Can you help me explain diabetes to a cranky old guy?
January 4, 2016 8:55 PM   Subscribe

Family member (FM), mid-seventies, healthy (some mild arthritis), stubborn. Talked into getting blood work and doctor exam because of family history of kidney problems. Kidneys are great, everything is great, except his blood sugar levels. Doctor says "diabetic," FM very resistant to diagnosis, doctor unable to explain in a way he can understand. I'm the one he talks to most freely, so ... how do I explain this when I don't understand it very well myself? Seeking explanations, and sources if possible.

(I may have some of these phrases wrong, I think he wasn't sure about them himself. If it's important I can ask him specific questions to call and ask the doctor's office.)

His 18 hour fasting glucose was 243. More importantly, his 3-month-average glucose average (?) was 10. The doctor said flatly that 10 is full blown diabetes and her choice of treatment was to immediately put him on injectable insulin. He says: that's ridiculous, I had a close friend who needed insulin injections, and it wasn't a "choice" -- he had to have the insulin to function. FM has no other symptoms of diabetes except the numbers on the test. (I was able to find lists of symptoms online, and he doesn't have any of them.) The doctor then offered medication (Metaformin?) to reduce the numbers. FM, who is on no other meds except occasional OTC pain relievers for arthritis, not willing to take something that his liver will have to handle when -- again, no symptoms. Finally agreed to consider changing his diet and exercise routine and get blood tested in 3 months. I doubt this will happen.

The real question he has, and which I am unable to answer, is why so much concern when he has no symptoms and is otherwise healthy? The doctor said "If untreated you are more likely to have a heart attack or stroke." FM says "I'm an old guy. Every day I'm more likely to have a heart attack or stroke. I have to die from something." Then he says, "How much safer would insulin make me from a heart attack? Where do they get their numbers? Do they check people who die from heart attacks to see what their blood sugar level was? Do these numbers come from true studies, or just manipulations of statistics? Who fixed the number at 10? The makers of insulin?"

Since "your doctor says so" is not a valid option here, where can I look? What should I beware of? I'm going to do a first screening of home research -- there is an amazing amount of pure crap available with a simple click on Google -- but I feel at a loss here.

And a second question, which I have not mentioned to FM but which crossed my mind: how accurate was that blood test? There is bound to be some measure of error, and doesn't it seem to be prudent to get a second blood test before starting someone on insulin? Or is that hopelessly either silly or paranoid?
posted by kestralwing to Health & Fitness (21 answers total) 14 users marked this as a favorite
 
He's in his 70's. Maybe he just doesn't care and doesn't want to make a major change to his lifestyle.

Basically he will die at some point if he doesn't reduce his blood sugar numbers. Maybe he is fine with that?
posted by paulcole at 9:15 PM on January 4, 2016 [9 favorites]


The 3 month average is his A1C test, which is pretty accurate. (See here: http://www.niddk.nih.gov/health-information/health-topics/diagnostic-tests/a1c-test-diabetes/Pages/index.aspx)

So why should he care if he's diabetic? Well, diabetes is a nasty disease. Does he want to keep all of his fingers and toes? He could lose them.

Kidney problems are exacerbated by uncontrolled diabetes (controlled includes medicine like metformin, diet, exercise, and possibly insulin). http://www.niddk.nih.gov/health-information/health-topics/kidney-disease/kidney-disease-of-diabetes/Pages/facts.aspx

So. Can you force him to become a model patient? Probably not. I'd encourage him to go to a diabetes class offered by a local hospital or insurer. Lots of people can change their behaviors and put off the bad parts of diabetes. Others don't and live grisly ends.

Second question: your family member DID have two blood tests. The A1C and fasting both showed diabetes.

(Info comes from my husband being diagnosed as Type 2 diabetic 18 months ago. He's lost 80 lbs and his blood sugars are now amazing for a diabetic.)
posted by heathrowga at 9:15 PM on January 4, 2016 [1 favorite]


Would family member be open to getting a second opinion from an endocrinologist, that is, a specialist who can answer all the relevant questions and not just say "take this medicine or you'll die"?
posted by CrazyLemonade at 9:17 PM on January 4, 2016 [6 favorites]


Also this:

"I'm an old guy. Every day I'm more likely to have a heart attack or stroke. I have to die from something."

