The full name of a chronic condition known to its practitioners as ‘IDDM', ‘Type 1' diabetes, ‘diabetes' or something similar to ‘that injection thing you do'. It is a distinct condition from the more common diabetic condition known as ‘Non-Insulin Dependent Diabetes Mellitus'¹. This condition, although affecting a far greater proportion (around 90%) of people who can call themselves ‘diabetic', does not often require injected insulin in its control, as the sufferer's body can still typically produce insulin - although the insulin so produced may not be sufficiently effective, or may not be produced in sufficient quantity, to allow the body to avoid presenting diabetic symptoms.

Insulin is a hormone, produced by the Islets of Langerhans in the pancreas of a normal individual, which effects the transport of glucose within the body from blood solution across cell membranes. IDDM is called "insulin dependent" because, although the sufferer can be kept alive quite well using exogenously administered² insulin, if the subject is forced to go without insulin he or she is likely to die after a comparatively short period of time unless other circumstantial factors - such as starvation - obtain. Death by IDDM actually involves the body virtually starving itself to death, as glucose builds up in the blood, without being able to be transported to the body organs as fuel.

'Diabetes'

Diabetes, although well known for thousands of years³ is still a broad classification for a metabolic disorder which is insufficiently understood - although controllable - even today. Only in the last 80 years, since the isolation of insulin in 1921 by Canadian medical researchers Frederick Banting and Charles Best, has the distinction between IDDM and NIDDM been possible. Almost all that is definitely understood about diabetes between cultures is that it is a condition of affluence: it is very difficult to have too much sugar in your blood when you can't find enough of anything to eat. This is why the condition was diagnosed first among affluent cultures such as the ancient Egyptian and the ancient Chinese, and more recently among Western societies.

The symptoms of IDDM are usually initially present as a subset of a general diabetic symptomatic group. The potential sufferer is likely have one or more of extraordinarily frequently-passed and sweet urine, sweating, flushing, cardiovascular impairment, weight loss, acetol breath⁴, and tiredness or lethargy. The only reliable indicator of the condition, however, is a significantly elevated blood sugar level⁵ which must be observed in combination with one or more of these secondary symptoms, and to continue for several hours after an initial observation.

The sub-condition which is IDDM may be diagnosed at almost any stage of a sufferer's life⁶, and the diagnosis is almost universally resented by those who are old enough to know what it is likely to mean. The condition is thought to be the result of an autoimmune process, which exterminates the pancreatic beta cells which a normal human body uses to produce insulin. Other factors, such as injury, may also influence the destruction of pancreatic beta cells, but the autoimmune process is thought to be the most common cause of IDDM. Exactly what triggers the autoimmune process is not known, although suspicion has focussed, at times, on trauma or shock, viral infection and genetic predisposition. The other digestive functions of the pancreas are typically unaffected by this process, resulting in a body which is perfectly capable of keeping itself fed, but not capable of actually using its food to supply the body's energy requirements.

Diabetic Control

This is the part of diabetes which diabetics themselves really detest, because of the constant nature of its necessity. Constant monitoring of BSLs, and constant gauging of time and dosage for next injections, all the time with no objective criterion for ‘doing it right', become wearing, even when dealt with by a full support team of medical personnel.

Diabetic control is the art⁷ of maintaining BSLs within a ‘normal' range. This potentially allows premium conditions for the diabetic's body to get on with all the other things it needs to do: digest, exercise, breathe, stay alive and so on. It is a lifetime pursuit once the sufferer has been diagnosed with IDDM - no breaks, no holidays, only consequences. The universally recognised medical tools for doing this are the Blood Glucose Meter⁸, the insulin syringe, pen, pump or dermal gas gun⁹, diet, and exercise. Each of these tools is also supplemented by others, for use in cases of exaggerated symptoms caused by elevated BSLs or other incidentals like illness. Diabetic control is also, however, complicated by a number of circumstantial factors.

The first and most important of these is that the testing and recording of BSLs are immediately anachronistic the moment measurements are taken. This reflects the fact that a measurement illustrates only one moment in an ongoing process: BSLs are never static, even in normal individuals (although the fluctuations of BSL in normal individuals occur within a much more limited range), and when a rising BSL can escalate very quickly into a high BSL, potentially resulting in a series of symptoms similar to those present at diagnosis, the person with diabetes still cannot know from a single blood glucose test which way the BSL is going. This can result in some potentially disastrous consequences - particularly if the BSL is falling, which may result in a phenomenon known as the ‘insulin reaction' or ‘hypoglycaemic attack'.

The maintenance of BSLs thus becomes something of a lottery in some circumstances, and can be compromised by something as simple as forgetting to do a blood test. The consequences of such compromises are usually fairly short-term if BSLs are going down at the time, but they can build up over long periods of inadvertently elevated BSLs.

