Vietnam Veterans with Diabetes, Diabetes, Vietnam, Veterans




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Posted by Randall W Brown on February 9, 2016 at 1:40 PM Comments comments (0)

Diabetes and Dementia May Be Linked

By Theresa Bebbington

WebMD Health News Reviewed by Sheena Meredith, MD

Feb. 20, 2015 -- People with mild cognitive impairment may be more likely to one day get dementia if they also have diabetes, depression, or low levels of the B vitamin folate, researchers say.

They also found that people who eat a Mediterranean-style diet have lower risks.

Mild cognitive impairment (MCI) refers to a group of symptoms in which people struggle with their ability to think and remember what they know. They often find it tricky to remember day-to-day things, but their memory troubles aren't severe enough to cause serious problems with everyday living.

Their decline in thinking and memory is greater than the typical slippage that happens with normal aging, although it's not as severe as with dementia.

Dementia refers to a group of symptoms that include severe memory loss and problems with thinking, solving problems, and using language. These problems are significant enough to affect a person's everyday life.

About 46% of people with MCI will get dementia within 3 years, compared to only 3% of people who have normal age-related thinking declines.

Millions of Americans have some type of dementia, including Alzheimer’s disease, according to the Alzheimer’s Association. This number is expected to grow in coming years.

The study, published in the American Journal of Psychiatry, reviewed 62 research studies to look for things that could indicate the risk of MCI worsening to dementia. Almost 16,000 people with MCI were included in these studies.

The researchers, led by Prof. Gill Livingston of University College London, found that in people with MCI:

Diabetes seems to make it more likely that MCI will progress to dementia.

Those who also have depression were at risk of MCI progressing to dementia, but evidence was inconclusive.

Those with lower folate levels were more at risk of MCI eventually becoming dementia.

People who are also lifelong heavy alcohol drinkers may be more likely to see MCI worsen to dementia. But moderate drinkers may be less likely than abstainers to progress to dementia.

"While there's currently no cure [for dementia], we know that the best way to reduce your dementia risk is to eat a Mediterranean diet rich in oily fish and vegetables, keep physically active, not smoke and have your blood pressure regularly checked," says Dr. Clare Walton, research manager at Alzheimer's Society in the U.K.

New Drug

Posted by Randall W Brown on March 10, 2015 at 10:30 AM Comments comments (0)

In late February, Sanofi announced FDA approval of its once-daily, long-acting basal insulin Toujeo. Toujeo is the same type of basal insulin (glargine) as Sanofi’s blockbuster Lantus, but a stronger version. In Toujeo, each milliliter of liquid carries 300 units of insulin (“U300”), whereas Lantus only carries 100 units of insulin per milliliter (“U100”). Sanofi hopes to bring Toujeo to the market in the next month – a very quick turnaround! It has also been tentatively approved in Europe, with a final decision expected in the coming months. Pricing and insurance information are not available at this time. Toujeo will be sold in a new SoloStar pen that will carry 450 units, 50% more than the 300-unit Lantus pen – a major improvement for the many people who require larger doses of insulin. In Sanofi’s New Medicines Seminar in November, we learned that Toujeo will come with a substantial patient support program, using multiple forms of contact (online, phone, in person) to help patients transition onto the new insulin. Toujeo’s approval was based on the results of the EDITION clinical trials, which evaluated its efficacy and safety compared to Lantus in over 3,500 adults with type 1 and type 2 diabetes. In short, Toujeo was found to be just as safe and effective as Lantus. In the trials, Toujeo was slightly more effective at lowering A1c than Lantus, had no significant difference in weight gain, and had mixed results for potential hypoglycemia benefits (some trials showed a benefit, others did not). We wonder if the real-world experience with Toujeo will show larger benefits on hypoglycemia. Full information on the drug’s dosing and side effects can be found here. Toujeo’s approval clears the path for a combination with the GLP-1 agonist lixisenatide. Novo Nordisk’s Xultophy (a combination of Victoza and Tresiba) is the only currently approved GLP-1 agonist/ basal insulin combination drug, having received approval in Europe last September. While Toujeo could be a valuable option for many by itself, we most look forward to its combination with lixisenatide. –ER/AJW - See more at:


Posted by Randall W Brown on February 22, 2015 at 1:30 PM Comments comments (0)

Welcome to the TCOYD Research Registry


On the next pages you will find a complete description of the Registry, its purpose and what will happen if you decide to become a member. At the end, you can click a button to sign up.


If you agree to participate, you will then be asked to complete a very brief survey so that in the future we can invite you to participate in new projects that might be right for you. Please note you must be 18 years or older to participate.


Your participation will help us to learn more about diabetes.


Please begin by clicking "Next"



Risks, Complications & Treatments

Posted by Randall W Brown on February 19, 2015 at 1:10 PM Comments comments (0)

Comprehensive Guide to Research on Risk, Complications and Treatment

Substance abuse is described as the excessive use of a substance such as alcohol or drugs that results in significant clinical impairments as well as the loss of ability to function academically, professionally, and socially [1]. An individual who was healthy before the substance abuse began will typically begin to experience serious health problems over time, but extensive damage may be avoided or reversed if effective substance abuse treatment is received.

This is not the case, however, for individuals who have been diagnosed with diabetes, and although this is a manageable disease with proper treatment, substance abuse may cause it to become life-threatening. This guide will discuss, in detail, how substance abuse can negatively impact the life and health of a person with diabetes.

Types of diabetes

Diabetes, also referred to as diabetes mellitus, is a condition in which the body is unable to properly regulate blood sugar levels. There are two forms known as type 1 and type 2 diabetes, but in order to better understand the difference between the two types, the role that insulin plays in the regulation of healthy blood sugar levels will be briefly described. During the digestive process, carbohydrates are broken down into glucose, which is a form of sugar that easily enters the bloodstream and is used by the body for energy.


The pancreas normally responds to increasing blood sugar levels by initiating the production of the hormone known as insulin. As insulin levels increase, it signals the transfer of glucose into cells throughout the body and it also ensures that excess glucose will be stored in the liver in order to prevent high blood sugar levels.

Type 1 diabetes, which is also called juvenile or insulin dependent diabetes, develops due to the loss of cells in the pancreas that are responsible for producing insulin. This causes either no insulin or miniscule amounts to be produced. Type 1 diabetes is also commonly referred to as juvenile diabetes because it is often diagnosed during childhood [2].

"Hyperglycemia refers to abnormally high blood sugar levels and this occurs when there is not enough insulin in the body."

Type 2 diabetes, which is the most common form, develops as a result of the body’s inability to properly use insulin. This inappropriate response is referred to as insulin resistance. Initially the pancreas begins to produce extra insulin in order to counteract the body’s resistance, but eventually the pancreas cannot produce the amount of insulin that is needed to maintain normal blood sugar levels [3].

Although the mechanisms are different, both of these types of diabetes prevent sugar that is in the form of glucose from entering the body’s cells and if the condition is not properly treated, blood sugar levels become dangerously high.


