What’s good about having diabetes

Getting Type 1 diabetes is seen by many people as a complete disaster. Effective treatment has been around for less than a hundred years and before that life expectancy after diagnosis was very short, with most patients dying before they had reproduced.

Although there are environmental triggers, the existence of diabetes is largely determined by a number of genes. How is it that these genes persist in a population over generations if many of the carriers of those genes do not reproduce?

We can infer an answer to this question by looking at single gene diseases in which the situation is clearer. For example thalassaemia, sickle cell disease, G6PD and other red cell disorders gave heterozygotes some resistance to the effects of malaria, the cystic fibrosis gene protected against cholera and the gene for haemochromatosis was useful in dealing with anaemia due to hookworm and other causes.

So these serious diseases persist because their effects were not all bad.

(Aside: I am aware of research showing how a gene with effects that are all deleterious at a young age can persist in a population, but I think this mechanism does not apply to diabetes. Genetic diseases that kill the elderly do not impede the survival of the gene. In fact they may enhance it)

Why do Type 1 diabetic genes persist in the population. The answer has to be that some of these genes confer a survival advantage. What advantage? I don’t know but there must be one. It may be that diabetic genes improve performance to a small degree in a broad range of activities and a specific advantage will never be determined. ( the evidence in favour of this will be in a later post) 

I used to think about what life would be like if I didn’t have diabetes. I wouldn’t have the hassle, but on the other hand I wouldn’t have the advantages. Maybe my skiing abilities would be much worse.

So don’t hate your diabetes. Learn to deal with the downsides, so that the good effects can shine through.

Peripheral Neuropathy

Peripheral Neuropathy

Tests of peripheral nerve function used by some doctors can fail to detect what to patients are significant degrees of dysfunction.
I know this personally from being a patient with a massive lumbar disc herniation, pronounced to have normally functioning nerves by some doctors. Surgery removal of the offending bit of disc was spectacularly successful.
If you can do the following then you can be assured that your peripheral nervous system is functioning pretty well.

If you can't do this maybe you should think about whether you have a nerve problem and need to alter your management. Perhaps you should be more sceptical of advice you have previously received. It is well documented that many asymptomatic T1s, who are normal according to doctors physical examination, actually have low peripheral nerve conduction velocities and amplitudes. A doctor's opinion without nerve conduction studies is really not that reassuring.
Also note that riding a unicycle with a training wheel (aka bicycle) requires much much less nerve function.

Race nutrition

A few weeks ago I competed in the Kangaroo, Australia's premier long distance cross country ski race, and one of the world loppet series.
There were around a thousand entrants in the race over all classes.
I managed to be the 12th Australian home among those over 55, my best placing yet in my age cohort.
What did I have for breakfast before the race? A bowl of cornflakes and 2 cups of coffee. That is all. At the race itself I had a pre-race gel and some of the energy drink supplied by the race organisers. I would have been slower if I had started the race with a stomach full of rolled oats.

For those diabetics interested in maintaining their physical abilities as they age, I recommend Diabetics Athlete's Handbook by Sheri Colberg, although it has no specific information for those like me who also have Addison's disease. It has several sections on various matters relevant to older active diabetics, but doesn't go into the minutiae of what treatment strategies are associated with long term success in maintaining physical capabilities. Disappointingly, dosage recommendations are all in the form of a relative change in dose. There is no data on what absolute value of dosages are associated with long term success. Nonetheless I consider it essential reading.

Common sense says that if you want to be a healthy and active Type 1 diabetic when you are retired, you need to look at such people and follow a management plan which matches their's in diet, insulin dosage, and physical activity parameters. No randomised trial is going to measure such a long term outcome any time soon. Unfortunately, few medical researchers show any sign of appreciating the benefits of a case control approach.

Unexplained deaths in young diabetics and other poor treatment outcomes

Here is the text of a letter to the editor I had published recently in the online section of several newspapers:

Diabetes deaths

Yet another death of a young diabetic reported in The Canberra Times ("Woman may have lived if response had been quicker", August15, p3). A Canberra hospital staff member has told me there are many poor outcomes among a group of their patients with type 1 or juvenile onset diabetes. When is the Health Minister going to respond to the systemic issues relating to diabetes care, which have been notified to him?
Dr Nick Melhuish, Hughes

Read more: http://www.theage.com.au/it-pro/experiences-of-bullying-are-not-invalidated-by-turcs-issues-20150818-gj24wg.html#ixzz3mhXcLOXs

 I am also aware of a third young Canberra diabetic who also died in similar circumstances, soon after moving away.

