Meals with Diabetes

It would really be nice just to eat what I want, or even just to eat what was good for me. But when you’re using an insulin pump with carbohydrate counting, things are never that simple.

The scale was tared for the weight of the pan; only the asparagus is weighed. This is only 6 grams of carbohydrate; asparagus is not a high-carbohydrate food.

Carbohydrate counting is a relatively complex way to handle the interplay between food and insulin. The simplest way, which is what the doctors started me on 40 years ago, was a rigid diet (the diabetic exchange diet) and an equally rigid schedule of insulin shots. It worked all right during the honeymoon phase, but few people stick to it, and by 10 years ago it wasn’t working. Even when I tried counting carbohydrates to get a more accurate food intake, the intake being dictated by my doctor, I still had problems. Sometimes I would go into shock at the most unexpected times (including while eating); at other times I would go high for no apparent reason.

It wasn’t until I got an insulin pump that I learned the most important lesson of carbohydrate counting: you adjust your insulin to what you are eating, your measured blood sugar at mealtime, and how your body reacts. Some doctors are still not comfortable with this.

The standard method of carbohydrate counting just counts the grams of carbohydrate in a meal, leaving the fat and protein to themselves except for avoiding too much fat and making sure there is enough protein. This works as long as each meal contains about the same balance of fat, carbohydrate and protein. When this balance varies, it’s better to use a complex formula that includes all three, as all eventually show up as glucose in the blood. One formula I’ve seen is grams of carbohydrate plus half the grams of protein plus one-fourth the grams of fat. I use grams of carbohydrate plus half the grams of protein, unless fat makes up more than 40% of the meal. (Not often.)

But how do you get those grams?

If you’re eating prepared food you read the nutrition label. These are actually available online for many national restaurant chains, though it means going online before you go out to eat, or order it sent. (It may also shock you at the amount of fat present.) If you are eating out other than at a national chain, you have to guess – and check your blood sugar often after eating. If you are cooking with fresh food at home, you need to weigh everything and refer to some kind of list, such as the one put out by the FDA, which has nutritional information for all kinds of foods. (The FDA list is available as an iPhone app, and there are may other food listings of this sort online.) Needless to say, this greatly slows down the process of preparing a meal, which is why I tend to rely rather heavily on frozen meals – reading the nutrition labels before I buy!

As to how to weigh food, the ideal is a gram scale, usually digital and battery-powered. Mine’s almost worn out from use, but it’s an essential part of food preparation for me.

As to getting all those weights into a meal, I use a computer program called Diet Sleuth, though it means running back and forth between the kitchen and the computer room to enter the foods I’m going to eat. Next week I’ll describe how it works.

Award and Medicare

Well, I’ve had a couple of good days. First was the email Thursday that Tourist Trap was a finalist in the Reader Views Literary Awards. Yes, that’s the same one Homecoming received last year.

Then I got a phone call from the clinic saying the box of replacement sets had arrived, and I picked them up Friday, thus ending a very nervous couple of weeks.

Replacement sets?

The other end of that plastic cord feeds into me.

I use an insulin pump. It’s about the size of a small stack of business cards, and it normally lives in my pocket. It contains a reservoir of insulin, which theoretically should be changed every three days. (I normally average about six, because that’s how long a full reservoir lasts me, and I have yet to see any drop in effectiveness after six days at body temperature.) The pump gradually pushes that insulin out very fine tubing a couple of feet long to a set, which is fastened to my body by a piece of adhesive and has a fine Teflon cannula piercing my skin and delivering insulin into the subcutaneous tissue. The set has a needle which is used to insert the cannula under the skin, and is then removed. The set has to be changed every three days – any longer than that in the skin, and scar tissue starts to build up and insulin no longer gets through. These sets are not reusable; in fact they become medical waste.

I’m lucky to have very good supplemental insurance as well as Medicare, and every 3 months I get shipped 30 sets. A couple of weeks ago the shipping company called me to check how many sets I had.

