New approach to type 2 diabetes management

UnknownGet your heart checked

A few weeks ago I attended a seminar given by Amylin Pharmaceutical, manufacturer of Byetta and Symlin, in of all places Carnegie Hall. I have no complaints, it included lunch and a tour – and an important education. 

Amylin’s seminar, “New Approach to type 2 Diabetes Management” had five prestigious presenters at the helm: Dr. Louis Aronne, Clinical Professor of Medicine, Weill Cornell Medical College and obesity expert; Dr. Robert Chilton, Cardiovascular surgeon, University of Texas Health Science Center; Dr. Donna Ryan, Obesity expert, Pennington Biomedical Research Center; MEd Molly Gee, Dietician, Baylor College of Medicine; Dr. Matthew Wintle, UK, Director of R&D, Amylin.

The new approach proposes that the same attention on glucose control for type 2s must be given to cardiovascular risks. We heard from the presenters that type 2 diabetes is a cardiovascular disease. As Dr. Chilton warned, people with type 2 diabetes have a two-to-four-fold increase in risk of stroke and coronary heart disease and a two-to-five-fold increase in risk of heart failure, and will likely die due to cardiovascular disease. Cardiovascular risks: obesity, blood pressure, cholesterol, triglycerides and inflammation, (also known as metabolic syndrome) typically accompany type 2 diabetes. If we don’t control these health ailments, cardiovascular events will occur in greater numbers as the tide of type 2 diabetes rises.

In all disclosure, Amylin is working on a drug that will help control cardiovascular disease risks as well as glucose, and not produce weight gain. The catch-22 of course is that weight gain contributes to cardiovascular risk and some diabetes medications cause weight gain.  

I came away from the Amylin seminar thinking unmanaged type 2 diabetes is a time bomb, and for the first time I understood why the American Diabetes Association has long advocated a low fat/high carb diet; obesity prompts the hormonal imbalances that create metabolic syndrome. I won’t get into healthy fats vs. unhealthy fats or that unused carbs also turn into fat. Suffice to say, if you have type 2 diabetes, get your vitals checked and ask about your heart health.

As February is American Heart Month it’s a good time to learn more about your heart health and risk for heart disease. Cardiovascular disease is America’s number 1 killer – every 25 seconds someone experiences a cardiovascular event and every minute someone dies. It is time, I agree, to think ‘heart’ as well as ‘sugar’ if you have type 2 diabetes. 

I’ve long heard that people with type 2 diabetes have as much chance of having a heart attack as people who’ve already had one. Somehow it doesn’t sink in unless you’ve had a heart attack or until you see, as I did, the stunning pictures of what clogged arteries look like. 

To show support for heart month, this Friday you’re encouraged to wear red. I’d also ask you to show support for your heart: Take a walk and make that doctor’s appointment to check out your heart-health. Then you can toast your heart-healthy actions with a glass of heart-healthy red wine. 

My CGM sensor report

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The CGM iPro sensor I wore for five days (see post below) came off Monday morning in a hurricane. Not exactly what you think, but I like the drama. My walk from the subway station to the hospital to see my CDE was in a rainstorm at high gale winds we rarely see here in New York – umbrellas discarded on the streets, puddles knee-high. Were it not for the fact that my iPro site was itching like mad for two nights from the sticky tape over it I’m not sure I would have braved the storm at all.

By the time I arrived at the hospital the entire front of my jeans was soaked so that I was wringing water out of the cuffs. I was eternally grateful that not only did I brave the storm, but that my CDE did as well. Moments later the CGM came off, a lot more easily than it went in thank goodness, and we downloaded the results. Luckily the battery lasted for as long as I wore it, just over five days. That’s not always the case, but it was here. Hallelujah!

Then we stared at pages of graphs, charts and numbers of my blood sugar numbers as picked up by the sensor every five minutes and I got to see my patterns throughout the day, and night. 

Since I was doing finger sticks at least four times a day along with wearing the sensor, my daytime numbers were not surprising, and, my daytime numbers are typically understandable to me. When I’m a little high it’s usually because I didn’t calculate the carbs in a meal or snack correctly. When I’m a little low it’s usually for the same reason, or my powerwalk lowered me slightly more than I expected. Being insulin-sensitive, as many type 1s are, a half unit of my rapid-acting insulin has an impact. 