The ACT Health Minister still refuses to comment of the issue of poor Type 1 diabetic outcomes. And while the complication rates of surgeons are subject to intense scrutiny, and made public if they are a few standard deviations from the norm, the outcomes of treatment provided by physicians are swept under the carpet. Despite the number of poor outcomes reported to me, I believe there has never even been any audit in Australia of outcomes in people with diabetes and Addison's disease.

I have read much of the original literature on the subject of "unexplained" deaths in young diabetics, and it certainly does not support the view that these deaths are unrelated to treatment methods or lifestyle variables.

My glucometer reading was 2.3 mmol/L (41mg/dl) so I decided to play chess

My glucometer reading, correctly done, was 2.3 mmol/l so I decided to play chess. I do not recommend that you try this yourself.

A Government health website states the following
"When BGL's fall below 2.8mmol/L, brain function slows down, causing reduced concentration and response time, confusion, poor coordination, blurred vision, and can lead to unconsciousness."

That certainly used to be something like what happened to me. (apart from the blurred vision and unconsciousness parts)
However, since I started ignoring medical advice and doing my own thing I am much better off.

Last weekend, my heart was a bit faster and pounding a bit stronger than normal. Usually I would just eat straight away, but I decided to check my blood and got a reading of 2.3 (or 41mg/dl).
Instead of eating, I decided to play a game of lightning chess against Fritz with a handicap setting of 1.
Rules: touch piece, if the game takes longer than 5 minutes, or I fail to notice a check, I lose. No taking back moves.
Here is the game

Total game time was 2 minutes and 37 seconds. A pretty scrappy game, but I am no grandmaster and that is about as well as I play when my blood sugar is normal and I am making each move in a bit over 2.5 seconds average.
I checked my glucometer reading again after the game with my usual impeccable technique, and it read 2.3 again, so I ate some food, but much less than that same Govt website says one should.

Conclusion: No evidence of cerebral impairment at a glucometer reading of 2.3. How low does my blood sugar have to fall before my ability to play lightning chess is noticeably impaired? Stay tuned.

If you have diabetes, you really should learn the science behind avoiding brain fatigue when your sugar is low.

Addison's disease

I was never much of a runner at school. I never represented the school in cross country and there was only one year where I just scraped in to the track team for one event.
Yet after 18 years of T1 diabetes I now run much faster than most of the people who outshone me at school.
In yesterday's Parkrun I posted the 4th best time for M55s since Ginninderra parkrun began.

http://www.parkrun.com.au/ginninderra/

I am still quite a few minutes behind the best ever time, but that gives me something to aim for.
A few reasons for my success.

1.I have been playing around with different steroid doses for sporty days.
My current favourite for races around an hour or two, which I used yesterday because Parkrun was not my only outing, is
Prednisolone 5mg
Hydrocortisone 15mg
Fludrocortisone 100 mcg
I had these at 4:30 am to make sure they were working before the start of the run, then no other steroids for the rest of the day. Of course doses like these are completely inadequate for a big ski day.

2. My diabetes management is completely contrary in most respects to what doctors recommend. Standards of medical research in this part of the world are appallingly low, both in general and with respect to diabetes. Look for yourselves at the original research that underpins your treatment and you will be horrified. Has anyone ever seen an article on T1DM in an Australian medical journal that has been even remotely helpful in their management? Many of the strategies that I use are described by Australian doctors as ineffective or deleterious. Yet I manage to do OK. Go figure.

3. I had the best ever earworm for the run. Mahalis's Just Like a Star. I was into the final kilometre before I had a chance to even think about how the run was going.

Skiing 6.9.15

After 10 years of skating track skating, I finally persuaded one of my kids to try backcountry skiing. A worthwhile trip up Twynam via Tate east ridge, despite the icy conditions for the first 200 vertical metres of the descent from Twynam. Strong cold winds meant we didn't stop for lunch until we got to Illawong.
Levimir 6U and Nrapid 4U in Jindabyne was good for the trip. Cold conditions and high winds meant testing BSLs was quite impractical for the middle few hours of the trip.

Intro

Everyone knows that young people with diabetes can do amazing things, even win an Olympic medal. But what happens to Type 1 diabetics after they reach legal retirement age and have had diabetes for many years? How do they manage? Here is my story.

Skiing 11/9/15

Backcountry ski trip to Leatherbarrel Creek from Dead Horse Gap.

Beautiful spring skiing. All up 1500 vertical metres of ascent and descent on mainly soft snow.
Levimir 8U and Novorapid 3U wtih breakfast and Novorapid 3U with lunch. I stuffed my face with carbs all day, but still had to eat more when I got back to the car at DHG to keep my readings up.
Mt Kosciuszko is near the horizon centre in the last pic.

Rod's Strava track from the day: