A Day in the Life of Person Who Has Had Type 1, “Juvenile Onset, Insulin Dependent” Diabetes Mellitus (T1DM) for 57 Years ()
I am a 57-year-old person with T1DM. Needless to say, how we manage T1DM has changed significantly and markedly over the past 57 years. Discovery of insulin revolutionized the management of diabetes is appropriately acknowledged to be “one of the greatest achievements of modern medicine” [1]. Currently, we have continuous glucose monitoring (CGM) and glucose meters to check finger stick blood glucose to monitor blood sugars (BS). Both are very easy, convenient, and accurate means that provide us up to the minute BS readings ideal for insulin treatment adjustments. These allow us to control our BS within the desired range chosen for individual patients. For administering insulin, we now have many methods such as insulin syringes/pens, continuous subcutaneous insulin infusion (CSII) pumps, smart insulin pens, inhaled insulin, and insulin patches—and there’s even a closed loop artificial pancreas (CSII + CGM).
Believe me, as difficult as diabetes management may seem or sound to many people with T1D or T2D today, it is a far cry from diabetes treatment and management over the last 50 years.
Now, I will relate the T1DM management procedures I was taught by the hospital staff at the time I was first diagnosed.
I will start by taking you through the typical things I did for my diabetes growing up with T1D back in the 1960s. The “finger stick” method for testing BS came out in the early 1980’s—this was a godsend for us with diabetes! Prior to this if I wanted an actual blood sugar reading (which was done every 3 months prior to my doctor appointment) I had to go on a Saturday morning to the laboratory at Resurrection Hospital in Park Ridge, IL (about a 15-minute drive from my home) for a fasting BS testing. A week later, my BS level would be discussed with my doctor at the clinic and adjustment in my insulin regimen was recommended.
Back in the 1960s I routinely did urine sugar testing utilizing ClinitestTM (Miles Laboratories) tablets every morning, before meals and at bedtime. I urinated into a container and then placed 5 drops of urine and 10 drops of water into a test tube with a ClinitestTM tablet. I had to wait 60 seconds for it to turn color, then shake it and wait another 60 seconds. Then, I had to hold the test tube alongside a color comparison chart to see my urine sugar as follows: none (blue color), trace (green color), or 1+, 2+ or 3+ (different shades of tan to orange) indicating the amount of sugar in my urine specimen. (It was an exothermic reaction, so I had to be careful where I held the test tube!!) This is what I used at home during grade school for morning, before meal, and at bedtime urine sugar readings. Later ClinitestTM tablets were replaced by Tes-TapeTM (Eli Lilly and Company) [2] to make the testing much easier and more user friendly (for males!). Using easier Tes-TapeTM, I put the strip into the stream of urine and then held the strip to the back of the Tes-TapeTM container to read the coloration and determine the negative or plus amount of sugar1. I continued to use Tes-TapeTM during my high school years starting in the late 1960s.
The most difficult issue with the urine glucose testing methods was usually for the morning urine sugar testing on awakening. I had to do a “double-void”, which consisted of emptying my bladder completely as soon as I woke up in the morning, then drinking 2 - 8 ounces of water and testing the second voided urine. This procedure supposedly provided a more accurate reading of urine sugar (and therefore relating to my BS) before my morning injection of insulin. (Let me tell you, it was sometimes difficult to hurriedly obtain a second voided urine specimen!!)
Timing was an issue with the daily morning ritual consisting of double-void urination to get an accurate reading (accurate was very questionable considering the kidney’s glycemic threshold of sugar excretion!!), then, calculating the insulin dose based on my urine sugar amounts, injecting my insulin dose 30 - 45 minutes before eating breakfast (remember just regular insulin (RI) was available back then!!) and then walking to grade school or later going to the bus stop for high school. Obviously, it was quite a morning exercise I went through every school day as compared to present day. Today I use CGM or finger stick BS to get an immediate BS reading and I adjust my insulin dose based on carbohydrate counting just 5 - 10 minutes before I eat if my BS reading is within normal. Wow, how times have changed and improved for people with diabetes!!