During this five day period I also went high after a birthday lunch for my mom who turned 80 – a poor calculation on the calamari and spring rolls! But mom, you’re worth it. And I discovered just as routine is my savior, so is my experience. Since I was logging my numbers, I used the carb counts on packages more than usual and that led me more astray than the educated guesses I typically make based on years of testing. Perhaps it’s because food manufacturers are allowed a 20% margin on the carb counts listed on their packages, so beware.

But what I really wanted to know from this experiment is what my numbers do overnight, and that was the reveal. Around midnight they start sliding downward hour after hour. Around 5 AM they are at their lowest, in the high 50’s/low 60’s, and then they begin to gradually come up between 5:30 and 6:30 AM and then rise more swiftly. If I wake up and test my blood sugar around 6:30 AM the number’s usually around 75 or 80, a half hour later they’re 90 or 100. A half hour after that they’re climbing over 100. This is without doing anything or eating anything.

“This is perfectly normal,” said my CDE and nothing to worry about. In the morning your liver is pumping out glucose-raising hormones to get you ready for the day (dawn phenomenon). Even if you’re a little over 100 before you take your injection, it’s fine.” O.K., I’m relieved about that since my boundaries are admittedly narrow. 

“Can I prevent the overnight slide or morning rise?,” I asked. “Not really, this is your body and you’re doing fine. The only thing that might reduce the overnight low is cutting back on your Lantus one unit, but I don’t think you need to do that. You don’t go that low at 5 AM and then you come back up. “Would a pump level this out?,” I asked. “Yes, and that’s when most of my patients change to a pump, when multiple injections just can’t do more for them.”

So what I know is I’m working the MDI (multiple daily injections) system as best I can. I keep my blood sugar between 120 and 140 before I go to sleep, on the higher end of that range if I’ve had wine with dinner since that creates a slightly greater drop overnight. Then I blunt the morning rise with one unit of my rapid-acting insulin as soon as I wake up and take the rest of my breakfast dose just before or during my morning meal.

My concern that I drop so low overnight, like to 30 or 40 mg/dl, that my liver shoots out glucagon to save me from dying turned out to be false. That is a relief. Also, while I don’t log my numbers ordinarily, I’m already obsessive enough, if you log your numbers – and for most people this is an invaluable exercise – make sure you also note what you eat and any exercise. Most log books don’t give you space for this. So log your numbers on a simple sheet of paper. A bunch of numbers without these references is an incomplete picture.

I highly recommend if you have access to wearing a trial CGM for a few days to see your pattern that you do so. This kind of information can lead to an important change or modification in your treatment plan. I know I’ll be sleeping better from now on.

Note: Our bodies are different. Don’t base any of your own treatment decisions on my results. Check with your health care provider to be safe.

Just a little bionic

UnknowniPro sensor – 5-day CGM

Noticing I was becoming a sugar-testing junkie recently, I opted to get hooked up to a CGM for a 5 day trial period, save some finger skin and see if I could learn something. 

My recent addiction to knowing where my numbers are, beside a proclivity to perfection, is largely because my blood sugars rise sooo rapidly in the morning. Can I shut the barn door more quickly so I don’t have to do two boluses before breakfast? The first to merely blunt the rise. 

My new CDE put this on me in her office and what should have been a rather simple affair turned out to be quite a painful one. I wasn’t prepared for the tugging, gripping and sensation of tearing skin when this thing went in. In fact you’ll see quite a bit of redness around it which is my blood. My CDE told me it is not uncommon to bleed and not a problem. OK, but it didn’t exactly lift my spirits and it did make me utter, “Diabetes is not exactly a pain-free disease!”

When I left my CDE’s office, newly bionic, I walked about 20 blocks to meet a friend for lunch. Each footfall, I was overly aware of this gizmo dug into my side and the very fact that my walking was impacting my blood sugar. A weird thing for your brain to be so focused on an automatic body function. When I sat down to lunch I copped the banquette seat feeling vulnerable and exposed to any passer by who might ram into my poor abdomen. Well, it’s not really on my abdomen, but I don’t know what you’d call this side area.

Leaving the restaurant I began to experience my plastic gizmo differently. I felt somehow as though it was now my helpmate. As though I was not in this all alone anymore. I found this quite comforting and recognized it as a wholly new feeling.

Now, two days in, I’m used to my CGM, it doesn’t hurt but the five inches of sticky tape that’s holding it in place grips and pulls as I twist and turn. And while my plastic companion is (hopefully) tracking my numbers, so am I four times a day in a log book, along with carb counts and activities, just in case anything goes awry. 

