believe that name-
calling and abusive language are more effective than
polite discussion, support and interchange of information.
They are wrong, and the vast majority of participants
support a more civilized and polite view of humanity.
Since misc.health.diabetes is unmoderated, we all have to
live together.
A few m.h.d. participants have received abusive email. Some
are afraid to expose such abuse, having been told that email
must always be private. However, abusive email is no more
deserving of privacy than obscene phone calls or threatening
letters. There is no authority to which you can report
abusive email (unless it contains an actual threat, in which
can you may be justified in contacting a law enforcement
agency). Steve Kirchoefer <swkirch(AT)chrisco.nrl.navy.mil>
is willing to try to mediate problems with email. Though
Steve has no official authority, he has experience in
dealing with problems on the net and may be able to help
clear up such problems. Send him complete copies of any
abusive email.
------------------------------
Subject: The newsgroup charter
The actual charter which led to the creation of the
newsgroup in May 1993 follows. This charter was proposed by
Steve Kirchoefer <swkirch(AT)chrisco.nrl.navy.mil> and
approved by a public vote of the Usenet readership, and is
the official statement of the scope and purpose of this
newsgroup.
1. The purpose of misc.health.diabetes is to provide a
forum for the discussion of issues pertaining to
diabetes management, i.e.: diet, activities, medicine
schedules, blood glucose control, exercise, medical
breakthroughs, etc. This group addresses the issues of
management of both Type I (insulin dependent) and Type
II (non-insulin dependent) diabetes. Both technical
discussions and general support discussions relevant to
diabetes are welcome.
2. Postings to misc.health.diabetes are intended to be for
discussion purposes only, and are in no way to be
construed as medical advice. Diabetes is a serious
medical condition requiring direct supervision by a
primary health care physician.
------------------------------
Subject: Newsgroup posting guidelines
The following posting guidelines were adopted by a vote of
m.h.d participants in September 1994.
Posting guidelines for misc.health.diabetes:
Postings to misc.health.diabetes should be compliant with
the standards for all material posted to Usenet. The
following articles may be found in news.announce.newusers,
and should be reviewed by all posters:
-Emily Postnews Answers Your Questions on Netiquette -
Answers to Frequently Asked Questions about Usenet -A Primer
on How to Work With the Usenet Community -Rules for posting
to Usenet -What is Usenet?
Posting to misc.health.diabetes should be compliant with the
group charter, [which is in the previous section].
In addition to the above, the following guidelines are
emphasized as particularly relevant for contributions to
misc.health.diabetes:
-No personal attacks or insults. Avoid argumentative
debates. Responses should concentrate on the issues
presented.
-No private discussions. Take private discussions to email.
When in doubt, use email.
-Edit responses to avoid unnecessary inclusions of
earlier postings.
-Edit subject lines as necessary to remain consistent with
the topic.
-Support factual statements with your sources. If you can
not recall the source, then say so. Do not imply authority
which you can not actually support.
Additional information can be found in the general FAQ
posted periodically to this group.
------------------------------
Subject: What is glucose? What does "bG" mean?
Glucose is a specific form of sugar, one of the simplest.
It is the form found in the bloodstream. "Blood sugar"
always refers to blood glucose, and is abbreviated bG.
All bG meters are specific for glucose and will not
respond to other sugars, such as fructose, sucrose,
maltose and lactose.
Although sucrose (table sugar) is the most common sugar in
food, glucose is also common. Most fruits, fruit juices, and
soft drinks contain large amounts of glucose, and many foods
contain small amounts. This means that you must be very
careful to clean any food residue from your fingers before
drawing blood for a bG check. Since the normal level of bG
is only 1g/L (=100mg/dl), it only takes a tiny speck of
glucose on your finger to contaminate the sample and give
you a falsely high reading. 10 *micrograms* of glucose could
raise the reading enough to cause you to overreact
dangerously.
------------------------------
Subject: What are mg/dl and mmol/l? How to convert? Glucose?
Cholesterol?
There are two main methods of describing concentrations: by
weight, and by molecular count. Weights are in grams,
molecular counts in moles. (If you really want to know, a
mole is 6.23*10^23 molecules.) In both cases, the unit is
usually modified by milli- or micro- or other prefix, and is
always "per" some volume, often a liter.
This means that the conversion factor depends on the
molecular weight of the substance in question.
mmol/l is millimoles/liter, and is the world standard unit
for measuring glucose in blood. Specifically, it is the
designated SI (Systeme International) unit. "World
standard", of course, means that mmol/L is used everywhere
in the world except in the US. A mole is about 6*10^23
molecules; if you want more detail, take a chemistry course.
mg/dl (milligrams/deciliter) is the traditional unit for
measuring bG (blood glucose). All scientific journals are
moving quickly toward using mmol/L exclusively. mg/dl
won't disappear soon, and some journals now use mmol/L as
the primary unit but quote mg/dl in parentheses,
reflecting the large base of health care providers and
researchers (not to mention patients) who are already
familiar with mg/dl.
Since m.h.d is an international newsgroup, it's polite to
quote both figures when you can. Most discussions take place
using mg/dl, and no one really expects you to pull out your
calculator to compose your article. However, if you don't
quote both units, it's inevitable that many readers will
have to pull out their calculators to read it.
Many meters now have a switch that allows you to change
between units. Sometimes it's a physical switch, and
sometimes it's an option that you can set.
To convert mmol/l of glucose to mg/dl, multiply by 18.
To convert mg/dl of glucose to mmol/l, divide by 18 or
multiply by 0.055.
These factors are specific for glucose, because they
depend on the mass of one molecule (the molecular weight).
The conversion factors are different for other substances
(see below).
And remember that reflectance meters have a some error
margin due to both intrinsic limitations and environmental
factors, and that plasma readings are 15% higher than
whole blood (as of 2002 most meters are calibrated to give
plasma readings, thus matching lab readings, but this is a
recent development), and that capillary blood is different
from venous blood when it's changing, as after a meal. So
round off to make values easier to comprehend and don't
sweat the hundredths place. For example, 4.3 mmol/l
converts to 77.4 mg/dl but should probably be quoted as 75
or 80. Similarly, 150 mg/dl converts to 8.3333... mmol/l
but 8.3 is a reasonable quote, and even just 8 would
usually convey the meaning.
Actually, a table might be more useful than the raw
conversion factor, since we usually talk in
approximations anyway.
mmol/l mg/dl interpretation ------ ----- --------------
2. 35 extremely low, danger of unconciousness
3. 55 low, marginal insulin reaction
4. 75 slightly low, first symptoms of
lethargy etc.
5.5 100 mecca 5 - 6 90-110 normal preprandial in
nondiabetics
6. 150 normal postprandial in nondiabetics
7. 180 maximum postprandial in nondiabetics
8. 200
9. 270 a little high to very high depending
on patient
10.5 300
11. 360 getting up there 22 400 max mg/dl for some
meters and strips 33 600 high danger of severe
electrolyte imbalance
Preprandial = before meal Postprandial = after meal
More conversions:
To convert mmol/l of HDL or LDL cholesterol to mg/dl,
multiply by 39. To convert mg/dl of HDL or LDL cholesterol
to mmol/l, divide by 39.
To convert mmol/l of triglycerides to mg/dl, multiply by 89.
To convert mg/dl of triglycerides to mmol/l, divide by 89.
To convert umol (micromoles) /l of creatinine to mg/dl,
divide by 88. To convert mg/dl of creatinine to umol/l,
multiply by 88.
------------------------------
Subject: What is c-peptide? What do c-peptide levels mean?
Thanks to Andrew Torres <andym(AT)ku.edu> for this section.
