Tuesday, August 24, 2021

It's Complicated: Eating with Diabetes--When Your Stomach is Broken

 Last night I came across a Tweet from Ginger Vierira (@GingerVieira) that caught my eye. I thought about it for a few minutes before responding (always a smart thing on Twitter). 

How has type 1 diabetes affected your relationship with food? I'd like to included your answers in an article I'm working on! Feel free to reply to this tweet or send me a DM if you'd like to contribute. <3 Thank you! #t1d #type1diabetes

It's a complicated issue. In a nutshell, with Type 1 Diabetes (T1D) we have to calculate how many carbohydrates we eat and administer an appropriate dose of insulin. Okay, it's a lot more complex--meauring blood glucose (BG), adjusting the insulin dose to get to a target, etc. If you've done it, you know.

But her question is complex, too. Insulin is expensive as hell and more than a few people follow a diet low in carbohydrates that requires a lower dose of insulin. If you can't afford it, the obvious solution is to use as little as possible. Tragically, so-called "insulin rationing" can be deadly. Too many people are forced to do that and it'll definitely affect your relationship with food.

It's long been proven that keeping blood glucose as close to normal as possible leads to fewer diabetes complications. The Diabetes Control and Complications Trial, or DCCT, was so conclusive that it was ended early so that the information could be shared promptly. Consequently there is a school of thought that the healthiest strategy is to best manage T1D a "low carbohydrate" diet is the way to go. Dr. Richard K. Bernstein is the acknowledged pioneer if this approach and it's most vocal advocate. Details, pros and cons can be found here. Again, like insulin rationing, if you want (or feel the need) to follow this approach, it'll also inform your relationship to food.

There is another way of thinking about carbs and diabetes: if you know how many carbs are in a meal, and how your body utilizes insulin, then you can eat like a person without diabetes--within reason. I'll put an emphasis on "WITHIN REASON." A Big Mac, large fries, large strawberry shake and an apple pie has 283 grams of carbohydrate--103% of the recommended daily allowance (their number, not mine). Whether you have T1D or not, that'll give your pancreas some serious pain.

But what if your stomach doesn't work right? To review 8th grade anatomy, after you swallow food it enters the stomach. Acidic digestive juices are secreted and along with the stomach contracting to mix it up, after a while it empties from the stomach and enters the small intestine. If there is a problem with how the stomach contracts, or passes it to the small intestine, you might have gastroparesis. "Paralyzed stomach" is a loose translation, and this complication affects 1 in 3 people with T1D. I've been wrestling with it for over a decade and I can tell you it makes living with T1D a monumental challenge. Here's why:

When we inject (or pump) insulin at mealtime, we are counting on the predictable rate of action of insulin. We are also counting on the speed that the carbohydrates start getting converted to glucose. Done right, blood glucose will rise (it does that in people without T1D) but not too much. But with gastroparesis, the food is held in the stomach for too long, or it empties too slowly. Consequently the insulin starts working but if there isn't any of that food to work on your BG will dive. That's bad and can result in hypoglycemia, or low BG. Normally you treat the low BG with carbs, but now you have just added more carbs on top of the carbs from the meal. Guess what: your BG is going to spike, likely resulting in hyperglycemia. The solution to that is more insulin. Welcome to the Gastroparessis Hamster Wheel.

There are dietary recommendations on how to eat with gastroparesis. The University of Virginia's guide is well respected, as are tips from the International Federation For Functional Gastrointestinal Disorders or IFFGD. Both are useful and naturally before starting this, or any diet or treatment for T1D always talk to your doctor or a Diabetes Care and Education Specialist.

So how do you manage T1D with gastroparesis, and how does that inform our relationship with food? I'll describe my experiences in future posts. In the meantime, be well and stay safe!

Monday, August 16, 2021

Continuing Education For Patients

 "I don't know what I don't know." That thought crosses my mind a lot, whether it is using my computer, figuring out whether to take a class, or in managing my Type 1 Diabetes (T1D). Fortunately in the case of people with diabetes (PWD) we have a great resource ready, willing and able to help. Those professionals are your friendly, neighborhood Diabetes Care and Education Specialist. 

