What’s going on? After more than 50 years with Type 1 diabetes, I am not only still here; thus far I have none of the dire complications I’ve been hearing about since I was a little kid. By ticking off all the things that aren’t wrong with me, I don’t mean to brag, but to convey a sense of astonishment:
People with diabetes (PWDs) are at least twice as likely to develop cardiovascular disease as people without it. The odds against me are stacked even higher because of family history: my father died suddenly of a heart attack when he was only 40. His father died of a heart attack at the age of 53 (it was his third). I’m 59. My body shows no traces of cardiovascular problems. Why am I here at all?!
My kidneys are normal. My eyes are fine, there is no trace of diabetic retinopathy, one of the leading causes of blindness in the U.S. There is no diabetic neuropathy in my feet or anywhere else. I can still make love. Wounds in my toes sometimes don’t heal as quickly as I think they should, and that might have something to do with diabetes, but it’s unclear.
Yes, I’ve wrestled with lifelong depression, and there is strong evidence that depression is also a complication of what I used to call My Shitty Condition when I was a teenager, but it is also a complication of the human condition.
Why have I beaten the odds and remained intact? Am I living proof that biological carnage can be staved off by carefully controlling blood sugar and taking other precautions? That’s probably a partial answer to this puzzle.
Several studies have shown that tight control of blood glucose substantially reduces the risk of diabetic complications. The main gauge for measuring such control is the Hemoglobin A1c test. I’ve routinely met the target A1c number suggested by clinicians: less than 7 percent. I prick my fingers and test my blood glucose every few hours (sometimes even more) and constantly adjust my insulin dosage and diet. For decades, I’ve also dutifully taken an “ACE inhibitor” to prevent kidney problems, baby aspirin to help reduce potential blood clots, a statin drug to control cholesterol. I try to get regular exercise and not eat (too much) crappy food. I meditate and do what I can to stave off stress and be here now.
But don’t think of me as a role model, Saint Dan the Diabetic. Although my control has been more consistent in recent years, I’ve done more than my share of binging and rebelling, of rushing to the refrigerator at 3 AM like a werewolf hunting for mint chocolate chip ice cream. And there have been many days when the blood glucose numbers have swooped way up and swooped way down several times within the same 24 hours. Yet somehow this wild ride hasn’t wreaked havoc on my insides. So I am convinced that, in addition to anything I’ve done, the dumb luck of my gene pool, or at least the maternal section of the pool, is also critically important.
My mother’s mother, Pearl Weiner, was a fount of memorable, Yiddish-inflected complaints about her health. She would point to her stomach and proclaim: “I’ve got a revolution in the poopik. The Bolsheviks, they’re here!” After a long bout with painful shingles, she once announced, “Or you get up or you get down, you want to take a rope and hang yourself.” She also became severely depressed after her husband Sholem died when she was 64, and never completely snapped out of it, which must have compromised her immune system to some extent. My father once got exasperated with her, and I remember telling him, a few years after Sholem’s death, that she didn’t have long to live and we should be nice to her. She lived until she was 92.
I am happy to report that her daughter, my mother, is 86 and still among us, driving to mahjong games and her Yiddish Club in New Haven. Perhaps I have inherited from both of them some kind of fierce cellular determination to keep on keeping on.
More possible clues come from researchers at the Joslin Diabetes Center, who studied recipients of the Joslin Gold Medal award. That is given to people who have had Type 1 diabetes for 50+ years (I just received one). The researchers learned something surprising: in longtime dia-survivors there was NO relationship between complications and blood sugar control, a marked contrast to other studies.
Here is the Joslin team’s very careful wording: “It is possible that Medalists without complications had better control during early diabetes than those who developed complications. However…glycemic control was not related to complications in this cohort despite a wide range of HbA1c (5–14).”
The researchers concluded that those without complications were “enriched with protective factors.” This study, like others, showed that PWDs with complications tended to have specific combinations of molecules called AGEs (advanced glycation endproducts). But the Joslin study also showed that the diabetic codgers with one combination of AGEs were less likely to have retinopathy.
Perhaps I lack the nasty AGE combinations and have “protective factors,” which my opthalmologist wants me to bottle. If so, did my blood glucose control have anything to do with my particular, life-preserving molecules? Probably. But some of my metabolic comrades in that study group also had decent A1c scores and still had complications, while some with execrable scores appeared to be doing ok.
One explanation that pops up in the medical literature is the idea of “metabolic memory.” Some scientists propose that early, intensive control of blood sugar in PWDs has enduring benefits that outweigh less rigorous diabetes management later on. And there is also “bad metabolic memory,” when the body somehow “remembers” poor control and doesn’t respond to efforts to improve it. But until someone one comes up with a convincing explanation of metabolic memory or another good reason for the puzzling results of the Joslin study, I will assume that mysterious sets of molecules are protecting my heart, kidneys, eyes and nerves, and I have not done much, if anything, to earn them.
Please. If you have diabetes (Type 1 or 2), don’t use this as an excuse to stop controlling blood sugar. That would be extraordinarily dumb. Don’t bet that strenuous efforts to manage this disease are just not worth it; there is too much evidence that they matter. We just don’t know precisely how much they matter. I plan to keep testing my blood and to live with the relentless, inner patter of instructions that accompanies this disease, and to fine-tune my body as if it were a car with 200,000 miles that I intend to keep.
But I am also going to keep reminding myself that there is only so much I can do, only so much I can control, and the rest is out of my hands. And I am going to try to enjoy and appreciate the biochemical gifts I’ve (probably) inherited from my grandmother Pearl.