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How much is too much?! Damage…

I always tell patients “Anxiety is, essentially, being asked a question that impacts your life and having no answer.

Being part of Gen X I am fortunate to have a certain amount of comfort with this. You see, once upon a time someone would ask us a question and we would just look at them and say “I don’t know” and move on! Because we did not have the answer! We also did not have the world’s sum of information in our pockets! If we were VERY fortunate, we had a MASSIVE set of WORLD BOOK encyclopedias at home that our grandparents bought by saving receipts at the grocery store for the better part of 2 years. And those encyclopedias were all the knowledge we had about the world both outside our immediate world, our scientific world. They were also probably about 15 years out of date. (I know my set had the USSR and two Germanies, and there was zero change I was ever going to know what countries existed in central Africa or ended in “-stan” anywhere in the world.) So, suffice it to say that we had a very different level of confidence not knowing things. We were fed misinformation from those older (and therefore presumed wiser) than us. (Like some sort of mystical band of folk) If were made anxious about a lack of answer to some question that plagued us we got transportation to a library and begged the assistance of an actual human being at a reference desk and this biblio-wizard showed us the wonders of a card catalog and we delved into more outdated tomes…. Scratch the itch of anxiety’s drive to know the answer long enough and you might just end up with a degree and have some capacity for answering questions in that limited area of knowledge!

anxiety

Fast forward a decade or so and we have the sum of human knowledge strapped to our wrists, and rampant anxiety because we must find THE ABSOLUTE CORRECT ANSWER to every question.

Nowhere is this truer than when the question pertains to our own bodies. And so, today, the public servant of the reference librarian has mutated into the glutton of greed that feeds off our anxiety offering us the “truth behind” everything. Offering people answers is big BIG business in our modern age where we have all the information but none of the ability to figure out what is real. We truly have come full circle back to the “Wise person” in the tent bilking every passer through out of their hard-earned money to tell them their future. Only now we call it “Web MD” Forget “Big Pharma” “Big INFO” is king!.  Those of us from the generations of “I don’t know” are inoculated against a bit of anxiety. We tend to deal with it a bit easier. But the more we live in the world of “Big info” the more prone we are to big anxiety in the face of no solid answers to our questions.

In diabetes nursing one of the questions I get asked the most is “How much is too much damage?”

Everyone wants to quantify the amount of time spent out of range with the amount of damage done to their body. Unfortunately, as with everything the answer is just not that simple. If it were I could just run someone’s Dexcom data through a formula and tell them the day they’ll die. It’s also not so simple because our bodies are simply AMAZING beyond words!

People ask me all the time “Knowing what you know about bacteria and viruses I bet you are really paranoid” I vehemently disagree and say “Absolutely not! Because the more I learn about the human body and how it protects, fights, heals, and responds to the ongoing threats to our survival, I am FAR more amazed by this body than I am by those threats!”

Unfortunately, when we are told we have diabetes we are given just enough information to set up a lot of questions. Then we are sent home. We are not given many solid answers. So we heat to “big info” hungry for answers. Instead, we are fed anxiety. So, we have a “target range” and are told to stay in it, because to not stay in it will cause harm.

SO, being the logical beings we are the next logical questions is “How much is too much?” which kicks off the anxiety spiral.

“Is it hours high that’s the problem or single big highs?
Or sustained big highs?
Or every minute high?
Or only certain amount of time high?
Or only going so high?

Is it every low?
How long low?
How far low?
Only symptomatic lows?
What about highs that feel like lows?
What if I sleep through the low?
What if I go high because of a low?
Do they somehow balance out?!”

“If I stay in range for years will that balance out the years I was out of range?
How much time do I have to be in range to balance the damage done by being high?
What does that ratio look like?
Can I bank time in range now for time I place to be out of range later?
How perfect does my blood sugar have to be to stop the damage done by the time my blood sugars were not perfect in the past?”

When we ask “how much is too much damage?”, we are seeking information without the capacity to see the truth.

What we need to be thinking is “How incredible is my body and what does it need to run?”

bandaid

The answer with diabetes management, time in range, Time high and time low, is just like every other kind of injury and illness.

What we are really talking about is our body’s ability to prevent problems, defend against ongoing assault, cope with past damage, rejuvenate from sustained damage, and continue functionality despite damage taken. These will all depend on the acuity, frequency, and duration of the damage sustained.

When it comes to low acuity injury (mild abrasion, minor infection, non-symptomatic excursions in blood sugar (BG 140-250, 70-55) as long as low acuity injuries are neither frequent, not long in duration they are actually blocked from harming the body at all. They call under the scope of prevention. A scuff is not harming us, you can scuff your leg, then scuff the other leg, then your elbow the day after that, then your hand. And then the day after that another scuffed knee, then scuff your forehead…. and so on, for the majority of your life, you’ll not develop scuffing syndrome or a scuffatoma, or die at a young age of chronic scuffing.

