Wednesday, September 10, 2008

Diabetes is like D&D

What induces perfectly logical people to think the human body is like a simple engineering problem? Yes, on some level, you put something in and get something out. But is it always the same? Then why do people think Type 1 diabetes is the same way? You put something in and always get the same results. If you get a bad result, you did something wrong.

Even doctors do this, which still astounds me (although it probably shouldn't). They think diabetes should be easy to control. Oh, and even diabetes doctors do this. I read the following in a book about managing mainly Type 1 diabetes (which I'm not going to name here but my version says 2006): If you take insulin, then tests must be made at least three times a day - before breakfast, dinner, and bedtime. In times of stress or illness, add a fourth test, before lunch. There's rarely a need to do it more often than that. Right! Because blood sugar is always completely predictable, am I right? It goes on to note: To complicate your life, here's more advice. To determine whether you are taking enough very fast-acting insulin such as Humalog, NovoLog, or Apidra before each meal, for a couple of days check your blood again two hours after lunch, dinner, and bedtime to see if you're in the ballpark. That sounds like a lot of tests. Good thing it's only for a couple days. The book reassures: On the other hand, some compulsive patients insist on checking their blood sugar as often as five or six or seven times a day and taking insulin accordingly. This is not necessary. Oh, great, I can stop checking so much and just expect my body to behave in a completely predictable fashion. Surely insulin-to-carb ratios and basal rates will never change, right? There's no such thing as bg going wacky due to illness, stress, hormones, the diabetes fairy. Only crazy people would think so! (The book continues with such gems as one should NEVER eat sugar, even children, and that insulin doesn't need to be refrigerated).

See how easy it is? We should all throw out testing more than three times a day, adjusting insulin, basal testing, insulin pumps. Forget it! All you need to is take the same amount of insulin and eat the same amount of carbs per meal, and you'll always be fine!

Well, as we all (hopefully) know that this isn't true. If I (with LADA) can't get good control without testing 8 times a day, I don't know how anyone else could. I eat the same breakfast every day, and have for at least three years. So do I get the same result every day? Of course not. I can look for the patterns, of course, but some mornings I'm going to need a correction, and others I might even end up low, without changing any of the other factors. So every time you have a situation, you act, the dice roll, and while you can increase the probability of an outcome, there's no guarantee you're going to get the result you want. I do think that following the advice above will lower the probability significantly. But even if you "do everything right," get educated, pick up the latest tools - you're still subject to the whims of the dice, or the diabetes fairy.

What's weird is that even when it *is* predictable, people still don't get it. "Why is your blood sugar low?" Well, guys you told me I couldn't eat anything for 12 hours and then made me walk 1/4 mile to the lab and fill out a bunch of paperwork. I could see that coming a mile away. "Why is your blood sugar high?" Well, I was planning to go shopping, so I took less insulin with lunch, but for some reason you decided you didn't want to. "Why don't you start eating right away? It makes me really uncomfortable." Well, I have to wait for the insulin to kick in, and I'm not going to take it before the food comes because I have learned my lesson there. "Why did you get upset after I stole half the food off your plate after I told you I didn't want any? That's rude!" (Left as an exercise for the reader).

Anyway, back to another day of rolling the dice and wishing for a +12 Stick of Clue.


Scott K. Johnson said...

Great post Lili.

I am shocked (although not necessarily surprised) that the quotes are taken from a book dated 2006.


Minnesota Nice said...

"This is not necessary....." (?????) Oh mercy.

Sarah S. said...

If you find that +12 stick of clue, mind if I borrow it occasionally? or tell me which boss drops it ;)
Seriously, I'm horrified that a recently published tome of diabetes knowledge would have something that outdated in it. The only way that strategy might work is if you have the exact same schedule every day and never ever do anything on a whim. That's totally unrealistic, and even if you did go that route, it's still all a probability game - it's not all "a+b=good blood sugar."
On the D&D side: Maybe this book is a cursed object that brings your Int or Wis down permanently if you try to live by what it suggests, or maybe it subtracts from your diabetes lore. Whoever wrote it must be lawful evil.

Lili said...

Scott - Thanks. I kept the book for my wall of shame bookshelf.

MN - Don't you feel so liberated now?

Sarah - Hahaha. What's funny is that this book tells you your life will be so much better and less restricted when you eat on a schedule, have the same number of carbs at every meal, never adjust your insulin, and never eat quick-acting carbs, especially sugar. Doesn't that sound like freedom? I think you're right.

Sarah S. said...

I think they're probably defining "better" as strictly "lower probability of weird numbers." By contrast, I think most people define "better" as "happier" or "less worried" or something more universal.
Part of me wants to completely geek out and make up an rpg about diabetes as a result of this exchange. Maybe something with a deck of cards rather than dice, or d6s that doesn't involve too much esoteric gamer knowledge. Something that might give people a taste of what we're really dealing with when we try and do it "by the book" vs. according to what works. What do you think?

Lili said...

Sarah - No, I think they mean better as "less worried," because you just follow the rigid plan and don't ever have to think about your diabetes. What's weird is that it also says you'll avoid complications this way and be able to achieve your target range (which is the lowest I've ever seen in a diabetes book). I don't know what they were smoking, but I just don't see how that's possible.

I think a game is a great idea.