Health problems caused by uncontrolled diabetes

​Uncontrolled diabetes may result in serious medical problems such as hyperglycemia or hypoglycemia [4, 5]. Hyperglycemia refers to abnormally high blood sugar levels and this occurs when there is not enough insulin in the body. Hypoglycemia, or abnormally low blood sugar levels, occurs when there is too much insulin in the body and not enough sugar in the blood in the form of glucose. Both of these complications can cause a number of dangerous health problems that include [4, 5]:

Organ damage (e.g., kidneys) if hyperglycemia develops

Damage to the small blood vessels in the eyes, which may lead to blindness

Nerve damage, called diabetic neuropathy, which may lead to skin ulcers and other injuries that heal poorly

Paralysis and limb amputations due to nerve damage and cumulative injury

Blood vessel damage in the heart, which increases the risk of atherosclerosis, heart attacks and strokes

An increased susceptibility to high blood pressure

A coma or even death due to hyper- or hypoglycemia

In addition, when insulin levels are too low, the body may also begin to break down fat and use it as an energy source, but this causes toxic acids called ketones to build up in the bloodstream. This phenomenon is known as diabetic ketoacidosis and it is a medical emergency [6]. These types of complications are intensified by alcohol and drug abuse. Furthermore, alcohol abuse as well as a poor diet throughout childhood or adulthood have been labeled as possible causes for type 2 diabetes [3].

The negative impact of alcohol abuse on diabetes

Individuals who have been diagnosed with diabetes have to be especially careful when consuming alcohol. Typically, women who have diabetes are advised to consume only one drink a day and only two drinks are advised for men with diabetes.

However, if a person with diabetes already has hypertension, nerve damage, or eye problems, the consumption of alcohol is usually not recommended at all. This is because drinks such as wine and beer contain carbohydrates that can be broken down into glucose (sugar) and consuming more than the recommended amount of alcohol may cause blood sugar levels to rapidly increase.

Alcohol slows down the liver

Drinking alcohol also hinders the liver from releasing stored glucose; this can lead to dangerously low blood sugar levels. It takes about two hours for the liver to break down the alcohol that is contained in one drink. The energy spent in doing so would otherwise be utilized for a healthy release of stored glucose. All told, alcohol slows down the body’s reaction time, disrupts the liver’s ability to release glucose, and may cause individuals with type 1 or 2 diabetes to slowly develop hypoglycemia [7, 8].


For individuals who have type 1 diabetes, even drinking small amounts of alcohol along with a meal in the evening may result in the onset of hypoglycemia up to 24 hours later [7, 9]. This is believed to be due to the delay in the regulatory processes of the liver as well as the impaired ability of the individual to detect a drop in blood sugar early enough to improve the condition by eating, for example [9]. These types of health problems worsen dramatically in individuals with diabetes who not only drink, but abuse alcohol.

Furthermore, the symptoms of hypoglycemia and alcohol intoxication are quite similar sometimes. Failure to discern a hypoglycemic episode from acute intoxication can easily result with the person with diabetes not receiving the proper care. If the person with diabetes is not wearing an I.D. bracelet, hypoglycemia may not be suspected right away, even when evaluated in an emergency room. The resultant delay of care can put the individual at further risk of suffering from more serious complications.

Alcohol worsens nerve damage

One of the complications of uncontrolled diabetes is nerve damage, and excessive alcohol consumption or alcohol abuse can worsen the symptoms. If diabetic nerve damage develops it can affect both sensory (e.g., sensitivity to touch and temperature) and motor function.


Alcohol abuse causes a condition known as hyperalgesia in which the already damaged nerves become even more sensitive to pain [10, 11]. In other words, if an individual with diabetes is already suffering from pain due to nerve damage, alcohol abuse can dramatically increase the amount of pain that is felt.

In addition, alcohol abuse leads to a continuous release of certain hormones that are meant to control pain and prevent further damage to the body. What results, however, is a sustained increase in activity of the nervous system, which will actually further intensify pain signaling [12, 13].

Therefore, alcohol abuse makes it much harder for the body to control the pain that may have already developed due to diabetic nerve damage and in doing so makes the individual’s condition dramatically worse.

Alcohol abuse makes eye problems worse

An occasional drink may cause temporary double vision or blurry vision, but alcohol abuse can worsen any type of eye disease that has been caused by an individual’s diabetes [14]. Alcohol slows down brain activity, which causes the pupils to react more slowly and this alters their ability to widen or constrict properly.

Over time, this also permanently weakens the muscles in the eyes. As a result, alcohol abuse can lead to blurred vision or double vision that is permanent, especially in diabetics who may have already had existing vision problems.


Alcohol abuse also causes blood vessels in the eyes to swell and this produces a red, bloodshot appearance. Rapid eye movement, in which the eyes involuntarily move back and forth, may develop over time as well in the individual abusing alcohol.

If a person with diabetes begins to develop eye problems, the right form of treatment may help slow or prevent further vision loss. However, individuals with diabetes who also drink excessive amounts of alcohol will experience unchecked deterioration of their vision.

The vision loss that occurs from alcohol abuse is somewhat gradual and for some individuals, alcohol abuse is even linked to the onset of type 2 diabetes [3]. The effects of alcohol abuse on vision are more prominent in individuals with type 2 diabetes [14]. This is mainly because type 1 diabetes is often diagnosed during childhood and adolescence, while type 2 diabetes is typically diagnosed during adulthood.

Alcohol reduces the effectiveness of diabetes medication

Alcohol reduces the effectiveness of insulin injections or pumps that most type 1 diabetics use and certain medications that promote insulin activity in type 2 diabetics, such as Prandin (meglitinides) and sulfonylureas (glyburide, glipizide) [15, 16].


Insulin injections and pumps provide specific quantities of insulin to type 1 diabetics. Pumps, in particular, are programmed to deliver a small amount of insulin continuously throughout the day and a larger amount during mealtime. Drinking large amounts of alcohol alters blood sugar levels and makes it difficult for an individual to properly program the insulin pump. In other words, the pump cannot automatically adjust the insulin dosage to accommodate the rapidly changing blood sugar levels after alcohol consumption. In addition, drinking excessive amounts of alcohol decreases the body’s ability to respond to injected insulin. This is because the body begins to focus much of its metabolic energy on removing the alcohol from the system, which prevents proper blood sugar regulation. This situation can become especially dangerous for type 1 diabetics.

In addition, certain medications for type 2 diabetics stimulate the pancreas in order for more insulin to be produced after a meal. Alcohol, however, prevents the body from responding to the diabetes pills in a timely manner, thereby hindering the ability of the body to work in conjunction with the medication to regulate blood sugar levels.

Drinking excessive amounts of alcohol even makes some individuals more hungry than usual. Additionally, an intoxicated individual is more apt to make poor food choices, and have more difficulty gauging the amount eaten. The combination of eating too much along with the alcohol’s potential to lower the effectiveness of medication can result in high blood sugar levels (hyperglycemia).

Drug use and diabetes

Substance abuse isn’t limited to just alcohol. Substance abuse can also include the excessive use of recreational or illegal drugs, which are defined as chemical agents that change the way the brain and body normally function [1]. Recreational and illegal drugs are those that have not been approved by a physician for medical purposes. This guide will focus on those drugs that are used by people with diabetes that can negatively impact their health.


