A few years ago, I listened to a piece on NPR’s Inflection Point. The guest was a brilliant behavioral designer from Stanford. She explained that when she approaches a project, she starts with the future in mind. She talked about imagining future possibilities. “Why not,” she said, “imagine an awesome future?”
I’m going to begin in the same way. What I hope to accomplish with my story is to change the common perception of what it means to live with diabetes. I hope to ignite something in someone—to spark an idea that could change lives.
I come from the world of campaigns and politics where we are taught to share through storytelling. I want to talk about health, technology, and diabetes through the lens of my own life.
In 2014, the climbing bug hit me hard. I started spending all my free time in climbing gyms. And I spent all my spare change on climbing gear. This recent shift in my life brought with it community, strength, and new heights of self-confidence even though I was only in my early twenties. Life was good.
I was feeling so good, in fact, that I applied for a “Live your Dream” climbing grant from the American Alpine Club and the North Face to climb in the French Alps during the summer of 2015.
As a budding rock climber and mountaineer, going to Chamonix meant a chance to take my skills to the next level. In February, when I found out I had received the grant, I pushed full steam ahead to train and grow my skill set. I outlined a series of climbing trips to help me prepare.
In May of 2015, I planned a trip to climb Mt. Whitney in California. When the weekend was finally upon us and we started our climb, we were greeted with an unexpected storm that dumped about 4 feet of fresh snow on the mountain.
After just a few hours on the trail, I started feeling completely defeated. I didn’t want to let my partner down or let it appear that I was incredibly out of shape. So, I cinched my pack down and kept on trucking forward. But something was off.
My head hurt, but it wasn’t the familiar pounding from altitude. My stomach was in knots, but I assumed it was just the borrowed pack sitting awkwardly on my abdomen. And why, I wondered, did I have to stop and use the restroom every 15 minutes?
I didn’t want to admit it, but I wanted to turn around and go back down so many times. Just when things seemed too difficult and I couldn’t take more than 10 steps without stopping, the clouds broke and I finally saw the towering granite spires of Mount Whitney’s summit.
With that motivation, we pushed on to high camp to spend a freezing sleepless night near the summit. In the morning, all hopes of an alpine start melted into the sounds of wind whipping past our tent. When the sun finally shone through, we hustled up a steep snow gully for the summit ridge.
Just a few hundred feet shy of the summit, we decided to turn around—dark storm clouds were looming on the west side and the white mist of the morning was now engulfing us to the east. Without ropes, we were not willing to break trail in fresh snow over loose rock.
As we descended, my symptoms started to abate. I thought, perhaps, what I had been feeling was altitude sickness after all. When we finally got back home, however, I still wasn’t fully recovered.
Of course, I thought, I was run down from the trip and the climb. But soon, intense thirst and dehydration started to cripple me. After a week of these symptoms and sleepless nights running to the bathroom upwards of 3 times, I administered a home glucose test and discovered I had dangerously high blood sugar.
On May 29, my life changed forever. I was rushed to the ER and soon diagnosed with Type 1 diabetes.
I want to quote from someone that I look up to. Maybe you all remember the rock climber Tommy Caldwell who is well-known for free climbing the dawn wall on El Capitan in Yosemite. In his Ted talk, he spoke about adversity, especially referencing the moment when he severed his finger with a table saw. He shared these thoughts:
“If we reframe adversity as adventure, we allow ourselves to be exposed to challenge, that challenge can energize us and show us who we are.”
Even if we don’t open ourselves up, conflict is going to find its way in. After all, conflict is natural so we should make an effort to be prepared. Now, obviously, I was not prepared for the huge challenge that I was about to face being diagnosed with Type 1 diabetes.
The day that I was diagnosed, part of me felt like a victim. But another part of me remembered that I have overcome. I had faced challenges in my life before and I could turn this hardship into something else. After all, hardship is what makes us feel more deeply. And the ability to truly feel creates passion. And passion is what leads us to defy the odds.
When I left the hospital, I wasn’t feeling sorry for myself. I was feeling the drive to understand the future. I was focused on how I was going to be able to keep climbing. And how I was going to incorporate diabetes into my life. This was a rebirth of who I was and how I was going to accept the disease and a different lifestyle, but keep on climbing.
Now, I want to take a moment and not discount the hardship and the pain realizing that life is drastically different with a diagnosis of Type 1 diabetes.
While I chose at that moment to focus on the future and let passion and determination push me to keep climbing, I honestly say that life with diabetes is not easy. There are many days that are hard. Times that you just want to pretend that you don’t have to prick your finger 20 times a day. Or pretend that you don’t have a disease that limits what you eat and then makes you feel sick for no reason.
Being strong doesn’t mean that you can’t show defeat. Just like in climbing, if the weather is bad, if the conditions are not right, and you’re not feeling it, you must let it go. You give in.
You accept that this time, the mountains are going to win. Similarly, with diabetes, I may not ever conquer this disease, but I can open myself up to vulnerability, let people in when I need help, and find support amongst others to feel better.
Being vulnerable and reaching out—showing that this disease can have a difficult and sometimes heartbreaking effect on my life is not weakness. It is strength.
Mountaineers who are honest and turn away when the conditions are bad when the avalanche risk is too high are the smart ones. They’re the ones that acknowledge that mother nature is more powerful than we are. And it is more important to face another adventure than to give everything up for this one chance.
This is how climbing has been a metaphor for my life. This is how I continue every day and wake up with a positive attitude and try.
After diagnosis, I brought that determination with me when I walked into my endocrinologist’s office and asked:
“What do I need to do to get this under control so I can continue to climb?”
My healthcare providers became my team. They were willing to help me get there. But first, I needed more gear. this, of course, was music to my ears.
They outfitted me with a continuous glucose monitor (CGM) from Dexcom. With this tool, I was able to get real-time results of my blood sugar levels and additional information on what direction it’s trending in.
This technology radically changes the daily life of any diabetic. In fact, it has been clinically proven that CGM users experienced an average 1% reduction of their blood glucose levels (A1C) after 24 weeks of regular use.
But for a mountain athlete, this became my lifeline. A clear insight into the fluctuations of my blood sugar as I would move through the mountains. In the first month, this tool showed me things I couldn’t even feel or predict.
Just a few short months after diagnosis, it was time to head out to France. For as much research as I had put into the trip, nothing could have prepared me for the experience of seeing the mountains for the first time.
From the Aiguille du Midi station, we roped up and descended the ridge to the Col du Midi plateau. Finally, on the glacier, I had a real moment of awakening. I felt the culmination of emotions from planning this expedition and the course of my own life.
I remember tears streaming down my face just acknowledging the work I had put in to achieve this goal. With this larger-than-life backdrop, it is inevitable to feel so small, yet I have never felt so alive and connected to the world around me.
I don’t have words for some of the experiences that I have had, so I’ll let these photos do the talking. 
What I can tell you, though, is that these mountains are an unforgiving place for people. Despite that, I didn’t let diabetes stop me from trying myself in this terrain.
My CGM has allowed me to be a ski mountaineer and rock climber in Yosemite. It also makes some of life’s simpler tasks possible for a diabetic.
For example, I don’t have to worry about dying in my sleep from dangerously low blood sugars because I have an alarm. Further, the closest people in my life also get notifications on their phones.
I can go to class and discretely manage my disease so that I can focus on my future. My friend with a diabetic child can finally sleep through the night for the first time in 4 years instead of having to wake her daughter up every few hours to prick her finger. This is life-changing technology.
In the 18 months after I was diagnosed, I lived a fuller value life than in the years without diabetes. And, since then I continue to take on new challenges
Ultimately, I decided to go back to school to become a nurse practitioner. One of the biggest motivations for that decision was my experience at the intersection of health and technology in diabetes care.
I became a licensed nurse in 2019 and worked briefly as an RN Diabetes Educator at UCSF’ Benioff Children’s Hospital before taking a position as an RN at the George Mark Children’s House’s Center of Excellence in Pediatric Care. I am currently a nurse practitioner trainee at the VA in San Francisco.
I wanted to become a nurse practitioner because I see a discrepancy in healthcare delivery. These innovations are ground-breaking, they are changing lives, but not enough. We can do better. We are only as strong as our most vulnerable. Together, we can shed light on the changing face of this disease by investing in more research and support.
It is very easy to look at the data and forget the individual that lives behind each point. So let me represent one data point to remember—and that is the impact that full access to these technologies can have.
First published 5/16/17. Reviewed and updated for republication 2/20/21.
What if you could age slower and maintain your ability to be active and enjoy your family well into your 70’s or 80’s or beyond? What if you could delay the onset of chronic disease by almost a decade? Well, that is no longer a dream. Thanks to advances in the science of aging and chronic disease, we know that there are things that you can do now to impact your health and, perhaps, your longevity.
Let’s start our discussion by diving into some of the basic science related to prolongation of a healthy lifespan. Don’t worry, we are going to start with a video and it’s going to be fun.
First, check out this very entertaining short TED talk by Cynthia Kenyon who is a top scientist at the University of California at San Francisco Medical School. Then come back to this post for an expanded discussion.
The importance of Dr. Kenyon’s work and that of contemporary aging researchers is that they showed, for the first time, that aging and age-related chronic diseases aren’t things that “just happen” to us. [1] They are, in fact, related to an evolutionarily-conserved complex, highly regulated, and interconnected series of biochemical pathways.
Central to these pathways is a molecule called mTOR which stands for mechanistic Target of Rapamycin. It is so-named because rapamycin, a naturally occurring substance, inhibits the many of the activities of mTOR triggering a variety of metabolic and clinical outcomes. The most well-known of which is the extension of healthy lifespan.[2, 3]
mTOR exists as a complex of proteins called mTOR complex or mTORC. There are actually two different forms mTORC known as mTORC1 and mTORC2. Activation of the complexes occurs via different pathways. Once activated the mTOR complexes, in turn, activate or inhibit pathways critical to cell function. [2, 3]
mTORC1 and 2 are activated or inactivated depending on the availability of nutrients and certain other substances in the cell’s environment (e.g., glucose, amino acids, and various growth factors). In fact, you can think of mTORC as integrating and responding to the energy status of the cell’s environment.
