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.

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.”