these visits should be examination of your feet.
Such an examination is not merely to look for injuries, bUsters, or what have you.
EquaUy important is the discovery of dry skin, athlete's foot, pressure points from iU-fitting shoes, ingrown or fungus-infected toenaUs, and cal luses.
Your shoes should also be examined for areas where they have been stretchedby prominences on your toes, suggesting that they are smaUer than your feet.
Any of these can cause or may indicate prob lems that could lead to ulcersof the feet and should be corrected.
Dry skin is best treated with daUy appUcations of animal or vegetable oUs such as vitamin E oU, olive oU, emulsified lanoUn, mink oU, emu oU, or any proprietary oU other than mineraloU.
The cure foriU-fitting shoes is new shoes (possiblycustom-made) with awide toe box with a deep rise.
CaUuses frequendy requirethe purchase of custom orthotics that redistributethe pressure on the bottoms of your feet.
Grinding offcal luses is not the solution, as caUuses are a symptom, not a cause, of excess pressure.
Their removal is the most common cause of amputa tions in patients that I see at my hospital'swound careclinic.
Resting blood pressures, repeated every few minutes until the low est reading is obtained,are mandatoryat everyvisit ifyour blood pres sureis even sUghdy elevated.
If your blood pressure is usuaUy normal, it should be checked every twelvemonths anyway.
Over the courseof a year or two, other aspects of physical examina tion should be performed.
The tests need not be done aU at one visit, but may be staggered.
These include osciUometric studies ofthe blood circulation in your legs, an electrocardiogram, tests for sensation in your feet, and acompleteeyeexam.
The eyeexamshouldincludepupU- laryreflexes, visual acuity, intraocular pressure, the Amsler gridtest, a test for double vision, and examination of your lenses, anteriorcham bers, and retinas through dUated pupUs.
This last exam must be per formed with certain specialized equipment that should include direct and indirect ophthalmoscopes and a slitlamp.
If your physician is not so equipped, or if he has previouslyfound potentialvision-threatening changes in your eyes, you should be referred to an ophthalmologist or retinologist.
If your initial physical exam disclosed diabetic complications such as earlysigns of neuropathy, carpal tunnel syndrome, or Dupuytren's contractures,examination for these compUcations should be periodi- caUy repeated.
The R-R interval study should be repeated every eigh teen months, even if it was initiaUy normal.
384 Treatment
The best treatment for the computations of diabetes is prevention. The second best treatment is detection in the very early stages, whue reversal is stillpossible. For theseand the reasons mentioned above, I stronglyrecommendvisits to your physician every two months, or at least everythree months.
24 What You Can Expect from Virtually Normal Blood Sugars
I am convinced frommypersonal experience, from the experiences of my patients, and from reading the scientific Uterature, that people with normal blood sugars do not develop the long-term compUcations of diabetes. I am further convinced that diabetics with even slightly elevated blood glucose profiles may eventuaUy experi ence someof the long-termconsequences of diabetes, but theywiU de velop moreslowly andlikely beless severe thanforpeople withhigher blood sugars. In thischapter, I wiU tryto describe some of thechanges that I and other physicians have observed when the blood sugars of our patients dramaticaUy improve.
MENTAL CHANGES
Most common, perhaps, is the feeling of being more alert and no longer chronicaUy tired.
Many people who "feel perfectly fine" before their blood sugars are normalized comment later that they had no idea that they could feelso much better.
Another common occurrence relates to short-term memory.
Very frequentiy patients or spouses wiU refer to a patient's"terrible mem ory." When I first began my medical practice, I would askpatients to phone meat nightwith theirblood sugar dataforfine-tuning of med ications.
My wife, a physician specializing in psychoanalytic medicine, sometimes overheard my end of the conversation and would com ment, "Thatperson hasa dementia." Weeks later, shewould again hear my end of a conversation with the same individual, and would com ment on the great improvement of short-term memory.
This became
386 Treatment
so common that I introduced an objectivetest for short-term memory into the neurologic exam that I perform on aU new patients.* More than halfmynewpatients indeed display this mUd form of dementia, which appears to Uft after several months of improved blood sugar. The improvement is usuaUy quite apparent to spouses.