When times are good and energy, oxygen, nutrients, and growth factors is plentiful, mTORC1 is activated and stimulates metabolic pathways that lead to growth. When times are tough, those pathways are suppressed and the pathways related to survival are activated.
Here are some of the cellular functions mTORC1 regulates [2,4]:
The last two functions are inhibited when energy, nutrients, and growth factors are plentiful.
mTORC2 is activated by insulin and growth factors. [2,4] It regulates the following:
Rapamycin inhibits most but not all of the activities of mTORC1. However, it does not inhibit mTORC2 in the short run. There is some evidence that chronic administration of rapamycin, however, can inhibit mTORC2.[4] Further, there are important feedback pathways between mTORC1 and mTORC2.
Living organisms on our planet are subject to varying availability of nutrients and other sources of energy. In order to survive, they must be able to sample the energy availability in their surroundings and adjust accordingly.
mTOR-linked pathways provide that mechanism. Receptors found in cell membranes have both an external-facing component and an internal-facing component. The external component binds to nutrients, such as glucose, amino acids, oxygen, and various growth factors. As described above, this leads to the activation or inactivation of different intermediate proteins that ultimately activate or inhibit mTOR.
For example, during times of energetic stress, a protein known as AMPK is activated. This in turn inhibits mTORC1 and leads to activation or inhibition of other intermediate compounds. The result is a state of cellular activity that favors prolongation of lifespan.[5]
Although the pathways are incompletely understood, it is of note that dietary restriction – a self-induced famine in a way – is also associated with longevity.[5] We must remember, though, because of complex feedback loops, the ability to prolong lifespan via these mechanisms is not limitless.
On the other hand, during times of plenty, the availability of glucose increases. In addition to reducing the activation of AMPK, it also triggers the release of the hormone insulin and insulin-like growth factor). This leads to mTOR activation and the creation of a state that favors growth and development. Unfortunately, it can also lead to amongst other things, elevated lipid levels that favor the development of chronic diseases.
Understanding the molecular biology of the mTOR pathways has some very practical applications. For example, as we have already pointed out, restricting calories is associated with reduced levels of some factors that inhibit mTORC1. This, then, is associated with lifespan extension.[5] Intermittent fasting [6] and exercise [7] also reduce mTOR activity.
Also, restricting carbohydrates in people with Type 2 diabetes is known to lower blood glucose, insulin, and IGF-1 levels. The benefits of this type of diet do not require weight loss, although many do lose weight with carbohydrate restriction. In fact, some experts have called for dietary carbohydrate restriction to be the first intervention prescribed in Type 2 diabetes management.[8]
The prevailing American high-carbohydrate, high-fat fast-food diet, on the other hand, drives extra calorie intake and as well as higher levels of the factors that activate mTORC1. This, unfortunately, leads to metabolic conditions that accelerate the development of chronic diseases such as diabetes and heart artery problems.[9]
Metformin is the most commonly prescribed drug for Type 2 diabetes. Multiple mechanisms of action, both direct and indirect have been proposed for this drug, including microbiome modification.[10]
However, it has also been shown to interfere with the same signaling pathways that we have been discussing. Specifically, it leads to the reduction of glucose, IGF-1, insulin levels, and the inhibition of mTORC1. [11]
This results in a metabolic state that favors important health outcomes, including the following:
Further, the drug has been proven to be safe with relatively few serious side effects. And, it is cheap, making it accessible even for people without health insurance.
Metformin is the also first drug approved by the FDA to enter a clinical trial to assess its effect on prolongation of a healthy lifespan. According to American Association for Aging Research, the Targeting Aging with Metformin (TAME) trials are a “series of nationwide, six-year clinical trials at 14 leading research institutions across the country that will engage over 3,000 individuals between the ages of 65-79.”
These trials will test whether those taking metformin experience delayed development or progression of age-related chronic diseases—such as heart disease, cancer, and dementia.
As mentioned, the drug rapamycin inhibits mTORC1 activity and is associated with a prolonged lifespan. However, systemic rapamycin has unacceptable side effects, so its use is limited in humans.
It is used, however, for local applications. One example is the use of Sirolimus (the brand name of rapamycin) in early versions of drug-eluting stents (DES) used to treat coronary artery disease. [13]
More recently, scientists have modified rapamycin to create less toxic forms of the drug. They are known as rapalogs. These include everolimus, zotarolimus, and biolimus. Together with improved stent platform materials, the use of these DESs has been shown to lower thrombotic events related to the stents. [14]
There are a number of drugs that are used for cardiovascular disease that specifically impact the mTORC pathways by various mechanisms. For example, lisinopril (an ACE inhibitor), losartan, an angiotensin receptor blocker [15], atorvastatin, a statin [16], and eplerenone [17], a mineralocorticoid receptor blocker, all reduce oxidative particle formation. Indirectly, this leads to the inhibition of mTORC. [18]
This, as we know, leads to metabolic changes that favor healthy aging. These effects on the mTOR-related signaling pathways may be the reason why these medications lower the risk of heart attack and stroke more than they reduce the target risk factors of blood pressure, lipid, and glucose levels.
Interfering with this core signaling is a form of precision medicine that impacts the molecular biology that causes cardiovascular disease, cancer, and accelerated aging. These medications are antioxidants that work.
Here is the most shocking insight. The same core signaling that causes accelerated aging, chronic disease, and ultimately death is essential to produce a perfectly developed newborn. At the moment of conception, there is a single cell that will ultimately become all the cells in the body with their vastly different functions.
The DNA for every cell in your body is the same. Epigenetic regulation determines which genes are turned on or off in a particular cell type. For example, normal EGFR function is necessary to establish pregnancy [19][successfully at the very beginning of life. However, it contributes to chronic disease development later in life.
Angiotensin II is required to form a normal fetal kidney [20], but inappropriate activation later in life contributes to developing hypertension, chronic kidney disease, and congestive heart failure.
mTOR activation via nutrient sensing and growth factor signaling in the fetus directs a master symphony [21] of switching genes on in just the right place, at just the right time, with just the right intensity for an exact amount of time to produce a perfect infant.
However, the same genes that are essential to coordinate normal development cause disease and death with chaotic activation later.
The human genome project did not give us the answers for accelerated aging and common chronic diseases. These problems are caused by normal genes that are inappropriately switched on later in life by things like aging, unhealthy diets, and tobacco smoke.
Specific highly effective generic medications with few side effects can block the signaling from those genes and lead to dramatically better clinical outcomes at a lower cost. Caloric restriction, intermittent fasting, exercise, and the specific medications mentioned all impact the same signaling pathways.
In order to fully unlock the potential of primary care, we need to move from management of risk factors (e.g., blood pressure, glucose levels) to manipulations of the metabolic pathways that are at the heart of many chronic diseases. We believe that “metabolic medicine” is the key to a healthier future
2. Papadopoli D, Boulay K, Kazak L, et al. mTOR as a central regulator of lifespan and aging [version 1; peer-review: 3 approved] latest versions as of 07/27/20. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6611156/pdf/f1000research-8-18802.pdf
3. Weichhart T. mTOR as a regulator of lifespan, aging, and cellular senescence. Gerontology. (2018) 64(2):127-134. https://pubmed.ncbi.nlm.nih.gov/29190625/
4. Samidurai A, Kukreja R, Das A. Emerging role of mTOR signaling-related miRNAs in cardiovascular diseases. Oxidative Medicine and Cellular Longevity. Volume 2018, Article II6141902, 23 pages https://www.hindawi.com/journals/omcl/2018/6141902/
5. Longo V, Antebi A, Bartke A, et al. Interventions to Slow Aging in Humans: Are We Ready? Aging Cell (2015) 14, 497-510. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4531065/
6. de Cabo R, Mattson M. Effects of intermittent fasting on health, aging, and disease. NEJM (2019) 381:2541-2551. https://www.nejm.org/doi/full/10.1056/NEJMra1905136
7. Dreyer H, Fujita S, Cadenas J, et al. Resistance exercise increases AMPK and reduces 4E-BP1 phosphorylation and protein synthesis in human skeletal muscle. J Physiol (2006) 576:2, 613-624. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1890364/
8. Feinman R, Pogozelski W, Astrup, A, et al. Dietary carbohydrate restriction as the first approach in diabetes management: Critical review and evidence base. Nutrition (2015) 31:1-13. https://www.sciencedirect.com/science/article/pii/S0899900714003323
9. Samidurai A, Kulreja R, Das A. Emerging Role of mTOR Signaling-Related miRNAs in Cardiovascular Diseases. Oxidative Medicine and Cellular Longevity (2018) Article ID 6141902. https://www.hindawi.com/journals/omcl/2018/6141902/
10. Rena G, Hardie D, Pearson E. The mechanisms of action of metformin. Diabetologia (2017) 60(9):1577-1585. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5552828/
11. Amin S, Lux A, O’Callaghan F. The journey of metformin from glycaemic control to mTOR inhibition and the suppression of tumor growth. Br. J. Clin Pharmacol (2019) Jan, 85(1):37-46. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6303203/
12. Kasznicki J, Sliwinska A, Drzewoski J. Metformin in cancer prevention and therapy. Ann Trans Med (2014) June;2(6):57 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4200668/
13. Serruys P, Regar E, Carter A. Rapamycin eluting stent: the onset of a new era in interventional cardiology. Heart (2002) 87:305-305. https://www.researchgate.net/publication/277539488_Rapamycin_eluting_stent_the_onset_of_a_new_era_in_interventional_cardiology
14. Im E, Hong, M-K. Drug-eluting stents to prevent stent thrombosis and restenosis. Expert Rev Cardiovasc Ther (2016) 14(1):87-104 https://pubmed.ncbi.nlm.nih.gov/26567863/
15. Ding G, Zhang A, Huang S et al. ANG II induces c-Jun NH2-terminal kinase activation and proliferation of human mesangial cells via redox-sensitive transactivation of the EGFR. AM J Physiology Renal Physiol (2007) 293:F1889-G1897 https://journals.physiology.org/doi/pdf/10.1152/ajprenal.00112.2007
16. Tanaka S, Fukumoto Y, Minami T. et al. Statins exert the pleiotropic effects through small GTP-binding protein dissociation stimulator upregulation with a resultant Rac1 degradation. Arterioscler Thromb Vasc Biol (2013) July;33(7). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3863549/pdf/nihms-536909.pdf
17. Huang S, Zhang A, Ding G et al. Aldosterone-induced mesangial cell proliferation is mediated by EGF receptor transactivation. Am J Physiol Renal Physiol (2009) 296: F1323-F1333 https://journals.physiology.org/doi/pdf/10.1152/ajprenal.90428.2008
18. Blagosklonny M. From rapalogs to anti-aging formula. Oncotarget (2017) 8(22) 35492-35507. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5482593/pdf/oncotarget-08-35492.pdf
19. Large M, Wetendorf M, Lanz R et al. The Epidermal Growth Factor Receptor Critically Regulates Endometrial Function during Early Pregnancy. PLoS Genet (2014) 10(6):e1004451 https://doi.org/10.1371/journal.pgen.1004451
20. Gubler M, Antignac C. Renin-angiotensin system in kidney development: renal tubular dysgenesis. Kidney (2010) International 77(5): 400-406. https://www.sciencedirect.com/science/article/pii/S0085253815542646
21. Hennig M, Fiedler S, Jux C et al. Prenatal Mechanistic Target of Rapamycin Complex 1 (mTORC1) Inhibition by Rapamycin Treatment of Pregnant Mice Causes Intrauterin Growth Restriction and Alters Postnatal Cardiac Growth, Morphology, and Function. J Am Heart Assoc (2017) 6:e005506. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5586418/pdf/JAH3-6-e005506.pdf
Reviewed and updated with new references on 8/14/20.