I will keep you posted next week when gizmo comes off. It would be dandy to have learned something more than which pants slide easily over gizmo and which ones don’t.  

Today brings a new score for endo

In my last post I scored my new endocrinologist according to my own devised criteria.  The tally was: 6.75 out of 10. Today, I am raising that score as new information has arrived. 

This morning endo called me at home with my test results from the labs taken the day of my visit last week. First, I’m impressed by the call. My previous endo never called unless there was a problem. Second, I’m impressed endo called on Labor Day weekend. OK, maybe endo is working, but still it’s nice. And I’m a sucker for nice.

Third, endo gave me my results in plain English not medical gobeldigook and while endo expressed concern about one test result endo took a prudent attitude and recommended we revisit this next time we take this test. Efficient, endo also sounded a tad warmer than our first/last meeting. Also, endo is faxing my A1c result to the organization I requested last week. At first I was confused who endo was faxing my test result to because I had forgotten! So endo is on the ball. All tolled, I’m raising endo’s score to a full 7. 

You might think I should raise it to 8, but 8’s pretty special in my book out of only 10. Besides, I’m fairly confident endo may still go up on my score card as we continue to work together and I’m looking forward to see what I discover during more visits over the next few months. 

 

Bracelet in hand, or rather on hand

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If you’ve been following my search for, and acquisition of, my very first medic alert bracelet, you know I found one on American Medical ID. You’ll also know I bought just the plaque, the center part of the bracelet that holds the essential emergency information, and enlisted my friend who makes jewelry to make the actual chain.

While you can certainly order your bracelet with a chain, I figured it would be nice to have the chain be a little special. I also used that as an incentive to actually wear this new adornment.

So pictured here is the outcome. The top picture shows the bracelet with the plaque, it’s sterling silver and the information is on the back. There’s actually enough room between the plaque and my wrist that you don’t have to take the bracelet off, as I suspected someone would, to read the info. You can just flip it to the back side while still on my wrist. The second picture shows the two-toned chain I had my friend create.

I’m pretty happy. It’s a nice looking piece of jewelry and yet recognizable as a medical alert from the emblem. I have found the plaque, since it is heavier than the chain, tends to often fall to the side of my wrist or the underside of my wrist, amazing the smallest things we don’t think about. But I guess it doesn’t really matter. It’s there, where nothing was there before, and that matters more. 

As to my question of whether it would bother me to wear a constant reminder that I have diabetes, I actually haven’t found that it does. Maybe it’s because I’m still liking the bracelet I designed. To be honest, since I have made an agreement with myself that I will not take it off, since you know what will happen if I do–I’ll run out of the house on a short errand, not put it on, and something will happen where I’d need it–so far I notice soap has a tendency to find a home in the little links. Oh, well….

The Apidra pen arrives this year

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Unknown-1Lantus SoloStar® Pen

Just a bit of news: Apidra, a rapid-acting insulin used before meals like Humalog and Novolog has just won FDA approval to be packaged in a prefilled disposable pen, to be called ” SoloSTAR®.” They’ll be available in pharmacies sometime this year.

Apidra and Lantus are both Sanofi-Aventis products. If you use the Lantus pen SoloSTAR®, (Lantus being long-acting insulin most patients use once or twice a day to cover the fasting state), the two pens will come in different colors to help tell them apart. And trust me, there are endless accounts of patients mixing up their rapid and long-acting insulins because the pens or vials look so much the same. However, I’ll have to reserve judgment as what I saw didn’t look that far afield from the Lantus pen: a grey blue vs. a blue grey? What’s so hard about making it in green or orange? 

 

I’m an Apidra user after years of using Humalog. For me, Apidra works faster than Humalog which means I need to use less and its quicker action gives you the advantage of injecting during and sometimes after a meal depending on what you’re eating. This takes a lot of the guesswork out making my doses a wee bit more accurate. 

Timing insulin, the last installment

Never mind what you call that!!! How high am I going to go?!

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 The American Diabetes Association advises that postprandial blood glucose shouldn’t exceed 180 mg/dl (plasma value) at two hours after the start of a meal. Personally I find this number exceedingly high and was surprised it was not lowered in their recent January 2009 Standards of Care. Many other diabetes educators I know find it high as well and several other associations and experts believe the two-hour postmeal goal should be less than 140 mg/dl. Whew! Better. 