My view on things like this is that many older people might be ok with the idea of just dropping dead one day, yet not many seem to think about the awfulness of dying slooowly, where you loose a toe here and there, or maybe your eyesight, then the liver, then you cough up blood for days, etc etc etc. Isn't diabetes the silent killer? Or is that another disease?
posted by CrazyLemonade at 9:22 PM on January 4, 2016 [9 favorites]


The analog I use for my rural population is sugar in the gas tank. They have too much sugar in their blood and it will gum up the works and cause massive engine failure sooner or later unless they do something about it.

That said I'm not too sure how hard I would try to control the serum glucose level of a 70 year old, most of the organ damage takes up to ten years to cause the bad problems.

Now is the time to make dietary changes though, carbs are not his friend. Metformin and aggressive carb restriction might get his HBA1C down to 8 in six months if he wants it bad enough.
posted by hobo gitano de queretaro at 9:25 PM on January 4, 2016 [9 favorites]


This ICU nurse's description of diabetes (via this FPP) seems to have hit home with a lot of people. An excerpt:
Sugar is corrosive to the blood vessels (just ask any nurse who’s pushed dextrose 50% into an IV and watched the vein blow) and over time even moderately high blood sugars rip and scar your arteries and veins. This is incredibly bad for things like your legs, which are the farthest from your heart and have a hard time getting blood back and forth to begin with. A few years of sticky scratchy sugar blood, and the nerves die from poor circulation, wounds stop healing because no blood is getting to them, and eventually your legs just rot off. The syrupy-sweet blood is just fudge sauce on the leg-flesh sundae that bacteria love to eat. This is why diabetics lose their legs. (The nerve damage is why diabetics go blind.)

Your kidneys, likewise, are almost entirely made of blood vessels. Too much sugar gouging out your kidneys = scarred up kidney circuits that are too damaged to let the water through. Bonus: when your blood sugar is insanely high, your kidneys can try to compensate by squeezing sugar directly out through your blood filters, which lets you piss away the dangerously gooey stuff… but rips holes in your filters, essentially. This is why diabetics have kidney failure and end up on dialysis.

On top of all that, your heart and brain blood vessels get shredded to boot, which is why diabetics have so many strokes and heart attacks. Diabetes is bad shit.
posted by maudlin at 9:25 PM on January 4, 2016 [29 favorites]


Yeah, I'll second the "read up on what diabetes does to your feet" suggestion. It is bad, and it can really hurt the quality of life of an otherwise healthy person. You can get terrible in-the-hospital-on-IV-antibiotics type infections from cutting your toenails wrong.
posted by LobsterMitten at 9:26 PM on January 4, 2016


To answer his comment about his friend with diabetes: there are two main kinds, type 1 and type 2. Type 1, which usually strikes young, your body stops producing insulin. If you don't inject yourself with insulin, you die. Type 2, your body still produces insulin, but it's resistant to it; your blood sugar regulation gets worse and worse over time. Metformin is a drug for treating type 2: it makes your body more sensitive to insulin.

As for his fasting blood glucose and his A1c: normal fasting blood glucose is 100 and below. 100-140 is "prediabetic", and >140 is full-blown diabetic. You usually need two independent readings of >140 to get a diagnosis. Normal A1c is about 5.7 or below; anything above 6.4 is considered diabetic. (IIRC there's some wiggle room in those numbers, depending on what lab you go to, but 10 is way out of whack no matter what.)

(FWIW IANAD, but I was diagnosed with type 2 diabetes several years ago.)
posted by asterix at 9:46 PM on January 4, 2016 [5 favorites]


I'm a nurse, the reason blood sugars need to be kept within a certain range (which non-diabetics do without assistance) is due to the long-term effects of uncontrolled blood sugars (specifically high blood sugars: they are the ones that damage).

Usually someone who has been diagnosed with diabetes has actually been dealing with high blood sugars for up to a decade or so before it is recognized.

High blood sugar is thicker than blood that is within a normal range. It damages every single tissue in your body, but slowly, over time... unless the blood sugar spikes extremely high, which can cause immediate and permanent damage. You know how the heart pumps freshly oxygenated and nutrient-filled blood to every single cell in your body... and how initially, that blood is pumped into the 'big pipes' of the aorta, and then the arteries which are a little smaller, and then to the capillaries which are so small you could barely even compare their thickness to the head of a pin? ... and from the capillaries, to the blood vessels which carry the de-oxgenated blood back to the heart again? Well, the capillaries touch every cell in our bodies - it is in the capillaries that we exchange oxygen and nutrients for the cells for the waste and toxins that the cells don't want anymore. It is in the capillaries that thick blood (high blood sugar) doesn't pass through very well.