Although drugs tend to affect people in different ways, the harmful side effects of most recreational and illegal drugs make them especially dangerous for individuals who have diabetes. Drug abuse may result in both physical and mental problems (e.g., organ or brain damage) that can alter an individual’s ability to properly use diabetes medication.

Taking drugs can also lead to an addiction, depression, or an unexpected overdose. Moreover, many illegal drugs may counteract or reduce the effectiveness of medication that people with diabetes use to maintain healthy blood sugar levels. Complications due to drug use that lead to hyper- or hypoglycemia can result in coma, or death for a person who is diabetic. Understanding the health risks that are associated with diabetes and drug abuse is an important way to stay safe and healthy.

The effects of smoking on diabetes

Compared to the general population, the rates of cigarette smoking are much higher in alcohol and substance abusers. No guide would be complete without inclusion of the harmful effects of smoking in individuals with diabetes who may or may not also be concurrent substance abusers.

On its own, uncontrolled diabetes may result in damage to the blood vessels of the heart, which increases the risk of heart diseases (e.g., atherosclerosis), heart attack and strokes [4]. Smoking is harmful for people who do not have diabetes because it reduces blood circulation throughout the entire body, increases the risk of heart disease, and speeds up the progression of heart disease [17].


Consequently, individuals who have diabetes are at an even greater risk of suffering from heart problems if they smoke. Individuals with diabetes who smoke also tend to die more often from heart disease than individuals with diabetes who do not smoke [18]. This is because diabetic complications may have already started to damage blood vessels in the heart and smoking further compounds this circulatory deterioration.

People with diabetes who smoke also tend to suffer from vision problems, lung disease, cancer and reduced blood sugar control; the latter of which is especially a problem for type 1 diabetics [19-21]. Moreover, smoking in combination with heavy drinking increases the risk of developing kidney disease [22], and individuals with diabetes who do not smoke are already susceptible to kidney damage. If an individual’s diabetes is being properly controlled through medication, refraining from smoking altogether or quitting is essential toward maintaining good health.

The effects of illicit drugs on diabetes

One of the main problems that can occur from taking illicit drugs is that often individuals with type 1 diabetes forget to eat properly, which can lead to alarmingly low blood sugar. However, diabetic individuals may also forget to administer their regularly scheduled insulin injection or set their pump properly and failing to do so can lead to dangerously high blood sugars levels.


Forgetting to eat is especially dangerous for type 1 diabetics because low blood sugar levels may cause the body to begin to break down fats and release toxic acids, called ketones, into the bloodstream. This condition is known as ketoacidosis and the symptoms that it causes—dehydration, vomiting, abdominal pain and a sweet acetone-like smell on the breath—indicate that immediate medical attention has become necessary.

Although type 1 diabetics are highly susceptible to this condition, individuals who have type 2 diabetes rarely suffer from it.

Many individuals with type 2 diabetes do not usually need insulin injections and instead manage their condition with different types of prescribed medication that include:

Pills that help stimulate the pancreas to create more insulin during specific times of the day (e.g., mealtime).

Pills that reduce the production of glucose (sugar) in the liver or cause excess amounts of glucose to be excreted through urine.

Pills that slow the breakdown of starches into glucose by preventing the digestion of certain foods in the intestine.

Similar to the problems that occur for type 1 diabetics, taking illicit drugs can cause individuals with type 2 diabetes to forget to take their medication at appropriate times and this results in high blood sugar levels.

Commonly taken illicit drugs

There are three common types of illicit drugs that may be taken by individuals with and without diabetes. These include: stimulants, depressants and hallucinogens.

Although there is not a lot of information available regarding how illicit drugs affect people with type 1 and type 2 diabetes, the side effects that certain substances are known to cause put individuals with diabetes at an increased risk of suffering from serious health problems.


Stimulants are substances that speed up processes in the body such as blood pressure and heart rate, but also have the ability to increase body temperature. Nicotine, caffeine, methamphetamine (e.g., speed or crystal meth), ecstasy (MDMA) and cocaine all have stimulant effects.

Individuals with diabetes who take stimulants often suffer from low blood sugar (hypoglycemia) because the body breaks down carbohydrates faster than usual. If this begins to happen, a source of carbohydrates such as a glass of juice or a few pieces of candy have to be quickly consumed to avoid the symptoms of hypoglycemia, such as shaking, dizziness and even fainting. However, the stimulant may alter mental processes, decrease a person’s ability to recognize the symptoms of low blood sugar or cause a person to forget to eat altogether.

Ecstasy (MDMA)

One commonly taken illicit drug with stimulant effects is ecstasy (MDMA). Ecstasy is usually purchased on the street, meaning that the actual contents of the drug are unknown. In other words, it is hard to know whether the drug contains just ecstasy or additional harmful substances.

Individuals with diabetes often think that ecstasy is safer than other drugs such as crystal meth or speed [23], but it contains many of the same poisonous ingredients as other stimulants. Harmful side effects that are extremely dangerous for individuals already managing diabetes include:

Emotional problems such as depression, anxiety or paranoia

Memory and sleep problems

The breakdown of muscle tissue, which leads to the release of muscle enzymes into the bloodstream that may cause kidney damage or kidney failure

A rapid decrease of sodium (salt) in the blood, which leads to a loss of normal functions in the body

An irregular, rapid or slow heartbeat, which can be fatal


These types of complications can hinder an individual’s decision to take their scheduled medication or, if taken, render the medication ineffective.

After a stimulant is taken, there frequently may also be a loss of appetite. This can be quite dangerous when it occurs, since an individual who has diabetes may begin to experience low blood sugar but not the usual queues to start eating. Another short-term effect of stimulants is that they can make one feel as if they are able to engage in physical activity for prolonged periods without taking a break. This is particularly problematic for type 1 diabetics who forget to eat or become dehydrated as they may develop the aforementioned condition of ketoacidosis, which is a medical emergency.

Dizziness, nausea and vomiting may also develop shortly after taking stimulants such as ecstasy and this, in turn, influences the amount of food consumed and the resultant changes in blood sugar levels.

Stimulants, in general, cause various changes in the body that make it hard for blood sugar levels to be regulated properly. Moreover, the emotional and physical side effects can influence the way an individual with diabetes takes medication, putting them at further risk of suffering from fatal complications.


Cocaine is a highly addictive stimulant that causes blood vessels to constrict and subsequently increases blood pressure. This side effect increases the risk of heart attacks and strokes in individuals with diabetes who are already predisposed to these health problems due to their condition.


Cocaine use also causes appetite suppression. Regular cocaine users tend to eat fewer balanced meals than those who do not use cocaine [24]. Cocaine abuse is also associated with the increased consumption of fatty foods [24].

This type of irregular eating pattern can become quite harmful for diabetics. Forgetting to eat properly due to a reduced appetite will eventually lead to dangerously low blood sugar levels (hypoglycemia); an especially problematic health issue for type 1 diabetics. However, having difficulty gauging the amount fatty foods that are eaten when feelings of hunger or hypoglycemia eventually prompt an individual with diabetes to eat may hinder the effectiveness of medication such as insulin injections or diabetes pills and cause hyperglycemia.