I’ve placed two posts here in the last two weeks that are excerpts from Hope Warshaw’s (R.D., B.C.-A.D.M., C.D.E.) wonderful article, “Rapid-Acting Insulin
Timing It Just Right.” Diabetes educator and dietitican Warshaw explains how to better time your insulin with your meals to get your post prandial blood sugars where you want them. Among the suggestions are occasionally checking your blood glucose after a meal at hours one, two, and three to help you determine when your blood glucose level peaks and starts to come down again. The overall key to controlling postprandial highs is better timing of rapid-acting insulin. Here are several other useful tips from her article:  

Low glycemic index foods – If your blood glucose is less than 100 mg/dl before a meal and you plan to have a meal with a low glycemic index, wait until you start to eat to take your rapid-acting insulin.

Uncertain carbohydrate intake – If you don’t know how much carbohydrate you will eat at a meal, consider splitting your rapid-acting insulin dose. Take enough insulin before the meal to cover the amount of carbohydrate you are sure you will eat. Then as the meal goes on and you know how much more carbohydrate you will eat, take more insulin to cover that amount. This method is easiest if you are on an insulin pump. (But I can attest that it’s doable even on Multiple Daily Injections)

Drawn-out meals – Pump users who are planning to have a meal that is eaten over time, such as a cocktail party or Thanksgiving dinner or a meal that is higher in fat or lower in glycemic index and high in fiber, (it will slow your glucose rise) may use one of the optional bolus delivery tools on their insulin pump. Most insulin pumps allow you to deliver a bolus over time rather than all at once or to deliver some of the bolus immediately and the rest over the next few hours. People who inject insulin could take half their bolus at the start of a meal and the other half an hour or two later. (I do this and sometimes even inject 3 x as I graze. No it’s not fun but it does help more closely match the correct dose of insulin to what and when you’re actually eating.)

Snacks – Alison Evert, R.D., C.D.E., a diabetes educator at Joslin Diabetes Center at Swedish Hospital in Seattle, advises people to “take rapid-acting insulin with any amount of carbohydrate over 10 grams.” Although it is common to think that a few grams won’t make a big difference, the reality is that 10 grams of carbohydrate can raise many peoples’ blood glucose 30 or more points.

Unused bolus insulin – While the duration of action of rapid-acting insulin is usually given as 3–4 hours, some diabetes experts believe it may continue to lower blood glucose level for as long as 5 hours. You can assume that about 20% of a dose of rapid-acting insulin is used each hour after it is given. In John Walsh’s book Using Insulin and on his Web sitehttp://diabetesnet.com/diabetes_control_tips/bolus_on_board.php, he provides a table that shows insulin activity at 1, 2, 3, 4, and 5 hours after bolus doses of insulin from 1 to 10 units.

When two doses of rapid-acting insulin overlap, their effects overlap, too, and the result can be hypoglycemia. Therefore, when you’re considering the size of a bolus dose of insulin, it is critical that you factor in what Walsh calls “the unused insulin” or “bolus [insulin] on board.” This is the amount of “active” rapid-acting insulin left from a previous injection or bolus dose from a pump that continues to lower your blood glucose.

For instance, before lunch, you take a bolus of rapid-acting insulin. Three hours later you decide to have a snack with 30 grams of carbohydrate. You check your blood glucose and find that it’s high at 195 mg/dl. Assuming 1 unit of insulin for you covers  45 mg/dl, you calculate you’ll need two units of insulin to bring your blood glucose level down to your premeal target of 100 mg/dl and another two units to cover the snack you’re about to eat. You take the insulin, and several hours later, your blood glucose has dropped to 55 mg/dl. Why? Because you didn’t factor in the hour or so of action left from the bolus or injection you took at lunch.

To prevent hypoglycemia from unused insulin, get in the habit of thinking about when you took your last bolus dose and how much (if any) action is still left before taking another bolus to “correct” high blood glucose. Most pumps have a built-in feature that keeps track of how much of a previous bolus dose is still active. For us MDI people we have to log it on paper or in our heads.

Even though I’ve had diabetes for 37 years and injected insulin for 32 (Yes, I’m a type 1 who was misdiagnosed with type 2 and on oral meds the first 5 years) you can always learn something new or refresh what you know. 

Thank you Hope. 