This not only makes it harder for the heart to pump the blood (high blood pressure & heart disease), but the blood can form clots which can either remain in place and cut off the nutrient train/waste removal to the cells (poor circulation & poor wound healing, and prone to infection), or be dislodged and send the clot to the heart (heart attack), the lungs (pulmonary embolism), or to the brain (stroke). This can happen in every single cell. Ok, so that's just the part that you and your FM seem to have caught as being a possible issue.

Now, the other stuff that you didn't seem to get from your FM's doctor. This type of capillary damage can happen in your eyes. (diabetic retinopathy = eventual blindness) Many uncontrolled diabetics will experience blurry vision with high blood sugar which comes and goes, until it becomes permanently scarred and damaged. It can happen in your kidneys. (kidney failure requiring dialysis = strict schedule to have a machine do what your kidneys have done for you all your life - to remove fluid and toxins from the blood- includes numerous visits to the clinic weekly for hours at a time and needles and tubing...) chronic kidney disease does not kill you quickly!

Also, more damage caused by this high blood sugar is to the nerves. (diabetic neuropathy) Unfortunately, while it may be nice not to notice if you stub or scratch your foot, neuropathy can also make a person feel things that aren't there: usually burning sensations, or 'pins and needles'. Also, when a person with neuropathy doesn't realize that they scratched their skin, and since wounds don't heal well without nutrients, oxygen, and waste removal, those teeny-tiny scrapes can turn into long-term ulcers that require bandages and specialized wound care (poor healing wounds = time to schedule nurse visits in home or clinic). Worse case scenario, the person could lose more than fingers and toes - they can lose entire legs - if an infection has spread to the bone.

So, the long story short: keep blood sugars under control to avoid certain predictable degenerative conditions that are life- and limb-threatening. It's not about how it kills you: it's about how it makes your life a living torture.
posted by itsflyable at 10:36 PM on January 4, 2016 [19 favorites]


The real question he has, and which I am unable to answer, is why so much concern when he has no symptoms and is otherwise healthy?

Because your family member has two very clear, unarguable symptoms of disease already, those two blood tests. They aren't some kind of biomarker or disease stand in, they are the disease itself. Having that much glucose in your blood is not healthy or normal, it only comes about due to disease. And the A1c level is a direct measure of how much damage has been done to his red blood cells, which is a disease outcome of its own as well as a very well validated marker of recent blood sugar levels. The levels are set by a lot of research and input from many sources (not by the drug companies) and even then if you want to argue about the exact cut off (which people of course do), your family member's numbers are so high that they are far beyond the quibbling zone.

And the fun thing is, both of these things are not only directly caused by the disease state, they go on to cause more disease and damage as has already been described. You don't need to wait until there is frank damage to other organs before doing anything and it's actually better if you don't. That damage is already underway (hence the damaged haemoglobin) and has been for some time.

There is no 'otherwise healthy' in a systemic disease like this, that's why it sucks so much. But there is a lot that can be done including 'lifestyle factors' (aka diet and exercise, each of which work independently from each other so both are worth persuing) as well as increasing numbers of medications. Type 2 diabetes is a progressive disease, it feeds on itself and gets worse, so anything you can do now to stop or slow the damage will pay off forever afterwards.
posted by shelleycat at 12:49 AM on January 5, 2016 [3 favorites]


To answer his comment about his friend with diabetes: there are two main kinds, type 1 and type 2. Type 1, which usually strikes young, your body stops producing insulin. If you don't inject yourself with insulin, you die. Type 2, your body still produces insulin, but it's resistant to it; your blood sugar regulation gets worse and worse over time. Metformin is a drug for treating type 2: it makes your body more sensitive to insulin.

This. Type 1 and Type 2 are essentially completely different things with some similar characteristics (e.g. they are both related to blood sugar and insulin). The causes, treatment, symptoms, etc are different. This is why referring to just "diabetes" causes confusion, as with FM thinking he's had the same diagnosis as his friend. It's like saying you "broke a bone" - is the bone your skull or your toe or your arm? Because the implications, treatment, etc are obviously completely different depending which it is.
posted by EndsOfInvention at 3:42 AM on January 5, 2016


> That said I'm not too sure how hard I would try to control the serum glucose level of a 70 year old, most of the organ damage takes up to ten years to cause the bad problems.