Healthy Life Extended by Eight Years in a Landmark Study
Heart Attacks: When Will We Finally Do What Needs to Be Done
Is There Really a Way to Reverse Diabetes?
A Unifying Hypothesis of Chronic Disease and Aging
Erectile Dysfunction: Is It a Sign of Heart Disease?
Why We Need to Unlock the Full Potential of Primary Care
Reshaping Healthcare: What We Can Learn From Alaska
There are powerful reasons to move to a value-based primary care system. Highly effective primary care is an indispensable piece of that effort. It is critically important that we move rapidly from Primary Care 1.0 and 2.0 to Primary Care 3. The latter provides a molecular medical management framework as opposed to the traditional organ system management. We believe that implementing this type of approach will unlock the full potential of primary care.
Research demonstrates that a focus on primary care has many benefits. These include:
Primary care provider reimbursement generates just 7.7% of healthcare costs but PCPs direct most spending through their referrals. There is evidence that this is exacerbated when PCPs are employed by hospital systems.
It is important to recognize that the costs of care are not distributed evenly:
An interesting twist is that primary care has already begun to segment. For example, urgent care providers and hospitalists are organized to meet the specific needs of people with acute or intensive needs. In addition, some primary care providers are specializing in delivering care almost exclusively via telemedicine. Primary care teams that focus on chronic conditions are critical to improve overall health and save money.
Let’s look at the different stages of Primary Care using the management of cardiometabolic disease as an example.
(c) Bill Bestermann MD
In primary care 1.0, physicians practice what is called “usual care.” They manage chronic conditions, such as the prevention and management of chronic kidney disease (CKD), using any medication that has been approved for the purpose. They may not specifically take into account the molecular medicine and the root causes of the condition.
Many of these patients are diabetic and hypertensive. Aggressive treatment of these conditions is needed to prevent the development and progression of kidney disease to end-stage renal disease requiring dialysis.
Related Content: A PCP Imperative: Integration of Behavioral and Physical Health Care
In addition, socioeconomic factors also play an important role. The cost of care can be a huge barrier to effective primary care access not only for the uninsured but also for the under-insured and those with high cost-sharing plans.
For people who can gain access to current primary care, treating hypertension and diabetes in usual care can be effective in preventing progression to dialysis. However, depending on which drugs are chosen to manage them, costs of care can vary widely.
Failure to prevent the progression of CKD poses significant health risks for patients. For example, one study found that “cardiac and vascular mortality are several times higher in dialysis patients than in the general population.”
Further, progression to dialysis is very expensive. The diabetic patient without CKD costs $10,721 annually. With stage 3 CKD and any progression, the cost is $31,693. The dialysis patient costs $62,091 a year.
Once a patient goes on dialysis, they automatically go on Medicare.
Even if you are miserly and hard-hearted…even if you care nothing for the plight of people less fortunate than you… you are going to pay for their much more expensive care down-stream.
It is in everyone’s hard financial interest to see that every American has access to cost-effective primary care, including critical generic medications.
As effective as Primary Care 1.0 is, it does not begin to realize the benefits that we could deliver with currently available best practice paradigms for chronic condition management. This is what takes place in Primary Care 2.0.
Using the prevention of CKD as an example again, we see that physicians aggressively and cost-effectively manage diabetes and hypertension using drugs that go beyond traditional risk factors.
They also follow guidelines that advocate focused, multifactorial interventions based on scientific evidence. And, they take cost into account by using generic drugs that target root causes. They also set aggressive clinical targets following their patients closely so they can tweak the interventions as needed.
The Steno-2 trial is a great example of such an intervention. Participating physicians followed a protocol that combines ACE inhibitors for hypertension, statins for cholesterol, metformin for diabetes, and aspirin to prevent clots.
When applied, this approach has produced impressive results:
Luckily, optimal medical therapy can be systematized, industrialized, and scaled. There is no reason why patients cannot reliably receive this type of treatment regardless of whether they live in a big city or a small town.
Similar approaches could also (Note: this article is behind a paywall) be used to reduce the incidence of Alzheimer’s disease and other expensive chronic conditions in addition to dialysis. We believe that Primary Care 2.0 is a much more effective way to manage cardiometabolic diseases.
It is only with Primary Care 3.0 that we begin to see its full potential. There are thousands of people developing the new science of molecular medical management. However, few are working on translating the new science from bench to bedside.
This is unfortunate because this new approach can move us beyond a system arranged around traditional risk factors and organ systems. It can move us to a much more precise approach targeting the molecular biology that forms the basis of chronic diseases and accelerated aging.
Understanding the full potential of primary care redesign requires a very short trip into the basic science weeds. If you just understand the rest of this article and the links, you will understand what next-generation chronic disease management could be. It is not that hard.
For example, elevated LDL cholesterol levels are a traditional target for therapies to reduce the risk of cardiovascular events, such as heart attacks and stroke. However, about half of all heart attacks occur in people with normal levels of LDL cholesterol. This suggests that other factors may be contributing to the risk in those people. Several seminal studies have pointed at inflammation as a critical pathway in the pathogenesis of atherosclerosis.
Paul Ridker is a cardiologist at Harvard Medical School. He is the leading proponent of the “inflammatory hypothesis” of cardiovascular disease. The 2008 Jupiter trial made him famous in medical circles.
The trial enrolled 17,802 healthy patients with normal LDL cholesterol levels (according to guidelines at the time) but a high level of the inflammatory marker C-reactive protein (CRP). Half of the patients were randomly assigned to receive the statin and half did not.
Although many in the public think of statins as cholesterol-lowering drugs, they also have significant effects in reducing inflammation. The results were dramatic leading the cessation of the trial after a median of ~2 years. Rosuvastatin treatment cut the incidence of a first cardiovascular event in these individuals by half. LDL levels were reduced by 50% and CRP by 37%.
The CANTOS trial
Dr. Ridker expanded this concept in the 2017 CANTOS trial designed to determine the impact on cardiovascular events if inflammation was reduced but cholesterol levels were not impacted.
Patients with a history of heart attack and a high CRP received the injectable monoclonal antibody canakinumab that neutralizes the inflammatory mediator interleukin 1B (initiates inflammatory signaling cascade). That intervention reduced heart attacks by 15%.
This study provided compelling evidence that targeting inflammation instead or (or in addition to) lowering lipids is a viable approach to the prevention of cardiovascular disease.
In a follow-up review, Ridker and his colleague, Aaron Aday, wrote the following:
“Successfully addressing traditional CVD risk factors should not falsely reassure clinicians and patients that nothing more can be done to further reduce [CVD] risk…”
Dr. Ridker summarizes the implications like this: “CANTOS is what we call systems biology.
When I was a medical student, we taught heart, lung, kidney, brain. however, We don’t do that anymore. Instead, We teach inflammation, fibrosis, and metabolism.
The best scientists at Harvard are calling for a move away from a medical system designed around organ systems. Instead, they advocate moving toward a system based on genetics, epigenetics, and molecular biology. This is because the same molecular signaling that causes a heart attack also causes stroke and kidney failure.
It makes no sense to send these people to cardiologists, neurologists, and nephrologists. The best management will not come from partialists. It will come from generalists who are experts in molecular medical management. That, in a nutshell, is primary care 3.0.
Healthy Life Extended by Eight Years in a Landmark Study
Heart Attacks: When Will We Finally Do What Needs to Be Done
Is There Really a Way to Reverse Diabetes?
A Unifying Hypothesis of Chronic Disease and Aging
Erectile Dysfunction: Is It a Sign of Heart Disease?
Reshaping Healthcare: What We Can Learn From Alaska
Study after study has shown that people fear vision loss more than they fear cancer, stroke, heart disease, and other serious health problems. But a new study shows that Americans are scared about an issue they know very little about. And what they don’t know is putting them at risk of vision loss, including blindness.
