Is this case of diabetes properly managed?

[ewmon]

A middle-aged, set-in-his-ways, sedentary, overweight (BMI>25), former alcoholic is controlling his diabetes with diet alone. He checks his blood sugar 8 to 10, sometimes 15, times a day, and the numbers I have seen him record are about 125 through 150 mg/dL, once as high as 200, and he says he once measured down in the 80s, which he said was "not good". He often will test his blood, gulp down a snack, and 15 to 30 minutes later, test his blood again.

 

He claims he's heat intolerant, he seems to sweat a bit more than others do in the same situations (but I never see any beading or running sweat), he drinks a lot of ice water (sometimes a quart or two at a sitting) and so, he also urinates frequently. He claims he must snack often during the day, which does not resemble eating, but more like taking the food as med (ie, gobbles it quickly and doesn't seem to taste or enjoy it).

 

He's bipolar and on a med for it, but I think he acts very OCD about controlling his diabetes. Trying to do anything with him is like being part of a three-ring circus because he's seems almost constantly engaged in activities related to his diabetes.

 

Does this case of diabetes seem properly managed? Is he possibly overly attentive to avoid having to take insulin? Or is he more likely obsessing?

 

Thanks.

[Neco Vir]

To begin with I must say I will not be able to get through all you have asked to be answered.

Doctors recommend how many times a day one should test their blood sugar based on eating habits and the medicine they're taking. While I think it seems your friend is testing too much, do not take that as advice or anything, I just don't know and hope another member can help on that.

Heat intolerance is most likely due to hypothyroidism.

Polyphagia is a major symptom of diabetes in which one has a big appetite and I suspect that is what you're talking about with the snacking.

Polydipsia is a another major symptom, in which one drinks more fluids than normally.

Polyuria, is yet another major symptom of diabetes, that one urinates frequently.

The only two causes of lost of taste that are diabetes-related (as far as I know) are Bell's Palsy and oral candidiasis. However, I wouldn't think your friend has either. Some people just lose their joy of food and flavor when they get diabetes, it's a sort of mental or emotional effect.

 

I cannot say on the last question.

Hope this helps!

Edited August 4, 2010 by Neco Vir

[Marat]

The patient you describe is in the early stages of type 2 diabetes, which is a condition caused by a genetic predisposition in interaction with excess weight and sedentary lifestyle. In the early stages of type 2 diabetes, the patient is still producing insulin from his own pancreas, but his body is resistant to insulin action, so he may need to limit his intake of food and increase his activity to avoid placing excess demands for insulin production on the pancreas. As the excessive demand for insulin gradually wears out the pancreatic beta cells of the type 2 diabetic, these patients will have to progress from managing their condition by diet and exercise to taking drugs which stimulate the pancreas to put out extra insulin, and finally they may wind up having to inject insulin after the pancreatic insulin production capacity is completely exhausted.

 

Since the patient is still at the very early stage of being able to get reasonable blood glucose levels with dietary controls alone, and is even having occasional hypoglycemic episodes (blood sugar in the 80s) which are the opposite of diabetes, the person is being a bit obsessive with testing blood sugar as often as you describe. That said, many endocrinologists are themselves now quite obsessive about blood sugar control, and some would insist on the patient testing blood sugar this many times a day. It would be more sensible if the patient were simply to devote some of the effort involved in excessive blood sugar testing toward the more useful endeavor to lose some weight, since this would make the blood sugar levels much more easily managed, though it would not cure the condition.

 

It is worth noting that there is an increasing amount of evidence that the complications of diabetes may be caused by genetic and autoimmune processes which accompany the condition rather than by the excess blood sugar per se, so the patient's obsessive blood sugar control may not be solving as many problems as he might believe.

[swansont]

15 times a day seems excessive to me, but if one is recently diagnosed, testing often is how you figure out how you respond to different foods and situations. Results of 125-150 seem like reasonable numbers. If that's the level after eating, are you sure he's diabetic? Fasting sugar of 125 is the threshold, IIRC. Anyway, obsessing is better than the alternative of not caring much at all.

