January 11, 2016

Double Diabetes

Concept, food, meal.

As most of us know, there are two major kinds of diabetes, type 1 and type 2. The former normally affects younger people, and is autoimmune in origin, leading to a complete loss of the insulin-producing cells in the pancreas. People with T1D are always immediately insulin dependent upon diagnosis and require insulin for the rest of their lives to survive. In contrast, type 2 diabetes is often diagnosed in older people, although the average age is coming down, and does not require insulin injections until later on when the disease has progressed. T2D is driven by peripheral insulin resistance which then overextends the pancreas, and literally tires it out. The insulin resistance seen in T2D is exacerbated by obesity and increased body weight, which is a reason for T2D to be growing all over the world due to poor diet and lack of exercise.

When I was diagnosed in 1989, a majority of T1D people were thin or average weight, while T2D were almost always overweight unless they took their disease seriously and changed behavior to avoid the progression toward insulin dependence. My initial therapy was the Novo pen, using human insulin of two kinds – long-acting for once daily basal and short-acting before each meal. I had to time my meals carefully, since the insulin was less fast-acting than nowadays, and the long-acting insulin didn’t completely cover me for 24 hours.Diabetes Blog Pic 2

Today, I would have been recommended an insulin pump, or so-called continuous insulin therapy, which as it sounds, provides a basal rate of insulin throughout the day, and only requires dialing up the delivery of insulin when or prior to eating carbs. This therapy together with improved glucose measuring tools – my first glucose materials were not even automatic, I had to compare the color on the strip with a panel on the tube – such as continuous glucometers worn on the abdomen and small, sophisticated episodic meters that measure the blood glucose in 5 seconds have given people with diabetes much more freedom as well as better control.

However, the other big change compared to 25 years ago, is the approach healthcare professionals and people involved in the diabetes infrastructure have taken when it comes to living life with diabetes including restricting diet and limiting dosing. I was told to never touch toast, pancakes, soft drinks or other very high carb containing foods that did not bring nutrition. I was educated by dieticians who explained the effects of the toasted surface of a piece of bread vs a piece of bread that was made out of multigrain and not toasted. I was recommended not to drink orange juice or eat potatoes, and definitely not have cinnamon buns, a very common treat in my home country of Sweden.  Today, although we are learning more and more about the risks of sugar on our health, as related to heart disease, Alzheimer’s and obesity, and people all over the world are trying low carb approaches to lose or maintain weight as well as improve cognitive functions and reduce morbidities, we are seeing a surprising phenomenon in the type 1 diabetes community. First we need to understand that there is an inherent conflict between the T1D and T2D camps, with some from the former almost discriminating against the latter and for sure not wanting to learn from or be mixed up with each other. Parents of T1D children and people living with T1D see themselves as having a disease that they did not deserve, while they see the disease T2D as a sign of laziness and lack of discipline. The truth remains that as T2D progresses, people with that type of diabetes end up with a poorly functioning pancreas, and will need to use the same kind of approach to therapy as the T1D crowd. The complicating problem in the case of T2D is the initial manifestation and the very cause of the disease, insulin resistance.

Going back to the late 80s and early 90s, when I was a young person with diabetes and new to the space, I was presented with some advice and comments, that surely are not used any longer – I was told that having diabetes actually would give me a head start on a healthy approach to life and that there were certain signs that I could learn to observe and act upon. At 16, and a serious athlete, I was eating a lot to fuel my body, but anyone going through puberty and reducing the amount of activity due to increasing demands from school or work, risk weight gain. In the US this is often called the Freshman 20, and it appears everywhere in some shape or form.  I was educated about the diet that would keep my sugars stable and that happens to be a kind of diet which is good for everyone! I realized I would have to say no to certain treats and foods, and that my friends and uninformed colleagues would look at me a little differently unless I opened up about the reasons to be diligent about sugar and simple carbs, but most of the time I saw it as an opportunity to stay healthy, not just with my diabetes, but with my weight, my body and my mind.

I have to admit that there were a number of occasions when I heard people asking about me, and even confronting me about my restrictions, and since I was very secretive about my T1D, it was awkward, but I did not care. In contrast, what I am seeing now is that parents and people with T1D are more concerned about “being allowed to eat normally” and “enjoying treats”, as long as one dials up the pump and measures the blood glucose often. I am not against diligent control and being on top of one’s measurements – this is critical and has really become easier with today’s technology, but what I find sad is that people with T1D are supposedly not changing behavior to accommodate for their disease and even more importantly, taking advantage of their disease to live a healthy life!

Double diabetes is increasing dramatically, and what it means is that one suffers from both T1D and T2D, by having T1D and then eating the wrong foods, dialing up the insulin, increasing in weight and then becoming insulin resistant. Insulin is a metabolic factor, allowing for glucose to be used for energy by the cells including the brain, but it is also an anabolic hormone which builds fat when in excess. As a T1D person I used about 2-6 units of insulin prior to my meals, and nowadays it is not unusual for people to be using 10 times that due to insulin resistance. People with this condition are not only at an increased risk for microvascular complications if they do not exert glucose control, but they also have increased risk for cardiovascular disease and orthopedic conditions due to their bodies being overweight and their insulin resistance.

I do not want us to go back to old technology and I do not want to discriminate against people with diabetes when it comes to their diets, but I urge parents and people with diabetes to consider their diagnosis as an opportunity to live healthier than if they had not been diagnosed! Healthy food can be and is delicious. There is no advantage of letting your child enjoy frosted birthday cakes or drinking coke. In fact, if one starts early, children do not get addicted to the high sugar meals that get them in so much trouble later on. I am not prescribing diet plans that are boring and resemble spa visits, but there are a number of ways to provide healthy meals that will possibly convert the other parents into treating their kids to a so-called “diabetic” diet!