Blood Glucose Test Strips
Let's face it: the newly diagnosed PWD gets hit with a ton of information and lifestyle changes beginning the minute they are told "you have diabetes." When it happened to me in 1994, I had to learn about mixing Regular and NPH insulin, reading a blood glucose test strip by holding it next to the strip container and comparing the colors, as well as learning all about meal exchanges. Thank God times have changed. What hasn't changed is that I was lucky to have a trained pro (called a Certified Diabetes Educator, or CDE back in the old days) to teach me in those first scary and overwhelming days. 

Now that we have rapid acting insulin, continuous glucose monitors (CGM), insulin pumps and apps to help figure out carb counting, the daily life of PWD is both easier and safer. But as tools and techniques have changed, how have we addressed growing and updating the knowledge we need to live our best diabetes life? We still have an army of trained, dedicated pros, but how are they keeping us current on best practices, tips and tricks? 

In my case, somewhere along the line the "Meal Exchange List" got dumped and replaced with "Carb Counting." If I recall correctly, when that change happened there wasn't a push to retrain patients that I was aware of. Somewhere along the line it came up in conversation and I got a 'down and dirty' explanation on how to count carbs and we figured out how to dose insulin with that information. 

When I started using a CGM in 2005 the process was more formalized. Dexcom had training materials that my CDE and I used to learn how to use it and check my proficiency. When I moved from multiple daily injections to pump therapy (first with Medtronic and now with Tandem) a similar formula was used. For the most part, these big changes in how I manage diabetes have been big events where my DCES gave me training and checked my knowledge and skills before turning me loose.

But what about the skills and knowledge gaps that I don't know about? Usually those might be identified in an appointment with my Endocrinologist or DCES if my A1C is out of whack or CGM data uncovers an issue with lows or post-meal high blood glucose readings. I could also look at the ADCES patient education pages, and comprehensive as it is, it doesn't directly fulfill my individual needs. But what about things that aren't obvious, or that it might take a longer conversation to uncover?

Here's a thought: patients could benefit from formalized "Continuing Education" just like our professional care team does. Ideally it would leverage online skill and knowledge assessments. We all do online surveys from time to time so this isn't anything revolutionary or new. This would allow our DCES to tailor our training to address what we need without taking up precious appointment time. It would be limited to the areas pertinent to our type of diabetes, the tools we use, and the skills necessary to have a healthier life.

Would it put DCES out of business? No--if anything it would increase the number of patients they can help by making more efficient use of the time they spend with patients. Identifying their needs before they walk in the door would allow more time to be spent on teaching as opposed to assessment and then teaching. The patient and the DCES would focus on skill and confidence building within an evidence based framework. No more shooting in the dark or wondering if the patient has the knowledge they need or if an opportunity was missed.

Continuing education for patients: it is long overdue.

Wednesday, August 4, 2021

Screwy A1C? Maybe its Your Kidneys...

You've got an appointment with your GP or Endocrinologist coming up and they set you up for a Hemoglobin A1C test. You get it done and on the big day it is higher than you expected. Annoyed, you start thinking of how in the world was it so high when your finger sticks seemed decent or your Continuous Glucose Monitor (CGM) data looked pretty good. If you are like me, we start thinking of how we're going to explain this. Before the appointment starts you feel like your already on defense.

To begin with, let's review what an A1C actually is. According to the CDC, it is a blood test that measures your average blood glucose over the last three months. Specifically,

"When sugar enters your bloodstream, it attaches to hemoglobin, a protein in your red blood cells. Everybody has some sugar attached to their hemoglobin, but people with higher blood sugar levels have more. The A1C test measures the percentage of your red blood cells that have sugar-coated hemoglobin."