Question is, has this been the case for 20 years or more already? This sounds like a guy who has not been receiving regular medical care.
posted by megatherium at 4:44 AM on January 5, 2016 [2 favorites]


The real question he has, and which I am unable to answer, is why so much concern when he has no symptoms and is otherwise healthy?

Hyperglycemia is something you get used to over time. If a healthy person suddenly had a blood glucose of 243, they would feel like shit. Their eyesight would be significantly altered. They would have headaches, incredible thirst, frequent urination, difficulty concentrating, and fatigue.

But if you're a type 2 diabetic -- which means his typical blood glucose level has been inching up gradually, probably for years -- you get used to these symptoms over time and no longer notice them. Your relative might be familiar with the old example of the frog in a pot: if you try to drop a frog in a pot of boiling water, it will hop out immediately. But if you start a frog in a pot of cool water and set it to boil, it won't move. Your relative is in a pot of boiling water right now. Whether he notices the symptoms or not doesn't change how damaging they are to his body.
posted by telegraph at 5:32 AM on January 5, 2016 [4 favorites]


Building on what telegraph says, a lot of symptoms that he's attributing to old age - tiredness, having to pee all the time, etc. - might improve with better blood sugar control. You might want to take a look at some resources from www.diabeteseducator.org
posted by mskyle at 6:01 AM on January 5, 2016 [2 favorites]


And a second question, which I have not mentioned to FM but which crossed my mind: how accurate was that blood test? There is bound to be some measure of error, and doesn't it seem to be prudent to get a second blood test before starting someone on insulin? Or is that hopelessly either silly or paranoid?

Normal blood sugar should be under 100, especially after fasting for 18 hours. His was 243. He has diabetes. Also, why was he fasting for 18 hours? It's usually 12 hours or less.

His a1C was 10. Doctors usually recommend it be under 6 or 7. They're prefer it be under 5, but that's hard to do. He has diabetes.

This aren't simple rounding errors. He has diabetes, there is no question of that, none.

You mention him being stubborn. Is he cranky? This might be a side effect of long term diabetes damage. It tends to affect your moods, but it happens so slowly over time, it appears natural to the person. Only be taking the medication for a while and seeing the difference, does one really start to see the subtler effects.

All that said, he's mid 70s and on the slow train to death. Changing much of anything at this point probably does seem silly to him, especially since he generally feels fine. You probably could try some sort of analogy based on a his likes or hobbies. So if he likes cars, talk about how you can run a car with a busted X for a while, but eventually it breaks and really messes things up. Far better to do preventive maintenance so that the decline is gradual as possible.
posted by Brandon Blatcher at 6:42 AM on January 5, 2016 [3 favorites]


To reiterate, the option isn't to drop dead suddenly, but to live with debilitating complications of diabetes: neuropathy which is pain in the extremities, amputation, kidney failure and dialysis.

My uncle died a long, lingering death due to poorly managed diabetes and I wouldn't wish that on anyone. Watching a once vibrant man reduced to a dude in a hospital bed with no ability to care for himself...that is NOT the legacy he wants to leave his family.

My Dad was diagnosed with diabetes and he was completely asymptomatic. He took it very seriously, did everything his doctor said. He lived with type II for 30 years. Now he's on injectable insulin and at 80, he's still here, doing pretty darn good all things considered.
posted by Ruthless Bunny at 6:51 AM on January 5, 2016 [1 favorite]


"The real question he has, and which I am unable to answer, is why so much concern when he has no symptoms and is otherwise healthy?"

Your ability to sense your own blood sugar level is a lot like the idiot light for oil pressure on your car's dashboard. It only lights up after serious damage has been happening for a period of time. You don't wait until the idiot light goes on before you check your oil, do you? (A 70 yo guy should get this analogy.) Similarly, when you finally, actually feel symptoms - thirst, blurred vision, whatever - it's a sign that you've already been actively damaging your blood vessels for a while. Yes, without knowing it. A1C and daily BG testing is a like a gauge that lets you see how close or how far your are from beginning to do damage. Check your damn oil.
posted by klarck at 7:07 AM on January 5, 2016 [3 favorites]


Agreeing with all the explanations above. Diabetes is typically not very symptomatic until it's been very severe for quite a while, but I think that your relative will find that if he gets treatment, his energy levels will improve and he will feel overall better.