“Two. When are you going to ship them?”

“We did, a couple of weeks ago.”

I have them ship to my doctor’s office, because in my experience mail order pharmacies never adequately package temperature-sensitive medications being shipped to regions where 40-below temperatures are common, and in some shipments I get continuous glucose sensors which must not be frozen. So I called the clinic, which usually calls me when a package arrives for me.

They couldn’t find the box.

By that time the pharmacy was closed, so when I called back the next morning I got the details of the shipment. They insisted it had been signed for at the clinic and gave me the exact time and date of delivery.

I called the clinic back. I think it took about a day before they finally said that yes, they had received the box. The person who signed for it remembered it. So did several staff members. But they couldn’t find it, and they’d looked everywhere. They said they’d call the mail-order pharmacy back and pay for a replacement shipment. (This is stuff no local pharmacy carries.)

The mail order pharmacy said that Medicare rules did not allow them to send out a replacement shipment – never mind that it was the clinic, not me, that verified I had never received the sets that are essential to my life, or that the clinic was willing to pay for the replacement shipment.

The clinic combed the offices of the doctors that treat diabetes, and managed to come up with a few sets to tide me over. They also called the pump (and set) manufacturer. The manufacturer FedExed me a few more sets. Finally, Thursday, the clinic called and said they had the sets from the manufacturer, and I picked them up yesterday.

I realize that Medicare does have a huge fraud problem. But in this case the clinic was offering to pay for the lost shipment, so what kind of fraud did they think was involved? It’s not as if the sets were valuable to anyone else, but they are life or death to me.

Three Approaches to Health Care

There are three ways of approaching less than optimal health: prevention, treatment and cure. All have their strong and weak points; all are political hot cakes at the moment.

I think most individuals and societies would agree that the best solution is to stay in good health. It is also a solution that is not always possible. It is, however, the approach that is responsible for the dramatic drop in childhood death in developed countries.

Prevention measures are generally lumped as public health. Clean drinking water, proper sewage disposal, nutritious food, clean air and immunizations all fall into this category. So do measures intended to reduce accidental injury or death (such as seat belts) and those encouraging a healthier life style. Prevention would also include such highly controversial measures as not passing on genes known to have a deleterious effect on health.

In general prevention measures are good for the population, but affect individual choice. They may also affect the bottom line of corporations with a great influence on public policy, such as the food industry.

Some of what I need for treatment of diabetes. I want a cure!

By treatment I refer to ongoing treatment — the pill (or shot) for everything or treatments such as dialysis which must be repeated regularly for the life of the patient. Certainly it is better to have a treatment than not! I am alive today thanks to insulin. But treatment is generally expensive and is often lifelong. Further, treatment of this sort almost always has undesirable side effects. In my case, insulin can produce hypoglycemia which can kill. It should be noted that some “cures,” such as organ transplants, may then produce a condition in which lifelong treatment (anti-rejection drugs) is needed.

A cure implies a return to normal health. In some cases (such as the common cold) a cure is mainly a matter of time, with supporting treatment to prevent secondary infections or ease symptoms. Some cancers are curable with surgery, especially if caught early. Broken bones or other traumatic injuries can often be cured, especially in the young. A number of conditions, however, have no cure. Research on cures is ongoing, but the profit from a true cure is usually not as great as from lifelong treatment. Given that most health research today is profit-driven, research on cures tends to take a back seat to research on treatments.

I’ll probably return to this in the future, looking at one of the three approaches at a time. For right now, how would you order the importance of the three approaches?

Health

One of the things I blog about is health and health care. Here are links to posts on this topic. This post will be linked from the Index page, and I will add new posts as they go live.