So what does this have to do with kidneys? First, if you have Diabetes there is a 1 in 3 chance that you have Chronic Kidney Disease (CKD is a complication of diabetes more accurately called Diabetic Nephropathy). Second, if you have CKD you could also have anemia. If your kidneys are not working well, they may not be making the red blood cells your body needs. The American Kidney Fund does a great job explaining the details of anemia. If your doctor hasn't told you that you are anemic, a quick look at any of your hemoglobin tests will indicate that if the numbers are on the low end. Even if you don't have CKD, you still could have anemia. One study of 200 patients found that 22% had anemia, and of those 41% had normal kidney function and in 27% the cause could not be determined.

But what does this have to do with your A1C? Studies show that anemia has an impact on A1C, and one study cautioned that anemia should be fixed before A1C results are used to guide diabetes treatment decisions. That study has links to other published studies reinforcing the point.

So as a patient, how do you explain this to your doctor when they inevitably say something like "your A1C is too high" or "you need to do better at controlling your diabetes." Yeah--that annoys me, too and if you're going to hunt bear, bring the big guns. Last month, I had a first appointment with a new GP and knew this conversation was coming. What I did was to do a little homework beforehand.

First, I got the results of my most recent A1C, hemoglobin (HGB) and red blood cell (RBC) tests. On April 30, 2021 my A1C was 8.6%. Ugh! My hemoglobin on June 16, 2021 was 9.7 (normal range is 12-17 g/dL) and the RBC was 3.13 (normal is 4.2 to 5.4 M/cmm).

Next, being a Dexcom CGM user I went into their Clarity online system and ran a custom report. I configured it to start on April 30 and going back 90 days so that the CGM data would match the same period the A1C was supposed to measure. I printed it out to take to the appointment.

One thing about CGM reports: I've found that a lot of my doctors are impressed with the technology and once they understand it they find it is a useful tool. A lot of specialists don't have the time to learn about it and that is where we can be our own best advocates. More than once I've carried a copy of the summary page when I thought glycemic control might be part of our conversation. By and large when I show it to them, explain how I use it to optimize control of my diabetes it helps reassure them that I am an informed partner in achieving the best possible outcomes we can achieve by working as a team.

I also printed out a couple of the articles listed above to give to the doctor. First to add some credibility to what I'm saying I wanted to send a signal that I'm relying on vetted, peer-reviewed information--not some Facebook charlatan. Second, with the way doctors have jammed schedules and also want to stay informed, I was trying to support him with both challenges.

When appointment day arrived, one of the first things the doctor said was "you need to get your A1C down." I replied, "Well doctor, I have CKD and anemia. That skews the A1C higher than what my Continuous Glucose Monitor data shows. The A1C is just one data point, but the CGM takes a measurement every 5 minutes which provides 25,920 glucose reading over the same 90 days. While my lab A1C was 8.6%, the equivalent A1C based on CGM data was 7.6%"

I didn't bother explaining the virtues of Time In Range (the emerging gold standard of glycemic control) or standard deviation or other statistics. Our time together is limited and my role is the patient getting care and not an educator. But in the end, I made my case, got the care I needed (for the most part) and hopefully impressed my doctor with the impression that I was an informed partner.

I hope this is helpful and that you don't need to actually need to use this.
Kindest regards,

Thursday, February 22, 2018

Coaching in Type 1 Diabetes: A Patient's Perspective

One of my "Twitter Buddies" is a Certified Diabetes Educator who is working on an advanced degree. On Twitter she asked the question, "Okay, working on a school discussion. No better people to ask them those with DM themselves: What's your favorite coaching strategy from your HCP to help you prevent complications? #DSMA" Since my answer would run longer than 280 characters, here goes.

I essentially have two distinct health care teams. My primary care provider is a GP who treats veterans in the Veterans Affairs healthcare system. That patient population likely has fewer people with Type 1 Diabetes than a more diverse population than those seen by a GP in private practice. He generally helps me with regular health concerns. When it comes to Diabetes, he generally defers to my Endocrinologist while at the same time helping me get care for some of the Diabetes-related issues.

The other part of my team is led by my Endocrinologist who divides her time between the VA and work in a teaching hospital. This gives her intimate familiarity and experience at helping me manage the nuances of Type 1 Diabetes.