 

@ Neco Vir: snacking is a strategy to limit blood sugar spikes, since you avoid having large amounts of carbs at one sitting.

[Neco Vir]

@ Neco Vir: snacking is a strategy to limit blood sugar spikes, since you avoid having large amounts of carbs at one sitting.

 

Yeah, sorry about that, my misunderstanding of what he meant by snacking, thanks for clearing it up.

 

 

[ewmon]

Wow! Thank you everyone, I very much appreciate the information you gave me.

 

This evening his sugar tested at nearly 300 mg/dL, so he didn't eat his snack. This is also the first time I saw him have tremors. I just googled diabetes tremors, and it says that low sugar causes them, so this seems contradictory except that maybe he also has Parkinson's, which diabetes can cause.

 

And his diet doesn't seem healthy: His snacks throughout the day, every day, consist of nutrition bars and peanut-butter-on-whole-wheat sandwiches, but he says he eats chicken-based meals at home.

[swansont]

Wow! Thank you everyone, I very much appreciate the information you gave me.

 

This evening his sugar tested at nearly 300 mg/dL, so he didn't eat his snack. This is also the first time I saw him have tremors. I just googled diabetes tremors, and it says that low sugar causes them, so this seems contradictory except that maybe he also has Parkinson's, which diabetes can cause.

 

And his diet doesn't seem healthy: His snacks throughout the day, every day, consist of nutrition bars and peanut-butter-on-whole-wheat sandwiches, but he says he eats chicken-based meals at home.

OK, 300 mg/dL answers that question.

 

Peanut butter on whole wheat was one of the suggestions for my dad's diet after he was diagnosed.

 

The real question of whether the sugar is being managed well is the hemoglobin A1C blood test, which gives an indication of the average levels over ~3 months.

[Marat]

There is no way that the blood glucose reading of 300 would be associated with tremors, which must have come from some independent problem. Acute effects of hyperglycemia only appear when the blood sugar gets up around 600 and stays there, at which point it can cause somnolence and confusion from hyperosmolar coma, and if persistent for many days, can lead to diabetic ketoacidosis, which causes the patient's breath to smell like nail polish remover and can also cause coma which can be difficult to correct. High blood sugar levels below that will be asymptomatic, aside from increasing thirst and urination.

 

There is considerable debate now on the best diet for diabetics, since a high-protein, high-fat diet, avoiding carbohydrates, can allow the patient to achieve better blood sugar control, but this is exactly the kind of diet which promotes cardiovascular disease, arteriosclerosis, and renal failure, which are also problems associated with diabetes. Frequent snacking is a useful management tool for diabetes since it avoids the sudden spikes in blood sugar which come from taking large amounts of calories all at once in a large meal.

 

Although traditionally diabetic management has focused on blood sugar management, the large-scale ACCORD study of type 2 diabetics recently found that there was a significantly higher death rate among patients whose blood sugars were aggressively managed to keep them close to normal, but that the death rate declined if the blood sugar was moderately elevated. The death rate started to increase again only when blood sugar levels became extremely high. For years studies have shown a disconnect between hyperglycemia and diabetic complications, and it is now becoming accepted that genetic and autoimmune factors are also important in causing these problems. Of course, the more genetic and autoimmune factors contribute to the complications of diabetes, the less important it is to focus on blood sugar control. See M. Centofani, "Diabetes Complications: More than Sugar?" Science News, vol. 149, no. 26/27, p. 421 (1995).

[ewmon]

True, Marat. I saw him shaking again today and I decided to ask him, and he said the ice water makes him shiver!! (I think he's obsessive ... just a smidgen.) He also said he eats nine PB&WW sandwiches daily, which is 630 calories for the bread alone (35/slice), not counting the PB and the nutrition bars.

