05 November 2006

November is National Diabetes Month

I never knew that November could contain anything else other than NaNoWriMo, but it is also National Diabetes Month. The American Diabetes Association has information on their website. 14 November is World Diabetes Day.

Many people think that Diabetes is a Western country problem, caused by bad lifestyle and obesity - but it's growing in incidence and prevalence in Thailand and Laos and has become an epidemic in India. In Asia, people almost feel they've 'made it' if they have this disease of the rich; with the emphasis in primary health care on diarrhea and malnutrition, most developing countries do not treat the problem seriously. On the World Diabetes Day website, there's information on the Indigenous Diabetes Forum in Australia as well as an online journal with fascinating articles.

This is useful information for me because I hope to get an informal CME series going in one of the province hospitals I've been working in. People tell me that there is no diabetes here - yet I'm sure there are many reasons for the lack of number of people with the diagnosis - low index of suspicion, not understanding how it can present so doctors are not ordering the tests; people are probably dying from complications of diabetes but they are diagnosed with something else.

Along with another growing problem, trauma (from motor vehicle accidents, armed conflict, post-conflict states and availability of small arms being the biggies), diabetes is increasingly become an important cause of mortality and morbidity. In developing countries, primary care addresses important childhood diseases, diarrhea, acute respiratory tract infections, malnutrition, etc. These are important but trauma, diabetes, CVD are examples of non-communicable diseases which mostly affect adults - and if the caretakers are killed or sick because of these, the whole family is affected.

The current situation

One of the problems that diabetics complain about is inconsistency. Why is it that exercise and sticking to the diet doesn't give the same blood sugar readings from day to day?

My fasting blood sugar yesterday morning was 106; the day before I had not had a chance to exercise. In fact, I had gone to a meeting where I had a cup of coffee and a piece of cake. I went to the office later where there was a small going away party and I had a glass of wine. Going home, I stopped at a restaurant and had a hamburger. So the following morning, my blood sugar was very good.

Yesterday, I ran for one mile in the morning. Had a small bowl of granola with nonfat milk as well as my usual cup of coffee. In the afternoon, I went to the gym ran 5 miles on the treadmill, lifted weights for a half hour total, and swam (I usually stay there two hours). I ate a green salad. After that I walked through the Boun That Luang festival, the biggest Buddhist festival in the country. Returned home after dark, ate a small portion of rice, yogurt, steamed vegetables and malai kafta. This morning, my blood sugar was 130. Go figure.

I guess the main thing I - and other diabetics - have to remember is that looking at blood sugars on a day to day basis is like trying to figure out what's going on with the stock market. We're always getting these dire reports - the stock market plunged on this day, followed by reports that it soared the next. When you focus on the day-to-day stuff, you lose sight of the trends.

The trends are the most important. Frankly during the past week, I haven't exercised as much as I should have - I've stayed too late at work everyday. When I get tired, I eat out and don't make the best food choices. If I focus on my figures, yeah it's a mystery. But when I look at my life, it's not so strange.

Our bodies are not machines. There are a millions processes going on that we can't even imagine. It always boggles my mind that our bodies can function at all. I have to remind myself that the blood sugar figures are just part of my total person; I'm a diabetic but I'm not my blood sugar readings.

04 November 2006

Shock and...uh, more shock

I'd start at the beginning but which beginning? To write good fiction, the writer should never start with a flashback but find the part of the story that should be told first, not too early and not too far into the story.

I could interview myself - take a history with chief complaint and its seven dimensions , review of symptoms with significant positives and negatives, past medical history, current medications and allergies. That's what I would do with my patients but I specialized with providing services for minorities and so was never surprised when the story would start with, "My family offended a spirit when we escaped to Thailand."

All I can start with, for myself, is "I always knew that it would happen." When I worked as a Physician Assistant in a health center in California, most of my patients were diabetic. I read a lot on endocrinology, attended continuing medical education programs on diabetes and the new drugs that were coming out (this was in 1996). I tried to convince my patients to follow their diets, take their pills and to exercise.

Reality was otherwise. For Asian people, being heavy after generations of deprevation, was a sign of good health. Medications should be taken for a short time - they are strong and they are supposed to cure the patient. Take medicines daily for a long period of time? What kind of poor medicine is it? And exercise - a Hmong woman laughed when I suggested it. "In the neighborhood where I live, it's more dangerous to exercise."

So, I digressed. I wanted to write about me, not about the people who were not me. Only to say, "I would never get Diabetes." I ate properly (mostly vegetarian), exercised and for a long time, watched my weight. However, I've been living in SE Asia for the past ten years. People entering prosperity - big wedding parties, dinners with friends, alcohol flowing like a tsunami.

In 2002, I visited the US. As usual, I bought too many books and trinkets I could not get in Asia. Hefting around the suitcase hurt my back, so I decided to get a physical and back x-ray. I learned I had spondylolthesis, a back condition where one vertebra slips against the one below it. Now that I had a reason for my back pain, I went into kind of a slump. Didn't exercise very much, but on the plus side - I let other people carry my bags for me. I gave up my trusty backpack for a trusty roller bag (and thereby entered middle age).

I gained weight and at my next physical, I was stunned to learn that I had a high blood sugar. A doctor was about to put me on a medication that I didn't want to take, so he referred me to someone else (Thai doctors are not accustomed to having their patients ask questions)

The endocrinologist was cool and decided that since my HbA1c was normal, that it was probably impaired glucose tolerance and we'd try diet and exercise. So I joined a gym and got myself back into running and bicycling. Strangely enough, I started to feel better; in fact, even more hopeful. But during a long trip in October last year, I gained ten pounds and returned home feeling down. In between some eye lid infections and meetings, I got down to Bangkok several times and started an overdue physical exam.

In January 2006, I worked for a month in Vietnam. When I returned home, I had to go to the field so it was full month before I received the results of my blood tests from November. My fasting blood sugars were above 250 and my HbA1c was 7.5, kinda high.

The real shock was the recheck. My fasting blood sugar was 359 and my HbA1c was 11.2! So my doctor started me on Glucophage 850 in the mornings and 500 at night.

We'll jump over the past six months. I just returned from Bangkok and my fasting blood sugar was 110 and my HbA1c was 5.5. I've been consistent with medicines and checking my fingersticks both fasting and several times a week, 2 hours after a meal. I've been fanatic about execise and I've lost 30 pounds since January.

So that's the background. There's a lot more. And there will be a lot more. There always is.