When I first met my PCP several years ago, he reviewed my electronic health record and said, "You need to get your A1C down." This is something I already knew going back to 1994 when I was diagnosed and shortly after the Diabetes Control and Complications Trial was published. That trial basically said there is a definitive scientific basis for the notion than lower blood glucose levels result in a lower incidence of common complications arising from Diabetes. What my PCP was saying was something I already knew, was something I was working hard to accomplish on a daily basis, but because of challenges from other complication it was something I was unable to do.

I told him something along the lines of "I've read the DCCT, I know what it says, and my Endocrinologist and I are working real hard at optimizing my A1C. However, between gastroparesis, hypoglycemia unawareness, impaired kidney function impacts on insulin efficacy and despite frequent blood glucose monitoring, use of a Continuous Glucose Monitor and the most advanced insulin pump available to me, this is (for now) as good as it gets." What I was communicating was that I am aware of the importance of lowering my A1C, but am also knowledgeable about my illness and the various factors in my particular situation that make this goal challenging. I also said, "What I need help with from you is in managing these variables." I was asking for his expertise and experience and showing him that I was going to be cooperative and willing to do my part with helpful guidance from him. Just saying "You need to lower your A1C" was simple but not helpful - what I was looking for was concrete, actionable and realistic tools and tips to meet that objective. So far, with that common outlook in place, this relationship has worked out pretty well.

With my Endocrinologist, the coaching relationship is a bit different. I am fortunate that our relationship is (as I see it) a fully collaborative partnership. As we discuss my case, we take into account clinical best practices and work them into realistic lifestyle choices that will most safely lead to optimal glycemic control. She is in close contact with my gastroenterologist, nephrologist and cardiologist as well as my PCP - the idea being that she stays informed about the other issues having a bearing on my Diabetes management.

While my healthcare team helps "Coach" me to be as healthy and happy as I can be with all of these challenging conditions, I believe that just like an athlete, coaching can only do so much - the actual performance is up to me.