A survey[mfn]This survey was conducted online within the U.S. by The Harris Poll on behalf of the American Academy of Ophthalmology among 3,512 U.S. adults ages 18 and over between August 8 and 27, 2019. Data by race/ethnicity were weighted where necessary by gender, age, region, income, education, household size, marital status, employment, and specific eye conditions of interest to bring them into line with their actual proportions in the population. The data for each race/ethnicity group was then combined into a grand total to reflect the proportions of each race/ethnicity within the U.S. adult population. Propensity score weighting was also used to adjust for respondents’ propensity to be online.[/mfn] conducted by The Harris Poll shows that while 81% of adults say they are knowledgeable about eye/vision health, less than 1 in 5 (19%) were able to correctly identify the three main causes of blindness in the U.S., which are glaucoma, age-related macular degeneration (AMD) and diabetic eye disease.
Why does this matter? Because most people are also unaware of key facts that could protect them from vision loss, according to the survey. For example, only around one-third of adults (37%) know you do not always experience symptoms before you lose vision to eye diseases. And less than half (47%) are aware your brain can make it difficult to know if you are losing your vision by adapting to vision loss.
Ophthalmologists, physicians who specialize in medical and surgical eye care, have more tools than ever before to diagnose these eye diseases earlier and to treat them better. But these advances cannot help patients whose disease is undiagnosed.
Further, ophthalmologists cannot adequately care for patients who are unaware of the seriousness of their disease. Far too often, ophthalmologists witness the consequences of patients entering our office too late to avoid severe vision loss.
In 2020, we want all Americans to have a clear vision when it comes to eye health. That starts with educating yourself about eye diseases.
The consequences of failing to increase awareness about eye health can be dire. Right now, the number of Americans affected by these potentially blinding eye diseases is expected to double within the next 30 years, due mainly to the aging of the population.[mfn]The Future of Vision: Forecasting the Prevalence and Cost of Vision Problems. Prevent Blindness. Retrieved December 3, 2019, from https://www.preventblindness.org/sites/default/files/national/documents/Future_of_Vision_final_0.pdf[/mfn]
It’s important to note that vision loss affects more than the eyes. Vision loss is also associated with the following:
All of these complications of vision loss can worsen other chronic illnesses.
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Another key finding from the Harris poll is that less than half (47%) of respondents were aware that vision loss and blindness does not affect all people equally. But your risk of developing an eye disease varies significantly by your age, ethnicity, family history, and whether you smoke. Here are some relevant facts:
The Harris poll also found that only around one-third of adults surveyed (37%) know that vision loss is not inevitable as you age. Many people think vision loss is just a normal part of aging but it doesn’t have to be. You can take many steps to reduce your risk of vision loss, including
Just because you can see well, doesn’t mean all is well. That’s why the American Academy of Ophthalmology recommends that healthy adults see an ophthalmologist or an eye care professional for a comprehensive, baseline eye exam by age 40 and have their eyes checked every year or two at age 65 or older.
People who have other risk factors will need to be seen more frequently. People with diabetes should have a dilated eye exam every year. African Americans, age 40 and older, and people with a family history of glaucoma should have a dilated eye exam every 2 years.
If you are concerned about the cost of the exam, the Academy’s EyeCare America® program may be able to help. This program provides eye care through volunteer ophthalmologists for eligible seniors 65 and older and those at increased risk for eye disease. See if you’re eligible, visit www.aao.org/eyecareamerica.
Medicare provides an annual dilated eye exam for Medicare beneficiaries over 65 at high risk for glaucoma. Those eligible for this service are people with diabetes, family history of glaucoma, or African Americans over 50. To learn more, call 800-633-4227.
2020 is the year to get smart about eye health. For ophthalmologist-reviewed information about eye diseases and treatments, eye health news, and tools to locate an ophthalmologist, visit AAO.org/EyeSmart.
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As children enter their teenage years, the desire to rebel is ubiquitous almost to the point of cliché. But what about those young people with chronic diseases whose burgeoning independence heralds a new era in their medical management?
Parents and carers who are used to helping their children manage their health conditions can find it difficult to step back. They find it hard to allow young people to find their own ways of managing their conditions – and making their own mistakes.
A recent case study followed Adam [mfn]Transition from pediatric to adult-oriented health care: a challenge for patients with chronic disease Callahan, S. Todd MD; Winitzer, Rebecca Feinstein MS, MSW; Keenan, Peter RN, MS, PNP Current Opinion in Pediatrics: August 2001 – Volume 13 – Issue 4 – p 310-316 Adolescent medicine[/mfn], a type 1 diabetic who’d been managing his blood sugar monitoring and insulin regime with increasing independence since he was at primary school. In his teens, he began regularly attending his local A&E department with life-threatening diabetic ketoacidosis, requiring admission to ICU on three occasions in the months after his 15th birthday.
He was quiet and withdrawn at appointments with his consultant and barely spoke to his parents. His specialists knew that he was aware of the risks of poor management. And that he was very capable of looking after his diabetes, yet he continued regularly becoming seriously ill.
James’ case highlights the impact of chronic illness on teenagers, and the fine line between self-neglect, rebellion, and deliberate self-harm in adolescents who manage their own long-term conditions. External influences weighed heavily on James. In this case, wanting to be like his friends. In particular, he starting drinking alcohol and finding himself unable to manage his blood sugars. And so in frustration gave up on his insulin regime. This is typical, almost unavoidable, and requires understanding and careful management.
Chronic illness can refer to a wide spectrum of needs ranging from profound learning disability, total physical care needs and communication difficulties all the way through to people with less serious problems. Less serious illnesses, such as eczema or allergies, still require good management practices and can have a significant impact on general wellbeing.
The level of input people with chronic conditions requires varies widely, but there are some issues common to almost all adolescents with long-term conditions. There are, however, some people who may never be able to take any control of their condition or care needs.
Teenagers with health needs requiring regular input from specialists are likely to be transferred at some point from pediatric to adult services. This may mean that they will be expected to have a higher degree of self-management, to engage independently with services, and to advocate for themselves when they meet barriers.
The close families of these young people are in a unique position. They can help equip their teens for their future self-management, and get them through the often-difficult adolescent years, promoting independence without mutiny.
Some areas have trialed specific transitional clinics designed to ensure a straightforward switch between pediatric and adult services[i].
Teens want to be like their friends but they also want to be unique. They don’t have to be subject to pressure from their peers to want to fit in. They get that from within.
Any engagement with external influences can give a glimpse of a different, more desirable lifestyle. And, it’s rare that a leading role in movies or television series will be someone with a disability or chronic healthcare needs. How idyllic are the lives of TV characters who are never shown injecting themselves with insulin, discretely managing their stoma or missing parties at venues without ramps or elevators?
At a time of physical changes, of increasing variation from person to person, and emerging awareness of sexuality and appearance, most young people will struggle with self-image at some point. This can be particularly problematic in people with chronic health conditions, and not just those affecting their physical appearance. Family support is important, but the influence of peers, media, and societal attitudes to health and appearance are profound and need to be addressed both at home and in a wider context.
The teenage years are well-known to be the time when people experiment with previously forbidden behaviors. This is the time when people start having sex, smoking, drinking alcohol or taking illicit drugs. And this seems to be even more prevalent in teenagers with chronic conditions.[mfn]Health Risk Behaviors in Adolescents With Chronic Conditions Joan-Carles Surís, Pierre-André Michaud, Christina Akre, Susan M. Sawyer Pediatrics Nov 2008, 122 (5) e1113-e1118; https://doi.org10.1542/peds.2008-1479[/mfn]
Some conditions may even reduce the teenagers’ ability to assess risk or might mean that they feel indifferent to risks to their health. In addition, some medications can be affected by the use of illicit drugs or alcohol. This can place them more at risk of significant problems caused by drug interactions.
Mitigating these kinds of risks requires a multi-agency approach. A cohesive front at home, school, and any specialist services promoting an atmosphere of openness, safety, and responding without judgment or criticism.
This is the time when many young people have to become independent with their medical routine. When they were very young it was easy to advise them, to make sure they used their inhalers, applied their creams, took their tablets.
Now they have bodily autonomy, and they might not want to involve their parents when they’re having symptoms. And they may not want to admit that they are struggling to fully manage their condition themselves.
Starting early, where possible, can have good results. Even from a fairly young age, many children can take a degree of ownership over their condition and treatment, meaning a smoother transition to greater independence.
Teenagers can be CRUEL. Children can be cruel. Adults can also be cruel but they’ve usually learned to hide it at least a little.
Physical or face-to-face abuse is nothing new, and it can be horrific and difficult to deal with. Institutions such as schools and care settings will have a lot of experience with bullying and should have robust measures in place to address these issues.
However, teenagers now have more avenues for cruelty and bullying than ever before. With the relative anonymity of social media, cyberbullying allows for some extremely nasty behavior. The flip side of this is that people with chronic conditions and people experiencing bullying have access to a huge network of people in similar positions, and support can come thick and fast.
People’s likelihood to access healthcare has historically been gender-related. Broadly, and with due respect to shifting attitudes towards historic gender roles, women go to see their doctor more than men do.
Traditionally they more likely need to access medical services because of the burden of contraception, pregnancy, and birth. In addition to more likely being the main carer for young children and so attend child health checks. Women have been simply more used to routinely accessing healthcare.
This has led to some discrepancies between men and women accessing services[mfn]Doyal, L., Payne, S. and Cameron, A. (2003) Promoting gender equality in health, Working Paper 11, Manchester: Equal Opportunities Commission[/mfn], which may influence any young person in a household. Add to this a continued, though hopefully changing, pressure particularly on boys and men to be ‘strong’ and not show perceived weakness.