C-peptide blood levels can indicate whether or not a person
is producing insulin and roughly how much.
Insulin is initially synthesized in the form of proinsulin.
In this form the alpha and beta chains of active insulin are
linked by a third polypeptide chain called the connecting
peptide, or c-peptide, for short. Because both insulin and
c-peptide molecules are secreted, for every molecule of
insulin in the blood, there is one of c-peptide. Therefore,
levels of c-peptide in the blood can be measured and used as
an indicator of insulin production in those cases where
exogenous insulin (from injection) is present and mixed with
endogenous insulin (that produced by the body) a situation
that would make meaningless a measurement of insulin itself.
The c-peptide test can also be used to help assess if high
blood glucose is due to reduced insulin production or to
reduced glucose intake by the cells.
There is little or no c-peptide in blood of type 1
diabetics, and c-peptide levels in type 2 diabetics can be
reduced or normal. The concentrations of c-peptide in non-
diabetics are on the order of 0.5-3.0 ng/ml.
------------------------------
Subject: What's type 1 and type 2 diabetes, and
gestational diabetes?
The term diabetes mellitus comes from Greek words for
"flow" and "honey", referring to the excess urinary flow
that occurs when diabetes is untreated, and to the sugar in
that urine.
Diabetes mellitus (DM) comes in the following
classifications (which some will argue don't really
represent the actual types very well):
type 1 -- characterized by total destruction of the insulin-
producing beta cells, probably by an autoimmune reaction.
Onset is most common in childhood, thus the common (but
now deprecated) term "juvenile-onset", but the onset up
to age 40 is not uncommon and can even occur later.
Patients are susceptible to DKA (diabetic ketoacidosis).
There seems to be some genetic tendency, but the genetic
situation is unclear. Most patients are lean. Always
as IDDM (insulin dependent diabetes mellitus).
type 2 -- characterized by insulin resistance despite
adequate insulin production. A large majority of patients
are overweight at onset, and a majority are female. Most
are over 40, hence the common (but now deprecated) terms
"adult-onset" or "maturity-onset", but onset can occur at
any age. Patients are not susceptible to DKA (diabetic
ketoacidosis). There is a strong genetic tendency, but
not simple inheritance. Depending on the individual,
treatment may be by diet, exercise, weight loss, oral
drugs which stimulate the release of insulin, or insulin
injections -- and usually a combination of several of
these. Also referred to as NIDDM (non insulin dependent
diabetes mellitus) *even when treated with insulin* -- a
confusing terminology which, unfortunately, is supported
by the ADA.
gestational -- occurs in about 3% of all pregnancies as a
result of insulin antagonists secreted by the placenta.
It is recommended that all pregnant women receive a
screening glucose tolerance test (GTT) between the 24th
and 28th weeks of pregnancy to detect gestational
diabetes early if it occurs, as diabetes can cause
serious difficulties in pregnancy. Sometimes requires
insulin treatment. Not susceptible to DKA (diabetic
ketoacidosis). Usually disappears after childbirth, but
about 40% of patients develop type 2 diabetes within five
years. Most authorities state that the typical patient is
female ...
malnutrition-related -- severe malnutrition sometimes
causes diabetes -- hyperglycemia and all the usual
symptoms. The reason is unknown, and since this syndrome
occurs almost entirely in third world countries, research
on this form of diabetes is nearly nonexistent.
other types -- sometimes called secondary. A catchall for
forms not covered by the types described above. Causes
include loss of the entire pancreas (to trauma, cancer,
alcohol abuse, or exposure to chemicals), diseases that
destroy the beta cells, certain hormonal syndromes, drugs
that interfere with insulin secretion or action, and some
rare genetic conditions.
These terms are not used entirely consistently. Some doctors
will refer to any diabetic using insulin as type 1, and will
refer to the early onset of type 1 diabetes as type 2 until
insulin therapy is required. This usage does not fit with
most modern usage as described above (type 1 is beta cell
destruction, type 2 is insulin resistance). The situation is
complicated by the fact that early in the course of the
disease it can be difficult to determine which type is
occuring, especially for patients in their 30's, the age
when the onset of both types is common.
Different patients respond very differently to what is
categorized above as the same disease. The root causes of
all forms of diabetes are not understood, and are likely
more complex and varied than the simple categories show.
Type 1 diabetes likely has a few root causes, and type 2
diabetes probably has a larger number of root causes.
There are also well documented reports of cases of diabetes
with unexplained combinations of syndromes from types 1 and
2. These are sometimes referred to as "type 1-1/2", and the
reasons are not understood.
The classification above is not completely standard, and
other classifications exist.
About 90% of diabetes patients are type 2 (some 12 million
in the US), and about 10% are type 1 (some 1 million in the
US). Discussion on m.h.d tends to run about 2/3 type 1, I'd
guess. This probably reflects the fact that type 1 diabetes
is harder to ignore, and that type 2 seldom strikes the
younger people who are more likely to have net access. Type
2 is *not* less serious.
"1" and "2" are often written in Roman numerals: type I,
type II. Because typography is often unclear on computer
terminals, I've stuck with the Arabic numeral version.
Diabetes accounts for about 5% of all health care costs in
the US, some US$90 billion per year.
------------------------------
Subject: Is it OK to discuss diabetes insipidus here?
What is it?
Diabetes insipidus (DI) results from abnormalities in the
production or use (two main types) of the hormone arginine
vasopressin. The main symptoms are excessive thirst and
massive urination. The excess urine flow is devoid of sugar.
There are no blood glucose abnormalities, and in fact there
is nothing in common with diabetes mellitus except the
excess urination when untreated.
Diabetes insipidus caused by failure to produce vasopressin.
This is known as neurogenic DI (or central DI, or pituitary
DI). It can be treated with hormone replacement (by nasal
spray or other routes). DI caused by failure to use
vasopressin (nephrogenic DI) is more difficult to treat, but
several drugs are available which help.
DI is much less common than diabetes mellitus, though a few
people have discussed it on misc.health.diabetes and are
reading m.h.d. Such participation is certainly welcome, but
because the number of DI patients is only 1 or 2 per 10,000
population (25,000-50,000 in the US), there probably isn't a
critical mass for discussion on Usenet.
I'm aware of two organizations which offer support
specifically related to DI.
DIARD publishes a support newsletter, maintains a support
network, distributes information on DI, and promotes
education and research related to DI, and has a web page
with information and links:
Diabetes Insipidus and Related Diseases Network 535 Echo
Court Saline, MI 48176-1270 USA +1 734 944 0078 email:
GSMAYES(AT)aol.com web:
http://members.aol.com/ruudh/dipage1.htm
The DI Foundation publishes a quarterly newsletter, Endless
Water, promotes public awareness and understanding of DI,
and provides informational material to patients, medical
practitioners and researchers:
The Diabetes Insipidus Foundation, Inc. 4533 Ridge Drive
Baltimore, MD 21229 USA +1 410 247 3953 email:
diabetesinsipidus(AT)maxInter.net web:
http://diabetesinsipidus.maxInter.net (http://diabetesinsipidus.maxinter.net/)
------------------------------
Subject: How about discussing hypoglycemia?
Sure ...
To clarify: the term "hypoglycemia" is used to refer to two
distinct conditions. The word just means "low blood
glucose". This can occur as an insulin reaction, the result
of too much injected insulin (taken to treat diabetes)
compared to food intake and exercise. But low blood glucose
can also be a chronic condition resulting from abnormalities
of insulin secretion, and this chronic condition is also
called hypoglycemia.
Chronic hypoglycemia may be caused by beta cells which
overreact to an increase in blood glucose (bg) by releasing
too much insulin, which then causes a too-rapid drop in bG.