General
A Pain in the Back 8/12/11
Pain Gel 10/1/11
The Cost of Health Care 10/8/22
Cranberry Recipes 11/24/11
Three Approaches to Health Care 1/21/12
Vitamin D 10/4/12

Cancer
Breast Cancer part 1 2/12/11
Breast Cancer Part 2 2/19/11
Breast Cancer 3: Mammograms 2/27/11
Radiation Therapy for Breast Cancer 3/12/11
Chemotherapy and Quilts 8/6/13
A Chemotherapy Fashion Show 8/15/13
Chemo, Hair Loss and Wig 8/22/13
Happy News: CT Scan 9/24/13
A to Z Reflections 5/8/14
Cancer Survivor 6/14/14
More cancer 10/6/14

Diabetes
Insulin Pumps 5/20/10
Cataract Surgery Complications 1/29/11
Diabetes and Blood Sugar 2/5/11
Complications of Diabetes 5/27/11
Diabetes: What’s in a Name 7/15/11
Conversation Piece (fiction) 10/20/11
Measuring Blood Sugar 11/12/11
Your Mileage May Vary 11/26/11
Continuous Glucose Monitors 12/3/11
Award and Medicare 3/3/12
Meals With Diabetes 5/19/12
Diet Sleuth: A Useful Meal Planning Tool 5/26/12

Contuous Glucose Monitors

Continuous Glucose Monitors (CGMs) are a relatively recent development in diabetes control. They are still controversial with many insurance companies, though prevention of even one high-cost ambulance trip to the emergency room should make them cost-effective. But they do have problems.

There are three devices that I am aware of, worldwide, and others in development. The best, according to users, is the Navigator – but it has been withdrawn from the US market. This leaves the Dexcom and the Medtronic sensors. My own experience has been entirely with the Medtronic sensor, but all three work in basically the same way, on interstitial fluid, and all are subject to the same problems of time lag.

Medtronics transmitter (white) and the visible part of the sensor (clear) with a U.S. quarter for scale. I use IV 3000 to hold everything in place.

The sensors available today consist of some kind of reusable transmitter, a receiver, and a disposable needle which injects a small disposable sensor under the skin. The sensor is then connected to the transmitter, which lies against the skin.

The sensors are expensive. The price today at the Medtronic store is $42 a sensor, with an official life of 3 days. (Most people actually manage to use them longer, and in fact I find they are most accurate on days 3-5, though I rarely get one that lasts more than a week.) The big advantage of the Medtronic system is that the Medtronic insulin pump (the kind I have) acts as the receiver, though separate receivers are available. The official life span on the Dexcom sensor is 7 days, though I understand they are correspondingly more expensive. Comments from users of the Dexcom are solicited!

A continuous sensor is extremely useful in that it allows you to see how your blood glucose varies between finger sticks, and also allows you to see whether it is rising, falling or staying reasonably constant. The Medtronic sensor allows you to choose whether to see a 3-hour, a 6-hour, a 12-hour or a 24-hour graph of your blood sugar, or download values about 5 minutes apart to a computer, and I believe the Dexcom sensor is similar. On the negative side, CGM accuracy is highly variable, and it needs regular calibration with a finger-stick meter. There is a further problem (at least with the Medtronic system) with alarms.

I used to eat protein bars for breakfast. They had a good balance of protein, carbohydrate and fat, they took no weighing, and they were consistent day to day. They also produced a considerable spike in blood sugar in the hour after breakfast, easily identified on the CGM graph but missed in finger-stick testing. When I switched to Greek yogurt with fruit, also a good balance of protein and carbohydrate but without the fat, my blood sugar graph leveled out. In fact, the CGM has allowed me to identify many regular meals as causing spikes or delayed rises in blood sugar. (The fat in the bars was not the problem; in fact fat delays the absorption of carbohydrates, but much of the carbohydrate in the bars was fast-absorbing sugars.)

I am not alone in finding trends more useful than absolute numbers. A high blood sugar (within reason) is not really a problem if the blood sugar is decreasing, nor is a moderately low reading with an upward trend. On the other had, a high reading going up or a low reading going lower is cause for immediate finger-stick confirmation and treatment if the reading is confirmed. A low reading at night or if I’m planning to drive is always reason for finger-stick confirmation.