A hospital where patient experience is paramount

Need a snack? Fruit-only

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The Botanical Garden

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Me and the CEO, Mr. Liak

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Kind reminders to be healthy

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 Can you imagine a hospital where floors are carpeted so you feel calm, soothed and protected? Where doors open silently so as not to jar your jangled nerves? Where vending machines are only filled with fresh fruit and the healthier the meal in the cafeteria the less it costs? How about elevator doors covered in exotic floral motifs and a Diabetes Center where you never wait more than ten minutes to be seen?

I could never have imagined these things but instead I saw them with my own eyes here in Singapore at the Alexandra Hospital. The hospital sits amid a lush and beautiful botanical garden that volunteer employees care for and each floor of the hospital has a view of greenery. In this tropical paradise even medicinal herbs are flowering in the gardens.

This hospital is the vision and result of its CEO, Mr. Liak, and his passionate staff. It is their mission to create a place of healing where people are helped to make healthy choices, even if it’s just taking the stairs instead of the elevator.  No wonder stairways are easily accessible throughout the hospital, not hidden behind impenetrable or locked doors, and they are marked by big wooden red hearts that say, “Please give your heart a lift, use the stairs.”

I had the pleasure to meet Mr. Liak and discuss the state of healthcare in Singapore and the U.S. and the work I am doing bringing a more positive attitude to managing diabetes. Mr. Liak spent three hours with me and my husband, who has worked with him in the past, generously sharing what some would call a contrarian view: give diabetes patients a year of treatment and education and if they improve and own their management, encourage them to be peer-mentors wherein they can give back, help other patients and help the hospital provide its services to more patients. If they don’t take responsibility for their care after a year, patients are free to seek help elsewhere and leave space for new patients at Alexandra Hospital.

To say the least it makes one think. In the U.S. the health care system does not particularly motivate patients to become self-reliant and responsible for their care, and we know this is paramount managing diabetes. In fact, I have heard upon occasion a critical tone from my own endocrinologist’s office when I come in for a yearly visit rather than every three months. But why do I need to come four times a year? I am a well-educated patient managing my diabetes daily and getting the necessary tests as appropriate. I can easily discuss my test results with my doctor over the phone and make any necessary adjustments. I am doing what medical professionals say they want patients to be capable of doing, managing my own diabetes!

After chatting about societal influences on health care and patient behavior, I gave Mr. Liak five copies of my book, The ABCs Of Loving Yourself With Diabetes. His face lit up, he loved it. He said this is what we need, a more cheerful and optimistic attitude about managing diabetes. And with that he toured my husband and I through the hospital halls including what resembled a “war room” filled with storyboards, flow charts and feedback circles reflecting plans for the new, expanded hospital they are building. At every touch-point in the new hospital the patient will be accommodated, from a simple registration process to remote controls where patients can control the light and air temperature of their room. Where room furniture is being built with drawers and countertops that allow patients to put more than one thing in and on them. And who is in the hospital bed photo testing all the equipment? None other than Mr. Liak himself.

Our tour stopped at the Diabetes Centre where I was introduced to the staff and two copies of my book were handed to the Diabetes Centre Director and diabetes nurse. Talk began of translating my book into the Malaysian language, Malay. Thank goodness my head had not grown so large that I could not still get it through the door to the cafeteria where our tour ended. And over a bowl of vegetables and tofu Mr. Liak told me it was a dream of his to employ someone such as myself to consult with his professional staff and help inspire and encourage other patients. Can you imagine? In Singapore, you don’t have to, it’s on the drawing boards.

Leaving Alexandra Hospital I thought if I ever need to be in the hospital maybe I would consider, if time permitted, hopping a flight to Singapore. Meanwhile, I’m happy to do what I can to help the staff and patients here. And now that I’ve finished this post, do what most people who are not in the hospital do in Singapore, shop. 

ADA recommends treating type 2 diabetes more aggressively

I could be snide and say, “Well, that only took a million years” or I could be thankful and say a lot of patients should now live longer with less complications.

In an article, “New Major Changes in Recommendations for the Treatment of Type 2 Diabetes by ADA and EASD” that appeared in DiabetesInControl, an online newsletter for health professionals, the ADA has issued new recommendations for treating type 2 diabetes more aggressively. 

What motivates the change appears to be the conclusion, “that much of the morbidity associated with long-term microvascular and neuropathic complications can be substantially reduced by interventions that achieve glucose levels close to the non-diabetic range. Although new classes of medications and numerous combinations have been demonstrated to lower glycemia, current-day management has failed to achieve and maintain the glycemic levels most likely to provide optimal healthcare status for people with diabetes.”

