Articles
In 1997, Meyer K. came to me as a slim 82-year-old retired widower
with type I diabetes since the age of 51. Because of diminished cognition,
unsteady gait, reduced vision and other problems caused by his long
history of very high blood sugars, he was cared for by a younger gentleman.
His care giver did not speak English and was not skilled in elementary
arithmetic. He measured the insulin, and Meyer gave himself the injections.
The pair were brought to me by Meyer's children because of his bouts
of severe hypoglycemia with loss of consciousness and his hospitalizations
for diabetic ketoacidosis.
At his first visit, Meyer's HbA1c was 10.4%. This corresponded to
an average blood sugar of approximately 320 mg/dl over the prior four
months.
Meyer admitted to feeling depressed for several
years and had been suffering from chronic diarrhea for three years.
This condition would frequently attack without enough warning for
him to reach the toilet, and he did not respond to the ordinary anti-diarrhea
medications that he took several times a day. Because of this condition,
he rarely left home for fear of an "accident." he also complained
of frequent belching during and after meals.
A Plethora of Problems
Physical examination revealed a number of long-term diabetic complications.
Meyer suffered from cataracts, periodontal disease, missing teeth,
peripheral sensory neuropathy, postural hypertension, severely impaired
short-term memory, glaucoma, double vision in all directions of gaze,
severe sympathetic neuropathy in his feet, diminished pulsatile circulation
in his left ankle, the classic "claw" shape of "diabetic
feet" and weak/wasted muscles in the hands and feet.
Most important was severe impairment of heart rate variation during
deep breathing. In nondiabetics his age, the vagus nerve slows the
heart rate by about 25 percent from inhaling to exhaling. Meyer's
only slowed by two percent.
Questions:
- What could be causing Meyer's frequent belching and poor BG control?
- What is the ideal treatment regimen for Meyer considering his
obstacles to treatment?
Solution #1:
Since the vagus nerve is also the major mediator of digestion, and in
particular stomach emptying, it was clear that Meyer must also be suffering
from gastroparesis, a weakness or paralysis of the muscles of the stomach.
This extreme neuropathy of his vagus nerve probably explained his frequent
belching.
Meyer's gastroparesis predicted that it would be nearly impossible
to normalize his blood sugars because gastroparesis renders stomach
emptying and digestion of meals unpredictable. You never know what
amount of a meal will eventually be converted to blood sugar, so you
never know when and how much insulin would be needed to cover a given
meal on a given day.
As a result, many gastroparetics who take insulin will experience
dangerously low blood sugars after a meal fails to leave the stomach,
only to experience very high blood sugars eight, twelve or twenty
hours later, after the stomach finally empties and the insulin taken
for the meal is no longer working. One could easily cope with this
if it happened the same way every day, but it doesn't. For further
information on diagnosing and coping with this condition, see chapter
21 of my book, Dr. Bernstein's Diabetes Solution, Little, Brown,
1997.
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