Such a condition, called reactive hypoglycemia, is usually
handled by dietary adjustments, in particular avoiding
refined sugars and large meals which stimulate the
overreaction. This often requires an effort in calculating
the diet and monitoring bG levels that is equal to what
anyone with diabetes needs.
Tumors (insulinomas) can cause a steady overproduction of
insulin. These generally require surgical removal.
There are other causes as well. Mayer Davidson discusses
some in his book _Diabetes Mellitus: Diagnosis and
Treatment_. But you'll have to find the Second Edition,
because he dropped this chapter from the Third Edition. I
don't believe anyone claims to understand all the causes of
hypoglycemia. The US NIDDK has a booklet online which
discusses some of the less common causes:
http://www.niddk.nih.gov/health/diabetes/pubs/hypo/hypo.h-
tm
So chronic hypoglycemia is closely related to diabetes
mellitus in being a disorder of insulin production and use,
and requires many of the same techniques for its treatment.
The two are a natural for discussion in the same newsgroup.
Which is good, since there really isn't anywhere else in
Usenet at present to discuss chronic hypoglycemia. Welcome.
A hypoglycemia mailing list, HYPO-L, is available and sees
moderate traffic. See the section on mailing lists in part 4
of this FAQ for subscription information.
Lars Idema maintains a hypoglycemia FAQ and information on a
variety of hypoglycemia resources on the Internet. See his
web page at
http://hypoglykemie.nl (http://hypoglykemie.nl/)
------------------------------
Subject: Helping with the diagnosis (DM or hypoglycemia)
and waiting
Diagnosis of marginal type 2 diabetes, and even more so of
hypoglycemia, can be an iffy task. Single-point blood
glucose measurements often miss significant readings,
especially for hypoglycemia. While I don't recommend self-
diagnosis, you can take some steps on your own to aid your
health care team in your diagnosis and treatment. These are
safe and useful steps. The first is purely monitoring and
not treatment or diagnosis on your part. The others are good
advice for anyone who does not have some other medical
condition to contraindicate the action, and are particularly
good for those with type 2 diabetes.
12) Get a blood glucose meter and start checking your blood
glucose before meals and at bedtime. Keep records. Also
note what you ate, any exercise, any unusual stress. If
you suspect type 2 diabetes, also try to check an hour
after eating. If you suspect hypoglycemia, check any
time you have suspicious symptoms; you may also want to
set up a few runs where you check every 15-30 minutes
for up to five hours after eating.
Don't try to make any adjustments based on the readings
until you review them with your doctor -- just keep the
record and show it to the doctor. This will give the doctor
more information than any examination or lab test can give.
Furthermore, if you are waiting for an appointment, this
record will put you ahead of the game when you actually see
the doctor. (If during this monitoring you see a dramatic
rise in blood glucose, to preprandial levels of 250 mg/dl
[15 mmol/L] and above, call the doctors and say you need an
appointment *now*, not in a month, not next week, and quote
your bg levels.)
As an additional advantage, doing this monitoring on your
own will demonstrate to the doctor that you are willing to
put in this kind of effort. Often doctors are reluctant to
ask patients to put in serious time to monitor their health
because so many patients don't follow up.
Blood glucose meters and all the supplies are OTC items.
(True in the USA, and I haven't heard of any country with a
different policy.) However, depending on where you live and
what type of insurance or national medical coverage you
have, you may have to pay from your own pocket if you do not
have a prescription or proper pre-authorization. For a month
or so of monitoring, this is probably worth the cost.
13) Increase your exercise level, within levels that are
safe in light of any other medical conditions. In other
words, if you are not already in an exercise program,
consult your doctor. Exercise will also help with other
stresses you are under. This is primarily applicable if
you suspect type 2 diabetes, but may help with
hypoglycemia also.
14) Improve your diet if you are not already watching it
carefully. A standard diet with moderate calories and
fat is good at this stage, until you see the specialist.
If you suspect hypoglycemia, you may want to be
especially careful of eating large amounts at one time,
and avoid concentrated sugars.
------------------------------
Subject: Exercise and insulin
Charles Coughran <ccoughran(AT)ucsd.edu> contributed
this section.
The best way to deal with problems associated with diabetes
and exercise begins with understanding of what goes on in
the metabolic system of normal people and what the
differences are for diabetics. Only with such understanding
can you make intelligent choices about pharmacological
tactics. Relying on rules of thumb can cause more problems
it solves because of the wide variability of individual
responses and the wide variety of diseases that fall under
the rubric of diabetes. Not to mention, I have seen postings
where the rules of thumb were clearly misunderstood.
While the following is intended for those who take insulin,
it may assist those on oral medications as well. Exercise in
this context means extended aerobic activity, say a minimum
of 20 minutes of jogging. This is a somewhat simplified
account but I think it captures the most important aspects
for exercise related bg control. Comments encouraged.
When a normal person starts to exercise, the insulin output
of his pancreas goes down. At first blush, this seems
backward since the muscles are working hard and therefore
require more glucose to be transported from the blood into
the cells. There are two reasons more glucose can be
transported with less available insulin. The first is that
during exercise insulin becomes much more efficient. The
mechanism of this effect is not fully understood, but it
helps overcomes the reduction in circulating insulin.
Second, exercise activates non-insulin mediated glucose
transport pathways. These pathways are not sufficient to
handle the load in the absence of insulin, but do increase
the effective insulin efficiency.
When insulin levels decline relative to the
counterregulatory hormones -- glucagon, epinephrine,
norepinephrine, growth hormone, and cortisol -- the liver is
stimulated to release stored glucose. The blood glucose that
is being transported into the cells is replaced by that from
hepatic stores. It is this hormonal balance system that
keeps the levels of blood glucose in the normal narrow range
during exercise.
For those of us who inject insulin, the first problem is
obvious. Our circulating levels of insulin do not react to
exercise. Absent any correction, when the muscles demand
glucose and insulin becomes more efficient our blood glucose
plummets and we become hypoglycemic. This is the reason for
a commonly encountered prohibition to not schedule exercise
when your insulin is peaking. The higher the level of
circulating insulin, the more pronounced the effect.
One solution is to reduce our circulating insulin levels by
reducing insulin intake. Here specific advice starts to be
difficult due to the wide variety of insulins, regimens, and
individual variability. The spectrum spans from a Type II
who takes a little NPH to help his beta cells out to a c-
peptide free pumper. I have spoken to diabetic runners whose
tactics would put me in an ambulance, even though our
situations seem to be very similar. You see a lot of advice
of the form, "reduce your insulin 2 units for every hour of
strenuous exercise". This kind of advice ignores real world
variability and is sometimes much worse than useless.
Clearly, someone who takes one shot/day has a much more
limited ability to adjust circulating insulin levels than
someone using multiple injections or a pump.
The other approach is to increase blood glucose levels by
eating carbohydrates timed to arrive at the blood stream in
the form of glucose when it is needed. The easiest way to do
that is usually to eat fast acting carbohydrates during or
immediately preceding exercise. Again, there are rules of
thumb around about so many grams of carbohydrates for a
particular length of exercise at some defined level. Again,
they seem to be swamped by individual and circumstantial
variability.
Some of us do a combination of both and pump up our bg
levels somewhat before exercise and reduce insulin levels to
keep things on an even keel.
The bottom line is to make careful adjustments and test, and
test, and test, to find out how things work for your
particular body.