[Marat]

In the patient's present state, with what seems like mild, early-stage, type 2 diabetes, I would agree that his concerns seem to express some obsessive-compulsive tendencies. However, in more serious cases of diabetes, such as the patient's will eventually become, patients are positively required to be obsessive-compulsive about blood sugar levels and their measurement, so it becomes impossible to distinguish the compliant diabetic from the obsessive-compulsive diabetic. The patient you describe may be just anticipating that stage, so it is difficult to say that he has just neurotically invented his need to obsess over blood sugar management, since he does have a disease requiring that intervention to at least some degree.

[PhDwannabe]

In the patient's present state, with what seems like mild, early-stage, type 2 diabetes, I would agree that his concerns seem to express some obsessive-compulsive tendencies.

 

Hope this doesn't get us too far afield here. I would be very careful about throwing around the names of mental illness. I understand where this is coming from, and I do appreciate that you stayed tentative (e.g., "seem," "tendencies"), while many others simply want to smack a sticker with the name of a disorder onto someone. Nonetheless, I do want to point out a few things:

 

1) OCD is a serious anxiety disorder, which is often best typified by the connection of anxiogenic thoughts (obsessions) to anxiolytic behaviors (compulsions). Often, these compulsions end up highly ritualized (we all have our visions of people with OCD checking the oven six--not five! not seven!--times. It actually isn't a terribly inaccurate picture.) The term "OCD" has entered the popular imagination as something which describes people who are fastidious, perfectionistic, rule-bound, or observably neurotic about having things just-so. OCD, though, is really a bit more than that. The DSM-IV-TR actually includes a diagnosis which more closely matches this, one which fewer people seem to know about: OCPD, or Obsessive-Compulsive Personality Disorder. This tends to be a somewhat milder syndrome, closer to what I just described, and is thought of as more "driven by personality style" than by a disordered level of anxiety. It's difficult for me to exhaustively describe what we (I'm a psychology graduate student, so I use the group pronoun for the profession) mean by that, so I'll leave it there.

 

2) Perhaps even more importantly than that, what many of us consider to be the most important factor in diagnosing disorders is a clinical level of distress. Nearly every diagnosis for a mental disorder includes the provision that diagnoses are not made unless there is significant interference with a person's daily life functioning. Who generally gets to decide that? Well, they do. In the OCD diagnosis, this is Criterion C.

 

3) Finally, when an obsession is about a real-life problem, well, in short, it isn't an obsession (at least, not the kind we're thinking of when we make an OCD diagnosis.) "The oven will explode if I don't check it six times" is not a real-life problem. "My blood sugar is unstable and I'm trying to manage it with diet" is. It doesn't really count as sort-of an obsession, clinically--it just doesn't count (This is Criterion A2, if you fancy a look through the DSM!). Also, even more relevant in this case, we don't make diagnoses of most disorders when they're well-accounted for by a general medical condition. This is Criterion E. I can tell you from a clinical perspective (full disclosure: student clinician) that, based on the information here, that more than applies.

 

 

Marat, I hope it doesn't sound like I'm hounding you--I know you were being tentative. Given what I was just mentioning about general medical condition exclusions, I also agree with you in saying:

 

The patient you describe may be just anticipating that stage, so it is difficult to say that he has just neurotically invented his need to obsess over blood sugar management, since he does have a disease requiring that intervention to at least some degree.

 

That about sums up my last point, too. It's difficult to say anything, since all of our information is secondhand and over a text medium! Can't make too many solid diagnoses over that--medical, psychological, or otherwise. Anyway, I just wanted to shed a little light on this part of the discussion.

 

 

Thanks,

DJ

[Mr Skeptic]

So in summary, you've been carefully following someone, and asking around online, to see if they are being too obsessive about their health?