Because your body rapidly repairs the damage, it does not do enough damage or take enough of your body’s resources to heal to impair growth, reproduction, feeding, cell copying, or any other essential functioning.

No shortening or life or loss of function. Likewise, occasional blood sugar excursions have no long-term lasting impact on body functioning. Our body heals from the issue and keeps right on going. Mechanisms are in place to cope with these excursions preventatively without compiling injury upon injury. We may have transient glucose in our urine; we may have brief transient reduce optimum performance But as soon as blood sugars normalize the symptoms abate and we continue life as usual just like we carry on as soon as the sting of a scuff passes.

(just imagine how horrific a shape mankind would be in if every scrape was cumulative, or every little viral infection added toward our total illness. We would not have made it past the primordial ooze as a species, much less to the top of the food chain! The protective and regenerative capabilities of the human body are what allow us to sustain countless micro-injuries and excursions from homeostasis both noticed and unnoticed every day and carry on.) When we focus on THIS aspect of our physiology rather than our perceived fragility due to our diabetes we can live with a sense of respectful boldness and empowerment rather than fear and anxiety!

But if we take our abrasion, and make it higher acuity, like a scrape that bleeds (BG> 300) now our body is going to have a sustained injury, we will temporarily lose some functionality. It will heal. But it will take a little time and may leave some mild scarring. We certainly don’t want to make it a high-frequency occurrence. We can cope and rejuvenate ourselves on our own.

If it’s severe like road rash (BG>800) well now we’ve got risk of long-term functionality loss. We’ve got to seek medical attention here. This is a one-time event but it’s too big for our body to just shake off we have lost our defense, we can’t cope on our own, we hope for rejuvenation with time, but first we want to support to maintain functionality so we can continue t function and hopefully regain full functionality with minimal scarring and loss of range of functionality.

Now let’s take our scuff (or say chronic >40% of our day BG elevations or >4%mild lows) scuff the same knee, day, after day, after day, after day, after day, and your body will put measures into place to defend itself. A callus will start to form, defending that part of the body from harm. Our low acuity issue has become high frequency.  In terms of blood sugar this may be kidney function starting to shift to release more glucose in urine. It may mean a blood pressure shift to accommodate the ongoing adrenal hits associated with chronic hypoglycemia or shifts in blood flow patterns. Again, we go from a defensive to a coping state. We are functional but that function has shifted slightly. We want to exit this state to allow the body to rejuvenate so that the coping state does not become permanent.

If we stay in this state beyond our body’s ability to cope for our scuff this is now simply an unhealing open wound constantly being assaulted with touch (in terms of blood sugars our elevations persist for years, or the percentages continue to rise over months). We may see the coping progress to a state where we begin to see damage that impedes functionality.

For our knee, we will see chronic inflammation that reduces mobility, scar tissue forms around the wound bed to seal it off from the surrounding tissues. The knee joint stiffens as the body attempts to force immobility.

For blood sugars: Kidneys may start to see nephrons damaged from trying to cope with elevated blood sugars. Blood vessels may begin to constrict. Brain pathways may begin to realign to meet the needs of ongoing lower glucose levels to maintain functionality at a reduced level of chronic hypos. We are now moving from coping and rejuvenation to just adapting to past damage to maintain functioning. This is going to be irreversible. We can still get out of this range to stop the progression of further maladaptive changes in our bodies, but we can’t reverse what’s already been laid in place.

And of course, we can see in terms of either high acuity, or high frequency, if either of these states continues for long the issues are going to progress from localized issues impacting on area and organ of the body, to multiple areas and organs. This sets off a chain reaction in the body of systemic illness or multi-organ injury.

Our body can cope with isolated issues relatively well, but systemic issues shorten lifespan.

So the answer to “How much is too much damage?”  or to be more accurate “How incredible is my body and what does it need to run?” is not “Avoid all damage” because we can no more do that than avoid ever scraping a knee! But it is to avoid combining acuity, frequency and duration. If blood sugar is going to be out of range, try not to let it go too far, for too long, too often.  One of these things the body can handle just fine. Two of these things the body can do ok with. But it will impair us temporarily and will take some time energy and resources to spring back, all three and we may well be facing irreversible damage.

But no matter what happened yesterday, or for years in the past. Every day is a fresh day with a fresh opportunity to make our choices. So, if you’re struggling with anxiety, I recommend working with our team of experts to help get some answers.

We may be just the diabetes-wizards you need. And if today is the day you’re deciding to make some better choices we consider it a privilege to be part of that journey alongside you.

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