Methamphetamines are very dangerous for people who have diabetes because this drug alters insulin activity and hormone production, which leads to the release of too much glucose (sugar) and results in high blood sugar levels [25].

Methamphetamine use can also lead to a loss of appetite, memory loss and depression, especially if it is taken regularly. All of which may result in unhealthy blood sugar levels for diabetics.


Depressants refer to substances that slow down normal processes in the body and physical activity by altering the manner in which the brain sends and receives signals. Alcohol, marijuana (cannabis) and benzodiazepines (BZD), as well as opioids such as methadone, codeine, morphine and heroin can be loosely categorized in this group based on their depressant effects.


Marijuana, most frequently used as a recreational drug, is one of the most commonly used substances by adolescents who have type 1 diabetes [26]. Most people with diabetes who take marijuana assume that it is less harmful than heroin or cocaine, but the effects that marijuana has on mental processes can lead to serious problems such as:


Increased hunger (typically referred to as having the munchies) – this may result in overeating that, in turn, leads to high blood sugar levels (hyperglycemia).

Low blood sugar (hypoglycemia) if the intoxication of the drug causes an individual with diabetes to forget to eat.

Short-term memory problems, which may cause people to take their insulin injections or diabetes medications incorrectly or eat foods that negatively alter their blood sugar levels without realizing it.

Concentration, cognition, as well as hand-eye coordination may be impaired by marijuana, resulting in forgotten or improper administration of diabetes meds.

Depressive symptoms and an altered state of mind may develop if marijuana is taken regularly and substance abuse develops.

Serious damage to different organs such as the kidneys and heart if marijuana is combined with alcohol.


Heroin, in particular, is a highly dangerous and addictive depressant that is typically bought on the streets. Similar to other depressants, it alters eating habits and hormone production, making it harder for the body to maintain healthy blood sugar levels even when a diabetic is taking insulin or diabetes pills [27]. Additional harmful effects include:

A brief sense of euphoria followed by a state of drowsiness and confusion that can make an individual forget to take an insulin shot or diabetes pill.

Slowed breathing, which may lead to death.

Liver, brain, and lung damage

Blood vessel damage, bruising, and poor circulation


People who have diabetes are already highly susceptible to blood vessel and organ damage, ulcers and amputations due to circulation problems. Taking drugs such as heroin causes extensive damage to the body that a diabetic would struggle to recover from without intensive substance abuse treatment.

Other opioids such as morphine also increase the concentration of several hormones including glucagon, which is a hormone produced in the pancreas that leads to higher levels of glucose (sugar) in the bloodstream [27]. Tight control of blood sugar levels becomes difficult with these effects. Opioids, in this way, counteract the effects of some diabetes medication and should be avoided by diabetics.



Hallucinogens, as the name sounds, are substances that may cause hallucinations by affecting the mind and the senses. If hallucinations occur, an individual may see objects that are distorted or not really there and this may cause paranoia, abnormal behavior and panic attacks.

PCP, LSD, ketamine, mescaline and magic mushrooms are all classified as hallucinogens. Ecstasy and large amounts of marijuana may also elicit effects similar to the hallucinogens,


Ketamine is a dissociative drug with some hallucinogenic properties that is often used for medical purposes as a general anesthetic. It prevents sensory information such as pain signals from being sent and received by the brain. The effects that ketamine can have on a person depends of different factors such as weight, height, and health status. For most people, it causes distorted hearing, vision, thinking, and emotional changes.

Serious complications and bodily injury may occur for people with diabetes who use this drug mainly due to side effects such as feeling detached from the body or not being able to move at all. Ketamine also causes confusion, concentration problems and memory loss, which leads to changes in eating patterns and forgetfulness.


As mentioned in conjunction with other substances, type 1 diabetics who forget to take their insulin or forget to eat often develop ketoacidosis and this is a medical emergency due to the toxic buildup of acid in the blood. Type 2 diabetics are not as susceptible to ketoacidosis, but those who forget to take their medication risk suffering from dangerously high blood sugar or low blood sugar if they forget to eat. These types of complications can also lead to a coma and become fatal.

Moreover, chronic ketamine abuse has been linked to damage of the gastrointestinal and urinary tract, the brain, heart and liver [28]. These types of health problems are extremely dangerous for type 1 and type 2 diabetics.

Additional side effects that may occur after taking ketamine include:

Panic and anxiety attacks, paranoia, dangerous and abnormal behavior

Blurred vision, slurred speech and slower than normal hand and eye coordination

Increased heart rate, blood pressure and breathing

Sweating, drowsiness, nausea and vomiting

Unless a licensed physician is administering this drug under close supervision, it should not be taken by people who have diabetes.

The dangers of mixing drugs

People who are struggling with substance abuse may also mix different drugs or combine them with alcohol. These combinations can increase the risk of fainting, vomiting, breathing abnormalities, impulsive or dangerous behavior, accidents, as well as overdose and death. Diabetes can quickly become a deadly condition if medication is not taken or if its effects are reduced due to illicit drugs and alcohol that may be circulating in the body. Furthermore, if a person is not quickly identified as having diabetes (by medical chart notation, or detection of diabetic I.D. bracelet), and he or she presents as a patient to an emergency room with symptoms of a combination drug overdose or alcohol intoxication, diabetic specific treatment may be delayed or overlooked altogether.

Reducing harm for those with diabetes

Taking any type of drug other than what has been prescribed to treat diabetes may alter blood sugar levels as well as the body’s ability to use diabetes medication. The following are important steps that should be taken to avoid serious health complications:

Ask questions and do research about the side effects of a new medication before deciding if it should be taken. Doctors can usually answer questions about possible drug interactions and side effects; reputable internet sources often provide useful information as well.

Ill advised as it may be to do so; individuals with diabetes who decide to take an illicit or new drug should always do so in the presence of another person who knows what type of drug it is. This helps ensure that the appropriate care will be provided if serious complications arise.

Never stop taking diabetes medication as this often results in high blood sugar levels and other serious health problems (e.g., organ damage, coma).

Always wear a diabetic medical I.D. bracelet as this helps individuals quickly identify this condition and often saves lives when an emergency arises.

Find ways to avoid peer pressure and stand up to people who initiate it. True friends do not pressure each other to put their health at risk.

Seek professional treatment for substance abuse

Type 1 diabetes is diagnosed in children and adolescents more often than in adults, and substance abuse—particularly the use of recreational drugs—is becoming increasingly popular among adolescents [29]. Alcohol use and cigarette smoking are more prevalent among adults with type 2 diabetes, although the use of illicit drugs is also a common problem among diabetics [30].

Substance abuse is one of the leading preventable causes of death and emergency room visits even though a number of effective treatments have been established, apparently due to people failing to seek treatment for at least 10 years after the substance abuse started [30]. As a result, substance abuse is currently a major health concern.