Thus, we have the perfect conditions for teenage boys to hide or revolt against their medical needs. In contrast to this, though, some studies have found teenage boys with chronic conditions to have objectively higher expectations for their physical fitness. Girls, on the other hand, seemingly adapt more around their condition[mfn]Williams, C. (2000) Doing health, doing gender: teenagers, diabetes and asthma Social Science & Medicine Volume 50, Issue 3, February 2000, Pages 387-396 https://doi.org/10.1016/S0277-9536(99)00340-8[/mfn] –this too could influence individual teens’ access to healthcare.
The effect of a supportive, understanding parenting and family approach in promoting health in young people and not just those with chronic health conditions, is paramount. Allowing teenagers to develop essential autonomy while overseeing the management of their health needs can be tricky.
It can be particularly hard for parents to relinquish control when they’ve always taken charge of their children’s health and care needs. The very time when young people may be able to learn to manage their chronic conditions coincides with the period in their lives with the most hormonal, emotional and physical upheaval[mfn]Yeo, M and Sawyer, S. (2005) Chronic illness and disability BMJ; 330: 721 https://doi.org/10.1136/bmj.330.7493.721[/mfn].
The natural changes of adolescence impact heavily on chronic condition management and vice-versa – an irony, unfortunately, lost to sardonic teens.
[1] Transition from pediatric to adult-oriented health care: a challenge for patients with chronic disease Callahan, S. Todd MD; Winitzer, Rebecca Feinstein MS, MSW; Keenan, Peter RN, MS, PNP Current Opinion in Pediatrics: August 2001 – Volume 13 – Issue 4 – p 310-316 Adolescent medicine
[2] Health Risk Behaviors in Adolescents With Chronic Conditions Joan-Carles Surís, Pierre-André Michaud, Christina Akre, Susan M. Sawyer Pediatrics Nov 2008, 122 (5) e1113-e1118; https://doi.org10.1542/peds.2008-1479
[3] Doyal, L., Payne, S. and Cameron, A. (2003) Promoting gender equality in health, Working Paper 11, Manchester: Equal Opportunities Commission
[4] Williams, C. (2000) Doing health, doing gender: teenagers, diabetes and asthma Social Science & Medicine Volume 50, Issue 3, February 2000, Pages 387-396 https://doi.org/10.1016/S0277-9536(99)00340-8
[5] Yeo, M and Sawyer, S. (2005) Chronic illness and disability BMJ; 330 :721 https://doi.org/10.1136/bmj.330.7493.721
Just because you’ve got your driver’s license doesn’t mean that you should forget about biking. Sure, there are scenarios where having a car does come in handy, but for everything else, cycling is the way to go.
After all, there are certain benefits of riding a bike that driving a car could never live up to – some are quite obvious, like the health benefits of biking, and others not so much.
Whether you’re looking to include some physical activity into your daily life, or want to do something good for the environment, this article will give you plenty of reasons why hopping on your bike could be the best thing you did in a while!
Your health comes first, which is why I wanted to start this article with a round-up of some of the most important health benefits you’ll experience as soon as you get in the habit of cycling instead of driving!
Photo Source: Pixabay
Sure, your thigh muscles and your glutes might be the first ones to come to mind. But, when you think about getting a good workout, here’s the thing:
By getting your heart rate up cycling strengthens your heart muscles. It also reduces your risk of developing several cardiovascular diseases, including stroke, high blood pressure, and heart attack.
Moreover, compared to those who lead a sedentary lifestyle, those who participate in physical activities such as biking can experience an overall improvement in cardiovascular function, too.
And while I don’t recommend ditching your blood pressure meds just yet, there’s a reason to believe that including cycling into your daily routine might have a positive impact on your blood pressure. It can almost be as effective as prescription medication. If you’re a poor Paintballer like me, you may notice your bruises healing faster too!
Besides the evident impact it has on your cardiovascular health, cycling also lowers your risk of cancer. Now, I know that might seem too good to be true. But the link between moderate levels of physical activity and cancer has been the subject of several studies, and so far, the results seem promising:
Type 2 diabetes has become a serious public health concern. Given that the two primary factors that help lower the risk of developing this condition are as simple as maintaining a “normal” weight and eating a healthy diet, seeing the rates continue to rise is quite shocking.
Considering the high number of diabetes-related complications, I don’t have to tell you how vital it is to keep this condition under control.
And, as a recent study suggests, cycling might be the way to lower glucose levels. The study examined the link between commuting and recreational cycling habits and their risk of type 2 diabetes. They found a link does exist – the more time you spend cycling, the lower your risk of developing this disease.
While the exact number might be hard to pinpoint, as it depends on a lot of factors, including your weight, speed, and resistance, to name a few, one thing’s certain:
Now, when I say „a lot,“ I mean something along the lines of 240 to 355 calories per half an hour of moderate-speed biking.
I’m stating the obvious here, but riding a bike involves a lot of pedaling. The repetitive motion causes large muscles in the lower body to contract and expand continuously. It makes it a perfect example of isotonic exercise.
Moreover, even though it seems like your lower body is doing all the work, your core, as well as your arms are engaged, too. This is especially true for all the adrenaline junkies who do trail-biking, but if you venture off the beaten road, get a mountain bike.
Photo Source: Pexels
Last, but not least, there’s a reason to believe that all these health-promoting effects that cycling has on your body – such as preserving muscle mass, maintaining a healthy weight, and stable cholesterol levels – might have an „anti-aging“ effect on your immune system, too.
As we age, our thymus gland begins to shrink, which affects its capability to produce new T-cells, and, as a result, we become more susceptible to all sorts of new threats, including infections and immune disorders. By the time we reach the age of 65, we’re left pretty vulnerable.
New research shows that the thymuses of “senior” cyclists maintained their functionality, producing as many T-cells as the glands of much younger individuals. In short, thanks to cycling, these seniors had immune systems that could rival those of healthy 20-year-olds!
Now, besides the apparent health benefits of biking, there are a few more reasons why choosing your bike over a car might be the best commuting-related decision you’ve made in a long time.
So, if improving your overall health isn’t a reason enough for you, let’s take a look at how biking can affect other aspects of your life, as well!
That said, if you’re seriously thinking of retiring your car for good, you might want to look into electric bikes – because we all have days when we don’t feel like pedaling.
Before you ride off into the sunset, here’s what I’d like you to remember:
There is such thing as “too much of a good thing.”
It’s better to start small and give your body some time to adjust, especially if you haven’t been the most physically active person in the past. And don’t worry; you won’t miss out on any of the health benefits of biking if you choose to take it slow.
Oh, and one last thing:
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Here’s my daily routine – roll to the left, swipe my finger across my phone, open Facebook. I look to see if I missed anything in the news last night.
Deny it if you want, but your morning probably looks much the same as mine. It’s a habit that was formed from days, weeks, and months of repetition.
Most importantly, it was completely effortless. Not once did I tell myself that I was going to make Facebook a part of my daily routine.
However, the reality is that most habits are nowhere near as easy to form as a Facebook habit. They take an overarching goal and an easy and simple set of actions. They also often require a catalyst to serve as initial motivation.
So, let’s talk about the motivation for managing diabetes. Every 21-seconds in the U.S., someone is newly diagnosed with diabetes.
Almost 10% of the population is currently living with it. In fact, it is the seventh leading cause of death in the U.S. It claims more lives every year than AIDS and breast cancer combined.
Diabetes is also the costliest chronic condition in our country with one in every seven dollars spent on its treatment and its complications.
The good news is that although there is no cure for diabetes, it can be managed. Research shows that lifestyle choices and forming healthy habits play an important role in preventing, delaying, or managing the condition.
It’s clear that the diabetes care industry is ripe for innovative solutions that can help deliver the ease and simplicity that people need to form healthy habits.
Related story: Is There Really A Way to Reverse Diabetes?
There is an increasing focus on this space. Startups and social enterprises are now delivering solutions that help people on their journey towards better managing their diabetes. They do this by emphasizing behavior change and the importance of taking one step at a time.
Here are four holistic resources to help you take the first step toward forming healthy habits and leading a healthy life with diabetes.
Research shows that the key to forming healthy habits is setting goals that are both specific and challenging. They must be specific enough to have actionable steps and yet challenging enough to push the goal setter.
For example, if your overall goal is to reduce your A1C by 2 points in six months, start by creating a monthly action plan that incorporates activities such as portion control, meal preparation, and daily exercise in increasing amounts.
The Let’sBeWell Diabetes Box. Photo supplied by the author
The “Let’s Be Well Diabetes Box™ is a new product that helps millions of Americans living with diabetes reach their health goals.
Developed as a collaboration between AARP and the American Diabetes Association, the box is for people with type 2 diabetes who are looking for practical ways to help manage their condition. It includes a carefully selected mix of wellness products and information that people can use to achieve their specific and challenging goals.
Available online at www.LetsBeWellBox.com for $19.99, the box can be purchased by caregivers, friends, family members, or people with diabetes, and shipped directly to the recipient
Meditation and visualization have positive effects in helping people achieve their health goals. Recent studies have shown that meditation can help people with diabetes control their blood sugar levels.
Other benefits include reduced stress associated with managing diabetes, helping to relieve chronic pain, and minimizing the risk of cardiovascular disease.
Photo source: Headspace
Many meditation apps have appeared on the scene. The Headspace App is a simple tool that allows you to begin experiencing how meditation can help you achieve your goal.
Founded with the mission to improve the health and happiness of the world, the app uses research-proven methods to teach people the basics of meditation and mindfulness.
The app provides a free Basics pack for those just starting out and a paid subscription service for those seeking to go deeper into their practice.
The power of peer pressure is an age-old tactic that, when spun the right way, can help you achieve your goals.
By committing your goal to someone else, you increase your chances of following through by 65%. If you set accountability appointments with this person, the chances increase to 95%!
The process starts by identifying a community of people to act as your accountability partners. A great resource to get started is ADA’s Living with Type 2 Diabetes program.
Photo source: sceenshot from ADA’s website
This free, yearlong program provides participants with information on emotional health, eating healthy, physical fitness and more. Most importantly, it gives members special access to online support communities and local events.
All of us know how difficult it is to form healthy eating habits. Cost is a factor but research finds that convenience, or lack thereof, is the biggest hurdle to people practicing healthy eating habits.
Many people opt for the convenience of fast food and other highly-processed cuisines to feed themselves and their families.
Meal delivery services are stepping in to fill the void. Companies are offering those with diabetes a way to form healthy eating habits, by giving them convenient and simple ways to design their own culinary experiences.
Fresh, diabetes-friendly food is delivered directly to your doorstep as prepared meals from BistroMD Silver Cuisine. With a range of prices, there’s an option that can meet most budgets.
The most difficult part of making any lifestyle change is taking the first step.
The key to success is your commitment to an overarching goal. But it is also important that you take a consistent set of actions each day. Luckily, innovative resources for managing diabetes are available to help you achieve your goals.
Related story: Is the future of American healthcare digital?
With a little patience and consistency, managing your diabetes will soon come as naturally as rolling over and checking your Facebook feed.
Originally published on May 5, 2018, this post has been updated for republication.
Some new healthcare companies claim to “reverse diabetes” with a lifestyle intervention that primarily focuses on the blood glucose and hemoglobin A1c level. That claim may be a clever marketing ploy, but it has little to do with the latest science on diabetes.
Although their intervention reduces carbohydrate and sugar intake dramatically and it does lower blood glucose. The problem is that it does not address the core issue in Type 2 diabetes.
Type 2 diabetes is defined by a blood glucose of 126 or higher or a hemoglobin A1c of 6.5 or higher. If you introduce sugar and carbohydrate restriction and cause weight loss, the glucose and hemoglobin A1c levels will fall below those numbers and so, by that definition, diabetes is “cured.” The patient no longer meets the criteria for a diabetes diagnosis.
But this premise ignores fundamental and important realities. High glucose levels cause changes in gene expression that persist after the glucose returns to normal causing atherosclerosis and other complications. This well-known phenomenon is called metabolic memory.
Metabolic memory is a critical concept that points to the broader reality of people living with Type 2 diabetes. The high glucose levels found in people with the condition are only one part of the complex molecular biology that causes diabetic complications.
The cardiovascular complications of diabetes begin in the fetus and even in the lifestyle choices of prior generations. Overfeeding or underfeeding in the parental generation can produce infants that are too small or too large based on inappropriate activation or inactivation of genes (epigenetics). That inappropriate switching on or off is persistent and many genes are involved causing hypertension, diabetes, and cardiovascular complications in adults.
Patients may themselves switch these genes on or off later in life by gaining weight or smoking. These genes cause diabetes by killing insulin-producing cells in the pancreas and increasing insulin resistance leading to high glucose which further increases oxidative particles and switches on additional genes that cause diabetic complications.
These genes remain switched on even when the glucose is lowered. Therefore, it is very important to continue to take medications that interfere very specifically with the signaling that these genes generate.
Promoting the message that cardiometabolic medication should be stopped when the glucose falls below the diabetic level is not in keeping with the latest science and contrary to diabetic guidelines.
The American Diabetes Association (ADA) guidelines recommend metformin use even in prediabetic patients who have a BMI of 35 or greater, have a history of gestational diabetes, or an increasing fasting glucose or hemoglobin A1c. That is because metformin reduces progression to diabetes by about 31%.
Roughly half of prediabetic patients will progress to diabetes despite weight loss. Even patients in the later stages of prediabetes may have lost 70-80% of their insulin-producing function.
These prediabetic patients should not stop metformin when they have lost weight and their glucose improves. There is a tendency for diabetes to reappear with age. Certainly, metformin should not be stopped in patients who already have diabetes regardless of their glucose level.
Metformin reduces diabetic complications by interfering with signaling that has nothing to do with blood glucose levels. It inhibits the same master metabolic switch as the active ingredient in the drug-eluting coronary artery stent.
The increased risk of major cardiovascular events does not disappear with diet and weight loss, however, metformin directly reduces that risk. Type 2 diabetics lose about 10 years of life. If they are on metformin, they live a bit longer than normal people. Metformin is safe and costs only about $4 a month. It is dangerous to recommend “stopping diabetic medications once the glucose is controlled by lifestyle interventions.”
Controlling glucose levels has beneficial effects on microvascular events like retinopathy, neuropathy, and kidney damage but it does not reduce the problems that cause most serious cardiovascular complications, death, disability, and costs. Most diabetics die of cardiovascular disease.
Lowering the glucose with lifestyle or any medication approved for the purpose does NOT reduce cardiovascular events. In fact, aggressive glucose lowering with medication and lifestyle caused more people to die.
This is especially important because cardiovascular event incidence and other complications can be dramatically mitigated with a comprehensive solution that brings to bear lifestyle management and medications that interfere with the molecular biology that causes cardiometabolic complications.
Lowering the glucose by any means below the diabetic level, stopping the medication, and expecting complications to fall makes sense, but that idea is not supported by the evidence.
Take a look at the diagram below. Type 2 diabetes occurs mostly in patients with extra abdominal fat caused by poor diet. Increased nutrition and fat switches genes on/off that increase angiotensin II, aldosterone, HMG CoA Reductase, and mTOR activity.
Angiotensin receptor blockers (ARBs), spironolactone, statins, and metformin interfere directly with the molecular signaling cascades that these genes activate. Blocking angiotensin II with an ARB, aldosterone with spironolactone, HMG CoA reductase with a statin, and mTOR with metformin dramatically reduces cardiovascular events in multiple settings. The genes involved are switched on before diabetes develops.
In fact, these elements contribute to diabetes development. Increased mTOR activity directly increases insulin resistance. Blocking mTOR with metformin reduces progression to diabetes.
Elevated aldosterone levels make a strong contribution to metabolic syndrome development. Blocking angiotensin II reduces progression to diabetes.
Blocking HMG Co A reductase with a statin actually increases the incidence of diabetes but has a powerful impact on cardiovascular events and other outcomes. Even that can likely be explained by a hard look at the molecular biology. Blocking HMG CoA reductase with a statin does lower LDL cholesterol but it also reduces Coenzyme Q10 production. Coenzyme Q10 is a powerful antioxidant and it is important for mitochondrial function. Impaired mitochondrial function may be important in the modestly increased risk of diabetes in patients who take statins.
The best treatment for type 2 diabetes is not a matter of either lifestyle or medication. Effective treatment requires best practice implementation of lifestyle measures along with medications that interfere with the molecular biology causing disease. For most patients, medical treatment will include metformin, statins, and angiotensin receptor blockers.
It is important to move beyond a medical system focused on risk factors and organ systems.
There is a very complex interplay in the molecular biology that causes hypertension, diabetes, high cholesterol, and related complications. Reversing diabetes with weight loss and dietary interventions makes perfect sense but improving cardiovascular outcomes and reducing costs to the fullest extent requires a more comprehensive solution. We can treat chronic disease with precision medicine and molecular biology now.
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A Type 1 Diabetes Diagnosis Didn’t Stop Her from Climbing
Imagine the following doctor-patient conversation:
Doctor: Hello Bill. How are things?
Bill: Well not so good…actually doc they’re terrible. My diabetes has been totally out of control. My blood sugars are always seeming to run very high. And I am not feeling great, in part because I still cannot lose weight. In fact, I’ve actually gained 13 pounds in the last 4 months.
[And maybe, more importantly, imagine the doctor does not interrupt Bill at this point but lets him continue.]
Bill sighs, and continues after a couple second pause:
Bill: But worse than my actual health, my wife thinks it’s all my fault. My son is so worried that he is continually checking up on me. And don’t get me started on my boss. She says I’m not working hard enough. But worst of all, my daughter-in-law is so concerned that I am sick that she won’t let me be alone with my 4-year-old granddaughter. She thinks that I might have a heart attack or be in a coma at any moment. HELP ME!!!! Please.
Doctor: Thinks, but doesnt say, HELP ME!!!! Please
This story, in many variations, is all too common. Where should the doctor start? How to make a difference in this person’s life? Health is just a means to what Bill really wants – so how does the doctor help him get the health he needs for the life he wants?
The traditional approach to a patient like Bill is to focus on his blood sugar values and to see if adding or modifying medications will improve his glucose control. The doctor might have him talk with a diabetes educator to learn more about diabetes and glucose management, meet with a pharmacist to fine tune his existing medications, and meet with a dietitian to improve his eating. This approach could have some impact, but all too often the gains don’t last.
Controlling Bill’s blood sugar might be the easiest thing to do and the place to start. It is certainly what most doctors and other healthcare providers have been trained to do. A complementary approach, based on decades of research from a variety of fields, is to focus on increasing Bill’s self-efficacy – increasing his confidence and competence to accomplish his goals – while helping him better manage his condition(s). If Bill can have a lasting transformation in his attitude and outlook, he will be better equipped to define his personal priorities, set attainable short-term and long-term goals, and improve not only his medical outcomes but attain his life goals as well.
The good news is that research proves that this approach works to help patients like Bill. At Canary Health, we have the good fortune to partner with Dr. Kate Lorig and her team – true pioneers and leaders in this field. Dr. Lorig’s work began over 30 years ago at Stanford University where she created the Chronic Disease Self-Management Program (CDSMP). CDSMP is a peer-to-peer, 6-week, in-person, group-based, intervention for adults with one or more chronic conditions. CDSMP has been shown in hundreds of papers from around the world to increase self-efficacy, lessen depression, improve medication adherence, minimize pain, improve important medical outcomes, and lower healthcare costs.
Canary Health’s Better Choices Better Health (BCBH), the digital version of the in-person CDSMP, is proven to engage those who are unable or prefer not to attend in-person workshops. It has the same protocol and curriculum as in-person CDSMP, using a unique digital approach that builds individual and group engagement in self-management.
Each online workshop consists of about 25 adults with at least one chronic condition. BCBH does not require real-time attendance and can be done at the convenience of the user. Two trained peer-facilitators moderate each workshop. Participants are asked to login at least three times weekly for a total of about two hours. Weekly activities include reading content, making and posting an action plan, participating in problem-solving and guided conversations, and posting questions, concerns or accomplishments. Group members comment on posts made by other participants to give wisdom and support. Once the six-week intervention is completed, participants are encouraged to join the online BCBH alumni community to continue to post questions or concerns and to receive and provide support to others. (Go to www.canaryhealth.com to learn more or to https://goo.gl/Av6R5g to see a BCBH demonstration)
Recently published papers (Reference 1,2) from a large study (N =1,232) with Anthem beneficiaries with type 2 diabetes, demonstrated that 12 months after the six-week in-person (N=232) and digital (N=1010) BCBH intervention, the following outcomes were seen:
Now, let’s return to helping Bill and patients like Bill. With the patient in a better frame of mind, and with more confidence that his or her priorities and goals are on the path to success, the next step is to support sustainable behavior change. This is best accomplished when individuals are able to get the support they need from peers and from professionals. Coupled with evidence-based, peer-to-peer support, healthcare professionals can provide expert clinical and treatment advice, augmented by the data and information provided by connected devices or connected medications (such as connected glucometers, scales, spirometers, smart insulin pens/insulin pumps). This approach, called Digital Therapeutics, is demonstrating great promise with a variety of chronic diseases including diabetes.
1 A Diabetes Self-Management Program: 12-Month Outcome Sustainability From a Nonreinforced Pragmatic Trial – Lorig,KL; J Med Internet Res 2016 | vol. 18 | iss. 12 | e322 |
2 Evaluation of a Diabetes Self-Management Program on Type II Diabetes Patients’ Comorbid Illnesses, Healthcare Utilization, and Cost – Turner, RM, et al J Med Internet Res 2018 | vol. 20 | iss. 6 | e207 |
Diabetes is responsible for more than 60% of all non-traumatic lower limb amputations and losing a limb is a devastating event in a person’s life. There is often a significant loss of independence in one’s daily activities. A more sedentary lifestyle often comes with increased health problems including increased risk of blood clots, obesity, cardiovascular disease, infection, and stroke. Disability comes in many forms. Amputees suffer a higher incidence of depression, loss of financial independence, and inability to care for family members.
In the field of limb salvage, doctors and specialists equate saving a limb with saving a life. If an amputation can be avoided, there is better survival, fewer hospitalizations, and better quality of life. Why is that thousands of patients receive amputations, while standard available treatments are withheld? Let’s start by defining the problem.
According to the National Institutes of Health, peripheral arterial disease (PAD) affects 8 to 12 million people in the United States. PAD develops when the arteries that supply blood to the internal organs, arms and legs become completely or partially blocked as a result of atherosclerosis. There are many possible side effects of atherosclerosis including angina and heart attacks if the coronary arteries are involved; strokes and transient ischemic attacks if the carotid and vertebral arteries are involved; and claudication, non-healing leg ulcers and critical limb ischemia (CLI) if the lower extremity arteries are involved.
The 2 million people with CLI are at imminent risk of amputation. Over HALF of patients with CLI are dead within 5 years. To contrast, this far exceeds the mortality of most forms of cancers including breast, prostate and colorectal cancer. Awareness remains at an all-time low for PAD and CLI with only 1 in 4 people over age 50 aware of its existence.
The most common risk factors for developing PAD are smoking, high blood pressure, diabetes, and high cholesterol. Those who smoke or have a history of smoking have up to four times greater risk of PAD. The most important risk factor for limb amputation is PAD which leads to impaired arterial circulation to the extremity, which impairs wound healing, leading to gangrene and ultimately amputation.
Type 2 diabetes is caused by genetics and lifestyle factors. Currently, you can’t change your genetics. However, you can change your lifestyle to prevent PAD, which is what leads to amputation of limbs. Controlling diabetes, blood pressure, and cholesterol requires a commitment to yourself and your loved ones to adhere to your medication, diet, and exercise before it’s too late.
I tell my patients not to expect that medication will do all the work; moderate exercise at least 30 minutes a day is critical and a healthy diet with whole grains, vegetables, and fruits is just as important. If my patients are overweight or obese, a weight loss plan is not a choice, it’s a necessity. If my patient is diabetic, this means reducing sugar intake. The American Heart Association recommends no more than six teaspoons (25 grams or 100 calories) per day for women and no more than nine teaspoons (36 grams, 150 calories) per day for men. Your overall sugar intake should be less than 5 percent of your caloric intake.
For a diet of 2,000 calories per day, you should also aim for 28 grams daily of soluble fiber which is essential for blood sugar regulation. Soluble fibers are found in fresh fruits, beans, carrots, and oatmeal.
Eating and drinking healthy, exercising regularly, and controlling blood sugar level and avoiding tobacco can help prevent complications that lead to amputation.
Taking care of oneself requires a multidisciplinary care team approach that includes:
Unfortunately, even minor skin injuries can lead to a non-healing ulcer which can quickly turn to gangrene and necessitate amputation. If the patient has diabetic neuropathy, he/she may not feel an injury.
When a patient has diabetes, his/her chances of heart disease go up. Therefore, a cardiologist can order tests to see if the patient has signs of heart trouble. Symptoms such as shortness of breath or chest pain could indicate blocked arteries to the heart which can be treated with angioplasty to open up the blockage with a stent or flexible tube put in place to prevent it from coming back. Blockages in arteries to the heart that can’t be treated with angioplasty may require a cardiothoracic surgeon to do coronary artery bypass graft surgery.
Blocked arteries to the brain or lower extremities may require evaluation by a vascular specialist, and angioplasty or bypass can be done in these arteries too. Taking care of the heart reduces the chances of getting to the point of amputation.
Finally, any patient with PAD and CLI who is at risk for limb amputation should see a vascular interventional specialist prior to any surgical amputation. We can do both invasive and noninvasive studies to determine if a revascularization procedure is needed. Often times, restoring blood flow to the affected extremity can result in a total limb salvage or a much smaller amputation.
Genetics that cause diabetes cannot be controlled. However, American scientists have adapted a gene editing technology known as CRISPR (clustered, regularly interspaced, short palindromic repeat) to successfully treat mouse models of type 1 diabetes, kidney disease, and muscular dystrophy. CRISPR enables scientists to edit the genetic material of an organism allowing for DNA sequences to be easily altered and gene function to be modified. However, rather than cutting DNA, scientists at the Salk Institute for Biological Studies have repurposed CRISPR to kick-start the activity of other genes. Upon doing this, they were able to create new insulin-producing beta cells in mouse models of type 1 diabetes. Research like this must continue to find a cure for the complex disease.
UC Davis Vascular Center has launched a stem cell study to reduce amputations from vascular disease and diabetes using a patient’s own stem cell to increase blood circulation to the lower leg with the hope of preventing amputation due to severe arterial disease or diabetes.
Many advances are being made in the field of interventional vascular medicine as well. Smaller catheters and devices are used to remove plaque from affected arteries (atherectomy). There are new companies using sound and lithotripsy (Shockwave Medical) to help break up calcium in arteries affected with arteriosclerosis. Research is also being done using drug-eluting balloons that help open arteries and reduce the chance of them closing again.
Cardiologists like me who see patients every day with serious medical conditions also want to do something to help. We often see that there might be a better way. I am fortunate to have the opportunity to work with The Innovation Institute and their Innovation Lab in Newport Beach, California, to develop my own innovation related to improving patient outcomes. I hope to one day help provide hope for those stricken with diabetes.
How is U.S. healthcare broken? Let me count the ways:
I could go on and on about the problems in U.S. healthcare, but being a glass-half-full type, I would rather discuss what I believe is hope for a huge transformation in the way healthcare is delivered and consumed. It all revolves around that marvelous little computer that many of us continually engage with throughout the day: your smartphone. Add to that sensors that can pick up physiologic data, sophisticated analytics and artificial intelligence that can transform that data into information that you (and your healthcare providers) can react to, and responsive stuff in our homes, workplaces, schools, cars (the internet of things) that can be programmed to help us live healthier lives and treat illnesses at home. Top it off with new ways to communicate easily and efficiently with healthcare professionals who can provide appropriately timed coaching and advice and you can see how we can create a “healthcare system” that is at once more personalized, more people-centric, and more efficient than our current model of office- and facility-based care.
Let’s take a look at how these technologies could help with one of the most common health problems in America – overweight and obesity. Although most of us have been socialized to believe this is a problem of willpower, it is actually an unintended consequence of the complex biological systems that evolved to help ensure survival when food is scarce. The regulation of food-seeking behaviors is an intricate interplay of neurologic, hormonal, behavioral, biochemical, and genetic factors. This is why we have yet to come up with a magic bullet to help us lose weight and then maintain the weight loss over time. If you mess with one factor, the others kick into high gear to try to maintain the body’s energy stores.
How can technology help? Let’s say you are 15 pounds overweight and have developed pre-diabetes as a result. Your doctor has told you that you should lose weight or you could end up with full-blown diabetes with its attendant increased risk of having a heart attack, stroke, or amputation or developing kidney or eye disease. You’ve tried to lose weight before but after dropping a few pounds, your “willpower” collapses and you eat your way back and beyond your prior weight.
Now, instead of sending you out on your own to figure out how to “Just Lose Weight,” your doctor prescribes an array of digital tools to get you started. Some of the technologies I will describe are already available, some are in development, and some are, well, great ideas waiting for some enterprising digital health entrepreneur to make it real.
