By Laurence D. Chalem
Most of our lives we are caught up in the moment. Let us take a moment to look at diabetes from 10,000 feet up, where we can see clear patterns and insight emerge from the fog of hypoglycemia, and its opposite, hyperglycemia.
When injected bolus insulin is low or zero, and carbohydrate consumption is high, we are presented with the classical triad of diabetes symptoms: polyuria, polydipsia, and polyphagia: respectively, frequent urination, increased thirst and consequent increased fluid intake, and increased appetite.
Other manifestations will include weight loss (despite normal or increased eating), irreducible fatigue, and changes in the shape of the lenses of the eyes, resulting in vision changes.
When the glucose concentration in the blood is raised beyond the renal threshold, reabsorption of glucose in the proximal renal tubuli is incomplete, and part of the glucose remains in the urine (glycosuria).
Patients may also present with diabetic ketoacidosis (DKA), an extreme state of metabolic dysregulation characterized by the smell of acetone on the patient's breath; a rapid, deep breathing known as Kussmaul breathing; nausea; vomiting and abdominal pain; and any altered states of consciousness or arousal such as hostility and mania or, equally, confusion and lethargy. In severe DKA, coma may follow, progressing to death.
Where one eats a moderate amount of carbohydrates and injects a moderate amount of bolus insulin, lies the typical diabetes treatment. I define a moderate intake of carbohydrates as 30%-40% of calories; anything more than that could very well be considered high.
"Eat a balanced diet and learn to adjust your insulin accordingly" is the principal treatment that is followed here. It is possible to attain near-normal A1c levels with this approach, i.e., with great effort, however, normal bodyweight may prove unreachable.
At the other extreme, when injected insulin is high, and carbohydrates consumed are too low, severe hypoglycemia could result, necessitating a visit from the local paramedics when subsequent low blood glucose causes unconsciousness. If not attended to quickly, coma and death could occur.
Too, if carbohydrates and insulin injected are high, the result is a hyper-hypo-glycemic swing - a rollercoaster ride if you will - of great magnitude, where the patient is constantly adjusting carbohydrate and insulin loads to offset their blood sugar.
But look what happens when both carbohydrates consumed and insulin injected are as low as possible. If one doesn't eat a great many carbohydrates, and, subsequently, does not need to inject much insulin as a result, one can achieve a stable, normal blood sugar concentration and enjoy the benefits of a healthy, happy life including a stable or decreasing weight, and less anxiety not having to think about whether one has injected the right amount of bolus insulin or eaten the right amount of carbohydrates several times daily. And testing can be reduced to once a day, in the morning, to validate your successful basal insulin dosing, i.e., whether or not your morning BG is in the 70-110 mg/dL range. This home base is where thriving begins.
At the zero bolus-insulin and near-zero carbohydrate home, you may thrive for a long, long time.
Although the use of exogenous bolus insulin as a treatment to mitigate the effects of carbohydrate consumption was innovative, exciting, and promising nearly a century ago, its use has become - save on the acutely serious hyperglycemic - obsolete with the development of synthetic basal insulin, and the knowledge that carbohydrates are non-essential.
The lowest complexity matched with the lowest skill & knowledge, will result in a diabetic on the brink. It is quite easy for them to eat carbohydrates at will and develop the hyperglycemic symptoms of full-blown diabetes: polyuria, glycosuria, polydipsia, polyphagia, ketoacidosis, weight loss, etc., culminating in shortened life span. Knowledge for the patient about diabetes may be non-existent, and they will likely seek out medical attention for help, though, unfortunately, some don't or for many reasons even if they do, helpful advice is not available. Acquaintances will also most likely notice the change in persona or appearance, and they too will make it a point to tell the person that something is wrong.
"Diabetes Managed" represents a diabetic trying to follow the instructions and advice of his or her general practitioner, though both are influenced by a wide variety of stakeholders with oftentimes divergent self-interests.
By default, advocates of each group act in their own perceived best interest, based upon their knowledge and skill, which may in turn be based upon the state of information available at their time of training or education. Many of the stakeholders, with the exception of the end users themselves - the people with diabetes - have significant power. In fact, some have a near-absolute advantage in the marketplace - the ability to influence behavior without question or pause - leaving the buyer of an optimal diabetes treatment treating their diabetes sub-optimally, i.e., carbohydrate & bolus-insulin intensive.
And the results? Perhaps an HbA1c at or below 7%, weight gain, increasing blood pressure, too much time spent counting carbohydrates and measuring insulin doses, anxiety caused by constantly wondering whether or not too much or too little carbohydrates were eaten or insulin dosed, the ever present chance of hypo- or hyper-glycemia, constant blood sugar testing, and the list goes on.
Although the science behind the drugs that either limit the amount of glycogen released from the liver or that bind and carry glucose from the blood to the receptors that transport it across cell membranes is remarkable, it is based upon two assumptions: (I) that carbohydrates are an essential majority part of the diet, and/or (II) that through education, a patient cannot, will not, or should not keep from consuming them. Remove those key assumptions, and the house of cards from which that remarkable science is based comes toppling down.
As knowledge about diabetes increases, trusted advisers and patients alike will choose a less-complex method, one that transcends diabetes by avoiding the root cause of symptoms and complications - carbohydrates - and, instead, consuming fat & protein only, resulting in benefits such as healthy weight loss, satiety, reduced mTOR activity, normal blood pressure, etc.; in short, leading to a longer, happier, healthier life.
To transcend diabetes requires reduced carbohydrate consumption to near zero, with emphasis on a combination of fat and protein. It is orders of magnitude less complex, less worrisome, and less risky than counting carbohydrates and matching it with doses of bolus insulin. It is simple.
When the blood sugar function is optimized this way, then, a new, refreshing meaning to the words of Frederick G. Banting, largely credited for the idea behind the work which led to the discovery of insulin, becomes evident: "...with the relief of the symptoms of the disease...the pessimistic, melancholy diabetic becomes optimistic and cheerful."
Laurence D. Chalem (b. 1963), a type 1 diabetic, has been passionately researching diabetes for the last decade. In his most recent book, Essential Diabetes Leadership, Laurence investigates the literature of the last three centuries in search of an optimal treatment of diabetes.
Updated August 2011