Serious damage can occur in most major organs in the body, including the heart and kidneys, due to substance abuse [31]. People with diabetes are already highly susceptible to organ damage and heart disease. Mortality rates for diabetics who abuse drugs are much higher than for those who do not.

Drug dependent diabetics can experience painful and debilitating withdrawal symptoms upon stopping the consumption of alcohol or taking illicit drugs. Depending on substance type, a range of withdrawal symptoms exist, and may include: hyperhidrosis (heavy sweating), myalgia (pain throughout the body), fever, nausea, vomiting, diarrhea and intense cravings. When faced with symptoms such as these, it can become impossible for people with diabetes to properly control their condition – all the more reason to remain abstinent from using drugs in the first place.

Substance abuse is no easy issue, and is made even more complicated alongside chronic conditions such as type 1 and 2 diabetes. As illustrated, the combination of both can lead to serious complications and death. Avoiding drug use altogether or seeking treatment at the first sign of substance abuse is the best way to stay healthy. Management of diabetes and substance abuse can be aided by seeking the help of qualified professionals – anyone struggling with both is strongly urged to do so.

Learn more about diabetes and drug abuse:


Learn more about diabetes and alcohol:


Learn more about diabetes and smoking:



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Egton Medical Information Systems Limited. Repaglinide for diabetes: Enyglid, Prandin. London: Egton Medical; 2014.

Otsuka R, Watanabe H, Hirata K, Tokai K, Muro T, Yoshiyama M, Takeuchi K, Yoshikawa J. Acute effects of passive smoking on the coronary circulation in healthy young adults. JAMA. 2001; 286(4):436-41.

Qin R, Chen T, Lou Q, Yu D. Excess risk of mortality and cardiovascular events associated with smoking among patients with diabetes: meta-analysis of observational prospective studies. Int J Cardiol. 2013;167(2):342-50.

Klein R, Lee KE, Gangnon RE, Klein BE. Relation of smoking, drinking, and physical activity to changes in vision over a 20-year period: the Beaver Dam Eye Study. Ophthalmology. 2014; 121(6):1220-8.

Powell HA, Iyen-Omofoman B, Baldwin DR, Hubbard RB, Tata LJ. Chronic obstructive pulmonary disease and risk of lung cancer: the importance of smoking and timing of diagnosis. J Thorac Oncol. 2013; 8(1):6-11.

Stenström U, Andersson P. Smoking, blood glucose control, and locus of control beliefs in people with type 1 diabetes mellitus. Diabetes Res Clin Pract. 2000; 50(2):103-7.

Shankar A, Klein R, Klein BE. The association among smoking, heavy drinking, and chronic kidney disease. Am J Epidemiol. 2006; 164(3):263-71.

Ng RS, Darko DA, Hillson RM. Street drug use among young patients with Type 1 diabetes in the UK. Diabet Med. 2004; 21(3):295-6.

Ersche KD, Stochl J, Woodward JM, Fletcher PC. The skinny on cocaine: insights into eating behavior and body weight in cocaine-dependent men. Appetite. 2013; 71:75-80.

Treweek JB, Dickerson TJ, Janda KD. Drugs of abuse that mediate advanced glycation end product formation: a chemical link to disease pathology. Acc Chem Res. 2009 May 19;42(5):659-69.

Lee P, Greenfield JR, Campbell LV. Managing young people with Type 1 diabetes in a 'rave' new world: metabolic complications of substance abuse in Type 1 diabetes. Diabet Med. 2009; 26(4):328-33.

Gozashti MH, Mohammadzadeh E, Divsalar K, Shokoohi M. The effect of opium addiction on thyroid function tests. J Diabetes Metab Disord. 2014; 13(1):5.

Pappachan JM, Raj B, Thomas S, Hanna FW. Multiorgan dysfunction related to chronic ketamine abuse. Proc (Bayl Univ Med Cent). 2014; 27(3):223-5.

Lee P, Nicoll AJ, McDonough M, Colman PG. Substance abuse in young patients with type 1 diabetes: easily neglected in complex medical management. Intern Med J. 2005; 35(6):359-61.

Ghitza UE, Wu LT, Tai B. Integrating substance abuse care with community diabetes care: implications for research and clinical practice. Subst Abuse Rehabil. 2013; 4:3-10.

Brick J. Handbook of the medical consequences of alcohol and drug abuse. New York, NY: The Haworth Press; 2004.

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Complications and Aging

Posted by Randall W Brown on October 16, 2014 at 9:25 AM Comments comments (0)

Diabetic Complications and the Aging Population

At what age will people require more diabetic care?...


In this cohort study which looked at patients from 2004-2010 the main objective was to identify if there was an increased incidence of diabetic complications depending on how long participants have had diabetes as well as how old they are. Given the increasing age of the population, it's important to know which populations may require more care.


A short duration of diabetes was considered to be 0-9 years and a long duration of diabetes was ≥ 10 years. The age categories were divided into 60-69 years, 70-79 years, and ≥ 80 years of age. The diabetic complications which were measured included hyperglycemic events, hypoglycemic events, microvascular complications, cardiovascular complications, and all-cause mortality.


Looking at the duration of diabetes, in patients with a shorter or longer duration the main events were hypoglycemia and cardiovascular complications, with the longer duration patients having a higher incidence of both of these events. When comparing the differences in the age groups, an increasing age correlated with increasing rates of hypoglycemia, cardiovascular problems, and increased mortality. Interestingly, microvascular complications remained the same or even decreased with the increasing age of the groups. In conclusion, the populations with the most risk of these complications appear to be the oldest patients who have had the disease for the longest amount of time, with the most common complication being hypoglycemia.


Practice Pearls:

A longer duration of diabetes (≥10 years) increases the risks of diabetic complications.

Diabetic complications become more likely with increasing age, when comparing patients of the ages 60-69 years, 70-79 years, and ≥ 80 years.

Hypoglycemia was the most common diabetic complication across all age ranges involved in this study.

JAMA Internal Med., December 2013


Posted by Randall W Brown on October 16, 2014 at 9:25 AM Comments comments (0)

Low-carb Diet Recommended for Type 1 and 2 Diabetes Patients

Low-carbohydrate diets should be the first line of attack for treatment of type 2 diabetes, and should be used in conjunction with insulin in those with type 1 diabetes....

Conducted by a consortium of 26 physicians and nutrition researchers, the study suggests the need for a reappraisal of dietary guidelines due to the inability of current recommendations to control the epidemic of diabetes. The authors point to the specific failure of the prevailing low-fat diets to improve obesity, cardiovascular risk or general health, and to the persistent reports of serious side effects of commonly prescribed diabetes medications. By comparison, the authors refer to the continued success of low-carbohydrate diets in the treatment of diabetes and metabolic syndrome without significant side effects.


Barbara Gower, Ph.D., professor and vice chair for research in the UAB Department of Nutrition Sciences and one of the study authors, stated that, "Diabetes is a disease of carbohydrate intolerance." "Reducing carbohydrates is the obvious treatment. It was the standard approach before insulin was discovered and is, in fact, practiced with good results in many institutions. The resistance of government and private health agencies is very hard to understand."