[ewmon]

He began working with us a couple weeks ago, and we started noticing his behavior. He told me that he likes drinking 1 to 2 quarts of 32° ice water at a sitting until he's hypothermic and shakes (constantly). He somehow likes it. Others have noticed some of his various behaviors and mentioned them to him, and I've caught him repeatedly lying to others about it. He also has peculiar behaviors that have nothing to do with maintaining his blood glucose level. For example, he's germophobic and won't touch things that other people touch. He's also a former alcoholic. He seems wrapped up in his peculiar habits until someone breaks him out of them.

[Marat]

The problem with diabetes is that it is a spectrum disorder so the required interventions vary as well. In the case of the patient described here, since he now only requires dietary interventions to manage his condition and actually has occasional blood sugar values below the diabetic and even below the normal range at 80, it is difficult to define the point at which his management of his condition is still within the range of what is objectively required and when it starts to become obsessive. If someone with hypertension checks his blood pressure three times a day to see how effective his anti-hypertensive medication is, that seems objectively required and is thus a psychologically healthy response. But what if he is mildly hypertensive and he checks his blood pressure ten times a day. At that point something starts to seem suspicious. The situation with diabetes is further complicated by the fact that many clinicians have different views about how intense the patient's management of the disease should be, so here again, differentiating what is a normal response to the objective requirements of the disease versus what is a neurotic over-reaction to a real condition can be subtle.

 

Generally, the DSM-IV has always struck me as ridiculous in its excessive subdivision of categories and its elevation of phenomena from pop psychology to the level of 'real' diseases. If they keep this up, soon we shall have diagnostic entities like 'Global Warming Denialism Disorder' and 'Holocaust Scepticism Neurosis.' The fact that homosexuality used to appear among the roster of clinical entities until, for purely political reasons, a changing society required homosexuality to be re-defined as normal shows how silly the classification of diseases in the DSM has been. The interrator unreliability of schizophrenia as a diagnostic category makes the whole classification system suspect in my view. Sometimes I think that the last useful diagnostic innovation was Haslam's description of schizophrenia circa 1800.

[PhDwannabe]

Generally, the DSM-IV has always struck me as ridiculous in its excessive subdivision of categories and its elevation of phenomena from pop psychology to the level of 'real' diseases. If they keep this up, soon we shall have diagnostic entities like 'Global Warming Denialism Disorder' and 'Holocaust Scepticism Neurosis.' The fact that homosexuality used to appear among the roster of clinical entities until, for purely political reasons, a changing society required homosexuality to be re-defined as normal shows how silly the classification of diseases in the DSM has been. The interrator unreliability of schizophrenia as a diagnostic category makes the whole classification system suspect in my view. Sometimes I think that the last useful diagnostic innovation was Haslam's description of schizophrenia circa 1800.

 

Sorry to keep beating this, and it may get far afield from the topic, but I can't let this one go. I'm in school to be a psychologist, and believe me, nobody finds the DSM more ridiculous than psychologists. We're not generally in charge of the thing. It has a thousand problems, and the very nature of categorical diagnosis has its problems as well. (Often, the people who hate it have a knee-jerk reaction to support a system of dimensional, or spectrum diagnosis, which, believe me, has a set of problems which gives categorical diagnosis a run for it's money.) It's extremely difficult to adequately describe mental illness in a way that is consistent with research, diagnostically useful, and clinically useful. But that's no reason to:

1) throw the entire baby out with what is admittedly a lot of bathwater

2) sneer at it with slippery slope arguments about what insane thing they'll think up next.

 

Yeah, the psychiatrists annoy me for medicalizing so much of human experience. Yeah, drug companies sell more drugs that way, and they fund a lot of the research. This tired old conspiracy theory writes itself. BUT, guess what? What we have does have some utility. It is based, to a large extent, on good, solid peer-reviewed research. The details of diagnostic criteria mostly do have clinical meaning and ecological validity. We fiddle with these things constantly. Many people in the lab I work in, for instance, are concerned with Criterion A2 of Posttraumatic Stress Disorder (it requires a person to have experienced fear, helplessness, or horror during or immediately after the traumatic event). Very refined recent research has found less utility with this one than was first believed. So, a lot of people want to drop it.