So much for too much insulin. What happens when the
circulating insulin level is too low? When levels are so low
that even the increase in insulin efficiency doesn't
overcome the defect, glucose isn't transported into the
cells. Worse, since insulin levels are low the liver
continues to pump glucose into the blood. The result is bg
levels rise with exercise. The muscles get stressed due to
lack of fuel and the metabolism of fats kicks in, ketones
start being produced and the danger of ketosis or
ketoacidosis looms. This is the basis for another rule of
thumb which is often misunderstood. The rule is usually
stated "don't exercise when your bg is above 240 mg/dl (13.3
mmol/l) and ketones are present in the urine". This makes
sense because those are signs that you have inadequate
insulin supplies -- that's how many of us got diagnosed.
Exercise in those circumstances will make things worse, not
better. On the other hand, if you are 300 mg/dl (16.7
mmol/l) because you just drank a large regular cola by
mistake with lunch, exercise is a great way to bring that bg
down in a hurry. Why your bg is elevated is just as
important as the fact of the elevated level when deciding
whether or not exercise is contraindicated. The 240 is also
a somewhat arbitrary number. Some people start throwing
ketones at significantly lower levels.
In short: avoid exercise if your insulin level is too low.
Do exercise if you are sure your insulin level is adequate
but your blood glucose is too high.
Exercise also produces effects at longer time scales.
Sometime after exercise, there is often a take up of blood
glucose by the muscles to replenish depleted stores. This
most often occurs an hour or two after exercise, but has
been reported in the range of 1/2 hour to 48 hours. Again,
as is the case during exercise, artificially high insulin
levels will lead to hypoglycemia. The last rule of thumb is
to watch for hypoglycemia after exercise.
*SPECULATION BEGINS HERE* A problem some of us encounter
from time to time is a post exercise bg spike. Blood
glucose readings will be reasonable after exercise but
sharply elevated a few hours later. It is my speculation
that this represents circulating insulin levels that were
adequate to deal with exercise induced blood glucose demand
with its attendant insulin efficiency increase, but too low
to deal with the post exercise demand when insulin
efficiency has lowered somewhat. It has been my experience
that post exercise elevated bg levels respond to much less
insulin than would be required in a more normal situation.
It appears that insulin efficiency falls off after exercise
at some rate and you can be on the correct side of the
curve during exercise and the wrong side after. This
hypothesis is the best of a couple I have come up with.
*SPECULATION ENDS HERE*
Regular exercise over time scales of weeks or months can
reduce overall insulin requirements. In addition, as muscles
become trained and improve their internal storage, it feeds
back into the amount of glucose demand present during
exercise, and thus into the entire control cycle.
Diabetes makes exercise, and almost everything else, harder.
But, hey, if it was easy it wouldn't be any fun :-)
There are two very good, readable books from which you can
get more information. The better is Campaigne and Lampman,
_Exercise in the Clinical Management of Diabetes_. Almost as
good is _The Health Professional's Guide to Diabetes and
Exercise_ edited by Ruderman and Devlin and published by the
American Diabetes Association.
------------------------------
Subject: Who did this?
--
Edward Reid <edward@paleo.org> Tallahassee FL
Posting-Frequency: biweekly
Last-modified: 21 May 2003 (excludes change list and Table of Contents)
Changes: change URL on A1c variability (4 Jan) update A1c by
mail info (28 Jan) update links to ADA Clinical Practice
Recommendations (30 Apr) change attribution for software FAQ
(now Rick Mendosa) (20 May) remove outdated insuline pump
discussion (21 May)
------------------------------
Subject: READ THIS FIRST
Copyright 1993-2003 by Edward Reid. Re-use beyond the fair
use provisions of copyright law and convention requires the
author's permission.
Advice given in m.h.d is *never* medical advice. That
includes this FAQ. Never substitute advice from the net for
a physician's care. Diabetes is a critical health topic and
you should always consult your physician or personally
understand the ramifications before taking any therapeutic
action based on advice found here or elsewhere on the net.
------------------------------
Subject: Table of Contents
INTRODUCTION (found in all parts) READ THIS FIRST Table of
Contents GENERAL (found in part 1) Where's the FAQ? What's
this newsgroup like? Abuse of the newsgroup The newsgroup
charter Newsgroup posting guidelines What is glucose? What
does "bG" mean? What are mmol/L? How do I convert between
mmol/L and mg/dl? What is c-peptide? What do c-peptide
levels mean? What's type 1 and type 2 diabetes? Is it OK to
discuss diabetes insipidus here? What is it? How about
discussing hypoglycemia? Helping with the diagnosis (DM or
hypoglycemia) and waiting Exercise and insulin BLOOD GLUCOSE
MONITORING (found in part 2) How accurate is my meter? Ouch!
The cost of blood glucose measurement strips hurts my
wallet! What do meters cost? Comparing blood glucose meters
How can I download data from my meter? I've heard of a non-
invasive bG meter -- the Dream Beam? What's HbA1c and what's
it mean? Why is interpreting HbA1c values tricky? Who
determined the HbA1c reaction rates and the consequences?
HbA1c by mail Why is my morning bg high? What are dawn
phenomenon, rebound, and Somogyi effect? TREATMENT (found in
part 3) My diabetic father isn't taking care of himself.
What can I do? Managing adolescence, including the adult
forms So-and-so eats sugar! Isn't that poison for diabetics?
Insulin nomenclature What is Humalog / LysPro / lispro /
ultrafast insulin? Travelling with insulin Injectors:
Syringe and lancet reuse and disposal Injectors: Pens
Injectors: Jets Insulin pumps Type 1 cures -- beta cell
implants Type 1 cures -- pancreas transplants Type 2 cures
-- barely a dream What's a glycemic index? How can I get a
GI table for foods? Should I take a chromium supplement? I
beat my wife! (and other aspects of hypoglycemia) (not yet
written) Does falling blood glucose feel like hypoglycemia?
Alcohol and diabetes Necrobiosis lipoidica diabeticorum Has
anybody heard of frozen shoulder (adhesive capsulitis)?
Gastroparesis Extreme insulin resistance What is pycnogenol?
Where and how is it sold? What claims do the sales pitches
make for pycnogenol? What's the real published scientific
knowledge about pycnogenol? How reliable is the literature
cited by the pycnogenol ads? What's the bottom line on
pycnogenol? Pycnogenol references SOURCES (found in part 4)
Online resources: diabetes-related newsgroups Online
resources: diabetes-related mailing lists Online resources:
commercial services Online resources: FTP Online resources:
World Wide Web Online resources: other Where can I mail
order XYZ? How can I contact the American Diabetes
Association (ADA) ? How can I contact the Juvenile Diabetes
Foundation (JDF) ? How can I contact the British Diabetic
Association (BDA) ? How can I contact the Canadian Diabetes
Association (CDA) ? What about diabetes organizations
outside North America? How can I contact the United Network
for Organ Sharing (UNOS)? Could you recommend some good
reading? Could you recommend some good magazines? RESEARCH
(found in part 5) What is the DCCT? What are the results?
More details about the DCCT DCCT philosophy: what did it
really show? IN CLOSING (found in all parts) Who did this?
------------------------------
Subject: Where's the FAQ?
This FAQ attempts to answer the questions which have been
most frequently asked in misc.health.diabetes (m.h.d). This
is not a complete informational posting. My only criterion
for inclusion is that the topic has frequently appeared in
m.h.d, either by an explicit question, or implicitly by
posting a related question or a common misconception.
This FAQ is posted biweekly to the Usenet newsgroup
misc.health.diabetes. If you obtained this article by some
method other than reading Usenet, refer to the section on
"Online resources: diabetes-related newsgroups" for brief
information on how to obtain access to Usenet newsgroups and
misc.health.diabetes in particular.
Feel free to make copies of this FAQ for your personal use
or for a friend or relative, including to share with health
care providers. If you want to make this FAQ available to
others on an ongoing basis (for example, on a BBS), please
do *not* post or copy the entire FAQ. Instead, post only
this section, entitled "Where's the FAQ?". This will enable
others always to retrieve the most recent version.
I have removed the outdated informational posting on
insulin pumps.
An informational posting on diabetes-related software is
posted to m.h.d at the same time as this FAQ. See below for
retrieval information. It was developed and is maintained by
Rick Mendosa <mendosa(AT)mendosa.com>.
I've used ideas and information from many people in writing
this FAQ. With a few exceptions I haven't attempted to
identify them, but I thank them all. The words herein are
mine unless otherwise credited.
If you read this and it helps you, please let me know what
part helped, and why. If you read this and can't find what
you want, let me know that too. Such comments will help me
decide what is worth working on, and whether. You'd be
surprised how little feedback I get. If you are reading this
on the newsgroup, just reply to this article. If you found
this on the web, send email to <edward@paleo.org>.
These documents -- the FAQ and the software overview -- are
available from the news.answers archives at rtfm.mit.edu.
Using anonymous ftp, get the files:
/pub/faqs/diabetes/faq/part1 /pub/faqs/diabetes/faq/part2
/pub/faqs/diabetes/faq/part3 /pub/faqs/diabetes/faq/part4
/pub/faqs/diabetes/faq/part5 /pub/faqs/diabetes/software
or in web browser format:
ftp://rtfm.mit.edu/pub/faqs/diabetes/
If your net access is by email only, send an email message
to mail-server(AT)rtfm.mit.edu, subject ignored, body
containing:
send faqs/diabetes/faq/part1 send faqs/diabetes/faq/part2
send faqs/diabetes/faq/part3 send faqs/diabetes/faq/part4
send faqs/diabetes/faq/part5 send faqs/diabetes/software
If you are using the World Wide Web, you can reach a WWW-
formatted version of the FAQ and other documents via the URL
http://www.faqs.org/faqs/diabetes/
You can also retrieve the plain text by FTP from the
rtfm.mit.edu site mentioned above, which has long been the
most reliable source. However, it only offers the simplest
retrieval capability.
------------------------------
Subject: What's this newsgroup like?
Posting topics range through emotional support, treatment
techniques, psychological factors, health care practices,
and insurance. We talk about our problems, frustrations,
depressions and complications to find out how others handle
the same issues and for mutual support. The atmosphere is
generally a highly supportive one, and most participants
believe strongly that this is an important aspect. As in
other parts of the net, there are one or two regular
participants who believe that it is important to question
the motives and/or knowledge of anyone posting a new
problem. If you find that the first response is
antagonistic, please wait a few hours. Every antagonistic
response will elicit a dozen sympathetic responses.
Meta-topics include discussions of how to best convey health
information on the Usenet, ethical treatment of other
participants, what topics and information are appropriate
for m.h.d, where to find diabetes information, and what the
newsgroup should be like.
Betsy Butler says eloquently:
The positive posts of people who are in great control are
very motivating, but it is also helpful to hear from
people who don't find it so easy. I'm sure there are a
lot of people who struggle to keep control. The people
who are having trouble also need to know that there are
others who struggle, and that they are not alone. It can
be very intimidating, and a blow to self-esteem for
people to suggest that if you would just do X, Y and Z,
you will be in control. There are 100s of factors to
balance, and I think people need to be reassured that
"yes, it's hard to balance so many things, many of which
can't be measured or that don't act predictably."
Topics closely related to diabetes mellitus which do not
have their own place in Usenet are welcome. Examples are
diabetes insipidus, hypoglycemia, glucose intolerance, legal
and employment ramifications of chronic illness, effects on
family members, how family members can best provide support,
and so on. misc.health.diabetes tends to be inclusive of
anyone who needs it.
The same caveat applies here as in all newsgroups: the
advice is worth what you paid for it. This applies in spades
to a critical health topic such as diabetes. Never
substitute informal advice for a physician's care. Advice
given in m.h.d is *never* medical advice.
The variety of individual responses to diabetes is exceeded
only by the variety of individual responses to life. No two
patients respond alike, and many respond *very* differently
from others. These differences are physiological, not just
psychological. They reflect not only varying responses, but
the fact that diabetes itself probably has many causes, many
more than the few types currently recognized (see section on
types). When you read advice, realize that what works (or
doesn't work) for someone else may not work (or may work)
for you. When you give advice, try to remember that most
advice is relative to the individual, not absolute.
Recognize that you can't treat your own diabetes by a set of
rules, but only by knowing how your own individual body and
physiology work and by adjusting to your own mechanisms.
------------------------------
Subject: Abuse of the newsgroup
As mentioned above, a few participants believe that name-
calling and abusive language are more effective than
polite discussion, support and interchange of information.
They are wrong, and the vast majority of participants
support a more civilized and polite view of humanity.
Since misc.health.diabetes is unmoderated, we all have to
live together.
A few m.h.d. participants have received abusive email. Some
are afraid to expose such abuse, having been told that email
must always be private. However, abusive email is no more
deserving of privacy than obscene phone calls or threatening
letters. There is no authority to which you can report
abusive email (unless it contains an actual threat, in which
can you may be justified in contacting a law enforcement
agency). Steve Kirchoefer <swkirch(AT)chrisco.nrl.navy.mil>
is willing to try to mediate problems with email. Though
Steve has no official authority, he has experience in
dealing with problems on the net and may be able to help
clear up such problems. Send him complete copies of any
abusive email.
------------------------------
Subject: The newsgroup charter
The actual charter which led to the creation of the
newsgroup in May 1993 follows. This charter was proposed by
Steve Kirchoefer <swkirch(AT)chrisco.nrl.navy.mil> and
approved by a public vote of the Usenet readership, and is
the official statement of the scope and purpose of this
newsgroup.
1. The purpose of misc.health.diabetes is to provide a
forum for the discussion of issues pertaining to
diabetes management, i.e.: diet, activities, medicine
schedules, blood glucose control, exercise, medical
breakthroughs, etc. This group addresses the issues of
management of both Type I (insulin dependent) and Type
II (non-insulin dependent) diabetes. Both technical
discussions and general support discussions relevant to
diabetes are welcome.
2. Postings to misc.health.diabetes are intended to be for
discussion purposes only, and are in no way to be
construed as medical advice. Diabetes is a serious
medical condition requiring direct supervision by a
primary health care physician.
------------------------------
Subject: Newsgroup posting guidelines
The following posting guidelines were adopted by a vote of
m.h.d participants in September 1994.
Posting guidelines for misc.health.diabetes:
Postings to misc.health.diabetes should be compliant with
the standards for all material posted to Usenet. The
following articles may be found in news.announce.newusers,
and should be reviewed by all posters:
-Emily Postnews Answers Your Questions on Netiquette -
Answers to Frequently Asked Questions about Usenet -A Primer
on How to Work With the Usenet Community -Rules for posting
to Usenet -What is Usenet?
Posting to misc.health.diabetes should be compliant with the
group charter, [which is in the previous section].
In addition to the above, the following guidelines are
emphasized as particularly relevant for contributions to
misc.health.diabetes:
-No personal attacks or insults. Avoid argumentative
debates. Responses should concentrate on the issues
presented.
-No private discussions. Take private discussions to email.
When in doubt, use email.
-Edit responses to avoid unnecessary inclusions of
earlier postings.
-Edit subject lines as necessary to remain consistent with
the topic.
-Support factual statements with your sources. If you can
not recall the source, then say so. Do not imply authority
which you can not actually support.
Additional information can be found in the general FAQ
posted periodically to this group.
------------------------------
Subject: What is glucose? What does "bG" mean?
Glucose is a specific form of sugar, one of the simplest.
It is the form found in the bloodstream. "Blood sugar"
always refers to blood glucose, and is abbreviated bG.
All bG meters are specific for glucose and will not
respond to other sugars, such as fructose, sucrose,
maltose and lactose.
Although sucrose (table sugar) is the most common sugar in
food, glucose is also common. Most fruits, fruit juices, and
soft drinks contain large amounts of glucose, and many foods
contain small amounts. This means that you must be very
careful to clean any food residue from your fingers before
drawing blood for a bG check. Since the normal level of bG
is only 1g/L (=100mg/dl), it only takes a tiny speck of
glucose on your finger to contaminate the sample and give
you a falsely high reading. 10 *micrograms* of glucose could
raise the reading enough to cause you to overreact
dangerously.
------------------------------
Subject: What are mg/dl and mmol/l? How to convert? Glucose?
Cholesterol?
There are two main methods of describing concentrations: by
weight, and by molecular count. Weights are in grams,
molecular counts in moles. (If you really want to know, a
mole is 6.23*10^23 molecules.) In both cases, the unit is
usually modified by milli- or micro- or other prefix, and is
always "per" some volume, often a liter.
This means that the conversion factor depends on the
molecular weight of the substance in question.
mmol/l is millimoles/liter, and is the world standard unit
for measuring glucose in blood. Specifically, it is the
designated SI (Systeme International) unit. "World
standard", of course, means that mmol/L is used everywhere
in the world except in the US. A mole is about 6*10^23
molecules; if you want more detail, take a chemistry course.
mg/dl (milligrams/deciliter) is the traditional unit for
measuring bG (blood glucose). All scientific journals are
moving quickly toward using mmol/L exclusively. mg/dl
won't disappear soon, and some journals now use mmol/L as
the primary unit but quote mg/dl in parentheses,
reflecting the large base of health care providers and
researchers (not to mention patients) who are already
familiar with mg/dl.
Since m.h.d is an international newsgroup, it's polite to
quote both figures when you can. Most discussions take place
using mg/dl, and no one really expects you to pull out your
calculator to compose your article. However, if you don't
quote both units, it's inevitable that many readers will
have to pull out their calculators to read it.
Many meters now have a switch that allows you to change
between units. Sometimes it's a physical switch, and
sometimes it's an option that you can set.
To convert mmol/l of glucose to mg/dl, multiply by 18.
To convert mg/dl of glucose to mmol/l, divide by 18 or
multiply by 0.055.
These factors are specific for glucose, because they
depend on the mass of one molecule (the molecular weight).
The conversion factors are different for other substances
(see below).
And remember that reflectance meters have a some error
margin due to both intrinsic limitations and environmental
factors, and that plasma readings are 15% higher than
whole blood (as of 2002 most meters are calibrated to give
plasma readings, thus matching lab readings, but this is a
recent development), and that capillary blood is different
from venous blood when it's changing, as after a meal. So
round off to make values easier to comprehend and don't
sweat the hundredths place. For example, 4.3 mmol/l
converts to 77.4 mg/dl but should probably be quoted as 75
or 80. Similarly, 150 mg/dl converts to 8.3333... mmol/l
but 8.3 is a reasonable quote, and even just 8 would
usually convey the meaning.
Actually, a table might be more useful than the raw
conversion factor, since we usually talk in
approximations anyway.
mmol/l mg/dl interpretation ------ ----- --------------
2. 35 extremely low, danger of unconciousness
3. 55 low, marginal insulin reaction
4. 75 slightly low, first symptoms of
lethargy etc.
5.5 100 mecca 5 - 6 90-110 normal preprandial in
nondiabetics
6. 150 normal postprandial in nondiabetics
7. 180 maximum postprandial in nondiabetics
8. 200
9. 270 a little high to very high depending
on patient
10.5 300
11. 360 getting up there 22 400 max mg/dl for some
meters and strips 33 600 high danger of severe
electrolyte imbalance
Preprandial = before meal Postprandial = after meal
More conversions:
To convert mmol/l of HDL or LDL cholesterol to mg/dl,
multiply by 39. To convert mg/dl of HDL or LDL cholesterol
to mmol/l, divide by 39.
To convert mmol/l of triglycerides to mg/dl, multiply by 89.
To convert mg/dl of triglycerides to mmol/l, divide by 89.
To convert umol (micromoles) /l of creatinine to mg/dl,
divide by 88. To convert mg/dl of creatinine to umol/l,
multiply by 88.
------------------------------
Subject: What is c-peptide? What do c-peptide levels mean?
Thanks to Andrew Torres <andym(AT)ku.edu> for this section.
C-peptide blood levels can indicate whether or not a person
is producing insulin and roughly how much.
Insulin is initially synthesized in the form of proinsulin.
In this form the alpha and beta chains of active insulin are
linked by a third polypeptide chain called the connecting
peptide, or c-peptide, for short. Because both insulin and
c-peptide molecules are secreted, for every molecule of
insulin in the blood, there is one of c-peptide. Therefore,
levels of c-peptide in the blood can be measured and used as
an indicator of insulin production in those cases where
exogenous insulin (from injection) is present and mixed with
endogenous insulin (that produced by the body) a situation
that would make meaningless a measurement of insulin itself.
The c-peptide test can also be used to help assess if high
blood glucose is due to reduced insulin production or to
reduced glucose intake by the cells.
There is little or no c-peptide in blood of type 1
diabetics, and c-peptide levels in type 2 diabetics can be
reduced or normal. The concentrations of c-peptide in non-
diabetics are on the order of 0.5-3.0 ng/ml.
------------------------------
Subject: What's type 1 and type 2 diabetes, and
gestational diabetes?
The term diabetes mellitus comes from Greek words for
"flow" and "honey", referring to the excess urinary flow
that occurs when diabetes is untreated, and to the sugar in
that urine.
Diabetes mellitus (DM) comes in the following
classifications (which some will argue don't really
represent the actual types very well):
type 1 -- characterized by total destruction of the insulin-
producing beta cells, probably by an autoimmune reaction.
Onset is most common in childhood, thus the common (but
now deprecated) term "juvenile-onset", but the onset up
to age 40 is not uncommon and can even occur later.
Patients are susceptible to DKA (diabetic ketoacidosis).
There seems to be some genetic tendency, but the genetic
situation is unclear. Most patients are lean. Always
as IDDM (insulin dependent diabetes mellitus).
type 2 -- characterized by insulin resistance despite
adequate insulin production. A large majority of patients
are overweight at onset, and a majority are female. Most
are over 40, hence the common (but now deprecated) terms
"adult-onset" or "maturity-onset", but onset can occur at
any age. Patients are not susceptible to DKA (diabetic
ketoacidosis). There is a strong genetic tendency, but
not simple inheritance. Depending on the individual,
treatment may be by diet, exercise, weight loss, oral
drugs which stimulate the release of insulin, or insulin
injections -- and usually a combination of several of
these. Also referred to as NIDDM (non insulin dependent
diabetes mellitus) *even when treated with insulin* -- a
confusing terminology which, unfortunately, is supported
by the ADA.
gestational -- occurs in about 3% of all pregnancies as a
result of insulin antagonists secreted by the placenta.