The authors say their review of the medical literature shows that low-carbohydrate diets reliably reduce high blood sugar and at the same time show general benefit for risk of cardiovascular disease.


Richard David Feinman, Ph.D., professor of cell biology at SUNY Downstate Medical Center and lead author of the paper, added that, "We've tried to present clearly the most obvious and least controversial arguments for going with carbohydrate restriction." "Here we take a positive approach and look to the future, while acknowledging this paper calls for change. The low-fat paradigm, which held things back, is virtually dead as a major biological idea. Diabetes is too serious a disease for us to try to save face by holding onto ideas that fail."


Gower added that, "For many people with type 2 diabetes, low-carbohydrate diets are a real cure," said Gower. "They no longer need drugs. They no longer have symptoms. Their blood glucose is normal, and they generally lose weight."


The authors caution that people with diabetes who are already on drugs for type 2 diabetes or are on standard amounts of insulin should undertake conversion to a low-carbohydrate diet only with the help of a physician. Because the diet may have a similar sugar-lowering effect, it is critical that drug doses be tapered off in order to avoid dangerous low blood sugar.


Practice Pearls - As with all diabetes clinical recommendations, these should be tempered to meet the individual needs and circumstances of the patient. The 12 points of evidence from the study backed up by clinical studies are:


High blood sugar is the most salient feature of diabetes. Dietary carbohydrate restriction has the greatest effect on decreasing blood glucose levels.

During the epidemics of obesity and type 2 diabetes, caloric increases have been due almost entirely to increased carbohydrates.

Benefits of dietary carbohydrate restriction do not require weight loss.

Although weight loss is not required for benefit, no dietary intervention is better than carbohydrate restriction for weight loss.

Adherence to low-carbohydrate diets in people with type 2 diabetes is at least as good as adherence to any other dietary interventions and frequently is significantly better.

Replacement of carbohydrates with proteins is generally beneficial.

Dietary total and saturated fats do not correlate with risk of cardiovascular disease.

Plasma-saturated fatty acids are controlled by dietary carbohydrates more than by dietary lipids.

The best predictor of microvascular and, to a lesser extent, macrovascular complications in patients with type 2 diabetes is glycemic control (HbA1c).

Dietary carbohydrate restriction is the most effective method of reducing serum triglycerides and increasing high-density lipoprotein.

Patients with type 2 diabetes on carbohydrate-restricted diets reduce and frequently eliminate medication. People with type 1 usually require less insulin.

Intensive glucose-lowering by dietary carbohydrate restriction has no side effects comparable to the effects of intensive pharmacologic treatment.

Nutrition July 2014



Gout & Type 2 Links

Posted by Randall W Brown on October 16, 2014 at 9:20 AM Comments comments (0)

Gout Linked to Increased Type 2 Diabetes Risk

Gout appears to increase the risk of type 2 diabetes, especially in women...

Researchers followed more than 35,000 gout sufferers in the United Kingdom and found that women with gout were 71 percent more likely to develop diabetes compared with people without gout. For men, the increased risk was 22 percent.


"Gout seems to be contributing to the risk of diabetes independently of other diabetes risk factors, such as obesity," said lead researcher Dr. Hyon Choi, from the division of rheumatology, allergy, and immunology at Massachusetts General Hospital in Boston.


Gout causes intense pain and swelling in single joints, most often the feet, especially the joint at the base of the big toe. More than 3 million Americans suffer from the condition, men more often than women, according to the American College of Rheumatology. People with gout have excess uric acid in the body, which forms needle-like crystals that lodge in the joints.


Diabetes, characterized by high blood sugar levels, can lead to kidney damage, heart disease and limb amputations over time. Clarifying its relationship to gout "is essential," the study authors said. However, while the current research suggests gout raises the risk of diabetes, the study can't prove it. "The association is clearly there, but why that is so isn't known," Choi said.


Choi speculates that ongoing, low-level inflammation from gout may increase the risk for diabetes. Other risk factors shared by both diseases — high cholesterol and high blood pressure, for example — might also increase the risk, he said.


The researchers used data from health records on adult patients from January 1995 to May 2010. They zeroed in on about 35,000 people with newly diagnosed gout and compared them with more than 137,000 people without the condition.


To isolate the relationship between gout and diabetes, the investigators took age, sex and especially weight into account, because obesity is a risk factor for both gout and type 2 diabetes.


The study, found that almost three-quarters of the new cases of gout were among men with an average age of 61. Among women with new cases of gout, the average age was 68.


The odds of developing diabetes alongside gout was much more likely for women, the researchers found. Choi said the absolute risk of a woman with gout developing diabetes is about 5 percent, and for a man it's about 3 percent.


People with gout tended to drink more alcohol, saw their doctor more often, had more medical problems, and took steroids and diuretics more often than those who did not have gout, the study authors noted. Treatments for gout are available and are tailored individually.


Choi said the best way to reduce the risk of developing gout or diabetes is to control risk factors, such as blood pressure, cholesterol and weight.


"What this study tells us is that if the patient has gout, you have to be thinking that the patient is at increased risk for diabetes," he said. This may be independent of other factors normally associated with diabetes, such as obesity and high blood pressure, he added.


Published online Oct. 2 in the Annals of the Rheumatic Diseases





Posted by Randall W Brown on September 1, 2014 at 11:40 AM Comments comments (0)

Did you know that this year is the 20th Annual Taking Control Of Your Diabetes Conference and Health Fair in San Diego? Everyone here at TCOYD wants to celebrate the 20th anniversary of our very first conference with the people who matter to us the most, and that's YOU!


With our individualized type 1 and type 2 tracks along with a top-notch team of physicians, diabetes educators, nutritionists, podiatrists, pharmacists, exercise specialists and much more, it's going to be a day to remember.


Mark your calendars now for Saturday, November 8, 2014 at the San Diego Convention Center.


For detailed information and online conference registration click here.


The Edelman Report



Three Little Words - Tune in to TCOYD's YouTube Channel, TCOYDtv and watch the latest Edelman Report to get the most up-to-date information on diabetes care and management directly from Dr. Edelman. In this episode Dr. Edelman discusses the importance of coming out of the closet with your diabetes. Click here and watch now!


Things You Should Know

GradeGet Involved! VA San Diego Healthcare System in La Jolla is looking for volunteers to take part in a study to compare the long-term benefits and risks of four widely used diabetes drugs in combination with metformin, the most common first-line medication for treating type 2 diabetes. The project is called the GRADE study. For more information or to see if you qualify click here or call 858-552-8585 and ask to speak to Andrea Gasper (ext 1431) or Catherine DeLue (ext 6740).


The Bionic Pancreas Is Closer Than You Think - Check out TCOYD's Summer quarter newsletter for an interesting and informative article on the development and progress of the bionic pancreas. Edward Damiano, PhD, Associate Professor of Biomedical Engineering at Boston University, and special guest speaker at TCOYD's upcoming 20th Annual Conference and Health Fair in San Diego, played a key role in the development of this potentially life changing device for type 1's. Click here for more.


