I am convinced from my personal experience, from the experiences of my patients, and from reading the scientific literature, that people with normal blood sugars do not develop the long-term complications of diabetes. I am further convinced that diabetics with even slightly elevated blood glucose profiles may eventually experience some of the long-term consequences of diabetes, but they will develop more slowly and likely be less severe than for people with higher blood sugars. In this chapter, I will try to describe some of the changes that I and other physicians have observed when the blood sugars of our patients dramatically improve.
Most common, perhaps, is the feeling of being more alert and no longer chronically tired. Many people who “feel perfectly fine” before their blood sugars are normalized comment later that they had no idea that they could feel so much better.
Another common occurrence relates to short-term memory. Very frequently patients or spouses will refer to a patient’s “terrible memory.” When I first began my medical practice, I would ask patients to phone me at night with their blood sugar data for fine-tuning of medications. My wife, a physician specializing in psychoanalytic medicine, sometimes overheard my end of the conversation and would comment,“ That person has a dementia. ”Weeks later, she would again hear my end of a conversation with the same individual, and would comment on the great improvement of short-term memory. This became so common that I introduced an objective test for short-term memory into the neurologic exam that I perform on all new patients.*
More than half my new patients indeed display this mild form of dementia, which appears to lift after several months of improved blood sugar. The improvement is usually quite apparent to spouses.
Diabetic neuropathies seem to improve in two phases—a rapid partial improvement that may occur within weeks, followed by sustained very slow improvement that goes on for years if blood sugars continue to remain normal. This is most apparent with numbness or pain in the toes. Some people will even comment,“ I know right away if my blood sugar is high, because my toes feel numb again.” On the other hand, several patients with total numbness of their feet have complained of severe pain after several months of near-normal blood sugars. This continues for a number of months and eventually resolves as sensation returns. It is as if nerves generate pain signals while they heal or “sprout.” The experience may be very frightening and distressing if you haven’t been warned that it might occur.
* I recite six digits (Sam Spade’s license number) and ask the patient to repeat them in reverse order.
Erectile dysfunction affects about 60 percent of diabetic males, and is the result of years of elevated blood sugars. It may be defined as an inability to maintain a rigid enough penile erection for adequate time to perform intercourse. It usually results from neuropathy, blocked blood vessels, or both. We can perform simple tests to determine which of these causes predominates. When the problem is principally neurologic, I frequently hear the comment, sometimes after only a few weeks of near-normal blood sugar profiles, “Hey, I’m able to have intercourse again!” Unfortunately, this turnaround only appears to occur if the man was able to attain at least partial erections before. If at the original interview, I’m told, “Doc, it’s been dead for years,” I know recovery is unlikely to occur. If testing shows that the problem was due primarily to blocked blood vessels, I never see improvement. Note, however, that it’s normal to be unable to have erections when blood sugars are too low, say below 80 mg/dl.
Another remarkable change relates to autonomic neuropathy and associated gastroparesis. I have documented major improvement of R-R interval studies in many patients, and total normalization in a few. Along with this, we see reduction in signs and symptoms of gastroparesis. Usually such improvement takes place over a period of years. Although it occurs most dramatically in younger people, I’ve also seen it occur in seventy-year-olds.
Diplopia, or double vision, is caused by neuropathy of the nerves that activate the muscles that move the eyes. It is a very common finding in the physical examination that I perform, but rarely severe enough to be noticed by patients on a day-to-day basis. Here again, when testing is redone after a few years, we find improvement or even total cures with blood sugar improvement.
Vacuoles are tiny bubbles in the lens of the eye and are thought to be precursors of cataracts. I have seen a number of these vanish after a year or two of improved blood sugars. I have even seen the disappearance of small “spokes” on the lens that signify very early cataracts. I’ve seen mild cases of glaucoma cured by normalization of blood sugars, as well as retinal hemorrhages, macular edema, and microaneurysms.
Improvements in risk factors for heart disease, such as mild hypertension, elevated cholesterol/HDL ratios, triglycerides, and fibrinogen levels, are commonplace. They usually can be observed after about two months of sustained normal or near-normal blood sugars and continue to improve for about one year.
Similarly, improvements in early changes noted on renal risk profiles are often obtained, usually after one or two years, but sometimes after a few months.
It has long been known that elevated blood sugars adversely affect growth in children and teenagers. As blood sugars approach normal, children with delayed growth rapidly return to their prediabetic growth curves. I, unfortunately, missed this opportunity because I was thirty-nine years old when I finally figured out how to normalize my blood sugars. I did have, however, the joy of watching my nondiabetic son and some of my young diabetic patients become giants in comparison to me.
Most dramatic and commonplace is the feeling of satisfaction and control that nearly everyone experiences when they produce normal or nearly normal blood sugar profiles. This is especially true for individuals who had already been taking insulin, but appears also to occur in those who do not take insulin.
In the late 1970s, the methods of this book were used at the Rockefeller University to normalize blood sugars in a group of type 1 diabetics. They were initially tested by a psychiatrist using the Hamilton depression scale. The starting score for the group was in the “severely depressed” range. This dropped to normal after the patients became the masters of their blood sugars.
Last but not least is the feeling that we are not doomed to share the fate of others we have known, who died prematurely after years of disabling or painful diabetic complications. We come to realize that with the ability to control our blood sugars comes the ability to prevent the consequences of high blood sugars.
I have long maintained that diabetics are entitled to the same blood sugars as nondiabetics. But it is up to us to see that we achieve this goal.