What the sensor actually measures is a slight electrical signal, and this must be calibrated with a finger stick measurement to get the actual blood sugar reading. The calibration constant changes over the life of the sensor, and can drop very fast toward the end of sensor life. Consequently the sensor must be calibrated a minimum of twice a day, preferably when your blood sugar is fairly steady, and may give a lot of false low alarms near the end of its life.

Another problem is that the sensor measures the glucose concentration in the interstitial fluid, that is, the fluid between the cells. While this follows blood glucose, there is a significant time lag. My blood sugar can drop very rapidly, especially during exercise, and as a result CGM measurements during exercise can be much higher than my actual blood sugar. This time lag alone makes me very dubious about using this type of sensor for any closed-loop artificial pancreas.

My biggest complaint with the Medtronic system is the alarms. Ideally, to be most useful the CGM system should wake you up if your blood sugar starts to drop. In fact, the alarm is so low in volume and so high in frequency that I almost never hear it unless I am in a very quiet environment and there is only a layer of cloth between my ears and the pump, not a down comforter. This is partly my hearing, as others will sometimes point out to me that I am beeping. Yes, it does start vibrating eventually if I do not respond, but I feel the vibration only if the pump is tight against my skin. I usually feel it driving (well after I start going low) but often not at night.

Is it worth it? Yes, for me. But it definitely needs some improvements.

Your Mileage May Vary

YMMV.

That particular acronym, standing for Your Mileage May Vary, is all too common on the insulin-pumpers’ website.

It applies to those of us with any chronic disease, and one of the main problems with “evidence-based” medicine is that it tends to rely on how the “average patient” reacts. There is no such animal as an “average patient.”

I had first-hand experience of this when a doctor, pre-pump, tried to put me on what he called a sliding scale of insulin, and gave it also to nurses in the local hospital. They insisted on using his scale when I was in the hospital for something else. I looked at the dose of insulin they insisted was necessary when my blood sugar was a little high at bedtime, and said “that’s going to put me into insulin shock.” They insisted on giving me the dose anyway. Luckily insulin shock still woke me up back then, and at 3 am I woke up shocky, hit the call button, and demanded a snack for insulin shock. They insisted on checking my blood sugar first, which only confirmed what I had tried to tell them earlier. I know now that that particular sliding scale, which was probably worked out for the average diabetic of my weight, simply did not work for me. I am very insulin sensitive, and while I absolutely need insulin and will see a very fast and uncontrolled rise of blood sugar without it, I need a very small amount, given my weight.

It isn’t just person-to-person differences, either. It can be time of day, time of month, stress, air bubbles, absorption rate of injected or infused insulin, or just the natural cussedness of the universe. Sometimes it can be how what you eat gets into your bloodstream.

Your blood sugar does not rise the instant you put carbohydrates into your mouth. The food has to be chewed and swallowed, as almost nothing is absorbed directly from the mouth or esophagus. It has to reach the stomach. One of the side affects of diabetes in many people is gastroparesis, which is delayed passage of food through the digestive system. To further confuse the person trying to keep diabetes under control, this delay is highly variable.

As a general rule, food I eat at breakfast time gets into my bloodstream, as glucose, fairly quickly. I’ve taken to eating yogurt for breakfast because most of the carbohydrates are lactose, which absorbs fairly slowly, and because the relatively high protein content also slows absorption. At noon my food absorption is a little slower, and by dinner time it’s slower yet – slow enough I normally spread my insulin out over 4 hours or so.

Changing my eating habits, as I did two days ago for Thanksgiving dinner, can cause an unexpected change in how fast the dinner actually gets into my bloodstream as glucose.

I didn’t have a huge dinner, or an unbalanced one, but I had more than normal, and upped my pre-meal insulin to compensate. I kept to a four-hour dual bolus, but by the time we went to another house for dessert, my blood sugar was running low. We had pie for dessert. I had a small piece, and I was still low, but I did take more insulin to balance the pie.