Typically people with Type 2 DM are started on oral medications (metformin being a very safe standard first-line agent) but people whose diabetes is very uncontrolled at diagnosis are often offered insulin right off the bat for 2 reasons: 1) the pancreas normally responds to high blood sugar levels by pumping out more and more insulin. Eventually it kind of wrings out the very last dregs available to it and the cells that manufacture the body's own insulin are exhausted. Administering insulin kind of takes the burden off the pancreatic islet cells and allows faster and more effective glucose control than you can get with your own pancreas. Often people who are started on insulin for very high A1c measurements can eventually be controlled with oral medication and diet/lifestyle once their glucose is brought down to better levels. This is a much slower process with oral medications alone because most of the oral meds work by giving a boost to processes that are already going on in the body. For example, metformin makes your tissues more sensitive to the insulin that you produce. The DPP4 inhibitors (sitagliptin, linagliptin) work by inhibiting an enzyme that breaks down a substance that stimulates pancreatic insulin release, resulting in increased levels of that substance. If your pancreas is exhausted, you are not producing a lot of insulin of your own in the first place. Most oral agents decrease the A1c level (the 3-month level) by about 0.5 to 1%.

2) insulin is very safe and well tolerated these days and can actually be easier on people than taking a bunch of pills. FM is probably thinking of his Type 1 friend who probably checks his sugars 4 times a day and gives himself a shot each time. Insulin was kind of a last resort for Type 2 diabetics for a long time and so a lot of older folks kind of associate insulin treatment with people losing their legs, going on dialysis, etc. Modern insulin therapy for Type 2 diabetic patients often starts with a once-a-day shot of long-acting insulin, often given via an insulin pen where you just dial up a dose, and using a screw-off disposable needle that is so thin a lot of people don't even notice it. Many people only need to check their sugars once a day. (If people aren't well controlled on a single shot, we'll sometimes add mealtime insulin but many, many people with diabetes can be well managed without it).

That said, lots of people are like FM and the combination of a brand new diagnosis of Type 2 diabetes and a recommendation for insulin treatment is too much to take in all at once. In that case it's reasonable to start oral medications and keep talking, which it sounds like his doctor is doing. The damage caused by diabetes takes a long time, which is both a benefit (since it gives you an opportunity to intervene) but also a curse (since people don't notice anything wrong until a lot of damage has been done).
posted by The Elusive Architeuthis at 8:31 AM on January 5, 2016 [1 favorite]


THANKS to everyone who took the time to write such detailed, insightful answers. FM spent the night at my house and we were up most of the night, reading answers and talking about them, and talking about end of life issues, and what about God ... so glad we had these responses to talk about, rather than just looking at "information about diabetes" online.

I marked the answers he particularly responded to as "best answer" but they were all such a help. And special thanks to shelleycat and RuthlessBunny whose comments really touched his heart.

Going to get some sleep, but we will be back, if anyone else has comments.
posted by kestralwing at 9:17 AM on January 5, 2016 [11 favorites]


He sounds like a man who likes information - so here's some to work with

Data about diabetes

Some excellent articles from an excellent medical resource used by Doctors - these give trustworthy information

Diabetes Overview

Diabetes Treatment

Diabetes Complications

Data about risk

here's a cardiovascular risk calculator:

https://www.dtu.ox.ac.uk/riskengine/

Basically, plug in the details and it will predict your risk of getting a heart attack or stroke, and your risk of dying from those things, within a defined time period

Then fiddle with the HbA1c number (the long-term sugar marker which you say is 10 for him) and see how the risks change

I had a go at calculating risks assuming he's in the normal range for things like cholesterol and blood pressure, and he never smoked. The first image is what he's at now, the second is what he could be at if he controlled the diabetes and brought the HbA1c into normal range

http://imgur.com/a/1q3gL

So that's halving the chance of a fatal heart attack in the next ten years

(take this with a pinch of salt - it assumes a lot of things, and the numbers change with slight changes in his cholesterol levels, smoking history, etc. its more informative as a way of showing that uncontrolled type two diabetes is a significant risk factor for stroke and heart attack)
posted by DrRotcod at 1:32 PM on January 6, 2016


Thanks, DrRotcod. I transferred all these links to FM, and he's looking at them on his own. The whole discussion has made him more open to lifestyle changes (no more big bowl of ice cream every single night; back to deep water running more regularly). He has an appointment to have his AC1 levels checked in 3 months. He's not a guy that wants to live to be 100, but he enjoys life and doesn't want it to end sooner than it might.
posted by kestralwing at 5:51 PM on January 10, 2016 [1 favorite]


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