 

What's wrong with this, exactly? You dump a diagnostic system because they've changed their minds? I'm not going to dump astronomy because those idiots used to think the earth's orbit was circular. Good for them for figuring out it went around the sun at all--better still figuring out it does so in an ellipse. Science makes progress. The unfortunate but hopeful implication of that is that it's dumber today than it will be tomorrow. We change and refine and improve upon (and sometimes screw up entirely). And why does any of this matter for psychology? Because we help people--tons of them. Emperically validated diagnosis helps me choose empiricially validated treatment, which helps someone get better. Often a lot better. Better than they would've been if I would've been studying this 25, or 50 years ago. Better than they would've been without a halfway decent diagnostic system at all.

 

I apologize if I've continued something which may be off-topic. I'll shut up on this one now, and let the conversation return to the decidedly weird game of third-hand diabetes evaluation.

 

 

Thanks,

DJ

 

 

 

 

P.S.: Poor interrater reliability for schizophrenia? I'd love to see the literature on this one. Mail me a reference, eh?

[skyhook]

He began working with us a couple weeks ago, and we started noticing his behavior. He told me that he likes drinking 1 to 2 quarts of 32° ice water at a sitting until he's hypothermic and shakes (constantly). He somehow likes it. Others have noticed some of his various behaviors and mentioned them to him, and I've caught him repeatedly lying to others about it. He also has peculiar behaviors that have nothing to do with maintaining his blood glucose level. For example, he's germophobic and won't touch things that other people touch. He's also a former alcoholic. He seems wrapped up in his peculiar habits until someone breaks him out of them.

 

are you a boss and he is an employee ? or are you a doctor or some kind of health professionals and he is a patient that refuse to go on medication ? I'll presume you're the boss. and my sixth sense tells me, you seem to be finding a reason to fire him. That's the decision you have to make, I can't say right or wrong. I probably get fired often enough. Some companies have some health benefits for their employees, and if the employee have major health problems, the company may be footing large bills, but it is different in some countries, so maybe it didn't apply.

Does being eccentric get you fired ? As you mention tremors and alcoholism, I thought alcoholism caused tremors but I've not seen it myself except my late granddad being an alcoholic and getting violent and can't control his addiction. Drinking cold water, he feels very thirsty or something ? or trying to stay awake at work, sluggishness?

OCD is classified as a mental problem or disease. so is depression and anxiety disorders, schizophrenia. I can't tell my potential employer I've this or that condition , or I'll be at a huge disadvantage. probably never make it pass interview. and faced discrimination from colleagues. So an employee tries to hide his condition and the employers always try to weed out undesirable elements. but if OCD isn't serious, most patients will probably function just like the other employees, you just have to accept some eccentricity if you can accept that. man... its an uphill battle...

Edited August 12, 2010 by skyhook

[ewmon]

No, I never want to be a boss, and I'm not in the healthcare profession. I just worked with him, and simply cared about his wellbeing as one person to another. There were several of us concerned that he lived in his cramped little world filled with dysfunctional habits. He complained about the condition of his life, but he couldn't see his way out of his habits. Overall, he feels that nothing is his fault, his every problem is someone else's fault.

 

Interestingly enough, his boss let him go today for consistently failing to perform the minimum requirements for the job during his probationary period. The guy even admitted that he couldn't do the work and didn't like the work. He expected to be let go, and he wasn't disappointed when it happened.

[skyhook]

sorry about the wrong assumptions, sometimes I should just keep my mouth shut..haha..