By the time I got home I was well into insulin shock, with a blood sugar below 50, and over the next two hours I ate enough to bring it up to normal by bedtime.

Four hours later my blood sugar was over 300.

I’m pretty sure that what happened was that the relatively large dinner caused more than the usual delay between swallowing food and the actual rise in blood sugar. As a result the amount of insulin I took, which was reasonable for the amount of food I ate, was enough to put me into insulin shock. Later that night the food caught up with the insulin, but by that time I had eaten enough extra to treat the shock earlier that my blood sugar went high.

The only way a doctor can prevent this is by insisting that you eat exactly the same meals at the same times every day. But we’re people. Most of us can’t keep up that kind of regime. And if we don’t accept that rigid a regime, we have to be intelligent enough to treat ourselves, to a certain extent.

I’ll probably do the same thing for Christmas dinner. But I’ll know to spread the insulin out over more than 4 hours.

Cranberry Recipes

The blade to my food processor. That black is supposed to be all one piece.

Disaster struck as I was preparing to start the salad for Thanksgiving dinner — the chopper blade on my food processor is broken. It was fine when I put it away, but now the plastic that holds the blade to the processor is shattered. Guess I’ll have to use the old mini-chopper for the cranberries and chop the rest of the stuff by hand.

Here’s a photojournal of the process of making the salad without a food processor. Turned out the mini-chopper did help with the oranges, too.

Ingredients and tools for the salad. (The paring knife didn't quite make the picture.)

Chopping celery's not that hard--just make a few cuts lengthwise before you start.

Yes, the whole naval orange is cut up. The mini-chopper took it down to small pieces.

Frozen cranberries and nuts help each other in the mini-chopper. It took three rounds, though.

The mini-chopper could not handle the apple wedges, so I had to chop them by hand. Apples were left to last, when I started heating the apple juice and water for the Jello.

What, all those solids for such a little bit of Jello? (I used orange, as I couldn't find lemon.)

The finished salad, ready for the refrigerator.

Recipes?

It’s anything-goes-day as well as Thanksgiving, so I thought I’d share a couple of my favorites. After all, they go well with turkey leftovers, too.

The first is my mother’s recipe for a Jello salad, modified to avoid added sugar and take advantage of a food processor. Note that while the usual Jello salad is Jello with fruit in it, this one is fruit, nuts and vegetables with a little Jello holding it together.

Cranberry-Orange Salad

2 4-serving or 1 8-serving packages of sugar-free lemon Jello
1 12 oz can frozen apple juice concentrate
1 c water
1 seedless orange, washed but unpeeled, cut into chunks
2 cups celery, cleaned and cut into pieces
2 washed apples (Granny Smith preferred), cores removed and cut in chunks
3 cups raw cranberries, washed and (preferably) frozen This is one 12 oz bag.
1 cup walnuts

Heat the water and apple juice concentrate together to boiling, and dissolve Jello. Meanwhile, use the food processor to chop (coarsely) the remaining ingredients. (It may take several batches.) Place the chopped ingredients in a 9” x 13” pan, level them, and pour the dissolved Jello over them. Mix and level to get all of the chopped ingredients below the liquid, and chill until set.

Makes 24 servings of 82 Calories each. For each 68-gram serving:
13 g carbohydrate
1 g protein
3 g fat (mostly from the nuts.)

Don’t laugh at the gram measurement – when I eat this I weigh the portion, and I use the carbohydrate and and half the protein to figure my insulin dosage. The recipe may have no added sugar, but with all the fruits and the apple juice concentrate, it’s far from sugar-free.

A half recipe would probably fit nicely into an 8” x 8” pan; I’ve just never tried it that way as this is my regular contribution to potlucks and Thanksgiving dinners.

The second recipe isn’t mine and is probably quite familiar to NPR listeners, but here is the link to Mama Stamberg’s cranberry relish. It may sound strange and look like Pepto-Bismol, but it’s yummy. I freeze it in an ice cube tray.

Happy Thanksgiving!