The Top 20 Diabetes Questions - "Can I reverse diabetes?" "Will insulin make me gain weight?" "What foods should I eat before and after exercise?" "Can I drink alcohol?" Get answers to these and other common diabetes questions to help navigate diabetes management and reduce the stress or worry of a diagnosis. Diabetic Living's experts set the record straight on diabetes myths and misinformation so you have the power to make better choices and live a full, healthy life with diabetes. Click here


Donate Today


We would not be able to educate and motivate people around the country who

have diabetes without the generous support of our individual donors.

Please help us continue and give today!




Your donations make a difference in people's lives.

Our last conference was on June 7, 2014 in Washington, DC.

Here are just a few things that conference participants said:










Help TCOYD Meet the Challenge

TCOYD is excited to announce that 2014 brings additional support funding from The Leona M. and Harry B. Helmsley Charitable Trust as well as a new and exciting fundraising challenge.


The Helmsley Trust contribution that was monumental in the development of TCOYD's type 1 track, has challenged TCOYD to raise $75,000 in NEW donations. These new donations need to be gifts of $2,000 or more and from a person, foundation, or corporation who has never given that much previously. If TCOYD can meet this challenge by May 14, 2015, The Helmsley Charitable Trust will match it with an additional $75,000.


Please donate today and be a part of TCOYD's mission to educate and motivate people with diabetes to live happy, healthy, and productive lives.


If you are interested in donating Dr. Edelman wants to hear directly from you. Send an email to his personal account at [email protected]



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Posted by Randall W Brown on September 1, 2014 at 11:35 AM Comments comments (0)



by Adam Brown


twitter summary: Adam identifies at least 22 things that affect blood glucose, including food, medication, activity, biological, & environmental factors.


short summary: As patients, we tend to blame ourselves for out of range blood sugars – after all, the equation to “good diabetes management” is supposedly simple (eating, exercise, medication). But have you ever done everything right and still had a glucose that was too high or too low? In this article, I look into the wide variety of things that can actually affect blood glucose - at least 22! – including food, medication, activity, and both biological and environmental factors. The bottom line is that diabetes is very complicated, and for even the most educated and diligent patients, it’s nearly impossible to keep track of everything that affects blood glucose. So when you see an out-of-range glucose value, don’t judge yourself – use it as information to make better decisions.


As a patient, I always fall into the trap of thinking I’m at fault for out of range blood sugars. By taking my medication, monitoring my blood glucose, watching what I eat, and exercising, I would like to have perfect in-range values all the time. But after 13 years of type 1 diabetes, I’ve learned it’s just not that simple. There are all kinds of factors that affect blood glucose, many of which are impossible to control, remember, or even account for.


Based on personal experience, conversations with experts, and scientific research, here’s a non-exhaustive list of 22 factors that can affect blood glucose. They are separated into five areas – Food, Medication, Activity, Biological factors, and Environmental factors. I’ve provided arrows to show the general effect these factors have on my blood glucose (a sideways arrow indicates a neutral effect), but emphasize that not every individual will respond in the same way (and even within the same person, you may be different from day-to-day or over time). Certain factors may also apply more to type 1 vs. type 2 diabetes (or the other way around). The best way to see how a factor affects you is through personal experience – test your blood glucose more often or wear a CGM and look for patterns. Please email me at adam.brown(at) with your thoughts on this article or any factors you would add.






Typical Effect on Blood Glucose




More Information


1. Carbohydrates





Of all the three sources of energy from food (carbohydrates, protein, and fat), carbohydrates affect my blood glucose the most. Accurately counting carbs is very difficult, and getting the number wrong can dramatically affect blood glucose. The type of carbohydrate also matters – higher glycemic index carbs tend to spike blood glucose more rapidly.


Adam’s Corner in diaTribe #58


2. Fat




Fatty foods tend to make people with diabetes more insulin resistant, meaning more insulin is often needed to cover the same amount of food relative to a similar meal without the fat. On my pump, I typically use temporary basals or extended boluses (square and dual-wave) to cover high-fat meals. This effect is most notable if you eat a lot of fat at one time – for instance, when snacking on nuts, I’ll observe a steady rise in blood glucose over many hours.


Wolpert et al., Diabetes Care 2013


3. Protein







If you’ve ever eaten a protein-only meal with very few carbs (e.g., salad with chicken), you may have seen a noticeable rise in blood glucose (~20-50 mg/dl). Though protein typically has little effect on blood glucose, in the absence of insulin, it can raise blood glucose. When I’m eating a carb-free, protein-only meal, I still take a bit of insulin to cover it (usually an equivalent of about 10-15 g of carbs)


Franz, Diabetes Educator 1997



Smart et al, Diabetes Care 2013



4. Caffeine







Many studies have suggested that caffeine increases insulin resistance and stimulates the release of adrenaline. Personally, I know that if I have a cup of coffee, I’ll see at least a 20-30 mg/dl rise in blood glucose, particularly in the morning when I’m more insulin resistant.


Lane, Journal of Caffeine Research 2011


5. Alcohol






Normally, the liver releases glucose to maintain blood sugar levels. But when alcohol is consumed, the liver is busy breaking the alcohol down, and it reduces its output of glucose into the bloodstream. This can lead to a drop in blood sugar levels if the alcohol was consumed on an empty stomach. However, alcoholic drinks with carbohydrate-rich mixers (e.g., orange juice) can also raise blood sugar. When drinking alcohol, make sure you test your blood glucose often and that someone responsible nearby knows you have diabetes.


American Diabetes Association













Typical Effect on Blood Glucose




More Information


6. Medication dose







For those of us with diabetes on any medication (pills or insulin injections), the dose of medication directly impacts blood glucose – in most cases (but not always), taking a higher dose of a diabetes medication means a greater blood glucose-lowering effect


Your medication’s label and package insert


7. Medication timing







In addition to dose, medication timing can also be critical. For instance, taking rapid-acting insulin (Humalog, Novolog, Apidra, and Afrezza) 20 minutes before a meal is ideal for me - it leads to a lower spike in glucose vs. taking it at the start of the meal or after the meal has concluded. Note that this works best for me, although this can vary among individuals – please consult your health care provider to discuss the optimal timing of insulin. The timing of many type 2 diabetes medications matters a lot – some can consistently be taken at any time of day (e.g., Januvia, Victoza), while others are most optimally taken at meals (e.g., metformin).


Your medication’s label and package insert


8. Medication Interactions







Non-diabetes medications can interfere with your diabetes medications and blood glucose. Consult the information included in both your diabetes and non-diabetes medications.


ADA’s My Medicine Tracker







Typical Effect on Blood Glucose




More Information


9. Light exercise




Light activity can have a surprising glucose-lowering effect – I find that walking tends to lower my blood sugar by about 1 mg/dl per minute. I have seen drops as large as 46 mg/dl in 20 minutes, more than 2 mg/dl per minute and others see even more.