DIABETIC NEUROPATHIES
Diabetic neuropathies seemto improve in two phases , a rapid par tial improvement that may occur within weeks, foUowed bysustained veryslow improvement that goes on foryears ifbloodsugars continue to remain normal.
This is most apparent with numbness or pain in the toes.
Some people wiU even comment, "I knowright away if myblood sugaris high,because my toes feel numb again." On the other hand, several patientswith 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 eventuaUy resolves as sensa tion returns.
It is as if nerves generate pain signals whUe they heal or "sprout." The experience may be very frightening and distressing if you haven'tbeen warnedthat it might occur.
Erectile dysfunction affects about 60 percentof diabetic males, and is the result of years of elevated blood sugars.
It may be defined as an inabUity to maintaina rigid enough penUe erection for adequate time to perform intercourse.
It usuaUy results from neuropathy, blocked blood vessels, or both.
We can perform simple tests to determine whichof thesecauses predominates.
Whenthe problemis principaUy neurologic, I frequently hearthecomment, sometimes afteronlya few weeks of near-normal blood sugar profiles, "Hey, I'm able to have in tercourse again!" Unfortunately, this turnaround only appears to oc cur if the man was able to attain at least partial erections before.
If at the original interview, I'm told, "Doc, it'sbeen dead foryears," I know recovery isunlikely to occur.
Iftesting 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.
I recite six digits (Sam Spade's license number) and ask the patient to repeat them in reverse order.
What You Can Expectfrom Virtually Normal Blood Sugars 387
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 gas troparesis. UsuaUy such improvement takes place over a period of years. Although it occurs most dramaticaUy in younger people, I've also seen it occurin seventy-year-olds.
VISUAL IMPROVEMENTS
Diplopia, or double vision, iscaused byneuropathy of the nerves that activate themuscles thatmove theeyes.
It isavery common finding in the physical examination thatI perform, but rarely severe enough to benoticed by patients ona 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 thelens of theeye and are thought to be precursors of cataracts.
I haveseen a number of these vanish after a year or two of improved blood sugars.
I have even seen the disappear ance of smaU "spokes" on thelens thatsignify very early cataracts.
I've seen mUd cases of glaucoma cured by normalization of blood sugars, as weU as retinal hemorrhages, macular edema, and micro aneurysms.
OTHER IMPROVEMENTS
Improvements in risk factors forheartdisease, such asmildhyperten sion, elevated cholesterol/HDL ratios, triglycerides, and fibrinogen levels, are commonplace.
They usuaUy can be observed after about two months of sustained normal or near-normal blood sugars and continue to improve for about oneyear.
Sinularly, improvements in early changes noted on renal risk pro files are often obtained, usuaUy after one or two years, but sometimes after a few months.
It has long been known that elevated blood sugars adversely affect growth in chUdren and teenagers.
As blood sugars approach nor mal, chUdren with delayed growth rapidly return to theirprediabetic growth curves.
I,unfortunately, missed this opportunity because I was
388 Treatment
thirty-nine years old when I finaUy 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 com parison to me.
Most dramatic and commonplace is the feeUng of satisfaction and control that nearly everyone experiences when they produce normal or nearly normal blood sugar profiles.
This is especiaUy true for indi vidualswho had already been takinginsulin,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 Rocke- feUer University to normalizeblood sugars in a group of type 1 dia betics.They were initiaUy tested by a psychiatrist using the HamUton 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.
Lastbut not least is the feeling that we are not doomed to share the fate of others we haveknown, who died prematurelyafter years of dis- abUng or painful diabetic complications.
We come to reaUze that with the abiUty to controlour blood sugars comesthe abiUty to preventthe consequences of high blood sugars.
I have long maintained that diabetics are entided to the same blood sugars as nondiabetics. But it is up to us to see that we achieve this goal.
=== PART THREE
Your Diabetic Cookbook
RECIPES
Page Sauces 394 Breakfast Foods 398 Soups 401 Salads 405 Poultry 407 Beef, Lamb, and Veal 411 Pork 416 Seafood 417 Vegetable Entrees and Side Dishes 424 Quiches and Souffles 437 Desserts 439
25 Recipes for LowCarbohydrate Meals