Measuring Blood Sugar

Back in the middle of the 20^th century, long before I had diabetes or even thought much about it, I saw a magazine ad that talked about diabetes. It might have been an insulin ad. What I do remember was that it featured a Russian troika – a three-horse hitch – and likened controlling diabetes to driving a troika. Three things have to be balanced: insulin, food and exercise, and misjudging any of the three can throw you to the wolves.

That balancing act is hard enough today, with all the tools we have to help. It was a lot harder 42 years ago, when I was diagnosed. And I hate to think of what it must have been like at the time of the ad.

The key is being able to keep track of your blood sugar. Really high, and you need insulin – exercise may actually push you higher. A little high, and aerobic exercise may bring you down. Too low, and you need food, preferably fast-acting carbohydrates. But at the time of the ad, measuring blood sugar meant several hours of lab work, and you might hear back from the doctor the next day. In order to utilize food, insulin and exercise optimally, you have to have some idea of what your blood sugar is right now, and whether it is rising or falling.

There are some symptoms. Sweating, shaking, blurred vision, and tingling lips can all be symptoms of low blood sugar. They can also be due to other things. (I was put on hormones at menopause primarily because I could not tell the difference between a hot flash and low blood sugar.) But those symptoms tend to decrease with years of living with diabetes.

Symptoms of high blood sugar are even subtler. I may start feeling a little odd when my blood sugar is three or four times normal, but my feelings were certainly not enough to tell me when I was high. Anyway, in those days doctors normally prescribed a fixed amount of insulin and a fairly rigid diet, and pretty much ignored exercise.

My current glucose monitor

What was desperately needed was a way for diabetics to find out what their blood sugar was, preferably without slashing their fingers with a modified razor blade. (That’s how they used to get blood samples.) Eventually, and over the initial objections of some physicians and regulatory agencies who were afraid that patients would self-treat, glucose monitors were developed. From the point of view of most diabetics, the objections were just plain silly. We have to treat ourselves. We give ourselves shots of insulin (which cannot be taken by mouth because it would simply be digested.) We exercise. We eat. Doesn’t it make sense that the more we know about which of the three we need, the better?

The first monitors were reportedly large, clunky and slow. They improved rapidly, and by the time I got my first one, in the late ’80s, they were pocket sized (if you had large pockets.) My testing kit today fits easily into the belt pouch I use as a purse. I still have to poke my fingers many times a day, but I get results in five seconds. One important thing is not covered, though – I can’t tell whether I’m going up or down from an instantaneous reading.

There is also a problem of expense. Tight control means testing before each meal, at bedtime, before you drive, regularly during driving, and every 20 to 30 minutes when exercising. Test strips are not cheap, and there is a real problem getting insurance companies to cover enough strips.

I’m not the only person with diabetes to feel this way, and there’s been a good deal of research on continuous glucose monitors. The first one I tried was the glucowatch. This used a patch sensor on the arm or wrist, and gave the blood sugar on the “face’ of the watch. It could also be read by a computer. Drawbacks? Many. First, it would only operate for 12 hours, and took a while without readings to initialize. Second, the patch was very irritating to my skin. I invariably had a major welt that lasted a week or more when I removed the watch and patch. Third, any sweat made the readings unreliable – and sweating is a symptom of low blood sugar. The watch did confirm that I was having low blood sugars at night and that I responded by “bouncing” high – a fairly common reaction, and much better than staying low with possibly fatal results. But the combination of problems led me to stop using it.

Modern continuous glucose monitors are much better, though by no means perfect, and I’ll talk about them, and the problems with getting insurance companies to cover them, in the future.

Conversation Piece

This is a bit of flash fiction, written in the Summer Arts Festival. The assignment was to write a conversation between two people who don’t understand each other, one of whom has some kind of dominance over the other. I’d call this a dysfunctional school, but this sort of incident can happen–we’ve had similar accounts on the insulin-pumpers e-group.