Adam’s Corner in diaTribe #51


10. High-intensity and moderate exercise







Exercise is often positioned as something that always lowers blood glucose; however, high-intensity exercise, such as sprinting or weight lifting, can sometimes raise blood glucose. This stems from the adrenaline response, which tells the body to release stored glucose. Often, I find this happens when I’m exercising in the morning on an empty stomach. But this is not a reason to avoid high intensity exercise – studies show it can improve blood glucose for one to three days post-exercise! Note that in some cases high-intensity exercise can also drop blood glucose very rapidly (2-3 mg/dl per minute), especially if you have insulin on board in your pump. The best way to see how individual exercise sessions affect your blood glucose is to test prior and after activity.


“The Impact of brief, high-intensity exercise on blood glucose levels” (Diabetes Metab Syndr Obes 2013)







Typical Effect on Blood Glucose




More Information


11. Dawn phenomenon




The “dawn phenomenon” occurs in people with and without diabetes. The term refers to the body’s daily production of hormones around 4:00-5:00 AM. During this time, the body makes less insulin and produces more glucagon, which raises blood glucose. The best way to figure out how dawn phenomenon affects you is to wear a CGM or wake up and test your blood glucose early in the morning. If you take insulin, you may need to time your dose to cover this early morning rise in glucose. Note that not everyone experiences dawn phenomenon, but it is common!


Dawn phenomenon (ADA)


12. Infusion set issues (e.g., length of wear, occlusions, air bubbles)




Infusion sets are not as well understood as we would like, and a huge number of factors can lead to higher glucose levels: air bubbles in the tubing, an occluded cannula, an infected site, or even the location of the set. If you wear a pump and your glucose is unexpectedly high, a good first step is to change your set out. I find that my glucose always tends to run higher on the third day of wearing an infusion set. In addition, I tend to get the best absorption wearing sets in my buttocks and the worst absorption in my legs – yet again, this varies among patients.


“Insulin Infusion Set: The Achilles Heel of Continuous Subcutaneous Insulin Infusion” (JDST 2012)


13. Scar tissue and lipodystrophy




Using the same sites on the body for injections or infusion sets can lead to lipodystrophy and scar tissue buildup – these result in erratic absorption of insulin, leading to glycemic variability and making it harder to spend more time in range. To avoid these issues, rotate your injection/infusion sites and don't reuse needles.


Common Insulin Injection Challenges (BD)



Insulin Pump Therapy (AADE)


14. Insufficient Sleep




In my experience, I have found that I need nearly 25% more insulin on days following less than seven hours of sleep; my highest blood glucose of the day is even higher on days following little sleep; and my glucose is 21% more variable when I do not sleep enough. These findings are consistent with many studies, which have found that not getting enough sleep leads to worse diabetes control, insulin resistance, weight gain, and increased food intake.


Adam’s Corner in diaTribe #53 – see my full length article on sleep and glucose control for a more comprehensive list of related research studies


15. Stress and illness




Stress and illness can cause the body to release epinephrine (adrenaline), glucagon, growth hormone, and cortisol. As a result, more glucose is released from the liver (glucagon, adrenaline) and the body can become less sensitive to insulin (growth hormone, cortisol). In some cases, people are much more insulin sensitive right before getting sick and can tend to run low blood sugars. Personally, I have found exercise, time outside, and meditation to be most helpful against combatting stress.


UCSF Diabetes Education





16. Allergies




Though I have not found any studies on this topic, some patients report higher glucose levels when they have allergies. Some have speculated that it’s due to the stress hormone cortisol.


Can allergies raise glucose level? (Diabetes Forums)



Allergies and Blood Sugar (TuDiabetes)



17. A higher glucose level (“glucotoxicity”)




Hyperglycemia can lead to a state known as “glucotoxicity,” which can actually cause insulin resistance. Have you ever needed to correct a very high blood sugar with much more insulin than your correction factor would suggest? I find that simply having a high blood glucose for many hours makes me appear much more insulin resistant.


Vuorinen-Markkola et al., Diabetes 1992



Kim et al., Circulation 2006


18. Periods (Menstruation)







There is not a definite answer to the question of how periods affect women’s blood sugars. Many women report having higher blood sugar levels a few days prior to their period starting, but some women notice a sharp drop in sugar levels. To figure out how you respond, your best bet is to test your blood glucose often during this time of month.


Periods (Menstruation) and Diabetes (Diabetes UK)



Why are my blood sugars affected by my period? (DiabetesSisters)


19. Smoking




Some studies suggest that smoking can increase insulin resistance, and people with diabetes who smoke are more likely than nonsmokers to have trouble with insulin dosing and managing their diabetes. Smokers also have higher risks for serious complications.





Chiolero et al, AJCN 2008








Typical Effect on Blood Glucose




More Information


20. Insulin that has gone bad




I’ve fried my insulin by exposing it to direct sunlight or leaving it in the car on a hot day. If your insulin is normally clear, but suddenly turns cloudy, that could signal it has gone bad (note: NPH is always cloudy). Aside from a change in appearance, it can be hard to know if a vial of insulin has actually gone bad unless you try a new one. I’ve found that insulin that has “gone bad” will typically still work, but just not as well – I may need more insulin than I think to bring my glucose down, and the insulin may work unpredictably. Unopened insulin should be stored in a refrigerator at approximately 36-46 °F. According to the FDA, insulin can be left unrefrigerated at a temperature from 59-86 °F for up to 28 days.


Information regarding insulin storage (FDA)


21. An accurate blood glucose reading




While this seems fairly obvious, I often find myself testing multiple times in a row, since I do not believe the initial value – in many cases, the second time I get a much lower value, and it’s because I failed to wash my hands. For a meter that needs a tiny 0.3 microliter blood sample (the smallest currently on the market), a speck of glucose on the finger the weight of a dust particle will increase the reading by 300 mg/dl! I recommend retesting if you don’t believe the value on the meter; if you wear CGM, it’s great to reality check the meter value against your sensor reading. The diabetes online community has also done a lot of work advocating for more accurate blood glucose testing supplies – you can read more about their campaign here.


Glucose Monitoring After Fruit Peeling (Diabetes Care 2011)


22. Altitude




Though most studies related to diabetes and altitude concern the accuracy of blood glucose meters, there are some reports that altitude can increase insulin resistance. I’ve found that when I go to high altitude regions like Colorado, I need about 20-30% more basal insulin. However, if you go to a high altitude place to do activity (e.g., skiing), you may find that you need less insulin.


High Altitude Diabetes (A Sweet Life)



Blood Glucose and Altitude (Diabetes Forecast)


Postscript: Following publication, many readers have written me with additional factors that seem to affect blood glucose: sunburn, allergic reactions, administration of steroids, niacin, celiac disease, ambient temperature, hydration.


[Editor’s Note: Adam is a patient with diabetes and not a health care provider. Please consult with your health care provider before making any changes to your diet, insulin, or medication regimen.]


Adam is Senior Editor of diaTribe and Chief of Staff/Head, Diabetes Technology at Close Concerns. He is a graduate of the University of Pennsylvania and serves on the board of the San Francisco branch of JDRF. He was diagnosed with type 1 diabetes at the age of 12 and has worn an insulin pump for the last 12 years and a CGM for the past four years. Adam is passionate about exercise, nutrition, and wellness and spends his free time outdoors and staying active. He can be contacted at adam.brown(at) or @asbrown1 on twitter.


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