Sunday, May 14, 2017

Advocating for Affordable Insulin: Thinking Outside The Box

There is no issue of greater concern for people with Type 1 Diabetes than the rising cost of insulin. From Washington to your local pharmacy, people are furious, frustrated and scared. While some turn to social media to vent their anger and advocate for change, others look to Congress for a solution. The former might make folks feel like they are doing something (and feel better in the process). Traditional media (newspapers and TV news) have also covered the issue of the exorbitant cost of insulin. In addition, the President and some in Congress have said that out of control drug pricing is a problem that needs to be solved, but beside posturing, there has not been any substantive legislation introduced that could realistically be enacted.
In other words, there is a lot of 'buzz' about the issue. Other than a lawsuit alleging price fixing and collusion between the three major insulin manufacturers, there aren't any prospects of a solution anywhere on the horizon.
So what is the solution?
Each of the three major insulin manufacturers (Eli Lilly, Sanofi and Novo Nordisk) are publicly traded corporations. They view their primary obligation to provide value to their shareholders. Love it or hate it, that is why they exist.
Since they are focused on pleasing their shareholders, we could look at reaching equity owners as to get these corporations to manage insulin pricing differently. Sanofi currently has 2.584 billion shares trading at $49.21 each. Novo has 1.96 billion shares trading at $40.60 each. Lilly is priced at $80.19 per share, and with 1.103 billion shares outstanding has the lowest market cap of the three at $88,500,000,000. Unless you are Warren Buffet or Bill Gates and you put all your money into just one of these, you don't have the financial horsepower to bend them to your will. Scratch that idea.
Who sets insulin prices in the first place? Most likely it is a team of financial and managerial accountants who consider cost data, sales forecasts and guidance from senior management among other considerations. After crunching the numbers they arrive at a figure, it is approved by the executive(s) empowered with that authority, and then put into place. As conditions change, that price will be evaluated and the process repeats. But if they arbitrarily drop the price, revenue will fall and the bean counters will have to make it up somewhere else in order to (as always) keep investors satisfied.
Maybe appealing to the Chairman or CEO would work, right? If we leaned on him hard enough, couldn’t he just say 'the hell with it - we need to make insulin more affordable, so we are dropping the price to $X.XX per vial.' Well, no - for a couple of reasons. Like the bean counters, they are responsible for keeping the shareholders happy by maintaining optimal profitability. Secondly, making one group of customers happy would probably infuriate other customers. Dropping the cost for patients with diabetes would mean raising prices on products used by other patients. Placate the second group and the process is repeated ad nauseum. One thing Chairmen/CEOs avoid like the plague is unnecessary turmoil. Annoying customers and investors isn’t part of their job description. Which of us goes out of our way to jeopardize our livelihood - especially for a constituency that will likely be unsatisfied and won't do anything for us? Finally, they get paid to take heat when it comes, and part of that is weathering a storm – like insulin prices.
So who can get things done? The Board of Directors. They set the strategic direction of the corporation. As long as shareholders are generally happy, directors are empowered to do almost anything they want. By and large they have pretty wide latitude. Normally a Board wouldn't get so far into the weeds as setting prices for a product, but if there is enough pressure on them to get involved, they just might. Also, they aren’t the public face of the corporation. Nobody raises hell with them, so what a Chairman/CEO might brush off as part of their job might be enough to get a Director to ask hard questions. The kind of questions that a Chairman/CEO and his subordinates would have to answer.
Here would be my plan of attack:
I’d go after the Directors of Lilly. Sanofi and Novo Nordisk are multinational corporations that are headquartered overseas. They’d be less vulnerable to public heat in America than Lilly would be.
I’d look at their Board of Directors and their biographies. Which would be most likely influenced by the stories of patients who could not afford insulin? Maybe those with a healthcare background – particularly in patient care?
I’d look at the members of the Public Policy and Compliance Committee. Part of their charter is to “…review, identify and when appropriate bring to the attention of the board political, social and legal trends and issues, and compliance and quality matters that may have an impact on the business operations, financial performance or public image of the company.
I’d get the contact information for each of the directors I was going to contact. Google is your friend.
I’d send each of them a one page letter. They are more personal. They are not as easily dismissed as an email. They are not missed like a tweet (assuming some of them are on Twitter).
Here is what I would say:
  • I’d tell my story.
  • I’d identify myself as a customer.
  • I’d tell them my very life depends on their product.
  • I’d tell them how much I pay for their product, on top of my insurance premiums and co-pay.
  • I’d tell them what I cannot do for my family or myself because of how expensive their medicine is. I’d ask them how they would deal with these challenges if they were in my shoes.
  • I’d tell them what I think is a reasonable profit for insulin.
  • I’d ask them to contact me and tell me how they will make insulin affordable, when they will do it, and what they’ll do to keep it that way.
Most of all, I’d share that with other people with diabetes. I’d tell them what I did, who I contacted, what I said and I’d encourage them to do the same.

Sunday, April 30, 2017

Why Insulin Pumps Work Well With Gastroparesis

In a Facebook group for people with gastroparesis, a member with that and Type 1 Diabetes said that he'd been hospitalized a couple of times and that his doctor recommended that he should start using an insulin pump.

Gastroparesis is a complication of Diabetes where the stomach does not digest food properly. Most usually it means that the stomach does not move food along the digestive system as rapidly as a healthy stomach. Rather, for unknown reasons the food often just "sits there." One of the symptoms is excessive fullness (picture Thanksgiving afternoon but you only had a cup of yogurt). Others include pain, cramping, nausea and vomiting. The culprit is believed to be having had high blood glucose levels for an extended period of time, though other causes are being investigated.

On top of the nasty symptoms, gastroparesis makes controlling Diabetes challenging, if not impossible. I pointedly asked my Gastroenterologist what I needed to do to minimize the symptoms of gastroparesis. She said, "Get your A1C down and it will get better and possibly become unnoticeable." I passed that along to my Endocrinologist to get her advice on how to do that. She said that gastroparesis made it difficult, if not even dangerous to try and lower my A1C. Lovely.