 

here's my take on diabetes, from the limited info I gathered...One book I read sometime ago is about Inflammation. The author believe various diseases are caused by inflammation. heart diseases, strokes, and the likes and briefly mentioned diabetes. something like autoimmune system --inflammation -- diabetes, I'll have to read it again to be more precise . He or someone else might have said that wheat products have a substance that caused inflammation or an allergy. and to prevent heart disease, a tip is that the salt we take can be change to sea salt or pan salt, instead of pure sodium chloride. The magnesium in sea salts have a protective effect while calcium have a excite-ary effect. and also someone said that a good form of exercise is brisk walking.

the book, as usual, I'm not sure which author ... probably Stop inflammation now! by Fleming, Richard M , or Reverse Heart disease now by Sinatra, Stephen T

Of the food stuff, sweet potato( Ipomoea batatas) seems to be a suitable food for diabetes. and there is a bitter gourd( Momordica charantia) which have a small size variety which is said to be good for diabetes, but it is quite bitter and its an acquired taste.

I tend to believe apple is anti-inflammatory .

 

diabetes is a silent disease, and when it become serious, all the diseases pop up together.

Edited August 12, 2010 by skyhook

[Marat]

Although the predominant hypothesis now offered to explain the vascular and neurological complications of diabetes is that these arise from excess blood sugar levels, this hypothesis cannot explain how the disease starts in the first place. An alternative hypothesis has attempted to explain both the cause and the later complications of diabetes from the cytokine inflammatory response to autoimmune disease, which damages not only the nerves and vascular beds, but also the pancreatic beta cells. Interestingly, this response has been found in both autoimmune diabetics (type 1) and in what have always been considered to be non-autoimmune diabetics, the type 2 patients, suggesting that autoimmunity-induced inflammation, rather than hyperglycemia, may be the cause both of the onset of the disease and the downstream complications of it. The plausibility of this hypothesis is reinforced by the disconnect which has been noted between blood glucose normalization efforts in diabetic patients and the vascular and neurological damage associated with this disease. If excess glucose caused the complications, glucose control should always clearly reduce them, but it does not. In contrast, if autoimmunity is the problem, glucose control will only accomplish part of the job, since excess glucose also generates some hyperoxidation on its own, but not enough to explain the whole clinical picture.

[The_Platypus]

Hmm

This seems to be a case of diabetes type 2 .

However he shud go fr a 8hr fasting glucose level to establish it.

He may be having " Impaired glucose tolerance " , which is common in type 2 prediabetic patients.

However since he is a bipolar ( I assume , manic depressive ) , it may be possible that he may be overreacting to his medical conditions.

Some drugs also increase the urine output .

[Marat]

While there used to be just two subtypes of diabetes, juvenile and adult, now there is a proliferation of categories, including pre-diabetes, type 1, type 1.5, LADA, MODY, and type 2. Recently there has been a reaction against the proliferation of categories, as a result of some studies showing that autoimmune and genetic aspects play a key role in causing all forms of the disease. Since the patient in question here is an adult who does not have to inject insulin yet is still running blood glucose levels around 200 at times, it is a pretty good guess that he is an established type 2 patient.

 

An important drug for all types of diabetics has come out of Europe in recent years but it is still being ignored by the conservative medical establishment in North America, and that is Benfotiamine. It operates by blocking the downstream metabolism of excess sugar in the body to advanced glycation endproducts, and by doing this, it blocks the development of the characteristic damage which excess glucose normally does to nerves and the vascular system. This means, in theory, that diabetics could simply take a few Benfotiamine pills a day and get the same or better results that they now have to strive for by the obsessive compulsive management of constantly fluctuating glucose levels. Unfortunately, since Benfotiamine is classed as a pro-vitamin and so cannot be patent-protected, there is no money in marketing it, so the large-scale studies to demonstrate that it works better than intensive conventional blood sugar management will never be done. In addition, there is such a huge and profitable industry now in selling devices to measure and manage blood sugar, which would not be necessary if Benfotiamine were proved in large-scale studies to be more effective than blood sugar control, there is a strong resistance in the pharmaceutical industry to Benfotiamine ever gaining a foothold in the world of diabetes management.