From a longer-term perspective, it is not known how high BSLs can be allowed to be maintained, nor how low they can be allowed to be maintained, before permanent damage to the body results. Such damages, called ‘diabetic complications', are known to result from maintaining average BSLs which are ‘too high', but exactly how high that is is not known. It is also known that death can result from BSLs which are ‘too low' for an extended period of time¹⁰, but exactly how low ‘too low' is is also not known. No BSL threshold for complications development is known - although, again, several are suspected - and as a result complications are continuously feared, but difficult to deliberately avoid. It is also difficult to maintain both a short-term perspective and a long-term perspective on BSL control. The short-term perspective allows the next BSL to be manipulated in a way which will benefit the diabetic in the next few hours, but the long-term perspective would allow a much greater appreciation of exactly how much short-term manipulation is necessary to keep the diabetic alive and healthy.

In addition, other life factors also impact on the maintenance of BSLs. How much you eat, what you do, what you're feeling about what you do, and so on, are all likely to be unpredictable parts of a typical lifestyle, and the necessity of being aware of such things on an ongoing basis is often resented by insulin-dependent individuals even more than the imposition of injections and blood tests. The combination of factors involved in controlling BSLs can involve controlling numerous other parts of a life, and the resultant restriction of ‘spontaneity' is often perceived as one of the chief impediments of the condition. So many things, in fact, can impact on BSLs that the maintenance of a given BSL - or of BSLs within a certain, limited range - is practically impossible, yet this is what the diabetic seeking control is encouraged to achieve. These ‘other factors' are thus also instrumental in bringing about the widely acknowledged tendency of insulin-dependent diabetics to episodes of depression about their conditions, and consequent disruptions in control.

Diabetic complications

These are the principal negative consequences of the attempt to control the diabetic condition - the principal positive consequence being normal health, which it is sometimes difficult to appreciate as a significant achievement.

The principal complication of ‘over- control' is hypoglycaemia, which can really ruin your day, and the days of a lot of people around you if attempted with sufficient panache. Such complications are typically short-term, however, as they are comparatively easy to treat with sugary food or drink, and as it's very difficult to maintain a normal lifestyle when continuously twitching, soaked in sweat and unable to control your limbs. Not all hypos are quite so severe, but IDDM hypos are typically more dramatic than NIDDM hypos, due to the larger doses of insulin involved. The 'secondary complications' of hypoglycaemia are not so easy to treat. Injuries due to car crashes undergone while under the influence of hypoglycaemia, for example, are difficult to dismiss, and it is quite easy to smash your own head open while banging it on the ground in a fit of hypoglycaemic frustration.

An interesting, related complication of hypoglycaemia is the phenomenon known as ‘hypoglycaemic unawareness', which typically affects insulin-dependent individuals on intensive therapy. Widely encountered by insulin-dependents after the introduction of ‘human' - or genetically engineered - insulin analogues during the 1980s¹¹, this phenomenon eliminates native adrenal responses to an approaching hypo, meaning that the diabetic cannot ‘see them coming'. With habituation to lower BSLs, this also means that diabetics on intensive therapy are more prone to lose the behavioural symptoms which might characterise a hypoglycaemic episode from the ‘outside', too, until the episode is so well advanced that it is difficult to resolve without medical attention. As intensive therapy implies more injections¹² - and requires more blood testing - than would occur otherwise, this phenomenon increases the number of hypoglycaemic episodes that the diabetic is likely to have. As a result, due to the increasing popularity of intensive therapy in preventing other complications, hypoglycaemia has become a more visible and feared issue in the treatment of IDDM than it has ever been before.

The notable potential complications of ‘under-control', or maintaining BSLs which are too high, are generally longer-term, and include diabetic retinopathy¹³, diabetic neuropathy, diabetic nephropathy¹⁴, gangrene and subsequent amputation, impotence¹⁵ and lesser circulatory disorders. In the shorter term, a high BSL can make you feel bad - moody, short-tempered, lethargic, prone to urination - but there are fairly straightforward ways of dealing with this problem. Only if the high BSLs become habitual do you have to sweat on them.

Diabetic complications are direct products of medical practice's increasing ability to treat the diabetic condition, and apply as consequences across all types of Diabetes. They occur in insulin-dependent diabetics mostly because the administration of insulin allows them to live long enough for the complications to present, rather than simply to be killed by the condition itself. Diabetic complications are one of the chief burdens on the hospital systems of several developed countries, and the public health strategies of these countries for dealing with IDDM typically involve addressing a potential immunisation against the condition and instruction in the avoidance of complications, rather than a ‘cure' for IDDM itself, as most sufferers would actually wish. Some of the complications may also apply to insulin- dependent individuals who remain untreated, although IDDM more often causes death before the complications become a burden, as they do to treated individuals. Although a definite link between chronically high BSLs and complications has been established, the link is not definitely causal - so some people can ‘get away with' much higher BSLs than would be possible for others to do. The actual occurrence of complications can also frequently appear completely arbitrary, no matter how well-controlled the diabetic who suffers them.