The first tool your doctor prescribes is a smartwatch that can continuously collect physiologic data needed to keep you healthy while you are trying to lose weight (e.g., blood pressure, pulse, glucose level, activity level, estimates of calories in and out). The watch is also programmed to help you set reasonable weight loss goals based on your health metrics and personal desires. It is also able to send you messages of encouragement, point-of-eating information (approximately how many calories are in that “healthy” smoothie), and a hot-button to connect you instantly to your health coach and/or designated friends who can provide support at your weakest moments (“Those fries smell great now, but remember the wedding dress you want to fit into.”). The doctor also prescribes an electronic scale and body fat estimator and helps you download an app that lets you take pictures of food you are thinking about consuming and not only tells you how many calories it contains but also how many minutes of your preferred exercise you would have to do to work it off.
After two weeks, your Primary Care nurse receives a message from the digital weight loss program notifying her that your blood pressure is creeping up and your weight loss has stalled. She messages you to tell you that you may require medication to control your blood pressure if you can’t get your weight loss back on track. She will contact you again in a month to see if you have made progress.
Your weight loss coach is also notified that you are not meeting your pre-determined weight loss goals. He sets up a video conference to go over the data and determine what additional tools might be added to your program. During the conference, he discusses a variety of internet-enabled home appliances that can be programmed to help you on your weight loss journey. He notes that some are covered by your health insurance.
Nighttime snacking is identified as a particularly problematic source of excess calories – mostly in the form of full-fat thin mint ice cream. He recommends buying a digital “FridgeLocker” that requires a code to open the freezer after 7 pm. Only your normal weight husband and kids, also thin mint fans, have the code. He also recommends adding increased exercise nudges to your smartphone messaging. A digital check-in two weeks later shows that you are back on track to meet your weight loss goals.
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Why Digital Healthcare Can Never Replace Doctors
Big Data’s Promise for Potential in Healthcare
All of this is accomplished without office visits and without medications. It is highly personalized and provides automated and human support to help you keep going. It is so inexpensive that insurers have determined it is more cost effective to cover digital tools than to pay for weight loss drugs, bariatric surgery or complications of diabetes.
This is only one example how digitizing healthcare could transform the way we do health. I am sure, my dear readers, that you will think up a jillion other innovations, not just for preventive care, but also for chronic care and urgent care, that are better than the way we do things now. Please leave your ideas in the comment section below so they can inspire someone, somewhere to make them a reality.
I know first-hand that anatomy is a major part of the first year medical student experience. Whether I like it or not, anatomy ends up pervading my thoughts more often than I think it should, indiscriminately and unprompted by context. Tonight, as I follow my parents into our favorite Chinese restaurant and all-you-can-eat buffet, I marvel not at the quantity and variety of Asian cuisine but rather at the peculiarity of an education in medical anatomy.
Most people conceive of human anatomy through a Hollywood lens: blood, guts, heart, liver, kidneys, and stringy bits of whatever. Before medical school, I wasn’t aware of where the spleen is or what it looks like, and I had never heard of “fascia”. Many schools of medicine believe the best way to unravel the curious mystery that is human gross anatomy is in the laboratory: grueling four-hour sessions of careful poking and brusque yanking and a surprising amount of skinning. Thumbs cramp from clutching scalpels too tightly, backs ache from hunching and neck-craning, and a thick white film builds up on lips from dehydration and stench-dodging mouth-breathing. Gross anatomy lab is as much a physical experience as it is an intellectual experience. After all that time and effort spent, medical students are forced to face the plain and simple fact that, on the inside, we are all basically the same.
Medical students spend a significant amount of time in gross anatomy lab with one particular specimen of human anatomy: “their” cadaver. This cadaver has an age, a cause of death, and corporeal variations and alterations that gradually unveil its medical history.
At first, I had to consciously tell myself over and over again that the thing lying on the table is simply a learning tool—a well preserved, a model specimen of human anatomy. Still, every time I would shake my focus and step back from the table, I would catch a glimpse of curved palms or freckles or sparse gray hairs that would remind me otherwise. A neighboring cadaver had painted pink fingernails and silicone breasts, making her humanity even more undeniable.
It’s incongruous and unsettling to think about all this as I wade through aisles of food, perusing the trays of glistening sweet and spicy delight, melt-off-the-bone braised to perfection, and the lightly breaded salt-and-peppered nosh. I don’t think this happens to most people, but medical students will oftentimes be halfway through an appetizing meal when they realize they’re talking about something morbid and nauseating related to anatomy lab. Funnily enough, by the end of some of our longer anatomy labs, most of my classmates are wailing with hunger, establishing an unnatural association between picking over cadavers and pining after food.
I heard a factoid (more like a rumor) that formaldehyde stimulates appetite, but after lab, all I want is a diet soda. To me, this is despicable. Before medical school, I was vegan, totally off packaged, processed foods, and I wouldn’t even think about drinking soda, diet or not. I was also ten pounds lighter. It used to break my heart every time I had to grab lunch from a vending machine due to a hectic schedule or limited resources. Nowadays, I don’t give it a second thought. When it comes to food, my resolve has vanished because being hungry means being distracted and not doing quality work.
Medical school has turned out to be the busiest time of my life. In addition to four-hour blocks of gross anatomy lab and class time, there are extracurricular lunch meetings, the occasional volunteer shift at the student-run HOYA Clinic in south-east Washington DC, and then there’s the actual studying that is so central to being successful in medical school.
I have a Mind-Body Medicine session every week because I need a block of course time dedicated to relaxing. At least being hungry is something I don’t have to think about because food is everywhere. I am usually hard-pressed to find food that is affordable and healthy enough to meet my standards, but there is never a scarcity of food itself, and this could mean serious health problems for me in the long term.
Food nourishes you, energizes you, keeps you from being hungry, and most of the time it’s yummy. Food is a pleasant experience; it brings together families, friends, and acquaintances. Food is a major part of your lifestyle.
Unfortunately, the food culture in America has affected the lifestyles of many Americans for the worse. Take diabetes, for example. Everyone knows about diabetes; it has pervaded our lives, our culture, and our healthcare system. It is not news that this pervasion is connected to our changing relationship with food. After years of consuming Coca-Cola, fried food, and excess carbohydrates, my own mother found herself in the emergency room recovering from a stroke and a blood sugar level of over 400. When food and lifestyle give us problems, we turn to medicine for solutions.
Medicine is a chore. Medicine is the pills you have to take every morning with a full glass of water an hour before breakfast. Medicine is my mother having to carry around needles in her purse, wherever she goes.
Settling down to all-we-can-eat is her cue. My mother pulls out a bright orange needle from her Louis Vuitton. The needle is cleverly disguised to look something like a pen, but she still keeps it under the table, out of sight of the hovering waitresses and fellow restaurant patrons nearby.
It’s probably better that she keeps her insulin injections hidden. We’re in a crowded family buffet, after all, and no one wants to see that. She clicks the needle’s plunger then rubs her belly, wincing. She has to stab herself with needles and lancets every day, in the morning, at night, every time she eats, and there are only so many pricks a patch of belly or fleshy fingertips can take.
As I watch her soothe the injection site, my thoughts linger on the pain, but then the needle swiftly disappears back into her purse. The medicine’s in her body and the chore part is all over. Now she’s ready to dig into the dinner plate in front of her, which has been pre-loaded with food. The huge pile of hot and tasty is the instant reward she deserves for having to endure her tiny pains, needle clicks, and lancet pricks.
My mother hones in on her dinner, and I can’t help but think about the medicine of it all. Diabetes was one of the first things we learned about in medical school. There was a time, way back in the fall, when I was all too familiar with the specifics of insulin receptor desensitization, the most common sites where glucose can accumulate and result in organ failure, and the whole mess that is the pathophysiology of diabetes and its comorbidities. It was painful to learn about all of that because every mention of blindness, end-stage renal disease, or toes being amputated made me think of my mother, her orange needles, her over-pricked belly and fingers, and her plates of food.
She relishes in the duck. She loves duck because it’s flavorful and primarily consists of protein and fat, but most importantly it is very low in carbohydrates. I encourage her to eat more vegetables and avoid breaded, fried, starchy, processed things. To my mother, this boils down to keeping her glucometer reading from exceeding 120, either by cutting out several foods she enjoys or by simply injecting a few more cc’s of insulin a day.
It takes patience and persistence to constantly remind someone that her health is more important than how enjoyable a snack or meal is. Sometimes I lose my patience and reprimand her as if she were a child. I know I shouldn’t scold her. She knows she shouldn’t eat the muffins from Starbucks or the butter croissants from La Madeleine. To me, this is family medicine.
Maybe she’s had a particularly stressful day. I try not to imagine her at work because it stresses me out too. I know she spent her day, like any other day, sitting in her cubicle, staring at a computer screen, skipping lunch and eating whatever at irregular intervals, sitting in traffic for the tiresome hour-long commute from downtown back out to the suburbs.
After going through all that, surely she deserves some relief from the formidable demands on her mind and schedule to just enjoy dinner. And enjoying dinner is all she does. For most of our meals, she barely even speaks. She never talks about work because she already has to think and talk about it so much. And, unfortunately, it follows that because of work, she’s had little time to experience anything else she might want to talk about. She never asks me questions about how my day went, except maybe whether or not I’ve gotten any grades back. This communicates nothing to me except the fact that, at that moment, my aspirations to become a well-rounded physician do not hearten her more than food does.
The busier I get, the easier it is for me to understand my mother’s silence at the dinner table, and just how mindlessly rewarding food can be. I sigh, reminding myself to be patient with her, telling myself she has come a long way from Coca-Cola, fried chicken fingers, and funnel cakes.
We are lucky to have access to all the medications she needs to maintain her blood sugar and blood pressure within acceptable ranges. We are lucky to live near grocery stores that sell fresh produce and lucky to have the money to afford these things on a regular basis. I push around the saucy mushrooms and bok choy on my plate and hope my mother will be lucky enough to see me graduate from medical school with all of her toes.