Translation: Yea, we got new medicines to keep blood sugar in control but most people’s blood sugar still isn’t in control. 

So new ADA health-care providers therapeutic recommendations are to speed the introduction of insulin:

Step 1 — Lifestyle intervention and use of metformin because of its effect on glycemia, absence of weight gain or hypoglycemia, good tolerability profile and relatively low cost. 

Step 2 — Add another medication, either insulin or a sulfonylurea, within 2 to 3 months of starting step 1 or at any time when target hemoglobin A1c level is not achieved or if metformin is contraindicated or poorly tolerated. For patients who have hemoglobin A1c level of more than 8.5% or symptoms secondary to hyperglycemia, insulin is preferred, typically a basal (intermediate- or long-acting) insulin. 

Step 3 — Further adjustments by starting or intensifying insulin therapy with additional injections that might include a short- or rapid-acting insulin given before selected meals to curtail postprandial hyperglycemia. 

David M. Nathan, MD, from the Diabetes Center of Massachusetts General Hospital in Boston says, “The epidemic of type 2 diabetes and the recognition that achieving specific glycemic goals can substantially reduce morbidity, have made the effective treatment of hyperglycemia a top priority.”  Hmmm…it wasn’t before? Oops, there goes my snide side. Hard for a type 1 to fathom the laxity in treating type 2 diabetes. “Maintaining glycemic levels as close to the non-diabetic range as possible,” continued Nathan, “has been demonstrated to have a powerful beneficial effect on diabetes-specific microvascular complications, including retinopathy, nephropathy, and neuropathy, in the setting of type 1 diabetes; in type 2 diabetes, more intensive treatment strategies have likewise been demonstrated to reduce microvascular complications.”

We can only hope physicians will know the new recommendations and patients will get effective treatment. If I were a type 2 I’d ask my health care provider for the best treatment to control my blood sugar to normal levels, whether it’s with a pill or a syringe. For most of us, it’ll mean more years on the planet and spending them happier and healthier.

 

 

Can you imagine you may die today taking your insulin injection?

How our brains work faced with a disaster situation

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The other morning I heard on the Today show someone with type 1 diabetes say, “Any moment I could die,” referring to a low from taking too much insulin. Yes, it’s possible, but how many times do you ever think it could really happen to you? Ten times a week? Once a day? Ever? Never? People die of diabetes every day, but usually due to something that’s been brewing for years, like heart disease, stroke or kidney disease. Yet anyone using insulin can die any minute, any day, by erring with their dose.

So how is it that we can get up every day, go about our business, take our medicine and never think about this? I was musing about this because of a book I’m now reading, The Unthinkable: Who Survives When Disaster Strikes – and Why by Amanda Riply. It’s about how our brains work when we’re in dire circumstances: a fire, plane crash, kidnapping, 9/11. People don’t react and respond at all the way we expect. Our brain shuts down and it both heightens and blocks certain senses. People become temporarily blind or deaf, unable to see or hear–obviously blocking the horror of the event. Time appears to slow down for most, while it speeds up for some. People freeze, they literally go limp and lifeless, probably an adaptation of how we escaped predatory animals eons ago. We move into a space of denial and disassociation during the event.

Is this denial and disassociation at work when you take insulin, a life-giving and life-threatening medicine? I go far to protect myself living with diabetes: I’m enormously educated about diabetes, how it works, how to care for myself, I know how to prevent hypoglycemia (low blood sugar) and how to treat it if it should occur. Yet in 31 years of using insulin I’ve never had a Glucagon kit (injectible glucose if you lose consciousness) in the house and when I take my injection three to seven times a day I never fear or panic. In fact, I’m more likely to take a little too much insulin rather than a little too little, preferring to tolerate a low rather than long-term complications. I see insulin only as protecting me against complications, not the damage it can do.  

Just like any thought of the “unthinkable,” who ever thinks something awful will happen to them? There’s almost a kind of arrogance in this thinking. “Hubris” as a dear friend and I used to say, using the word often just because we loved how it sounded.  If the brain blocks us from thinking something horrible can happen to us ordinarily, maybe it’s doing the same every day when it comes to taking insulin. I guess it’s a good thing or we’d run screaming every time we had to pick up that syringe or press buttons on our pump. 

The Unthinkable is a fascinating read. You won’t find anything about diabetes in it, but then again, you might just get something about diabetes out of it.