Archive-name: diabetes/faq/part1
Posting-Frequency: biweekly
Last-modified: 15 Dec 2006 (excludes change list and Table of Contents)

Changes: add aspartame topic in research section (14 July 2005)
         fix Avogadro's number (15 Dec 2006)

------------------------------

Subject: READ THIS FIRST

Copyright 1993-2006 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?
  Is aspartame dangerous?
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 6.023*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
   ------     -----     --------------
     2.0        35      extremely low, danger of unconciousness
     3.0        55      low, marginal insulin reaction
     4.0        75      slightly low, first symptoms of lethargy etc.
     5.5       100      mecca
    5 - 6     90-110    normal preprandial in nondiabetics
     8.0       150      normal postprandial in nondiabetics
    10.0       180      maximum postprandial in nondiabetics
    11.0       200
    15.0       270      a little high to very high depending on patient
    16.5       300
    20.0       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
             requires treatment by insulin. Not sex-linked. Also referred to
             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

------------------------------

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.htm

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

------------------------------

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.

1) 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.

2) 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.

3) 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?