Now, I will talk about the insulins used back in the 1960s. Regular (quick acting) insulin (RI) and NPH (intermediate acting insulin) became available in both U40 (40 units/ml) and U80 (80 units/ml). U500 (500 units/ml) was available but only through a special order through Eli Lilly Pharmaceutical, Elkhart, Indiana, USA). The glass syringes (yes glass which had to be sterilized) had both U40 (40 U/ml) and U80 (80 U/ml) demarcation on the syringe. Therefore, you had to be very careful in making sure that you received the correct Insulin concentration from the drug store and then, when drawing up the insulin, that you were reading the correct concentration on the syringe (I used U40). The U100 insulin concentration as well as human insulin became available in the 1980s. The insulin that I utilized before recombinant DNA human insulin was a combination of 70% beef and 30% pork insulin (there was also pure beef or pure pork available).
I took a combination of Regular and NPH insulins. My procedure was to boil the glass syringe, plunger and 26-gauge needle in boiling water in a small saucepan for 10 minutes, then remove the items from the boiling water and let cool. Then I inserted the glass plunger into the syringe and then firmly put on the needle. Then I injected air into the NPH vial, withdrew the needle, and injected air into the regular vial (the amount of air injected corresponded to the units of insulin that would be withdrawn). Then I withdrew my Regular Insulin. Then, I inserted the same syringe into the NPH vial after I gently rotated the NPH vial for 20 rotations between my palms (you must mix well). You must remember that NPH is a suspension, and this is extremely important even now with any insulin suspension [3] [4] and withdrew out the correct units of NPH. You then must inject immediately after drawing up the insulins. I had to do it in this order because I never wanted to mix the cloudy intermediate acting NPH into the clear faster acting RI vial. A nurse told my mother when I was first diagnosed that it was like doing dishes “you could mix some of the rinse water into the soapy water but not the reverse!” That’s was how I remembered the correct way of drawing up the insulin!! I repeated the same procedure each day before dinner (after of course doing a double void specimen). After each injection I used a thin metal wire to clear out the needle and then a sharpening stone to sharpen the needle. Quite a time-consuming procedure before breakfast and dinner compared to what I do now!!
I have been asked to talk to many diabetes support groups over the years and before doing so I asked the CDEs if their patients are adherent with their blood sugar monitoring. Many times, of course they say “No—not as good as they could be!” I then describe with the diabetes support group the way of testing urine sugars and boiling the syringe as I did, and the support group people are amazed at the way “it used to be” and then they realize what they have available now for monitoring and treating their own diabetes. CDEs tell me that the monitoring increases with their patients after the counseling!
In retrospect, it is apparent that ongoing evolving treatment paradigms based on important innovations regarding development and manufacturing of Insulins with physiologic profiles, insulin administration devices and methods of glycemic monitoring of diabetes since the discovery of insulin (Table 1) have improved quality of life over 57 years of my life with diabetes as well as that of other diabetics. I am also convinced that these innovations have extended life span of subjects with diabetes. Finally, I also realize that, despite the rather large difficulties in my early Type 1 diabetes management, with the help of my family, especially my mom, as well as my doctors, other healthcare professionals and friends, I have lived a remarkably “normal” life with no significant complications. Moreover, with advent of much more modern methods, I expect to do well in future. For this I am extremely grateful. Therefore, I feel it is necessary that I share my story so others with both Type 1 and Type 2 diabetes are encouraged to take heart and know that there is always a way to live a long and healthy life. Thankfully, I have.
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Table 1. Chronology of important innovations with Insulins, insulin administering devices and methods and glycemic monitoring in diabetes since discovery of insulin.
Acknowledgements
My thanks to my good friend and colleague George S. Motto M.D., Board Certified in Endocrinology & Metabolism, 1973 for his review as well as Dr. Udaya Kabadi for helpful comments.
NOTES
*These views are my own and do not present any views of Sanofi.