For the uninitiated, here is how a person with diabetes normally uses insulin to control blood glucose. Before they consume a meal, they will measure their blood glucose. If it is above their target, they have to figure out how much insulin to inject to get it back to the desire range. Then, they count how many grams of carbohydrates are in the meal. Once it is eaten, those carbs convert to glucose and enter the bloodstream. To counteract that rise in glucose, an individualized formula is used to determine how much insulin will be necessary. They will add those two doses and inject the insulin about the time the meal is served.  Once injected, the insulin "peaks" at around one hour, then the amount in the person's system falls off gradually, disappearing completely after a few hours. This "rate of action" is designed to mimic how a person's blood glucose will rise shortly after a meal and then tail off. If the stomach is functioning properly and the person gets the calculations right, things often work out nicely.

Not so with Gastroparesis. Delayed or impaired stomach emptying screws up this delicate balancing act. Say a person is about to have a meal. They measure their BG, calculate the insulin correction. They count the carbohydrates in their meal, determine how much insulin to take for the meal, then add the two doses. They do the injection and have their meal. But since the food could sit for hours in their stomach, the insulin will take effect when their isn't an increase in the BG. As a result, their BG could drop to dangerously low levels. The person then would have to take some glucose to get it back to a safe level. But after wrestling with that, the food finally starts to digest and the carbs in the meal are converted to glucose and enter the bloodstream. Now the BG rises (in my case as many as 5 or 6 hours after a meal) but there isn't any of the insulin that was injected before the meal left to push the BG back down. Now the BG is too high, and the patient has to decide whether to ride it out or to inject some extra insulin to get the BG to where it ought to be.

That is how it works when using traditional shots. You could divide up the meal bolus and give yourself a couple of small shots over time, but that is unwieldy, somewhat complicated and impractical.

I use a Medtronic 530g Insulin Pump. It has  there are several features that allow me to tailor how much insulin is delivered and when. One option is to use a "square wave bolus." This delivers the insulin at a constant rate over a user selected time period. If I was eating a meal over a long duration (say a working dinner in a restaurant) and didn't need a correction, I'd use this. If a correction was needed, I would use a "dual wave bolus." With this, you get a user selected amount of insulin immediately and the remainder is delivered over time just like the "square wave bolus." You can also add some insulin to come on the front end on top of the correction bolus and the remainder later. After much trial and error, this is what I do. Most of the time it works fairly well, but not always. If a meal is particularly heavy, I might stretch out the length of the bolus from my typical one hour to an hour and a half or even two hours. If it is light and easily digested (like a can of Ensure) then I might decrease the time period, or shift more of the insulin to the beginning of the bolus.

To answer the gentleman's question of whether an insulin pump is the way to go for managing Type 1 Diabetes with gastroparesis, I'd unhesitatingly say that for many people it is. While more costly than shots, and somewhat more complicated, those drawbacks are more than offset by the flexibility it offers in dealing with a challenging and complex set of circumstances. If available to him, I'd enthusiastically encourage him to give it a try. It has made a real difference for me and given the current state of technology in diabetes management, this is the only way to go.

Tuesday, April 11, 2017

New NC Bill Could Get People With Diabetes Off The Road

If you have diabetes and have an accident, you could lose your drivers license if a bill being introduced in North Carolina becomes law. House Bill 653 would require reporting if a driver with diabetes had a 'diabetic coma' and was involved in an auto accident. It would mandate a temporary, and potentially permanent loss of a drivers license. It does not include similar consequences for other drivers with recognized medical conditions that could hamper safe driving.

For people with diabetes in North Carolina, getting a drivers license is no easy feat.  According to the NC DMV website, "If you suffer from a mental or physical disability that might affect driving safety, a license may not be issued. A disabled person may be issued a restricted license provided the disability does not keep him/her from driving safely" The process for getting a license requires when an applicant has a medical condition that might impact safe operation of a motor vehicle is spelled out in the DMV's "Medical Evalution Brochure." In addition to diabetes, it lists 11 other general and specific conditions that the DMV wants to know about.