It is recommended that all pregnant women receive a
screening glucose tolerance test (GTT) between the 24th
and 28th weeks of pregnancy to detect gestational
diabetes early if it occurs, as diabetes can cause
serious difficulties in pregnancy. Sometimes requires
insulin treatment. Not susceptible to DKA (diabetic
ketoacidosis). Usually disappears after childbirth, but
about 40% of patients develop type 2 diabetes within five
years. Most authorities state that the typical patient is
female ...
malnutrition-related -- severe malnutrition sometimes
causes diabetes -- hyperglycemia and all the usual
symptoms. The reason is unknown, and since this syndrome
occurs almost entirely in third world countries, research
on this form of diabetes is nearly nonexistent.
other types -- sometimes called secondary. A catchall for
forms not covered by the types described above. Causes
include loss of the entire pancreas (to trauma, cancer,
alcohol abuse, or exposure to chemicals), diseases that
destroy the beta cells, certain hormonal syndromes, drugs
that interfere with insulin secretion or action, and some
rare genetic conditions.
These terms are not used entirely consistently. Some doctors
will refer to any diabetic using insulin as type 1, and will
refer to the early onset of type 1 diabetes as type 2 until
insulin therapy is required. This usage does not fit with
most modern usage as described above (type 1 is beta cell
destruction, type 2 is insulin resistance). The situation is
complicated by the fact that early in the course of the
disease it can be difficult to determine which type is
occuring, especially for patients in their 30's, the age
when the onset of both types is common.
Different patients respond very differently to what is
categorized above as the same disease. The root causes of
all forms of diabetes are not understood, and are likely
more complex and varied than the simple categories show.
Type 1 diabetes likely has a few root causes, and type 2
diabetes probably has a larger number of root causes.
There are also well documented reports of cases of diabetes
with unexplained combinations of syndromes from types 1 and
2. These are sometimes referred to as "type 1-1/2", and the
reasons are not understood.
The classification above is not completely standard, and
other classifications exist.
About 90% of diabetes patients are type 2 (some 12 million
in the US), and about 10% are type 1 (some 1 million in the
US). Discussion on m.h.d tends to run about 2/3 type 1, I'd
guess. This probably reflects the fact that type 1 diabetes
is harder to ignore, and that type 2 seldom strikes the
younger people who are more likely to have net access. Type
2 is *not* less serious.
"1" and "2" are often written in Roman numerals: type I,
type II. Because typography is often unclear on computer
terminals, I've stuck with the Arabic numeral version.
Diabetes accounts for about 5% of all health care costs in
the US, some US$90 billion per year.
------------------------------
Subject: Is it OK to discuss diabetes insipidus here?
What is it?
Diabetes insipidus (DI) results from abnormalities in the
production or use (two main types) of the hormone arginine
vasopressin. The main symptoms are excessive thirst and
massive urination. The excess urine flow is devoid of sugar.
There are no blood glucose abnormalities, and in fact there
is nothing in common with diabetes mellitus except the
excess urination when untreated.
Diabetes insipidus caused by failure to produce vasopressin.
This is known as neurogenic DI (or central DI, or pituitary
DI). It can be treated with hormone replacement (by nasal
spray or other routes). DI caused by failure to use
vasopressin (nephrogenic DI) is more difficult to treat, but
several drugs are available which help.
DI is much less common than diabetes mellitus, though a few
people have discussed it on misc.health.diabetes and are
reading m.h.d. Such participation is certainly welcome, but
because the number of DI patients is only 1 or 2 per 10,000
population (25,000-50,000 in the US), there probably isn't a
critical mass for discussion on Usenet.
I'm aware of two organizations which offer support
specifically related to DI.
DIARD publishes a support newsletter, maintains a support
network, distributes information on DI, and promotes
education and research related to DI, and has a web page
with information and links:
Diabetes Insipidus and Related Diseases Network 535 Echo
Court Saline, MI 48176-1270 USA +1 734 944 0078 email:
GSMAYES(AT)aol.com web:
http://members.aol.com/ruudh/dipage1.htm
The DI Foundation publishes a quarterly newsletter, Endless
Water, promotes public awareness and understanding of DI,
and provides informational material to patients, medical
practitioners and researchers:
The Diabetes Insipidus Foundation, Inc. 4533 Ridge Drive
Baltimore, MD 21229 USA +1 410 247 3953 email:
diabetesinsipidus(AT)maxInter.net web:
http://diabetesinsipidus.maxInter.net (http://diabetesinsipidus.maxinter.net/)
------------------------------
Subject: How about discussing hypoglycemia?
Sure ...
To clarify: the term "hypoglycemia" is used to refer to two
distinct conditions. The word just means "low blood
glucose". This can occur as an insulin reaction, the result
of too much injected insulin (taken to treat diabetes)
compared to food intake and exercise. But low blood glucose
can also be a chronic condition resulting from abnormalities
of insulin secretion, and this chronic condition is also
called hypoglycemia.
Chronic hypoglycemia may be caused by beta cells which
overreact to an increase in blood glucose (bg) by releasing
too much insulin, which then causes a too-rapid drop in bG.
Such a condition, called reactive hypoglycemia, is usually
handled by dietary adjustments, in particular avoiding
refined sugars and large meals which stimulate the
overreaction. This often requires an effort in calculating
the diet and monitoring bG levels that is equal to what
anyone with diabetes needs.
Tumors (insulinomas) can cause a steady overproduction of
insulin. These generally require surgical removal.
There are other causes as well. Mayer Davidson discusses
some in his book _Diabetes Mellitus: Diagnosis and
Treatment_. But you'll have to find the Second Edition,
because he dropped this chapter from the Third Edition. I
don't believe anyone claims to understand all the causes of
hypoglycemia. The US NIDDK has a booklet online which
discusses some of the less common causes:
http://www.niddk.nih.gov/health/diabetes/pubs/hypo/hypo.h-
tm
So chronic hypoglycemia is closely related to diabetes
mellitus in being a disorder of insulin production and use,
and requires many of the same techniques for its treatment.
The two are a natural for discussion in the same newsgroup.
Which is good, since there really isn't anywhere else in
Usenet at present to discuss chronic hypoglycemia. Welcome.
A hypoglycemia mailing list, HYPO-L, is available and sees
moderate traffic. See the section on mailing lists in part 4
of this FAQ for subscription information.
Lars Idema maintains a hypoglycemia FAQ and information on a
variety of hypoglycemia resources on the Internet. See his
web page at
http://hypoglykemie.nl (http://hypoglykemie.nl/)
------------------------------
Subject: Helping with the diagnosis (DM or hypoglycemia)
and waiting
Diagnosis of marginal type 2 diabetes, and even more so of
hypoglycemia, can be an iffy task. Single-point blood
glucose measurements often miss significant readings,
especially for hypoglycemia. While I don't recommend self-
diagnosis, you can take some steps on your own to aid your
health care team in your diagnosis and treatment. These are
safe and useful steps. The first is purely monitoring and
not treatment or diagnosis on your part. The others are good
advice for anyone who does not have some other medical
condition to contraindicate the action, and are particularly
good for those with type 2 diabetes.
12) Get a blood glucose meter and start checking your blood
glucose before meals and at bedtime. Keep records. Also
note what you ate, any exercise, any unusual stress. If
you suspect type 2 diabetes, also try to check an hour
after eating. If you suspect hypoglycemia, check any
time you have suspicious symptoms; you may also want to
set up a few runs where you check every 15-30 minutes
for up to five hours after eating.
Don't try to make any adjustments based on the readings
until you review them with your doctor -- just keep the
record and show it to the doctor. This will give the doctor
more information than any examination or lab test can give.
Furthermore, if you are waiting for an appointment, this
record will put you ahead of the game when you actually see
the doctor. (If during this monitoring you see a dramatic
rise in blood glucose, to preprandial levels of 250 mg/dl
[15 mmol/L] and above, call the doctors and say you need an
appointment *now*, not in a month, not next week, and quote
your bg levels.)