The small office was too warm, but Cyril never thought of shedding his coat.  Instead, he straightened his tie, pulled himself up in his chair and glared at the student standing in front of him.  “Well?”

The boy–what was his name?  Jerry?   Jimmy?  Jimmy, that was it–refused to meet his eyes and scuffed his right foot on the floor.  “I ain’t done nothing.  What you want to go pickin’ on me for?”  He shoved his hands in his pockets and turned his head, pretending to study the books on the wall.

“Speak properly, boy, and stand up straight.”  Damn kids today.  No respect.   Snotty twelve-year old, thinking he knew more than an adult.  And his hands were tied.  Couldn’t touch the little bastards, no matter how much a good spanking would straighten them out. “Trying to use a cell phone in class isn’t nothing, boy.  Now hand it here.”

Jimmy backed up a step, and his hand tightened around the phone in his pocket.  “Don’t have a cell phone.”  Sweat began to bead on his forehead.

Cecil stared at the boy, outraged by the lie.  “So what’s that in your pocket?”

“None of your business.”

Cyril stood up, lips compressed.  “Give it here.”

“No!”  Jimmy backed away another step, his eyes flickering to the closed door.

Furious, Cyril lunged toward the boy, grabbing the object the youngster held and pulling it away.  It was tethered by a cord to the pocket, and he jerked it free and threw it down.  He heard it smash as it hit the floor.

Jimmy screamed.  “You bastard.  He ran to the broken plastic case and picked it up, crying openly now.  “My mom’ll kill me.  I made her promise not to tell.  New school–I thought the other kids didn’t need to know.  And since the divorce…”

Cyril took the smashed electronics from the boy’s unresisting hands, and suddenly saw the words in the back of the case.  Insulin pump.

The Cost of Health Care

Why is health care growing steadily more expensive?

Well, there are quite a lot of reasons. But the most obvious to me, the elephant in the room (and I’d don’t mean the GOP elephant) is something never mentioned by politicians. What’s more, we all cheer it on.

I mean the advances in medical science.

Face it. One of the man reasons medicine is costing more and more is simply that doctors can do more and more.

Take my own case. A century ago, I would have died before getting my Ph.D., and the most a doctor could have done was tell me that I had diabetes and it would kill me, painfully, probably within a year if not a few weeks. Oh, my life could have been somewhat extended by a starvation diet, but I wouldn’t have lived long, and I probably would not have stacked up much medical cost.

42 years ago, when I was diagnosed as having diabetes, there was a treatment, insulin. It was cheap—a slaughterhouse byproduct. Hypodermics were glass, and my fingertips were often scalded because those glass syringes had to be taken apart and boiled before each use. Blood sugar tests? Those were carried out in a laboratory, and took several hours. Urine tests were available, but it didn’t take me long to realize that I could have urine sugar so high the tests would scarcely read it while I had every physical symptom of blood sugar so low I almost passed out. The medicine of the time kept me alive, but my diabetes was not exactly well controlled. Probably my eye problems today can be traced in part to this poor control.

Since then I have gladly discarded the glass syringes for disposable plastic, swapped beef-pork insulin for genetically engineered (and much more expensive) human insulin, learned to test my blood sugar with a finger prick, begun using artificial insulins genetically engineered to act faster and slower than human insulin, started using an insulin pump, and added a continuous blood sugar monitor. My diabetes is under far better control, and in fact my blood sugar is usually within the normal range. Thank goodness I have good insurance, because all of this is appallingly expensive.

Diabetes is by no means the only disease to see this kind of improvement in care at an increase in cost. Many cancers that were once fatal or “curable” only by gross mutilation can now be treated with far less invasive surgery, drugs and radiation. More and more conditions that were once a death sentence can be treated, even if few can be really cured.

And as one result, medical costs have skyrocketed. People for whom nothing could be done are now treatable.

Greater possibilities are not the only reason medical costs have climbed, and I’ll touch on some of the others later. But we have to recognize that at least part of the cost increase is simply because doctors can do something other than just tell a patient, “You’re going to die soon.”