If one of those conditions is reported to DMV by a physician, family member, or law enforcement official, the driver can be required to fill out a "Medical Report Form" and have their physician provide their observations. There is then a hearing to decide whether or not that person will be allowed to drive. If they don't like the answer, they can appeal. They can also put in a request to be removed from the program. Like most things DMV, it is amorphous, tedious and annoying.

But the new legislation being introduced makes keeping a license harder, is discriminatory and fatally flawed it its underlying premise. If you have a wreck and somebody figures out you have diabetes, you could be put into that program. While that process is going on (for weeks or months) you cannot drive. The proposed law is also discriminatory since it only applies to people with diabetes and epilepsy - leaving out many other conditions that could make a driver potentially unsafe. Finally, where it pertains to diabetes, it singles out drivers suspected of having an accident caused by "diabetic coma" - an inexact phrase generally referring to extremely high or low blood glucose. In most respects, many symptoms occur long before coma is experienced - most of which would make driving impossible long before an accident could happen.

To fix this bill, several possible things should happen.
  • It should be killed in committee. 
  • All of the other conditions that are addressed in the North Carolina Drivers Medical Evaluation Program should be included in the interest of fairness, efficacy to the intent of the bill, and to ensure consistency throughout the program. 
  • Table the bill and instead create a Legislative Study Commission to ensure that the intended result is achievable, done equitably and protects both individuals with disabilities and the general public. 
  • Delete the term 'diabetic coma' and instead place language that is medically justifiable, objectively determined and supports the reality that diabetes effects different people in different way.
  • Delete language that arbitrarily suspends driving privileges prior to the completion of the administrative process. Such a suspension should only be allowable if there is clear and convincing evidence provided by a licensed physician that clearly states a driver cannot at any time safely operate a motor vehicle. 
  • Allowance should be made for the fact that blood glucose levels may make driving unsafe at one moment and as safe as any other driver in a matter of minutes.
  • Require that evaluations for driver fitness be covered by Medicaid.
On a poersonal note: I can assure you from personal experienced that having an automobile accident while in a 'diabetic coma' is next to impossible. I've been in three 'diabetic comas' and it is hard to drive a car when you are unconscious in an Intensive Care Unit.



1. Find your legislator and encourage them to NOT sign on as a co-sponsor of this bill. Doing so would indicate support of legislation that further marginalizes people with diabetes and in a way that will not accomplish the goal of safer roadways that this legislation intends.

2. Reach out to other people with diabetes in NC. Make them aware of this legislation, how it could affect them and encourage them to reach out to their legislator.

3.  Periodically check the bill status. When it is scheduled to come up before a committee, consider going to that meeting to personally express your opposition. That carries a lot of weigh with legislators, and is the easiest way to get a bill either changed or killed outright.


Entitled "Report/Car Accident Caused by Seizure or Coma," HB 653 would require that any automobile accident that was caused as the result of a driver suffering from a 'diabetic coma' must be reported. It further requires that the DMV "shall evaluate whether the medical condition affects the driver's ability to safely operate a motor vehicle and SUSPEND THE DRIVERS LICENSE OF THE DRIVER PENDING COMPLETION OF THE EVALUATION." (emphasis added). The proposed legislation goes of to state that, "If the Division determines that the medial condition does not affect the driver's ability to safely operate a motor vehicle, the Division shall restore the drivers license of the driver at no cost to the driver. If the Division determines that the medical condition does affect the driver's ability to safely operate a motor vehicle, the Division shall cancel the drivers license of the driver in accordance with G.S. 20-15(a)(4). Upon cancellation, the driver may appeal the decision of the Division  or seek issuance of a new restricted or unrestricted driver's license, in accordance with the process set forth in G.S. 20-9(g)." Finally, "reports under this section made by law enforcement officers and medical examiners are public records and are open to inspection by the general public at all reasonable times."