As an additional advantage, doing this monitoring on your
own will demonstrate to the doctor that you are willing to
put in this kind of effort. Often doctors are reluctant to
ask patients to put in serious time to monitor their health
because so many patients don't follow up.
Blood glucose meters and all the supplies are OTC items.
(True in the USA, and I haven't heard of any country with a
different policy.) However, depending on where you live and
what type of insurance or national medical coverage you
have, you may have to pay from your own pocket if you do not
have a prescription or proper pre-authorization. For a month
or so of monitoring, this is probably worth the cost.
13) Increase your exercise level, within levels that are
safe in light of any other medical conditions. In other
words, if you are not already in an exercise program,
consult your doctor. Exercise will also help with other
stresses you are under. This is primarily applicable if
you suspect type 2 diabetes, but may help with
hypoglycemia also.
14) Improve your diet if you are not already watching it
carefully. A standard diet with moderate calories and
fat is good at this stage, until you see the specialist.
If you suspect hypoglycemia, you may want to be
especially careful of eating large amounts at one time,
and avoid concentrated sugars.
------------------------------
Subject: Exercise and insulin
Charles Coughran <ccoughran(AT)ucsd.edu> contributed
this section.
The best way to deal with problems associated with diabetes
and exercise begins with understanding of what goes on in
the metabolic system of normal people and what the
differences are for diabetics. Only with such understanding
can you make intelligent choices about pharmacological
tactics. Relying on rules of thumb can cause more problems
it solves because of the wide variability of individual
responses and the wide variety of diseases that fall under
the rubric of diabetes. Not to mention, I have seen postings
where the rules of thumb were clearly misunderstood.
While the following is intended for those who take insulin,
it may assist those on oral medications as well. Exercise in
this context means extended aerobic activity, say a minimum
of 20 minutes of jogging. This is a somewhat simplified
account but I think it captures the most important aspects
for exercise related bg control. Comments encouraged.
When a normal person starts to exercise, the insulin output
of his pancreas goes down. At first blush, this seems
backward since the muscles are working hard and therefore
require more glucose to be transported from the blood into
the cells. There are two reasons more glucose can be
transported with less available insulin. The first is that
during exercise insulin becomes much more efficient. The
mechanism of this effect is not fully understood, but it
helps overcomes the reduction in circulating insulin.
Second, exercise activates non-insulin mediated glucose
transport pathways. These pathways are not sufficient to
handle the load in the absence of insulin, but do increase
the effective insulin efficiency.
When insulin levels decline relative to the
counterregulatory hormones -- glucagon, epinephrine,
norepinephrine, growth hormone, and cortisol -- the liver is
stimulated to release stored glucose. The blood glucose that
is being transported into the cells is replaced by that from
hepatic stores. It is this hormonal balance system that
keeps the levels of blood glucose in the normal narrow range
during exercise.
For those of us who inject insulin, the first problem is
obvious. Our circulating levels of insulin do not react to
exercise. Absent any correction, when the muscles demand
glucose and insulin becomes more efficient our blood glucose
plummets and we become hypoglycemic. This is the reason for
a commonly encountered prohibition to not schedule exercise
when your insulin is peaking. The higher the level of
circulating insulin, the more pronounced the effect.
One solution is to reduce our circulating insulin levels by
reducing insulin intake. Here specific advice starts to be
difficult due to the wide variety of insulins, regimens, and
individual variability. The spectrum spans from a Type II
who takes a little NPH to help his beta cells out to a c-
peptide free pumper. I have spoken to diabetic runners whose
tactics would put me in an ambulance, even though our
situations seem to be very similar. You see a lot of advice
of the form, "reduce your insulin 2 units for every hour of
strenuous exercise". This kind of advice ignores real world
variability and is sometimes much worse than useless.
Clearly, someone who takes one shot/day has a much more
limited ability to adjust circulating insulin levels than
someone using multiple injections or a pump.
The other approach is to increase blood glucose levels by
eating carbohydrates timed to arrive at the blood stream in
the form of glucose when it is needed. The easiest way to do
that is usually to eat fast acting carbohydrates during or
immediately preceding exercise. Again, there are rules of
thumb around about so many grams of carbohydrates for a
particular length of exercise at some defined level. Again,
they seem to be swamped by individual and circumstantial
variability.
Some of us do a combination of both and pump up our bg
levels somewhat before exercise and reduce insulin levels to
keep things on an even keel.
The bottom line is to make careful adjustments and test, and
test, and test, to find out how things work for your
particular body.
So much for too much insulin. What happens when the
circulating insulin level is too low? When levels are so low
that even the increase in insulin efficiency doesn't
overcome the defect, glucose isn't transported into the
cells. Worse, since insulin levels are low the liver
continues to pump glucose into the blood. The result is bg
levels rise with exercise. The muscles get stressed due to
lack of fuel and the metabolism of fats kicks in, ketones
start being produced and the danger of ketosis or
ketoacidosis looms. This is the basis for another rule of
thumb which is often misunderstood. The rule is usually
stated "don't exercise when your bg is above 240 mg/dl (13.3
mmol/l) and ketones are present in the urine". This makes
sense because those are signs that you have inadequate
insulin supplies -- that's how many of us got diagnosed.
Exercise in those circumstances will make things worse, not
better. On the other hand, if you are 300 mg/dl (16.7
mmol/l) because you just drank a large regular cola by
mistake with lunch, exercise is a great way to bring that bg
down in a hurry. Why your bg is elevated is just as
important as the fact of the elevated level when deciding
whether or not exercise is contraindicated. The 240 is also
a somewhat arbitrary number. Some people start throwing
ketones at significantly lower levels.
In short: avoid exercise if your insulin level is too low.
Do exercise if you are sure your insulin level is adequate
but your blood glucose is too high.
Exercise also produces effects at longer time scales.
Sometime after exercise, there is often a take up of blood
glucose by the muscles to replenish depleted stores. This
most often occurs an hour or two after exercise, but has
been reported in the range of 1/2 hour to 48 hours. Again,
as is the case during exercise, artificially high insulin
levels will lead to hypoglycemia. The last rule of thumb is
to watch for hypoglycemia after exercise.
*SPECULATION BEGINS HERE* A problem some of us encounter
from time to time is a post exercise bg spike. Blood
glucose readings will be reasonable after exercise but
sharply elevated a few hours later. It is my speculation
that this represents circulating insulin levels that were
adequate to deal with exercise induced blood glucose demand
with its attendant insulin efficiency increase, but too low
to deal with the post exercise demand when insulin
efficiency has lowered somewhat. It has been my experience
that post exercise elevated bg levels respond to much less
insulin than would be required in a more normal situation.
It appears that insulin efficiency falls off after exercise
at some rate and you can be on the correct side of the
curve during exercise and the wrong side after. This
hypothesis is the best of a couple I have come up with.
*SPECULATION ENDS HERE*
Regular exercise over time scales of weeks or months can
reduce overall insulin requirements. In addition, as muscles
become trained and improve their internal storage, it feeds
back into the amount of glucose demand present during
exercise, and thus into the entire control cycle.
Diabetes makes exercise, and almost everything else, harder.
But, hey, if it was easy it wouldn't be any fun :-)
There are two very good, readable books from which you can
get more information. The better is Campaigne and Lampman,
_Exercise in the Clinical Management of Diabetes_. Almost as
good is _The Health Professional's Guide to Diabetes and
Exercise_ edited by Ruderman and Devlin and published by the
American Diabetes Association.
------------------------------
Subject: Who did this?
--
Edward Reid <edward@paleo.org> Tallahassee FL
